NICE Guidelines JMS Flashcards
fibroadenoma indication for surgery
> 3cm
breast cyst treatment
Aspirate
If blood-stained, do a biopsy or excise
sclerosis adenosis
biopsy + excision
fat necrosis investigation
biopsy
duct papilloma treatment
Microdochectomy
Beast cancer screening programme
anyone aged 47-73 is invited for 3 yearly mammogram
given to younger patients if they have a first degree relative with:
- breast cancer <40
- bilateral breast cancer <50
- male breast cancer
4 indications for wide local excision
small cancer large breast
DCIS <4cm
peripheral tumour
solitary lesion
4 indications for mastectomy
Large cancer small breast
DCIS >4cm
central tumour
multifocal tumour
indications for adjuvant radiotherapy in breast cancer
- mastectomy with >4 lymph nodes involved
- after any wide local excision
treatment for ER+ tumours pre-menopausal & post-menopausal
tamoxifen for 5 years
anastrozole
contraindication for herceptin
History of heart disorders
management of angina
- aspirin, nitrate, statin for everyone
- CCB (no verapamil with heart failure) or beta blocker
- max dose
- CCB and BB (not verapamil and BB so use modified release nifedipine)
- PCI + other things like long acting nitrate, nicorandil (K activator)
monitoring statins
LFTs at baseline, 3 month, 12 month
investigating heart failure
- previous MI –> echo in 2 weeks
- no previous MI –> BNP. if normal, monitor. If elevated, echo in 6 weeks. If high, echo in 3 week.
treating systolic heart failure
ACE or BB (pro or carv)
spironolactone, ARB, hydralazine/nitrate if black
cardiac resynchronisation/digoxin
others (furosemide + vaccines)
hypertension management
ACEi or CCB
add other
add thiazide like (indapamine/chlorthalidone)
add spironolactone (if K >4.5 then add more thiazide)
alpha or BB
Centrally acting antihypertensives (methyldopa, monoxidine, clonidine)
primary prevention statins
20mg use if: - >10% 10 yr risk - most type 1 diabetics - CKD with eGFR <60
secondary prevention statins
80mg
use if:
- underlying IHD, PVD, Cerebrovascular disease
Non ST-elevation ACS
M O N A (aspirin 300, clop 300) heparin 5 days GRACE (>3% 6 month mortality then use tirofiban and PCI in 96 hours)
STEMI
M O N A aspirin 300, ticag 180 B A S H PCI
acute LV failure
oxygen diuretics opiates vasodilators inotropic agents CPAP ultrafiltration mechanical circulatory assistance (VAD, IAC)
CHADSVASC
CHF HTN A >75=2, >65=1 Diabetes Stroke/TIA = 2 V = PVD, MI, IHD Sc = female
0 = no treatment
1 in man = consider
1 in women = no treatment
=>2 = warfarin target INR 2.5 or NOAC
INR target first VTE
recurrent VTE
- 5
3. 5
foods to avoid on warfarin
sprouts, spinach, kale, brocolli
SVT
acute
prophylaxis
unstable –> DC cardio version
Stable
vagal manoeuvres
adenosine 6 12 12
DC cardio version
BB and ablation
HbA1c in diabetics
monitored every 6 months
target of 48mmol/mol (6.5%)
blood glucose targets
4-7
5-7 first thing in morning
insulin
Basal-bolus is first line (levemir and actrapid)
metformin can be used if BMI>25
driving and diabetes
inform if >=2 hypos in 12 months. no need to say if not on something that can induce hypos
T2DM first line treatment and target
metformin + lifestyle
48mmol/mol (6.5%)
when to add and what is T2DM second line treatment and target
if HbA1c >58mmol/mol (7.5%)
add one of any of the others apart from GLP-1 mimetic
53mmol/mol (7%)
third line treatment T2DM
a triple therapy
or insulin medium acting OD or BD (isophane)
or exanatide (GLP1 agonist)
thyrotoxicosis tremor control
propranolol
thyrotoxicosis first line drug
carbimazole
main SE of carbimazole
agranulocytosis
2nd line treatment for thyrotoxicosis
radioiodine treatment
treatment of hypothyroidism
thyroxine
starting dose of thyroxine
50-100micrograms (25 if elderly or IHD)
how often do you measure TFTs after starting or changing dose of thyroxine
8-12 weeks
therapeutic goal of thyroxine
normalisation of TSH
diagnostic criteria of DKA
glucose >11 or known DM
ketones >3 or ++ on urine
pH <7.3
bicarb <15
treatment of DKA
1000ml of saline in first hour (will need 5-8L over 24hrs)
IV insulin and when glucose gets <15 add dextrose
treatment of gastroparesis in diabetes
metoclopromide
BPPV diagnosis
clinical picture + positive Dix hallpike
BPPV treatment
epley
home Brandt-Daroff exercises
betahistine?
