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Very Old MBChB (see new) > Management > Flashcards

Management Flashcards

1
Q

MRI shows cerebral oedema, what do you do?

A

Osmotherapy using mannitol
Elevate head 30 degree up from bed
Diuretics and surgical decompression if necessary

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2
Q

A patient with cerebral oedema is being put on a ventilator, to what settings will you place the ventilator?

A

Hyperventilate on 100% oxygen
(This is to make the patient hypocapnic, this will cause cerebral vessel vasoconstriction, therefore lowering intercrainial pressure- note a risk of ischemia so 100% O2 counteracts this)

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3
Q

A patient informs you they’ve been diagnosed with sciatica, how do you advise treatment?

A

Encourage walking + stretching, not bed rest. Analgesics (e.g. gabapentin) and TCA (amitriptyline). Physiotherapy, possible discectomy

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4
Q

A patient has back pain, what lifestyle changes can you advise to help?

A

Lose weight, stay active, de-stress, cushioned shoes, heat packs, sleep with pillow between legs, yoga, lumbar supports, swimming, stop smoking, limit lifting, encourage good posture, physiotherapy + OTC analgesics

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5
Q

What is TENS?

A

Transcutaneous electrical nerve stimulation- Stimulates endorphin production so uses gate control theory to block signals going from spine to brain (FOR PAIN)

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6
Q

A 24yo comes for asthma review. She is currently using a salbutamol inhaler 100mcg prn and beclometasone dipropionate inhaler 200mcg bd, although her asthma is not well controlled. What is the next treatment step?

A

1- Add long acting B2 agonist (LABA) eg. Salmeterol
2- If doesn’t work increase steroid dose (400mcg)
3- Add leukotriene receptor antagonist (Montelukast)/ Sustained release theophylline tablet
4- Give steroid tablet

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7
Q

What are the 1st/2nd and 3rd line treatments for BPH?

A

1- Watchful waiting
2- Alpha-1 antagonists e.g. tamsulosin, alfuzosin
3- 5 alpha-reductase inhibitors e.g. finasteride (Block conversion of testosterone to DHT)

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8
Q

What is the first line treatment for CAP and HAP?

A

CAP: Co-amoxiclav
HAP: Piperacillin + Tazobactam

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9
Q

What is the treatment for TB? (4)

A

Rifampicin, Isoniazid, Pyrazinamide,Ethambutol

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10
Q

A 64yoF is in the GP clinic and following knee pain, stiffness and crepitus is diagnosed with OA. What do you advise and what management plan do you put in place?

A

Advise: Weight loss, good footwear, walking aids, possible thermotherapy
Advise exercise (regardless of age, pain, disability, co-morbidities). Exercises and physiotherapy are good
Management 1st line: Paracetamol and topical NSAIDS (not oral NSAIDS)

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11
Q

A patient who had OA of the knee diagnosed around 6months ago is complaining of pain in the knees. He is taking paracetamol and topical NSAIDS. His friend takes ibuprofen for pack pain orally and he wants to know if he can too, as he feels he can’t manage with his current pain level. How do you manage?

A

Put patient on paracetamol and codeine

- Consider NSAIDS only if paracetamol is ineffective

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12
Q

`A 68yoF with OA of the knee comes in because her pain is becoming too bad for her to manage. She is taking paracetamol, codeine and topical ibuprofen but this isn’t helping. What are the next 3 ‘steps on the management ladder’, assuming the preceding step does not provide enough relief?

A

Topical Capsaisin
Inter-articular methylprednisolone injections
Surgical replacement

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13
Q

A 30yoF comes into the GP with drenching night sweats for 6 weeks. They have been stopping her sleeping. She is also very stressed at work. What investigations do you do?

A
  • FBC/ESR: ESR and WCC are often raised in infection. A raised ESR and anaemia may indicate malignant causes, such as lymphoma.
  • FSH/LH: Menopause?
  • A glucose test w(reactive hypoglycaemia) if taken during the sweating episode.
  • TFT: thyrotoxicosis can cause chronic sweating.
  • LFT: may be abnormal in infection or malignancy affecting the liver, or in high alcohol consumption.
  • HIV is easily checked; remember the window period.
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14
Q

A 42yoM presents to the GP with a persistent cough for 3 weeks, yesterday he coughed up some blood. How do you manage?

