Treatment Flashcards

Question

What is the management for inguinal hernias?

Answer 1

Management the clinical consensus is currently to treat medically fit patients even if they are asymptomatic a hernia truss may be an option for patients not fit for surgery but probably has little role in other patients mesh repair is associated with the lowest recurrence rate unilateral inguinal hernias are generally repaired with an open approach bilateral and recurrent inguinal hernias are generally repaired laparoscopically The Department for Work and Pensions recommend that following an open repair patients return to non-manual work after 2-3 weeks and following laparoscopic repair after 1-2 weeks

Answer 2

Surgical repair is a necessity, given the risk of strangulation, and can be carried out either laparoscopically or via a laparotomy Hernia support belts/trusses should not be used for femoral hernias, again due to the risk of strangulation; In an emergency situation, a laparotomy may be the only option

Answer 3

Inducing remission Treating mild-to-moderate ulcerative colitis proctitis topical (rectal) aminosalicylate: for distal colitis rectal mesalazine has been shown to be superior to rectal steroids and oral aminosalicylates if remission is not achieved within 4 weeks, add an oral aminosalicylate if remission still not achieved add topical or oral corticosteroid proctosigmoiditis and left-sided ulcerative colitis topical (rectal) aminosalicylate if remission is not achieved within 4 weeks, add a high-dose oral aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid if remission still not achieved stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid extensive disease topical (rectal) aminosalicylate and a high-dose oral aminosalicylate: if remission is not achieved within 4 weeks, stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid Severe colitis should be treated in hospital intravenous steroids are usually given first-line intravenous ciclosporin may be used if steroid are contraindicated if after 72 hours there has been no improvement, consider adding intravenous ciclosporin to intravenous corticosteroids or consider surgery Maintaining remission Following a mild-to-moderate ulcerative colitis flare proctitis and proctosigmoiditis topical (rectal) aminosalicylate alone (daily or intermittent) or an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or an oral aminosalicylate by itself: this may not be effective as the other two options left-sided and extensive ulcerative colitis low maintenance dose of an oral aminosalicylate Following a severe relapse or >=2 exacerbations in the past year oral azathioprine or oral mercaptopurine

Answer 4

General points patients should be strongly advised to stop smoking some studies suggest an increased risk of relapse secondary to NSAIDs and the combined oral contraceptive pill but the evidence is patchy Inducing remission glucocorticoids (oral, topical or intravenous) are generally used to induce remission. Budesonide is an alternative in a subgroup of patients enteral feeding with an elemental diet may be used in addition to or instead of other measures to induce remission, particularly if there is concern regarding the side-effects of steroids (for example in young children) 5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective azathioprine or mercaptopurine* may be used as an add-on medication to induce remission but is not used as monotherapy. Methotrexate is an alternative to azathioprine infliximab is useful in refractory disease and fistulating Crohn's. Patients typically continue on azathioprine or methotrexate metronidazole is often used for isolated peri-anal disease Maintaining remission as above, stopping smoking is a priority (remember: smoking makes Crohn's worse, but may help ulcerative colitis) azathioprine or mercaptopurine is used first-line to maintain remission +TPMT activity should be assessed before starting methotrexate is used second-line Surgery around 80% of patients with Crohn's disease will eventually have surgery stricturing terminal ileal disease → ileocaecal resection segmental small bowel resections stricturoplasty perianal fistulae an inflammatory tract or connection between the anal canal and the perianal skin patients with symptomatic perianal fistulae are usually given oral metronidazole anti-TNF agents such as infliximab may also be effective in closing and maintaining closure of perianal fistulas a draining seton is used for complex fistulae a seton is a piece of surgical thread that's left in the fistula for several weeks to keep it open. This is useful because persisting fistula tracks after premature skin closure predispose to abscess formation perianal abscess requires incision and drainage combined with antibiotic therapy a draining seton may also be placed if a tract is identified

Answer 5

First-line pharmacological treatment - according to predominant symptom pain: antispasmodic agents constipation: laxatives but avoid lactulose diarrhoea: loperamide is first-line Second-line pharmacological treatment low-dose tricyclic antidepressants (e.g. amitriptyline 5-10 mg) are used in preference to selective serotonin reuptake inhibitors General dietary advice have regular meals and take time to eat avoid missing meals or leaving long gaps between eating drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks such as herbal teas restrict tea and coffee to 3 cups per day reduce intake of alcohol and fizzy drinks consider limiting intake of high-fibre food (for example, wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice) reduce intake of 'resistant starch' often found in processed foods limit fresh fruit to 3 portions per day for diarrhoea, avoid sorbitol for wind and bloating consider increasing intake of oats (for example, oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day).

Answer 6

Treatment Operable disease is best managed by surgical resection - the most common procedure is an Ivor-Lewis type oesophagectomy The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis resulting in mediastinitis In addition to surgical resection many patients will be treated with adjuvant chemotherapy

Answer 7

Management less than 20% are suitable for surgery at diagnosis a Whipple's resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas. Side-effects of a Whipple's include dumping syndrome and peptic ulcer disease adjuvant chemotherapy is usually given following surgery ERCP with stenting is often used for palliation

Answer 8

Uncomplicated- if Helicobacter pylori is negative then proton pump inhibitors (PPIs) should be given until the ulcer is healed if Helicobacter pylori is positive then eradication therapy should be given Acute bleeding- ABC approach as with any upper gastrointestinal haemorrhage IV proton pump inhibitor the first-line treatment is endoscopic intervention if this fails (approximately 10% of patients) then either: urgent interventional angiography with transarterial embolization or surgery

Answer 9

Treatment is usually surgical, with incision and drainage being first line, usually under local anaesthetic. The wound can then either be packed or left open, in which case it will heal in around 3-4 weeks; Antibiotics can be of use, but are only usually employed if there is systemic upset secondary to the abscess, as they do not seem to help with healing of the wound after drainage.

