GP Flashcards
What to advise on stopping COCP before surgery?
Stop pill 4 weeks before surgery and restart 2 weeks after, due to risk of VTE - advise alternative contraception
Asthma step by step guidelines in adults
SABA ICS LTRA LABA (Theophyilline, tiotropium) (Oral steroids) (Omalizumab)
Routine investigations for COPD
CXR (exclude cancer, bronchiectasis)
Bloods (anaemia, polycythaemia)
Post-bronchodilator spirometery
FEV1/FVC ratio level for diagnosis of COPD
<0.7
1st line inhaler therapy for COPD
SABA + SAMA
2nd line inhaler therapy for COPD with asthmatic features
LABA + ICS
2nd line inhaler therapy for COPD without asthmatic features
LABA + LAMA
COPD triple therapy?
LAMA + LABA + ICS
GP management for exacerbation of COPD
Prednisolone 30mg OD for 5 days
+
Amoxicillin 500mg TDS 5 days (or doxycycline, clarithromycin)
Palliative management of COPD secretions?
Hyoscine Hydrobromide
Management options for COPD secretions?
Acapella device
Carbocistiene
Hyoscine bromide
FEV1, FVC and FEV1/FVC ratio picture in obstructive lung disease?
FEV1 = <80% predicted
FVC = (near) normal
FEV1/FVC ratio = <0.7
FEV1, FVC and FEV1/FVC ratio picture in restrictive lung disease?
FEV1: <80% predicted
FVC: <80% predicted
FEV1/FVC ratio: Normal or increased >0.7
FEV1 percentage of predicted for mild, moderate and severe COPD?
o Mild COPD = FEV1 >80% predicted
o Moderate COPD = FEV1 50-79% predicted
o Very severe COPD = FEV1 30-49% predicted
FEV1 percentage of predicted for mild, moderate and severe COPD?
o Mild COPD = FEV1 >80% predicted
o Moderate COPD = FEV1 50-79% predicted
o Very severe COPD = FEV1 30-49% predicted
Stage 1 hypertension
Clinic BP >140/90
HPBM >135/85 - 149/94
Stage 2 hypertension
Clinic BP >160/100 - <180-120
HPBM BP >150/95
Stage 3 (severe) hypertension
Clinic systole >180
Clinic diastole >120
Discrepancy of BP between clinic and HPBM in white coat effect?
> 20/10
Diagnosis of malignant hypertension
> 200/130mmHg with signs of end-organ damage
Pulmonary oedema, papilloedema, nephropathy
Phaeochromocytoma symptoms
Labile/postural hypotension Headache Palpitations Pallor Profuse sweating
Cushing’s symptoms (hypercortisolism)
Truncal obesity Moon face Bruises Striae Weakness in upper arms and thighs Low libido Depression, mood swings
Step 1 hypertension Tx
Age <55, non afro-caribbean: ACE-i (or ARB)
Age >55, afro-caribbean: CCB, TLD
Step 2 hypertension Tx
ACE-i / ARB + CCB/TLD
Step 3 hypertension Tx
ACEi/ARB + CCB + TLD
Step 4 hypertension Tx
Spironolactone (if K+ <4.5)
Beta blocker (if K+ >4.5)
Consider specialist referral
Annual HTN review?
Check BP
Check renal function (creation, U&E, eGFR, dipstick for proteinuria –> ACR)
QRISK assessment
Target BP age <80
<140/90 in clinic
<135/85 HBPM
Definition of CKD
Presence of kidney damage (albuminuria) OR decreased kidney function (eGFR <60ml/minute) for >3 months
Stage 1 CKD
eGFR >90 with other evidence of chronic kidney damage (microalbuminuria, proteinuria, haematuria, structural abnormality)
Stage 2 CKD
eGFR 60-80ml/minute with other evidence of chronic kidney (microalbuminuria, proteinuria, haematruia)
Stage 3a CKD
eGFR 45-59ml/minute
Stage 3b CKD
eGFR 30-44ml/minute
Stage 4 CKD
eGFR 15-29ml/minute
Stage 5 renal failure (ERF)
eGFR <15ml/minute
Nephrotoxic drugs
Digoxin Iodine ACEi Metformin Opiates NSAIDs Diuretics Lithium
(DIAMONDL)
CKD medication treatment
Atorvastatin 20mg OD
Antiplatelet
Folic acid and Vitamin B
If diabetes and ACR >3mg/mmol, HTN and ACR >30mg/mmol OR ACR >70mg/mmol –> ACE-I or ARB
Otherwise –> CCB if over 55 or afro-caribbean
Investigations for heart failure
Nt-ProBNP (normal <100. Urgent referral >2000) LFTs - liver failure due to backlog U&Es Renal function - eGFR, ACR TFTs HbA1C FBC - infection Echo ECG CXR - ABCDE
Findings on CXR suggestive of HF
ABCDE
A - Alveolar oedema (interstitial oedema - hazy)
B - Kerley B lines (fluid in lung fissures)
C - Cardiomegaly (increased cardiothoracic ratio)
D - Dilated prominent upper lobe vessels
E - Pleural effusion (reduced costophrenic angle)
Classes of heart failure
Class I: no Sx during ordinary physical activity
Class II: slight limitation of physical activity by Sx
Class III: less than ordinary activity causes Sx
Class IV: inability to carry out physical activity due to Sx
Long-term medical management of heart failure
ABAL
A + B –> ACE-i (ramipril 10mg OD) + Beta blocker (bisoprolol 10mg OD). Titrate upwards.
