Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Y3 z Symptom differentials/cases > YR 3 Management > Flashcards

YR 3 Management Flashcards

1
Q

ALCOHOL WITHDRAWAL

A

o IV vitamin B complex (Pabrinex -prevents progression to Wernicke-Korsakoff)
o Reducing doses of Chlordiazepoxide (reduces symptoms alcohol withdrawal)
o Close attention to dehydration, electrolyte imbalances and infections
o Nutritional support
o Lactulose and phosphate enemas may help any encephalopathy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

ANAPHYLAXIS

A 
o	ABCDE
o	High flow Oxygen
o	IM Adrenaline 
o	IV Chlorpheniramine (antihistamine)
o	IV Hydrocortisone 
o	IV crystalloid/colloid to maintain blood pressure if hypotensive
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

ABSCESS

A

o - Incision and Drainage

o - Antibiotics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

CELLULITIS

A

o If Erysipelas : draw around the lesion, analgesia and Abx
o Medical: oral penicillins (flucloxacillin) or tetracyclines
o Surgical: orbital decompression needed in orbital cellulitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

INFECTIOUS MONONUCLEOSIS

A

o Bed Rest
o Paracetamol and NSAIDs (for fever and malaise)
o Corticosteroids in severe cases
o NB: do NOT give AMPICLLIN or AMOXICILLIN if infectious mononucleosis is suspected – nearly 100% patients with IM develop a maculopapular rash
o Avoid sport for 2 weeks (risk of splenic rupture)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

VARICELLA ZOSTER VIRUS

A

o Chicken Pox in children: treat symptoms
o Chicken Pox in adults: consider Aciclovir
o Shingles: Aciclovir, valaciclovir, famciclovir

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

ACUTE ASTHMA

A

o ABCDE
o Resuscitate
o Monitor O2 sats, ABG and PEFR
o High flow oxygen
o Salbutamol nebulizer (5mg, initially continuously, then 2-4hourly)
o Ipratropium nebulizer (0.5mg, QDS)
o Steroid therapy (100-200mg IV hydrocortisone, followed by 40mg oral prednisolone for 5-7 days)
o If no improvement  IV magnesium sulphate
o Consider IV aminophylline
o Consider IV salbutamol
o NB: normal PCO2 is a BAD SIGN in a patient having an asthma attack (patient is fatiguing and can’t blow off CO2)
o Treat underlying cause (e.g. infection)
o Give Antibiotics if underlying infection
o Monitor electrolytes closely because bronchodilators and aminophylline cause a drop in K+
o Discharge when:

 - PEF >75% predicted
 - Diurnal variation <25%
 - Inhaler technique checked
 - Stable on discharge medication for 24hours
 - Patient owns a PEF meter
 - Patient has steroid and bronchodilator therapy
 - Arrange follow-up

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

CHRONIC ASTHMA

A

o STEP 1
 Inhaled SABA as needed
o STEP 2
 1st line: low dose (400mcg/day) ICS + SABA as needed
 2nd line: leukotriene receptor anatagonist (LRTA) + SABA as needed
o STEP 3
 1st line: low dose ICS + LABA + SABA as needed
 1st line: medium dose (800mcg/day) ICS + SABA
 2nd line: low dose ICS + LRTA + SABA as needed
o STEP 4
 1st line: medium dose ICS + LABA (or tiotropium) + SABA as needed
 2nd line: medium ICS + LRTA + SABA as needed
o STEP 5
 1st line: high dose (2000mcg/day) ICS + LABA (or tiotropium) + immunomodulator + SABA as needed
o STEP 6
 1st line: oral corticosteroids + high dose ICS + LABA (or tiotropium) + immunomodulator + SABA as needed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

BRONCHIECSTASIS

A

o Treat acute exacerbations with TWO IV antibiotics, which cover Pseudomonas Aeruginosa (Aminoglycosides, Quinolones)
o Prophylactic Abx in patients with frequent exacerbations
o Inhaled corticosteroids (e.g. fluticasone) reduces inflammation and volume of sputum but doesn’t affect freq. exacerbations
o Bronchodilators
o Maintain hydration
o Flu Vaccination
o Physiotherapy (sputum and mucus clearance to reduce exacerbations)
o Bronchial artery embolization (if life-threatening haemoptysis)
o Surgical: localized resection, lung or heart-lung transplantation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

COPD

A

o Stop smoking
o Bronchodilators:
 SABA (salbutamol)
 Anticholinergics (ipratropium bromide)
 LABA (if >2 exacerbations a year)
o Steroids:
 Inhaled beclomethasone in all patients with FEV1 <50% of predicted or >2 exacerbations per year
 Regular oral steroids should be avoided
o Pulmonary rehabilitation
o Oxygen therapy
 Only if stopped smoking
 If PaO2 <7.3kPa on air during a period of clinical stability
 PaO2: 7.3-8kPa and signs of secondary polycythaemia, nocturnal hypoxaemia, peripheral oedema or pulmonary HTN
o ACUTE exacerbation:
 24% O2 via a venturi mask
 Increase slowly in no hypercapnia and still hypoxic (do an ABG)
 Corticosteroids
 Start empirical Abx therapy if evidence of infection
 Respiratory physiotherapy to clear sputum
 Non-invasive ventilation in severe cases
o Prevent exacerbations with pneumococcal and influenza vaccination

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

PNEUMONIA

A

o Empirical antibiotics
 - 0 markers: Oral amoxicillin
 - 1 marker: Oral/IV Amoxicillin + Erythromycin
 - >1: IV Cefuroxime/Cefortaxime/Co-amoxiclav + Erythromycin
 - Add metronidazole if: aspiration, lung abscess, empyema
 - Switch to appropriate Abx based on sensitivity
 (CAP)Legionella
• Fluoroquinolones (ciprofloxacin) and macrolide (clarithromycin)
 (CAP)Mycoplasma pneumonia
• Macrolides (clarithromycin)
 (CAP) Chlamydophilia Pneumoniae:
• Doxyclcine or Clarithromycin
 (HAP) S.Aureus
• Flucloxacillin +- Vifampicin, vancomycin for MRSA
 (HAP) Pseudomonas Aeruginosa
• Piptazobactam or ciprofloxacin +- gentamicin IV

o Supportive treatment: oxygen, IV fluids, CPAP, BiPAP or ITU care for respiratory failure
o For atypical, give a macrolide

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

TENSION PNEUMOTHORAX

A

o Maximum O2
o Insert large bore needle into 2nd IC space MCL
o Up to 2.5L of air can be aspirated
o Stop if patient coughs or resistance is felt
o Follow up CXR 2hrs and 2 weeks later

PRIMARY & PT <50YRS:

  • <2cm: oxygen and discharge
  • > 2cm aspiration, and IC drain if unsuccessful

SECONDARY OR PT>50

  • > 2cm: IC drain (aspirate if still >1cm)
  • 1-2 cm: aspiration
  • <1cm : high flow oxygen
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

RECURRENT PNEUMOTHORACES

A
  • Chemical pleurodesis (fusing of visceral and parietal pleura with tetracycline)
  • Surgical pleurectomy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

PULMONARY EMBOLISM

A 
o	Haemodynamically stable: 
	- O2
	- Anticoagulation with heparin or LMWH
	- Switch to oral warfarin for at least 3 months (maintain INR 2-3)
	- Analgesia 
o	Haemodynamically unstable: 
	- Resuscitate
	- O2
	- IV fluids
	- Thrombolysis with tPA may be considered if cardiac arrest is imminent 
o	Surgical/Radiological:
	Embolectomy 
	IVC filters
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

