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Sheff 3a > Chronic Disease - Joe Charlotte > Flashcards

Chronic Disease - Joe Charlotte Flashcards

1
Q

Stages of HTN? What else would you assess ?

A

Stage 1: BP (clinic) ≥140/90 & ABPM ≥135/85

Stage 2: BP (clinic) ≥160/100 & ABPM ≥150/95

Severe: BP (clinic) Systolic ≥180 or Diastolic ≥110

CV risk using QRISK2
Target and end organ damage 
-Urine AC ratio
U&E
Plasma glucose 
Serum cholesterol 
Fundoscopy - ?HTN retinopathy 
ECG
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2
Q

HTN management stage 1? Who would be offered antihypertensives in stage 1?

A

Lifestyle

<80 if any of 
-target organ damage
-established CVD 
-CKD 
-T1/2DM
QRISK2 >20%
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3
Q

Target BP in <80? In >80? Diabetic?

A

140/85
150/85
130/85

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4
Q

BP medication table

A

Under 55 - ACEi
Over 55 / black - CCB

2- ACEI + CCB

3- ACEi + CCB + Thiazide like diuretic

4 - resistant HTN
Consider adding a further diuretic / alpha blocker / beta blocker
-could seek expert advice

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5
Q

Target cholesterol for normal and high risk?

A

normal <5, high risk <4
LDL normal <3, high risk <2
HDL normal <1, high risk <1

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6
Q

Management of hypercholesterolaemia ? Statin s/e? What test do you do to monitor?

A

Lifestyle - smoking, exercise, reduce sat fat

Statins Eg simvastatin
Headache/GI most common
Muscle aches -> myopathy or rhabdomyosis
Rise in liver enzymes - monitor LFT 12/52 later
-> if ALT/AST is 3x upper limit need to reduce or stop

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7
Q

Mechanism of statins?

A

HMG CoA reductase inhibitors

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8
Q

What to do with 1st presentation of angina?

A

send to A&E -> follow ACS pathway

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9
Q

Post MI management? Which drugs? What is an absolute CI post STEMI and for how long?

A

Refer to cardiology - ?revascularisation
Attend cardiac rehab
Lifestyle changes
Manage co-morbid depression

Drugs 
B-blocker 
ACEi /ARB 
Statin 
Aldosterone antagonist 
Anti-anginals 
Warfarin if anterior MI 
Aspirin

CI- NSAIDS for 2 months

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10
Q

Target INR in AF?

A

2-3

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11
Q

2 options for control of AF?

A

New onset - consider cardioversion (AC 4/52)
Rate control - B-Blocker or rate limiting CCB (diltiazem), digoxin

OR

Rhythm control - amiodarone or flecainide
(NOT in IHD)

DONT DO BOTH

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12
Q

Types of inhaler ?

A 
SABA e.g. salbutamol, terbutaline
LABA e.g. salmeterol, formeterol
SAMA e.g. Ipratropium bromide
LAMA e.g. tiotropium bromide
Inhaled corticosteroid e.g. beclametasone, budesonide, fluticasone

(Sama = Short acting muscarinic antagonists)

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13
Q

What does theophylline / aminophyllin do?

A

Bronchodilators

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14
Q

Eg of a Leukotrine antagnonist?

A

Montelukast

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15
Q

What is cromoglycate used for? What is it not used for?>

A

Prophylaxis of Asthma / bronchospasm

Not useful during an acute asthma attack

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16
Q

Questions to assess asthma severity ?

A

In the last four weeks..

How many days did you have daytime asthma symptoms? How often did you need to use your reliever? How many days were activities limited by asthma?
How often did asthma symptoms occur at night or on waking?
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17
Q

Asthma management in adults

A

1 - Inhaled SABA PRN

2 -Add Inhaled corticosteroid 200-800mcg/day

3 - inhaled LABA
Good response = continue LABA
Some response = continue LABA and increase ICS to 800mcg/day
No response = Stop LABA, ICS to 800mcg/day

4- trail increase of ICS to 2000mcg/day
Add 4th drug - Eg montelukast / theophylline

5- daily oral steroids - lowest dose possible
Maintain ICS at 2000
Refer

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18
Q

NICE classification of COPD severity?