A –> Aldosterone antagonist (spironolactone)
L –> Loop diuretic (furosemide 40mg OD in morning)
Extra add on’s for HF management
Digoxin
Flu and pneumococcal vaccine
LVAD
Mental health management
What to do in a HF review?
Medication review BMI Basic obs U&Es eGFR ECG
3 features of typical angina (definition)
- Constricting/heavy discomfort to chest/jaw/neck/shoulders
- Brought on by exertion
- Relieved by rest or GTN
What is QRISK assessment tool?
- Calculates 10 year estimated risk of someone having an adverse cardiac disease (includes stroke, peripheral artery disease etc)
- Expressed as a percentage – 20% risk is 2 in 10 chance of developing cardiovascular disease within 10 years
Management of QRISK >10%
Lipid profile and FHx
Atorvastatin 20mg OD (check LFTs at 3 and 12 months)
Difference between unstable angina and NSTEMI on investigation?
Tropononin
MI = raised, angina = normal
Angina Primary Prevention
1st line: GTN Spray + Beta blocker
2nd line: CCB
Unstable angina primary prevention
Aspirin + antithrombin (fondaparinux)
Secondary prevention of ACS
4 As Aspirin (75mg) + (clopidogrel for first 12 months) Atorvastatin 80mg Atenolol 5mg ACE-i (ramipril 10mg)
Secondary prevention of ACS
4 As Aspirin (75mg) + (clopidogrel for first 12 months) Atorvastatin 80mg Atenolol 5mg ACE-i (ramipril 10mg)
Asthma steps in children
SABA ICS LTRA/LABA (LTRA if under 5) Thephylline/LAMA (tiotropium) Refer (monoclonal antibody - omalizumab) (oral steroids)
Metformin mechanism of action
Increases sensitivity to insulin, and decreases liver production of glucose
Metform SEs and contraindications
Diarrhoea, abdo pain Lactic acidosis (sick day rules - stop metformin)
Contraindication: renal failure
Sulphonyl urea:
Mechanism of action
SEs
HbA1C target
MOA: increased insulation production and secretion
SE: weight gain (lots of sugar saved), hypos, CV disease
Target: 53mmol/mol
SGLT-2 Inhibtiors (e.g. Gliflozin):
MOA
SEs
Contraindications
MOA: blocks glucose reabsorption in PCT, so glucose remains in urine
SE: weight loss, UTIs, thrush, ketacidosis
Contraindication: eGFR <60
Gliptins (DDP-4 Inhibitors)
MOA
SEs
Contraindications
MOA: inhibits DPP-4 enzymes which stop incretin production to slow insulin production
SEs: GI upset, URTI symptoms
GLP-1 Receptor agonists (Glutides)
MOA
SEs
Contraindications
MOA: increases insulin secretion, inhibits glucagon production, slows GI absorption. Subcut injection. most be BMI >35.
SE: weight loss, GI discomfort.
Contraindication: BMI <35
What does CHA2DS2-VASc stand for and what does it mean?
Congestive heart failure Hypertension A2 - age <75 (scores 2) Diabetes S2 - stroke/TIA (scores 2)
Vascular disease
Age 65-74
Sex (female)
If score >1 offer anticoagulation to patient with AF to prevent stroke risk (if score 1, consider)
What does the HAS-BLED score stand for and what does it mean?
Hypertension
Abnormal renal and liver function
Stroke
Bleeding
Labile INRs (whilst on warfarin)
Elderly
Drugs/alcohol
1st line treatment for AF
Lifestyle advice
+
Rate control: Beta-blocker (or CCB or digoxin)
Rhythm control management for AF?
