Management steps

Question 1

Asthma

Stable patient

Answer 1

1- Start with inhaled short acting beta agonist (SABA) like Albuterol, Pirbuterol, and Levalbuterol
2- Add a long term control agent to SABA:
* Low dose inhaled corticosteroids (ICS) like Beclomethasone, Budesonide, Fluticasone, Flunisolide, Mometasone and Triamcinolone are the best initial ones
* Cromolyn and nedocromil (mast cell inhibitors)
* Theophylline
* Leukotriene modifiers: Montelukast, Zafirleukast and Zileuton
3- Add a long acting beta agonist (LABA) like Salmeterol or Formoterol to a SABA and ICS or increase the dose of ICS
4- Increase the dose of ICS to maximum in addition to SABA and LABA
5- Omalizumab in addition to the above may be added in those who have an increased IgE level
6- Oral corticosteroids like Prednisone are added when all other therapies are not sufficient to control symptoms
7- All asthma patients should receive Influenza and pneumococcal vaccine

Question 2

Asthma

Acute exacerbation

Answer 2

1- Oxygen combined with inhaled SABA and a bolus of steroids
2- Ipratropium (slower than albuterol)
3- Magnesium (only in severe exacerbations not responsive to several rounds of albuterol while waiting for steroids to take effect (usually 4-6 hrs)
4- Epinephrine rarely used and it is a last resort drug
5- If no response and the patient develops respiratory acidosis then endotracheal intubation and mechanical ventilation

Question 3

Gastrinoma (Zollinger-Ellison syndrome)

Assessing metastasis

Answer 3

1- Abdominal CT or MRI

2- If -ve, then somatostatin receptor scintigraphy (nuclear octreotide scan) combined with endoscopic ultrasound

Question 4

GI bleeding

Answer 4

1- Fluid replacement with high volumes (1-2 L per hour) of saline or Ringer lactate in those with acute, severe bleeding
2- Packed red cells if hematocrit is below 30 in those who are older or suffer from coronary artery disease
3- Fresh frozen plasma if PT or INR is elevated and active bleeding is occuring
4- Platelets if the count is below 50,000 and there is active bleeding
5- Octreotide for variceal bleeding
6- Endoscopy to determine diagnosis and to treat (band varices, cauterize ulcers, inject epinephrine into bleeding gastric vessels)
7- IV PPIs for upper GI bleeding
8- Surgery if fluids, platelets and plasma will not control the bleeding
9- TIPS in those with failed octreotide and banding
10- Propranolol is used to just prevent subsequent episodes of bleeding
11- Antibiotics to prevent spontaneous bacterial peritonitis with ascites