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1
Q

ASTHMA
What is the long-term guideline mediation regime for asthma?

A
  1. low dose ICS/formoterol combination inhaler (AIR therapy) or if very symptomatic start low dose MART
  2. low dose MART
  3. moderate dose MART
  4. check FeNO + eosinophil level (if either is raised, refer to specialist).
    - If neither are raised = LTRA or LAMA in addition to moderate dose MART
    - if still not controlled, stop LTRA or LAMA and try other drug option (LTRA/LAMA)
  5. refer to specialist
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2
Q

COPD
What are the treatments for COPD?

A
  1. SABA or SAMA as required

if NO asthmatic features:
2. SABA as required, LABA + LAMA regularly

if asthmatic features:
2. SABA or SAMA as required, LABA + ICS regularly

  1. SABA as required, LABA + LAMA + ICS regularly
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3
Q

PHARMACOLOGY
give 2 examples of LABAs

A
  • salmeterol

- formoterol (full agonist)

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4
Q

PHARMACOLOGY
give an example of a SAMA

A

ipratropium

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5
Q

PHARMACOLOGY
give an example of a LAMA

A

tiotropium

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6
Q

PNEUMOTHORAX
what is the management for a secondary spontaneous pneumothorax?

A

SMALL (1-2cm)
- aspirate with 16-18G needle
- admit with high flow oxygen

LARGE (>2cm) or breathless
- insert chest drain
- admit with high flow oxygen

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7
Q

RESPIRATORY FAILURE
what are the causes of type 1 respiratory failure?

A
  • pneumonia
  • heart failure
  • asthma
  • PE
  • high altitude pulmonary oedema
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8
Q

RESPIRATORY FAILURE
what are the causes of type 2 respiratory failure?

A
  • opiate toxicity
  • iatrogenic
  • neuromuscular disease (MND, GBS)
  • reduced chest wall compliance (Obesity)
  • increased airway resistance (COPD)
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9
Q

PLEURAL EFFUSION
what is the light’s criteria?

A

exudate is likely if:
- pleural fluid to serum protein ratio >0.5
- pleural fluid LDH to serum LDH ratio >0.6
- pleural fluid LDH >2/3 upper limits of normal serum LDH

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10
Q

PLEURAL EFFUSION
what does low glucose in pleural fluid indicate?

A
  • rheumatoid arthritis
  • tuberculosis
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11
Q

PLEURAL EFFUSION
what does heavy blood staining in pleural fluid indicate?

A
  • mesothelioma
  • PE
  • tuberculosis
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12
Q

PLEURAL EFFUSION
what are the indications of a pleural infection?

A
  • purulent or turbid/cloudy fluid
  • clear fluid but pH <7.2 (chest drain must be inserted)
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13
Q

PULMONARY FIBROSIS
what are the causes of upper lobe pulmonary fibrosis?

A

SCART
- sarcoidosis
- coal miners pneumoconiosis
- ankylosing spondylitis
- radiation
- TB

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14
Q

PULMONARY FIBROSIS
what are the causes of lower lobe pulmonary fibrosis?

A

RASIO
- Rheumatoid
- Asbestosis
- Scleroderma
- Idiopathic pulmonary fibrosis (most common)
- other

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15
Q

ASTHMA
what are the investigations for asthma in adults?

A

1st line = FeNO or eosinophil levels
2nd line = bronchodilator reversibility with spirometry
3rd line = peak expiratory flow variability
4th line = skin prick or total IgE

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16
Q

ASTHMA
what are the investigations for asthma in children aged 5-16?

A

1st line = FeNO (asthma = >35)
2nd line = bronchodilator reversibility with spirometry
3rd line = peak expiratory flow variability
4th line = skin prick or total IgE

if still in doubt = bronchial challenge test

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17
Q

ASTHMA
what are the 3 drugs and their doses that should be immediately administered in an acute asthma exacerbation?

A
  • oxygen - 15L via non-rebreather
  • salbutamol nebuliser 2.5-5mg
  • IV hydrocortisone 20mg or 40-50mg oral prednisolone
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18
Q

LUNG CANCER
what paraneoplastic features are associated with small cell lung cancer?

A
  • ADH
  • ACTH (cushing’s)
  • Lambert Eaton syndrome
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19
Q

LUNG CANCER
what are the paraneoplastic features of squamous cell lung cancer?

A
  • parathyroid hormone-related protein (PTH-rp)
  • clubbing
  • hypertrophic pulmonary osteoarthropathy (HPOA)
  • hyperthyroidism
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20
Q

LUNG CANCER
what are the paraneoplastic features of adenocarcinoma lung cancer?

A
  • gynaecomastia
  • hypertrophic pulmonary osteoarthropathy (HPOA)
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21
Q

COPD
how is a mild exacerbation of COPD managed?

A
  • increase bronchodilator use + consider nebuliser
  • 30mg oral prednisolone for 5 days
  • only give antibiotics if sputum is purulent or signs of infection
  • 1st line abx = amoxicillin, clarithromycin or doxycycline
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22
Q

ACS
Describe the initial management of ACS

A
  • Analgesia - morphine + sublingual GTN
  • Oxygen (if SpO2 > 94%)
  • dual antiplatelets
    - ALL patients = aspirin 300mg
    - if PCI = prasugrel or clopidogrel
    - if fibrinolysis = ticagrelor or clopidogrel

MONA

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23
Q

ACS
Describe the secondary prevention therapy for people after having a STEMI

A
  • lifestyle changes
  • manage CVD risks
  • thrombolysis = 12 months aspirin 75mg + ticagrelor
  • PCI = lifelong aspirin + 12 months ticagrelor/prasugrel
  • ACEi
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24
Q

DVT
What investigations might be done in order to diagnose a DVT?