ATRIAL FIBRILLATION

A

o Rhythm Control
 -If >48hrs since onset of AF, anticoagulate for 3-4 weeks before attempting cardioversion
 -If <48hrs since onset of AF,
• DC cardioversion
• Chemical (flecainide or amiodarone if IHD)
 -Prophylaxis against AF : Sotalol, Amiodarone, Flecainide
o Rate Control (Chronic AF)
 Control ventricular rate with digoxin, verapamil and beta-blockers
 Aim for ventricular rate -90bmp
o Stroke risk Stratification (CHADS-Vasc)
 -Low Risk patients managed with aspirin
 -High Risk patients require anticoagulation with warfarin
 -RFs : previous thromboembolic event, >75yrs, HTN, DM, CVD, HF, impaired left ventricular function

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

CARDIAC ARREST

A

o Safety, ABCDE
o Advanced Life Support
 Attack Cardiac monitor and defibrillator
 If pulseless ventricular tachycardia or ventricular fibrillation (shockable rhythms)
• Defibrillate once (150-360 J biphasic, 360 J monophasic)
• Resume CPR for 2mins & reassess rhythm and shock again if still pulseless VT or VF
• Administer adrenaline (1mg IV) after second defibrillation and again every 3-5mins
• If shockable rhythm persists after 3rd shock – administer amiodarone 300mg IV
 If PEA of asystole
• CPR for 2, then reassess rhythm
• Administer adrenaline (Img IV) every 3-5mins
• Atropine (3mg IV, once only) if asystole or PEA with rate <60bpm
 During CPR:
• Check electrodes, paddle positions and contacts
• Secure airway
o Once secure, give continuous compressions and breaths
• Consider Mg, bicarbonate and external pacing
• Stop CPR and check pulse only if change in rhythm or signs of life
o Treatment of reversible causes:
 -Hypothermia: warm slowly
 -Hypokalaemia and Hyperkalaemia: correct electrolyte levels
 -Hypovolaemia: IV colloids, crystalloids and blood products
 -Tamponade: pericardiocentesis or chest drain
 -Tension pneumothorax: aspiration or chest drain
 -Thromboembolism: treat as PE or MI
 -Toxins: use antidote for given toxin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

ACUTE LEFT VENTRICULAR FAILURE

A

o Treat Cardiogenic shock
 (Severe cardiac failure with low BP)
 Managed in ITU by using inotropes (e.g. dobutamine)
o Treating pulmonary oedema
 -Sit the patient up
 -60-100% oxygen (and consider CPAP)
 -Diamorphine ( venodilator +anxiolytic)
 -GTN infusion (venodilator  reduced preload)
 -IV furosemide (venodilator and later diuretic effect)
 -Monitor BP, RR, O2 sats, urine output, ECG
 -Treat the Cause !

If the patient is worsening: further dose of furosemide, consider CPAP (improves ventilation by recruiting more alveoli, driving fluid out of alveolar spaces and into vasculature. Increase nitrate infusion without dropping systolic BP <100.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

CHRONIC LEFT VENTRICULAR FAILURE

A

o Treat the cause ! (e.g. hypertension)
o Treat exacerbating factors (e.g. anaemia)
o ACE inhibitors (Inhibits RAS and inhibits adverse cardiac remodelling, slows down progression of HF to improve survival)
o Beta-Blockers (Blocks the effects of a chronically activated sympathetic system. Slows the progression of HF and improves survival )
o Loop Diuretics
 - Alongside dietary salt restriction, can correct fluid overload
o Aldosterone Antagonist
 - Improves survival in patients with NYHA class III/IV symptoms on standard therapy
 Monitor K+ (drugs cause hyperkalaemia)
o Angiotensin Receptor Blockers
 - May be added in patients with persistent symptoms despite the use of ACE inhibitors and beta-blockers (monitor K+ again)
o Hydalazine and a Nitrate
 May be added in patients (particularly Afro-Caribbeans) with persistent symptoms despite the use of ACE inhibitors with beta-blockers
o Digoxin
 - Positive inotrope
o Cardiac resynchronization therapy
 Biventricular pacing improves symptoms and survival in patients with a left ventricular ejection fraction <35% , cardiac dyssynchrony (QRS >120msec) and moderate-severe symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

DEEP VEIN THROMBOSIS

A

o Anticoagulation
 -Heparin whilst waiting for warfarin to increase INR to the target range of 2-3
 -DVTs that don’t extend above the knee may be observed and anticoagulated for 3 months
 -DVTs extending beyond the knee require anticoagulation for 6 months
 -Recurrent DVTs require long-term warfarin
o IVC filter
 -Used if anticoagulation is contraindicated and there is risk of embolization
o Prevention
 -Graduated compression stockings
 -Mobilization
 -Prophlyactic heparin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

HEART BLOCK

A

o Chronic:
 -Permanent pacemaker recommended in complete heart block, advanced Mobitz type II, symptomatic Mobitz type I
o Acute:
 -If associated with clinical deterioration use IV atropine , and consider temporary pacemaker

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

HYPERTENSION

A

o Conservative
 -Stop smoking, lose weight, reduce alcohol, reduce dietary sodium
o Ix secondary causes
o Medical – treatment recommended if systolic >160mmHg and/or diastolic >100mmHg, or if evidence of end-organ damage.
o Stage 1: Clinic BP >140/90mmHg and subsequent ABPM or HBPM >135/85
o Stage 2: Clinic BP >160/90 and subsequent ABPM or HBPM>150/95
o Severe (stage 3): Clinic SBP>180 or clinic DBP>110
 ACE inhibitors/ARBs are first line if
• <55yrs
• Diabetic
• Heart Failure
• Left ventricular dysfunction
 CCBs are first line if:
• >55yrs
• Afro-Caribbean
• Thiazide diuretics can be used if CCBs not tolerated
o 2nd line:
 Combine ACEi/ARB with CCB
o 3rd line:
 Combine ACEi/ARB with CCB plus thiazide like diuretic
o 4th line
 ACEi/ARB + CCB + thiazide like diuretic +
• Further diuretic
• OR alpha-blocker
o (may be used in patients with prostate disease)
• OR beta-blocker
o May be considered in younger patients or in patients with AF
o Target BP
 Non-diabetic: <140/90mmHg
 Diabetes without proteinuria: <130/80mmHg
 Diabetes WITH proteinuria: <125/75mmHg
o Acute Malignant Hypertension Management
 -IV beta-blocker (e.g. esmolol)
 -Labetolol
 -Hydralazine sodium nitroprusside
 * NB avoid rapid lowering of BP, it can cause cerebral infarction because the autoregulatory mechanisms within the brain for regulating blood flow cause vasoconstriction of the vessels . Lowering rapidly would mean they don’t adapt.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

INFECTIVE ENDOCARDITIS

A 
o	Antibiotics for 4-6weeks
o	On clinical suspicion = empirical treatment with benzylpenicillin and gentamicin 
o	Streptococci- continue same as above 
o	Staphylococci: 
	flucloxacillin/vancomycin 
	gentamicin 
o	Enterococci:
	Ampicillin 
	Gentamicin 
o	Culture negative:
	Vacomycin
	Gentamicin 
o	Surgery: urgent valve replacement may be needed if there is a poor response to Abx
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

STABLE ANGINA

A

o Minimize cardiac risk factors (BP, hyperlipidaemia, DM)
 -All pts should receive aspirin 75mg/day unless contraindicated
o Immediate symptom relief (e.g. GTN spray)
o Long-term management
 Beta-blockers
• Contraindicated in : Acute HF, cardiogenic shock, bradycardia, heart block, asthma
 -Calcium Channel Blockers
 -Nitrates
o Percutaneous Coronary Intervention (PCI)
 Performed in patients with stable angina despite maximal tolerable medical therapy
o Coronary Artery bypass graft (CABG)
 Occurs in more severe cases (e.g. three-vessel disease)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

