CCC: Primary Care Flashcards
1
Q
What are the different types of generalised seizures?
A
- Tonic = Stiffness of one part or whole body
- Clonic = Rhythmic jerking of one side or whole body
- Tonic Clonic = tonic + clonic seizure with post-octal confusion and drowsiness
- Myoclonic = Shock like movement
- Atonic = Myoclonic shock movement followed by flaccid paralysis, no loss of consciousness
- Absence = psycho-motor arrest (5-15 s), upper eye lid retraction, twitching of mouth
2
Q
What are the different types of focal seizure?
A
Firstly split into
A. partial simple (no impaired awareness or post-ictal symptoms. Just focal neurological changes in sensory autonomic or motor function)
B. partial complex (impaired awareness and post-octal symptoms)
C. partial with secondary generalised (2/3rds of partial seizures develop into convulsive generalised seizures)
- Parietal - sensory changes such as paraesthesia
- Temporal (most common) - GI disturbances, memory impairment (amnesia, deja vu, jamais vu), dysphasia, post-octal confusion and impaired awareness
- Occipital - visual disturbances such as multi-coloured flashing lights
- Frontal - Dystonic posture but rapid recovery
3
Q
What are the investigations for epilepsy?
A
- EEG for all patients
- Can confirm diagnosis, cannot refute or exclude
- Can determine type but only works during seizure
- Use sleep deprived EEG (+ melatonin for children) or 24hr Ambulatory/video EEG if normal is ineffective - MRI/CT - not routinely done, but excludes infective or structural cause
- ECG - for all participants to detect any QTc prolongation or arrhythmia
- Bloods - for acquired causes e.g. glucose, TFT
4
Q
What is the primary treatment for the various seizure types?
A
1a. Tonic Clonic, Atonic, Absence
- Sodium valproate (1st line), Lamotrigine (2nd line),
1b. Myoclonic
- Sodium valproate (1st line), Levetirecetam or topiramate (2nd line)
1c. Focal
- Carbamazepine or Lamotrigine (1st line)
- Surgical intervention
- Vagal nerve stimulation (usually focal) - reduces volume and frequency of seizures
- Deep brain stimulation
5
Q
When would you consider discussing stopping Anti-epilptic drugs in an a known epileptic? How would you do this?
A
After 2 seizure free years
Wean down drugs over 2-3 months
6
Q
What is the criteria for DVLA driving in epileptics?
A
Type 1:
- Seizure free for 1 year (seizures include auras, partial and generalised)
- Prove any seizures incurred have all been during sleep (by diary)
Type 2:
- Must hold type 1 license
- Seizure free for 10 years
- No AEDs in 10 year period
7
Q
What are the side effects of Sodium valproate, Carbamazepine and lamotrigine?
A
Sodium valproate:
- N, V, Dizzy
- CYTP450 inhibitor
Carbamazepine
- drowsy, headache, dizzy, ataxic
- CYTP450 inducer
Lamotrigine
- drowsy, N, V, D, headache, blurred vision, tremor
8
Q
What are the HLA types associated with increased and decreased risk of DM type 1?
A
Increased risk - HLA-DR3, HLA-DR4
Decreased risk - HLA-DR2, HLA-DR5
9
Q
When does type 1DM typically present?
A
adolescents and child hood
10
Q
when does type 2DM typically present?
A
Middle age
11
Q
What are the typical symptoms of DM?
A
- Polyuria (±nocturnal enuresis)
- Polydipsia
- Weight loss
- Fatigue
- Poor wound healing - skin sepsis
- Candida
12
Q
What is the difference in presentation between type 1 and 2 DM?
A
Type 1 - childhood and adolescents, skinny with BMI < 25
Type 2 - middle aged and older, obese, south asian, +ve FHx,
13
Q
What is the difference in presentation between type 1 and 2 DM?
A
Type 1 - childhood and adolescents, skinny with BMI < 25
Type 2 - middle aged and older, obese, south asian, +ve FHx, acanthuses nigricans (black armpit)
14
Q
What is the regimen options for type 1 DM?
A
- Basal bolus injection regime - calculate carbohydrate to insulin ratio and administer bolus of short acting insulin before meals in addition to one or more intm or long acting insulin.
- SC insulin infusion pump - continuous or interval infusions of short/rapid acting insulin in addition to one or more intm or long acting insulin.