A
  1. WELLS score

if WELLS >2 DVT likely
- duplex ultrasound of leg within 4 hours (if not within 4 hrs, offer anticoagulation)
- d-dimer

if WELLS <1 DVT unlikely
- D-dimer with results within 4 hrs (if not within 4hrs offer anticoagulation)
- if D-dimer is raised = duplex USS
- if D-dimer normal = no further Ix

bloods - FBC, U&Es, LFTs, PT + APTT

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25
Q

HEART FAILURE
what is the management for chronic HF?

A

1st line = BB + ACEi (started one at a time)
If ACEi not tolerated, try ARB or hydralazine with nitrate

2nd line = aldosterone antagonist (SPIRONOLACTONE)

3rd line = cardiac resynchronisation therapy (CRT) or ICD insertion, digoxin (particularly in AF) or ivabradine

other options:
- fluid restriction
- loop diuretics (for symptom management)
- annual flu + pneumococcal vaccine

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26
Q

ABNORMAL ECGS
Give 3 effects hyperkalaemia on an ECG

A

GO - absent P wave
GO TALL - tall T wave
GO long - prolonged PR
GO wide - wide QRS

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27
Q

ABNORMAL ECGS
Give 2 effects of hypokalaemia on an ECG

A
  1. Flat T waves
  2. QT prolongation
  3. ST depression
  4. Prominent U waves

U have no Pot and no T, but a long PR and a long QT

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28
Q

ABNORMAL ECGS
Give an effect go hypocalcaemia on an ECG

A
  1. QT prolongation
  2. T wave flattening
  3. Narrowed QRS
  4. Prominent U waves
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29
Q

ABNORMAL ECGS
Give an effect of hypercalcaemia on an ECG

A
  1. QT shortening
  2. Tall T wave
  3. No P waves
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30
Q

ATRIAL FIBRILLATION
Describe the treatment for atrial fibrillation

A

HAEMODYNAMICALLY UNSTABLE
- 1st line = synchronised DV cardioversion

STABLE
onset <48hrs
- 1st line = rate control (BB or CCB)*
- 2nd line = rhythm control (flecanide or amiodarone)

onset >48hrs
- 1st line = rate control (BB or CCB)* + anticoagulation for at least 3 weeks, then offer rhythm control if appropriate

*consider digoxin 1st line in patients with AF + HF, those who do no exercise or other drugs excluded
avoid CCB in HF
avoid non-selective BB (e.g. propranolol) in asthma

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31
Q

ATRIAL FLUTTER
what is the management for atrial flutter?

A
  • Cardioversion
    - Give a LMWH
    - Shock with defibrillator
  • Catheter ablation = definitive treatment – creates a conduction block
  • IV Amiodarone – restore sinus rhythm
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32
Q

DVT
what are the components of the WELLS score?

A
  • active cancer
  • bedridden or recent major surgery
  • calf swelling >3cm compared to other leg
  • superficial veins present (non-varicose)
  • entire leg swollen
  • tenderness along veins
  • pitting oedema of affected leg
  • immobility of affected leg
  • previous DVT
  • alternative diagnosis likely (-2)

all score +1

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33
Q

PE
what are the components of the WELLs two level score?

A
  • clinical signs + symptoms of DVT (+3)
  • PE is no.1 diagnosis (+3)
  • tachycardia <100 (+1.5)
  • immobilisation for >3 days
  • previous PE/DVT (+1.5)
  • haemoptysis (+1)
  • malignancy with treatment in last 6 months (+1)
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34
Q

ATRIAL FIBRILLATION
which medications are used for rate control?

A

1st line = beta-blocker (bisoprolol) or CCB (diltiazem/verapamil)

consider digoxin 1st line when AF + HF

2nd line = combination therapy with any two
- beta-blocker (bisoprolol)
- diltiazem
- digoxin

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35
Q

ATRIAL FIBRILLATION
what medications are used for rhythm control?

A

if no structural/ischaemic heart disease = flecainide or amiodarone

if structural/ischaemic heart disease = amiodarone

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36
Q

SVT
what is the management?

A

UNSTABLE
- synchronised DC shock (up to 3 attempts)
- if unsuccessful, 300mg amiodarone IV + repeat shock

STABLE
- 1st line = vagal manoeuvres (Valsalva, carotid sinus massage)
- 2nd line = adenosine 6mg, if unsuccessful give 12mg then 18mg
- 3rd line = verapamil or BB
- long term = catheter ablation

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37
Q

VENTRICULAR TACHYCARDIA
what is the management of pulsed VT?

A

IF ADVERSE FEATURES PRESENT (HF, MI, shock syncope)
- 1st line = synchronised DC cardioversion (up to 3 attempts)
- 2nd line = amiodarone 300mg IV over 10-20 mins

IF NO ADVERSE FEATURES PRESENT
- 1st line = amiodarone 300mg IV
- 2nd line = synchronised DC cardioversion

if drug therapy fails
- ICD implanted

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38
Q

ANGINA
what is the long term management?

