GP Flashcards
Stage 1 HTN:
≥140/90
OR
ABPM daytime average reading of ≥135/85
Stage 2 HTN:
≥160/100
OR
ABPM daytime average reading of ≥ 150/95
Severe HTN:
≥180 diastolic
OR
≥110 diastolic
What is ‘essential’ HTN?
Primary idiopathic HTN i.e. cause unknown
Give 2 causes of secondary HTN:
Most commonly due to kidney or endocrine problems, for example:
- CKD (e.g. due to diabetes)
- Cushing’s syndrome (hypersecretion of corticosteroids)
Give 4 unmodifiable risk factors for HTN:
- Increasing age
- Family history
- Diabetes
- Ethnicity
What is malignant HTN? How does it present (3 signs/symptoms):
AKA accelerated phase HTN
A rapid rise in BP leading to vascular damage
Px:
- Severe HTN
- Headaches with visual disturbance
- Bilateral retinal haemorrage
What investigations should be carried out when diagnosing HTN? (4)
- Ambulatory BP monitoring over 24 houus
- Fasting glucose
- Cholesterol levels
- Other tests to look for potential end organ damage e.g. proteinuria, fundoscopy, ECG
How do you treat malignant HTN (AKA accelerated phase HTN)?
Admit for specialist treatment and urgent investigations
What are the first and second line treatments for HTN in someone with type 2 DM?
1st: ACEi (ramipril) or ARB (candesartan)
2nd: Add a CCB (amlodipine or nifedipine) or thiazide-like diuretic (bendroflumethiazide)
What are the first and second line treatments for HTN in someone without DM2 who is <55 years old and not black African or of African-Carribean family origin?
1st: ACEi (ramipril) or ARB (candesartan)
2nd: Add a CCB (amlodipine or nifedipine) or thiazide-like diuretic (bendroflumethiazide)
What are the first and second line treatments for HTN in someone without DM2 who is 55 years or older?
1st: CCB (amlodipine or nifedipine)
2nd: Add an ACEi or ARB or thiazide-like diuretic (bendroflumethiazide)
What are the first and second line treatments for HTN in someone who is black African or of African-Carribean family origin?
1st: CCB (amlodipine or nifedipine)
2nd: Add an ACEi or ARB or thiazide-like diuretic (indapamide)
What is the third line treatment for HTN in all groups?
A + C + D = ACEi/ARB and CCB and Diuretic
What medication might you add to a patient’s treatment once you have confirmed they have resistant HTN? (They are already on A+C+D)
Low dose spironlactone (if blood potassium is <4.5)
OR
Alpha-blocker or Beta-blocker (if blood potassium >4.5)
Also seek expert advise!
What type of drug is indapamide?
A thiazide-like diuretic
What type of drug is doxazosin?
An alpha-blocker (used in fourth line tx of HTN)
Name 3 drugs that increase the risk of idiopathic intracranial hypertension:
- combined oral contraceptive pill
- steroids
- tetracyclines e.g. lymecycline
- vitamin A
- lithium
What group of people typically experience idiopathic intracranial HTN?
Young overweight females
Give 4 typical features of idiopathic intracranial HTN;
- Headache
- Blurred vision
- Papilloedema
- Enlarged blind spot
- Sixth nerve palsy (may be present)
Which anti-HTN medication should not be prescribed to those suffering with gout?
Do not give thiazide-like diuretics, they exacerbate gout
What is the max dose of amlodipine you can give for HTN?
10mg per day
What side effect is commonly complained of when taking an ACEi?
Dry cough
What type of diuretic is furosemide?
Loop diuretic: inhibits NaCl reabsorption in the ascending loop of henle
What type of diuretic is spironolactone?
Potassium-sparing diuretic: acts on aldosterone-responsive segments of the distal nephron
Give 5 symptoms of heart failure:
- Breathlessness
- Fatigue
- Ankle swelling
- Nocturnal cough (+/- pink sputum)
- Orthopnea (breathless lying flat)
- Nocturnal wheeze
- Syncope
- Anorexia
Give 5 signs of heart failure:
- Raised JVP
- Tachycardia
- Tachypnoea
- Pulmonary rales (fine crackles indicating fluid in small airways)
- peripheral oedema
- Pleural effusion (dull to percussion, diminished or absent breath sounds, confirm with CXR)
- Hepatomegaly
What might pink frothy sputum and a nocturnal cough indicate?
