CD1 Flashcards
Target BP in patients over 80
<150/90
Target BP in patients under 80
<140/90
Target BP in diabetic patients or patients with CKD
<130/80
Drug options in emergency HTN (>180 with papilloedema)
nitroprusside, labetalol, GTN or phentolamine
Second line to statins
Ezetimibe
MOA of ezetimibe
Reduces bile secretion to minimise fat absorption
Investigation of patients with angina but low risk of coronary artery disease
CT coronary angiogram
Investigation of patients with angina and high risk of coronary artery disease
Dobutamine stress echo or coronary angiogram
MOA of ivabradine
Inhibits funny current to reduce heart rate
MOA of nicorandil
Calcium channel blocker
MOA of ransolazine
Sodium channel blocker
Management of patients with intermediate risk on GRACE score
antiplatelet and anticoagulant then non-emergency angiogram with or without stent insertion
Management of patients with low risk on GRACE score
non-invasive monitoring such as an echo or CT coronary angiography
Medication following an MI
Beta-blocker
ACE inhibitor
Statin
Anti-platelet for a year
Screening tests for complications after an MI
ECG and echo
Causes of acute AF
thyrotoxicosis, an infective exacerbation of COPD, pneumonia, alcohol (holiday heart syndrome) or an infection such as myocarditis
Causes of chronic AF
hypertension, ischaemic heart disease, dilated cardiomyopathy or idiopathic
How does “pace and ablate” therapy work?
AV node is ablated to isolate the ventricles, which are then paced with a pacemaker for rate control
When to choose chemical and electrical cardioversion in AF
Chemical if onset <48 hours ago, electrical if >48 hours ago
Medication after cardioversion
Anti-arrhythmic e.g. sotolol/flecainide
CHADSVASC cut off for anticoagulation
1 or more (unless female)
Use of BNP in diagnosis of heart failure
Guides how urgently an echo is needed
What is entresto?
a combination of sacubitril and valsartan which acts as a diuretic and ARB
Treatment for diastolic heart failure
Diuretics for symptomatic relief and specialist help
Why may patients with aortic stenosis get frequent nosebleeds and easy bruising?
The blood moving through the stiffened valve can disform von Willebrand factor, causing an acquired von Willebrand disease
Causes of chronic aortic regurgitation
hypertension, a congenital bicuspid valve, degeneration such as calcification, connective tissue disorders e.g. Marfan’s
Causes of acute aortic regurgitation
rheumatic heart disease
aortic dissection
infective endocarditis
Murmur in mitral stenosis
low-pitched rumbling diastolic murmur over the mitral area
Medication in aortic stenosis
Diuretics for symptom relief
Consider anticoagulant prophylaxis as increased risk of clots
Treatment of acute limb ischaemia
given anti-platelets (e.g. aspirin), anticoagulants (e.g. heparin) and analgesia (e.g. an opioid)
Consideration for surgery (revascularisation if limb is viable or amputation of limb isn’t viable)
Medication in mild - moderate peripheral vascular disease
Anti-platelets
Symptoms of HHS
polyuria, polydipsia, headache, nausea, vomiting and abdo pain, tachycardia, hypotension and confusion
Cancer most associated with Cushing’s
Small cell lung cancer
First line investigation in Cushing’s
24 hour urinary cortisol
Investigation of acromegaly
First line is look for raised serum IGF-1
Then oral glucose suppression test (growth hormone will remain high)
Then MRI to look for pituitary tumour
Complications of acromegaly
Diabetes
Hypertension
Cardiomyopathy
Sweating
Sleep apnoea (due to increased tongue size)
Colon cancer (screened for on diagnosis with a colonoscopy)
Reduced secretion of other pituitary hormones due to pituitary compression or visual field defects due to optic chiasm compression
Investigation of Cushing’s
First line test is usually 24-hour urinary cortisol
Midnight cortisol can be taken to show loss in circadian rhythm (it’s usually lowest at night)
Low dose dexamethasone suppression test involves giving a low dose of dexamethasone at 11pm then measuring serum cortisol at 8am and showing a lack of suppression
Once Cushing’s is confirmed and exogenous steroid use excluded, serum ACTH may be measured to see if it is ACTH dependent. The ACTH can be measured after a high-dose dexamethasone suppression test to see if the ACTH is from the pituitary gland (ACTH will fall) or an ectopic source (ACTH will stay high).