A
  • 1st line = beta blocker or CCB
  • 2nd line = combination of BB + CCB (nifedipine, or amlodipine)
  • 3rd line = long acting nitrate, ivabradine, nicorandil or ranolazine

all patients should be given aspirin + statin unless contraindicated

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39
Q

SAH
What is the management of SAH?

A

1st line
- nimodipine 60mg 4hrly
- endovascular coiling (2nd line = surgical clipping)

  • if raised ICP = IV mannitol, hyperventilation + head elevation
  • conservative = bed rest, stool softeners
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40
Q

SDH
What is the management of SDH?

A

IV mannitol

ACUTE
- monitor intracranial pressure
- decompressive craniectomy

CHRONIC
- can be monitored + managed conservatively
- burr hole decompression if pt is confused, has neuro deficit or severe image findings

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41
Q

STATUS EPILEPTICUS
What is the step-wise management of status epilepticus?

A

PRE-HOSPITAL/EARLY STATUS (<10 MINS)
- in community 1st line = buccal midazolam (2nd line = rectal diazepam)
- in hospital 1st line = 4mg IV lorazepam (2nd line = IV diazepam)
two doses of benzodiazepine given 10 mins apart

ESTABLISHED STATUS (>10 MINS)
- alert on-call anaesthetist
- one of following: phenytoin, levetiracetam, sodium valproate
if one fails, try another agent on list

REFRACTORY STATUS (>30 MINS)
- phenobarbitone
- general anaesthesia with propofol, midazolam or thiopental

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42
Q

BRAIN ABSCESS
What is the management of brain abscess?

A

1ST LINE
- empirical antibiotics (IV ceftriaxone + metronidazole)
- treat underlying cause

2ND LINE
- abscess drainage/excision

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43
Q

BRAIN DEATH + COMA
What are the components of ‘eyes’ in GCS?

A

E4 = opens spontaneously
E3 = opens to verbal command
E2 = opens to pain
E1 = no response

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44
Q

BRAIN DEATH + COMA
What are the components of ‘verbal’ in GCS?

A

V5 = orientated in TPP, answers appropriately
V4 = confused conversation, odd answers
V3 = inappropriate words (random, abusive)
V2 = incomprehensible sounds (groans)
V1 = no response

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45
Q

BRAIN DEATH + COMA
What are the components of ‘motor’ in GCS?

A

M6 = obeys commands
M5 = localises pain
M4 = withdraws away from painful stimulus
M3 = flexion to pain
M2 = extension to pain
M1 = no response

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46
Q

MULTIPLE SCLEROSIS
In terms of the symptoms of MS, what is Lhermitte’s sign?

A

Neck flexion causes electric shock sensation down spine

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47
Q

MULTIPLE SCLEROSIS
In terms of the symptoms of MS, what is Uhthoff’s phenomenon?

A

symptoms worsening in heat e.g. in the shower/exercise

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48
Q

EPILEPSY
what is the treatment for generalised myoclonic epilepsy?

A

male = sodium valproate
female = levetiracetam

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49
Q

EPILEPSY
what is the management for different types of seizures?

A

GENERALISED TONIC-CLONIC
- male = sodium valproate
- female = lamotrigine or levetiracetam

FOCAL SEIZURES
- 1st line = lamotrigine or levetiracetam
- 2nd line = carbamazepine, oxcarbazepine or zonisamide

ABSENCE SEIZURES
- 1st line = ethosuximide
- 2nd line (male) = sodium valproate
- 2nd line (female) = lamotrigine or levetiracetam

MYOCLONIC SEIZURES
- male = sodium valproate
- female = levetiracetam

TONIC OR ATONIC SEIZURES
- male = sodium valproate
- female = lamotrigine

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50
Q

TIA
What is the secondary prevention following a stroke/TIA?

A
  • 1st line = clopidogrel 75mg
  • 2nd line = aspirin 75mg + MR dipyridamole
  • 3rd line = MR dipyridamole
  • 4th line = aspirin 75mg

all patients = high dose statin (atorvastatin 20-80mg)

manage HTN, DM, smoking and CVD risk factors

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51
Q

ENCEPHALITIS
what is the management?

A

IV acyclovir

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52
Q

STROKE
How would a Total Anterior Circulation Infarct (TACI) present?

A

(involves middle and anterior cerebral arteries)
- unilateral hemiparesis +/- hemisensory loss of face, arm and leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphagia

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53
Q

STROKE
how would a Partial Anterior Circulation Infarct present?

A

2 of the criteria are present:
- unilateral hemiparesis +/- hemisensory loss of face, arm and leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphagia

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54
Q

STROKE
how does a lacunar infarct (LACI) present?

A

presents with one of the following:
- unilateral weakness (+/- sensory deficit) of face, arm and leg or all 3
- pure sensory stroke
- ataxic hemiparesis

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55
Q

STROKE
what vessels are affected in a lacunar infarct?

A

perforating arteries around the internal capsule, thalamus and basal ganglia

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56
Q

STROKE
how would a posterior circulation infarct (POCI) present?

A

presents with one of the following:
- cerebellar or brainstem syndromes
- loss of consciousness
- isolated homonymous hemianopia

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57
Q

STROKE
what is the presentation of lateral medullary syndrome?

A

IPSILATERAL
- ataxia
- nystagmus
- dysphagia
- facial numbness
- cranial nerve palsy

CONTRALATERAL
- limb sensory loss

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58
Q

STROKE
what vessels are affected in lateral medullary syndrome?

