Revision

Question 1

GBS vs M gravis

Definition

Cause

Sx

Ix

Tx

Answer 1

Question 2

Asthma inhalers step up Tx

Answer 2

Long term Asthma treatment for Adults

• (1) SABA
• (2) SABA + ICS
• (3) SABA + ICS + LTRA
• (4) SABA + ICS + LABA
• (5) SABA + MART (Low)
• (6) SABA + MART (Moderate)
• (7) Specialist
  
  • Muscarinic receptor antagonist
  • Theophylline
  • High dose ICS
  • Oral prednisolone

Question 3

COPD inhaler stepwise Tx

Answer 3

(1) 1 drug = SABA
(2) 2 drugs = SABA + (LABA or LAMA)
(3) 3 drugs = SABA + (LABA/ICS or LABA/LAMA)
(4) 4 drugs = SABA + LABA/LAMA/ICS

Question 4

Post-MI care

Answer 4

• Modify cardiovascular risk factors
• Drugs (ABCD)
  
  • ACE inhibitors
  • Beta blockers
  • Cholesterol control (Statin)
  • Dual antiplatelet
    
    • Aspirin (lifelong) + Ticagrelor (12 months)
• Echo: look for heart failure

Question 5

Treatment for STEMI

Answer 5

Initial –> MONAC

• Morphine + Metaclopramide
• Oxygen (if hypoxic)
• Nitrates (sublingual GTN)
• Aspirin + Clopidogrel
  
  • • PPI

Then

• If access to PCI < 90min
  
  • Angiopathy + PCI (or CABG)
  • • Anticoagulation (Heparin)
  • Continue Aspirin + Clopidogrel
• If no access to PCI within 90 min AND symptom onset < 12 hours
  
  • Thrombolysis (IV Alteplase)
  • Then, PCI

Question 6

Treatment of NSTEMI

Answer 6

Initial –> MONAC

• Morphine + Metaclopramide
• Oxygen (if hypoxic)
• Nitrates (sublingual GTN)
• Aspirin + Clopidogrel
  
  • • PPI
• + Anticoagulation ==> stabilise the clot
  
  • Fondaparinux or LMWH or Unfractionated Heparin

Then –> GRACE score

• High risk ==> Angiography + PCI
• Low risk
  
  • Admit to Ward
  • • Anticoagulation
  • • Elective PCI or CABG

Question 7

Tx of Unstable angina

Answer 7

Tx for Unstable Angina is the same as Post-MI care

• Modify cardiovascular risk factors
• Drugs (ABCD)
  
  • ACE inhibitors
  • Beta blockers
  • Cholesterol control (Statin)
  • Dual antiplatelet
    
    • Aspirin (lifelong) + Ticagrelor (12 months)

Question 8

Tx for stable angina

Answer 8

GTN + CBAS

• Sublingual GTN
• CCB or Beta blocker
  
  • Rate control to improve symptoms
  • Not both!
• Modify risk factors
  
  • Aspirin
  • Statin

Question 9

Tx of heart failure

Answer 9

ALL HF

• Loop diuretics (symptomatic)
• +/- Anti-platelet
• +/- Statin

If EF < 55% (systolic heart failure) ==> ABCD HI DICD

• (1) ABCD
  
  • ACE inhibitor + B blocker (​only start one at a time)
  • If EF < 35% –> +/- Spironolactone
• (2) +/- Hydralazine + Isosorbide dinitrate combination
• (3) If Heart failure + AF –> +/- Digoxin
• (4) If EF < 35% –> +/- ICD or CRT (if LBBB)
• (5) Heart transplant

Question 10

Tx of ischaemic stroke

Answer 10

• Onset < 4.5 hours
  
  • IV Thrombolysis (Alteplase or tPA)
  • +/- Thrombectomy
    
    • if within 6 hours of symptom onset
    • or up to 24 hours if limited infarct core on CT/MRI
  • Aspirin
    
    • ​Started after 24 hours
    • For 14 days
• Onset > 4.5 hours
  
  • Aspirin or Clopidogrel (for 14 days)
• Post-stroke care
  
  • Stop Aspirin after 14 days ==> switch to Lifelong Clopidogrel
    
    • ​Exception: AF and Stroke ==> anticoagulation (Warfarin, Apixaban)
  • + Statin
  • +/- Carotid endartectomy
    
    • If > 50% stenosis
  • • Modify cardiovascular risk factors

Question 11

Tx of haemorrhagic stroke

Answer 11

ABCDE

URGENT CT scan ==> confirm haemorrhagic stroke

Surgical evacuation of haematoma

• +/- Coil or Clip bleeding aneurysm
• +/- Ventricular drainage

Manage ICP

Post-stroke care ==> modify cardiovascular risk factors

Question 12

Tx of TIA

Answer 12

Onset of TIA < 7 days

• URGENT referral to TIA clinic (within 24 hours)
• If symptoms resolved –> Aspirin 300mg

Onset of TIA > 7 days

• Referral to TIA clinic (within 7 days)

Post-TIA care

• Clopidogrel (lifelong)
• • Atorvastatin
• +/- Carotid endartectomy (if >50% occlusion)
• Modify cardiovascular risk factors