Important conditions investigations and treatments

Question 1

T1DM

Answer 1

Investigations
- Fasting plasma glucose - >7
- Random plasma glucose - >11.1
- Oral glucose tolerance test - > 11
- HbA1C - > 48 mmol/L or >6.5% (pre diabetes >42mmol/mol)

TREATMENT
Basal bolus insulin

Question 2

DKA

Answer 2

Investigations
Serum ketone - elevated
RPG - >11.0
Venous blood gas (metabolic acidosis) - pH <7.3 (or HCO3- <15mmol)

Treatment
1st line
Rehydration with IV fluids FIRST
then insulin infusion
(can give potassium to replenish K+ stores)
(can give glucose to prevent hypoglycemia)

Question 3

T2DM

Answer 3

TREATMENT
First line - Lifestyle modifications (diet and exercise)

First line drug treatment
- Metformin

If HbA1C is above agreed threshold,
Other drugs include
- Sulphonylureas e.g. Gliclazide
- DPP4 inhibitors e.g. Gliptins
- SGLT 2 inhibitor e.g. Gliflozin

Question 4

Hyperosmolar hyperglycemic state

Answer 4

INVESTIGATIONS
- Increased serum osmolality
- RPG > 11.1
- Serum ketones will not be elevated (eliminates DKA)

TREATMENT
- Intravenous fluid replacement (saline) FIRST
Followed by intravenous insulin

Question 5

Hyperthyroidism

Answer 5

INVESTIGATIONS
First line - Thyroid function test
- Primary hyperparathyroidism - High T3,T4, low TSH (GRAVES - abnormality of thyroid gland)
- Secondary hyperparathyroidism - High T3,T4, high TSH (abnormality of pituitary gland)

GS - TSH receptor antibodies

Treatment
1st line- Carbimazole (Side effect of sore throat due to AGRANULOCYTOSIS) - decreases uptake of T3,T4 into cells

CONTRAINDICATED IN PREGNANCY
Give PROPYL THIOURACIL instead
(Thionamide) - decreases production of T3,T4 into cells.

• Radioactive iodine
• Last resort - surgery

Question 6

Hypothyroidism

Answer 6

INVESTIGATIONS
1st line - Thyroid function test
Hashimoto’s - Low T3,T4, High TSH
Secondary - Low T3,T4 and TSH.

GS - Anti TPO antibodies - elevated

TREATMENT
1st line - Levothyroxine (synthetic T4) - T4 levels must be monitored as often can cause iatrogenic hyperthyroidism

Question 7

Cushing’s syndrome

Answer 7

INVESTIGATIONS
1st line - Serum cortisol

GS- Overnight Dexamethasone suppression test (Dexamethasone given at 12am and readings taken at 8am)

If low dose dexamethasone suppresses cortisol levels - ACTH independent Cushing’s syndrome –> Adrenal cause

If high dose dexamethasone suppresses cortisol - ACTH dependent - Pituitary cause

High dose dexamethasone can suppress cortisol levels in Cushing’s syndrome but not due to adrenal adenoma/ectopic causes)

Plasma ACTH
ACTH low in adrenal adenoma, high in Cushing’s disease

MRI - for pituitary/adrenal adenoma

TREATMENT
Trans-sphenoidal resection of the pituitary gland

Unilateral adrenalectomy

(Also stop steroids)

Question 8

Acromegaly

Answer 8

INVESTIGATIONS
1st - Serum IGF-1 - elevated

GS - Oral glucose tolerance test (impaired glucose tolerance)

TREATMENT
1st - Trans-sphenoidal pituitary surgery

Drug treatment:
Somatostatin analogue - Ocreotide
GH antagonist - Pegvisomant
Dopamine agonist - Cabergoline

Question 9

Prolactinoma

Answer 9

INVESTIGATIONS
1st line - Serum prolactin

GS - Pituitary MRI

TREATMENT
1st line - Cabergoline (Dopamine agonist), Bromocriptine

Definitive - Trans-sphenoidal surgical removal of pituitary tumour

Question 10

Conn’s syndrome

Answer 10

INVESTIGATIONS
1st line - Aldosterone:renin ratio (high)
(in secondary hyperaldosteronism, both will be elevated so the ratio will be low)

GS - Elevated serum aldosterone that is not suppressed with fludrocortisone

ECG - Hypokalemia - U waves, small/inverted T waves, long PR and QT interval + ST depression.