A

posterior inferior cerebellar artery
(also known as Wallenberg’s syndrome)

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59
Q

STROKE
what is the presentation of Weber’s syndrome?

A
  • ipsilateral CN III palsy
  • contralateral weakness
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60
Q

MENINGITIS
what are the most common causes of viral meningitis?

A

enteroviruses e.g. coxsackie B, echovirus

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61
Q

APHASIA
what is the presentation of Wernicke’s aphasia?

A

speech is normal but sentences do not make sense (comprehension is impaired)

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62
Q

APHASIA
what is Wernicke’s aphasia

A

receptive aphasia (can speak but do not make sense, comprehension is impaired)

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63
Q

APHASIA
what is the presentation of Broca’s aphasia?

A

comprehension is normal
speech is non-fluent
repetition is impaired

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64
Q

APHASIA
what is Broca’s aphasia?

A

expressive aphasia (can comprehend but cannot speak fluently)

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65
Q

APHASIA
what is the presentation of conduction aphasia?

A

comprehension is normal
speech is fluent
repetition is poor

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66
Q

APHASIA
what is the presentation of global aphasia?

A
  • expressive + receptive aphasia
  • can communicate using gestures
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67
Q

APHASIA
where is the lesion for Broca’s (expressive) aphasia?

A

inferior frontal gyrus

68
Q

APHASIA
where is the lesion for Wernicke’s (receptive) aphasia?

A

lesion in superior temporal gyrus

69
Q

APHASIA
where is the lesion for conductive aphasia?

A

arcuate fasciculus

70
Q

CEREBELLAR LESIONS
what is the cause of finger-nose ataxia?

A

cerebellar hemisphere lesion

71
Q

CEREBELLAR LESIONS
what is the cause of gait ataxia?

A

cerebellar vermis lesions

72
Q

STROKE
what is the definition of a stroke?

A

rapidly developing neurological deficit of vascular origin lasting over 24 hours or resulting in death

73
Q

CROHNS DISEASE
What is the treatment for induction of remission for Crohn’s disease?

A

INDUCTION OF REMISSION
MILD (1st presentation/1 exacerbation in 1yr)
- 1st line = IV/PO steroid
- 2nd line = oral ASA (MESALAZINE)
- distal/ileocaecal disease = budesonide

MODERATE (>2 exacerbations in 1yr)
- 1st line = azathioprine or mercaptopurine
- 2nd line = methotrexate

SEVERE (unresponsive to conventional therapy)
- 1st line = infliximab or adalimumab (anti-TNF)
- 2nd line = other biological agents

REFRACTORY
- surgery

74
Q

ULCERATIVE COLITIS
What is the treatment for induction of remission for Ulcerative colitis?

A

INDUCTION OF REMISSION
PROCTITIS
- 1st line = topical ASA (RECTAL MESALAZINE)
- 2nd line = topical ASA + oral ASA (oral MESALAZINE)
- 3rd line = oral ASA + oral corticosteroid

PROCTOSIGMOIDITIS/LEFT-SIDED UC
- 1st line = topical ASA
- 2nd line = topical ASA + high-dose oral ASA / high-dose oral ASA + topical corticosteroid
- 3rd line = oral ASA + oral corticosteroid

EXTENSIVE DISEASE
- 1st line = topical ASA + high-dose oral ASA
- 2nd line = oral ASA + oral corticosteroid

SEVERE DISEASE
- should be treated in hospital
- 1st line = IV steroids (IV ciclosporin if contraindicated)
- 2nd line = IV steroids + IV ciclosporin or consider surgery

75
Q

VARICES
what is the treatment for gastroesophageal varices?

A
  • ABCDE
  • Rockfall Score (Prediction of Rebleeding and Mortality)
  • Bleeding Varices - Terlipressin + Prophylactic Antibiotics (Ciprofloaxcin), Balloon tamponade (Sengstaken-Blakemore tube), Endoscopic Banding, TIPS
  • Bleed Prevention - BB + Endoscopic Banding. Cirrhosis = screening endoscopy
76
Q

DIVERTICULAR DISEASE
what is the management for diverticulitis?

A

ANTIBIOTICS
- 1st line = co-amoxiclav (if penicillin allergic = ciprofloxacin/metronidazole)

ANALGESIA
- paracetamol

SUPPORTIVE
- high fibre diet

SURGERY

77
Q

C.DIFF
what is the treatment for c.diff?

A

1st line = vancomycin orally for 10 days
2nd line = oral fidaxomicin
3rd line = oral vancomycin +/- IV metronidazole

78
Q

ACHALASIA
what are the investigations?

A
  • oesophageal manometry (diagnostic) = excessive LOS tone
  • barium swallow = expanded oesophagus, fluid level (birds beak appearance)
  • CXR = wide mediastinum, fluid level
79
Q

ACHALASIA
what is the management?

A
  • 1st line = pneumatic (balloon) dilation
  • heller cardiomyotomy (if recurrent or severe symptoms)
  • intra-sphincteric botox injection
  • drug therapy (nitrates, CCBs)
80
Q

CONSTIPATION
what is the management for faecal impaction?

A

1st line = osmotic laxative (macrogol) +/- stimulant laxative (senna)

2nd line = suppository (bisacodyl/glycerol)

3rd line = enema (sodium phosphate)

81
Q

ABDOMINAL WALL HERNIAS
where are inguinal hernias found?