If carcinoma suspected, give CT/MRI scan
Treatment of prolactinoma
dopamine agonists (e.g. cabergoline) to reduce prolactin levels via negative feedback and shrink the tumour. If unresponsive to this, surgery may be considered
SIADH treatment
Diuretics and treatment of the cause if appropriate. In some patients tolvaptan may be used, which is a competitive inhibitor of ADH
First line investigations in Addison’s
U&Es will show hyperkalaemia and hyponatraemia (due to low aldosterone). 9 am cortisol would be measured (should be highest at this time)
How to interpret 9am cortisol in diagnosis of Addison’s
If very low, admit to hospital. If slightly low, refer for a synacthen test. If normal or high Addison’s is unlikely.
Symptoms of Addisonian crisis
dehydration, hypotension, confusion, abdominal pain, diarrhoea and vomiting, hyponatraemia and hyperkalaemia.
Treatment of Addisonian crisis
IV hydrocortisone and IV fluid resuscitation
Close monitoring of electrolytes with ECGs to look for any associated changes
Following initial resuscitation, an IV hydrocortisone and dextrose infusion is given and reduced over a few days
Frist line medication in hyperthyroidism
Carbimazole
Second line medication in hyperthyroidism
Propylthiouracil
Management of Grave’s ophthalmopathy
a combination of lifestyle changes like smoking cessation, medication such as steroids, decompressive surgery and irradiation
Management of thyrotoxic crisis
beta-blockers for symptomatic relief
propylthiouracil (a drug to reduce thyroid hormone) corticosteroids (reduce the conversion of T4 to T3)
iodine solution
First line medication in CKD
ACE inhibitors
Medications in mild alzheimers
acetylcholinesterase inhibitors such as donepezil and rivastigmine
Medications in severe alzheimers
an n-methyl-d-aspartic acid antagonist such as memantine
Extra-articular manifestations of RA
Ocular manifestations include dry eyes, episcleritis and scleritis
Oral manifestations include dry mouth and ulcers
Lung manifestations include pleuritis, interstitial lung disease and costochondritis
Cardiac manifestations include pericarditis, myocarditis, endocarditis and increased risk of ischaemic heart disease
Renal manifestations are glomerulonephritis
Neurological manifestations include peripheral neuropathy and carpal tunnel syndrome
Haematological manifestations include neutropenia, thrombocytopaenia and thrombocytosis
Skin manifestations include rheumatoid nodules (often on the elbow), rash and gangrene
Screening tests on patients with RA
hypertension, ischaemic heart disease and osteoporosis as these are common comorbidities that harm prognosis
Common DMARDs
methotrexate, leflunomide, sulfasalazine or hydroxychloroquine
ADRs of DMARDS
depends on drug but bone marrow suppression, hepatotoxicity, osteoporosis and increased risk of cancer and infections are common among many of them
Main antibodies in SLE
ANA
Lifestyle advice in SLE
avoid sun exposure, use sun screen, have the annual flu vaccine and regularly exercise
ESR and CRP in SLE
ESR usually raised
CRP usually normal
Symptoms of SLE
Symptoms are non-specific and can include fatigue, malaise, fever, splenomegaly, lymphadenopathy, weight loss, arthralgia, myalgia, mouth ulcers, rashes (classically a malar rash), headache, chest pain, altered sensation, dry eyes, dry mouth and hair loss. There may also be symptoms associated with inflammation in specific tissues.