- Set routine - inject at set times throughout day with short/rapid mixed with intm. or long acting insulin
15
Q
What is the treatment regime for type 2 DM (explain the ladder and when and how to progress)?
A
NB: Increase dose or go down ladder if blood glucose targets are not met (usually 48mmol HbA1c)
- Metformin (Biguanide)
- Double therapy with metformin and 1 of:
- Sulphonylurea (gliclzide, glimeperide)
- DPP4 (Sitagliptin)
- Pioglitazone
or consider GLP-1 (Exenetide) or SGLT2 (dapiglifozin) - Tripple therapy with metofrmin, sulphonylurea and pioglitazone or DPP4 (sitagliptin)
- Add insulin
16
Q
What is the treatment regime for type 2 DM (explain the ladder and when and how to progress)?
A
NB:
- Increase dose or go down ladder if blood glucose targets are not met (usually 48mmol HbA1c).
- R/V patients 4-12 weeks for every medication and dose change.
- R/V HbA1c every 3 months until stable then every 6
- Metformin (Biguanide)
- Double therapy with metformin and 1 of:
- Sulphonylurea (gliclzide, glimeperide)
- DPP4 (Sitagliptin)
- Pioglitazone
or consider GLP-1 (Exenetide) or SGLT2 (dapiglifozin) - Tripple therapy with metofrmin, sulphonylurea and pioglitazone or DPP4 (sitagliptin)
- Add insulin
IF METFORMIN ALLERGIC/INTOLERANT:
- Sulphonylurea or DPP4 or Pioglitazone
- Double therapy with two of the above
- Triple therapy with three of above
- Add insulin
17
Q
What are the key side effects of Metformin?
A
Weight loss, decreased appetite
18
Q
What are the key side effects of Sulphonylureas?
A
Weight gain, increased appetite, risk of hypos
19
Q
What are the key side effects/CIs of Pioglitazone?
A
DKA, HF, bladder Ca, Haematuria
20
Q
What are the key side effects of SGLT2 (dapiglifozin)?
A
decreased weight, polyuria, thrush
21
Q
What are the features of hypoglycaemia
A
Sympathetic over activity (<3.6mmol/L) - Tachycardia, sweaty, palpitations, anxiety, pallor, cold extremities
Neuroglycopoenia (<2.6mmol/L) - slurred speech, visual disturbance, confusion, seizures, coma
22
Q
What is the management pathway of an acutely unwell patient with hypoglycaemia?
A
- Measure blood glucose - determine severity (<4 hypo, <2.2 severe, <1.5 coma)
- Fast acting glucose (10-20g) i.e. glucagel, lucozade, glucose tablets - review blood glucose in 15 mins, repeat if still <4 mmol/L
If unconscious
- IM glucagon - review glucose at 15 mins
- 10% IV glucose infusion or 50mls of 50%
- Carbohydrate rich snack (once stable)
- Review medications
- Pabrinex (thiamine) if alcoholic
23
Q
What is the management of DKA?
A
- Fluid resuscitation with saline 0.9% regimen
- 1L over 1hr
- 1 L over 2hr
- 1L over 2hr
- 1L over 4hr
- 1L over 4hr
- 1L over 6hr - 10 Units of Actrapid insulin
- 0.1 units/kg/hr fixed rate dose
- stop insulin once glucose < 15, ketones <0.3, pH >7.3 and bicarb >18 - K+ supplementation (20 or 40mmols)
- Start in 2nd bag if K+ < 5.5 - Monitor UO, glucose, ketones (1 hrly), U+Es (4hrly), Blood gas (0, 2, 4, 8, 12hrs)
- Catheter - monitor UO
- Abx incase of concomitant infection
- LMWH - Tinzaparin or Dalteparin
24
Q
What is the management of DKA?
A
- Fluid resuscitation with saline 0.9% regimen
- 1L over 1hr
- 1 L over 2hr
- 1L over 2hr
- 1L over 4hr
- 1L over 4hr
- 1L over 6hr - 10 Units of Actrapid insulin
- 0.1 units/kg/hr fixed rate dose
- stop insulin once glucose < 15, ketones <0.3, pH >7.3 and bicarb >18 - K+ supplementation (40mmols)
- Start in 2nd bag if K+ 3.5-5.5
- if <3.5 seek senior r/v
- 10 mmol/hr max rate - anything more requires ICU - Monitor UO, glucose, ketones (1 hrly), U+Es (4hrly), Blood gas (0, 2, 4, 8, 12hrs)
- Catheter - monitor UO
- Abx incase of concomitant infection
- LMWH - Tinzaparin or Dalteparin
25
What is the management of DKA?