In first 48 hrs –> immediate cardioversion with flecainide/amiodarone (if structural heart disease)
If >48 hours –> anticoagulant for 3 weeks then do cardio version with flecainaide/amiodarone (if structural heart disease)
Annual review for AF
Check symptoms HR Review medications Assess stroke risk Assess bleeding risk Assess CVD risk
Causes of AF
Sepsis Mitral valve pathology (stenosis, regurgitation) Ischaemic heart disease Thryotoxicosis Hypertension
Other: heart failure, diabetes, acute infection, hypokalaemia
What does the Prisma-7 questionnaire assess for?
Frailty
What to ask about when assessing multi-morbidity?
- Establish disease burden
- Mental health, wellbeing, QOL
- Establish treatment burden
- ICE
- Social circumstance, health literacy, functional autonomy, coping strategies
- ?Palliative acre needs
- Assess for frailty
What to ask about when assessing multi-morbidity?
- Establish disease burden
- Mental health, wellbeing, QOL
- Establish treatment burden
- ICE
- Social circumstance, health literacy, functional autonomy, coping strategies
- ?Palliative acre needs
- Assess for frailty
BMI grades for overweight and obesity
- BMI 30-35kg/m2 = obesity grade I
- BMI 35-40kg/m2 = obesity grade II
- BMI >40/m2 = obesity grade III
Drug used for obesity management and main SEs/risks.
Orlistat - lipase inhibitor (reduces absorption of dietary fat)
SE: abdo discomfort, faecal urgency
Monitoring: weight 3 months + 6 months
Epilepsy history. What to ask?
ABC detail.
Video recording?
CBITE Colour Breathing Incontinence Tongue biting Eye rolling
If a patient >55 is already taking a CCB + ARB but remains hypertensive, which drug should you add in?
Thiazide like diuretic (indapamide)
HbA1C diagnostic levels
Pre-diabetic = 42-47mmol/L Diabetic = >48 mmol/L
SYMPTOMATIC = do test once ASYMPTOMATIC = do test twice
CAN’T use in: pregnancy, kids, renal failure, acute illness
Diabetes complications
Macro = cardiovascular risk Micro = nephropathy, neuropathy, retinopathy, erectile dysfunction
Sick Day Rules for Metformin use and why
Reduce dose
Metformin increases chance of lactic acidosis (because it inhibits gluconeogenesis so promotes anaerobic respiration), which is exacerbated when combined with metabolic acidosis caused by sepsis = bad news
When is urinary ACR classified as ‘raised’?
What are the levels for it?
> 3 mg/mmol = raised
<3 = normal 3-30 = moderately increased >30 = severely increased
For how long does someone have to have a change in eGFR for CKD to be diagnosed?
3 months
SBA:
An 85 year old lady is recovering post hip fracture. She is struggling to get up the stairs and get to the toilet on time.
Which is the most appropriate HCP for her to be referred to?
Occupational Therapist
SBA:
A 72 year old man lives alone, has multiple chronic conditions which affect his mental health. Which HCP should he see?
Social prescriber
What level BNP is normal and what are the referral guidelines?
Normal = <100
400 - 2000 = refer for specialist assessment and echo within 6 weeks
>2000 = refer for specialist assessment and echo within 2 weeks
23yo male. Constant localised pain left anterior chest wall. Anxious, feels has to catch breath sometimes. But able to run 5k without undue SOB.
Sats 99%.
HR 70.
Palpitation reproduces symptoms.
SBA: likely diagnosis?
Costochondritis
What other conditions can increase BNP?
AF
What scoring system can you use to monitor someones ability to live independently?
Barthel Index
When initiating treatment on an ACEi, how frequently should you check U&Es?
Check in 1-2 weeks
Check after each increase
Check annually thereafter
COPD inhaler stepladder
1st = SABA / SAMA
2nd without asthmatic features = LABA + LAMA
2nd line with asthmatic features = LABA + ICS
3rd line = triple therapy (LABA + LAMA + ICS)
Medication for infective COPD exacerbation
Amoxicillin 500mg TDS 5/7 + Prednisolone 30mg OD 5/7
Consider osteoporosis prophylaxis if >3-4 courses of prednisolone in 1 year
Initial drug treatment for someone with a new diagnosis of heart failure
1st line = A + B
Acei / ARB + beta-blocker
2nd line = A+L+Others Aldosterone antagonist Loop diuretic (Flozin (SGLT2 inhibitors) Digoxin Valsartan)
Drugs to stop in HF
NSAIDs (exacerbate HF)
Steroids (water retention)
Pioglitazone (water retention)
How do you diagnose T2DM/pre-diabetes?