Heart failure
Give 3 causes of left sided heart failure:
- Ischaemic heart disease (most common)
- Long standing HTN leading to LVH
- Dilated cardiomyopathy
- Aortic stenosis
- Other cardiomyopathies: hypertrophic, restrictive
Give 3 causes of right-sided heart failure:
- Left sided heart failure
- Left to right shunt e.g. ASD, VSD
- Chronic lung disease (cor pulmonale = raises pulmonary blood pressure, increased pressure needed to pump blood out of RV, leads to RVH)
3 signs of right sided heart failure:
- Raised JVP
- Hepatosplenomegaly
- Ankle oedema
3 signs of left sided heart failure:
- Paroxysmal dysponea
- Wheeze
- Weight loss
- Cold peripheries
- Dysponea & poor exercise tolerance
Signs of heart failure on CXR: (5)
A - alveolar oedema (bat wings) B - kerley b lines C - cardiomegaly D - dilated upper lobe vessels E - pleural effusions
Non-pharmacological management of chronic heart failure: (3)
- Lifestyle management (smoking cessation, exercise, reduce alcohol intake, fluid and salt restriction)
- Annual influenza and single pneumococcal vaccination
- Frequent monitoring: renal function, functional capacity, fluid status, cardiac rhythm, cognitive status, nutritional status
First, second and third line pharmacological management of a patient with chronic heart failure:
First line: ACEi and beta-blocker
Second line: aldosterone antagonist (spironolactone)
3rd line: ivabradine or sacubitril-valsartan or digoxin or hydralazine
Diuretics are also used to manage symptoms of fluid overload BUT they have no proven affect on reducing mortality
NB: Baseline and repeat U&Es are needed to monitor ACEi
What medication might you offer a patient with chronic heart failure who has found that their symptoms are not improving on furosemide, ramipril and bisoprolol?
Offer a low dose aldosterone antagonist e.g. spironalactone or eplerenone
NB: Mineralcorticoid/aldosterone receptor antagonists (MRAs) antagonise aldosterone, increasing Na excretion via diuresis, ultimately decreasing cardiac afterload
What might you offer a patient with chronic heart failure who wants to stop their ACEi because it gives them a dry cough?
Offer an ARB instead, e.g. candesartan
NB: patient must have normal renal function and normal serum potassium to start on an ARB
Name 2 drugs to use in the management of acute heart failure:
- Furosemide - 40-80mg IV
- GTN spray - 2 puffs sub-lingual
Start on beta blockers and ACEi/ARB after 48 hours once stable
NB: Do NOT give GTN if systolic BP <90
Give 5 keys things to do when managing acute heart failure:
- Sit patient upright
- Ventilate
- Monitor ECG
- Monitor BP: aim for systolic of 90-100
- Give diuretic & GTN spray
Sacubitril-valsartan is used as a third line treatment for chronic heart failure, what criteria must be met in order to prescribe it?
- Left ventricular fraction <35%
- Symptomatic heart failure despite use of ACEi or ARB
Initiate following an ACEi or ARB wash out period!
Describe the 4 NYHA levels of heart failure:
- No limitation of physical activity, no undue tiredness/SOB/palpitations
- Slight limitation of physical activity. Comfortable at rest. Ordinary activity causes some tiredness/palpitations/SOB.
- Comfortable at rest but minimal activity causes tiredness/palpitations/SOB
- Unable to carry out any physical activity without discomfort. Tired and SOB at rest. Increased discomfort on moving.
Give 4 essential investigations for chronic heart failure:
- NT-proBNP (informs how urgently further tests are needed)
- Imaging: echo & CXR
- Cardiomyopathy screen:
- serum iron and copper (haematochromatosis and wilson’s)
- Rheumatoid factor, ANCA/ANA, ENA, dsDNA
- Serum ACE (sacoidosis)
- Serum-free light chains (amyloidosis) - Other bloods: FBC, U&E, TFTs, troponin, lipids, HbA1c, TFTs
What blood tests are included in a cardiomyopathy screen?
Cardiomyopathy screen:
- serum iron and copper (haematochromatosis and wilson’s)
- Rheumatoid factor, ANCA/ANA, ENA, dsDNA (for autoimmune disease)
- Serum ACE (sacoidosis)
- Serum-free light chains (amyloidosis)
Hypothyroidism:
- Example cause
- 5 symptoms
- Treatment
- Hashimoto’s thyroiditis:
- autoimmune
- high TSH
- anti-TPO and anti-Tg antibodies - Symptoms:
- weight gain
- hoarse voice
- intolerance of cold
- low mood
- constipation
- carpal tunnel - Levothyroxine
Hyperthyroidism:
- Example cause
- 5 symptoms
- Treatment
- Grave’s disease:
- High T3 and T4
- Low TSH
- TSH-Rab antibodies - Symptoms:
- Weight loss
- Tremor
- Diarrhoea
- Periorbital oedema
- Tachycardia/arrhythmias - Carbimazole or propylthiouracil, thyroidectomy
Pathogenesis of type 2 DM:
Insulin resistance and progressive insulin secretion failure.