(Can lead to metabolic alkalosis due to increased aldosterone)

TREATMENT

First line - Oral spironolactone - Aldosterone antagonist (potassium sparing diuretic)

Primary hyperaldosteronism - Unilateral adrenalectomy

Question 11

Adrenal insufficiency

Answer 11

INVESTIGATIONS
1st line and GS - Short synacthen test - test the cortisol producing function of the adrenal glands.

Serology for Anti 21 alpha hydroxylase antibodies (Addison’s disease)

Serum ACTH - elevated in primary, depressed in secondary

TREATMENT
1st line - Hydrocortisone for glucocorticoid deficiency (cortisol)
Fludrocortisone - for mineralocorticoid deficiency (aldosterone)

ENSURE PATIENTS CARRY A STEROID CARD
Doses are doubled during an acute illness, trauma, night shift work

Question 12

SIADH- what state are you in?

Answer 12

INVESTIGATIONS
Combination of tests
Low serum sodium and high urine osmolality.
(Euvolemic Hyponatremia)

SHORT SYNACTHEN TEST TO EXCLUDE Adrenal Insufficiency (other cause of hyponatremia)

TREATMENT
1st - Fluid restriction (1L/day) - increases sodium concentration

For chronic cases –> Drugs e.g. Tolvaptan (vasopressin antagonist)
Demeclocycline - diminishes collecting ducts response to ADH (a tetracycline antibiotic)

Treat underlying cause - e.g tumour excision

Question 13

Diabetes insipidus

Answer 13

INVESTIGATIONS
1st line - Water deprivation (for 8 hours) and desmopressin test (Synthetic ADH)
Central - Urine osmolality is low before test and HIGH after test
Nephrogenic - Urine osmolality is low before and after test.

Measure urine volume - More than 3 litres a day.

Can investigate copeptin (fragment of precursor molecule for vasporessin)
Copeptin Low - Central DI (reduced vasopressin production)
Copeptin high - Nephrogenic DI (means reduced sensitivity is the cause)

TREATMENT
Central - Desmopressin (synthetic ADH)

Nephrogenic - Thiazides + treat underlying cause

Also ensure adequate water intake

Question 14

Hyperparathyroidism

Answer 14

INVESTIGATIONS
1st line - Serum calcium and PTH
Primary - High PTH, High Calcium, Low phosphate, High ALP
Secondary - High PTH, Low calcium, High phosphate
Tertiary - All high

Dexa scan - for bone density
ECG - Shows a short QT interval in Hypercalcemia

TREATMENT
Primary - Parathyroidectomy (removal of parathyroid adenoma)

If its secondary or tertiary, treat the cause
e.g. Bisphosphonates to prevent bone resorption
Rehydrate to prevent kidney stones

Question 15

Hypoparathyroidism

Answer 15

INVESTIGATION
First - Serum calcium and PTH
Low PTH, Low calcium, High phosphate

ECG - Long QT interval (hypocalcemia)

TREATMENT
1st line - Oral calcium supplements and vitamin D3

Question 16

Pheochromocytoma

Answer 16

INVESTIGATIONS
1st line and GS- Serum metanephrine and normetanephrine

CT scan of abdomen and pelvis for tumour
24 hour urinary catecholamines

TREATMENT
1st line - Alpha blocker (phenoxybenzamine) THEN beta blocker (atenolol)

Benign pheochromocytoma - Surgical excision of tumour

CAN LEAD TO HYPERTENSIVE CRISES

Question 17

Hypercalcemia

Answer 17

INVESTIGATION
1st line - Serum PTH
ECG - Short QT interval

TREATMENT
IV fluids (rehydration) and IV bisphosphonates
- Surgical removal of parathyroid adenoma

Question 18

Hypocalcemia

Answer 18

INVESTIGATIONS
Long QT interval on ECG.

Serum PTH and calcium

*Check for history of neck surgery - may point to parathyroid injury

TREATMENT
- Oral calcium and Adcal (Vit D3) supplements

Question 19

Stable angina

Answer 19

INVESTIGATIONS
1st line - Resting ECG - Normal

GS - CT coronary angiography - Shows stenosed atherosclerotic arteries (narrowing of artery)

TREATMENT
Symptomatic - GTN spray
Lifestyle modification –> Increase physical activity, smoking cessation, healthy diet

Pharmacological
1st line - Beta blockers (CI in asthma) in which case you give CCB (CI in heart failure)

2nd line - CCB + BB

Question 20

ACS

Answer 20

INVESTIGATIONS
1st line - 12 lead ECG
UA - usually no changes (possible ST depression)
NSTEMI - T wave inversion + ST depression
STEMI - ST elevation in at least 2 contiguous ECG leads