UNSTABLE ANGINA/NSTEMI

A

o Admit to coronary care unit
o Oxygen, IV access, monitor vital signs and serial ECG
o GTN
o Morphine (with metoclopramide to counteract nausea)
o Aspirin (300mg initially, followed by 75mg for at least a year if troponin positive or high risk)

If stratified by GRACE score to be intermediate to high risk, continue: (if not , maintain conservative strategy)
o LMWH (e.g. fondaparinux)
o Clopidogrel (300mg initially, followed by 75mg for at least a year if troponin positive or high risk)
o. IV nitrate (e.g.GTN)
o Beta-blocker (e.g. bisprolol)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

STEMI

A
  • Attach ECG monitor and IV access
  • 300mg Aspirin
  • 300mg Clopidogrel (or 180mg Ticagrelor)
  • 5-10mg IV Morphine + anti-emetic (e.g. metoclopramide)
  • If confirmed STEMI on ECG, and PCI is available within 120 mins: perform primary PCI
  • If not, consider fibrinolysis
    •Rescue PCI may be performed if continued chest pain or ST elevation after thrombolysis
    •STEMI patients and high-risk NSTEMI patients (harm-dynamically unstable) should receive immediate angiography +- PCI.
    • CABH considered in patients with 3 vessel disease

 -Secondary Prevention
• Anticoagulate with fondaparinux until discharge
• Dual antiplatelet therapy for a year (aspirin + clopidogrel)
• Beta blockers
• ACEi
• Statins (high dose atorvastatin)
• Control risk factors (stop smoking, manage diet and exercise)
 -Advice
• No driving for 1 month following MI
 -CABG
• Considered in patients with left main stem or three-vessel disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

PERICARDITIS

A 
o	Acute
	-Cardiac tamponade is treated with emergency pericardiocentesis 
o	Medical 
	-Treat underlying cause
	-NSAIDs for pain and fever relief 
o	Recurrent
	-Low-dose steroids
	-Immunosuppressants
	-Colchicine
o	Surgical 
	-Pericardiectomy performed in cases of constrictive pericarditis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

SVT

A

o If haemodynamically UNSTABLE:
 -Synchronized DC cardioversion
o If haemodynamically STABLE  Vagal & Chemical Cardioversion
 -Vagal manoeuvres (e.g. Valsalva, carotid massage)
• Carotid massage could dislodge atherosclerotic plaques, so is only performed in young patients
 If vagal manoeuvres fail
• 6mg bolus of Adenosine (2nd time increase to 12mg)
o Contraindicated in ASTHMA as it can cause bronchospasm . If so give verapamil 2.5-5mg
o Alternatives: atenolol, amiodarone
o If unresponsive to chemical cardioversion or tachycardia >250bpm or adverse signs (low BP, HF, low consciousness)
• Sedate and synchronized DC cardioversion
• OR IV amiodarone , OR IV digoxin, OR IV beta-blocker

o Ongoing management of SVT:
 AVNRT
• Radiofrequency ablation of slow pathway
• Beta-blockers
• Alternatives: feicanide, propafenone, verapamil
 AVRT
• Radiofrequency ablation
 Sinus Tachycardia
• Exclude secondary cause (e.g. hyperthyroidism)
• Beta-blocker or rate-limiting CCB

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

VARICOSE VEINS

A

o Conservative
 -Exercise- improves skeletal muscle pump
 -Elevation of legs at rest
 -Support stockings
o Venous Telangiectasia and Reticular Veins
 -Laser sclerotherapy
 -Microinjection sclerotherapy
o Surgical
 -Saphenofemoral ligation
 -Stripping of the long saphenous vein (don’t damage the short because high risk of damaging the sural nerve)
 -Avulsion of varicosities

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

VENOUS ULCER

A

o Graduated compression (reduced venous stasis)
 NOTE: must exclude diabetes, neuropathy and PVD before this is attempted
o Debridement and cleaning
o Antibiotics- if infected
o Topical steroids – may help with surrounding dermatitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

VENTRICULAR FIBRILLATION

A

o ! Urgent defibrillation and cardioversion
o Patients who survive need full assessment of left ventricular function, myocardial perfusion and electrophysiological stability
o Most survivors will need an implantable cardioverter defibrillator (ICD)
o Empirical beta-blockers
o Some patients may be treated with radiofrequency ablation (RFA)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

VENTRICULAR TACHYCARDIA

A

o ABC approach
o Check if the patient has a PULSE
o Pulseless: follow advanced life support algorithm
o Unstable VT – reduced cardiac output
 NB: VF and pulseless VT require defibrillation (unsychronised), but other VTs can be treated with synchronized cardioversion
 Correct electrolyte abnormalities
 Amiodarone
o Stable VT
 -These patients DON’T experience symptoms of haemodynamic compromise
 -Correct electrolyte abnormalities
 -Amiodarone
 -Synchronised DC shock (if above steps are unsuccessful)
o Implantable Cardioverter Defibrillator (ICD)
 -ICD is considered if:
• Sustained VT causing syncope
• Sustained VT with ejection fraction <35%
• Previous cardiac arrest due to VT or VF
• MI complicated by non-sustained VT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

FIBROADENOMA

A

Observation and reassurance, but if in doubt refer for USS +- FNA. Surgical excision if large

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

BREAST ABSCESS

A

o Antibiotics
o US guided FNA
o Surgical incision and drainage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

MASTITIS (can lead to a breast abscess)

A

o Encourage breast feeding in general, but NOT from the affected breast
o Analgesia
o Antibiotics (Dicloxacillin or Cephalexin- usually caused by Staph Aureus)
o Open incision or percutaneous drainage if abscess

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

ACROMEGALY

A

o Surgical
 Trans-sphenoidal hypophysectomy is the only curative treatment
o Radiotherapy
 Adjunctive to surgery
o Medical – if surgery contraindicated or refused
 -Subcutaneous somatostatin analogues
 -E.g. ocreteotide, lanreotide
 -SEs: abdo pain, steatorrhoea, glucose intolerance, gallstones
o Oral Dopamine Agonists
 -E.g. bromocriptine, cabergoline
 SEs: nausea, vomiting, constipation, postural hypotension , psychosis
o GH antagonist (pegvisomant)
o Monitor
 GH and IGF-1 levels can be used to monitor disease control

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

ADDISONIAN CRISIS

A

o Rapid IV fluid rehydration (0.9% saline, IL over 30-60mins, 2-4L in 12-24h)
o 50ml of 50% dextrose to correct hypoglycaemia
o IV 200mg hydrocortisone bolus followed by 100mg 6hourly (until BP is stable)
o Treat the precipitating cause (e.g. Abx for infection)
o Monitor temp, pulse, RR, BP, sat 02 and urine output

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

ADRENAL INSUFFICIENCY

A

o Lifelong replacement of:
 Glucocorticoids with hydrocortisone. (3/day)
 Mineralocorticoids with fludrocortisone
o Hydrocortisone dose needs to be increased during times of acute illness or stress
o If patient also has hypothyroidism, give hydrocortisone BEFORE thyroxine (to prevent precipitating an Addisonian crisis)
o Advice:
 -Have a steroid warning card
 -Wear a medic-alert bracelet
 -Emergency hydrocortisone on hand

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

CUSHING SYNDROME

A

o If iatrogenic – discontinue steroids, use lower dose or use a steroid-sparing agent
o Medical
 oUsed pre-operatively or if unfit for surgery
 oInhibit cortisol synthesis with metyrapone or ketoconazole
 oTreat osteoporosis
 Physio for muscle weakness
o Surgical
 oPituitary Adenomas – trans-sphenoidal adenoma resection
 oAdrenal adenoma/carcinoma – surgical removal of tumour
 oEctopic ACTH- treatment directed at the tumour
o Radiotherapy
 oPerformed in those who aren’t cured and have persistent high cortisol after trans-sphenoidal resection of the tumour
o Bilateral adrenalectomy may be performed in refractory Cushing’s disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

