GP Flashcards
What is atrial fibrillation?
Chaotic irregular atrial arrhythmia
What are the different types of atrial fibrillation?
Permanent: Cardioversion ineffective
Persistent: >7 days
Paroxysmal: <7 days
What is the clinical presentation of atrial fibrillation ?
IRREGULARLY IRREGULAR PULSE
Dyspnoea
Chest pain
Hypotension and tachycardia: palpitations
Syncope
What are the investigations for atrial fibrillation?
ECG: F fibrillatory waves, absent P and a waves, irregularly irregular narrow QRS complexes
CHADVASc score: assesses risk of stroke in AF + when to start anticoagulation
- 0: no anticoagulation + Aspirin alone
- 1: consider anticoagulation + Aspirin
- >1: offer anticoagulation (Warfarin) + Aspirin
What is the management for atrial fibrillation ?
- Rate control: beta-blocker (e.g. bisoprolol), CCB (not in HF) and digoxin (BCD)
- Rhythm control: return to normal sinus rhythm through cardioversion
Anticoagulation: asprin and Warfarin
Thrombin or Factor 10A inhibitor
Reduce Stroke risk
What are the 2 types of Cardioversion in AF?
Electrical DC
Pharmacological: Amiodarone
What are the risks of Cardioversion?
Embolism
Only attempt if symptomatic for >48 hours + long period of anticoags
How do you measure Stroke risk in AF?
CHA2DS2VASc
Score (/9):
- Congestive heart failure
- Hypertension
- Age
- 65-74 =1
- ≥75=2
- Diabetes
- Stroke/TIA
- Vascular disease
- Female
What is hypertension?
> 140/90: clinic
> 135/85: ambulatory
What are the causes of hypertension?
Primary (essential): no known cause
Secondary: a known underlying cause
ROPE
Renal disease
Obesity
Pregnancy
Endocrine (primary hyperaldosteronism, most common cause)
White coat syndrome
What are the causes of paediatric HTN?
Renal parenchymal disease (majority)
CoA
What type of HTN is most common?
Essential
How is HTN measured?
BP reading:record BP in both arms
Ambulatory blood pressure monitoring (ABPM)
Home blood pressure monitoring (HBPM)
How would you perform a HBPM?
Two consecutive measurements 1 minute apart
Patient seated
BD for 1 week
DO NOT INCLUDE 1ST DAY MEASUREMENTS (INACCURACY)
How would you perform a ABPM?
2/hr during waking hours
14 readings a day
What are the 3 stages of hypertension?
1 =
Clinical- >140/90
ABPM - >135/85
2=
Clinical- >160/100
ABPM - >150/95
3 = 180/110
How would you assess for end organ damage in hypertension?
Fundoscopy: hypertensive retinopathy
ECG: LVH or IHD
Urine dip: renal disease
What is the management for hypertension?
ABCD
Step 1
> 55 & stage 2 or above → ACEi
> 55 OR of black/African Caribbean → CCB
Step 2
ACEi / ARB + CCB (ACEi ARE CONTRAINDICATED IN BLACK/AFRICAN CARRIBEAN PEOPLE)
Step 3
ACEi/ARB + CCB + Thiazide diuretic
Step 4
Resistant HTN
Consider other drugs: sodium nitroprusside in emergencies
What would you do if a patient reaches stage 4 of hypertension management?
Resistant HTN:
Confirm elevated BP
Assess for postural Hypotension
Discuss Adherence
Potassium <4.5: low dose spironolactone
Potassium >4.5: AB or BB
How is hypertension monitored?
Treatment targets:
* < 80 yrs: <140/90
* > 80 yrs: 150/90
* CKD, previous stroke and diabetes: >130/80
Monitor U&Es regularly when using ACEi and diuretics
What are the side-effects of ACEi?
Cough
Angioedema
Hyperkalaemia
What are the side-effects of CCB?
Ankle swelling
Headache
Flushing
What are the side-effects of thiazide diuretics?
Hyponatraemia
Hypokalaemia
Dehydration
What are the side-effects of ARB?
Hyperkalaemia
What is the clinical presentation of pericarditis?
Pleuritic chest pain: eased by leaning forwards
Worsened by lying flat
Pericardial rub
Fever
Myalgias
What are the investigations for pericarditis?
Transthoracic echocardiogram: pericardial effusion shows a ‘dancing’ heart
ECG: widespread ST saddle elevation and PR depression
Bloods: raised ESR and CRP
Troponin
What is the management for pericarditis?
Viral: NSAIDs + colchicine (anti-gout, reduces inflammation and pain)
Bacterial: antibiotics + pericardiocentesis
What is the clinical presentation of MSK chest pain?
Worse on movement
Worse on palpation
Precipitated by trauma or cough
What is shingles?
Reactivation of a measles infection (HHV-3) (normally occurring during childhood)
Causes a painful rash along a dermatome
What is the clinical presentation of shingles?
