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CCC > CCC: Primary Care > Flashcards

CCC: Primary Care Flashcards

1
Q

What are the different types of generalised seizures?

A
  1. Tonic = Stiffness of one part or whole body
  2. Clonic = Rhythmic jerking of one side or whole body
  3. Tonic Clonic = tonic + clonic seizure with post-octal confusion and drowsiness
  4. Myoclonic = Shock like movement
  5. Atonic = Myoclonic shock movement followed by flaccid paralysis, no loss of consciousness
  6. Absence = psycho-motor arrest (5-15 s), upper eye lid retraction, twitching of mouth
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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)

  1. Parietal - sensory changes such as paraesthesia
  2. Temporal (most common) - GI disturbances, memory impairment (amnesia, deja vu, jamais vu), dysphasia, post-octal confusion and impaired awareness
  3. Occipital - visual disturbances such as multi-coloured flashing lights
  4. Frontal - Dystonic posture but rapid recovery
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3
Q

What are the investigations for epilepsy?

A
  1. 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
  2. MRI/CT - not routinely done, but excludes infective or structural cause
  3. ECG - for all participants to detect any QTc prolongation or arrhythmia
  4. Bloods - for acquired causes e.g. glucose, TFT
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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)

  1. Surgical intervention
  2. Vagal nerve stimulation (usually focal) - reduces volume and frequency of seizures
  3. Deep brain stimulation
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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

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6
Q

What is the criteria for DVLA driving in epileptics?

A

Type 1:

  1. Seizure free for 1 year (seizures include auras, partial and generalised)
  2. Prove any seizures incurred have all been during sleep (by diary)

Type 2:

  1. Must hold type 1 license
  2. Seizure free for 10 years
  3. No AEDs in 10 year period
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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

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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

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9
Q

When does type 1DM typically present?

A

adolescents and child hood

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10
Q

when does type 2DM typically present?

A

Middle age

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11
Q

What are the typical symptoms of DM?

A
  1. Polyuria (±nocturnal enuresis)
  2. Polydipsia
  3. Weight loss
  4. Fatigue
  5. Poor wound healing - skin sepsis
  6. Candida
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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,

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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)

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14
Q

What is the regimen options for type 1 DM?

A
  1. 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.
  2. SC insulin infusion pump - continuous or interval infusions of short/rapid acting insulin in addition to one or more intm or long acting insulin.
  3. Set routine - inject at set times throughout day with short/rapid mixed with intm. or long acting insulin
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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)

  1. Metformin (Biguanide)
  2. Double therapy with metformin and 1 of:
    - Sulphonylurea (gliclzide, glimeperide)
    - DPP4 (Sitagliptin)
    - Pioglitazone
    or consider GLP-1 (Exenetide) or SGLT2 (dapiglifozin)
  3. Tripple therapy with metofrmin, sulphonylurea and pioglitazone or DPP4 (sitagliptin)
  4. Add insulin
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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
  1. Metformin (Biguanide)
  2. Double therapy with metformin and 1 of:
    - Sulphonylurea (gliclzide, glimeperide)
    - DPP4 (Sitagliptin)
    - Pioglitazone
    or consider GLP-1 (Exenetide) or SGLT2 (dapiglifozin)
  3. Tripple therapy with metofrmin, sulphonylurea and pioglitazone or DPP4 (sitagliptin)
  4. Add insulin

IF METFORMIN ALLERGIC/INTOLERANT:

  1. Sulphonylurea or DPP4 or Pioglitazone
  2. Double therapy with two of the above
  3. Triple therapy with three of above
  4. Add insulin
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17
Q

What are the key side effects of Metformin?

A

Weight loss, decreased appetite

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18
Q

What are the key side effects of Sulphonylureas?

A

Weight gain, increased appetite, risk of hypos

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19
Q

What are the key side effects/CIs of Pioglitazone?

A

DKA, HF, bladder Ca, Haematuria

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20
Q

What are the key side effects of SGLT2 (dapiglifozin)?

A

decreased weight, polyuria, thrush

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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
  1. Measure blood glucose - determine severity (<4 hypo, <2.2 severe, <1.5 coma)
  2. 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

  1. IM glucagon - review glucose at 15 mins
  2. 10% IV glucose infusion or 50mls of 50%
  3. Carbohydrate rich snack (once stable)
  4. Review medications
  5. Pabrinex (thiamine) if alcoholic
23
Q

What is the management of DKA?

A
  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
  3. K+ supplementation (20 or 40mmols)
    - Start in 2nd bag if K+ < 5.5
  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
24
Q

What is the management of DKA?

A
  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
  3. 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
  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
25
Q

What is the management of DKA?

A
  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
Q

What are the symptoms of HONK?

A

Polyuria, polydipsia, dehydration
muscle weakness, leg pain, fatigue, lethargy
Decrease level of conciousness (depends on plasma osmolality)
Raised HR, RR, CRT; Low BP

27
Q

What are the key investigative findings for HONK?

A
  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
Q

What is the treatment for HONK?

A
  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
Q

What are the different forms of angina? (5)

A
  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
Q

What are the risk factors for CAD?

A

Obesity, increased age, immobility, poor diet, FHx, males, smoking,

31
Q

What is the difference between typical and atypical stable angina?

A

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
Q

What is the screening tool to predict risk of stroke and MI in CAD?

A

QRISK2

33
Q

What is the diagnostic management ladder for CAD/IHD?

A
  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
Q

What is the treatment for CAD/IHD?

A

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
Q

What is an absolute CI in patients with CAD/IHD?

A

Vasodilatory drugs due to synergistic effect with nitrate treatment
e.g. sildenefil (viagra) used with GTN

36
Q

What is the difference between systolic and diastolic HF?

A

Systolic:

  • failure of ventricles to contract fully
  • reduced CO and ejection fraction < 40%

Diastolic:

  • failure of ventricle to fully relax
  • Ejection fraction > 50%
37
Q

What is the diagnostic investigative ladder for potential HF patients?

A
  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
Q

What is the treatment for acute HF?

A
  1. Loop diuretic (furosemide) - bolus or infusion
  2. Add thiazide (bendroflumethiazide) if oedema clearance is inadequate
  3. ACEi (rampiril) and BB (bisoprolol)
39
Q

What is the treatment for chronic HF? How would you monitor the medication?

A

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
Q

What HF medications are dangerous to use with digoxin?

A

Furosemide and ARB - can potentiate hypokalaemia

41
Q

What is the classification system used to categorise severity of HF? Explain

A

New York Heart Association (NYHA)

1. Slight

42
Q

What is the most common indication for a implantable cardioverter?

A

Ventricular tachycardia or fibrillation

43
Q

What are the symptoms of LVF?

A

Pulmonary oedema - dyspnoea, orthopnoea, PND
Productive cough - nocturnal, pink frothy sputum
Fatigue
Cyanosis
Pulsus alternans
RV heave (pulmonary oedema)

44
Q

What are the symptoms of RVF?

A

Peripheral pitting oedema -
Ascites + nausea
Raised JVP

45
Q

What are the different types of AF? (5)

A

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
Q

What are the investigations ordered for AF?

A
  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
Q

What is the treatment of acute AF?

A
  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
Q

What is the treatment for chronic AF?

A
  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
Q

When do you start anti-coagulation in AF patients? What would you choose?

A

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
Q

How do you assess (a) stroke risk (b) bleed risk in AF?

A

Stroke = CHADVASC2

Bleed = HAS-BLED

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