Serum troponin
UA - Normal
NSTEMI - Elevated
STEMI - Elevated

GS - CT coronary angiogram - shows extent of occlusion

TREATMENT
Acute - MONA
IV Morphine
Oxygen if SATS <94%
GTN spray
Aspirin (+ clopidogrel)

Based on the Grace score - (risk of death within 6 months of discharge in patients with ACS)

If NSTEMI/UA –>
Low risk - Dual antiplatelet therapy - clopidogrel and aspirin
High risk - Immediate angiogram + consider PCI

STEMI –>
PCI - If within 12 hours of symptom onset
Thrombolysis with alteplase if >12 hours of symptom onset

Question 21

Heart failure

Answer 21

INVESTIGATIONS
1st line - Bloods
BNP levels - elevated (released from stressed ventricles)

ECG - abnormal, possible signs of LVH

Chest X-ray -
A - Alveolar oedema
B - Kerly B lines - interstitial oedema
C - Cardiomegaly
D - Dilated vessels
E - Pleural effusion

GS - Echocardiogram

TREATMENT
Conservative
- Lifestyle changes - Decrease BMI, exercise, stop smoking

Pharmacological (ABAL)
1st line - Ace inhibitor / Angiotensin receptor blocker
- Beta blocker
- Aldosterone antagonist
- Loop diuretic

(Chronic heart failure/worsening heart failure - Ivabradine)

Last resort
Surgery
- Revascularise
- Heart transplant

Question 22

AAA

Answer 22

INVESTIGATIONS
1st line + GS - Abdominal ultrasound

TREATMENT
Asymptomatic + unruptured –> Manage RF: Stop smoking, decreased BP, decrease BMI

Growing rapidly ,>5.5cm + unruptured –> EVAR (Endovascular aneurysm repair) or open surgery - laparotomy(more invasive)

Ruptured –>
STABILISE - ABCDE (resuscitate)
+
EVAR
SURGICAL EMERGENCY (100% mortality if not treated immediately)

Question 23

Aortic dissection

Answer 23

INVESTIGATIONS
1st line - Chest X-ray –> Widened mediastinum

GS - CT angiogram

(TROPONINS, CT angiogram)

Classify AD as type A or B via Stanford classification
A - Ascending aorta affected before the left subclavian artery
B - Descending aorta distal to the left subclavian artery

Treatment
Type A - Open surgery
Type B - Endovascular aneurysm repair

Medical prevention
+ Special Beta blocker - Labetolol
or if BB doesn’t work - Sodium Nitroprusside.

Question 24

Atrial fibrillation

Answer 24

INVESTIGATIONS
1st line + GS - ECG
Absent P waves + irregularly irregular QRS complex + Narrow QRS complex

TREATMENT
If Acutely, haemodynamically unstable (new onset AF within 48 hours, heart failure, chest pain) –> SYNCHRONISED DC (direct current) CARDIOVERSION

For stable, long term treatment (RATE CONTROL)
- Beta blockers (bisoprolol)
OR CCB (Verapamil)
+
DOAC if CHADSVASC score more or equal to 2 (Apixaban)

Last resort: radiofrequency ablation (permanent)

Question 25

What are the 2 shockable and 2 non shockable rhythms?
(In cardiac arrest)

Answer 25

Shockable
- Ventricular tachycardia
- Ventricular fibrillation

Non Shockable
- Pulseless electrical activity
- Asystole

Question 26

Atrial flutter

Answer 26

INVESTIGATIONS
1st line + GS - ECG
Saw toothed pattern (F wave?), often with a 2:1 block (2 P waves for 1 QRS) - atrial rate at about 300bpm

TREATMENTS
Acutely unstable (Shock, syncope, MI) –> Synchronised DC cardioversion

Stable -
1st line - rate control
BB - Bisoprolol
+
DOAC depending on CHADSVASC score

(Permanent - Radiofrequency ablation)

Question 27

Wolff parkinson white syndrome

Answer 27

INVESTIGATIONS
1st and GS - ECG
- Short PR interval
- Delta waves (in QRS complex) - slurred upstroke
- Wide QRS

TREATMENT
1st line - Vagal maneuvers
- Carotid massage
- Valsalva maneuver

2nd line - IV adenosine CI asthma give CCB - verapamil

Definite - last resort - Radiofrequency ablation of bundle of Kent.