Medications in SLE
immunosuppressants such as steroids, hydroxychloroquine, cyclophosphamide, mycophenolate mofetil and azathioprine
If this is ineffective, biological agents such as belimumab and rituximab may be considered
Causative agent of bronchiolitis
RSV
Symptoms of bronchiolitis
Symptoms are typically cold-like symptoms such as fever and a blocked nose followed by a cough, reduced feeding (may lead to signs of dehydration), increased work of breathing and use of accessory muscles, crepitations, a wheeze, cyanosis and tachycardia. Usually, the symptoms are mild and only last a few days
Age range for bronchiolitis
Young children (typically under 2)
Symptoms of PCOS
irregular or absent periods, infertility or reduced fertility, acne, hirsutism, male patten baldness, obesity, sleep apnoea and anxiety or depression
Blood tests in PCOS
FSH, LH (usually raised), oestrogen, progesterone, free testosterone (will be raised) and sex-hormone binding globulin (usually decreased)
Also tests for other differentials and risk factors e.g. diabetes
Monitoring in patients with PCOS who aren’t having regular periods
Trans-vaginal ultrasound scans for signs of endometrial cancer
Complications of PCOS
type 2 diabetes, gestational diabetes (people with PCOS should have an oral glucose tolerance test before they get pregnant and at 24-28 weeks to screen for this), cardiovascular disease, sleep apnoea and depression or anxiety
Second line medication in migraine prophylaxis
topiramate or amitriptyline
Complications of migraine
psychiatric conditions such as depression, anxiety and bipolar disorder
cardiovascular events, in particular stroke
Diagnosis of cystic fibrosis
Newborn heel prick screening
If this shows that a neonate is high risk, they will have a sweat test for increased chloride
Management of cystic fibrosis
Respiratory: pulmonary physiotherapy, bronchodilator inhalers, inhaled corticosteroids and shaking jackets or inhaled mucolytics to try and break up mucus. Prophylactic / treatment abx
Pancreatic / GI: high calorie and high fat diet, pancreatic enzyme supplementation, vitamin ADEK supplementation and proton pump inhibitors
Extra-pulmonary symptoms of pulmonary fibrosis
arthralgia, muscle pains, skin rashes and sleep apnoea
Prognosis in pulmonary fibrosis
Poor
Pulmonary fibrosis risk factors
older age
connective tissue disorders such systemic sclerosis
autoimmune disorders such as RA and lupus
exposure to chemicals such as coal dust, asbestos, silica, and mould
some medications such as amiodarone
smoking
family history or a genetic predisposition
chronic viral infections such as EBV and Hep C
GORD associated with aspiration
Medications in pulmonary fibrosis
Medical management with pirfenidone or nitedanib can slow disease progression but isn’t an option in all patients
Complications of pulmonary fibrosis
infective exacerbations, pulmonary hypertension, lung cancer, pulmonary embolism, right sided heart failure and cor pulmonale and coronary artery disease
Treatment of infective exacerbation of pulmonary fibrosis
Steroids
Gold standard in diagnosis of sleep apnoea
polysomnography, which uses an overnight EEG recording to look at brain activity, electro-oculograms to look at eye activity and electromyograms to look at muscle activity. Information from this can be used to calculate apnoea frequency
Standard test to diagnose sleep apnoea
overnight pulse oximetry and respiratory monitoring
Driving advice in sleep apnoea
Until it is controlled, the patient may need to stop driving as excessive daytime sleepiness increases risk of a road traffic accidents
MRC dyspneoa scale
grade 1 is SOB on strenuous exertion
grade 2 is SOB on mild exertion e.g. walking fast,
grade 3 is needing to walk slower and stop after 15 minutes
grade 4 is stopping for breath after 100 yards
grade 5 is SOB when dressing
Indications for home oxygen therapy in COPD
a PaO2 of <7.3 or who have a PaO2 of <8 and either pulmonary hypertension, peripheral oedema, nocturnal hypoxia or polycythaemia. It may be unsuitable for patients who smoke due to the fire hazard
First line investigation in asthma
NICE guidelines recommend fraction of exhaled nitric oxide (FeNO) as the first line investigation, which will be increased due to the production of nitric oxide by inflammatory cells.