Decreased uptake of glucose intro muscle and fat after eating.
Failure to suppress lipolysis.
Genes associated with Dm1:
HLA DR3/4
How do you differentiate between type I and II DM in practice?
Type I:
Younger onset
Presence of islet cell antibodies (ICA) and GADs
More likely to get DKA/ketouria
Pre-diabetes diagnostic criteria:
- HbA1c 42-47 mmol/l
- Fasting glucose 6.1-6.9 mmol/l
- OGTT at 2 hours 7.8-11.1 mmol/l
Diabetes diagnostic criteria:
HbA1c >48
Random glucose >11
Fasting glucose >7
OGTT 2 hours >11
How frequently should individuals with DM2 have their HbA1c checked?
Every 3 to 6 months at first, until it stabilizes on unchanging therapy
Then every 6 months
What is the target HbA1c value for an individual with DM2, controlled by diet, exercise +/- one drug?
48
unless! Using a medication associated with hypoglycaemia, in which case aim for: 53
First, second and third line treatment for DM2:
1st: Metformin titrated from 500mg OD
2nd: add a sulfonlyurea, pioglitazone, DPP-4 inhibitor or SGLT-2 inhibitor
3rd: Add another second line drug, or try metformin plus insulin instead
3 notable side effects of metformin:
- Diarrhoea
- Abdominal pain
- Lactic acidosis
Does not typically cause hypos!
How do metformin and pioglitazone work?
Increase insulin sensitivity and decrease liver production of glucose.
Do NOT typically cause hypos.
Example of a sulfonylurea:
How does it work?
Gliclazide
Stimulates insulin release frrom the pancreas
Why is gliclazide monotherapy avoided?
Increased risk of CVD and MI
Example of a DPP-4 inhibitor:
How does it work?
Sitagliptin
Increases GLP-1 activity, which increases insulin secretion, inhibits glucagon production and slows absorption in the GI tract
Example of a GLP-1 mimetic:
How does it work?
Exenatide (SC injection)
Mimics GLP-1 hormon, which increases insulin activity, inhibits glucagon production and slows absorption in the GI tract
IBS:
- Presentation
- Tx:
- 6 month hx of:
- abdo pain/discomfort
- bloating
- relieved by defecation or wind
- altered freq. or form
- mucus
- aggravated by eating - Diet advice, lifestyle advise, loperamide, antispasmodics, laxatives, SSRIs, TCAs
Ulcerative Colitis:
- Histology
- Symptoms
- Treatment
- Starts at the rectum and spreads continuously:
- red inflamed mucosa
- goblet cell delpletion
- crypt abcesses - Bowel changes, systemic features (fever, weight loss, anorexia, malaise)
- Inducing remission:
- first line = mesalazine
- second line = prednisolone
Maintaining remission:
- mesalazine
- azathioprine
- mercaptopurine
Chrohn’s:
1. Histology:
- Any part of gut to anus:
- skip lesions
- transmural inflammation
- granulomas
- cobblestone mucosa - Inducing remission:
- first line: prenisolone or hydrocortisone
- second line: azathioprine etc.
Maintaining remission:
- first line: azathioprine
- second line: methotrexate, infliximab etc.
When should someone with epigastric pain be referred for endoscopy to rule out gastric cancer?
If they are experiencing dysphagia or if they are over 55 with any ALARMS symptoms: A - anaemia L - loss of weight A - anorexia R - recent onset M - melaena S - swallowing difficulties
Management of GORD: (7)
- Lifestyle: decrease alcohol and tobacco
- PPI e.g. omeprazole
- H2 blocker e.g. ranitidine
- Antiacid e.g. magnesium trisilicate mix
- Avoiding eating <3hrs before bed
- Raise bed head
- H.pylori erradication
Investigations for coeliac:
Must eat gluten containing diet before investigations!
- total IgA
- IgA tTG
- EMAs
- DGPs
- Biopsy
- FBC (anaemia)
- Iron, ferritin, folate level
Two types of colorectal cancer:
- Familial adenomatous polyposis: due to mutations in the APC tumour suppressor gene
- Hereditary non-polyposis colorectal cancer (NHPCC): affects genes that code for DNA repair proteins
What tests are done in bowel cancer screening?