A

NICE Anyone over 40 with unexplained haemoptysis:

Referral on suspected cancer pathway for 2 week appointment

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15
Q

A 43yoF presents to the GP with a new cough and SOB over the last 4 weeks. She has a 30pk/yr smoking history. How do you manage?

A

NICE states urgent (2wk) CXR performed on anyone over 40 with 2 or more of:
- Cough, fatigue, SOB, chest pain, weight loss, appetite loss
(Or just 1 if smoker/ ever exposed to asbestos)

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16
Q

A 57yoM presents to the GP with what seems to be his 4th chest infection in the last 6months. He also has a swollen supraclavicular lymph node. How do you manage?

A

NICE states urgent (2wk) CXR in anyone over 40 with:

  • Persistent or recurrent chest infection
  • Finger clubbing, supraclavicular lymphadenopathy, thrombocytosis
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17
Q

You are called by a nurse as a patient on your ward is having a seizure, what do you do?

A

Establish if known epileptic
Wait 1-2 mins before action to see if it self resolves, ensure nothing can cause harm and that airway is open
- Prepare to escalate treatment

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18
Q

You are called by a nurse as a patient on your ward has been having a seizure for 4mins, what do you do?

A
  • ABCDE (if A blocked use oropharyngeal or nasopharyngeal tube)
  • Oxygen if required
  • Do BM and glucose if required. IV fluids if needed. FBC/ toxicology screen
  • Lorazepam 2-4mg if needed, can give 2nd dose if no response
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19
Q

You are called by a nurse as a patient on your ward has been having a seizure for 8mins. A BM came back normal and they have had two 4mg doses of lorazepam. What do you do?

A

IV phenytoin upto 50mg/min. Make sure you use a filter and monitor ECG as can cause arrhythmias
- After 20min of seizure always call anesthetics

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20
Q

You are called by a nurse as a patient on your ward has been having a seizure for 12mins. A BM came back normal and they have had two 4mg doses of lorazepam and IV phenytoin, yet is still unresponsive. What do you do?

A

Call anesthetics
- Should always have an anesthetics consult if can’t be brought out of seizures with initial management or if seizure duration >20mins

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21
Q

A patient is admitted by ambulance with an unresolved seizure. Before you arrive he has BM (normal) and has been given lorazepam. When you arrive he smells of alcohol, what additional medication to you give?

A

Thiamine 250mg over 10min

22
Q

As an FY1 you are called in the middle of the night to see an elderly patient with an exacerbation of their COPD. You do an ABG which shows paO2: 10.2kPa, paCO2: 6.8kPa, pH: 7.3, BE: +0.2mmol. They are on 28% oxygen. The nurse wants to know what you want to do with the patients oxygen levels?

A

Move down to 24% O2 (blue venturi mask)

Criteria for NIV is pO2

23
Q

A 16yoM presents in A+E with an acute exacerbation of his asthma. Afer being put on high flow oxygen and being given nebulised salbutamol, his pO2 is 9.1, pCO2 is 6.7 and his pH is 7.25. You note that from a previous blood gas 15mins ago his CO2 has increased (up from 5.8). You briefly consider that this could be due to not enough hypoxic dirve, how to you manage his oxygen levels?

A

Keep high flow O2. Never decrease oxygen in patients with asthma exacerbation’s, hypoxic drive would be a factor if COPD, but not in asthma!
- Call anesthetics and then wait to see if bronchodilators cause an improvement in symptoms

24
Q

A pregnant 26yoF patient presents with non smelling, cheesy discharge from her vagina for 2days. She says she has had fungal infections like this twice before, and doesn’t tolerate the topical clotrimazole or pessaries, so takes oral fluconazole. She asks for some more as she’s going away with her partner next week. What do you do?

A

Oral fluconazole and itraconazole are contra-indicated during pregnancy.
- Treat 7 days with intravaginal clotrimazole (pessaries)

25
Q

A 32yoF presents with an itchy vulva, she says white discharge has been coming out, which isn’t smelly. She’s also noticed soreness and painful intercourse. The symptoms have worsened as she has approached her period, but now she is on her period they feel slightly relieved. MLD+Tx+Advice?

A

Fungal (candida) infection
- Treat clotrimazole pressaries into vagina. If vulval symptoms add topical clotrimazole
Advise: Clean area daily, moisturize with E45 if sore, come back if no improvement in 7-14days

26
Q

A 62yoM with COPD presents to the GP with an increase in his SOB and increased frequency and intensity of his coughing. He is producing more sputum than normal also. In the surgery he is brought in by his wife and you notice he can’t remove is jumper without becoming breathless. How do you manage?

