CCC - Primary Care Flashcards
Asthma - Management
1) Salbutamol
2) ICS (200mg)
3) LABA
- benefit = continue
- some benefit, continue and increase ICS to 800mg
- no benefit - stop, increase ICS, trial LTRA
4) ICS to 2000
5) Oral prednisolone
- Refer
Asthma Review
- Smoking cessation
- Inhaler technique
- Symptom control (compliance)
- Admissions
- Exacerbations
- Flu jab and PCV
- Mood
Acute AF - Unstable
DC Cardioversion
Medical cardioversion: Amiodarone
Acute AF - Stable
Rate control:
- Bisoprolol 2.5mg
- Verapamil 40-120mg/8 hours
Anticoagulation with LMWH
Chronic AF - Rate control
Beta blocker
- Atenolol
- Not in asthma
Rate limiting calcium channel blocker
- Verapamil/diltazem
- Not in HF
Digoxin
- Only if sedentary life style
Chronic AF - Rhythm Control
ECHO
- No structural abnormality - flecainide
- Structural abnormality - amiodarone
- Surgical ablation
Stable Angina - 1st Line
Beta blocker - Bisoprolol 2.5mg OR Rate limiting Calcium channel blocker - Diltiazem/verapamil
Long Acting mononitrate
- Isosorbide mononitrate
- May become tolerant
GTN Spray/sublingual tablet
- Symptom relief
Stable Angina - Secondary Prevention
- Aspirin 75mg
- ACEi if diabetic
- Statin/hypertensive
Revascularisation
- CABG
- PCI (single vessel disease)
Stable Angina - Review
6 months - 1 year
- Symptoms (rest, exercise, duration)
- CVD risk
- Modifiable risk factors
- Medication r/v
SCREEN: Heart failure and depression
Q RISK 2 - Who?
Assess every 5 years
- > 40 years
- First degree relative with premature CVD or familial hyperlipidaemia
CVD - Modifiable risk factors
- Diet
- Smoking
- Stress
- Exercise
- Alcohol
CVD - Primary Prevention
> 10% in 10 years
- Atorvastatin 20mg
BP
- ACEi if diabetic
- Follow ACD rule
CHA2DS2VASC
Congestive heart failure Hypertension Age >75 (2) 65-74 (1) Diabetes Stroke/TIA/VTE Vascular disease (MI, angina, peripheral vasc. disease) Sex (Female = 1)
ANTICOAGULATE
- Men @ 1+
- Women @ 2+
HASBLED
Hypertension >160 Abnormal renal (1), liver (1) Stroke Bleeding history Labile INR Elderly (>65) Drugs - Alcohol (8U/week) - NSAIDs/anti platelet
COPD - FEV >50% (mild-mod)
SABA,
SABA + LABA,
Combohaler (ICS/LABA) + LAMA
OR
SAMA
LAMA
COMBOHALER + LAMA
COPD - FEV <50% (severe)
SABA
SABA + COMBOHALER
COMBO-HALER + LAMA
or
SAMA
LAMA
COMBOHALER + LAMA
COPD - Extra Management
STOP SMOKING!!
Rescue Pack
- Prednisolone 30mg 7 days
- Amoxicillin 500mg 5 days
COPD - Review
6M (severe), 1Y (mild-mod)
- Mood
- Smoking cessation
- Inhaler Technique
- O2 sats, BMI
- Medication
- Exacerbations, admissions
- Flu jab/PCV
CKD - Stages
1) >90 (normal)
2) 60-89
3a) 45-59
3b) 30-44
4) 15-29
5) <15
CKD - Stage 1-2 Management
- Annual monitoring
- ACEi
- CV risk
CKD - Stage 3a and 3b Management
- CVS Risk
- Investigate proteinuria, haematuria, declining eGFR, young age
- Decrease use of nephrotoxic drugs
CKD - Stage 4 Management
- Urgent referral
- Medication review if eGFR <30
Diabetes - Education
- Vaccinations
- Exercise (increase insulin sensitivity)
- Smoking cessation
- Work (if on insulin, no army, machinery, driving)
- Diet
Diabetes - Therapy
Diet and lifestyle for 3 months
If HbA1c >6.5% = Metformin
> 7.5% - Dual therapy
- Metformin + one other
> 7.5% - Triple therapy
- Metformin + sulphonylurea + DDPIV/pioglitazone
Still >7.5%
- Insulin
- Aim for HbA1c <7.0
Diabetes - Therapy (Metformin contraindicated)
DPPIV/Sulphonylurea/pioglitazone
Duel therapy - combo of any two
Insulin (aim <7.0%)
Metformin
Biguanide
- Increases insulin sensitivity,
- Decreases gluconeogenesis
GOOD - Weightloss, no hypos
BAD - GI disturbance, can give MR preparation
DO NOT USE IN eGFR <30
Sulphonylureas (Gliclazide)
- Increases production of insulin
GOOD - Rapid improvement, good if low eGFR
BAD - Weight gain, hypos
Pioglitazone
- Increases insulin sensitivity
- Preserves beta cell function
CONTRAINDICATIONS
- Heart failure
- Bladder Ca
DPP-IV Inhibitors (sitagliptin)
- Inhibits DPP-IV (which breaks down incretin)
Increase Incretin = increases insulin, decreases gluconeogenesis
SGLT-2 (dapaglifozin)
- Reduce glucose transporter on proximal tubule
- More glucose lost in urine
BAD - polyuria, polydipsia, UTIs, Candida
Statins - Primary Prevention
Atorvastatin 20mg
- QRISK2 >10%
- T1DM - >40 years or diabetes >10 years
- T2DM >10% qrisk
- CKD
Statins - Secondary Prevention Dose
Atorvastatin 80mg (20mg in CKD)
Statins - Monitoring
- ALT/AST at 3M and 12M
- Cholesterol at 3M (aim for 40% reduction in HDL)
Hypertension - Diagnosis
Measure BP in both arms
- > 140/90 measure again
- Ambulatory/home monitoring to confirm
Hypertension - Exam and Investigations
- Fundus
- 12 Lead ECG
- Urine (ACR and haematuria)
Bloods
- Glucose
- UEs + eGFR
- LFTs
- Lipids
Hypertension - Staging
1 ) 135-150/ 85-90
2) >150/>90
3) >180/>110
Hypertension - Who to treat?