Answer 10

They will heal provided there is no underlying inflammatory bowel disease and no distal obstruction, so conservative measures may be the best option Where there is skin involvement, protect the overlying skin, often using a well-fitted stoma bag- skin damage is difficult to treat A high output fistula may be rendered more easily managed by the use of octreotide, this will tend to reduce the volume of pancreatic secretions. Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal) these may necessitate the use of TPN to provide nutritional support together with the concomitant use of octreotide to reduce volume and protect skin. When managing perianal fistulae surgeons should avoid probing the fistula where acute inflammation is present, this almost always worsens outcomes. When perianal fistulae occur secondary to Crohn's disease the best management option is often to drain acute sepsis and maintain that drainage through the judicious use of setons whilst medical management is implemented. Always attempt to delineate the fistula anatomy, for abscesses and fistulae that have an intraabdominal source the use of barium and CT studies should show a track. For perianal fistulae, surgeons should recall Goodsall's rule in relation to internal and external openings.

Answer 11

intravenous cefotaxime is usually given for Spontaneous bacterial peritonitis

Answer 12

if no neurological involvement 1 mg of IM hydroxocobalamin 3 times each week for 2 weeks, then once every 3 months if a patient is also deficient in folic acid then it is important to treat the B12 deficiency first to avoid precipitating subacute combined degeneration of the cord

Answer 13

Think Sepsis 6 oxygen, cultures, antibiotics, fluids, lactate measurement and urine output monitoring

Answer 14

hydrocortisone: usually given in 2 or 3 divided doses. Patients typically require 20-30 mg per day, with the majority given in the first half of the day fludrocortisone Management of intercurrent illness in simple terms the glucocorticoid dose should be doubled, with the fludrocortisone dose staying the same

Answer 15

nephrogenic diabetes insipidus thiazides low salt/protein diet central diabetes insipidus can be treated with desmopressin

Answer 16

HbA1c should be monitored every 3-6 months adults should have a target of HbA1c level of 48 mmol/mol (6.5%) or lower. NICE do however recommend taking into account factors such as the person's daily activities, aspirations, likelihood of complications, comorbidities, occupation and history of hypoglycaemia Self-monitoring of blood glucose recommend testing at least 4 times a day, including before each meal and before bed more frequent monitoring is recommended if frequency of hypoglycaemic episodes increases; during periods of illness; before, during and after sport; when planning pregnancy, during pregnancy and while breastfeeding Blood glucose targets 5-7 mmol/l on waking and 4-7 mmol/l before meals at other times of the day Type of insulin offer multiple daily injection basal–bolus insulin regimens, rather than twice‑daily mixed insulin regimens, as the insulin injection regimen of choice for all adults twice‑daily insulin detemir is the regime of choice. Once-daily insulin glargine or insulin detemir is an alternative offer rapid‑acting insulin analogues injected before meals, rather than rapid‑acting soluble human or animal insulins, for mealtime insulin replacement for adults with type 1 diabetes Metformin NICE recommend considering adding metformin if the BMI >= 25 kg/m²

Answer 17

Metformin remains the first-line drug of choice in type 2 diabetes mellitus. metformin should be titrated up slowly to minimise the possibility of gastrointestinal upset if standard-release metformin is not tolerated then modified-release metformin should be trialled SGLT-2 inhibitors should also be given in addition to metformin if any of the following apply: the patient has a high risk of developing cardiovascular disease (CVD, e.g. QRISK ≥ 10%) the patient has established CVD the patient has chronic heart failure metformin should be established and titrated up before introducing the SGLT-2 inhibitor SGLT-2 inhibitors should also be started at any point if a patient develops CVD (e.g. is diagnosed with ischaemic heart disease), a QRISK ≥ 10% or chronic heart failure If metformin is contraindicated if the patient has a risk of CVD, established CVD or chronic heart failure: SGLT-2 monotherapy if the patient doesn't have a risk of CVD, established CVD or chronic heart failure: DPP‑4 inhibitor or pioglitazone or a sulfonylurea SGLT-2 may be used if certain NICE criteria are met Second-line therapy Dual therapy - add one of the following: metformin + DPP-4 inhibitor metformin + pioglitazone metformin + sulfonylurea metformin + SGLT-2 inhibitor (if NICE criteria met) Third-line therapy If a patient does not achieve control on dual therapy then the following options are possible: metformin + DPP-4 inhibitor + sulfonylurea metformin + pioglitazone + sulfonylurea metformin + (pioglitazone or sulfonylurea or DPP-4 inhibitor) + SGLT-2 if certain NICE criteria are met insulin-based treatment

Answer 18

fluid replacement most patients with DKA are deplete around 5-8 litres isotonic saline is used initially, even if the patient is severely acidotic please see an example fluid regime below. insulin an intravenous infusion should be started at 0.1 unit/kg/hour once blood glucose is < 14 mmol/l an infusion of 10% dextrose should be started at 125 mls/hr in addition to the 0.9% sodium chloride regime correction of electrolyte disturbance serum potassium is often high on admission despite total body potassium being low this often falls quickly following treatment with insulin resulting in hypokalaemia potassium may therefore need to be added to the replacement fluids if the rate of potassium infusion is greater than 20 mmol/hour then cardiac monitoring may be required long-acting insulin should be continued, short-acting insulin should be stopped

Answer 19

Management dietary protein restriction tight glycaemic control BP control: aim for < 130/80 mmHg ACE inhibitor or angiotensin-II receptor antagonist should be start if urinary ACR of 3 mg/mmol or more dual therapy with ACE inhibitors and angiotensin-II receptor antagonist should not be started control dyslipidaemia e.g. Statins

