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PACES Exams Management Flashcards

1
Q

Management of Cystic Fibrosis

A

Managed under the CF MDT…

Conservative:
	Chest physiotherapy & education
	Vaccinations
	Enzyme replacement
	Family planning counselling (in males)
Medical:
	ABx prophylaxis: Flucloxacillin
	Mucolytic: rhDNase or Mannitol dry powder
Surgical:
	Lung transplantation
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2
Q

Complications of Cystic Fibrosis

A

 Recurrent & chronic pulmonary infections:
P.aeruginosa, Burkholderia, Haemophilus, Aspergillus.
 Nutritional deficiency (failure to thrive)
 Endocrine: Diabetes Mellitus (insulin dependent), Osteoporosis, Infertility

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3
Q

Chronic Management of COPD

A

Conservative
 Smoking cessation
 Vaccinations
 Pulmonary Rehabilitation (MRC dyspnoea 3+)

Medical
Nebulisers:
 1st: a short acting inhaler (SABA or SAMA)
 2nd: a) switch to long acting (LABA + LAMA)
b) if asthma/reversible features (LABA + ICS)
 3rd: trial of all three (LABA + LAMA + ICS)

If still regular exacerbations/impaired mucus clearance – prophylactic azithromycin

Consider LTOT

Surgical
 Lung volume reduction surgery

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4
Q

Indications for LTOT in COPD

A 
Assessed via multiple ABGs
	PaO2 <7.3 
OR
	PaO2 <8.0 + any of the following:
	Polycythaemia
	Pulmonary HTN
	Peripheral oedema

Note: No LTOT if still smoking

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5
Q

Acute COPD management

A

Conservative
 Titrate oxygen between 88-92% using venturi
 Regular ABG monitoring

Medical
 Infection: qSOFA and Sepsis 6. Abx therapy
 Inflammation:
o SABA – 5mg Salbutamol nebulised
o SAMA – 0.5 micrograms Ipratropium bromide nebulised
o 30mg prednisolone for 5 days + nebulisers
 Ventilation: BiPAP -> intubation

Note: common bacterial cause is Haemophilus influenzae.

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6
Q

What classification system is used for COPD?

A

GOLD classification: Based on FEV1 as a % of predicted value for individual…

20, 30, 20 30 (interval sizes)

Stage 1: >80%
Stage 2: 79-50%
Stage 3: 49-30%
Stage 4: <30%

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7
Q

What are the levels of the MRC dyspnoea scale and what does it describe?

A

Symptomatic severity of dyspnoea (chronically)

1: Sports
2: Steep hill
3: slower
4: stop after 100m
5: stays at home (breathless on undressing etc.)

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8
Q

What classifcation is used to determine severity in heart failure?

A 
NYHA:
I.	No symptoms
II.	Ordinary activity causes dyspnoea
III.	Sub-ordinary causes dyspnoea
IV.	Dyspnoea at rest

Note: this is a functional assessment

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9
Q

What is the difference between a Pacemaker and an ICD?

A

An ICD is an Implanatable cardioverter defibrillator.

ICDs are installed to recognise tachyarrhthymias and shock the patient (without warning).

Pacemakers act as surrogate SANs. They maintain a heartbeat they do not stop it.

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10
Q

What are the types of Pacemaker?

A

Temporary
 Percutaneous (by defibrillator)
 Transvenous (by cardio)
 Epicardial (by cardiothoracics)

Permanent
 Single Chamber (RA or RV)
 Dual Chamber (RA + RV)
 Biventricular (RA + RV + LV)

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11
Q

What are some indications for Pacing?

A

Temporary:
 Bradycardia unresponsive to Atropine
 Post-MI (anterior) complications

Permanent:
 Sick Sinus syndrome*
 AF
 Heart Block (including trifascicular block)

*SAN dysfunction leading to tachy and brady spells

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12
Q

What are some potential complications of Pacemaker insertion?

