Management

Question 1

Bronchiectasis

Answer 1

• Physical training
• Postural drainage
• Antibiotics for exacerbations
• Bronchodilators
• Immunisations
• Surgery in selected cases

Question 2

angina

Answer 2

• all patients should receive aspirin and statin in absence of contraindications
• gtn to abort acute attacks

1st line
- beta blocker or rate limiting calcium channel blocker

2nd line
- increase monotherapy to maximum dose

3rd line

• add the other, use dihydropyridine instead
• if patient cannot tolerate this, then consider long acting nitrate, ivabradine, nicorandil or ranolozine

only add 3rd drug if patient awaiting assessment for pci or cabg

Question 3

copd; stable

Answer 3

general management

• smoking cessation
• annual influenza vaccine
• one off pneumococcal vaccine

1st line = saba or sama

2nd line

• fev1 >50% = laba or lama
• fev1 <50% = laba + ics, or lama

for patients with persistent exacerbations or breathlessness

• if taking laba then switch to laba+ics combination inhalers
• otherwise give lama and laba+ics combination inhaler

consider oral theophylline for those who cannot tolerate inhaled therapy

consider mucolytics

cor pulmonale

• treat oedema with loop diuretics
• consider ltot

Question 4

asthma; stable

Answer 4

• saba + low dose ics
• add laba

if no response to laba
- stop laba and increase steroid to medium dose

if some response to laba

• keep laba and increase steroid to medium dose
• also consider keeping current dosage and trialling ltra, theophylline or lama

next step is consider trials of

• increasing ics to high dose
• addition of fourth drug
• referral to specialist care

next step
- consider regular oral steroids

Question 5

hypertension

Answer 5

1st line

• ace inhibitor for under 55
• calcium channel blocker for over 55 or black

2nd line
- add the other

3rd line
- add thiazide diuretic

4th line

• if potassium less than or equal to 4.5, spironolactone
• if potassium greater than 4.5, increase dose of thiazide diuretic

5th line
- consider alpha/beta blocker

Question 6

diabetes mellitus type 2

Answer 6

• lifestyle modification and risk factor optimisation

1st line
- metformin

if hba1c greater than 58 add one of

• sulfonylurea
• pioglitazone
• gliptin
• sglt-2 inhibitor

if hba1c still greater than 58 add one to make triple therapy

consider insulin

if triple therapy not effective/not tolerated/is contraindicated and bmi is greater than 35
- consider adding glp-1 mimetic

Question 7

heart failure

Answer 7

• 1st line = ace inhibitor and beta-blocker; increase to max before adding more drugs
• 2nd line = aldosterone antagonist, arb or hydralazine + nitrate

if symptoms persist

• cardiac resynchronisation therapy
• digoxin; inotropic effect, strongly indicated if co-existent af

diuretics should be offered for fluid overload
annual influenza vaccine
one off pneumococcal vaccine; booster every 5 years for;
- apslenia
- splenic dysfunction
- ckd

Question 8

crohn’s disease

Answer 8

• stop smoking

inducing remission

• 1st line = glucocorticoids
• 2nd line = 5-asa eg mesalazine
• azathioprine/mercaptopurine may be used as add on therapy (not on their own)

refractory disease or fistulating crohns
- infliximab added

maintaining remission

• 1st line = azathioprine or mercaptopurine
• 2nd line = methotrexate
• mesalazine should be considered if the patient has had previous surgery

around 80% of crohns patients will eventually have surgery

Question 9

ulcerative colitis

Answer 9

• mild: < 4 stools/day, only a small amount of blood
• moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
• severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)

inducing remission

• rectal aminosalicylates or steroids for distal colitis
• oral aminosalicylates
• 2nd line = oral prednisolone
• severe colitis requires in hospital iv steroids

maintaining remission

• oral aminosalicylates eg mesalazine
• azathioprine and mercaptopurine

Question 10

generalised tonic-clonic seizures

Answer 10

1st line
- sodium valproate

2nd line

• lamotrigine
• carbamazepine

Question 11

partial seizures

Answer 11

1st line
- carbamazepine

2nd line

• lamotrigine
• sodium valproate

Question 12

myoclonic seizures

Answer 12

1st line
- sodium valproate

2nd line

• clonazepam
• lamotrigine

Question 13

absence seizures

Answer 13

1st line

• sodium valproate
• ethosuxemide