> 80 years and stage 1
Stage 2 and above
ACD Rule
<55 years
- ACEi
- ACEi + Ca2+ Channel blocker
- ACEi + Ca2+ Channel Blocker + Thiazide diuretic
> 55 years/afro carribean
- Ca2+ Channel blocker
- Ca2+ Channel blocker + ACEi (or ARB if afrocarribean)
- Ca2+ Channel Blocker + ACEi/ARB + Thiazide diuretic
Resistant
- Add another diuretic/beta blocker
Epilepsy - General Seizures
- Absence
- Tonic clonic (LOC, post ictal)
- Myoclonic (drop to ground)
- Atonic (fall, no LOC)
Epilepsy - Focal seizures
- Simple, no LOC
- Complex, post ictal, impaired awareness
- Focal -> generalised
Epilepsy - DVLA
Car
- 1 year fit free
HGV
One off - 5 years, no meds
Multiple - 10 years, no meds
Epilepsy - Safety
- Showers not baths
- Do not swim alone
- No climbing
- Medic alert bracelet
Epilepsy - Drugs
Carbamezepine
- P450 inducer
Sodium Valproate
- Teratogenic
- p450 inhibitor
Phenytoin
- P450 inducer
Lamotrigine
- Safe in pregnancy
Heart Failure - Investigations
Previous MI
- ECHO in 2 weeks
No prior MI - BNP
>400 = ECHO 2 weeks
100-400 - ECHO 6 weeks
<100 - unlikely, reconsider Dx
NYHA Scoring
1 - no limitation
2 - comfortable at rest, SOB on exertion
3 - ordinary activity limited
4- SOB at rest
HF - 1st line
Beta blocker (bisoprolol) ACEi (Ramipril) Loop Diuretic (furusomide 40mg)
HF - 2nd Line
Aldosterone antagonis (sprinolactone) ARB (valsartan)
HF - Further management
- Cardiac rehab
- Implantable cardio defic in LV failure
Bamford Classification
- unilateral hemiparesis/sensory loss of face arm and leg
- homonymous heminopia
- higher cognitive dysfunction
TACs and PACs
TACS
- All 3 present
- middle cerebral and anterior cerebral
PACS
- 2 of 3 present
LACS
Lacunar - internal capsule, thalamus and basal ganglia
- unilateral deficit of arm/leg/face
- ataxic hemiparesis
- pure sensory stroke
POCS
- cerebellar/brainstem syndrome
- LOC
- Isolated homonymous heminopia
Thrombolysis
CT showing infarct
- <4.5 hours
- <3 hours if over 80 years
Do CT 24 hours later to exclude haemorrhagic transformation of infarct
Thrombolysis contraindicated
300mg aspirin stat and for 2 weeks
- Clopidogrel 75mg OD lifelong
ABCD2 Score
Age >60
BP <140/90
Clinical
- Weakness (2)
- Speech disturbance (1)
- Other (0)
Duration
- > 60 (2)
- 10-59 (1)
- <10 (0)
Diabetes
TIA Management (based on score)
>4 = TIA clinic in 24 hours <3 = TIA clinic in 1 week
Regardless 24hours:
- AF
- Warfarin
- Crescendo TIA
TIA - Investigations
ECG to rule out AF
Stroke - Secondary prevention
- Clopidogrel 75mg
- Atorvastatin 80mg (start 24 hours post)
- Diet and lifestyle advice
- ACEi according to ACD rule
Stroke - DVLA
Do not drive for 1 month
NEVER if neglect/visual field defect