Answer 20

first-line treatment: amitriptyline, duloxetine, gabapentin or pregabalin if the first-line drug treatment does not work try one of the other 3 drugs tramadol may be used as 'rescue therapy' for exacerbations of neuropathic pain topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic neuralgia) pain management clinics may be useful in patients with resistant problems

Answer 21

Primary prevention : Atorvastatin 20mg OD should be offered first-line Secondary prevention: Atorvastatin 20mg 80mg OD

Answer 22

Management fluid replacement fluid losses in HHS are estimated to be between 100 - 220 ml/kg IV 0.9% sodium chloride solution typically given at 0.5 - 1 L/hour depending on clinical assessment potassium levels should be monitored and added to fluids depending on the level insulin should not be given unless blood glucose stops falling while giving IV fluids venous thromboembolism prophylaxis patients are at risk of thrombosis due to hyperviscosity

Answer 23

the definitive management is total parathyroidectomy conservative management may be offered if the calcium level is less than 0.25 mmol/L above the upper limit of normal AND the patient is > 50 years AND there is no evidence of end-organ damage patients not suitable for surgery may be treated with cinacalcet, a calcimimetic a calcimimetic 'mimics' the action of calcium on tissues by allosteric activation of the calcium-sensing receptor

Answer 24

the following guidelines are based on the BNF hypoglycaemia treatment summary. in the community (for example, diabetes mellitus patients who inject insulin): Initially, oral glucose 10-20g should be given in liquid, gel or tablet form Alternatively, a propriety quick-acting carbohydrate may be given: GlucoGel or Dextrogel. A 'HypoKit' may be prescribed which contains a syringe and vial of glucagon for IM or SC injection at home in a hospital setting: If the patient is alert, a quick-acting carbohydrate may be given (as above) If the patient is unconscious or unable to swallow, subcutaneous or intramuscular injection glucagon may be given. Alternatively, intravenous 20% glucose solution may be given through a large vein

Answer 25

vitamin D supplmentation a loading dose is often needed initially calcium supplementation if dietary calcium is inadequate

Answer 26

alendronate (biphosphonate) is first-line vitamin D and calcium supplementation should be offered to all women unless the clinician is confident they have adequate calcium intake and are vitamin D replete Unfortunately, a number of complicated treatment cut-off tables have been produced in the latest guidelines for patients who do not tolerate alendronate the T-score criteria for risedronate or etidronate are less than the others implying that these are the second line drugs if alendronate, risedronate or etidronate cannot be taken then strontium ranelate or raloxifene may be given based on quite strict T-scores (e.g. a 60-year-old woman would need a T-score < -3.5) the strictest criteria are for denosumab

Answer 27

Management topical lubricants may be needed to help prevent corneal inflammation caused by exposure steroids radiotherapy surgery

Answer 28

Anti-thyroid drugs have emerged as the most popular first-line therapy Carbimazole ATD therapy carbimazole is started at 40mg and reduced gradually to maintain euthyroidism typically continued for 12-18 months the major complication of carbimazole therapy is agranulocytosis an alternative regime is termed 'block-and-replace' carbimazole is started at 40mg thyroxine is added when the patient is euthyroid treatment typically lasts for 6-9 months patients following an ATD titration regime have been shown to suffer fewer side-effects than those on a block-and-replace regime Initial treatment to control symptoms propranolol is used to help block the adrenergic effects Graves' disease are referred to secondary care for ongoing treatment. Radioiodine treatment often used in patients who relapse following ATD therapy or are resistant to primary ATD treatment contraindications include pregnancy (should be avoided for 4-6 months following treatment) and age < 16 years. Thyroid eye disease is a relative contraindication, as it may worsen the condition

Answer 29

The treatment of choice is radioiodine therapy.

Answer 30

Management usually self-limiting - most patients do not require treatment thyroid pain may respond to aspirin or other NSAIDs in more severe cases steroids are used, particularly if hypothyroidism develops

Answer 31

encourage regular exercise such as swimming NSAIDs are the first-line treatment physiotherapy the disease-modifying drugs which are used to treat rheumatoid arthritis (such as sulphasalazine) are only really useful if there is peripheral joint involvement the 2010 EULAR guidelines suggest: 'Anti-TNF therapy should be given to patients with persistently high disease activity despite conventional treatments' research is ongoing to see whether anti-TNF therapies such as etanercept and adalimumab should be used earlier in the course of the disease

Answer 32

encourage regular exercise such as swimming NSAIDs are the first-line treatment physiotherapy the disease-modifying drugs which are used to treat rheumatoid arthritis (such as sulphasalazine) are only really useful if there is peripheral joint involvement the 2010 EULAR guidelines suggest: 'Anti-TNF therapy should be given to patients with persistently high disease activity despite conventional treatments' research is ongoing to see whether anti-TNF therapies such as etanercept and adalimumab should be used earlier in the course of the disease

Answer 33

explanation aerobic exercise: has the strongest evidence base cognitive behavioural therapy medication: pregabalin, duloxetine, amitriptyline

Answer 34

all patients should be offered help with weight loss, given advice about local muscle strengthening exercises and general aerobic fitness paracetamol and topical NSAIDs are first-line analgesics. Topical NSAIDs are indicated only for OA of the knee or hand second-line treatment is oral NSAIDs/COX-2 inhibitors, opioids, capsaicin cream and intra-articular corticosteroids. A proton pump inhibitor should be co-prescribed with NSAIDs and COX-2 inhibitors. These drugs should be avoided if the patient takes aspirin non-pharmacological treatment options include supports and braces, TENS and shock-absorbing insoles or shoes if conservative methods fail then refer for consideration of joint replacement