Question 28

Hypertension- how to assess end organ function

Answer 28

INVESTIGATIONS
If BP in hospital >140/90 mmHg, do Ambulatory blood pressure monitoring to confirm diagnosis (135/85 mmHg throughout the day)

Assess for end organ damage
- Fundoscopy - Papilloedema
- Urinalysis + eGFR - Kidney function
- Echo - LVH

TREATMENT
If <55 YO or T2DM (Not a black African)
1) Ace inhibitor
NO MATTER WHAT AGE/ETHNICITY, if patient has T2DM give Ace-Inhibitor

If >55 YO or Black African
1) CCB

2) Ace inhibitor + CCB
3) Ace inhibitor + CCB + Thiazide

Question 29

Symptoms and treatments of 1st, 2nd and 3rd degree AV blocks

Answer 29

1st degree
Sx - Usually asymptomatic
Tx - Asymptomatic so no treatment (Mobitz 1 also no treatment unless very symptomatic then give PACEMAKER)

2nd and 3rd degree
Sx - Syncope, fatigue, hypertension, chest pain, dyspnoea

MOBITZ 2 Tx–> Pacemaker

3rd degree
Tx –> IV atropine and pacemaker

Question 30

DVT

Answer 30

INVESTIGATIONS
If Wells Score is 1 or less (Unlikely DVT) –> Do a D-dimer test
- If its normal - DVT excluded
- If its elevated do a venous duplex ultrasound - where a reduced or absent spontaneous flow CONFIRMS the diagnosis

If Wells score is 2 or more (likely DVT) –> Do a venous duplex ultrasound (Diagnostic)

TREATMENT
1st line - DOAC (Apixaban, rivaroxaban)
LMWH if CI (renal impairment)

Non pharmacological treatment
- Physical activity - mobilisation, walking exercises
- Compression stockings

Question 31

PE

Answer 31

INVESTIGATIONS
1st line
If Wells score >4 (likely PE) –> CT pulmonary angiogram (diagnostic)

If Wells score <4 (unlikely PE) –> D-dimer test :
- If raised –> CTPA
- If not raised –> Not PE

ECG - Sinus tachycardia + S1Q3T3 (also sign of cor pulmonale)
T wave inversion of anterior and inferior leads + new RBBB

Chest X-ray - normal

TREATMENT
Non massive PE (usually this)
1st line
DOAC - Apixaban
LMWH if CI (renal impairment)

Massive PE
Thrombolytics e.g. alteplase, streptokinase

Question 32

PVD

Answer 32

INVESTIGATIONS
First line - Ankle brachial pressure index. (ratio of BP)
<0.9 = intermittent claudication
<0.5 = Chronic limb ischemia

Buerger’s test - elevate leg at 45 degree angle for 1-2 minutes, if there is pallor, test is positive

TREATMENT
Intermittent claudication
- Graded exercise therapy
- RF modification - Stop smoking, balanced diet, increase physical activity
- Pharmacological: Atorvastatin, clopidogrel

Chronic limb ischaemia
- Revascularisation surgery
PCI - if small
Bypass surgery - if bigger

Question 33

Acute limb ischemia treatment`

Answer 33

TREATMENT
If non viable limb (Sign of tissue loss, nerve damage or significant sensory loss)
–> Amputate

If limb is viable on assessment –> Urgent revascularisation
within 4-6 hours (Endovascular thrombolysis/thrombectomy, bypass surgery)

Question 34

Pericarditis

Answer 34

INVESTIGATIONS
FBC - ESR elevated, leukocytosis
GS - ECG - Localised PR depression + Global Saddle shaped ST elevation

TREATMENT
NSAIDS + colchicine

Question 35

Cardiac tamponade

symptoms + treatment + investigations

Answer 35

INVESTIGATIONS
1st line - ECG

Chest X-ray - Big heart
GS - Transoesophageal echocardiogram

Treat pericardial effusion with NSAIDS + colchicine

Treat cardiac tamponade with URGENT PERICARDIOCENTESIS

SYMPTOMS of cardiac tamponade
BECK’s Triad
- Hypotension
- Increased Jugular venous pressure
- Muffled S1+S2 heart sounds
+
Pulsus paradoxus

Question 36

IE

Answer 36

NVESTIGATIONS
1st line - 3 sets of blood cultures at 3 different sites over 24 hours
FBC
Urinalysis

GS - Transoesophageal echocardiogram

DIAGNOSIS MADE WITH MODIFIED DUKES CRITERIA
(2 major, 1 major 3 minor, 5 minor)

TREATMENT
S.viridans (S.bovis) - Benzylpenicillin (Pen G) + Gentamicin

S.aureus - Flucloxacillin

Enterococci –> Amoxicillin + Gentamicin

Question 37

Acute liver failure

Answer 37

INVESTIGATIONS
First - Liver function test
- Increased bilirubin, increased PT/INR and decreased serum albumin
- Increased ALT and AST