A

Send to hospital with suspected acute exacerbation of COPD
- Nebulised salbutamol 5mg over 4hrs
- Prednisolone 30mg/day for 7days
- AB (Amoxicillin) if purulent sputum
In hospital do FBC/ CXR/ sputum culture/ ECG/ U+E

27
Q

A patient is newly diagnosed with mild COPD. You have done all investigations and lifestyle counselling. What is the first step in their management?

A

SABA (Salbutamol 100micrograms prn)
OR
SAMA (ipratropium prn)

28
Q

A 64yoF comes in with slightly increasing SOB and worsening of her symptoms for about 3 weeks. She has COPD and takes salbutamol when required, however recently that has been 4-5 times per day. How do you manage?

A

Investigate FEV1

  • If over 50% predicted: Add LABA (salmeterol) or LAMA (tiotropium)
  • If under 50% predicted: Add LABA/ICS combo (seratide)
29
Q

A 64yoF comes in with slightly increasing SOB and worsening of her symptoms for about 3 weeks. She has COPD and takes ipratropium when required, however recently that has been 4-5 times per day. Her FEV1 is around 58% of predicted. How do you manage?

A

Add salmeterol (LABA)

  • Do not as LAMA as shouldn’t take LAMA and SAMA together
  • Do not add ICS as FEV1 is over 50%
30
Q

A 64yoF comes in with slightly increasing SOB and worsening of her symptoms for about 3 weeks. She has COPD and takes ipratropium when required, however recently that has been 4-5 times per day. Her FEV1 is around 48% of predicted. How do you manage?

A

Add salmeterol and ICS inhaler corticosteroid

  • Indicated as FEV1 less than 50%
  • Example of combined inhaler could be seretide
31
Q

A 64yoF comes in with slightly increasing SOB and worsening of her symptoms for about 2 weeks. She has COPD and takes salbutamol when required, she also takes seretide BD. Her FEV1 is around 48% of predicted. How do you manage?

A

Increase dose of seretide if possible
- Additionally could add tiotropium bromide
(Already on SABA, LABA and ICS so can only add LAMA)

32
Q

A 64yoF comes in with slightly increasing SOB and worsening of her symptoms for about 4 weeks. She has COPD and increasingly disabled because of the poor symptom control. She takes salbutamol when required, she also takes seretide BD and Spiriva OD. How do you manage?

A

Add oral theophyline/ oral steroid

- Already on SABA, LABA, ICS and LAMA (Seretide is salmeterol and fluticasone, Spiriva is tiotropium)

33
Q

A 7yo girl presents with irritability, fever (temp 39.2) and frequency of urination for 5days. Her urine is foul smelling and O/E she has tenderness in the suprapubic region. Urine dipstick is positive for nitrates and leukocytes. MLD and treatment?

A

UTI

10 day course of trimethoprim

34
Q

A 54yo homeless male presents with fever, cough, weight loss and general malaise for 2months, 2 weeks ago he was started on amoxicillin but this seems to have had no effect. Last week he started coughing up blood. How do you manage? (8 points)

A

Isolate the patient- suspected TB
- Do CXR/ 3x sputum culture/ Sputum Acid Fast Bacilli stain
- Do LFTs and kidney function to prepare for treatment
If TB found then notify and start:
- Isoniazid and Rifampicin for 6months
- Also start on pyrazinamide and ethambutol for 2months

35
Q

A 22yoF presents saying she thinks she has vaginal thrush. She says she’s had it before so used Canesten pessaries and cream brought OTC but that was two weeks ago and symptoms haven’t cleared up. How do you manage?

A

Investigate by sending off swabs and possibly testing pH (vaginal candidasis 4.5)
- Add oral fluconazole (2x150mg 3 days apart), NB this is CI in pregnancy

36
Q

Q) A 51-year-old man with a history of paroxysmal atrial fibrillation presents with palpitations. He has no other history of note and a recent echocardiogram was normal. An ECG confirms fast atrial fibrillation. In the notes you find a recent echocardiogram which shows no evidence of structural heart disease. Which one of the following agents is most likely to cardiovert him into sinus rhythm?
(Sotolol/ procainamide/ flecainide/ disopyramide/ digoxin)

A

Flecainide

37
Q

In AF what is the preferred way to cardiovert a stable patient?