DIABETES INSIPIDUS

A

o Treat the CAUSE
o Cranial DI
 -Give vasopressin analogue (desmopressin)
 -If mild – chlorpropamide or carbamazepine can be used to potentiate the residual effects of any residual vasopressin
o Nephrogenic DI
 -Sodium and/or protein restriction helps with polyuria
 -Thiazide diuretics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

DIABETES MELLITUS TYPE 1

A

o Glycaemic control
 -Advice and patient education
• Short-acting insulin (3 times daily before meals)
o Lispro
o Aspart
o Glulisine
• Long-acting insulin (once daily)
o Isophane
o Glargine
o Detemir
 -Insulin pumps
 -DAFNE courses (dose adjustment for normal eating)
 -Monitor
• Regular capillary blood glucose tests
• HbA1c every 3-6months
 -Screening and management of complications
 -Treatment of hypoglycaemia
• If reduced consciousness: 50ml of 50% glucose IV OR 1mg glucagon IM
• If conscious and cooperative: 50mg oral glucose + starchy snack
o In terms of counselling a patient
 -If you’re hypo before a meal, then you have given too much short-acting insulin at the previous meal
 -If you’re hypo in the morning, your long-acting is too high (so measure long acting efficacy first thing in the morning)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

DKA

A

Consider HDU/ICU input, central line, arterial line and urinary catheter if severe acidosis, hypotensive or oliguric 

  • 50 units soluble insulin in 50mL normal 0.9% saline
     (Use an insulin sliding scale )
     Continue until:
    • Capillary ketones <0.3
    • Venous pH >7.3
    • Venous bicarbonate >18mmol/L
     -From this point, change to SC insulin
     -Don’t stop the insulin infusion after 1-2 hours after the SC insulin has restarted
     -FLUIDS: 500mL normal saline over 15-30mins until SBP>100mmHg. IV dextrose is started in conjunction with 0.9% saline when blood glucose reaches 15mmol/L
     -Potassium replacement (because insulin drives potassium into cells)
     -Monitor blood glucose, capillary ketones and urine output hourly
     -Monitor U&;Es and venous blood gas
     -Broad spectrum Abx if infection is suspected
     -Thromboprophylaxis
     -NBM for at least 6hrs
     -NG tube if GCS is reduced
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

TYPE 2 DIABETES MELLITUS

A 
o	Glycaemic control 
	HbA1c above goal at Dx: lifestyle (cardiovascular risk reduction)+ metformin 
	If HbA1c above goal on metformin:
•	1st line: 
o	Metformin + lifestyle +
	SGLT2 inhibitor (empaglifolozin) 
	OR GLP-1 agonist (liraglutide) 
	OR DDP-4 inhibitor (sitagliptin) 
	OR sulphonylurea (glimepiride)
	OR basal insulin (insulin glargine) 
•	2nd line:
o	Metformin + lifestyle + 
	Alpha-glucosidase inhibitor (acarbose)
	OR thiazolidinedione (pioglitazone) 
	If HbA1c is above goal on metformin + either basal insulin or second non-insulin agent:
•	1st line :
o	Individualized augmented regimen + continued CVD risk reduction/lifestyle 
	Usually 3-drug combination, with metformin as a basis) 
o	Switch to basal-bolus insulin + continued CVD risk reduction 
•	2nd line:
o	Bariatric surgery

o Screening for complications
 -Retinopathy
 -Nephropathy
 -Vascular disease
 -Diabetic Foot
 -Cardiovascular risk factors (recommended in all patients at initial diagnosis)
• Blood pressure management
o First line: thiazide and/or ACEi/ARB and/or CCB
• Lipid management
o Atorvastatin
o Pregnancy – requires strict glycaemic control and planning of conception (BMJ: diet + basal-bolus insulin)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

HYPEROSMOLAR HYPERGLYCAEMIC STATE

A

management similar to DKA

 Except use 0.45% saline if serum Na+ >170mmol/L

44
Q

HYPERPARATHYROIDISM

A

o Acute hypercalcaemia
 -IV fluids
 -Avoids factors that exacerbate hypercalcaemia (e.g. thiazide diuretics)
 -Maintain adequate hydration
 -Moderate calcium and vitamin D intake
o Surgical management
 -Subtotal parathyroidectomy
 -Total parathyroidectomy
o Secondary hyperparathyroidism management
 -Treat underlying case (e.g. renal failure)
 -Calcium and vitamin D supplements may be needed

45
Q

HYPOPITUITARISM

A

o Hormone Replacement

  • Hydrocortisone : 20mg in morning, 10mg in evening, and double oral dose for febrile illness
  • L-thryoxine: 100mg daily (always taken after hydrocortisone to prevent addisonian crisis)
  • Sex hormones: Testosterone in males, oestrogen +- progesterone in females.
  • Growth hormones: SC 1.2U/day in adults
  • Posterior pituitary deficiency (damage to pituitary stalk): Desmopressin 10-20micrograms daily
46
Q

HYPOTHRYOIDISM

A

o Chronic
 Levothyroxine (25-200 mcg/day)
• !!Important to rule out adrenal insufficiency before starting thyroid hormone replacement
• Thyroid hormone replacement in the context of adrenal insufficiency can precipitate an Addisonian crisis
• Adjust dose based on clinical picture and TFTs

47
Q

MYXOEDEMA COMA

A

 Oxygen
 Rewarming
 Rehydration
 IV T4/T3
 IV hydrocortisone (in case hypothyroidism is secondary to hypopituitarism)
 Treat underlying cause (e.g. infection)

48
Q

HYPERALDOSTERONISM

A

o Bilateral Adrenal Hyperplasia
 -Spironolactone
 -Eplerenone can be used if the spironolactone side-effects are intolerable
 -Amiloride (potassium-sparing diuretic)
 -Monitor serum K+, creatinine and BP
 -ACE inhibitors and CCBs may also be added
o Aldosterone producing adenomas
 -Adrenalectomy
o Adrenal Carcinoma
 -Surgery
 -Post-operative mitotane (antineoplastic)

49
Q

PROLACTINOMA

A 
o	Goals 
	-Treat cause 
	-Relieve symptoms 
	-Prevent complications 
	-Restore fertility 
o	Dopamine Agonist (e.g. cabergoline and bromocriptine) 
	-Effective in most patients 
	-Usually need to be continued on a long-term basis 
o	If dopamine agonists are ineffective:
	-Surgery
	-Radiotherapy
50
Q

SIADH

A

o Treat the underlying cause
o Fluid restriction
o Vasopressin Receptor antagonists (e.g. tolvaptan)
o In severe cases: slow IV hypertonic saline and furosemide with close monitoring

51
Q

THYROIDITIS

A

o Pharmacological
 -Thyroid hormone replacement – oral levothyroxine sodium
 -Titrate dose based on patient’s needs
o Surgical
 -Considered if there is a large goiter that is causing symptoms due to compression of surrounding structure or if there is a malignant nodule

52
Q

VITAMIN D DEFICIENCY AND OSTEOMALACIA

A 
o	Vitamin D and calcium replacement 
o	Monitor 24h urinary calcium 
o	Also monitor 
	-Serum calcium 
	-Phosphate
	-ALP
	-PTH
	-Vitamin D 
o	Treat the underlying cause !
53
Q

BELLS PALSY

A

o Protection of cornea with protective glasses/patches or artificial tears
o High dose steroids beneficial if given <72hours
 HAVE to exclude Ramsay Hunt first
o Surgery
 -Lateral tarsorrhaphy (suturing the lateral parts of the eyelids together)
 -Performed if imminent or established corneal damage