1. Fluid resuscitation with saline 0.9% regimen
- 1L over 1hr
- 1 L over 2hr
- 1L over 2hr
- 1L over 4hr
- 1L over 4hr
- 1L over 6hr
2. 10 Units of Actrapid insulin
- 0.1 units/kg/hr fixed rate dose
- stop insulin once glucose < 15, ketones <0.3, pH >7.3 and bicarb >18
- Start 10% IV glucose at 125ml/hr added to normal saline regimen
3. K+ supplementation (40mmols)
- Start in 2nd bag if K+ 3.5-5.5
- if <3.5 seek senior r/v
4. Monitor UO, glucose, ketones (1 hrly), U+Es (4hrly), Blood gas (0, 2, 4, 8, 12hrs)
5. Catheter - monitor UO
6. Abx incase of concomitant infection
7. LMWH - Tinzaparin or Dalteparin
26
What are the symptoms of HONK?
Polyuria, polydipsia, dehydration
muscle weakness, leg pain, fatigue, lethargy
Decrease level of conciousness (depends on plasma osmolality)
Raised HR, RR, CRT; Low BP
27
What are the key investigative findings for HONK?
1. Plasma osmolality (2x (Na+K+) + glucose + urea) > 350 mosm/kg
2. High Na2+ (may be masked by hyperglycaemia)
3. High urea > creatinine
4. FBC - possible polycythaemia and leukocytosis
28
What is the treatment for HONK?
1. Fluid resuscitation using 0.9% Saline
- 1L over 30 mins
- 1 L with K+ over 2hr
- 1L with K+ over 2hr
- 1L with K+ over 6hr until rehydrated
- use 0.45% saline if Na > 160
2. Insulin infusion (Actrapid)
- 2/4 units per hour
- Once glucose is ≤15 --> stop insulin and start 5% dextrose infusion
3. LMWH - Tinzaparin or dalteparin as VTE prophylaxis
4. Monitor glucose, UO etc.
29
What are the different forms of angina? (5)
1. Stable - due to coronary atherosclerosis
- pain brought on by exercise, relieved by GTN or rest
2. Variant - due to coronary vasospasm
3. Unstable/crescendo
- pain brought on by minimal or no exercise, not relieved by GTN
- high risk of MI
4. Decubitus
- pain brought on whilst lying flat
5. Cardiac syndrome X
- anginal symptoms but with -ve coronary angiography
30
What are the risk factors for CAD?
Obesity, increased age, immobility, poor diet, FHx, males, smoking,
31
What is the difference between typical and atypical stable angina?
Stable angina
- Constricting central chest pain radiating to arms, neck or jaw
- Triggered by exercise
- relieved by GTN
Typical = all three features present
Atypical = two features present
Non anginal pain = one or less features present
32
What is the screening tool to predict risk of stroke and MI in CAD?
QRISK2
33
What is the diagnostic management ladder for CAD/IHD?
1. Bloods - troponin (exc MI), BNP (exc HF)
2. ECG - pathological Q waves, T wave inversion, BBB, axis deviation, ST depression
3. 64 slice CT coronary angiography (1st line diagnostic)
- detects significant CAD
4. MPS w/ SPECT, stress echo, first-pass contrast enhance MR perfusion (2nd line diagnostic)
- detects reversible myocardial ischaemia
34
What is the treatment for CAD/IHD?
Step 0
A. GTN spray (prophylaxis and treatment of angina)
B. Aspirin (75mg OD) or clopidogrel (2nd line)
C. ACEi i.e. ramipril
D. Statin i.e. atorvastatin (20mg)
Step 1
A. BB or CCB (dihydropyridine e.g. amlodipine or felodipine; rate limiting e.g. diltiazam, verapamil)
Step 2
A. Monotherapy with long acting GTN (isorbide mononitrate), ivabradine, nicorandil, ranolozine
B. Combination with BBB or CCB
Step 3
A. CABG if symptoms controlled by meds but evidence of prox 3 vessel disease, L main stem or high ischaemia
B. CABG or PCI if symptoms not controlled by meds
35
What is an absolute CI in patients with CAD/IHD?