Additional but not really required?
- FBC - (for haemolytic anaemia associated with Wilson’s disease)
- Abdominal ultrasound - to eliminate budd chiari syndrome
- EEG - electroencephalogram - assess hepatic encephalopathy

MANGEMENT
1st - Intensive care management
- Tracheal intubation
- Analgesia
- IV fluids

Then treat underlying cause
- Paracetamol causes - N acetylcysteine
- Budd chiari syndrome - LMWH

Treat complications
- Cerebral oedema - IV mannitol
- HE - Lactulose
- Ascites - Spironolactone
- Haemorrhage - vitamin K

Definitive - Liver transplant

Question 38

Alcoholic liver disease`

Answer 38

INVESTIGATIONS
First - LIVER FUNCTION TEST
- Increased bilirubin, decreased albumin, increased PT
- AST:ALT >2

FBC - Macrocytic anaemia (increased deposition of cholesterol on RBC membrane)

GS - Liver biopsy - shows extent of alcoholic liver disease

(Can do AUDIT and CAGE questionnaire)

TREATMENT
1st - STOP DRINKING ALCOHOL + give diazepam for alcohol withdrawal symptoms (delirium tremens)

• Consider prednisolone based on Maddrey’s discriminant function (>32 positive, poor prognosis)

Tranexamic acid (to reduce/prevent bleeding)- reduces mortality risk in GI bleeds

Definitive - Liver transplant

Complications - HE, Acites, hepatocellular carcinoma, Wernicke krsakoff syndrome

Question 39

NAFLD

Answer 39

INVESTIGATIONS
Liver function test - Increased ALT (but ALT:AST <0.9)

GS - Liver biopsy

Liver ultrasound - use fibrosis 4 score to estimate risk of advanced fibrosis and need for liver biopsy

TREATMENT
First - Lifestyle modification- Healthy diet and exercise for weight loss (no smoking and alcohol)

Vitamin E to improve histological fibrotic liver appearance.

(Can lead to HCC, HE, Ascites, portal hypertension)

Question 40

Liver cirrhosis

Answer 40

INVESTIGATIONS
LFT - low albumin, raised bilirubin, raised prothrombin time
- Platelet count reduced (liver has impaired ability to produce thrombopoietin)

Abdominal ultrasound - liver surface nodularity, ascites, splenomegaly

(Transient elastography for determining degree of fibrosis)

GS - Liver biopsy
(Use child pugh score for prognosis of patients with chronic liver failure/cirrhosis - severity of liver cirrhosis)

TREATMENT
3 things
1) Treat underling cause
- avoid alcohol, NSAIDS, high dose paracetamol, treat any hep B and C

2) Monitor complications
e.g. use ultrasound to monitor ascites and endoscopy to monitor oesophageal varices

3) Manage complications e.g. spironolactone/diuretics for ascites

2nd line - Liver transplant

Question 41

All viral hepatitis

Answer 41

Check with notesCh

Question 42

Cholelithiasis

Answer 42

INVESTIGATION
Abdominal ultrasound - where you may find:
- Gallstones in the gallbladder/ducts
- Dilation of the ducts
- Acute cholecystitis

LFT - show a large increase in ALP (in an obstructive picture) - maybe slight increase in transaminases

Can do Endoscopic retrograde cholangiopancreatography (ERCP_ = endoscope inserted through oesophagus and stomach to sphincter of oddi. (can inject contrast)

TREATMENT
Analgesia - diclofenac/paracetamol + LAPAROSCOPIC CHOLECYSTECTOMY

Question 43

Cholecystitis

Answer 43

INVESTIGATIONS
- Abdominal ultrasound scan - shows evidence of cholecystitis:
+ Thickened gallbladder wall
+ Stones in gallbladder
+ Pericholecystic fluid (fluid around the gallbladder) - caused by the inflammation
GS - MRCP

FBC - leukocytosis (inflammation triggers immune response)

TREATMENT
Laparoscopic cholecystectomy - (should be done within 1 week of diagnosis according to NICE)
+
Analgesia - (ibuprofen/diclofenac)

(Antibiotics -Piperacillin and tazobactam….. Ciprofloxacin)

Question 44

Ascending cholangitis

Answer 44

INVESTIGATION
First - Abdominal ultrasound - dilated bile duct, common bile duct stones

LFTs - increased conjugated bilirubin

GS - MRCP (magnetic resonance cholangiopancreatography) - non invasive (ERCP is invasive but can be used for treatment)

TREATMENT
1st - IV antibiotics (for E.coli ceftriaxone)

After 24 hours-
Endoscopic retrograde cholangiopancreatography (ERCP) - places a drainage stent to allow for biliary tree decompression and stone extraction.