Faecal occult blood test (FOB) or the new faecal immunochemical test (FIT)
Who is offered bowel cancer screening?
All adults aged 60 to 74 are invited to use a home testing FOB kit every two years
In some areas anyone aged over 55 is offered a one off screening flexible sigmoidoscopy
What is Rovsing’s sign?
Pain greater in the RIF than LIF when pressing on the LIF
Indicates appendicits
Symptoms of appendicitis:
- Starts as periumbilical pain that moves to the RIF
- Tender with guarding
- Rebound tenderness
- Tachycardia
- Fever
- Peritonism
- Anorexia
- Constipation
What is charcot’s triad?
A sign of acute cholangitis (infection of the biliary tree):
- Fever (with chills)
- Right upper quadrant pain
- Jaundice (with dark urine, pale stools and pruritus)
5 radiological features of osteoarthritis:
- joint space narrowing
- osteophyte formation (bony projections)
- subarticular sclreosis
- subchondral cysts (fluid filled sacs in the joint space)
- abnormalities of the bone contour/outline
Diagnostic features of osteoarthritis: (3)
- Over 45 years old
- Activity related pain
- No morning stiffness or morning stiffness but it lasts <30 minutes
What is gout?
Deposition of monosodium urate monohydrate cyrstals within joints.
Monosodium urate is dervied from purine breakdown.
Causes of gout:
Hyperuricaemia caused by:
- Overproduction e.g. psroasis, excessive meat eating, hyperlipidaemia
- Under excretion e.g. alcohol, HTN, renal problems
Above what concentration of uric acid are crystals likely to form (causing gout)?
Above 0.36
How do you treat gout?
Immediate relief: 1. elevate 2. ice pack 3. steroids Prevention: 1. weight loss 2. low purine diet 3. allopurinol 4. NSAIDs
What causes osteoporosis?
Can be primary (relating to menopause or increasing age) or secondary (range of causes including IBD, cushing’s iatrogenic)
Lack of oestrogen causes increased bone resportion and decreased bone deposition.
Lack of calcium causes inccreased bone resporption.
What does FRAX calculate?
The ten year probability of a major osteoporotic fractice in people aged 40 to 90
5 examples of drugs that can increase the risk of osteoporosis and fractures:
- Long term depot injections
- Long term antidepressants
- PPIs
- Pioglitazone (anti-diabetic tx)
- Some AEDs e.g. carbamazapine
Components of FRAX: (12)
Age Weight Sex Height Prev fracture Prev hip fracture Smoker Glucocorticoids RA Secondary osteoporosis Alcohol 3 or more units/day BMD
What are the values for a normal, osteopenic, osteoporotic and severely osteoporotic T score?
Normal = >-1
Osteopenia = -1 to -2.5
Osteoporosis = Less than -2.5
Severe osteoporosis = Less tjan -2.5 plus a fracture
Who should you use FRAX on?
Women >65
Men >75
Younger patients with risk factors e.g. previous fragility fracture, hx of falls, low BMI, long term steroids, endo or rheum disorders
What is polymyalgia rheumatica?
An inflammatory condition that causes pain and stiffness in the:
- shoulders
- pelvic girdle
- neck
Strongly associated with GCA
NICE diagnostic criteria of polymyalgia rheumatica: (5)
At least two weeks of:
- BIL shoulder pain that may radiate to the elbow
- BIL pelvic girdle pain
- Worse with movement
- Interferes with sleep
- Morning stiffness for at least 45 mins
Can also include systemic features: low mood, weight loss, low grade fever
How do you treat polymyalgia rheumatica?
15mg of prednisolone per day
Assess in 1 week - should show good response
Assess again in 3-4 weeks - should see 70% improvement
Continue until symptoms fully controlled then decrease slowly
What type of hypersensitivty reaction is involved in asthma?
type 1
Asthma management in adults:
Step UP when: using SABA ≥3 times/week or waking up at night once a week with symptoms
Step DOWN when: well controlled with no symptoms at all
- Salbutamol PRN
- Add ICS e.g. beclametasone
- Add a LABA e.g. salmeterol
- Increase ICS
- Increase ICS again, consider an LTRA
What is CURB-65?
Criteria for managing pneumonia, one point for each of: C - confusion U - urea >7 R - resp rate >30 B - BP <90 sys or <60 dias 65 - ≥ 65 years old
What action is required for following CURB-65 scores?
0 to 1
2
3-5
0 to 1 = treat in community
2 = consider inpatient treatment
3 to 5 = inpatient admission with possible ITU care
How do you treat low severity community acquired pneumonia?
Five days of amoxicillin