Components of a MART inhaler
long acting beta agonist and a low dose inhaled corticosteroid
Definition of poorly-controlled asthma
symptoms in the day or night, frequent use of rescue medication or a severe exacerbation needing in-patient treatment
Histology of ulcerative colitis
crypt abscesses, inflammatory infiltration and goblet cell depletion
Histology of Crohn’s
inflammatory infiltration, lymphoid hyperplasia and granulomas
Extra-intestinal manifestations of IBD
mouth ulcers, arthritis, ankylosing spondylitis, sacroiliitis, erythema nodosum, gangrene, episcleritis or uveitis, PSC (in ulcerative colitis), fatty liver disease, gallstones, renal calculi and osteoporosis
Imaging after a diagnosis of Crohn’s
endoscopy is usually done to look for duodenal disease
CT or MRI scans may be used to look for abscesses or fistulae or to assess perianal disease
Diet in a flare or Crohn’s
Liquid diet
Medication in crohn’s
Steroids first line
Immunosuppressants or Mesalazine second line
Biologics third line
Follow-up in mild diverticulitis managed in the community
48 hours and safety netting advice
Management of moderate diverticulitis
The patient should be made nil-by-mouth until they have been surgically reviewed and they should be started on IV antibiotics (typically co-amoxiclav) and fluids
Antibody testing for coeliac disease
First this is IgA anti-tissue transglutaminase (tTGA) and if this is negative then IgA anti-endomysial (EMA) would be tested (total IgA should be tested at the same time to ensure these tests are valid)
What condition is dermatitis herpetiformis associated with?
Coeliac
Histology of coeliac
villous atrophy, crypt hyperplasia and inflammatory infiltration
Diagnosis of coeliac disease
Antibody testing
If positive, endoscopy and biopsy
Symptoms of dermatitis herpetiformis
very itchy papulovesicular rash with a typical histological appearance
What serious malignancy does coeliac predispose to?
enteropathy-associated T cell lymphoma
Cause of chronic pancreatitis
alcohol consumption, genetics, autoimmune destruction or an unknown cause
Classification of chronic pancreatitis
large duct pancreatitis - large ducts that can be seen on imaging are calcified and damaged
small duct pancreatitis - smaller ducts are damaged (not due to calcification)
Symptoms of chronic pancreatitis
The main symptom is episodes of severe epigastric pain which radiates to the back.
Other symptoms include nausea and vomiting, decreased appetite, symptoms of malabsorption such as weight loss, steatorrhea, protein deficiency and diabetes
What country is associated with a high incidence of autoimmune chronic pancreatitis?
Japan
Risk factors for chronic pancreatitis
Males
Alcohol consumption is a major risk factor.
Smoking
Family history is a risk factor and genetics
Biliary disease
ERCP imaging
Metabolic disorders such as hypercalcaemia
Trauma
Cystic fibrosis
Some drugs
Abdominal radiotherapy
Indication for secretin test
Chronic pancreatitis
What is a secretin test?
A secretin test involves giving secretin to stimulate the pancreas then using an endoscope to collect the pancreatic secretions for analysis in order to assess pancreatic function
Imaging in chronic pancreatitis
CT scan to look for duct atrophy, calcification or dilation
Secretin enhanced MRI or MRCP scan
Endoscopic ultrasound to assess the duct walls
Conservative management of chronic pancreatitis
Lifestyle advice (smoking and alcohol cessation)
Pain relief (NSAIDs initially but often opioids are needed)
In patients with ductal strictures, ERCP can be used to insert a stent into the ducts which can reduce pain
Lipase supplements to reduce the symptoms of malabsorption
In around a third of patients (particularly those with small vessel disease), giving supplements of pancreatic enzymes improves symptoms.
How pancreatic enzyme supplements are given
Trial for 1 month then continued for 6 months at a time if symptoms improve
Surgical options in chronic pancreatitis
open, laparoscopic or endoscopic
procedures include cyst decompression, stone dislodging, decompression of duct dilation and in some cases removal of the pancreas (sometimes the duodenum as well)
Some newer surgical and pain management treatments are being studied
Complications of chronic pancreatitis
malabsorption, diabetes, pericardial, peritoneal or pleural effusion, cysts, GI bleeds and increased risk of pancreatic cancer
Scoring system in chronic liver disease
Child-Pugh score
Medication to reduce portal hypertension
Beta-blockers
Management of hepatic encephalopathy
Laxatives (lactulose) and antibiotics if evidence of infection
Management of ascites
diuretics (spironolactone and a loop diuretic)
paracentesis if severe
Screening in patients with chronic liver disease
Patients should be monitored for hepatocellular carcinoma with ultrasound scans with or without AFP levels
Drug to reduce desire to drink
Naltrexone