A

above + medial to pubic tubercle

82
Q

ABDOMINAL WALL HERNIAS
where are femoral hernias found?
why are they dangerous?

A

below + lateral to pubic tubercle (more common in women)
are at high risk of strangulation

83
Q

CROHN’S DISEASE
what is the management for maintenance of remission in crohn’s disease?

A
  • 1st line = azathioprine or mercaptopurine
  • 2nd line = methotrexate
  • post surgery = consider azathioprine +/- methotrexate

STOP SMOKING

84
Q

ULCERATIVE COLITIS
what is the management for the maintenance of remission in UC?

A

MILD-MODERATE
- proctitis + rectosigmoid = topical ASA / topical ASA + oral ASA / oral ASA
- left-sided + extensive = low dose oral ASA

SEVERE (severe exacerbation or >2 exacerbations
- oral azathioprine or oral mercaptopurine

85
Q

UPPER GI BLEED
when is Glasgow-Blatchford scoring system used?

A

risk assessment before endoscopy to help decide if a patient can be managed as an outpatient

86
Q

UPPER GI BLEED
what is the management of a variceal bleed?

A

terlipressin
prophylactic antibiotics (ciprofloxacin)
endoscopy
band ligation
TIPS

87
Q

UPPER GI BLEED
what is the management of non-variceal bleed?

A

PPI after endoscopy

88
Q

RECTAL CANCER
what blood marker can be used to monitor response to treatment?

A

carcinoembryonic antigen (CEA)

89
Q

PEPTIC ULCER
what is the management of h.pylori?

A

7 day course of:
- PPI + amoxicillin + (clarithromycin or metronidazole)

if penicillin allergic
- PPI + metronidazole + clarithromycin

90
Q

BLOOD TRANSFUSION REACTIONS
what is the mechanism of action for acute haemolytic transfusion reactions?

A

ABO incompatibility
RBC destruction by IgM antibodies

91
Q

BLOOD TRANSFUSION REACTIONS
what is the management for acute haemolytic transfusion reaction?

A
  • immediate transfusion termination
  • send blood for direct Coombs test, repeat typing + cross match
  • fluid resuscitation with IV saline
92
Q

BLOOD TRANSFUSION REACTIONS
what is the mechanism of action for non-haemolytic febrile reactions?

A

due to white blood cell HLA antibodies

93
Q

BLOOD TRANSFUSION REACTIONS
what is the management for non-haemolytic febrile reactions?

A
  • slow or stop transfusion
  • paracetamol
  • monitor
94
Q

BLOOD TRANSFUSION REACTIONS
what is the mechanism of action for mild allergic reaction?

A

thought to be caused by foreign plasma proteins

95
Q

BLOOD TRANSFUSION REACTIONS
what is the management for a minor allergic reaction?

A
  • temporarily stop transfusion
  • antihistamine (cetirizine)
  • once symptoms resolve, transfusion may be continued with no need for further work up
96
Q

BLOOD TRANSFUSION REACTIONS
what can cause anaphylaxis?

A

patients with IgA deficiency who have anti-IgA antibodies

97
Q

BLOOD TRANSFUSION REACTIONS
what are the clinical features for transfusion-related acute lung injury (TRALI)?

A
  • hypoxia
  • fever
  • HYPOTENSION
  • pulmonary infiltrates on CXR
98
Q

BLOOD TRANSFUSION REACTIONS
what is the mechanism of action for transfusion-related acute lung injury (TRALI)?

A

non-cardiogenic pulmonary oedema
thought to be secondary to increased vascular permeability caused by host neutrophils that become activated by substances in donated blood

99
Q

BLOOD TRANSFUSION REACTIONS
what is the management for transfusion-related acute lung injury (TRALI)?

A
  • stop transfusion
  • supportive care
  • oxygen
100
Q

BLOOD TRANSFUSION REACTIONS
what are the clinical features of transfusion-associated circulatory overload (TACO)?

A
  • pulmonary oedema
  • HYPERTENSION
101
Q

BLOOD TRANSFUSION REACTIONS
what is the management for transfusion associated circulatory overload (TACO)?

A
  • slow or stop transfusion
  • consider loop diuretic (furosemide)
  • consider oxygen
102
Q

DOACs
what is the mechanism of action?

A

Rivaroxaban, apixaban and edoxaban= direct factor Xa inhibitor
Dabigatran = direct thrombin inhibitor

103
Q

DOACs
how can they be reversed?

A

Rivaroxaban + apixaban = andexanet alpha
Dabigatran = idarucizumab
Edoxaban = no reversal agent

104
Q

LMWH
what is the mechanism of action?

A

activates antithrombin III
forms a complex that inhibits factor Xa

105
Q

LMWH
how can it be reversed?

A
  • protamine sulfate
106
Q

WARFARIN
how would you manage INR > 8?

A

MAJOR BLEED OR REQUIRE SURGERY
- stop warfarin
- give IV vitamin K
- give dried prothrombin complex concentrate (PCC) or Fresh frozen plasma (FFP) if PCC is unavailable

MINOR BLEED
- stop warfarin
- IV vitamin K
- repeat vitamin K dose after 24hrs if INR still too high
- restart warfarin when INR<5

NO BLEED
- stop warfarin
- oral vitamin K
- repeat vitamin K dose after 24hrs if INR still too high
- restart warfarin when INR <5

107
Q

WARFARIN
how would you manage INR 5-8?