menieres acute attack
buccal or IM prochlorperazine
prevention of menieres
betahistine
vestibular rehab
driving and menieres
don’t until controlled
PUD treatment
1st line = PPI + amox + clarithromycin (7day course)
retest for H.pylori 4 weeks later using C13 breath test
2nd line = PPI + BC + met + tetracycline
retest
repeat 2nd line
retest
refer
criteria for emergency upper GI endoscopy
Anaemia Loss of weight Anorexia Recent onset of progressive symptoms Malaena/haematemesis Swallowing difficulty
management of diverticular disease - general
fibre
management of diverticular disease - mild attacks
conservative with antibiotics
Severity classification of diverticulitis and management based on that
Hinchey 1 = paraboloni abscess --> drain 2 = pelvic abscess --> drain 3 = purulent perforation --> Hartmanns or lap washout 4 = faeculent perforation --> Hartmanns
CRC monitoring
carcinoembryonic antigen
screening programme for CRC
60-74 (50-74 in scotland) is invited for faecal occult blood
if positive, get colonoscopy
of these, 5/10 are normal, 4/10 have polyps, 1/10 has cancer
asymptomatic gallstone disease
in gallbladder
in CBD
no treatment
remove as will cause problems
acute cholecystitis
Antibiotics + supportive therapy
resect 1 week later
Upper GI bleeding
Blatchford = bleeding risk stratification Rockall = rebleed
fissure in ano
GTN ointment or diltiazem cream
botulinum toxin
internal spinchterotomy
haemorrhoids
lifestyle fibre and fluids
injection sclerotherapy/band ligation/HALO
rectal cancer
high up
near dentate line
preop radiotherapy + surgery:
anterior resection
abdominoperineal resection of rectum
acute pancreatitis grading
Glasgow PAO2 <8 Aage >55 Neutrophils WBC >15 Calcium Renal function urea Enzymes LDH >600; AST >200 Albumin Sugar >10
3 or more of the above means it is severe
imaging of choice for chronic pancreatitis
CT pancreas with contrast
Intestinal obstruction
Drip and suck
cyclizine or ondansetron can be used
NOT metoclopromide as it is prokinetic
when to start antiepileptics
2 seizures >24 hours apart
1 seizure + >60% risk of another one
epilepsy syndrome in a child
risk of another seizure is unacceptable
generalised tonic clonic
sodium valproate
myoclonic
sodium valproate
focal seizure
carbamazepine
absence seizure
ethosuximide
pregnancy
lamotrigine
parkinsons
motor? levodopa No motor? - non-ergot derived dopamine agonists (bromocriptine, cabergiline, pergolide) - MAO-B (seleginine) - levodopa
2nd line
- COMT inhibitor (entacapone)
drug induced parkinson’s
procyclidine (antimuscarinic)
diagnosing MS
2 episodes in space and time
OR
1 episode that fulfils McDonald criteria
acute MS
methypred
chronic management of MS
1st line = beta interferon
2nd line = choose from:
- glatiramer = immune decoy/suppressant
- natalizumab = a4b1 preventing BBB crossing of WBC
- alemtuzumab = glycoprotein CD52
- fingolimod = sphingosine 1 phosphate stops leaving lymph nodes
MS symptoms relief: residual volume bladder dysfunction
self catheterisation
MS symptoms relief: bladder dysfunction with no residual
anticholinergics oxybutinin
MS symptoms relief: oscilloscopia
gabapentin
spasticity
baclofen or gabapentin
fatigue
CBT or amantadine
stroke diagnosis
ROSIER score >0
- syncope = -1
- seizure = -1
- asymmetrical face/arm/leg = +1 each
- speech/visual field disturbance = +1 each
stroke investigation
CT head
swallowing assessment
ischaemic stroke acute treatment
within 4.5 hours –> alteplase
300mg aspirin stat
CI of thrombolysis
>4.5 hours brain cancer recent stroke seizure with stroke active bleeding pregnancy varices hypertension >200
secondary prevention of stroke
in hospital
at home
intermittent pneumatic calf pump
statin if >3.5
clopidogrel 75mg for life (After 2 weeks) - if CI use aspirin and dipyridamole
BP control
haemoragic stroke treatment
control BP to 100-120
reverse anticoagulation
call neurosurgeons
alzheimers management
triple therapy of anticholinesterases (donepezil, galantamine, rivastigmine)
2nd line = memantine (NMDA antagonist)
TIA (in past week)
300mg aspirin stat
send in to hospital
delerium
haloperidol is first line sedative
status epilepticus
rectal diazepam/IV loraz/buccal midaz
IV loraz
phenytoin
anaesthesia
subarachnoid haemorage
ABCDE + neurosurgery review
After:
- nimodipine CCB (reduces deficits)
- stools softness, antitussives (reduces rebreeds)
acute migraine
triptan
migraine prophylaxis
2 or more over 1 month (60% effective)
1st = propranolol + topiromate 2nd = gabapentin + acupuncture (10 sesh/5-8wks)
menstrual = triptans