A

Immediate
 Bleeding
 Pneumothorax/haemothorax

Early
 Infection: endocarditis & sepsis
 Insertion site infection
 VTE

Late
 Wire displacement (pacing failure)
 Device malfunction & Twiddler’s syndrome (fiddling with it)

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13
Q

Management of Pulmonary oedema

A 
Conservative:
	Sit them upright
	15L non rebreathe and titrate <94%
	Fluid balance review
	Monitor Weight & renal function

Medical:
 Diuretics: Furosemide 40mg IV infusion

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14
Q

Management of Chronic Heart failure

A

Heart failure treatment is carried out by the MDT including specialist cardiac failure nurses.

Conservative
 Monitor exercise tolerance.
 Smoking & alcohol cessation
 Cardiac rehabilitation: Exercise and weight loss
 Vaccination: Annual influenza + one off pneumococcal

Medical
 Prognostic benefit: 1st: ACEi + Beta Blocker, 2nd: Spironolactone
 Symptom relief: Diuretics

Surgical
 Heart transplant

Note: 3rd line is specialist: Entresto is used if <35% Ejection Fraction

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15
Q

Management of Acute Asthma

A

Conservative
 Peak flow + ABG
 15L Oxygen via Non-rebreathe mask to maintain >94%

Medical:
 1st: 5mg nebulised Salbutamol + 40mg Prednisolone PO for 5 days
 2nd: 0.5mg nebulised Ipratropium (4 hourly)
 3rd: 2g Mg Sulphate IV (SENIOR)

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16
Q

Diagnostic criteria of asthma in adults

A

 PEF variability >20%
 FEV1 >12% / 200ml
 FeNO > 40 ppb

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17
Q

Grading of acute asthma severity

A

Moderate >50%
Severe >33% Tachyp, Tachyc + cannot complete sentence
Life threatening <33% SpO2 <92%, Silent chest, Hypotensive
Near fatal Raised PaCO2

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18
Q

Chronic Asthma management in Adults

A

Conservative
 Personalised Asthma action plan (check inhaler technique)
 Trigger avoidance (vacuum cleaning, mattress covers)
 Breathing exercise programmes
 Weight loss

Medical
 1st: SABA + low ICS
 2nd: LABA + low ICS
 3rd: LABA + low ICS + LTRA
 4th: Conversion to MART (+/- LTRA)
 5th: MART with Medium ICS dose (+/- LTRA)
 6th: MART with High ICS dose or add LAMA or REFER
Note: from 5th step – can continue with MART as shown or revert back to separate drugs i.e. LABA and ICS inhalers.

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19
Q

Management of pulmonary fibrosis

A 
Conservative:
	Smoking cessation
	LTOT
	Pulmonary rehabilitation
Medical
	None
Surgical
	Lung transplantation
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20
Q

Antibiotic therapy of HAP

A

 <5 days of admission = cefuroxime

 >5 days of admission = Piperacillin with Tazobactam

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21
Q

Causes of AF

A

Reversible
 Intrinsic Cardiac: pericarditis, myocarditis, MI, WPW, cardiac surgery
 Intrinsic Respiratory: PE, pneumonia.
 Extrinsic: Hyperthyroidism, alcohol, caffeine, iatrogenic

Irreversible
 Structural: heart failure, HOCM.
 Valvular: Mitral valve disease
 Ischaemic: IHD

22
Q

Acute management of AF

A

<2 days since onset:
 Rhythm control: DC cardioversion -> Flecainide (not in IHD) -> Amiodarone
>2 days since onset:
 Rate control: Beta blockers (if contra- diltiazem), Amiodarone can be used in paroxysmal AF

Note: catheter ablation +/- pacemaker can also be considered in Slow AF

23
Q

Long term management of AF

A

If reversible, treat cause.
Conservative
 Optimise stroke/IHD risk factors. D&E

Medical
 Anticoagulation: DOAC, Warfarin
 Bisoprolol for rate control
 Flecainide* (if paroxysmal AF, no other co-morbidities)

Surgical (invasive)
 Catheter Ablation
 Pacemaker insertion

24
Q

Management of Parkinson’s

A

PD treatment is principally governed by a consultant neurologist but executed by the MDT.

