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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
Criteria for bariatric surgery?
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
26
What are the options for bariatric surgery?
Gastric bypass Gastric banding Sleeve gastrectomy
27
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?
CCB eg Amlodipine | Lifestyle changes
28
73yr old lady, currently on lisinopril and felodipine, her clinic and ABPM are consistently >150/90. What should be added next?
Thiazide like diuretic Eg Indapamide
29
Most common side effect of ACE-I, CCB, thiazide like diuretic?
Dry cough swollen ankles hypokalaemia/sexual dysfunction
30
4 medications every patient should be on post MI?
``` B-blocker Aspirin ACEI/ ARB Antianginal ?warfarin ```
31
What agent reverses warfarin? NOAC?
Vit K | Beriplex
32
What should be considered when deciding between warfarin and NOAC?
Risk of fall/bleeding, how easy it will be to monitor, dietary changes
33
Name two groups of medications that can be used in the rate control of AF and an example of each?
B blocker (any apart from SOTALOL), Rate limiting CCB (non-dihydropyridine) e.g. diltiazem, cardiac glycoside e.g. digoxin
34
Which drug is contraindicated for rhythm control in AF if the patient has IHD?
Flecainide
35
Two examples of an ICS?
Beclamethasone, budesonide, fluticasone
36
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?
ontinue formeterol and increase ICS to 800mcg/day. Then add 4th drug or increase to 2000.
37
``` Intepret this ABG: 65 yr old gentlemen brought into A&E with COPD exacerbation. On 28% oxygen via simple facemask. pH 7.35 PaO2 7.3 PaCO2 11.2 HCO3 36.0 ```
Type 2 resp failure, chronic | As bicarbonate has increased
38
What oxygen saturations are the target for COPD patients on oxygen therapy?
88-92%
39
Three things that require annual review in a diabetic?
Renal function, hba1c, BP, eyes, feet
40
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?
>11.1
41
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?
Metformin, 2 others (sulphonylurea/glitazone/gliptin) and GLP1 agonist e.g. exanatide
42
If a 76 yr old gentlemen is found to have an eGFR of 38, what stage CKD does he have?
3b
43
Following lifestlye | What treatment option for patient with a BMI of 52 ?
Surgery
44
Benefits of NOACs over warfarin
Don’t have to change diet - Vit K Quicker onset / offset when stopped Less regular monitoring required
45
Presentation of hypokalaemia? If severe?
Constipation Generalised weakness and muscle pain Respiratory failure - dude to involvement of resp muscles Parathesia Tetany Ileus
46
Ix in hypokalaemia? ECG findings?
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
Digoxin therapeutic range? When do you worry about toxicity? What happens in toxicity? Features
1-1.5nmol/L 2 Renal dysfunction and hypokalaemia N+V, diarrhoea, confusion, dizziness, headache, blurred vision
48
Monitoring in digoxin?
U+Es Ventricular rate - aim for <90 Check K if signs of toxicity and withhold drug if any hypokalaemia
49
What would you do if a clinic BP >140/90?
Confirm with ambulatory BP of home of >135/85
50
Causes of secondary hypertension
``` Cushings Conn’s Renal artery stenosis Coarctation of the aorta Phaeochromocytoma Renal disease - PKD, glomerulonephritis ```
51
Ix in HTN? | 3 specific tests for secondary causes?
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
1st line in diabetes
Lifestyle advice Healthy diet - low fat and sugar Increase exercise Smoking cessation Try for 3 months -> drug treatment
53
Name at least 4 common long term complications of diabetes
``` CV Nephropathy Eye disease Neuropathy Ulcers ```
54
3 acute complications of diabetes
Hypoglycaemia Hyperosmolar hypergycaemic state Diabetic ketoacidosis
55
Sx of hypoglycaemia ? Why? Mx? If unconscious? In hospital?
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
Which electrolyte changes in DKA?
Potassium -> released from cells Some is excreted in urine Levels in blood are still high
57
Mx of DKA
Fluids for dehydration Insulin to lower blood glucose Electrolytes (K) [This all helps to reverse acidosis]
58
Blood pH in DKA
<7.35
59
When you give insulin for DKA what is the risk? How do you avoid
Risk of Hypokalaemia as insulin causes K->Cells Use a dextrose-insulin infusion
60
What does the high blood glucose in Hyperosmolar hyperglycaemic state do?
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
What is the genetic cause of COPD? What else does it cause?
Alpha 1 - antitrypsin deficiency Cirrhosis and liver failure in a minority
62
Complications of COPD
``` Reduced mobility Depression and anxiety Cor pulmonale Recurrent chest infections Secondary polycthaemia Type 2 respiratory failure ```
63
DDs of COPD
``` Asthma Bronchiectasis Heart failure Lung Ca Interstitial lung disease Anaemia TB ```
64
Ix in primary care for COPD
CXR and FBC PHQ-9 and GAD7 O2 sats ECG and Echo - If cor pulmonale features Sputum culture - if purulent and persistent
65
DDs of acute exacerbation of COPD
``` Pneumonia Aspiritation Pneumothorax Acute HF PE Lung ca Pleural Effusion Upper airway obstruction ```
66
COPD management steps
1 - SABA 2 If FEV1 is <50% -> LABA+ICS or LAMA If FEV1 >50% -> LABA or LAMA 3 Triple therapy
67
Mx of COPD exacerbation ? If sputum Sx ?
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
If you regularly need to prescribe prednisolone for COPD exacerbations what do you need to be aware of
Risk of osteoporosis
69
When would you consider O2 therapy in COPD ?
``` <30% FEV1 Cyanosis Polyccythemia Peripheral oedema Raised JVP O2 sats <92% ```
70
Causes of HF
Myocardial Valvular Pericardial Arrythmias High output states - Anaemia, hyperthyroid, pagets Volume overload - CKD Obesity Drugs / alcohol
71
What are poor prognostic features of HF
``` Reduced ejection fraction Co-morbidities Worsening sx Obesity / cachexia Smoking Mi hx ```
72
Complications of HF
``` AF Depression Cachexia CKD Sexual dysfunction Sudden cardiac death ```
73
Sign and Sx of HF
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
Ix in HF? If Hx of MI? No Hx of MI?
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
Mx of heart failure
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
What needs to be checked 2 weeks into use of ACEi ?
U+E
77
Mechanism for dry cough with ACEi ?
Bradykinin accumulation
78
Key first treatment in DKA ?
IV saline
79
Most important intervention in preventing deterioration in COPD ?
Smoking cessation
80
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?
ICS + LABA Or LAMA
81
What drug treatment most effectively help symptoms in heart failure?
Loop diuretics
82
Diagnostic Ix for HF in patient who has had an MI?
Echocardiogram

Sheff 3a (30 decks)

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