What should I prescribe?

Question 1

Primary hypertension with type 2 diabetes
Primary hypertension without diabetes, <55 and not black

Answer 1

1- ACEi or ARB
2- ACEi or ARB + CCB or thiazide-like diuretic
3- ACEi or ARB + CCB + thiazide-like diuretic

+offer lifestyle advice
use clinical judgement for pts with frailty or multimorbidity

Question 2

Primary hypertension without diabetes and >55
Primary hypertension without diabetes and black

Answer 2

1- CCB
2- CCB + ACEi or ARB or thiazide-like diuretic
3- ACEi or ARB + CCB + thiazide-like diuretic

+offer lifestyle advice
use clinical judgement for pts with frailty or multimorbidity

Question 3

Step 4 treatment of resistant hypertension (if BP not controlled on optimal tolerated doses)

Answer 3

If the person is already taking three antihypertensive drugs and blood pressure is not controlled (resistant hypertension), consider adding spironolactone if blood potassium level is 4.5 mmol/L or lower.

Monitor renal function and sodium and potassium within a month of commencing treatment and repeat as needed.

Alpha and beta blockers should be considered instead if high [K+]

Question 4

Chronic HF
(aims: reduction in symptoms, managed increase in exercise tolerance, address comorbidities (arrhthymias, hyperlipidemia, diabetes) increase quality of life and slow progression of HF)

Answer 4

Correct underlying cause e.g. valve repair/angioplasty
Non-pharm: reduce salt and liquid intake , avoid salt substitutes as can cause hyperK
Pharm: Diuretics e.g. furosemide

Question 5

HFpEF

Answer 5

Offer Diuretics e.g. furosemide
Offer personalised exercise based cardiac rehabilitation programme

Question 6

HFrEF

Answer 6

Offer diuretics e.g. furosemide
Offer ACEi (or ARB if intolerant) and BB
an MRA e.g. spiranolactone

Question 7

Acute HF

Answer 7

IV nitrates, sympathetic ionotropes

Question 8

H. pylori

Answer 8

Triple therapy:
PPI (e.g. omeprazole) and two antibiotics (typically metronidazole and tetracycline)
Leicester guidelines are clarithromycin and amoxyxillin/metronidazole if penicillin allergic

Question 9

Asthma first line

Answer 9

Step 1: SABA e.g. salbutamol “reliever”
Step 2: Low-dose inhaled corticosteroids “preventer”

Question 10

Acute, severe and life-threatening asthma

Answer 10

O2
High dose nebulised B2 agonist (salbutamol)
Nebulised ipratropium bromide
Oral steroids e.g. prednisolone

Consider i.v. aminophylline if life threatening and no success with above

Question 11

Wolff-Parkinson-White Syndrome

Answer 11

Flecainide
(Amiodarone)
Avoid AV node blocking drugs as can cause VF

Question 12

T2DM

Answer 12

1st line - Metformin

Question 13

Arterial thrombi

Answer 13

Rich in platelets so anti-platelet therapy (low in fibrin, usually form at site of atherosclerosis)

Question 14

Secondary prevention post MI

Answer 14

Lifestyle modifications - diet, exercise smoking cessation
Cardiac rehab

Medical:
- ACEi e.g. Ramipril 10mg (improves cardiac remodelling of heart, reduces BP)
- Duel anti-platelet: aspirin (lifelong) + clopidogrel (12 months)
- Beta blocker e.g. Bisoprolol 5mg (prevents arrhythmia and lowers BP)
- Statin e.g. altorvastatin 80mg

Question 15

Acute exacerbation of COPD

Answer 15

Nebulised salbutamol and/or ipratropium
Air driven if hypercapnic/acidotic
Oral steroids
Antibiotics

Question 16

Benign paroxysmal positional vertigo

Answer 16

Epley manoeuvre to treat - shifts crystals away from stereocillia

Presents with vertigo only
Short lived episodes (seconds) triggered by movement of head
Dix-Hallpike test to diagnose

Question 17

Meniere’s disease

Answer 17

Symptomatic control with:
- prochlorperazine, which helps relieve severe nausea and vomiting
- antihistamines, which help relieve mild nausea, vomiting and vertigo

Vertigo, hearing loss and tinnitus (typically unilateral)
Also aural fullness, N&V
Longer lasting symptoms - 30 mins up to 24 hrs)
Recurrent episodes and hearing may deteriorate over time
Thought to be due to increased fluid pressure in inner ear but not fully understood

Question 18

Central retinal artery occlusion

Answer 18

Ocular massage - try to dislodge thrombus but not strong evidence it works

Sudden painless loss of vision in one eye developing over seconds - due to embolus causing occlusion
Cherry red spot (macula - thinner so well perfused choroid shows through) on fundoscopy - pale retina due to ischemia (pallor)

Question 19

Open-angle glaucoma

Answer 19

Prostaglandin analogue eye drops (e.g. latanoprost), may need surgery

Chronic - most common
Trabecular network deteriorates with age
Mainly asymptomatic - picked up on routine eye tests
Increased IOP -> optic disk cupping
Gradual loss of peripheral vision
Optic nerve damage secondary to raised IOP

Question 20

Closed-angle glaucoma

Answer 20

Drugs to reduce IOP then surgery

Acute - less common
Narrowing of the iridocorneal angle
Ophthalmological emergency -> sight threatening

Acutely painful red eye, irregular oval-shaped pupil (fixed), blurring of vision, halo’s around lights (due to corneal oedema), N&V

Question 21

AF

Answer 21

Rate control to slow conduction through AV node and reduce HR
1st line - Bisoprolol
Verapamil if asthma

Rhythm control to keep in normal rhythm
- Sotalol
- Flecainide

Question 22

Ectopic beats (aka atrial tachy)

Answer 22

1st line - Bisoprolol
Ca channel blockers if asthmatic

Question 23

Sinus tachy

Answer 23

1st line - Ivabradine - no drop in blood pressure
2nd - Bisoprolol
Verapamil if asthma

Question 24

Intestinal volvulus

Answer 24

Surgery - emergency

Sigmoid colon most commonly affected but also seen in caecum
Increased in children with intestinal malrotation -> improper anchoring of intestines to posterior abdo wall
When colon twists around mesentry

Coffee bean sign in sigmoid

Caused by: constipation, high fibre diet

S&L bowel obstruction
CT abdo and pelvis

Question 25

Ventricular Tachy

Answer 25

Without haemodynamic instability (/low risk) - IV Amiodarone
High risk - DC Cardioversion

Question 26

Torsades de pointes

Answer 26

IV magnesium sulphate

Question 27

High risk bradycardia

Answer 27

IV atropine

Question 28

Supraventricular tachy

Answer 28

1- Valsalva manoeuvre (blow through tube)
2- Carotid sinus massage
3- IV Adenosine or verapamil
4 - DC cardioversion

Question 29

Sinus tachy

Answer 29

Propranolol or bisoprolol

Question 30

Stress urinary incontinence

Answer 30

Duloxetine
(combined seratonin and NA uptake inhibitor - increases storage phase)

Question 31

Urge urinary incontinence

Answer 31

1st line - Oxybutynin (Muscularinic anticholineric)
Alternative - Mirabegron (Beta-3 adrenoceptor agonist)