Conservative
 Patient education
 Care plan discussed early for progression
 Vaccinations
 Physiotherapy: improve walking ability (posture & muscle strength)
 OT: home modification including coloured floor and lasers (to stop freezing)
 SALT referral (swallowing, talking, drooling)
 Diet advice: less protein near medication times, VITAMIN D & CALCIUM
 Mental health monitoring
Medical
 MAO-B inhibitors (selegiline) = Mild
 Dopamine agonists (ropinirole) = Moderate
 Levodopa & carbidopa (madopar) = severe
Surgical
 Deep brain stimulation (severe disease)

25
Q

Complications of Parkinson’s

A

 GI: eating, swallowing, constipation + urinary incontinence
 MSK: Mobility, postural hypotension, falls risk
 Psych: Depression, Dementia, sleep difficulty, sexual dysfunction,

26
Q

How can ischaemic stroke be classified?

A

Oxford-Bamford:
TACS (all 3) or PACS (2 of 3)
 Unilateral weakness/sensory deficit of face, arm and leg
 Homonymous hemianopia
 Higher cerebral dysfunction
POCS (just posterior circulation syndrome – no partial. One of below:)
 CN palsy + contralateral S/M deficit
 Conjugate eye movement disorder (both eyes in same direction)
 Cerebellar dysfunction
 Isolated homonymous hemianopia
LACS (one of:)
 Pure Sensory
 Pure Motor
 Sensory/motor stroke (no other features)
 Ataxic Hemiparesis

27
Q

Acute management of a confirmed Ischaemic stroke

A

Conservative
 Senior clinician involvement
 Urgent Referral to hyper acute stroke unit

Medical
 300mg Aspirin
 If <4.5 hours: Thrombolysis – Alteplase or Streptokinase (BP <185/110)

Surgical
 If <6 hours: Mechanical Thrombectomy* (additionally)
 If <24 hours: Mechanical Thrombectomy*
There is a 1/25 chance of haemorrhagic transformation after thrombolysis.
*Mechanical thrombectomy is used for proximal anterior/posterior circulation strokes. Generally reserved for severe strokes (NIHSS 5+) in patients with a good baseline.

28
Q

Chronic management of an Ischaemic Stroke

A

Conservative
 Transfer to stroke rehabilitation unit
 Physiotherapy
 SALT assessment
 Occupational therapy (to review any needed home changes etc.)
 Consider package of care
 Secondary prevention via risk factor modification…

Medical: secondary prevention
 Aspirin 300mg for 2 weeks
 Clopidogrel monotherapy 75mg for life
 High dose Statin

Surgical
 Carotid endarterectomy

29
Q

What can be used to grade the severity of an acute stroke?

A

NIH Stroke Score. It correlates to prognosis.

30
Q

Risk factors for Ischaemic stroke

A 
Non-modifiable:
	FH
	Ethnic origin (south east Asian & afro-Caribbean)
Modifiable: 
	Atrial fibrillation
	Diabetes (& obesity)
	Hypercholesterolaemia
	Smoking
	Alcohol
31
Q

Risk factors for haemorrhagic stroke

A 
VASC'D:
	Vascular anomaly (Aneurysmal disease, AVM or cavernous angioma)
	Amyloid angiopathy
	Small vessel disease – HYPERTENSION. 
	Coagulopathy
\+ Drugs: cocaine, alcohol, smoking.

Note: Haemorrhagic transformation can also occur in ischaemic strokes

32
Q

Acute management of haemorrhagic stroke

A 
Conservative
	Sit upright as possible (reduce ICP)
	Regular neuro-observations
	Senior clinician involvement
	Immediate referral to Neurosurgery
	Consider anticoagulation reversal if on anticoagulant.

Medical
 Blood pressure: aim for 130 to 140 SBP.