A

MINOR BLEED
- stop warfarin
- give IV vitamin K
- restart warfarin when INR<5

NO BLEED
- withhold 1-2 doses of warfarin
- reduce subsequent maintenance dose

108
Q

ACNE VULGARIS
Describe the treatment for mild to moderate acne

A

12 week fixed course of one of the following:
- topical adapalene + topical benzoyl peroxide
- topical tretinoin + topical clindamycin
- topical benzoyl peroxide + topical clindamycin

109
Q

PSORIASIS
what is the management?

A

1st line
- patient education
- regular emollients
- topical corticosteroids + vit D for 4 weeks

  • if poor response, continue for 4 more weeks
  • if poor response after 8 weeks, stop corticosteroid + take vit D BD
  • if poor response after 12 weeks, potent topical steroid BD for 4 weeks

2nd line
- short-acting dithranol
- phototherapy

3rd line
- DMARDS (methotrexate, apremilast, ciclosporin)
- biologics (adalimumab, infliximab)

110
Q

ROSACEA
what is the management?

A

CONSERVATIVE
- high factor sun cream
- camouflage cream to conceal redness

SYMPTOM CONTROL
- flushing = topical brimonidine gel or oral propranolol
- telangiectasia = laser therapy
- papules/pustules
- mild-moderate = 1st line - ivermectin (other options = topical metronidazole, topical azelaic acid)
- mod-severe = topical ivermectin + oral doxycycline

111
Q

ACNE
what is the management of moderate to severe acne?

A

1st line = 12 week fixed course of one of the following:
- topical adapalene + topical benzoyl peroxide
- topical tretinoin + topical clindamycin
- topical adapalene + topical benzyl peroxide + oral lymecycline/doxycycline
- topical azelaic acid + oral lymecycline/doxycycline

2nd line = isotretinoin (acutane)

112
Q

CHLAMYDIA
How would you manage chlamydia?

A
  • Test for other STIs, contraceptive advice, ?safeguarding if child.
  • Doxycycline 100mg BD for 7d (C/I pregnancy or breastfeeding).
  • 1g azithromycin stat dose in pregnancy (erythromycin or amoxicillin safe too)
  • Referral to GUM for partner notification + contact tracing.
113
Q

GONORRHOEA
What is the management of gonorrhoea?

A
  • 1g single dose IM ceftriaxone
  • if needle phobic = oral cefixime 400mg (single dose) + oral azithromycin 2g (single dose)
  • Follow-up test of cure with NAAT testing or cultures
114
Q

SYPHILIS
What is the clinical presentation of primary syphilis?

A

SYMPTOMS
- single painless ulcer (chancre) on genitals
- occasionally chancre on throat, anus or intravaginally

115
Q

SYPHILIS
How would you manage syphilis?

A
  • Specialist GUM (full STI screening, contact tracing, contraceptive information).
  • early syphilis = Single dose IM benzathine benzylpenicillin or PO doxycycline if allergic
  • late latent/gummatous = 3 doses IM benzathine benzylpenicillin once weekly for 3 weeks
  • cardiovascular syphilis = 3 days of PO prednisolone + 3 once weekly doses IM benzathine benzylpenicillin
  • neurosyphilis = 14 days IM procaine penicillin + oral probenecid
116
Q

GENITAL HERPES
What is the clinical presentation of genital herpes?

A
  • Multiple painful ulcers
  • Neuropathic type pain (tingling, burning, shooting)
  • Flu Sx (fatigue, headaches, fever, myalgia)
  • Dysuria
117
Q

GENITAL HERPES
What is the management or primary genital herpes contracted before 28w gestation?

A
  • Aciclovir during infection
  • Prophylactic aciclovir from 36w gestation onwards to reduce risk of genital lesions during labour + delivery
  • Asymptomatic at delivery can have vaginal if >6w from initial infection, if Sx then c-section
118
Q

GENITAL HERPES
What is the management of primary genital herpes after 28w gestation?

A
  • Aciclovir during infection + immediate prophylactic aciclovir
  • C-section in all cases
119
Q

CANDIDIASIS
What is the management of candidiasis?

A

1st line = oral fluconazole 150mg single dose
2nd line = clotrimazole 500mg intravaginal pessary single dose

  • if there are vulval symptoms, consider topical imidazole in addition to oral/intravaginal antifungal
  • if pregnant, only local treatments (creams/pessaries) may be used - oral is contraindicated
120
Q

LYMPHOGRANULOMA VENEREUM
what are the clinical features?

A

Painless genital ulcer
Painful Inguinal lymph nodes

Proctitis, rectal pain, rectal discharge (in rectal infections)
Systemic symptoms such as fever and malaise

121
Q

LYMPHOGRANULOMA VENEREUM
what is the management?

A

Treatment is with antibiotics. Common regimes include:

Oral doxycycline 100 mg twice daily for 21 days
Oral tetracycline 2 g daily for 21 days
Oral erythromycin 500 mg four times daily for 21 days

122
Q

CHANCROID
what are the clinical features?

A
  • painful genital ulcer
  • tender unilateral inguinal lymphadenopathy
123
Q

CHANCROID
what is the management?

A
  • single dose AZITHROMYCIN
  • alternatives = ceftriaxone, erythromycin or ciprofloxacin
  • partner notification + treatment
  • abscess drainage
124
Q

ERECTILE DYSFUNCTION
what is the management?