54
Q

STATUS EPILEPTICUS

A

o ABC (100% oxygen)
o Check glucose (give glucose 50ml 50% if hypoglycaemic)
o IV/PR DIAZEPAM – repeat again after 10mins if seizure doesn’t terminate
o If seizure recurs, consider IV phenytoin – an ECG monitor is required
o If this also fails, consider general anaesthesia (e.g. thiopentone) – intubation and mechanical ventilation required
o Treat the cause (e.g. hypoglycaemia or hyponatraemia)
o Check plasma levels of anticonvulsants (because status epilepticus is often caused by lack of compliance with anti-epileptic medications)

55
Q

NEWLY DIAGNOSED EPILEPSY

A

o Only start anti-convulstant treatment after >2 unprovoked seizures
o FOCAL
 -1st line: lamotrigine or carbamazepine
o GENERAL
 1st line: sodium valproate
o Start treatment with only one anti-epileptic drug
o Other anti-convulsants: phenytoin, levetiracetam, clobazam, topiramate, gabapentin, vigabatrin
o Patient Education:
 -Avoid triggers
 -Seizure diaries
 -Particular consideration for women of child-bearing age because the anti-epileptic drugs can have teratogenic effects
o Surgery may be considered for refractory epilepsy

56
Q

HORNERS SYNDROME

A

o It is a sign and not a disease in itself
o So, the management depends on the cause (e.g. management for carotid dissection is very different to management of apical lung tumours)

57
Q

MENINGITIS

A

o IMMEDIATE IV Antibiotics (before LP)
o First choice: 3rd generation cephalosporin (e.g. cefotaxime or ceftriaxone)
o Benzylpenicillin may be used as an initial blind therapy
o Dexamethasone IV
 Shortly before or with the first dose of Abx
 Associated with a reduced risk of complications
o Resuscitation
 -Manage in ITU
 -Notify public health services

58
Q

MIGRAINE

A

o Acute:
 -NSAIDs
 -Triptans (5-HT1 agonist) – e.g. sumatriptan
 With antiemetic ( metoclopramide)
o Prophylaxis
 -1st line: Beta-blockers or topioramate
 -Amitriptyline
 -Menstrua migraines can be controlled with the oral contraceptive pill
o Advice
 -Avoid triggers
 -Rest in a quiet dark room during episodes

59
Q

STROKE

A 
o	Acute 
	-If<4.5hrs from onset
	-Exclude hemorrhage using CT-head 
	-If hemorrhage excluded, thrombolysis with IV Alteplase , 10% bolus, 90% infusion at a dose of 0.9mg/kg
	-300mg Aspirin 
	-Formal swallowing assessment 
	-GCS monitoring 
	-Thromboprophylaxis 
	-Heparin anticoagulation may be considered if there is a high risk of emboli recurrence of stroke progression 
o	 Prevention
	-Continue with 75mg aspirin for 2 weeks then switch to lifelong clopidogrel or dipyramidole 
	-Lifelong anticoagulation if AF
o	Surgical 
	-Carotid endarterectomy
60
Q

TENSION HEADACHE

A

o Reassurance
o Address triggers (stress, anxiety)
o Advice on avoiding medications that can cause medication-induced headaches (e.g. opioids)
o Simple analgesia (e.g. ibuprofen, paracetamol, aspirin)
o TCAs considered in frequently recurrent episodic tension headaches or chronic tension headaches

61
Q

TRANSIENT ISCHAEMIC ATTACK

A

o Patients with acute neurological symptoms that resolve completely within 24hours should be given 300mg aspirin immediately and assessed urgently within 24hours
o Patients with confirmed TIA should receive:
 -Clopidogrel – 300mg loading dose and 75mg thereafter
 -High-intensity statin therapy – e.g. atorvastatin 20-80mg
o Secondary Prevention
 -Antiplatelets
 -Antihypertensives
 -Lipid-modifying treatments
 -Management of AF
o Assessment of future stroke risk: ABCD2

62
Q

MACROCYTIC ANAEMIA

A 
o	Pernicious Anaemia 
	-IM hydroxycobalamin for life 
o	Folate Deficiency 
	-Oral folic acid 
	-If B12 deficiency is present, it must be treated before the folic acid deficiency
63
Q

MICROCYTIC ANAEMIA

A 
o	Iron Deficiency 
	Oral Iron supplements 
o	Sideroblastic Anaemia 
	-Treat the cause 
	-Pyridoxine used in inherited forms 
	-Blood transfusion and iron chelation can be considered if there is no response to other treatments 
o	Lead poisoning 
	Remove the source 
	Dimercaprol 
	D-penicillinamine
64
Q

SICKLE CELL DISEASE

A 
o	ACUTE PAINFUL CRISIS
	-Oxygen 
	-IV fluids 
	-Strong Analgesia (IV opiates) 
	-Antibiotics 
o	Infection Prophylaxis
	-Penicillin V
	-Regular vaccinations (particularly against capsulated bacteria e.g. pneumococcus)
o	Folic Acid 
	-If severe haemolysis or in pregnancy 
o	Hydroxyurea/Hydroxycarbamide
	-Increases HbF levels 
	-Reduces the frequency and duration of sickle cell crisis 
o	Red Cell Transfusion 
	-For SEVERE anaemia 
	-Repeated transfusions (with iron chelators) may be required in patients suffering from repeated crises
o	Advice
	-Avoid precipitating factors, good hygiene and nutrition, genetic counselling, prenatal screening 
o	Surgical 
	-Bone marrow transplantation 
	-Joint replacement in cases with avascular necrosis
65
Q

GIANT CELL ARTERITIS

A

o Check ESR first
o Immediately give high dose oral prednisolone (40-60mg/day) to prevent visual loss
o Reduce the dose gradually according to symptoms and ESR to a maintenance dose of 7.5-10mg/day
o Low dose ASPIRIN (plus PPIs for gastroprotection) to reduce the risk of visual loss , TIAs or stroke
o If GCA is complicated by visual loss: IV pulse methylprednisolone (Ig for 3days) followed by oral prednisolone

66
Q

POLYMYALGIA RHEUMATICA

A

o Corticosteroids
o Steroid sparing agents (MTX) are sometimes used
o Assistance from physiotherapy and occupational therapy
o Monitor for adverse effects of steroids (osteoporosis)

67
Q

ACUTE KIDNEY INJURY

A

o Treat the cause
o 4 components to management :
 -Protect patient from hyperkalaemia (10% 10mL calcium gluconate)
 -Optimise fluid balance
 -Stop nephrotoxic drugs
 -Consider for dialysis
o Monitor serum creatinine, sodium, potassium, calcium, phosphate and glucose
o Identify and treat infection (Abx)
o Urgent relief of urinary tract obstruction
o Refer to nephrology if intrinsic renal disease is suspected
o Renal Replacement Therapy (RRT) considered if :
 -Hyperkalaemia refractory to medical management
 -Pulmonary oedema refractory to medical management
 -Severe medical acidaemia
 -Uraemic complications

68
Q

BENIGN PROSTATIC HYPERPLASIA

A

o Emergency:
 -Catheterisation
o Conservative (if mild):
 -Watchful waiting
o Medical
 -Selective alpha-blockers (e.g. Tamsulosin) to relax the smooth muscle of the internal urinary sphincter and prostate capsule
 -5alpha-reductase inhibitors (e.g. finasteride) will inhibit the conversion of testosterone to dihydrotestosterone , which can reduce prostate size by around 20%
o Surgery
 -TURP (complications include retrograde ejaculation, haemorrhage, incontinence, TURP syndrome, urinary infection, erectile dysfunction, urethral stricture)
 -Open prostatectomy