renal stones imaging
Initial = USS Best = CTKUB no contrast
medical management of urinary stones
IM/rectal diclofenac
tamsulosin + nifedipine
indication for medical management of stones
<5mm and no obstruction
indication for ECSL
5mm-2cm
indication for percutaneous nephrolithotomy
> 2cm or complex shape (e.g. staghorn)
indication for decompression with stent or percutanoues nephrostomy
hydronephrosis or pyrexia
prevention of stones:
calcium
oxalate
urate
thiazides
cholestyramine
allopurinol/urinary alkalisation (bicarb(
BPH
1st line = tamsulosin
2nd line = finasteride (takes 6 months)
prostate cancer
T1/T2
T3/T4
Metastatic
- brachy, radio, surgery
- hormonal therapy
- only hormonal therapy:
cyproterone acetate (prevents DHT/antiandrogen)
goserelin (GnRH analogue)
degarelix (gnRH antagonist)
CKD management of anaemia
replenish iron stores
give EPO
CKD and HTN
ACEi
when GFR <45, furosemide
AKI diagnostic guidelines
<0.5ml/kg/hr for more than 6 hours
GFR 50% rise in 7 days
rise in creatinine >26 in 48 hours
hyperkalaemia management
1st thing = calcium gluconate
others = insulin+dextrose, salbutamol
to get rid of K = resonium, dialysis
diagnosing asthma
FeNO >40ppb
spirometer FEV1/FVC <70%
reversibility of FEV1 >12%
chronic management of asthma
SABA \+ ICS \+ LTRA \+ LABA \+ increase ICS in a MART \+ increase ICS and add theophylline refer onwards
Move up if using SABA 3x or more a week
COPD diagnosis
FEV1/FVC <70% and symptoms
Management of COPD
SABA or SAMA Add LAMA or LABA (if FEV1 <50%, add ICS to LABA) Add all three theophylline mucolytics
indications for home use oxygen
ankle oedema two ABGs with pO2 <7.3 FEV1 <30% cyanosis polycythaemia raised JVP Sats of less than 92% on room air
investigating legionella
psittacosis
urinary antigen
sputum PCR
Assessment of pneumonia
Confusion <8/10 AMTS Urea >7 RR >30 BP <90/60 <65
0-1 = home with 5 days of amox (3%) 2-3 = hospital with amox/clari 7 days (3-15%) 4-5 = ITU with tazocin (15%)
recovery timeline for pneumonia
1 week = fever
4 weeks = chest pain + sputum
6 weeks = cough + breathlessness
6 months = fatigue
acute asthma management
Oxygen Salbutamol back to back through oxygen neb Hydrocortisone/ pred for at least 5 days Ipratropium bromide just once Magnesium IV salbutamol Escalate
acute asthma severity
moderate = 50-75% peak flow
acute severe = 33-50% Peak flow, can’t complete sentences. RR>25, pulse >110.
life-threatening = <33% peak flow, <92% sats, cyanosis, silent chest, normal CO2
COPD exacerbation when to give Abx
Anthsonian criteria. give Abx when 2 of:
- increased sptutum
- increased purulence
- increased breathlessness
target sats for COPD
88-92
if proven to not be CO2 retainer, 94-98
indications for BIPAP with COPD
acidosis <7.35
type 2 respiratory failure
unresponsive to CPAP with cardiogenic pulmonary oedema
weaning from tracheal intubation
pneumothorax management
primary
<2cm –> review in clinic
>2cm or breathless –> aspirate, wait, clinic or drain
secondary
1-2cm aspirate and then maybe drain
>2cm drain and admit
Wells score
diagnosing PE
DVT = 3 points PE most likely = 3 points HR>100 = 1.5 points surgery <3wks, immobilisation>3days = 1.5 points previous DVT/PE = 1.5 points haemolytic = 1 point malignancy = 1 point
For PE
If <4 –> D-dimer and PERC
if >4 –> CTPA
For DVT
>=1 you doppler the leg
0 then you do D-dimer
If pregnant, allergic or CKD, V/Q scan instead of CTPA
treating PE
massive with shock –> thombolysis
no shock: 5 days of LMWH start warfarin within 24 hours 3 months if provoked, 6 months if unprovoked INR 2.5 if first, 3.5 if recurrent
pregnant or cancer –> LMWH for 6 months
post thrombotic syndrome treatment
compression stocking and elevation
no prophylaxis anymore
treatment for peripheral artery disease
exercise training
80mg statin
clopidogreal (better than aspirin)
other: vasodilator, angioplasty, stent, bypass
AAA surgery indications
> 5.5cm
1cm/year growth
pain
EVAR is surgery of choice
venous ulcers treatment
4 layer compression banding
if fail to heal after 12 weeks, skin graft
screening for osteoporosis
women >65, men >75 use FRAX
if low risk –> nothing
if high risk –> treat (alendronate and vita/Ca
if medium –> DEXA and recalculate
rate control
atenolol
verapamil/diltiazem
digoxin (unless HF then first line)
rhythm control
DC cardio version if there isn’t a reason they’re in AF
sotalol
amiodarone
flecanaide (is paroxysmal and normal heart)
complete heart block
temporary pacing until surgery puts pacemaker in
atropine can be used until then.
0.5mg up to 6 times up to 3mg