(Consider cholecystectomy to prevent recurrence once stable)

Question 45

PBC

Answer 45

Investigations
- LFT - increased ALP, increased conjugated bilirubin

Serology for autoantibodies
- Anti mitochondrial antibodies (AMA) - most specific to PBC
- (Anti nuclear antibodies present sometimes)

FIRST LINE IMAGINE - ABDOMINAL ULTRASOUND (to rule out other causes of cholestasis - obstructive mass, PSC)

TREATMENT
1st line - Ursodeoxycholic acid
(decreases toxicity thus decreasing inflammation and reducing cholestasis – and dampens immune response)

Cholestyramine - give for pruritus

Question 46

PSC

Answer 46

INVESTIGATIONS
- LFT - increased ALP, increased GGT supports liver origin rather than bone origin (for raise in ALP)

(pANCA positive but not helpful in diagnosis)

GS - MRCP - beaded appearance of bile ducts

TREATMENT
- no proven effective treatment

Conservative treatment (lifestyle changes - maintain healthy wait, limit alcohol)
- ERCP can be used to treat strictures
- Colestyramine given for pruritus relief

Definitive treatment - liver transplant

LEADS TO CHOLANGIOCARCINOMA

Question 47

Acute pancreatitis

Answer 47

INVESTIGATIONS
GS - Blood test for serum lipase/serum amylase
(Lipase - elevated for longer
more specific) –> Leakage from pancreatic cells

LFT - Elevated ALT (suggests gallstone pathology)

Ultrasound - diagnostic for gallstones

Assess severity - using glasgow score

TREATMENT
ABCDE
- IV fluid resuscitation
- Analgesia
- IV antibiotics if infection
Nil by mouth

Use ERCP for gallstones

Question 48

Chronic pancreatitis

Answer 48

INVESTIGATIONS
1st - Faecal fat - increased (indicator of exocrine function)

GS - Abdominal US and CT scan –> shows pancreatic calcification + dilated pancreatic duct (diagnostic)

(unlikely to see increased lipase and amylase)

TREATMENT
1st - Alcohol and smoking cessation + analgesia (ibuprofen)

For patients with exocrine pancreatic insufficiency –> Pancreatin (pancreatic enzyme replacement therapy)
(Insulin regime for diabetes)

Question 49

Coeliac disease

Answer 49

Investigations
1st line - Serology for anti-TTG IgA antibodies (above normal range)
- ALSO total IgA to EXCLUDE IgA deficiency (because if you have IgA deficiency, you will have a low anti-TTG leading to a false negative)

GS - Endoscopy and biopsy –> Showing crypt hyperplasia and villous atrophy (and epithelial lymphocyte infiltration)

TREATMENT
1st line - Gluten free diet (+ vitamins and mineral supplementation to replace for malabsorption)

Question 50

GORD

Answer 50

INVESTIGATIONS
If no red flags - straight to treatment (clinical/symptomatic diagnosis)

If red flags present (dysphagia, haematemesis, weight loss)
- Endoscopy –> may show oesophagitis or barrett’s oesophagus (stratified squamous to simple columnar)

Oesophageal manometry –> to measure LOS pressure and function

TREATMENT
1st - lifestyle modifications (stop smoking, avoid heavy meals before bed, lose weight, reduce coffee and alcohol)

2nd - PPI (H2 receptor antagonist if CI)

Last resort –>
Surgery - Nissen fundoplication (laparoscopic fundoplication) –> tightens the junction between the esophagus and stomach to prevent acid reflux.

Question 51

Bowel obstruction

Answer 51

INVESTIGATIONS
1st line - X ray (dilated bowel loops)
GS - Abdominal contrast CT scan

ABG including lactate - elevated lactate indicates poor tissue perfusion

TREATMENTS
ABCDE - mainly supportive care
1st LINE (DRIP AND SUCK) -
- Fluid resuscitation
- Antiemetics and analgesia
- Nasogastric decompression + nil by mouth (NG tube is to prevent aspiration of vomit + deliver substances to stomach)
(Give catheter to measure urine output)

For people with closed loop bowel obstruction/evidence of bowel ischemia –> Urgent surgery (mostly laparoscopy)

Question 52

COPD

Answer 52

INVESTIGATIONS
Spirometry - A FEV1/FVC ratio less than 0.7 would indicate airflow obstruction

Diffusing capacity of the lung for carbon monoxide (DLCO) - Low in COPD -< 60% predicted (normal in asthma)