69
Q

Epididymitis and orchitis

A

o Medical
 -Antibiotics (type depends on causative organism – Chlamydia, Gonococcus, E.Coli or Klebsiella)
o Surgical
 -Exploration of testicles if testicular torsion cannot be excluded clinically
 -Required if an abscess develops

70
Q

TESTICULAR TORSION

A

o Exploration of the scrotum within 6 hours of onset of symptoms
o After the testicle is twisted back into place, a bilateral orchidopexy is performed
 -Suturing the testicle to the scrotal tissue to prevent recurrence
o If the testicle is necrotic, orchidectomy may be performed

71
Q

URINARY TRACT CALCULI

A

o ACUTE
 -Analgesia
 -Bed rest
 -Fluid replacement
 -Urine collection to try and retrieve any stone that has passed (stones <5mm usually pass spontaneously)
 -An obstructed, infected kidney is an emergency and should be treated as soon as possible to relieve the obstruction (percutaneous nephrostomy)
o REMOVAL OF CALCULI
 Urethroscopy
• A scope is passed into the bladder and up the ureter to visualize the stone
• It can be removed by a basket or broken up with a laser
• If the stone can’t be removed, a JJ stent should be placed to allow urine drainage
 Extracorporeal shock-wave lithotripsy (ESWL)
• Non-invasive
• An electromagnetic shockwave is focused onto the calculus to break it up into smaller fragments that can pass spontaneously
 Percutaneous nephrolithotomy (PCNL)
• Performed for large, complex stones (e.g. staghorn calculi)
• After making a nephrostomy tract, a nephroscope is inserted, which allows disintegration and removal of stones
o Treatment of the Cause
 Depends on the cause (e.g. parathyroidectomy if hypercalcaemia due to hyperparathyroidism, allopurinol if hyperuricaemia)
o Advice
 Increase oral fluid intake

72
Q

URINARY TRACT INFECTION

A

o Empirical treatment of uncomplicated UTI:
-Trimethoprin or Nitrofurantoin
 -Treat for 3-6 days
 -NB: men with UTI may need a longer course of Abx
o Alternative treatments: Co-amoxiclav or Cefalexin
o Prophylactic Abx in recurrent cystitis associated with sexual intercourse

73
Q

ACUTE CHOLANGITIS

A

o Resuscitation: may be required if the patient is in septic shock
o Broad spectrum antibiotics : given once blood cultures have been taken (select drugs that are effective against anaerobes and Gram-negative organisms: e.g. cefuroxime and metronidazole)
o Most patients respond to antibiotics but endoscopic biliary drainage is usually required to treat the underlying obstruction
o Management depends on severity:
 Stage 1 (Mild)
• Antimicrobial therapy
• Percutaneous, endoscopic or operative intervention for non-responders
 Stage 2 (Moderate)
• Early percutaneous or endoscopic drainage
• Endoscopic biliary drainage is recommended
 Stage 3 (severe)
• Note: severe cholangitis counts as including shock, conscious disturbance, acute lung injury, AKI, hepatic injury or DIC
• Treatment of organ failure with ventilatory support, vasopressors etc
• Urgent percutaneous or endoscopic drainage
• Definitive treatment required once the clinical picture improves

74
Q

ALCOHOLIC HEPATITIS

A

o ACUTE
 -Thiamine
 -Vitamin C and other multivitamins (can be given as Pabrinex)
 -Monitor and correct K+, Mg2+ and glucose
 -Ensure adequate urine output
 -Treat encephalopathy with oral lactulose or phosphate enemas
 -Ascites- manage with diuretics (spironolactone with/without furosemide)
 -Therapeutic paracentesis
 -Glypressin and N-acetylcysteine for hepatorenal syndrome
o Nutrition
 -Via oral or NG feeding is important
 -Protein restriction should be avoided unless the patient is encephalopathic
 -Nutritional supplementation and vitamins (B group, thiamine and folic acid) should be started parenterally initially, and continued orally
o Steroid Therapy
 Reduces short-term mortality for severe alcoholic hepatitis

75
Q

ANAL FISSURE

A

o Conservative
 High-fibre diet
 Softening the stools with a laxative
 Good hydration
o Medical
 -Liocaine ointment (local anaesthetic)
 -GTN ointment (relaxes the anal sphincter and promoted healing)
 -Diltiazem (relaxes the anal sphincter and promotes healing)
 -Botulinum toxin infection
o Surgical
 -Lateral sphincterotomy
 -This relaxes the anal sphincter and promotes healing but it has complications (e.g. anal incontinence) so it’s reserved for patients who are intolerant or not responsive to non-surgical treatments

76
Q

APPENDICITIS

A 
o	Prompt appendicectomy 
o	Antibiotics 
	Cefuroxime
	Metronidazole 
o	Laproscopy: diagnostic and therapeutic advantages
77
Q

BARRETT’S OESOPHAGUS

A

o Pre-malignant/ high grade dysplasia:
 Oesophageal resection
 Eradicative mucosectomy
 Note: only appropriate if patients are young and fit
o Other techniques:
 Endoscopic targeted mucosectomy
 Mucosal ablation by epithelial laser, radiofrequency (HALO) or photodynamic ablation (PD)
o Low-grade dysplasia- annual endoscopic surveillance is recommended
o No pre-malignant changes found:
 -Surveillance endoscopy and biopsy performed every 1-3 years
 -Anti-reflux measures (e.g. high dose PPI)

78
Q

BILIARY COLIC

A 
o	Analgesia 
o	IV fluids 
o	NBM
o	Surgical 
	Laparoscopic cholecystectomy 
o	ERCP can also be used to help remove stones or stent a blocked bile duct
79
Q

CHOLECYSTITS

A

o Conservative
 -If only mild biliary colic: follow a low-fat diet
o Medical
 -NBM
 -IV fluids
 -Analgesia
 -Anti-emetics
 -Antibiotics (if infection is present)
 -Note: if symptoms persist despite antibiotic treatment, suspect a localized abscess or empyema, which would require drainage
 -If obstruction: urgent biliary drainage by ERCP or via percutaneous route is necessary
o Surgical
 -Laproscopic Cholecystectomy

80
Q

CIRRHOSIS

A

o Treat the cause
o Avoid alcohol, sedative, opiates, NSAIDs and drugs that affect the liver
o Nutrition is important (NG feeding is indicated)
o Enteral supplements should be given
o Treating complications:
 -Encephalopathy:
• Treat infections
• Exclude GI bleed
• Use lactulose and phosphate enemas
o Normally, the liver breaks down ammonia that is absorbed in the GI tract, however, in cirrhosis the ammonia can go through the liver without being broken down and exert toxic effects on the brain
o Important: lactulose reduces the absorption of ammonia from the gut which reduces the amount of ammonia reaching the brain
• Avoid sedation
 -Ascites
• Diuretics (spironolactone with/without furosemide)
• Dietary sodium restriction
• Therapeutic paracentesis (with human albumin replacement)
• Monitor weight
• Fluid restrict if plasma sodium <120mmol/L
• Avoid alcohol and NSAIDs
 -Spontaneous Bacterial Peritonitis
• Antibiotics (e.g. cefuroxime and metronidazole)
• Prophylaxis against recurrent SBP with ciprofloxacin)
 -Surgical
• Consider TIPS (transjugular intrahepatic portosystemic shunt) – this helps reduce portal hypertension
o However, it may precipitate encephalopathy because it provides a route for blood from the GI tract to bypass the liver
• Liver transplant is the only curative method

81
Q

COELIAC DISEASE

A

o Advice:
 Avoid gluten (wheat, rye and barley products)
o Medical:
 Vitamin and mineral supplements. Oral corticosteroids if disease does not subside with avoidance of gluten