A

Medically (flecainide or amiodarone)

38
Q

What is the most appropriate next step in the following scenario: poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a thiazide diuretic. K+ under 4.5mmol/l?

A

Increase thiazide diuretic dose

- Spironolactone would be added if K+ was over 4.5mmol

39
Q

What is the most appropriate first-line anti-anginal for stable angina in a patient with known heart failure, if there are no contraindications?

A

Atenolol

40
Q

A 64-year-old woman presents to the Emergency Department with a cough, fever, diarrhoea and myalgia. The cough is non-productive and and has been getting gradually worse since she returned from holiday in Spain one week ago. Her husband is concerned because over the past 24 hours she has become more drowsy and febrile. He initially thought she had the ‘flu but her symptoms have got progressively worse. She is normally fit and well but drinks around 20 units of alcohol per week.

On examination pulse is 76/min, blood pressure 104/62 mmHg, oxygen saturations are 94% on room air and temperature is 38.4ºC. Bilateral coarse crackles are heard in the chest. She has hyponatremia. What is the treatment?

A

Legionella

Diagnosis
- Urinary antigen

Management
- Erythromycin

41
Q

What AB do you use to manage atypical pneumonias?

A

Macrolide

Erythromycin

42
Q

A 21 year old gentleman is under the cardiologists for investigation of prolonged QT-syndrome. He presents to your surgery with a 5 day history of cough productive of thick, green sputum, fevers and lethargy. Examination reveals a temperature of 39ºC, oxygen saturations of 96% on air and crackles at the right lung base. Which of the following drugs should be used to treat his condition?

  • Co-amoxiclav
  • Metronidazole
  • Doxycyline
  • Erythromycin
  • Amoxicillin
A

Amoxicllin
- This is a typical pneumonia

Don’t use erythromycin as it can make long QT syndrome worse!

43
Q

A 35-year-old woman has been advised to come and see you by her dentist. Ten days ago she had a tooth extraction but unfortunately bled profusely post-procedure, necessitating transfer to the local maxillofacial unit for suturing. She reports no history of bleeding previously and is otherwise well. What is the most likely diagnosis?

A

Von Willebrands Disease
- Most common bleeding disorder, normally mild and only presents with bleeding after injury, tending to be at the mucus membranes

44
Q

A 31-year-old woman complains of a four week history of retrosternal ‘burning’ pain. The pain is often worse following eating. Her past medical history includes depression and she uses Microgynon (a combined oral contraceptive pill). Clinical examination is unremarkable. MLD?

A

GORD
Both depression and combined oral contraceptive pill use are common and therefore do not necessarily point to one diagnosis in particular. The history is however classical for oesophagitis and hence a diagnosis of gastro-oeophageal reflux disease is likely.

45
Q

A 25-year-old man complains of intermittent central chest pains over the past four weeks. He has no past medical history of note other than a pilonidal abscess operation 9 months ago. The pain is described as ‘heavy’ and often associated with tingling in his lips and fingers. The episodes usually happen at rest and last several minutes. MLD?

A

Anxiety

The peripheral tingling is caused by hyperventilation and hence supports a diagnosis of anxiety.

46
Q

A 44-year-old man presents with central, severe chest pain which started around one hour ago. There is no radiation of the pain or associated shortness-of-breath. He has had some similar fleeting pains over the past two weeks but these settled spontaneously after a few seconds. His basic observations are pulse 84 / min, blood pressure 134 / 82 mmHg and respiratory rate 18 / min. MLD?

A

MI

The location, severity and nature of the pain point towards myocardial ischaemia.

47
Q

A patient has had a mechanical valve replacement, anticoagulation are they started on and what are the respective target INR’s for aortic and mitral valves?

A

Warfarin and aspirin lifelong (if no CI)
Target INR
- Aortic: 2.0-3.0
- Mitral: 2.5-3.5

48
Q

How do you manage K+ >6.5mmol/L ?

A

Severe: Dextrose infusion with insulin (with Calcium gluconate first to protect the heart)

49
Q

How do you manage hypocalcaemia?

A

IV Calcium gluconate

50
Q

How do you manage a mild hyperkalaemia?

A

Nebulised salbutamol

51
Q

How do you treat hyperuricaemia?

A

Allopurinol

or Rasburicase

Very Old MBChB (see new) (3 decks)

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