Symptomatic = only 1 test needed Asymptomatic = repeat test needed
Random blood glucose/OGTT = >11.1mmol/L (7.8-11.1 = pre-diabetes)
Fasting blood glucose = >7mmol/L
HBa1C = >48mmol/L (42-47mmol/L = pre-diabetes)
T2DM treatment ladder
(Diet & lifestyle advice)
- Metformin
- Dual therapy (DPP4 inhibitors (gliptins), sulphonylurea (gliclazides), pioglitazone, SGLT2 inhibitors (flozins - use in HF).
- Insulin / GLP1 agonist (BMI >35)
T2DM treatment ladder
(Diet & lifestyle advice)
- Metformin
- Dual therapy (DPP4 inhibitors (gliptins), sulphonylurea (gliclazides), pioglitazone, SGLT2 inhibitors (flozins - use in HF).
- Insulin / GLP1 agonist (BMI >35)
Which TD2M drugs cause hypos
Sulphonylureas
Insulin
SE of metformin
GI upset (can give modified release) Lactic adiposis (sick day rules! Stop taking) Renally excreted - cannot give in eGFR<30, check U&Es before
DPP4 inhibitors: type of drug, MOA, SE
Gliptins e.g. sitagliptin
MOA = stop breakdown of incretins, which increase insulin production
SE = GI upset, pancreatitis.
Pioglitazone: MOA, SE, CI
MOA = similar to metformin, increases insulin sensitivity
SE = (lots!!) weight gain, fracture risk, fluid retention, bladder cancer association
CI = osteoporosis, HF, cancer
Sulphonylureas: type of drug, MOA, SE
Gliclazides
MOA = increase insulin production/secretion from beta cells
SE = hypos, weight gain, SIADH (hyponatraemia), CV risk if used as monothearpy
SGLT-2 inhibitors: type of drug, MOA, SE, CI
Flozins e.g. empagiflozin
MOA = prevent reabsorption of glucose into blood at PCT by inhibiting SGLT-2 protein = glucose excreted in urine
SE = weight loss, thrush/UTIs, DKA
CI = renal failure (eGFR <60)
GLP-1 agonist = indication, type of drug, MOA, SE
Indication = 3rd line after dual therapy for T2DM. Can only be used in those >35 BMI who will benefit from weight loss.
MOA = increases insulin secretion and slows GI absorption. SE = weight loss, GI upset, pancreatitis / pancreatic cancer
Annual review for diabetes
HbA1c
BMI
BP (aim <140/80 or <130/80 in CKD)
Urinary ACR - >3 / urine dipstick positive for proteins then start ACE-i
Diabetic foot check
Diabetic retinopathy screen
Lifestyle discussion
QRISK score and start atorvastatin 20mg if >10%
Insulin user - check sites for lipodystrophy
Losartan drug class
ARB
Indapamide drug class
Thiazide like diuretic
Lercanidipine drug class
CCB
Lisinopril drug class
Ramipril
School exclusion rules scarlet fever
24 hours after commencing abx
Remoglifozin drug class
SGLT-2 inhibitors
Prevent glucose reabsorption in PCT - Increase flow of urine
SE = thrush, UTI, weight loss, DKA
Gliclazides drug class
Sulphonyl urea
Increase insulin production/secretion
(SE: weight gain, hypos, SIADH)
Sitgliptin drug class
DPP4 inhibitors
Inhibit breakdown of incretins - increases insulin resistance
SE: Pancreatitis, GI upset
antihypertensive of choice for a patient age >55 with type 2 diabetes?
Ace-i (Better for kidneys- will probably need later on anyway)
Treatment for primary hyperthyroidism
Carbimazole - SECONDARY CARE ONLY (Can cause agranulocytosis)
Propylthiouracil - Primary care for symptom management + refer (inhibits production of new thyroid hormone
CURB 65 score cut offs and meaning
Confusion Urea >7 Resps >30 BP <90 or <60 Age 65
1 = OUTPATIENT (LOW RISK) 2/3 = INPATIENT (MODERATE RISK) 4/5 = HDU/ICU ADMISSION (HIGH RISK)
CENTOR CRITERIA for tonsillitis and management
Tonsillar exudate
Tender anterior cervical lymphadenopathy
Fever (>38)
Absence of cough
0-3 = 17% likely bacteria 3-4 = 30-50% likely bacteria
What follow up is needed after hospital admission for CAP?
CXR at 6 weeks
Treatment of otitis externa
Topical neomycin + dexamethasone (Otomise spray)
Watch out for spread to temporal bone
Migraine treatment
1st line = Topiramate (teratogenic)
2nd line = Propranolol