82
Q

CROHN’S DISEASE

A

o Acute exacerbation
 -Fluid resuscitation
 -IV/oral corticosteroids
 -5-ASA analogues (e.g. mesalazine and olsalazine)
 -Analgesia
 -Parenteral nutrition may be necessary
 -Monitor markers of disease activity e.g. fluid balance , ESR, CRP, platelets, Hb
o Long-term
 -Steroids- for acute exacerbation
 -5-ASA analogues – decreases the frequency of relapses (useful for mild to moderate disease)
 -Immunosuppression: using steroid-sparing agents (e.g. azathioprine, 6-mercaptopurine , methotrexate) reduces the frequency of relapses
 -Anti-TNF agents: (e.g. infliximab and adalimumab) – very effective at inducing and maintaining remission. Usually reserved for refractory Crohn’s
o General Advice
 Stop smoking
 Dietician referral (low fibre diet necessary if there are strictures present)
 Surgery indicated if:
• Medical treatment fails
• Failure to thrive in children in the presence of complications
• Involves resection of affected bowel and stoma – however high risk of disease recurrence)

83
Q

DIVERTICULAR DISEASE

A

o Asymptomatic
 Soluble high-fibre diet (20-30g/day)
o GI bleed
 PR bleeding usually managed conservatively with IV rehydration, antibiotics and blood transfusion if necessary
 Angiography and embolization or surgery if severe
o Diverticulitis
 IV antibiotics
 IV fluid rehydration
 Bowel rest
 Abscesses may be drained by radiologically sited drains
o Surgery
 Necessary in patients with recurrent attacks or complications (e.g. perforation and peritonitis)
 Open surgery :
• Hartmann’s procedure (proctosigmoidectomy leaving a stoma)
• One-stage resection and anastomosis (risk of leak) with or without defunctioning stoma
 Laproscopic drainage, peritoneal lavage and drain placement can be effective

84
Q

GASTROENTERITIS

A

o Bed Rest
o Fluid and electrolyte replacement with oral rehydration solution (containing glucose and salt)
o IV rehydration if severe vomiting
o Most infections are self-limiting (will go away with time)
o Abx used only if severe or if infective agent has been identified
o If botulism is present (due to Clostridium botulinum) treat with botulinum antitoxin (IM) or in ITU

85
Q

GASTROINTESTINAL PERFORATION

A 
o	Resuscitation 
	-Correct fluid and electrolytes 
	-IV antibiotics (with anaerobic cover) 
o	Surgical 
	-Large Bowel 
•	Identify site of perforation 
•	Peritoneal lavage 
•	Resection of perforated section (usually as part of a Hartmann’s procedure) 
	-Gastroduodenal 
•	Laparotomy 
•	Peritoneal lavage 
•	Perforation is closed with an omental patch 
•	Gastric ulcers are biopsied 
•	H.Pylori eradication if positive for H.Pylori 
	-Oesophageal 
•	Pleural lavage 
•	Repair of ruptured oesophagus
86
Q

GORD

A 
-Advice:
•	Weight loss 
•	Elevating head of bed 
•	Avoid provoking factors 
•	Stop smoking 
•	Lower fat meals 
•	Avoid large meals late in the evening 
	-Medical:
•	Antacids
•	Alginates
•	H2 antagonists (e.g. ranitidine) 
•	PPI (e.g. lansoprazole, omeprazole) 
	Endoscopy
•	Annual endoscopic surveillance – looking for Barrett’s oesophagus 
•	May be necessary for stricture dilation or stenting 
	Surgery 
•	Antireflux surgery if refractory to medical treatment 
	Nissen fundoplication 
•	Fundus of the stomach is wrapped around the lower oesophagus – helps reduce the risk of hiatus hernia and reduce reflux
87
Q

HAEMORRHOIDS

A

o Conservative
 -High-fibre diet
 -Increase fluid intake
 -Bulk laxatives
 -Topical creams (e.g. local anaesthetics)
o Injection Sclerotherapy
 -Induces fibrosis of the dilated veins
o Banding
 -Barron’s bands are applied proximal to the haemorrhoids
 -The haemorrhoid will then fall off after a few days
o Surgery
 -Reserved for symptomatic 3rd and 4th degree haemorrhoids
 -Milligan-Morgan haemorrhoidectomy – excision of three haemorrhoidal cushions
 -Stapled haemorrhoidectomy is an alternative method
 -Post-operatively the patient should be given laxatives to avoid constipation

88
Q

INGUINAL HERNIAS

A

o Surgical
 -Usually elective repair of uncomplicated hernias
 -Mesh repair
• Hernia is surgically reduced and a mesh is inserted to reinforce the defect in the transversalis fascia
 -Laproscopic Mesh repair
 -Emergency:
• If obstructed or strangulated
• Laparotomy with bowel resection may be indicated if the bowel is gangrenous

89
Q

HIATUS HERNIA

A

o Medical
 -Modify lifestyle factors (e.g. lose weight)
 -Inhibit acid production (e.g. PPIs)
 -Enhance upper GI motility
o Surgical
 Necessary in a minority of patients
 -Usually performed in patients with complications of reflux disease despite aggressive medical treatment or pulmonary complications (e.g. aspiration pneumonia)
 -Nissen fundoplication
• Stomach is pulled down through the oesophageal hiatus and part of the stomach is wrapped (360degrees) around the oesophagus to make a new sphincter and reduce the likelihood of herniation
 -Belsey Mark IV fundoplication
• Same but 270degree wrap
 -Hill Repair
• Gastric cardia is anchored to the posterior abdominal wall

90
Q

INTESTINAL OBSTRUCTION

A

o General
 -Gastric aspiration via NG tube if the patient is vomiting
 -IV fluids
 -Electrolyte replacement
 -Monitor vital signs, fluid balance and urine output
o Surgical
 -Emergency laparotomy in acute obstruction

91
Q

IRRITABLE BOWEL SYNDROME (IBS)

A

o Advice
 -Dietary modification
o Medical : depends on main symptoms affecting the patient
 -Antispasmodics (e.g. buscopan)
 -Prokinetic agents (e.g. domperidone, metoclopramide)
 -Anti-diarrhoeals (e.g. loperamide)
 -Laxatives (e.g. senna, movicol, lactulose)
 -Low-dose TCAs (may reduce visceral awareness)
o Psychological therapy
 -CBT
 -Relaxation and psychotherapy

92
Q

LIVER FAILURE

A

o Resuscitation – ABC
o Treat the cause if possible
 -N-acetylcysteine (treatment for paracetamol overdose, which accounts for 50% of liver failure cases)
o Treatment/prevention of complications (invasive ventilation and cardiovascular support is often required)
 -Monitor: vital signs, PT, pH, creatinine, urine output, encephalopathy
 -Manage encephalopathy: lactulose and phosphate enemas
 -Antibiotic and antifungal prophylaxis
 -Hypoglycaemic treatment
 -Coagulopathy treatment- IV vitamin K, FFP, platelet infusions
 -Gastric mucosa protection – PPIs or sucralfate
 -AVOID sedatives or drugs metabolized by the liver
 -Cerebral oedema – decrease ICP with mannitol

93
Q

MALLORY-WEISS TEAR

A

o 80-90% of the time, the bleeding from a Mallory-weiss tear will stop on its own
o Surgery may be necessary if the bleeding does not stop
 Injection sclerotherapy
 Coagulation therapy
 Arteriography
o NB: transfusions may be required if blood loss has been severe
o Anti-reflux medications may also be prescribed

94
Q

NON-ALCOHOLIC STEATOHEPATITIS (NASH)

A 
o	Conservative:
	-Blood pressure
	-Diabetes
	-Cholesterol 
	-Lost weight 
	-Stop smoking 
	-Exercise regularly 
	-Reduce alcohol consumption (although it’s not caused by alcohol, excessive drinking can make it worse)
95
Q

