Planning management

. Learn management algorithms for the most common acute scenarios, chronic diseases and symptoms.

. Use 10 scenarios with worked answers to reinforce these principles.

Structure of the Section within the PSA

The ‘Planning management’ section will have 8 questions with 2 marks available per question, so a possible total of 16 marks. You will be asked to identify the most appropriate prescription (which may be preventative, curative, symptomatic or palliative) from a list of five for each scenario (see Question 4.1).

Introduction

In this chapter, we have divided the likely exam scenarios up into three sections: management of acute conditions, management of common chronic conditions and symptom control.

As with Chapter 2, the practical summaries in each of the three sections incorporate common scenarios in clinical practice and medical examinations, while encompassing those most likely to be seen in the PSA exam.

Management of Acute Conditions

The management of any sick patient must always begin with a practised routine of assessing their airway, breathing, circulation, disability and exposure. Realistically, for the PSA most answers will be from the specific management, but do not forget the obvious solutions such as oxygen for the hypoxic patient, or fluids for the hypotensive patient.

Respiratory Emergencies

Acute exacerbation of asthma (Fig. 4.4)

Figure 4.4 Acute asthma treatment.

Acute exacerbation of chronic obstructive pulmonary disease (COPD)

Same treatment as asthma (see Fig. 4.4), but add antibiotics if infective exacerbations. Patients are also more likely to have type 2 respiratory failure, so use high-flow oxygen with care. Remember, hypoxia will kill much quicker than hypercapnia. Therefore, in the acute setting, even if a very sick patient has known COPD, apply high-flow oxygen then review it quickly after an arterial blood gas (ABG). This is the same in the PSA: providing the patient is not peri-arrest (in which case high-flow should be applied), 28% oxygen is a safe starter in patients with COPD with ABG 30 min later to assess the effect.

Pneumothorax

If secondary (i.e. patient has lung disease) then always needs treatment: chest drain if>2 cm or patient SOB or if>50 years old; otherwise aspirate.

If tension pneumothorax (i.e. clinical distinction but often tracheal deviation+/−shock) then emergency aspiration required, but will need chest drain quickly.

Otherwise (i.e. if primary) determine whether the patient needs treatment:

if<2 cm rim and not SOB then discharge with outpatient follow-up in 4 weeks.

if>2 cm rim on CXR or feels SOB then aspirate and if unsuccessful aspirate again, and if still unsuccessful then chest drain.

Pneumonia

See Figure 4.5 for treatment algorithm. Use mnemonic CURB65 to assess severity of community-acquired pneumonia and hence treatment: Confusion (abbreviated mental test score (AMTS)≤8/10), Urea>7.5 mmol/L, Respiratory rate>30/min, Blood pressure (systolic)<90 mmHg and age≥65 years. For the patient with none or one of these then home treatment is possible; with two or more of these then hospital treatment with oral or IV antibiotics according to policy and severity is required; and with more than three of these then consider ITU admission.