Management of common conditions Flashcards
Cluster headache:
Investigations:
Management:
Prophylaxis:
Ix. Most will have neuroimaging - MRI
Mx. Acute = 100% oxygen + SC Triptan
Prophylaxis = Verapamil
Migraine (ACUTE)
Investigations:
Management:
Oral triptan and NSAID or
Oral triptan and paracetamol
For younger people try nasal triptan
If these measures are ineffective give non-oral dose of metoclopramide or prolchlorperazine
Migraine (prophylaxis)
Management:
If treatment averse or resistant:
Propranolol
Topiramate (not to to be given in women of child-bearing age)
or 10 sessions fo acupuncture of 6 weeks
Trigeminal neuralgia
Mx:
Carbamazepine
Failure to respond to therapy = referral to neurology
Meningitis
Mx:
If meningococcal disease is suspected: IM Benzyl penicillin
If no indication for delaying LP (rash, increased ICP, bleeding risk)
IV blood and cultures
IV antibiotics (>50 years = Cefotaxime + Amoxicillin)
consider IV dexamethasone
CT scan not normally indicated
Meningitis bloods
Ix.
Bloods (FBCs, UEs, glucose, clotting profile, lactate, CRP)
Meningitis contact prophylaxis (last 7 days)
Ciprofloxacin or Rifampicin
Not needed if found to be pneumococcal cause
SAH
Investigation:
Management:
Non contrast CT scan
If symptoms occurse < 6 hours ago, NO LP
If > 6 hours, do LP
If confirmed, referral to neurosurgery and neuroradiology (coiling)
SAH complication treatment:
Vasospasm - Nimodipine
Idiopathic increased ICP:
Weight loss
Diuretics - acetozolamide
Intracranial venous thrombosis treatment:
Investigation:
Management:
MRI venography = gold standard
Anti-coagulation - LMWH
Temporal arteritis
Ix.
Mx.
Inflammatory markers (ESR increased), CRP)
Temoral artery biopsy
CK normal
High dose steroids
If visual loss: IV hydrocortisone
Urgent ophthalmology review
Failure to respond to therapy should prompt consideration of alternative diagnosis
What should be co-prescribed with long term steroids
Bone protection - bisphosphonates
Glaucoma (acute - closed angle)
Ix.
Mx.
Ix. Tonometry and gonioscopy (slit lamp)
URGENT referral
Eye drops: direct parasympathomimetic (pilocarpine) plus timolol
IV acetazolamide
Definitive treatment:
Laser iridotomy
Glaucoma (open angle)
Ix.
Mx.
Ix.
Perimetry (visual fields)
Slit lamp (optic nerve damage)
Tonometry
Corneal thickness measurement
Gonioscopy
Mx.
1) prostaglandin analogue (PGA) eyedrop Latanoprost
2) beta-blocker, carbonic anhydrase inhibitor, or sympathomimetic eyedrop
Vestibular neuronitis
Buccal or IM prochlorperazine (rapid relied)
Short course prochlorperazine or antihistamine
Vestibular rehabilitation exercises for chronic Sx.
Labyrinthitis (similar to vestibular neuronitis but with hearing impairment) Mx.
usually self-limiting Prochlorperazine
Meniere’s disease Mx.
ENT assessment required to confirm the diagnosis
acute attacks: buccal or IM prochlorperazine. Admission is sometimes required
Prevention: betahistine and vestibular rehabilitation exercises may be of benefit
Patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved
Usually self resolves in 5-10 years
Vestibular schwannoma
Ix. MRI cerebellopontine angle
Mx. Surgery
Stroke
Ix.
Mx.
Ix.
Mx. Aspirin 300mg if a haemorrhagic stroke has been excluded
Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours),
Stroke - secondary prevention
Clopidogrel
if CI, Aspirin + dipyridamole
Aortic stenosis (symptomatic or valvular gradient >40 mmHg)
Valve replacement
TAVR or balloon valvuloplasty
Parkinson’s diagnosis
Usually clinical but may use SPECT scan to differentiate between that an essential tremor
Epilepsy Ix.
EEG after first seizure
Acute seizure treatment
IF seizures persist for 5-10 minutes - DIAZEPAM (rectally or nasally or sublingually)
Postural (orthostatic hypotension)
Fludrocortisone or midodrine
STEMI mx.
initial triple management for all patients in absence of contraindications
Aspirin
Clopidogrel
Unfractionated heparin (prior to PCI)
STEMI mx.