Vasodilatory drugs due to synergistic effect with nitrate treatment
e.g. sildenefil (viagra) used with GTN
36
What is the difference between systolic and diastolic HF?
Systolic:
- failure of ventricles to contract fully
- reduced CO and ejection fraction < 40%
Diastolic:
- failure of ventricle to fully relax
- Ejection fraction > 50%
37
What is the diagnostic investigative ladder for potential HF patients?
1. BNP + USS
- >400 --> doppler USS in 2weeks (confirms)
- 100-400 ---> doppler USS in 6 weeks (confirms)
- <100 = HF unlikely
2. ECG
- Left or right axis deviation, R or LVH
3. CXR
- Alveolar oedema (bat wings), Kerley B lines (IS oedema), Cardiomegaly, Dilated upper lobe vessels, pleural effusion
4. Spirometry, PEFR, D-Dimer - rule out other causes
38
What is the treatment for acute HF?
1. Loop diuretic (furosemide) - bolus or infusion
2. Add thiazide (bendroflumethiazide) if oedema clearance is inadequate
3. ACEi (rampiril) and BB (bisoprolol)
39
What is the treatment for chronic HF? How would you monitor the medication?
1a. ACE-i (ramipril)
- Monitor U+E, eGFR, ACR, creatinine at start and after each change in dose
1b. BB (bisoprolol)
- Monitor ECG
2a. ARB (Losartan) or Alodosterone antagonist (spironolactone) - 2nd line
2b. Hydralazine and nitrate - 2nd line (preferred if Afro-carribean)
5. Ivabradine and Digoxin - 3rd line (if EF < 35% and NYHA 2-4)
40
What HF medications are dangerous to use with digoxin?
Furosemide and ARB - can potentiate hypokalaemia
41
What is the classification system used to categorise severity of HF? Explain
New York Heart Association (NYHA)
| 1. Slight
42
What is the most common indication for a implantable cardioverter?
Ventricular tachycardia or fibrillation
43
What are the symptoms of LVF?
Pulmonary oedema - dyspnoea, orthopnoea, PND
Productive cough - nocturnal, pink frothy sputum
Fatigue
Cyanosis
Pulsus alternans
RV heave (pulmonary oedema)
44
What are the symptoms of RVF?
Peripheral pitting oedema -
Ascites + nausea
Raised JVP
45
What are the different types of AF? (5)
Acute - AF resolves within 48 hrs
Paroxysmal - AF resolves with 7 days
Persistant - 2 or more episodes of AF that requires cardioversion to resolve
long standing
Permanent - AF > 1 year not resolved with cardioversion
46
What are the investigations ordered for AF?
1. ECG
- 24 hr ambulatory ECG - if symptomatic or asymptomatic episodes are < 24hrs apart
- ECG event recorder - if symptomatic episodes are > 24hrs apart
2. Bloods
- TFTs, FBC, Troponin, BNP,
3. Echo
- Atrial enlargement (left usually)
47
What is the treatment of acute AF?
1. Cardioversion - if acute AF with haemodynamic instability
- Electric preferred
- Chemical if electric not possible - IV Amiodarone or Flecanide
2. Heparin (LMWH - Tinzaparin in Leeds) - to all new patients with AF
48
What is the treatment for chronic AF?
1. Rate control
a. BB (bisoprolol) or rate limiting CCB (diltiazam)
- don't use soltalol unless in hospital
b. Digoxin mono therapy (not often used anymore)
c. Combine 2 of BB, CCB and Digoxin
2. Rhythm control
a. Cardioversion - Electric and Amiodarone (4 weeks before and 12 months after)
b. BB
c. Dronedarone
3. LA ablation - if drug treatment has failed or paroxysmal
4. LA appendage occlusion
49
When do you start anti-coagulation in AF patients? What would you choose?
CHADVASC score ≥ 1
1. NOAC - Rivaroxaban, Apixapan, dabigatran
- do not use if eGFR < 30
- cannot miss a dose
- most not irreversible
2. Warfarin
- aim for INR 2-3
- aspirin as alternative
50
How do you assess (a) stroke risk (b) bleed risk in AF?
Stroke = CHADVASC2
Bleed = HAS-BLED