A

1st line
- lifestyle modification (weight loss, physical activity, reduced alcohol, smoking cessation, BP control)
- psychosexual counselling
- phosphodiesterase-5 (PDE-5) inhibitors = SILDENAFIL (viagra)
- vacuum erection device

2nd line
- intracavernous injection therapy
- surgical intervention (penile prosthesis implant)

125
Q

ACID-BASE ABNORMALITY
what are the different causes of metabolic acidosis?

A

NORMAL ANION GAP
- GI bicarbonate loss (diarrhoea, ureterosigmoidstomy, fistula
- renal tubular acidosis
- drugs (acetazolamide)
- ammonium chloride injection
- addisons disease

RAISED ANION GAP
- lactate (shock, hypoxia)
- ketones (DKA, alcohol)
- urate (renal failure)
- acid poisoning (salicylates, methanol)

126
Q

ACID-BASE ABNORMALITY
what are the causes of metabolic alkalosis?

A

usually GI/renal
- vomiting/aspiration
- diuretics
- liquorice, carbenoxolone
- hypokalaemia
- primary hyperaldosteronism
- cushings syndrome
- Bartter’s syndrome
- congenital adrenal hyperplasia

127
Q

ACID-BASE ABNORMALITY
what are the causes of respiratory acidosis?

A

Caused by inadequate alveolar ventilation, leading to CO2 retention
- COPD
- decompensation in other respiratory conditions (life-threatening asthma/pulmonary oedema)
- sedative drugs (benzodiazepines, opiate overdose)
- GBS

128
Q

ACID-BASE ABNORMALITY
what are the causes of respiratory alkalosis?

A

caused by excessive alveolar ventilation, resulting in more CO2 than normal being exhaled.
- anxiety leading to hyperventilation
- PE
- salicylate poisoning
- CNS disorders (stroke, SAH, encephalitis)
- altitude
- pregnancy

129
Q

OVERDOSE
what is the criteria for liver transplant following paracetamol overdose?

A

KINGS COLLEGE HOSPITAL CRITERIA FOR LIVER TRANSPLANT
- pH < 7.3 24 hours after ingestion

or all of the following
- prothrombin time >100 seconds
- creatinine >300umol/L
- grade III or IV encephalopathy

130
Q

ANAPHYLAXIS
what is the management for children?

A

IM adrenaline
- <6m = 100-150 micrograms
- 6m - 6yrs = 150 micrograms
- 6-12yrs = 300 micrograms

131
Q

RHEUMATIC FEVER
What are the major criteria in rheumatic fever?

A

JONES –

  • Joint arthritis (migratory as affects different joints at different times)
  • Organ inflammation (pancarditis > pericardial friction rub)
  • Nodules (subcut over extensor surfaces)
  • Erythema marginatum rash (pink rings of varying sizes on torso + proximal limbs)
  • Sydenham chorea
132
Q

RHEUMATIC FEVER
What are the minor criteria in rheumatic fever?

A

FEAR –

  • Fever
  • ECG changes (prolonged PR interval) without carditis
  • Arthralgia without arthritis
  • Raised CRP/ESR
133
Q

ASTHMA
What is the stepwise management of chronic asthma in <5y?

A
  1. SABA + low dose ICS (trial for 8-12 weeks)

IF SYMPTOMS RESOLVE
2. stop SABA + low dose ICS for 3 months
3. if symptoms recur restart SABA + low-dose ICS and titrate up to moderate dose ICS as needed
4. consider further trial without treatment
5. SABA + moderate dose ICS + LTRA
6 stop LTRA + refer to specialist

IF SYMPTOMS DO NOT RESOLVE
2. check inhaler adherence, review if alternative diagnosis is likely
3. refer to specialist

134
Q

ASTHMA
What is the stepwise management of chronic asthma 5-12yrs?

A
  1. SABA + ICS
  2. decide whether MART pathway or conventional pathway is more suitable

MART PATHWAY
3. SABA + low dose MART
4. SABA + moderate dose MART
5. refer to specialist

CONVENTIONAL PATHWAY
3. SABA + ICS + LTRA (trial for 8-12 weeks)
4. SABA + low dose ICS/LABA (+/- LTRA)
5. SABA + moderate dose ICS/LABA (+/- LTRA)

135
Q

CONSTIPATION
What is the medical management of constipation?

A
  • 1st = MACROGOL (osmotic) laxative like polyethylene glycol + electrolytes (Movicol)
  • 2nd = stimulant laxative if no effect like Senna, bisocodyl ± osmotic laxative (lactulose) or stool softener (docusate) if hard stools
  • 3rd = consider enema ± sedation or specialist manual evacuation
  • Continue for several weeks after regular bowel habit then gradual dose reduction
136
Q

BILIARY ATRESIA
What is the management of biliary atresia?

A

1st line
- Kasai portoenterostomy
- ursodeoxycholic acid

2nd line
- liver transplant

137
Q

EPILEPSY
What is the management of generalised seizures?

A
  • 1st line = sodium valproate
  • 2nd line = lamotrigine, carbamazepine (TC), clonazepam (myoclonic)
138
Q

EPILEPSY
What is the management of focal seizures?

A
  • 1st line = carbamazepine or lamotrigine
  • 2nd line = levetiracetam or sodium valproate
139
Q

EPILEPSY
What is the management of absence seizures?