A

Stage 1; Mild: FEV1 > 80%
Stage 2; Moderate: FEV1 50-79%
Stage 3; Severe: FEV1 30-49%
Stage 4: Very severe: FEV1 < 30% (or FEV1 < 50% but with respiratory failure).

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19
Q

2 types of resp failure?

A

Type 1 = Pink Puffers = Low O2 and normal/low CO2

Type 2 = Blue Bloaters = Low O2 and high CO2.
Become unresponsive to high CO2 drive and only breathe in response to hypoxia

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20
Q

Management of T1DM ? Review what? How often? Poor control? Target HBA1C?

A

Insulin – mixture of short and long acting insulin e.g. Novorapid boluses and Detemir BD
Individual care plan
Review annually – includes BP, renal function, eye check, foot check
If poor control refer to Diabetologist
Target HbA1c <48 mmols/mol

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21
Q

T2DM management steps

A

1- Lifestyle Modifications – recheck HbA1c in 2-3 months

2- Biguanide e.g. Metformin – titrate upwards to max. dose as needed (monitor renal function)

3- If HbA1c still >58 add second agent - sulphonylurea (gliclazide, glibenclamide), pioglitazone or DPP4 inhibitor (e.g. sitagliptin)

4- Add a third agent (another of those listed in step 3)

BMI <35  commence insulin therapy
BMI >35  GLP1 agonist e.g.exenatide

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22
Q

Target BP in CKD? How does this change if they have DM? What should be offered to all CKD? When are they refered?

A

<140/90
<130/80

Statin and an antiplatelet as secondary prevention of CVD

Refer to renal at stage 4+

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23
Q

Lifestyle management of obesity?

A

Diet 600kcal/day deficit

Physical activity 30mins of moderate activity 5 days per week

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24
Q

Drug management of obesity? How long for? When would you proceed straight to surgery?

A

Orlistat if BMI >30 or >28 with risk factors Eg, T2DM
-given for 3/12 then only continued if lost 5% of body weight

Proceed to surgery if BMI >50

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25
Q

Criteria for bariatric surgery?

A

BMI >35 and recent dx of T2DM

Asian and recent dx of T2DM with BMI >25

BMI >40 or BMI >35 with sig. assoc. disease + all non surgical methods failed + seen by specialist + fit for anaesthetic and surgery + patient commits to long term follow up

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26
Q

What are the options for bariatric surgery?

A

Gastric bypass
Gastric banding
Sleeve gastrectomy

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27
Q

53yr old Jamaican, BP in clinic 152/97, and APBM of 140/80, eGFR 100, T1DM. Does he need treatment? If so what is first line?

A

CCB eg Amlodipine

Lifestyle changes

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28
Q

73yr old lady, currently on lisinopril and felodipine, her clinic and ABPM are consistently >150/90. What should be added next?

A

Thiazide like diuretic Eg Indapamide

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29
Q

Most common side effect of ACE-I, CCB, thiazide like diuretic?

A

Dry cough
swollen ankles
hypokalaemia/sexual dysfunction

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30
Q

4 medications every patient should be on post MI?

A 
B-blocker 
Aspirin 
ACEI/ ARB 
Antianginal 
?warfarin
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31
Q

What agent reverses warfarin? NOAC?

A

Vit K

Beriplex

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32
Q

What should be considered when deciding between warfarin and NOAC?

A

Risk of fall/bleeding, how easy it will be to monitor, dietary changes

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33
Q

Name two groups of medications that can be used in the rate control of AF and an example of each?

A

B blocker (any apart from SOTALOL), Rate limiting CCB (non-dihydropyridine) e.g. diltiazem, cardiac glycoside e.g. digoxin

34
Q

Which drug is contraindicated for rhythm control in AF if the patient has IHD?

A

Flecainide

35
Q

Two examples of an ICS?

A

Beclamethasone, budesonide, fluticasone

36
Q

33 yr old with uncontrolled asthma. Currently taking terbutaline PRN, beclametasone 400mcg/day and they have recently completed a trial of formeterol which provided some relief. What is the next step?

A

ontinue formeterol and increase ICS to 800mcg/day. Then add 4th drug or increase to 2000.

37
Q 
Intepret this ABG:
65 yr old gentlemen brought into A&amp;E with COPD exacerbation. On 28% oxygen via simple facemask. 
pH 7.35
PaO2 7.3
PaCO2 11.2
HCO3 36.0
A

Type 2 resp failure, chronic

As bicarbonate has increased

38
Q

What oxygen saturations are the target for COPD patients on oxygen therapy?