Answer 35

prednisolone e.g. 15mg/od patients typically respond dramatically to steroids, failure to do so should prompt consideration of an alternative diagnosis

Answer 36

Chronic plaque psoriasis - regular emollients may help to reduce scale loss and reduce pruritus first-line: NICE recommend: a potent corticosteroid applied once daily plus vitamin D analogue applied once daily should be applied separately, one in the morning and the other in the evening) for up to 4 weeks as initial treatment second-line: if no improvement after 8 weeks then offer: a vitamin D analogue twice daily third-line: if no improvement after 8-12 weeks then offer either: a potent corticosteroid applied twice daily for up to 4 weeks, or a coal tar preparation applied once or twice daily short-acting dithranol can also be used Secondary care management Phototherapy narrowband ultraviolet B light is now the treatment of choice. If possible this should be given 3 times a week photochemotherapy is also used - psoralen + ultraviolet A light (PUVA) adverse effects: skin ageing, squamous cell cancer (not melanoma)

Answer 37

Chronic plaque psoriasis - regular emollients may help to reduce scale loss and reduce pruritus first-line: NICE recommend: a potent corticosteroid applied once daily plus vitamin D analogue applied once daily should be applied separately, one in the morning and the other in the evening) for up to 4 weeks as initial treatment second-line: if no improvement after 8 weeks then offer: a vitamin D analogue twice daily third-line: if no improvement after 8-12 weeks then offer either: a potent corticosteroid applied twice daily for up to 4 weeks, or a coal tar preparation applied once or twice daily short-acting dithranol can also be used Secondary care management Phototherapy narrowband ultraviolet B light is now the treatment of choice. If possible this should be given 3 times a week photochemotherapy is also used - psoralen + ultraviolet A light (PUVA) adverse effects: skin ageing, squamous cell cancer (not melanoma) Systemic therapy oral methotrexate is used first-line. It is particularly useful if there is associated joint disease ciclosporin

Answer 38

Chronic plaque psoriasis - regular emollients may help to reduce scale loss and reduce pruritus first-line: NICE recommend: a potent corticosteroid applied once daily plus vitamin D analogue applied once daily should be applied separately, one in the morning and the other in the evening) for up to 4 weeks as initial treatment second-line: if no improvement after 8 weeks then offer: a vitamin D analogue twice daily third-line: if no improvement after 8-12 weeks then offer either: a potent corticosteroid applied twice daily for up to 4 weeks, or a coal tar preparation applied once or twice daily short-acting dithranol can also be used Secondary care management Phototherapy narrowband ultraviolet B light is now the treatment of choice. If possible this should be given 3 times a week photochemotherapy is also used - psoralen + ultraviolet A light (PUVA) adverse effects: skin ageing, squamous cell cancer (not melanoma) Systemic therapy oral methotrexate is used first-line. It is particularly useful if there is associated joint disease ciclosporin Scalp psoriasis -NICE recommend the use of potent topical corticosteroids used once daily for 4 weeks if no improvement after 4 weeks then either use a different formulation of the potent corticosteroid (for example, a shampoo or mousse) and/or a topical agents to remove adherent scale (for example, agents containing salicylic acid, emollients and oils) before application of the potent corticosteroid

Answer 39

symptomatic: analgesia, NSAIDS, intra-articular steroids sulfasalazine and methotrexate are sometimes used for persistent disease symptoms rarely last more than 12 months

Answer 40

DMARD monotherapy +/- a short-course of bridging prednisolone Monitoring response to treatment NICE recommends using a combination of CRP and disease activity (using a composite score such as DAS28) to assess response to treatment Flares flares of RA are often managed with corticosteroids - oral or intramuscular ( methylprednisolone methotrexate is the most widely used DMARD. Monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis. Other important side-effects include pneumonitis sulfasalazine leflunomide hydroxychloroquine

Answer 41

Bilateral hilar lymphadenopthy alone - usually self-limiting Acute sarcoidosis - bed rest, NSAIDs Steroid treatment: oral or IV, depending on severity of disease Indications for steroids patients with chest x-ray stage 2 or 3 disease who are symptomatic. Patients with asymptomatic and stable stage 2 or 3 disease who have only mildly abnormal lung function do not require treatment hypercalcaemia eye, heart or neuro involvement Immunosuppressants: in severe disease

Answer 42

Basics NSAIDs sun-block Hydroxychloroquine the treatment of choice for SLE If internal organ involvement e.g. renal, neuro, eye then consider prednisolone, cyclophosphamide

Answer 43

managed by specialist teams (e.g. renal, rheumatology, respiratory) to allow an exact diagnosis to be made. The mainstay of management is immunosuppressive therapy.

Answer 44

Treatment urgent high-dose glucocorticoids should be given as soon as the diagnosis is suspected and before the temporal artery biopsy if there is no visual loss then high-dose prednisolone is used if there is evolving visual loss IV methylprednisolone is usually given prior to starting high-dose prednisolone there should be a dramatic response, if not the diagnosis should be reconsidered urgent ophthalmology review patients with visual symptoms should be seen the same-day by an ophthalmologist visual damage is often irreversible other treatments bone protection with bisphosphonates is required as long, tapering course of steroids is required low-dose aspirin is sometimes given to patients as well, although the evidence base supporting this is weak

Answer 45

This is essentially prompt and extensive fasciotomies In the lower limb the deep muscles may be inadequately decompressed by the inexperienced operator when smaller incisions are performed Myoglobinuria may occur following fasciotomy and result in renal failure and for this reason these patients require aggressive IV fluids Where muscle groups are frankly necrotic at fasciotomy they should be debrided and amputation may have to be considered Death of muscle groups may occur within 4-6 hours