PCI or thrombolysis (streptokinase)
Which investigation should be completed following thrombolysis in MI
ECG 90 minutes after to check for >50% resolution
Acute chest pain (cardiac related) initial Ix.
glyceryl trinitrate
Aspirin 300mg. NICE do not recommend giving other antiplatelet agents (i.e. Clopidogrel) outside of hospital
O2 - only if <94%
perform an ECG as soon as possible but do not delay transfer to hospital. A normal ECG does not exclude ACS
Acute chest pain (cardiac related) when to refer
current chest pain or chest pain in the last 12 hours with an abnormal ECG: emergency admission
chest pain 12-72 hours ago: refer to hospital the same-day for assessment
chest pain > 72 hours ago: perform full assessment with ECG and troponin measurement before deciding upon further action
Stable angina Ix.
If cannot be excluded on clinical assessment alone
1) CT coronary angio
2) non-invasive functional imaging (looking for reversible myocardial ischaemia - perfusion scan)
3) invasive coronary angiography
Viral pericarditis mx.
Treat underlying cause - most will be viral cause
combination of NSAIDs and COLCHICINE is now generally used for first-line for patients with acute idiopathic or viral pericarditis
Viral pericarditis Ix.
ECG - widespread ST elevation - PR depression is MOST SPECIFIC ECG marker
Transthoracic echocardiograph
Bloods - inflammatory markers, Troponin will be raised in 30% patients
Angina - drug management - All patients should receive ASPIRIN and STATIN
Angina Mx.
Asprin plus statin
GTN
CCB or BB
-> CCB/BB in combo
if ineffective:
a long-acting nitrate
ivabradine
nicorandil
ranolazine
PE ix.
CTPA (WELLS score > 4)
D-dimer (poor specificity)
ECG
Chest X-ray (to exclude other pathology)
PE Ix. IF PE unlikley, (Wells <4)
D-dimer
PE Ix. If wells >4 but CTPA suggests NO DVT
Proximal leg ultrasound
What should be given in the interim if PE likely (>4) and delay in getting CTPA
DOAC
How long should all patients. W/ PE be anti-coagulated for
At least 3 months
If ‘provoked’ i.e pt. has active disease may be stopped
If ‘unprovoked’ treatment likely to be extended to 6 months
PE with haemodynamic instability Mx.
Thrombolysis
Primary pneumothorax tx.
(<2cm)
(>2cm)
if Pt. not short of breath and rim of air <2cm - consider discharge. If breathless, aspirate
If rim of air >2cm or pt. breathless - CHEST DRAIN
Secondary pnemothorax tx.
If the pt. is > 50 years old and the rim of air is > 2cm /patient is short of breath then a CHEST DRAIN should be inserted.
otherwise ASPIRATION should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours
if the pneumothorax is less than 1cm then the BTS guidelines suggest giving OXYGEN and admitting for 24 hours
Persistent/ recurrent pneumothorax tx.
Video-assisted thoracoscopic surgery (VATS) should be considered to allow for mechanical/chemical pleurodesis +/- bullectomy.
Dyspepsia mx. for those who do not meet referral criteria
- Review medications for possible causes of dyspepsia
- Lifestyle advice
- Trial of full-dose proton pump inhibitor for one month OR a ‘test and treat’ approach for H. pylori
Dyspepsia who gets URGENT referral
- All patients who’ve got dysphagia
- All patients who’ve got an upper abdominal mass consistent with stomach cancer
- Patients aged >= 55 years who’ve got weight loss, AND any of the following:
upper abdominal pain
reflux
dyspepsia
Dyspepsia who gets ROUTINE referral
Patients with haematemesis
Patients aged >= 55 years who’ve got:
treatment-resistant dyspepsia or
upper abdominal pain with low haemoglobin levels or
raised platelet count with any of the following: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain
nausea or vomiting with any of the following: weight loss, reflux, dyspepsia, upper abdominal pain
Chronic heart failure tx.
1) ACEi plus BB
2) Spironolactone
3) To be initiated by a specialist - Ivabradine, sacubitril-valsartan, digoxin
Hydralazine (esp. in afro-carribeans)
Acute heart failure mx.
IV loop diuretics
Oxygen
Vasodilators - GTN (given if concomitant MI)
Should regular CHF medications be stopped in acute heart failure
No, with the exception of BB if HR <50
Pts. with respiratory failure from heart failure mx.