Dermatomal pain:
- Macular vesicular rash in dermatomal distribution
Pain preceeds rash
Malaise, myalgia, headache and fever
Disseminated infection: if immunosuppressed
What are the investigations for shingles?
Clinical presentation of skin lesions
Viral PCR, culture and immunohistochemistry
How is shingles managed?
Conservatively
Oral aciclovir: if high risk
Zoster vaccine
VZV immunoglobulin
Calamine lotion and chlorphenamine (antihistamine): itching
What is the clinical presentation of aortic dissection?
Sudden severe ‘tearing’ chest pain
May radiate to the back if type B
Does not radiate to arms
Syncope
Unequal upper limb BP
What are the investigations for aortic dissection?
CT angiogram
ECG
CXR
ECHO
How is Aortic Dissection treated?
Medical emergency
Type A: open surgery
Type B: TEVAR
What are 4 causes of transient non-visible haematuria?
- UTI
- Menstruation
- Vigorous exercise
- Sexual intercourse
What are 6 causes of persistent non-visible haematuria?
- Cancer
- Stones
- BPH
- Prostatitis
- Urethritis
- Renal: IgA nephropathy
How can you investigate haematuria?
- URINE DIP:
- Persistent = 2/3 samples 2 weeks apart
- Renal function
- Albumin:creatinine ratio:
- Protein:creatinine ratio PCR
Urine microscopy
When should you urgently refer haematuria?
> 45yrs+:
- Unexplained visible haematuria
- Visible haematuria persisting after UTI management
OR
60yrs+
- Unexplained non-visible haematuria
- Dysuria
- Raised WCC
What is the Referral Guidance for chest pain?
Current/within 12hrs + abnormal ECG: EMERGENCY ADMISSION
12-72hrs ago: REFERRAL FOR SAME DAY ASSESSMENT
>72hrs ago: FULL ASSESSMENT, ECG + TROPONIN
What is venous thrombus embolism (VTE)?
Blood clot enters circulation
What is pulmonary embolism?
Obstruction of the pulmonary arteries 2° to an embolus
How many more times common are DVTs than PEs?
What percentage of DVTs lead to PE?
DVT 3x more common
16% in untreated patients
What is the clinical presentation of VTE?
- Paralysis/paresis
- Entire leg swollen
- Tenderness/pain
- Erythema
- Calf swelling >3cm compared to the other leg
- Pitting oedema
- Distended veins
What is the clinical presentation of PE?
Dyspnoea + dyspnea
Syncope
Pleuritic chest pain
Cyanosis: hypoxia
Elevated JVP: suggests cor pulmonale
DVT signs: positive Wells score
Cough +/- haemoptysis
Haemoptysis
Tachycardia + tachypnoea
Crackles
Fever
What is the Well’s score?
Calculates risk of DVT
What comprises the Well’s score?
PC:
- Paralysis/paresis/recent immobilisation
- Localised tenderness along the deep venous system
- Entire leg swollen
- Calf swelling > 3cm compared to other leg measured 10cm below the tibial tuberosity)
- Pitting oedema confined to affected leg
- Collateral superficial veins present
- PMH
- Bedridden recently > 3 days or major surgery within 12 weeks
- Active cancer (treatment or palliation within 6 months)
- Previous DVT
- DH
- OCP/HRT
- SH
- Long haul flight
- Smoking
What are the investigations for PE/DVT if the Wells score is:
≥2?
≤1?
Well’s Score:
≥2 = Duplex US of deep veins within 4hrs + D-Dimer
≤1 = D-Dimer within 4hrs
For both test:
FBC
U&E
LFTs
Antiphospholipid antibodies
What are the investigations for PE?
Well’s Score:
- ≥2 = Duplex US of deep veins within 4hrs + D-Dimer
- ≤1 = D-dimer within 4hrs
Computed tomographic pulmonary angiography (CTPA): visualisation of clot
- ABG: Type 1 respiratory failure (O2 <8kPa)
- ECG: S1Q3T3 (inverted T in V1-V6 and RBBB)
For both test:
- CXR
- ECHO
- FBC
- U&E
- LFTs
- Antiphospholipid antibodies
What is the gold standard in diagnosing PE?
CTPA
What is the management of a VTE/DVT?
LMWH (e.g. enoxaparin) :
- 5 days OR INR >2.0 for 24hr
- 6 months if active cancer
Wafarin:
- 3 months
- 6 months: if unprovoked
Fondaparinux sodium: inhibits factor X
Compression stockings
IVC filters
DOAC: rivaroxaban
Unfractionated heparin: in CKD
What should be given if the USS is delayed when diagnosing a VTE?
LMWH
If the VTE is unprovoked what should be done?
Test for Malignancy:
- CXR
- Bloods (FBC,Ca,LFTs)
- Urinalysis
- Abdo CT or mammogram: - If >40yrs
What is the management of PE?