Answer 46

flucloxacillin for 6 weeks clindamycin if penicillin-allergic

Answer 47

intravenous antibiotics which cover Gram-positive cocci are indicated. The BNF currently recommends flucloxacillin or clindamycin if penicillin allergic antibiotic treatment is normally be given for several weeks (BNF states 4-6 weeks) patients are typically switched to oral antibiotics after 2 weeks needle aspiration should be used to decompress the joint arthroscopic lavage may be required

Answer 48

watchful waiting alpha-1 antagonists e.g. tamsulosin, alfuzosin decrease smooth muscle tone of the prostate and bladder considered first-line: NICE recommend if moderate-to-severe voiding symptoms (IPSS ≥ 8) 5 alpha-reductase inhibitors e.g. finasteride block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH indicated if the patient has a significantly enlarged prostate and is considered to be at high risk of progression . This however takes time and symptoms may not improve for 6 months the use of combination therapy (alpha-1 antagonist + 5 alpha-reductase inhibitor) was supported if there is a mixture of storage symptoms and voiding symptoms that persist after treatment with an alpha-blocker alone, then an antimuscarinic (anticholinergic) drug such as tolterodine or darifenacin may be tried surgery transurethral resection of prostate (TURP)

Answer 49

analgesia good fluid intake consider antibiotic therapy if patients: are systemically very unwell have pre-existing co-morbidities have a CRP of 20-100mg/L (offer delayed prescription) or a CRP >100mg/L (offer antibiotics immediately) NICE Clinical Knowledge Summaries/BNF currently recommend doxycycline first-line doxycycline cannot be used in children or pregnant women alternatives include amoxicillin

Answer 50

admission all patients with life-threatening should be admitted in hospital patients with features of severe acute asthma should also be admitted if they fail to respond to initial treatment. other admission criteria include a previous near-fatal asthma attack, pregnancy, an attack occurring despite already using oral corticosteroid and presentation at night oxygen if patients are hypoxaemic, it is important to start them on supplemental oxygen therapy if patients are acutely unwell they should be started on 15L of supplemental via a non-rebreathe mask, which can then be titrated down to a flow rate where they are able to maintain a SpO₂ 94-98%. bronchodilation with short-acting beta₂-agonists (SABA) high-dose inhaled SABA e.g. salbutamol, terbutaline in patients without features of life-threatening or near-fatal asthma, this can be given by a standard pressurised metered-dose inhaler (pMDI) or by an oxygen-driven nebulizer in patients with features of a life-threatening exacerbation of asthma, nebulised SABA is recommended corticosteroid all patients should be given 40-50mg of prednisolone orally (PO) daily, which should be continued for at least five days or until the patient recovers from the attack during this time, patients should continue their normal medication routine including inhaled corticosteroids. ipratropium bromide: in patients with severe or life-threatening asthma, or in patients who have not responded to beta₂-agonist and corticosteroid treatment, nebulised ipratropium bromide, a short-acting muscarinic antagonist IV magnesium sulphate the BTS notes that the evidence base is mixed for this treatment that is now commonly given for severe/life-threatening asthma IV aminophylline may be considered following consultation with senior medical staff patients who fail to respond require senior critical care support and should be treated in an appropriate ITU/HDU setting. Treatment options include: intubation and ventilation extracorporeal membrane oxygenation (ECMO) Criteria for discharge been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours inhaler technique checked and recorded PEF >75% of best or predicted

Answer 51

Step Notes 1 Newly-diagnosed asthma Short-acting beta agonist (SABA) 2 Not controlled on previous step OR Newly-diagnosed asthma with symptoms >= 3 / week or night-time waking SABA + low-dose inhaled corticosteroid (ICS) 3 SABA + low-dose ICS + leukotriene receptor antagonist (LTRA) 4 SABA + low-dose ICS + long-acting beta agonist (LABA) Continue LTRA depending on patient's response to LTRA 5 SABA +/- LTRA Switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a low-dose ICS 6 SABA +/- LTRA + medium-dose ICS MART OR consider changing back to a fixed-dose of a moderate-dose ICS and a separate LABA 7 SABA +/- LTRA + one of the following options: increase ICS to high-dose (only as part of a fixed-dose regime, not as a MART) a trial of an additional drug (for example, a long-acting muscarinic receptor antagonist or theophylline) seeking advice from a healthcare professional with expertise in asthma Maintenance and reliever therapy (MART) a form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required MART is only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, formoterol) also changed. For adults: <= 400 micrograms budesonide or equivalent = low dose 400 micrograms - 800 micrograms budesonide or equivalent = moderate dose > 800 micrograms budesonide or equivalent= high dose.

Answer 52

physical training (e.g. inspiratory muscle training) - has a good evidence base for patients with non-cystic fibrosis bronchiectasis postural drainage antibiotics for exacerbations + long-term rotating antibiotics in severe cases bronchodilators in selected cases immunisations surgery in selected cases (e.g. Localised disease)

Answer 53

General management >smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion annual influenza vaccination one-off pneumococcal vaccination pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above) Bronchodilator therapy a short-acting beta2-agonist (SABA) or short-acting muscarinic antagonist (SAMA) is first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators the next step is determined by whether the patient has No asthmatic features/features suggesting steroid responsiveness add a long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA) if already taking a SAMA, discontinue and switch to a SABA Asthmatic features/features suggesting steroid responsiveness LABA + inhaled corticosteroid (ICS) if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS if already taking a SAMA, discontinue and switch to a SABA NICE recommend the use of combined inhalers where possible