CPAP
Pneumonia investigations
Chest x-ray
CRP monitoring is recommend for admitted patients to help determine response to treatment
in intermediate or high-risk patients NICE recommend blood and sputum cultures, pneumococcal and legionella urinary antigen tests
Pneumonia - post infection counselling
1 week - Fever should have resolved
4 weeks - Chest pain and sputum production should have substantially reduced
6 weeks -Cough and breathlessness should have substantially reduced
3 months - Most symptoms should have resolved but fatigue may still be present
6 months - Most people will feel back to normal.
All cases of pneumonia require what at 6 weeks
Repeat CXR
Pulmonary fibrosis Ix. and tx.
Spirometry - restrictive pattern
impaired gas exchange: reduced transfer factor (TLCO)
Imaging: bilateral interstitial shadowing (typically small, irregular, peripheral opacities - ‘ground-glass’ - later progressing to ‘honeycombing’) may be seen on a chest x-ray but
HIGH RESOLUTION CT SCAN is the investigation of choice and required to make a diagnosis of IPF
Prognosis is poor 3-4 years.
Anti-fibrotic medications may buy time
Oxygen and lung transplant required
Asthma management (7)
1) SABA
2) SABA + low dose ICS
3) SABA + low dose ICS + Leukotriene receptor antagonist
4) SABA, ICS, LABA
5) SABA +/- LTRA plus switch LABA/ICS for low dose MART
6) SABA +/- LTRA plus switch LABA/ICS for medium dose MART
7) SABA +/- LTRA plus switch LABA/ICS for high dose MART
Acute asthma steroid dose
All patients should be given 40-50mg of prednisolone orally (PO) daily, which should be continued for at least FIVE DAYS days or until the patient recovers from the attack
Acute asthma attack recovery - when can pts. be discharged (3)
Stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours
inhaler technique checked and recorded
PEF >75% of best or predicted
COPD stable management
SABA or SAMA as required
Asthmatic features?
YES - SABA PRN LABA + ICS
NO - SABA PRN LABA/LAMA
SABA, LABA, LAMA, ICS
COPD general management
smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
annual influenza vaccination
one-off pneumococcal vaccination
pulmonary rehab to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)
Initial investigations for suspected gallstones
Abdominal ultrasound
LFTs
Mx. Biliary colic
If imaging shows gallstones and history compatible then laparoscopic cholecystectomy
mx. Acute cholecystitis
Imaging (USS) and cholecystectomy (ideally within 48 hours of presentation) (2)
Mx. Gallbladder abscess
Imaging with USS +/- CT Scanning
Ideally, surgery although subtotal cholecystectomy may be needed if Calot’s triangle is hostile
In unfit patients, percutaneous drainage may be considered
Mx. Cholangitis
Fluid resuscitation
Broad-spectrum intravenous antibiotics
Correct any coagulopathy
Early ERCP
Mx. Gallstone ileus
Laparotomy and removal of the gallstone from small bowel
Suspected acute appendicitis Ix.
Lipase
Amylase
Early ultrasound (although not required for diagnosis if lipase >3 times normal and characteristic pain)
Contrast enhanced CT scan
Scoring systems for acute pancreatitis
APACHE II
Ranson
Glasgow
Differentiating factor between gastric and duodenal ulcers
Gastric ulcers = WORSE with eating
Duodenal ulcers = relieved by eating
Peptic ulcer disease (uncomplicated) - Investigations
H.pylori test
Peptic ulcer disease - active bleeding Mx.
ABCDE approach
IV PPI
Endoscopy
If this fails, Interventional angiography or surgery
Peptic ulcer disease - perforation Ix.
Erect chest x-ray
Upper GI bleed - 2 scoring systems when is each used:
Glasgow blatchford - helps clinicians decide whether patient patients can be managed as outpatients or not
Rockall - after endoscopy, risk of rebleeding and mortality
Management of NON-VARICEAL bleeding
NO PPIs before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding although
PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy
i
f further bleeding then options include repeat endoscopy, interventional radiology and surgery
Management of VARICEAL bleeding
Terlipressin and prophylactic antibiotics PRIOR to endoscopy
For pts. w/ Oesophageal varices - band ligation
For pts. w/ gastric varices - injections of N-butyl-2-cyanoacrylate
Transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures
Upper GI bleeding Mx.
Resuscitation (platelet transfusion if actively bleeding platelet count of less than 50 x 10*9/litre
FFP to patients who have either a fibrinogen level of less than 1 g/litre,
prothrombin complex concentrate to patients who are taking warfarin and actively bleeding)
Endoscopy
Then splits into variceal vs. non-variceal bleeding treatment
Loin to groin pain initial investigations
Urine dipstick
RFTs
FBCs, CRP
Calcium level
Clotting profile if percutaneous intervention forecasted and Blood cultures if infective cause suspected
Renal colic Mx.
