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CCC > CCC: Primary care (2) > Flashcards

CCC: Primary care (2) Flashcards

1
Q

What is the acute management of stroke?

A

ABCDE

  1. Admit to stroke unit
  2. Urgent CT/MRI if:
    - Within 4hrs (thrombolysis time frame), GCS < 13, headache during stroke, risk of haemorrhage, signs of raised ICP

3a. Thrombolysis (alteplase or streptokinase) within < 4.5hrs
3b. Decompressive hemicranectomy - if MCA infarct
3c. Surgery - if haemorrhage

  1. Aspirin 300mg
  2. Clopidogrel 300mg then 75mg OD (modified release dipyridamole as alternative)
    5b. Warfarin if AF
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2
Q

What are the symptoms of stroke?

A 
C/L hemiplegia 
C/L semi-sensory loss 
I/L facial palsy 
Dysphasia, slurred speech 
Visual disturbances - usually homo hemianopia
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3
Q

After discharge from the hospital all stroke patients must have a specific investigation. What and when is this?

A

Carotid artery doppler - 1 week after admission

If thrombosis is present >70% of the lumen a carotid endarterectomy will be performed due to stroke risk.

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4
Q

What are the long term medications for stroke patients?

A
  1. Statin
  2. Anti-HTN - ramipril (move up ladder accordingly)
  3. Anti-DM treatment
  4. Anti-platelet treatment (clopidogrel) or anti-coagulant (warfarin)
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5
Q

When can patients with stroke or TIA drive?

A

Cannot drive for 1 month

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6
Q

How long does a TIA last?

A

< 24 hrs

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7
Q

What is a crescendo TIA?

A

≥ 2 episodes of TIA in < 48hrs

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8
Q

What is the ABCD2 screen? What is the score for action?

A

ABCD2 calculates risk of developing a stroke following TIA

Score ≥ 4 = treatment initiation

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9
Q

What is the criteria for admission with TIA?

A

Persisting symptoms and signs
Age < 45 yo
Patient with AF
Crescendo TIA

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10
Q

What system is used to classify the types of stroke?

A

Oxford-Bamford system

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11
Q

What is the long term management of a stroke patient regarding rehabilitation (8)?

A
  1. Cognitive assessment - assess severity of speech, language and memory impairment
  2. SALT - improve a/dysphasia
  3. Occupational therapy - changes to home
  4. Social worker - discharge and benefits
  5. Vision - eye movement therapy
  6. Swallow therapy x3 a week
  7. Orthotics + podiatrist
  8. Physio + dietician
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12
Q

What assessments can you do on a patient to assess stroke?

A

PNS exam:

  1. Power - U/L weakness
  2. Sensation - U/L sensory loss
  3. Reflexes - often normal
  4. Tone - often normal
  5. Gait assessment - ataxic, foot drag

CNS exam:
1. Optic (CN II) - neglect when wagging fingers, drawing clock

Sip test:

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13
Q

What is the criteria for CT with a suspected stroke patient?

A 
< 4hrs since stroke onset 
High risk of bleed 
GCS < 13 
Raised ICP 
Severe headache at presentation
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14
Q

What is the difference in spirometry results between obstructive and restrictive lung disorders?

A

Obstructive:
FEV1 = reduced
FVC = reduced or normal
FEV1/FVC ratio = reduced

examples: Asthma, COPD, bronchiectasis

Restrictive
FEV1 = reduced
FVC = significantly reduced
FEV1/FVC ratio = normal or increased

examples: pulmonary fibrosis, asbestosis, sarcoidosis

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15
Q

What is the long term management for COPD?

A
  1. SABA or SAMA (if SABA is not tolerated or ineffective)
    2a. FEV1 ≥ 50% = LABA or LAMA (if LAMA stop SAMA)
    2b. FEV1 < 50% = ICS + LABA combi (fostair) or LAMA (if LAMA stop SAMA)
  2. Combine ICS + LABA combi and LAMA
  3. Add Theophylline
  4. Oxygen therapy
    a. STOT - for short term relief of dyspnoea not controlled by medication
    b. LTOT - if O2kPA < 7.3 and one of: peripheral oedema, pulmonary HTN, polycythaemia, nocturnal hypoxiaemia with sats < 90%,
    b. Ambulatory oxygen for all patients on LTOT
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16
Q

What other medications must you offer COPD patients?

A
  1. Annual influenza and pneumococcal vaccination
  2. Nicotine replacement therapy + smoking cessation advice
  3. Buprirone or varenecilline
  4. Rescue packs - prednisolone, SABA and Abx (amoxicillin, doxycycline, erythromycin)
17
Q

What must be given for aftercare of COPD exacerbation.

A
  1. Prednisolone (30mg PO 7-14 d)
  2. Pulmonary rehabilitation - includes physical training, disease education, nutritional, psychological and behavioural intervention
18
Q

What are the features of a COPD CXR?

A 
Hyperventilation - > 5 anterior ribs seen 
Reduced vascular markings 
Bullae 
Flattened hemi-diaphragm 
Large central pulmonary artery
19
Q

When is an USS warranted in CKD?

A

CKD stage 4/5, refractory HTN or haematuria

20
Q

What is the chronic management for CKD?

A
  1. Stop all nephrotoxic drugs: NSAIDS, gentamicin, diuretics, contrast if eGFR < 30
  2. Furosemide - if fluid overload
  3. Folic acid or folate - if anaemic
  4. ACEi, ARB or rening inhibitor - HTN control
    - start if ACR > 3 + DM, ACR > 30 + HTN, ACR >70
  5. Atorvastatin and Apixaban (or warfarin) - CV prophylaxis
  6. Recombinant EPO - if EPO deficiency anaemia
  7. Pamidronate, Zolindronic acid, Bisphosphonates, Alfacalcidol and Ca+ supps - if renal bone disease
21
Q

What is the investigative ladder for HTN?

A
  1. BP assessment in clinic
    - if > 140/90 offer ABPM
    - if >180/110 start anti-HTN treatment immediately
  2. ABPM
    - records two readings every hour
    - must have ≥ 14 reading to gain average
  3. HBPM
    - give if ABPM is not tolerated
    - 2 readings 1 minute apart whilst seated and
    - 2 readings one at night and morning and
    - BP recordings for at least 4 d (ideally 7)
22
Q

What is the criteria for urgent same day referral to specialist for HTN?

A

Accelerate blood pressure

- BP > 180/110 and papilloedema ± retinal haemorrhage or suspicion of phaeochromocytoma

23
Q

What must you screen for in patients with HTN?

Tip: think systems

A

CKD

  • Blood - eGFR, Urea (if >7.8), Creatinine, Glucose (DM)
  • Urine - ACR (if >1 = pre-CKD, >3 = significant), haematuria

QRISK2
- 10 year % risk of MI or stroke

24
Q

What is the management pathway for HTN?

A
  1. Lifestyle advice
    - stop smoking, diet, exercise, alcohol, caffeine
  2. Anti-HTN Tx
    - if BP > 140/90 and one of: target organ damage, established CV or renal disease, DM, QRISK2 of 20%
    - if BP > 160/90

Step Under 55 yo Over 55 ± Afro-Caribbean
1 ACE-I or ARB Ca2+ blocker or thiazide diuretic
2 A + C or A + D
3 A + C + D
4 Add:
a) α-blocker – Tamulosin or
b) Further diuretic – low dose K+ sparing (spironolactone) or high dose thiazide related (indapamide)
c) Beta blocker

25
Q

What is the target range for BP control

A

if < 80yo: clinic 140/90, home 135/85

if > 80yo: clinic 150/90, home 145/85

CCC (7 decks)

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