Answer 54

increase the frequency of bronchodilator use and consider giving via a nebuliser give prednisolone 30 mg daily for 5 days it is common practice for all patients with an exacerbation of COPD to receive antibiotics. NICE do not support this approach. They recommend giving oral antibiotics 'if sputum is purulent or there are clinical signs of pneumonia' the BNF recommends one of the following oral antibiotics first-line: amoxicillin or clarithromycin or doxycycline. NICE Clinical Knowledge Summaries recommend admission if any of the following criteria are met (please see the link for the full list) severe breathlessness acute confusion or impaired consciousness cyanosis oxygen saturation less than 90% on pulse oximetry. social reasons e.g. inability to cope at home (or living alone) significant comorbidity (such as cardiac disease or insulin-dependent diabetes) Oxygen therapy COPD patients are at risk of hypercapnia - therefore an initial oxygen saturation target of 88-92% should be used prior to the availability of blood gases, use a 28% Venturi mask at 4 l/min and aim for an oxygen saturation of 88-92% for patients with risk factors for hypercapnia but no prior history of respiratory acidosis adjust target range to 94-98% if the pCO2 is normal Nebulised bronchodilator beta adrenergic agonist: e.g. salbutamol muscarinic antagonists: e.g. ipratropium Steroid therapy as above IV hydrocortisone may sometimes be considered instead of oral prednisolone IV theophylline may be considered for patients not responding to nebulised bronchodilators Patients with COPD are prone to develop type 2 respiratory failure. If this develops then non-invasive ventilation may be used typically used for COPD with respiratory acidosis pH 7.25-7.35 the BTS guidelines state that NIV can be used in patients who are more acidotic (i.e. pH < 7.25) but that a greater degree of monitoring is required (e.g. HDU) and a lower threshold for intubation and ventilation should be used bilevel positive airway pressure (BiPaP) is typically used with initial settings: Expiratory Positive Airway Pressure (EPAP): 4-5 cm H2O Inspiratory Positive Airway Pressure (IPAP): RCP advocate 10 cm H20 whilst BTS suggest 12-15 cm H2O

Answer 55

only 20% suitable for surgery mediastinoscopy performed prior to surgery as CT does not always show mediastinal lymph node involvement curative or palliative radiotherapy poor response to chemotherapy Surgery contraindications assess general health stage IIIb or IV (i.e. metastases present) FEV1 < 1.5 litres is considered a general cut-off point* malignant pleural effusion tumour near hilum vocal cord paralysis SVC obstruction

Answer 56

weight loss continuous positive airway pressure (CPAP) is first line for moderate or severe OSAHS intra-oral devices (e.g. mandibular advancement) may be used if CPAP is not tolerated or for patients with mild OSAHS where there is no daytime sleepiness the DVLA should be informed if OSAHS is causing excessive daytime sleepiness

Answer 57

Using CURB65, 0: low risk (less than 1% mortality risk) NICE recommend that treatment at home should be considered (alongside clinical judgement) 1 or 2: intermediate risk (1-10% mortality risk) NICE recommend that ' hospital assessment should be considered (particularly for people with a score of 2)' 3 or 4: high risk (more than 10% mortality risk) NICE recommend urgent admission to hospital CRP < 20 mg/L - do not routinely offer antibiotic therapy CRP 20 - 100 mg/L - consider a delayed antibiotic prescription CRP > 100 mg/L - offer antibiotic therapy Management of low-severity CAP amoxicillin is first-line if penicillin allergic then use a macrolide or tetracycline NICE now recommend a 5 day course of antibiotics for patients with low severity community acquired pneumonia Management of moderate and high-severity CAP dual antibiotic therapy is recommended with amoxicillin and a macrolide a 7-10 day course is recommended NICE recommend considering a beta-lactamase stable penicillin such as co-amoxiclav, ceftriaxone or piperacillin with tazobactam and a macrolide in high-severity community acquired pneumonia All cases of pneumonia should have a repeat chest X-ray at 6 weeks after clinical resolution to ensure that the consolidation has resolved and there is no underlying secondary abnormalities

Answer 58

Primary pneumothorax -if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered otherwise, aspiration should be attempted if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted Secondary pneumothorax -if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted. otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours Iatrogenic pneumothorax less likelihood of recurrence than spontaneous pneumothorax majority will resolve with observation, if treatment is required then aspiration should be used ventilated patients need chest drains, as may some patients with COPD Persistentent / recurrent pneumothorax -If a patient has a persistent air leak or insufficient lung reexpansion despite chest drain insertion, or the patient has recurrent pneumothoraces, then video-assisted thoracoscopic surgery (VATS) should be considered to allow for mechanical/chemical pleurodesis +/- bullectomy. Discharge advice Smoking patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men Fitness to fly absolute contraindication, the CAA suggest patients may travel 2 weeks after successful drainage if there is no residual air. The British Thoracic Society recommends not travelling by air for a period of 1 week post check x-ray Scuba diving the BTS guidelines state: 'Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.'

Answer 59

The standard therapy for treating active tuberculosis is: Initial phase - first 2 months (RIPE) Rifampicin Isoniazid Pyrazinamide Ethambutol (the 2006 NICE guidelines now recommend giving a 'fourth drug' such as ethambutol routinely - previously this was only added if drug-resistant tuberculosis was suspected) Continuation phase - next 4 months Rifampicin Isoniazid The treatment for latent tuberculosis is 3 months of isoniazid (with pyridoxine) and rifampicin OR 6 months of isoniazid (with pyridoxine) Patients with meningeal tuberculosis are treated for a prolonged period (at least 12 months) with the addition of steroids Directly observed therapy with a three times a week dosing regimen may be indicated in certain groups, including: homeless people with active tuberculosis patients who are likely to have poor concordance all prisoners with active or latent tuberculosis

Answer 60

Management is with either surgery, radiotherapy or observation.