Genetic test for A1AT deficiency

ABG - TYPE 2 RESPIRATORY FAILURE (Hypercapnia, hypoxia and respiratory acidosis)

Chest X-ray –> flattened diaphragm and hyperinflation of the lung - Barrel Chest

TREATMENT
Actual 1st line treatment -
Smoking cessation and preventive vaccines for influenza and pneumococcal (as airway obstruction increases risk of infection)

1st line - Salbutamol (SAB2A)

2nd line - Salbutamol + Salmeterol (LAB2A) + Tiotropium bromide (LAM3A)

If still doesn’t work - add ICS

Question 53

Asthma

Answer 53

INVESTIGATIONS
1st line - Spirometry
An FEV1:FVC ratio <70% indicates obstructive pathology (asthma/COPD)

Bronchodilator reversibility - Improvement in FEV1 post bronchodilator administration (irreversible in COPD) >12% improvement in FEV1

Fractional exhaled nitric oxide - Increased (biomarker for asthma - eosinophilic inflammation?)

Expiratory peak flow >20% (checking diurnal variation)

Sputum microscopy
- Charcot leyden crystals - eosniophil breakdown products
- Curshmann spirals- plugs formed from bronchial epithelial shedding

TREATMENT
Algorithm
1) SAB2A (salbutamol) PRN
2) SAB2A + Inhaled corticosteroids (budesonide)
–> Check compliance and inhaler technique if still does not work. If still not ok –> Step 3
3) SAB2A + inhaled corticosteroids + Leukotriene receptor antagonist (montelukast)
4) SAB2A + inhaled corticosteroids + Leukotriene receptor antagonist + LAB2A (salmeterol)
5) Everything + increase dose of inhaled corticosteroid

Question 54

Tuberculosis

Answer 54

INVESTIGATIONS
1st line - Chest X-ray
Shows lung cavitations
Ghon focus/complex
Appearance of millet seeds distributed across lung firlds - indicated disseminated milliary tuberculosis

GS
Sputum culture (3 separate samples collected) - They are acid fast bacilli that stains bright red on a Ziehl-Neelson stain

Lung biopsy - Caseous granulomas

Two tests to look for an immune response to tuberculosis (positive means has an immune response)

Mantoux skin test - (people with latent TB have a positive tuberculin skin test with an induration >5mm after 72 hours)

Interferon Gamma release assays - If WBC have become sensitised to the bacteria antigen in a previous infection/contact with M.tuberculosis, there will release interferon gamma on further contact.

TB TO SPINE - POTT disease

TREATMENT
RI6PE2 (Ripe) - all to be taken at same time
Rifampicin - 6 months
Isoniazid - 6 months
Pyrazinamide - 2 months
Ethambutol - 2 months

Question 55

Pneumonia

Answer 55

INVESTIGATION
1st line - Chest X-ray –> shows consolidation (accumulation of fluid filled (exudate) alveoli and adjoining ducts)

Sputum culture + stain with Ziehl Neelson - Identify the causative organism

ABG - Type 1 respiratory failure

CURB 65 - Assessses severity of penumonia

TREATMENT
Community acquired pneumonia (mild- CURB is 0-1)
1st line - Oral Amoxicillin
If penicillin allergy – Clarithromycin

CURB=2
Oral Amoxicillin + clarithromycin

Community acquired pneumonia (high severity - CURB 3-5)
IV Co amoxiclav + Clarithromycin

For legionnaires disease - clarithromycin (A NOTIFIABLE DISEASE)

Question 56

Cystic fibrosis

Answer 56

INVESTIGATIONS
GS - Sweat test (measures amount of chloride in the sweat- more chloride than usual) >6ommol/L

Faecal elastase test - decreased due to pancreatic insufficiency

Genetic test for CFTR gene- delta F508 mutation

• Screened for at birth with the newborn bloodspot test (New borns might have high immunoreactive trypsinogen)

TREATMENT
No cure

Conservative –> Chest physiotherapy (clears mucus), exercise (improves resp function), no smoking

Drugs –> Mucolytic drugs (N acetyl cysteine), CREON tablets (+ ADEK fat soluble vitamins for patients with pancreatic insufficiency), bronchodilator (salbutamol)

P.aeruginosa - Ciprofloxacin
S.aureus - Flucloxacillin

Question 57

Bronchiectasis

Answer 57

INVESTIGATIONS
Imaging –> 1st line - Chest X ray - Dilated bronchi with thickened walls

GS –> HIGH RESOLUTION CT scan - SIGNET RING SIGN + tram track sign - dilated bronchioles next to each other. (bronchus markedly dilated compared to the pulmonary artery)

