Management Flashcards
Management of asymptomatic PAD
My management would include non-pharmaceutical and pharmaceutical management targeting modifiable risk factor reduction.
Risk factor reduction- smoking, DM, start Clopidogrel, start a statin
investigation of other vascular beds= AAA once off
Management of intermittent claudication
My management for this patient would be both non-pharmacological and pharmacological with emphasis on modifiable risk factor reduction and intervention tailored to lifestyle limitations.
all patients: Reduction of risk factors: smoking, DM, start an antiplatelet, statin,
check the vascular beds: AAA
Patients IC greater than 100: rehabilitation program- supervised exercise
and education about foot care
Patients life style impact: imaging of duplex US and angiography
consider surgical intervention: taking into account patient preference, risk benefit (angioplasty and bypasses limited lifespan about a year). only 10% develop CLI.
Management of critical limb ischemia
My management of this patient would involve non-pharmacological and pharmacological treatment with emphasis on risk factor reduction and revascularisation.
RF: smoking, diabetic control, start a statin, checking the other vascular beds: AAA
imaging: arterial tree using CT angiogram and duplex scan if revascularisation is appropriate. (for use in elderly with severe comorbities- primary amputation no imaging needed)
Discuss your revascularisation options in this patient with chronic limb ischemia?
The three main options are angioplasty, endarterectomy, and arterial bypass.
Angioplasty- is the procedure where a wire is inserted peripherally from the femoral artery to the site of the lesion (illiac and superficial femoral artery lesions) Then the balloon (using the wire guidance) is inflated at the site of the lesion. Stenting can be considered in illiac but not SFA.
Tight blockages of the common femoral- endarectomy while long occlusions and multi-level stenosis can be treated by bypass.
So as you mentioned the pulse is irregularly irregular. What is the management of atrial fibrillation?
My management of atrial fibrillation can be divided into general treatment which includes investigation of underlying precipitants and management of those, specific treatment which can be subdivided into rate and rhythm control and ongoing management.
My first consideration would be red flags: HF, hypotension, a decreasing GCS, and chest pain. This would indicate that the patient is heamodynamically unstable.- senior help. RESUS ATLS guidelines. shock.
conservative: treatment of the underlying cause. Investigations: ECG,
FBC (WBC), UE, TFT, alcohol, Mg, Ca, plus or minus D dimer (PE), troponin *chest pain and suggestive ECG. CXR, ECHO and CTCA (if CAD)
Rate and rhythm control
So the patient with A fib is heamodynamically unstable as you before mentioned… out line your steps of management.
- ATLS guidelines- Airway high flow non-rebreather mask.
Breathing (lowering GCS less than 8 calling for anaesthetic review)
Circulation: wide bore 13G needle IV access.
First shock, then DC cardioversion, then IV amiodarone
Important to keep in mind that chronic A fib is unlikely to cause shock, so be vigilant in looking for an alternative cause of shock like sepsis.
So the patient is heamodynamically stable you mentioned the options of rate or rhythm control which do you want and why?
if the rate is less than 110 bpm
Beta blockers or non-dihydropyridine calcium channel blockers
heart failure use digoxin as well
So the patient is young and has new onset A Fibrilliation what is your management?
rhythm control (not a great choice in elderly, established AF, LA dilatation, and mitral valve disease.
This can be chemical or electrical cardioversion
chemical (flecainide if no structural heart disease or amiodarone- if structure heart disease)
second line is AV ablation
Should this patient be put on anticoagulation?
almost all patient’s with A fib need lifelong anticoagulation including 4 weeks prior to DC cardioversion (unless negative TOE)
and 4 weeks afterwards (atrial stunning). To determine the risk /benefit of starting anticoagulation the HASBLED score (risk) and CHA2DS2VASc score. Warfarin, NOACS (apixaban, dabigatran, edoxaban, and rivero alban) or dalteparin
Outline your management for supraventricular tachycardia?
My management would include acute and chronic treatement using both non-pharmacological and pharmacological approaches. Noting any red flag signs of heart failure, hypotension, decreased GCS, and chest pain, which would need immediate emergency management.
What is your acute treatment for SVT
Presence of red flags: ATLS protocol- ABCs calling for senior help
Management of rheumatoid arthritis
Management of this patient can be divided into pharmacological and non-pharmacological with the latter involving a multidisciplinary team.
Pharmacological: induce remission and symptom control
non-pharmacological: physiotherapy, OT, podiatry, psychological interventions, rheumatology, and integration with primary care.
Surgery= refractory to medical treatment, stress fracture, worsening function, imminent actual tendon rupture.