A

88-92%

39
Q

Three things that require annual review in a diabetic?

A

Renal function, hba1c, BP, eyes, feet

40
Q

If an asymptomatic patient has an incidental random plasma glucose test done with a result of 12.0 what does the result of his GTT have to be to be diagnosed as diabetic?

A

> 11.1

41
Q

If a 68 year old morbidly obese lady has a HbA1c of 60 and is been considered for insulin therapy. What medications should they have already tried?

A

Metformin, 2 others (sulphonylurea/glitazone/gliptin) and GLP1 agonist e.g. exanatide

42
Q

If a 76 yr old gentlemen is found to have an eGFR of 38, what stage CKD does he have?

A

3b

43
Q

Following lifestlye

What treatment option for patient with a BMI of 52 ?

A

Surgery

44
Q

Benefits of NOACs over warfarin

A

Don’t have to change diet - Vit K
Quicker onset / offset when stopped
Less regular monitoring required

45
Q

Presentation of hypokalaemia? If severe?

A

Constipation
Generalised weakness and muscle pain

Respiratory failure - dude to involvement of resp muscles
Parathesia
Tetany
Ileus

46
Q

Ix in hypokalaemia? ECG findings?

A

U+Es - Low Sodium = Thiazide use / loss of volume
Bicarbonate
Glucose
Chloride
Magnesium - often accompanies and needs to be corrected

Urine - check for K/Na/Osmolarity

ECG - Flat T waves, ST depression, Prominent U waves

47
Q

Digoxin therapeutic range? When do you worry about toxicity? What happens in toxicity?
Features

A

1-1.5nmol/L
2

Renal dysfunction and hypokalaemia

N+V, diarrhoea, confusion, dizziness, headache, blurred vision

48
Q

Monitoring in digoxin?

A

U+Es
Ventricular rate - aim for <90

Check K if signs of toxicity and withhold drug if any hypokalaemia

49
Q

What would you do if a clinic BP >140/90?

A

Confirm with ambulatory BP of home of >135/85

50
Q

Causes of secondary hypertension

A 
Cushings 
Conn’s 
Renal artery stenosis 
Coarctation of the aorta 
Phaeochromocytoma 
Renal disease - PKD, glomerulonephritis
51
Q

Ix in HTN?

3 specific tests for secondary causes?

A

End organ damage
12 lead ECG ± echo
U+E, eFR and urine dipstick
Renal USS

CVD risk
Blood glucose
Fasting lipids

Secondary causes
24hr urinary metanephrines - Phaochromocytoma
Dexamethasone suppression - Cushings
Renin/aldosterone ratio -Conns

52
Q

1st line in diabetes

A

Lifestyle advice
Healthy diet - low fat and sugar
Increase exercise
Smoking cessation

Try for 3 months -> drug treatment

53
Q

Name at least 4 common long term complications of diabetes

A 
CV 
Nephropathy 
Eye disease 
Neuropathy 
Ulcers
54
Q

3 acute complications of diabetes

A

Hypoglycaemia
Hyperosmolar hypergycaemic state
Diabetic ketoacidosis

55
Q

Sx of hypoglycaemia ? Why?
Mx?
If unconscious?
In hospital?

A

Pale, sweaty, nausea, clammy
-due to adrenergic response in attempt to get more glucose

Oral glucose - Eg biscuit -> more long term carbs

IM glucagon

IV dextrose 50ml 25%

56
Q

Which electrolyte changes in DKA?

A

Potassium -> released from cells

Some is excreted in urine
Levels in blood are still high

57
Q

Mx of DKA

A

Fluids for dehydration
Insulin to lower blood glucose
Electrolytes (K)

[This all helps to reverse acidosis]

58
Q

Blood pH in DKA

A

<7.35

59
Q

When you give insulin for DKA what is the risk? How do you avoid

A

Risk of Hypokalaemia as insulin causes K->Cells

Use a dextrose-insulin infusion

60
Q

What does the high blood glucose in Hyperosmolar hyperglycaemic state do?

A

Causes water to leave cells into blood
-> urine -> dehydration

->Altered mental state + risk of VTE

[Do see some kenonaemia and acidosis but not as much as DKA]

61
Q

What is the genetic cause of COPD? What else does it cause?