Spirometry –> Obstructive with FEV1:FVC ratio <0.7

Sputum culture –> to check for infection (Most common H.influenzae, P.aeruginosa)

TREATMENT
No treatment
Conservative –> Chest physiotherapy (e.g. postural drainage), stop smoking, vaccines against infections (influenza)

Drugs –> Bronchodilators

During infections
P.aeruginosa –> Ciprofloxacin

Question 58

Pleural effusion

Answer 58

INVESTIGATIONS
1st line + GS Chest X-ray –> blunting of costophrenic angle, fluid in lung fissures and tracheal deviation

To establish the underlying caused via Light’s criteria –> Pleural aspiration (thoracocentesis) –> analyse for protein count, WBC+RBC cell count, pH, glucose, lactate dehydrogenase

TREATMENT
Small effusion
Conservative management –> Treating the chest infection with antibiotics

Large effusion (commonly will be chest drain)
Chest drain

Last resort - Pleurodesis –> surgical fusion of pleural layers to prevent fluid buildup (obliterate pleural space)

Question 59

Pneumothorax

Answer 59

NVESTIGATIONS
1st line + GS Erect Chest X-ray (patient standing upright) –> Visible rim between lung margin and chest wall, absent lung markings, tracheal deviation to the other side, darker area (collapsed lung)

British thoracic society guidelines to measure the size of a pneumothorax

CT thorax –> can help detect small pneumothorax and accurately assess size of the pneumothorax

TREATMENT
Check the document
Pleural aspirate
Chest drain

(tension pneumothorax - needle aspiration 2nd ICS midclav)

Question 60

Pulmonary fibrosis

Answer 60

INVESTIGATIONS
1st line - Spirometry shows airway restriction - FEV1:FVC ratio is >0.7 but FVC is reduced (<0.8 of normal)
Restriction –> difficulty getting air into the lungs (reduced chest expansion) - TLC is reduced

GS - High resolution CT scan of chest = Ground glass/honeycomb appearance with traction bronchiectasis - dilation of bronchioles

TREATMENT
1st line - Pirfenidone (Anti-fibrotic medication)
or
Nintedanib
(Both growth factor inhibitors)
Smoking cessation

Last resort - Lung transplant

Question 61

Sarcoidosis

Answer 61

INVESTIGATIONS
1st line - Chest x-ray - Bilateral hilar lymphadenopathy
High resolution CT

U and E - Hypercalcemia

GS- Histology
Biopsy of affected area - shows non caeseating granulomas (with epithelioid cells)

Urine dipstick - proteinuria (renal)
LFTS - liver
ECG - Heart

• Serum ACE - elevated
• Serum calcium - elevated
• Soluble IL-2 - elevated
• CRP - elevated

MANAGEMENT
Mild - No treatment
First line - Corticosteroids (consider giving bisphosphonates to prevent bone loss)

2nd line - Immunosuppressants - methotrexate, azathioprine

Question 62

Pulmonary hypertension

Answer 62

NVESTIGATIONS
1st - Chest X-ray –> Right ventricular hypertrophy

ECG - P pulmonale - Peaked P waves RVH –? Tall R waves in V1 and 2, Deep S waves in V5 and 6 (RVH) + right atrial enlargement
Echocardiogram - Right ventricular hypertrophy

GS - Right heart catheterisation demonstrating the mean pulmonary arterial pressure is >20mmHg

TREATMENT
Phosphodiesterase 5 inhibitors - Sildenafil
(Also used for treating sexual dysfunction)

Calcium channel blockers

Endothelin receptor antagonists - Bosentan

Question 63

SCLC

Answer 63

INVESTIGATIONS
First line- Chest x-ray, CT
GS - Bronchoscopy AND biopsy

MRI staging via TNM

TREATMENT
More aggressive
If early - Chemotherapy, radiotherapy
If metastasised - Palliative

Question 64

NSCLC

Answer 64

INVESTIGATIONS
1st line imaging - Chest X-ray, CT
GS - Bronchoscopy + biopsy

MRI staging - TNM

TREATMENT
Less aggressive than SCLC

Early - Surgical excision of tumour
Metastasised - Chemotherapy, radiotherapy

Question 65

Mesothelioma

Answer 65

INVESTIGATIONS
1st line - Chest x-ray - pleural thickening with or without effusion
CT scan would provide more detail.

GS - pleural biopsy

TREATMENT
Mostly palliative care

(can try surgery + chemotherapy if found early and operable) - generally resistant to radiotherapy