Medicine (5)

Question 1

Management of status epilepticus

Answer 1

1. Rectal diazepam / buccal midazolam
2. IV lorazepam
3. IV phenytoin (phenobarbital if already on regular phenytoin)
4. Anaesthesia (propofol / thiopental sodium)

Question 2

Treatment of generalised tonic-clonic seizures

Answer 2

Generalised tonic-clonic seizures

• sodium valproate
• second line: lamotrigine, carbamazepine

Question 3

Treatment of absence seizures

Answer 3

Absence seizures (Petit mal)

• sodium valproate or ethosuximide

*sodium valproate particularly effective if co-existent tonic-clonic seizures in primary generalised epilepsy

DO NOT use carbamazepine → it may exaggerate absence seizures

Question 4

Treatment of myoclonic seiures

Answer 4

Myoclonic seizures

• sodium valproate
• second line: clonazepam, lamotrigine

DO NOT USE carbamazepine → it may exacerbate myoclonic seizures

Question 5

Treatment of focal seizures

Answer 5

Focal seizures

• carbamazepine or lamotrigine
• second line: levetiracetam, oxcarbazepine or sodium valproate

Question 6

SEs of sodium valproate

Answer 6

Question 7

SEs of carbamazepine

Answer 7

Question 8

seizure vs syncope

Answer 8

Question 9

A 43 year old male with known epilepsy is being withdrawn from his

AED under the care of his neurologist. During this period, he suffers a tonic-clonic seizure.

What does the DVLA state in this case?

Answer 9

• Cannot drive for at least 6 months + goes back on previous AED
• He can start driving once he goes back to his previous AED – has to be seizure-free for 6 months after going back to his previous AED

Question 10

DVLA and epilepsy guidance

Answer 10

Question 11

The differential diagnosis for ‘tired all the time’

Answer 11

Question 12

Red flags for an adult with ‘tiredness’

Answer 12

• unintentional weight loss (5% of body weight in 6–12 months)
• Lymphadenopathy suggestive of malignancy
• Other symptoms and signs of malignancy, such as haemoptysis, dysphagia, rectal bleeding, breast lump, or postmenopausal bleeding
• Localizing/focal neurological signs

Question 13

Blood tests for patient presenting with ‘tiredness’

Answer 13

• Full blood count
• Erythrocyte sedimentation rate or C-reactive protein
• Renal and liver function tests
• Thyroid stimulating hormone
• Random blood glucose or HbA1c
• IgA tissue transglutaminase (for coeliac disease)

Question 14

Type 1 vs Type 2 Diabetes Mellitus

Answer 14

Question 15

Microvascular and macrovascular complications of diabetes

Answer 15

Question 16

What to look for an examination of a diabetic patient?

Answer 16

Question 17

What to look/examine for on diabetic foot examination?

Answer 17

Question 18

Values diagnostic of diabetes mellitus

Answer 18

Question 19

Values of pre-diabetes and diabetes glucose

Answer 19

Question 20

Conservative management of T2DM

Answer 20

• Lifestyle management (diet, exercise, smoking cessation, reduce alcohol consumption)
• Education about the condition
• Offer structured group education programme (DESMOND: Diabetes Education for Self-Management for Ongoing and Newly Diagnosed)
• Monitor for complications (inform about annual screening for retinopathy, foot problems, nephropathy and cardiovascular risk factors)

Question 21

Medical management of T2DM (other than hypoglycaemic agents)

Answer 21

• Lipid modification – ither atorvastatin 20mg for primary prevention if QRISK2 >10% or >85 or atorvastatin 80mg for secondary prevention of cardiovascular disease
• Blood Pressure – ACE inhibitor is first line for all patients with diabetes diagnosed with hypertension (if African/Caribbean – prescribe concurrent diuretic or calcium channel blocker)

Question 22

Steps in hypoglycaemic agents selection for T2DM

Answer 22

Question 23

Metformin

• class
• MoA
• SEs

Answer 23

(Biguanide)

Metformin

MoA: Reduces the rate of gluconeogenesis and

increases insulin sensitivity

*Does not affect insulin secretion or cause

hypoglycaemia or predispose to weight

gain

Side effects: Diarrhoea

Question 24

Gliclazide

• class
• MoA
• SEs

Answer 24

(Sulfonylureas)

Gliclazide, Tolbutamide, Glibenclamide

MoA: Act on beta cells to promote insulin

secretion in response to glucose and other secretagogues

*Ineffective in patients with no remaining

beta cell function

Side effects: Promote weight gain, risk of

hypoglycaemia

Question 25

**Glitazones** - name, class - MoA - SEs

Answer 25

***Thiazolidinediones*** Glitazones (piaglitazone) **MoA:** * Reduce insulin resistance by interaction with PPAR-y receptor * They reduce hepatic glucose production and enhance peripheral glucose uptake **SEs:** Pioglitazone is only remaining agent but has adverse effects: fluid retention, heart failure and bladder cancer

Question 26

**Gliptins** - class, names - MoA - SEs

Answer 26

**Dipeptidyl peptidase-4 inhibitors (DPP4)** saxagliptin, sitagliptin **MoA:** Enhance the incretin effect (oral glucose response \> IV glucose due to GLP-1 and GIP) **Side effects:** nausea, pancreatitis NICE advise continuing DPP-4 inhibitor only if there is a reduction of \> 0.5 percentage points in HbA1c in 6 months

Question 27

***Exenatide*** - class - MoA - justification for continuous taking

Answer 27

***GLP-1 agonists*** (exanatide, liraglutide) MoA: * Injectable long-acting analogues of GLP-1 * They promote insulin release, inhibit glucagon release * reduce appetite * delay gastric emptying \*Major advantage is glucose control with weight reduction \* Given by subcutaneous injection before meals NICE advise patients to have achieved a 1% reduction in HbA1c and 3% weight loss after 6 months to justify the ongoing prescription of GLP-1 mimetics

Question 28

**Gliflozins** - names - MoA - SEs

Answer 28

***Gliflozins*** (dapagliflozin, canagliflozin) **MoA:** SGLT2 inhibitors (sodium/glucose transporters) which prevent reabsorption of glucose by the kidney tubules **Side effects:** urinary tract infections, weight loss

Question 29

***Insulin*** - MoA - SEs

Answer 29

**Insulin** **MoA:** * Promotes glucose uptake into tissues * Stimulates glycogen, fatty acid and protein synthesis * Inhibits gluconeogenesis **Side effects:** hypoglycaemia, weight gain

Question 30

Features of **Wernicke's encephalopathy**

Answer 30

**CAN OPEN** * *C**onfusion * *A**taxia * *N**ystagmus * *O**phthamoplegia * *PE**ripheral * *N**europathy