IM diclofenac
Renal colic Ix.
Non-contrast CT KUB (within 14 hours of admission)
Management of renal stones < 5mm
Will likely pass spontaneously
Tx. options for renal stones if not passing spontaneously
Shockwave lithotripsy
Ureteroscopy
Percutaneous nephrolithotomy
Stone burden of less than 2cm in aggregate mx.
Lithotripsy
Stone burden of less than 2cm in pregnant females
Ureteroscopy
Complex renal calculi and staghorn calculi mx.
Percutaneous nephrolithotomy
Diverticulitis ix.
FBC - Increased WCC
CRP raised
CXR - pneumoperitoneum??
AXR - dilated bowel lumen
CT - best modality in suspected abscess
Diverticulitis mx.
Mild - oral antibiotics
Severe or if symptoms are not settling w/in 3 days - IV antibiotics w/ admission
Pyelonephritis Ix.
Pts. should have MSU (mid-stream urine culture) PRIOR to commencing antibiotics
Pyelonephritis Mx.
7-10 days broad spectrum antibiotics
CEPHALOSPORIN OR QUINOLONE
Consider hospital admission
Gastroenteritis incubation periods
1-6 hrs:
12-48 hrs:
48-72 hrs:
> 7 days:
1-6 hrs: Staphylococcus aureus, Bacillus cereus*
12-48 hrs: Salmonella, Escherichia coli
48-72 hrs: Shigella, Campylobacter
> 7 days: Giardiasis, Amoebiasis
Acute diarrhoea: when to send stool sample
Systemically unwell; needs hospital admission and/or antibiotics.
Blood or pus in the stool.
Immunocompromised.
The person has recently received antibiotics, a proton pump inhibitor (PPI) or been in hospital (specific testing for Clostridium difficile should also be requested).
Hx. foreign travel (tests for ova, cysts, and parasites should also be requested) -> amoebae, Giardia, or cryptosporidium are suspected, particularly if diarrhoea is persistent (14 days or more) or the person has travelled to an at-risk area.
There is a need to exclude infectious diarrhoea.
UC gradings: mild, moderate, severe
mild: < 4 stools/day, only a small amount of blood
moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers
UC (proctitis) mx.
Topical Mesalazine
if no response in 4 weeks, add high dose ORAL salicylate
If remission still not achieved, add ORAL or TOPICAL corticosteroid
UC (proctosigmoiditis/left-sided colitis) Mx.
Topical Mesalazine
if no response in 4 weeks, add high dose ORAL salicylate or comination w/ steroid
If remission still not achieved, add ORAL corticosteroid
UC (extensive disease) Mx.
Topical AND ORAL Aminosalicylate
If remission not achieved in 4 weeks - stop topical treatments and go high dose oral aminosalicylate and steroid
UC (severe) disease Mx.
Should be treated in hospital
IV steroids first line
UC - maintaining remission mx.
topical (rectal) aminosalicylate alone (daily or intermittent) or
an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or
an oral aminosalicylate by itself: this may not be effective as the other two options
Left sided UC - Maintenance dose of ORAL aminosalicylate
UC if more than 2 flares/year
Azathioprine or mercaptopurine
Crohns - Mx.
Acute flares:
Maintain remission:
GLUCOCORTICOIDS (oral, topical, IV)
5 - asa drugs are second line to this
Azathioprine (TPMT test prior to start) or mercaptopurine are used first line to maintain remission
Thyroid disease investigations:
serum TSH and T4 levels
Antibody testing ->
Anti-thyroid peroxidase (anti-TPO) antibodies
TSH receptor antibodies
Thyroglobulin antibodies
Other: scintigraphy
Thyrotoxicosis treatments:
propranolol: often used at the time of diagnosis to control thyrotoxic symptoms such as tremor
Carbimazole
Radioiodine treatment
UTI female mx.
3 day course antibiotics (Nitro,trimetho)
Send urine culture if pt. >65 years or has haematuria
should you treat asymptomatic bacteriuria in CATHETERISED pts.
NO, only if symptoms
Asymptomatic bacteriuria
Aurine culture
Nitrofurantoin (should be avoided near term), amoxicillin or cefalexin. This should be a 7-day course
the rationale of treating asymptomatic bacteriuria is the significant risk of progression to acute pyelonephritis
a further urine culture should be sent following completion of treatment as a test of cure
UTI in males Mx.
7 day course of nitrofurantoin/ trimethoprim