ACUTE PANCREATITIS

A

o Assessment of severity has two main scales:
 Modified Glasgow Score (combined with CRP >210mg/L)
 APACHE-II Score
o Medical management:
 -Fluid and electrolyte resuscitation
 -Urinary catheter and NG tube if vomiting
 -Analgesia
 -Blood sugar control
 -HDU and ITU care
 -Prophylactic antibiotics may be useful in reducing mortality
o ERCP and sphincterotomy
 -Used for gallstone pancreatitis, cholangitis, jaundice or dilated common bile duct
 -Ideally performed within 72 hours
 -All patients presenting with gallstone pancreatitis should undergo definitive management of gallstones during the same admission or within 2 weeks
o Early detection and treatment of complications
 -E.g. if there are persistent symptoms or >30% pancreatic necrosis or signs of sepsis  image guided fine needle aspiration for culture
o Surgical
 -Necrotising pancreatitis should be managed by specialists
 -Necresectomy (drainage and debridement of necrotic tissue) may be necessary

96
Q

CHRONIC PANCREATITIS

A

o General
 -Treatment is mainly symptomatic and supportive (e.g. dietary advice, stop smoking/drinking, treat diabetes, oral pancreatic enzyme replacement, analgesia)
 -Chronic pain management may need specialist input
o Endoscopy therapy
 -Sphincterotomy
 -Stone extraction
 -Dilatation and stenting of strictures
 -Extracorporial shock-wave lithotripsy (ESWL) is sometimes used to fragment larger pancreatic stones before removal
o Surgical
 -May be indicated if medical management fails
 -Lateral pancreaticojejunal drainage (modified Puestow procedure)
 -Pancreatic resection (pancreaticoduodenectomy or Whipple’s procedure)
 -Limited resection of pancreatic head (Beger procedure)
 -Combining opening of the pancreatic duct and excavation of the pancreatic head (Frey procedure)

97
Q

PEPTIC ULCER DISEASE AND GASTRITIS

A

o Acute
 -Fluid resuscitation needed if the ulcer is perforated or bleeding (IV colloids/ crystalloids)
 -Close monitoring of vital signs
 -Endoscopy
 -Surgical treatment
 -NB: patients with upper GI bleeding should be treated with IV PPIs at presentation until the cause of bleeding is identified
o Endoscopy
 -If the ulcer is bleeding, haemostasis can be achieved with:
• Injection sclerotherapy
• Laser coagulation
• Electrocoagulation
o Surgery
 Indicated if the ulcer has perforated or if the bleeding ulcer can’t be controlled
o Helicobacter pylori eradication
 -Triple therapy for 1-2 weeks
 -Various combinations may be recommended- usually a combination of 2 antibiotics + PPI (e.g. clarithromycin + amoxicillin + omeprazole)
o If peptic ulcer disease is not associated with H.Pylori:
 -Treat with PPIs or H2 antagonists
 -Stop NSAID use
 -Use misoprostol (prostaglandin E1 analogue) if NSAID use is necessary

98
Q

PERIANAL ABSCESSES AND FISTULAE

A

o Requires SURGICAL treatment
o Open drainage of Abscess
o Laying open of fistula
 -A probe can be inserted to explore the fistula
 -A dye can be inserted into the external opening to allow you to find the internal opening
 -Low fistula
• Fistulotomy
• Care must be taken to prevent damage to the anal sphincter
 -High fistula
• Fistulotomy would cause INCONTINENCE so is not performed
• Seton – a non-absorbable suture that is threaded through the fistula and allows drainage
 -Antibiotics

99
Q

PERITONITIS

A

o Local peritonitis
 Depends on cause
 Some causes may require surgery (e.g. appendicitis)
 Some causes can be treated with antibiotics (e.g. salpingitis)
o Generalised peritonitis
 Patient may be at risk of death from sepsis or shcok
 IV fluids
 IV antibiotics
 Urinary catheter
 NG tube
 Central venous line (to monitor fluid balance)
 Laparotomy
• Remove the infected or necrotic tissue
• Treat cause
• Peritoneal lavage
 Primary peritonitis: should be treated with antibiotics
o Spontaneous Bacterial Peritonitis (SBP)
 Cefotaxime + Vancomycin

100
Q

PILONIDAL SINUS

A 
o	Acute pilonidal abscess
	Incision and drainage
o	Chronic pilonidal sinus 
	Excision under general anesthesia with exploration 
o	Prevention 
	Good hygiene 
	Shaving
101
Q

PORTAL HYPERTENSION

A

o Difficult to treat directly, focus on underlying cuase
o Conservative
 Salt restriction
 Diuretics
o Treatment of oesophageal varices if present
o Non-selective beta-blockers – reduces portal pressure and reduces risk of variceal bleeding
o Terlipressin can reduce portal venous pressure
o Transjugular Intrahepatic Portosystemic Shunt (TIPS) – surgical shunt placed between the hepatic portal vein and the hepatic vein to ease congestion in the portal vein
o Liver Transplant

102
Q

ULCERATIVE COLITIS

A 
o	Acute:
	IV rehydration 
	IV corticosteroids 
	Antibiotics 
	Bowel rest
	Parenteral feeding may be necessary 
	DVT prophylaxis 
	If toxic megacolon: patient is likely to need a proctocolectomy because toxic megacolon has a high mortality 
o	Management of mild disease 
	Oral or rectal 5-ASA dervatives (e.g. mesalazine, olsalazine) and/or rectal steroids 
o	Management of moderate to severe disease 
	Oral 5-ASA 
	Immunosuppresion (with azathioprine, cyclosporine, 6-mercaptopurine or infliximab (anti-TNF monoclonal antibody)) 
o	Advice
	Patient education and support 
	Treat complications 
	Regular colonoscopic surveillance 
o	Surgical 
	If medical treatment fails, presence of complicatios or to prevent colonic carcinoma 
	Procedures:
•	Proctocolectomy with ileostomy 
•	Ileo-anal pouch formation
103
Q

VIRAL HEPATITIS A & E

A

o No specific management other than bed rest and symptomatic treatment (e.g. antipyretics, antiemetics or cholestyramine (for severe pruritis)
o Prevention and control
 Public health – safe water, sanitation and food hygiene
 Notifiable disease
 Immunisation available for HAV
• Passive immunization with IM human immunoglobulin (effective for a short amount of time )
• Active immunization with attenuated HAV vaccine offers safe and effective immunity for those travelling to endemic areas and high-risk individuals

104
Q

VIRAL HEPATITIS B AND D

A

o Prevention: blood screening, safe sex, instrument sterilization
o Passive immunization
 -Hep B Ig following acute exposure and to neonates born to HBeAf-positive mothers (in addition to active immunization)
o Active immunization
 -Recombinant HBsAg vaccine for individuals at risk and neonates born to HB
o Acute HBV hepatitis
 -Symptomatic treatment (antipyretics, antiemetics and cholestyramine) and bed rest
 -Notifiable disease
o Chronic HBV
 -Interferon alpha (standard or pegylated)
• Side -effects: flu-like symptoms
 Nucleoside/nucleotide anal-goues (adefovir, entecavir)

105
Q

VIRAL HEPATITIS C

A

o Prevention
 -Screen blood, blood products and organ donors
 -Needle exchange schemes for IV drug users
 -Instrument sterilization
 -No vaccine available
o Medical
 -Acute – mainly supportive (antipyretics, antiemetics, cholestyramine)
 -Chronic
• Pegylated interferon-alpha
• Ribavirin (guanosine nucleotide analogue)
• Duration:
o HCV genotype 1 or 4: 24-48 weeks
o HCV gentotype 2 or 3: 12-24 weeks
 -Regular US of the liver may be needed if the patient has cirrhosis

Y3 z Symptom differentials/cases (31 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions