Therapeutic case scenarios

Question 1

What is CURB-65

Answer 1

Score used to determine severity, prognosis and necessity for hospital admission and subsequent IV Abx, for patients with pneumonia

Question 2

Standard treatment for HPT with angina pectoris

Answer 2

B-blocker +

Calcium channel blocker

Question 3

Standard treatment for HPT with coronary artery disease

Answer 3

B-blocker +
ACE inhibitor
(Use verapamil [calcium channel blocker] if B-blocker contraindicated)

Question 4

Standard treatment for HPT, post myocardial infarction

Answer 4

B-blocker +

ACE inhibitor

Question 5

Standard treatment for HPT in heart failure

Answer 5

ACE inhibitor +
Carvedilol (non-selective B/a1-blocker) +
Spironolactone +
Hydrochlorothiazide or furosemide

Question 6

Standard treatment for HPT with left ventricular hypertrophy

Answer 6

ACE inhibitor

Question 7

Standard treatment for HPT with stroke

Answer 7

Hydrochlorothiazide

Question 8

Standard treatment for HPT with diabetes mellitus type 1 or 2, with/without evidence of microalbuminuria or proteinuria

Answer 8

ACE inhibitor +

Diuretic (added in 60-80% of patients)

Question 9

Standard treatment for HPT with chronic kidney disease

Answer 9

ACE inhibitor +

Diuretic (added in 60-80% of patients)

Question 10

Standard treatment for HPT with isolated systolic hypertension

Answer 10

Hydrochlorothiazide +

Calcium channel blocker

Question 11

Standard treatment for HPT in pregnancy

Answer 11

Alphamethyldopa

Question 12

How to use CURB-65?

Answer 12

1 point each for:
C - Confusion
U - Urea >7 mmol/L
R - Respiratory rate >30/min
B - BP < 90mmHg systolic or < 60mmHg diastolic
65 - Age >65 years

Score 0-1: Home treatment possible
Score 2: Hospital therapy
Score 3+: Severe pneumonia

Question 13

Approach to treating pneumonia with CURB-65

Answer 13

First, always exclude TB
Score 0-2, with no co-morbidities: Penicillin G 2MU 6hrly, followed by amoxicillin 1g PO (send pt home)
Score 0-2, with co-morbidity or >65 y/o: 3rd gen cephalosporin e.g. ceftriaxone IV
Score 3+: Ceftriaxone IV + clarithromycin IV
Pneumonia+penicillin allergy: Moxifloxacin IV

Question 14

Syndromic approach to vaginal discharge

Answer 14

Metronidazole [stat] + {Trichomonas vaginalis}
Cefixime [stat] + {Neisseria gonorrhoea}
Doxycycline [7 days] {Chlamydia trachomatis} (Doxy replaced by Amoxicillin in pregnancy)

Question 15

Approach to vaginal discharge if not sexually active in past 3 months

Answer 15

Metronidazole [stat] +

Clotrimazole [7 days] {antifungal}

Question 16

Approach to male with urethral discharge and/or dysuria

Answer 16

Cefixime [stat] +
Doxycycline [7 days]

If symptoms don’t improve within 7 days - Metronidazole [stat]

Question 17

Approach to patient with genital ulcers

Answer 17

Benzathine benzylpenicillin {Treponema pallidum} +
Erythromycin {Haemophilus ducreyi +
Aciclovir {Herpes simplex virus}

Question 18

Approach to patient with uncomplicated UTI

Answer 18

Quinolone e.g. ciprofloxacin [stat]

Question 19

Approach to patient with complicated UTI

Answer 19

Quinolone e.g. ciprofloxacin [twice daily for 7 days]

Question 20

Approach to UTI in pregnancy and adolescence

Answer 20

Co-amoxiclav [thrice daily for 7 days]

Question 21

Pyelonephritis

Answer 21

Quinolone e.g. ciprofloxacin [7-10 days]

Question 22

Otitis media

Answer 22

Amoxicillin [5 days]

If penicillin-allergic - macrolide

Question 23

Approach to lower abdominal pain

Answer 23

First exclude pregnancy, recent delivery, fever (refer)
If nitrites in urine and no cervical tenderness - treat as UTI
Otherwise:
Ceftriaxone [stat] +
Doxycycline [14 days] +
Metronidazole [14 days]

Question 24

Uncomplicated bacterial sinusitis

Answer 24

Amoxicillin [5 days]