Surgical
 Burr Hole
 Craniotomy
 Specific cause: aneurysm coiling, AVM removal.

33
Q

Acute management of UC flare

A

Conservative
 If Severe, admit.
Medical:
Mild
 1st: Topical Aminosalicylate (proctitis) e.g. sulfasalazine
 2nd: + High dose PO aminosalicylate (if extensive)
Severe
 1st: IV steroids
 2nd: IV ciclosporin
 3rd: Infliximab
Note: Toxic Megacolon can develop – which might need a life-saving Colectomy.

34
Q

Chronic UC management

A

Conservative
 Diet: smaller meals, fluids, supplements + food diary
 Osteoporosis monitoring
 Bowel cancer screening (10 years after diagnosis)
Medical
 Aminosalicylates (topical or PO)
 Azathioprine PO
 Biologics: infliximab
Surgical
 Total colectomy with permanent Ileostomy
 Total colectomy with Ileoanal pouch anastomosis

35
Q

Management of an Acute Crohn’s flare

A

Conservative
 Admit

Medical
 1st: Corticosteroids +/- Azathioprine / methotrexate
 2nd: Budesonide +/- Azathioprine / methotrexate
 3rd: Aminosalyclates +/- Azathioprine / methotrexate
Note: if in bowel obstruction, manage accordingly.

36
Q

Long term management of Crohn’s

A 
Conservative
	Smoking cessation
	Referral to an IBD nurse specialist
	Surveillance colonoscopy for bowel cancer (after 10 years)
	Monitoring for osteoporosis

medical
 1st: azathioprine
 2nd: Methotrexate
 3rd: Biologic drugs

Surgical
 Ileo-caecal resection
 Colectomy (various forms)
 Strictuloplasty

37
Q

Complications of IBD

A

Systemic
 Eyes: Episcleritis, anterior uveitis
 Skin: Erythema nodosum, Pyoderma gangranosum, Apthous ulcers
 Joints: enteropathy associated arthritis, osteoporosis
 Constitutional: weight loss, faltering (in paediatric patients)
Gastro-intestinal
 Nutritional deficiency: B12, folate, iron, vitamin D
 Colorectal Cancer, (PSC)
 Bowel obstruction
 Fistulae
 Strictures
 Anal fissures

38
Q

Management of acute pancreatitis

A 
Conservative
	Fluids (monitor urine output)
	Anti-emetics: consider NBM
	Electrolyte monitoring (hypoglycaemia, hypocalcaemia)
	Critical care outreach
Medical
	Analgesia (opiod)
	Enteral nutrition (NG feeding)
	Chlordiazepoxide & Pabrinex
Invasive
	Cholecystectomy (if due to gallstones)
	ECRP (if due to biliary obstruction)
	Pancreatic necrosectomy* (for infected necrosis)
39
Q

Complications of acute pancreatitis

A

 Local: Pseudocyst*, Abscess, Haemorrhagic pancreatitis

 Systemic: hypovolaemic shock, hypoglycaemia, hypocalcaemia

40
Q

Complications of Chronic pancreatitis

A

 Endocrine failure: T1DM
 Exocrine failure: malabsorption, mineral deficiencies (osteoporosis)
+ Pancreatic pseudocyst (again)

41
Q

How is an ectopic pregnancy managed and what are the indications for each option?

A

Expectant
 Stable + pain free + tubal ectopic <35mm + no FHB + Serum hCG <1000 + will follow up.
 Consider if <1500 hCG
Treatment…
 Repeat serum hCGs on Day, 2, 4, 7 (think: 24/7) after first test
 Education

Medical
 No significant pain + tubal ectopic unruptured >35mm + no FHB + <1500 + will return to follow up
 Consider if 5000 > x < 1500
 Note: must have no confirmed intrauterine pregnancy
Treatment…
 IM Methotrexate
 Repeat serum hCGs (4, 7 + weekly until negative) + FBC & LFTs on day 7.
 Education (no pregnancies for next 3 months)