A

Alpha 1 - antitrypsin deficiency

Cirrhosis and liver failure in a minority

62
Q

Complications of COPD

A 
Reduced mobility 
Depression and anxiety 
Cor pulmonale 
Recurrent chest infections 
Secondary polycthaemia 
Type 2 respiratory failure
63
Q

DDs of COPD

A 
Asthma 
Bronchiectasis 
Heart failure 
Lung Ca 
Interstitial lung disease 
Anaemia 
TB
64
Q

Ix in primary care for COPD

A

CXR and FBC
PHQ-9 and GAD7
O2 sats
ECG and Echo - If cor pulmonale features
Sputum culture - if purulent and persistent

65
Q

DDs of acute exacerbation of COPD

A 
Pneumonia 
Aspiritation 
Pneumothorax 
Acute HF 
PE 
Lung ca 
Pleural Effusion 
Upper airway obstruction
66
Q

COPD management steps

A

1 - SABA

2
If FEV1 is <50%
-> LABA+ICS or LAMA

If FEV1 >50%
-> LABA or LAMA

3
Triple therapy

67
Q

Mx of COPD exacerbation ? If sputum Sx ?

A

Consider admission
Increase dose / frequency of SABA

Prescribe oral corticosteroids Eg Prednisolone for 1-2 weeks

If purulent sputum / pneumonia Sx -> ABx Eg Amoxicillin for 5 days

Follow up when stable to optimise treatment, review self management, review inhaler

68
Q

If you regularly need to prescribe prednisolone for COPD exacerbations what do you need to be aware of

A

Risk of osteoporosis

69
Q

When would you consider O2 therapy in COPD ?

A 
<30% FEV1 
Cyanosis 
Polyccythemia 
Peripheral oedema 
Raised JVP 
O2 sats <92%
70
Q

Causes of HF

A

Myocardial
Valvular
Pericardial
Arrythmias

High output states - Anaemia, hyperthyroid, pagets
Volume overload - CKD
Obesity
Drugs / alcohol

71
Q

What are poor prognostic features of HF

A 
Reduced ejection fraction 
Co-morbidities 
Worsening sx 
Obesity / cachexia 
Smoking 
Mi hx
72
Q

Complications of HF

A 
AF 
Depression 
Cachexia 
CKD 
Sexual dysfunction 
Sudden cardiac death
73
Q

Sign and Sx of HF

A

Sx
Breathlessness, fluid retention, fatigue, syncope
Specific - Orthopnoea (Breathless when laying down), PND

Signs
Tachycardia, hypertension, tachypnea, basal creeps, oedema, obesity, murmurs
Specific - Displaced apex, gallop rhythm, raised JVP , hepatomegaly, ascities

74
Q

Ix in HF?
If Hx of MI?
No Hx of MI?

A

ECG - everyone

Bloods
U+E, eGFR, FBC, TFTs, LFT, HbA1C, lipids

Urine analysis

CXR

MI -> refer to cardio and do an echo within 2 weeks

No-> Measure BNP or NT-pro-BNP

  • if normal hear failure unlikely
  • if high -> refer to cardio and organise echo
75
Q

Mx of heart failure

A

1 - review drugs and see if contributing to sx

2- Prescirbe a loop diuretic (Eg furosemide) for Sx relief

3- Prescribe an ACEi and B-blocker
-start one at a time (any order)

4- Refer if still symptomatic

Consider anti-platelet
Consider statin
Annual flu and pneumococcal vaccine
Cardiac rehab

76
Q

What needs to be checked 2 weeks into use of ACEi ?

A

U+E

77
Q

Mechanism for dry cough with ACEi ?

A

Bradykinin accumulation

78
Q

Key first treatment in DKA ?

A

IV saline

79
Q

Most important intervention in preventing deterioration in COPD ?

A

Smoking cessation

80
Q

Hazel has COPD. She is taking Salbutamol 2 pubs 4 times daily. Despite this she still has SoB. He FEV1 is 44%, what is the most approitate management option?

A

ICS + LABA
Or
LAMA

81
Q

What drug treatment most effectively help symptoms in heart failure?

A

Loop diuretics

82
Q

Diagnostic Ix for HF in patient who has had an MI?

A

Echocardiogram

Sheff 3a (30 decks)

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