You mentioned pharmacological treatment for RA can you elaborate?
induce remission:
Disease modifying anti-rheumatic drugs
Methotrexate, Leflunomide, and sulfasalazine
bridging therapy with glucocorticoids (DMARDS takes three months)
failure of two DMARDS (MTX)- biological therapy- TNF inhibitors Etanercept or inflixamab (do chest X-ray before and also interferon test)
symptom control= NSAIDS with PPI
Management of Psoriasis
Management of this patient can be divided into pharmacological and non-pharmacological approaches.
non-pharmacological: removal/ avoidance of trigger infection (strep), trauma, drugs (lithium, Beta blockers, anti-microbial, NSAIDS, stress
pharmacological:
topical
systemic
phototherapy
What are the topical treatments for psoriasis?
emollients- relieve dryness, fissures, irritation E45 vitamin D analogues= calcipotriol topical steriods- not for face tar-steriod- descale calcineurin inhibitors- tacrolimus
When would you give systemic therapy in psoriasis?
large surface area pustular psoriasis erythrodermic psoriasis psoriatic arthropathy failure of topical agents first line is methotrexate if rapid response required ciclosporin
What is the management of Giant cell arthritis
Management of this patient would involve urgent systemic steroid treatment to preserve vision and induction of remission of the condition.
urgent management:
prednisolone PO bone protection and PPI
gradual dose reduction once sx resolved
treat relapses similarly
long term management *if relapsing disease
methotrexate and toculizumab anti- IL6
Management of gout
Management of this patient can be divided into pharmacological and non-pharmacological, with the avoidance of triggers being of particular importance.
Pharmacological can be subdivided into acute and chronic:
acute: symptom relief- NSAIDS indomethacin plus PPI
colchicine (poor compliance due to GI side-effects)
corticosteroids (last resort)
chronic: (2nd time) bridging therapy with NSAID or colchicine (3 months) and do a 24 hour urine uric acid test
little uric acid—{ uricosuric agents- probenecid) greater than 800mg secreted (allopurinol xanthine oxidase inhibitor)
avoid drugs: thiazides, loop diuretics
certain foods: seafood, red meat
Management of scleroderma
The management of scleroderma is dependent on it’s severity. It involves the management of the symptoms, which differ depending on organ involvement. This can be divided into pharmacological and non-pharmacological.
no cure—- sx
Raynaud’s= vasodilators CCB, endothelin receptor antagonist
digital ulcers- phosphodiesterase inhibitors- sildenafil
ILD- cyclophosphamide, azathioprine, steriods
pulmonary HTN- endothelin receptor antagonists, sildenafil
GORD- antacids
malnutrition SBO- tetracycline
kidney involvement- ACE inh, ARBs
non pharm- PT, OT, rheumatologist, depression screening, support, integration into primary care
Management of Lupus
Management of this patient would involve pharamacological and non-pharmacological treatment. Treatment depends on disease severity and organ involvement.
Pharm-
flares- * mild/moderate/severe
for maintenance
mild flare SLE
hydrochloroquine, low dose steriods, skin flare topical steriods
moderate flare of SLE
organ involvement steriods, DMARDS, mycophenolate may be needed.
severe life threatening SLE
high dose steriods
mycophenolate
rituximab
For SLE maintenance
NSAIDS
steriod sparing agents- azathioprine, MTX
belimumab- add on therapy in antibody and disease where disease activity is high
What are the non- pharmacological management of SLE?
general: sun block high SPF cover skin when in sun MDT physiotherapy rheumatology specialities- dermatology, cardiology, respiratory screen for depression, support integration into primary care
Management of osteoarthritis
management fo OA can be divided into pharmacological and non-pharmacological and also surgical in selected cases.
non-pharm avoid aggrevating factors but remain active
weight loss
foot wear physio
OT
pharm- topical- NSAIDS capsaicin,
oral- paracetamol, NSAIDS
injection- intraarticular or periarticular corticosteroids
What is the surgical management of OA
indications- uncontrolled pain, progressive immobility, functional impairment surgical procedures- washout and debridement joint replacement arthrodesis- fuse joint osteotomy- realign joint
Management of Ank spond
Management of ankylosing spondylitis involves both pharmacological and non-pharmacological approaches. non-pharm patient education assess disease severity- BATH index avoidance of aggrevating activities PT, OT Pharmacological pain relief (nsaids, opioids if severe) sulfasalazine - peripheral involvement anti- TNF alpha infliximab and etanercept
What is the Bath index
6 questions
fatigue, morning stiffness duration, severity
spinal pain, arthralgia, enthesitis (inflammation at the site where the tendon meets the bone- achilles)
Management of interstitial fibrosis
Management of this patient once confirmed to be interstitial pulmonary fibrosis can be divided into non-pharmacological and pharmacological management and potentially surgical.
non-pharm- using GAP model (gender, age, physiology- FVC and DLCO)
RF = smoking, vaccination
pulmonary rehab and education, assistive breathing techniques,
incorporation into a MDT PT, OT, respiratory nurse specialist, SW and resp physician
Pharm- anti-reflux microaspiration of gastric and oesophageal contents (omeprazole)
avoid- sildenafil, warfarin, azathioprine, co-trimoxazole
nintedanib- receptor blocker for multiple tyrosine kinases that mediate elaboration of fibrogenic growth
perfinidone- anti-fibrotic agent (monitor LFTs for both)
LTOT
palliative care