Answer 61

BPPV has a good prognosis and usually resolves spontaneously after a few weeks to months. Symptomatic relief may be gained by: Epley manoeuvre (successful in around 80% of cases) Brandt-Daroff exercises

Answer 62

Cautery if you can see source blood is visible Packing not visible First line- Topical antiseptic - naseptin- chlorhexidine + first aid dont use if peanut soy allergy If bleeding doesnt stop a10 - 15 minutes Cautery/ anterior pack If fails sphenopalatine ligation in theatre

Answer 63

Supportive rest during the early stages, drink plenty of fluid, avoid alcohol simple analgesia for any aches or pains consensus guidance in the UK is to avoid playing contact sports for 4 weeks after having glandular fever to reduce the risk of splenic rupture

Answer 64

ENT assessment is required to confirm the diagnosis patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved acute attacks: buccal or intramuscular prochlorperazine. Admission is sometimes required prevention: betahistine and vestibular rehabilitation exercises may be of benefit

Answer 65

topical antibiotic or a combined topical antibiotic with a steroid fluclocallin topical - oral antibiotics (flucloxacillin) if the infection is spreading If a patient fails to respond to topical antibiotics then the patient should be referred to ENT.

Answer 66

Acute otitis media is generally a self-limiting condition that does not require an antibiotic prescription. There are however some exceptions listed below. Analgesia should be given to relieve otalgia. Parents should be advised to seek medical help if the symptoms worsen or do not improve after 3 days. If an antibiotic is given, a 5-7 day course of amoxicillin is first-line. In patients with penicillin allergy, erythromycin or clarithromycin should be given. Antibiotics should be prescribed immediately if: -Symptoms lasting more than 4 days or not improving -Systemically unwell but not requiring admission -Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease -Younger than 2 years with bilateral otitis media -Otitis media with perforation and/or discharge in the canal

Answer 67

avoid allergen intranasal corticosteroids nasal irrigation with saline solution

Answer 68

Treatment with penicillin type antibiotics is indicated for bacterial tonsillitis. The indications for tonsillectomy are controversial. NICE recommend that surgery should be considered only if the person meets all of the following criteria sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections) the person has five or more episodes of sore throat per year symptoms have been occurring for at least a year the episodes of sore throat are disabling and prevent normal functioning Other established indications for a tonsillectomy include recurrent febrile convulsions secondary to episodes of tonsillitis obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils peritonsillar abscess (quinsy) if unresponsive to standard treatment Strep pyogenes common pathogen for tonsillitis

Answer 69

Needle aspiration inscision + drainage IV antibiotics Tonsillectomy Prevent recurrence

Answer 70

offer 360° selective laser trabeculoplasty (SLT) first-line to people with an IOP of ≥ 24 mmHg NICE 360° SLT can delay the need for eye drops and can reduce but does not remove the chance they will be needed at all a second 360° SLT procedure may be needed at a later date prostaglandin analogue (PGA) eyedrops should be used next-line NICE the next line of treatments includes: beta-blocker eye drops carbonic anhydrase inhibitor eye drops sympathomimetic eye drops surgery in the form of a trabeculectomy may be considered in refractory cases. Prostaglandin analogues (e.g. latanoprost) Increases uveoscleral outflow Once daily administration Adverse effects include brown pigmentation of the iris, increased eyelash length Beta-blockers (e.g. timolol, betaxolol) Reduces aqueous production Should be avoided in asthmatics and patients with heart block Sympathomimetics (e.g. brimonidine, an alpha2-adrenoceptor agonist) Reduces aqueous production and increases outflow Avoid if taking MAOI or tricyclic antidepressants Adverse effects include hyperaemia Carbonic anhydrase inhibitors (e.g. Dorzolamide) Reduces aqueous production Systemic absorption may cause sulphonamide-like reactions Miotics (e.g. pilocarpine, a muscarinic receptor agonist) Increases uveoscleral outflow Adverse effects included a constricted pupil, headache and blurred vision

Answer 71

softening of the lid margin using hot compresses twice a day 'lid hygiene' - mechanical removal of the debris from lid margins cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo is often used an alternative is sodium bicarbonate, a teaspoonful in a cup of cooled water that has recently been boiled artificial tears may be given for symptom relief in people with dry eyes or an abnormal tear film

Answer 72

Non-surgical: In the early stages, age-related cataracts can be managed conservatively by prescribing stronger glasses/contact lens, or by encouraging the use of brighter lighting. These options help optimise vision but do not actually slow down the progression of cataracts, therefore surgery will eventually be needed. Surgery: Surgery is the only effective treatment for cataracts. This involves removing the cloudy lens and replacing this with an artificial one. NICE suggests that referral for surgery should be dependent upon whether a visual impairment is present, impact on quality of life, and patient choice. Also whether both eyes are affected and the possible risks and benefits of surgery should be taken into account. Prior to cataract surgery, patients should be provided with information on the refractive implications of various types of intraocular lenses. After cataract surgery, patients should be advised on the use of eye drops and eyewear, what to do if vision changes and the management of other ocular problems. Cataract surgery has a high success rate with 85-90% of patients achieving 6/12 corrected vision (on a Snellen chart) postoperatively.

Answer 73

Management is difficult and the prognosis is poor any underlying conditions should be identified and treated (e.g. intravenous steroids for temporal arteritis) if a patient presents acutely then Intraarterial thrombolysis may be attempted but currently, trials show mixed results.