A
  • Ethosuximide or sodium valproate
140
Q

EPILEPSY
What is the management of myoclonic seizures?

A
  • 1st line = sodium valproate
  • 2nd line = clonazepam
141
Q

DEVELOPMENTAL DELAY
what are the referral points?

A
  • doesn’t smile at 10 weeks
  • cannot sit unsupported at 12 months
  • cannot walk at 18 months
142
Q

KAWASAKI DISEASE
What is the diagnostic criteria for Kawasaki disease?

A

Fever + 4 (MyHEART) –

  • Mucosal involvement (red/dry cracked lips, strawberry tongue)
  • Hands + feet (erythema then desquamation)
  • Eyes (bilateral conjunctival injection, non-purulent)
  • lymphAdenopathy (unilateral cervical >1.5cm)
  • Rash (polymorphic involving extremities, trunk + perineal regions
  • Temp >39 for >5d
143
Q

VACCINATIONS
What vaccines are attenuated?

A
  • MMR, BCG, nasal flu, rotavirus + Men B
144
Q

VACCINATIONS
What vaccines are given at…

i) 2m?
ii) 3m?
iii) 4m?

A

i) 6-in-one, rotavirus + men B
ii) 6-in-one, rotavirus + PCV
iii) 6-in-one, men B

145
Q

VACCINATIONS
What vaccines are given at…
i) 1y?
ii) 3y + 4m?
iii) 12-13y?
iv) 14y?

A

i) Men B, PCV, Hib/Men C + MMR
ii) MMR, 4-in-one preschool booster = DTaP + IPV
iii) HPV
iv) 3-in-1 teenage booster = tetanus, diphtheria + IPV, men ACWY

146
Q

VACCINATIONS
Which vaccines are included in the 6-in-1 injection?

A
  • diphtheria
  • tetanus
  • pertussis DTaP (whooping cough)
  • polio IPV
  • Haemophilus influenza B (HiB)
  • Hepatitis B
147
Q

TETANUS
when is tetanus vaccine given?

A
  • 2 months
  • 3 months
  • 4 months
  • 3-5 years
  • 13-18 years

5 doses are now considered adequate long term protection

148
Q

TETANUS
how can you classify a wound?

A
  • clean wound
  • tetanus prone wound
  • high-risk tetanus prone wound
149
Q

TETANUS
what is classed as a clean wound?

A
  • less than 6 hours old
  • non-penetrating injury
  • negligible tissue damage
150
Q

TETANUS
what is classed as a tetanus prone wound?

A
  • puncture type wounds in contaminated environment
  • wounds containing foreign bodies
  • compound fractures
  • wounds/burns with systemic sepsis
  • certain animal bites and scratches
151
Q

TETANUS
what is classed as high risk tetanus prone wound?

A
  • heavy contamination with material likely to contain tetanus spores e.g. soil, manure
  • wounds or burns that show extensive devitalised tissue
  • wounds or burns that require surgical intervention
152
Q

TETANUS
how would you manage a patient who has had a full course of tetanus vaccines, with the last dose < 10 years ago?

A

Regardless of wound severity:
- no vaccine required
- no tetanus immunoglobulin

153
Q

TETANUS
what is the management for a patient that has had a full course of tetanus vaccine with the last dose >10 years ago?

A

if tetanus prone wound:
- vaccine dose

if high risk wound:
- vaccine dose
- tetanus immunoglobulin

154
Q

TETANUS
how would you treat a patient with unknown or incomplete vaccination history?

A
  • vaccine regardless of wound severity
  • if tetanus prone or high risk = vaccine + immunoglobulin
155
Q

LOCAL ANAESTHETIC
what is the management of local anaesthetic toxicity?

A

20% lipid emulsion

156
Q

HEPATIC ENCEPHALOPATHY
what is the 1st line management?

157
Q

HEPATIC ENCEPHALOPATHY
what is the secondary prophylaxis?

A

lactulose + rifaximin

158
Q

CXR
how can you tell the difference between lung collapse and pleural effusion on CXR?

A
  • lung collapse = trachea deviates towards affected side
  • pleural effusion = trachea deviates away from affected side
159
Q

ACUTE LIMB ISCHAEMIA
what is the management for acute limb threatening ischaemia?

A

IV heparin (usually unfractionated)

160
Q

HYPERKALAEMIA
how can excess potassium be removed from the body?

A
  • calcium resonium
  • furosemide
  • dialysis
161
Q

PROSTATE CANCER
what is a complication of GnRH agonists?

A

can cause a tumour flare when first started, causing bone pain, bladder obstruction + other symptoms

162
Q

HYPERTHYROIDISM IN PREGNANCY
what is the management?

A
  • 1st trimester = propylthiouracil
  • 2nd and 3rd trimester = carbimazole
163
Q

CUSHINGS SYNDROME
what VBG results would be seen?

A

hypokalaemic metabolic alkalosis

164
Q

CUSHINGS
what does the following indicate?

cortisol = not suppressed
ACTH = suppressed

A

cushing’s syndrome (adrenal adenoma)

165
Q

CUSHINGS
what does the following indicate?

cortisol = suppressed
ACTH = suppressed

A

cushing’s disease (pituitary adenoma)

166
Q

CUSHINGS
what does the following indicate?

cortisol = not suppressed
ACTH = not suppressed

A

ectopic ACTH syndrome

MY REVISION - ALL TO DO 2 (24 decks)

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