Surgical (any)
	Significant pain
	>35 mm
	FHB visible
	>5000 serum hCG
Treatment…
	Laparoscopic > open
	1st: Salpingectomy
	2nd: Salpingotomy IF infertility risk factors
	IF RHESUS NEGATIVE: 250IU (no kleihauer)
	Education
	Advise to take urine pregnancy test after 3 weeks
42
Q

Management of Multiple Sclerosis

A

MS treatment is guided by a consultant neurologist and carried out by the MDT.
Conservative
 Smoking cessation
 Patient Education: referral to MS specialist Nurse
 Symptom control: Sleep hygiene, CBT, Intermittent self catheterisation
 PT/OT
 SALT referral
Medical
 Symptom control: Baclofen (anti-spasmodic), amitriptyline, Oxybutynin
 Disease modifying drugs: Beta-interferon (specific criteria)

43
Q

Complications of Multiple Sclerosis

A

 Immobility & fatigue
 Swallowing & Speech difficulties
 Incontinence
 Driving: need to inform DVLA

44
Q

Describe the general management of Osteoarthritis

A 
Conservative
	Weight loss: diet & exercise
	Physiotherapy 
	Occupational therapy
	Walking aids & orthotics
	Adjunctive alternative medicine – if all else fails
Medical
	Analgesia…
I.	Paracetamol + topical NSAIDs
II.	Oral NSAIDs or opioids (codeine)
	Intra-articular steroid injections
	Intra-articular hyaluronic acid injections
Surgical
	Joint washout & debridement
	Corrective Osteotomy
	Arthroplasty
	Arthrodesis
	Amputation (small joints)
45
Q

Complications of Hip/Knee athroplasty

A 
Local…
Immediate
	Intra-operative fracture
	If cement: Cement reaction
	Nerve injury*
Early
	Wound infection
	Joint infection
Late
	Aseptic loosening
	Prosthetic infection & loosening
	Stress fractures
	Dislocation
Systemic….
Immediate
	Anaesthetic complications: tooth damage, malignant hyperthermia, allergic reaction
	Fat embolism syndrome
	Bleeding/anaemia
Early
	PE/DVT
	Sepsis
	Ileus
	Deconditioning
Late
	Leg length discrepancy
46
Q

How is Rheumatoid Arthritis diagnosed?

A 
Using the EULAR criteria:
EULAR criteria >6 points
	Joint involvement number
	Antibodies
	Acute Markers
	Symptoms >6 weeks
47
Q

Describe the management of RhA

A 
Conservative
	Monitoring via DAS 28 (<2.6 is remission) + Osteoporosis risk assessment
	FBC & LFTs monitoring
	PT/OT assessment
	Analgesia: NSAIDs (in early disease)

Medical
 DMARD monotherapy: methotrexate, sulfasalazine, hydroxychloroquine
+ Steroids: intra-articular depots
 DMARD dual therapy
 Biologic agents (if DAS >5.1 despite 2 DMARDs)
Note: Methotrexate should not be taken during illness. Steroids can be used to ‘bridge’ the latent effect of DMARDs when starting therapy.

48
Q

How is Ankylosing Spondylitis diagnosed?

A

New York: 1 feature + Radiographic Sacroilitis
 >3 months back pain
 Limited limber spine movement
 Reduced chest expansion

49
Q

How is Ankylosing spondylitis managed

A

Conservative
 BASDAI & Spinal pain VAS (>4/10 = high disease activity)
 1st: Analgesia (NSAIDs)
 Physiotherapy
Medical
 Axial: TNF alpha antagonists e.g. Infliximab
 Peripheral: DMARDs

50
Q

What are some complications of ankylosing spondylitis?

A 
	Atlanto-axial subluxation
	Apical fibrosis
	Aortic regurgitation
	Achilles Tendonitis
	AV node block
	IgA Nephropathy
	Amyloidosis
	CaudA EquinA

PACES Vivas (4 decks)

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