Answer 74

normally a self-limiting condition that usually settles without treatment within 1-2 weeks topical antibiotic therapy is commonly offered to patients, e.g. Chloramphenicol. Chloramphenicol drops are given 2-3 hourly initially whereas chloramphenicol ointment is given qds initially topical fusidic acid is an alternative and should be used for pregnant women. Treatment is twice daily contact lens users topical fluoresceins should be used to identify any corneal staining treatment as above contact lens should not be worn during an episode of conjunctivitis advice should be given not to share towels school exclusion is not necessary

Answer 75

first-line: topical or systemic antihistamines second-line: topical mast-cell stabilisers, e.g. Sodium cromoglicate and nedocromil

Answer 76

All patients optimise glycaemic control, blood pressure and hyperlipidemia regular review by ophthalmology Maculopathy if there is a change in visual acuity then intravitreal vascular endothelial growth factor (VEGF) inhibitors Non-proliferative retinopathy regular observation if severe/very severe consider panretinal laser photocoagulation Proliferative retinopathy panretinal laser photocoagulation following treatment around 50% of patients develop a noticeable reduction in their visual fields due to the scarring of peripheral retinal tissue intravitreal VEGF inhibitors often now used in combination with panretinal laser photocoagulation examples include ranibizumab strong evidence base suggests they both slow progression of proliferative diabetic retinopathy and improve visual acuity if severe or vitreous haemorrhage: vitreoretinal surgery

Answer 77

Referral contact lens wearers assessing contact lens wearers who present with a painful red eye is difficult an accurate diagnosis can only usually be made with a slit-lamp, meaning same-day referral to an eye specialist is usually required to rule out microbial keratitis stop using contact lens until the symptoms have fully resolved topical antibiotics typically quinolones are used first-line cycloplegic for pain relief e.g. cyclopentolate

Answer 78

Treatment the AREDS trial examined the treatment of dry ARMD in 3640 subjects. It showed that a combination of zinc with anti-oxidant vitamins A,C and E reduced progression of the disease by around one third. Patients with more extensive drusen seemed to benefit most from the intervention. Treatment is therefore recommended in patients with at least moderate category dry ARMD. vascular endothelial growth factor (VEGF) VEGR is a potent mitogen and drives increased vascular permeability in patients with wet ARMD a number of trials have shown that use of anti-VEGF agents can limit progression of wet ARMD and stabilise or reverse visual loss evidence suggests that they should be instituted within the first two months of diagnosis of wet ARMD if possible examples of anti-VEGF agents include ranibizumab, bevacizumab and pegaptanib,. The agents are usually administered by 4 weekly injection. laser photocoagulation does slow progression of ARMD where there is new vessel formation, although there is a risk of acute visual loss after treatment, which may be increased in patients with sub-foveal ARMD. For this reason anti-VEGF therapies are usually preferred.

Answer 79

high-dose steroids recovery usually takes 4-6 weeks

Answer 80

admission to hospital for IV antibiotics due to risk of cavernous sinus thrombosis and intracranial spread

Answer 81

Management any patients with new onset flashes and floaters should be referred urgently (<24 hours) to an ophthalmologist for assessment with a slit lamp and indirect ophthalmoscopy for pigment cells and vitreous haemorrhage

Answer 82

same-day assessment by an ophthalmologist oral NSAIDs are typically used first-line oral glucocorticoids may be used for more severe presentations immunosuppressive drugs for resistant cases (and also to treat any underlying associated diseases)

Answer 83

urgent review by ophthalmology cycloplegics (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine, cyclopentolate steroid eye drops

Answer 84

conservative artificial tears may sometimes be used

Answer 85

immediate referral to an ophthalmologist topical aciclovir

Answer 86

The management of AACG is an emergency and should prompt urgent referral to an ophthalmologist. Emergency medical treatment is required to lower the IOP with more definitive surgical treatment given once the acute attack has settled. There are no guidelines for the initial medical treatment emergency treatment. An example regime would be: combination of eye drops, for example: a direct parasympathomimetic (e.g. pilocarpine, causes contraction of the ciliary muscle → opening the trabecular meshwork → increased outflow of the aqueous humour) a beta-blocker (e.g. timolol, decreases aqueous humour production) an alpha-2 agonist (e.g. apraclonidine, dual mechanism, decreasing aqueous humour production and increasing uveoscleral outflow) intravenous acetazolamide reduces aqueous secretions Definitive management laser peripheral iridotomy creates a tiny hole in the peripheral iris → aqueous humour flowing to the angle

Answer 87

Co-amoxiclav

Answer 88

Flucloxacillin

Answer 89

More than 4cm - massectomy Mutifoccal tumor Central tumor Large lesion in small WIDE lOCAL LESION Small lesion in large breast sollitary lesion peripheral tumour Less than 4cm Pre meno - tamoxifen ( increase risk endometrial cancer) Post - aramotase inhibitor anastrozole AGE 30+ unexplained breast lumb Age 50+ discharge retraction 1 nipple only = 2 week wait cancer Nonurgent referal <30 unexplained breast lump

Answer 90

Excision <3cm

Answer 91

Localised Localised advanced T1-T2 and T3 T4- Radical prostactemy- complication erectlile dysfunction Raditherapy Complication- proctitis T1-T2 sig morbility - watchful wait Metastic prostate - GrH agonsit Cover wirth antiandrogen to prevent tumour flare Biclutamide

Answer 92

TURBT risk - smoking anoline dyes

Answer 93

Oral high dose Dexamethathone whole Mri spine within 24hrs

Answer 94

Primary prevention atorvastatin 20mg

Answer 95

Low dose aspirin- primary prevention Life long warfirin - secondary preention after 1st VTE

Answer 96

Single topuical therapy Topical retinoids / bezoyl peroxide Topical combination theray of above Oral antibiotics - tetracyclines - Erythromycin Cocp for females oral isotretinon - specialst superviosn -tetragenic

Answer 97

Adrenal adenoma - laproscopic surgery Bilateral hyperplasia antagonist e.g spironolactone

Answer 98

Hyrocortisone split in 2 first half of day Flutrocortison Give Iv FOR CRISES Double the hydrocortisone keep flucro the same recurrent illness + addisons disease