On clinical suspicion and only stopped once ruled out:
1) LMWH (e.g. enoxaparin):
- 5 days OR INR >2.0 for 24hr
- 6 months if active cancer
2) Wafarin:
- 3 months
- 6 months: if unprovoked
3. DOAC: apixabanorrivaroxaban
4. Compression socks: prophylaxis
5. Inferior vena cava filter
6. THROMBOLYSIS (e.g. e.g. alteplase) : in haemodynamic compromise e.g. alteplase
7. Surgical embolectomy
How do you monitor treatment in VTE/PE/DVT?
Anti-Xa: anti-thrombin III inhibits factor Xa and stops coagulation cascade
What may affect a V/Q scan?
Previous PE
AV malformations
Vasculitis
Radiotherapy
What are lymphomas?
Lymphoproliferative disorder (specifically B-cells) that predominantly involves the lymph nodes and extranodal sites
What is Hodgkin’s lymphoma?
A lymphoma associated with Reed-Sternberg cells (owl’s eye nuclei)
Name the 4 different types of Hodgkins Lymphoma
Nodular Sclerosing: Majority + women (lacunar cells)
Mixed Cellularity (Reed-Sternberg cells)
Lymphocyte predominant
Lymphocyte depleted
What is Non-Hodgkin’s Lymphoma?
Malignant proliferation of lymphocytes other then Hodgkin’s
What are the presentations of lymphomas?
Painless, asymmetrical and non-tender lymphadenopathy (rubber): cervical, axillary or inguinal
B-cell symptoms: night sweats, fever & weight loss
Itching
Pain when drinking alcohol
Recurrent infections
Alcohol induced node pain
Normocytic anaemia
What features may suggest a poor prognosis in lymphoma?
B-symptoms:
- Weight loss >10%
- Fever >38
- Night sweats
Poorer:
- > 45yrs
- Stage 4
- Haemoglobin < 10.5
- Lymphocytes < 600 or 8%
- Male
- Albumin
- WCC > 15000
What s the difference between Hodgkin’s and Non-Hodgkin’s in terms of:
- Histology
- B-symptoms
- Extra-nodal disease
Histology:
Hodgkins= Reed-Sternberg cells
B-symptoms:
Hodgkins = Early
Non-Hodgkins = Late
Extra-nodal disease:
Hodgkins = Less common
Non-Hodgkins = More common
What are the investigations for Hodgkin’s lymphoma?
Blood smear: Reed-Sternberg cells
Raised serum LDH
Diagnosis: FBC, ESR, CRP, CXR and lymph node biopsy
Staging: MRI and PET scan
What are the investigations for non-hodgkin’s lymphoma?
Diagnosis: FBC, ESR, CRP, CXR and excisional lymph node biopsy
Staging: MRI, CT and PET scan
What are laboratory signs of Hodgkin’s lymphoma?
Lymphocyte proliferation
Reed-Sternberg cells
What is the staging used for lymphomas?
Ann Arbor system:
1. 1 node
- ≥2 nodes on same side of the diaphragm
- Lymph nodes on both sides of diaphragm
- Extra-nodal involvement
+ A: no B symptoms
+ B: present B symptoms
How are Hodgkin’s lymphomas managed?
ABVD:
Adriamycin
Bleomycin
Vinblastine sulfate
Dacarbazine
What is the treatment for non-hodgkin’s lymphoma?
R-CHOP:
Rituximab
Cyclophosphamide
Hydroxydaunorubicin hydrochloride
Vincristine
Prednisone
Stem cell transplantation
What is are the complications of lymphomas?
Chemotherapy: risk of leukaemia, infertility, nausea, vomiting, hair loss etc
Radiotherapy: risk of cancer and damage to tissues
What is COPD?
Progressive and irreversible obstructive airway disease
What two conditions encompass COPD?
Emphysema and Bronchitis
What are the causes of COPD?
- Smoking
- Alpha-1 antitrypsin deficiency
- Occupational exposure: dusts, chemical agents and fumes
What is the clinical presentation of COPD?
Tar staining of fingers: NO CLUBBING
ESPECIALLY IF A SMOKER!
Cough + sputum production: NO haemoptysis
Blue bloater: chronic bronchitis
Pink puffer: emphysema
Dyspnea
Recurrent respiratory infections
Symptoms do not improve with salbutamol
Barrel chested
Wheezing on auscultation: from airway narrowing
Coarse crackles: sudden opening of the airways
What are the spirometer readings for COPD?
All FEV1/FVC ratio of <0.7
FEV1 (% of predicted):
>80 = Stage 1 Mild
50-79 = Stage 2 Moderate
30-49 = Stage 3 Severe
<30 = Stage 4 Very Severe
How is COPD diagnosed?
Considered in any patient >35yrs who are current/ex-smokers with ≥1 symptoms of COPD
Spirometry:
- FEV1/FVC ratio <0.7
- Bronchodilator does not reverse
Chest X-ray: flattened diaphragm, hyperinflation and bullae
Pulse oximetry
ABG: detects cyanosis
What is the management of COPD?
- SABA(salbutamol)/ SAMA (ipratropium)
- LABA + LAMA ((salmetrol or tiotrium) Anoro Ellipta) or LABA+ICS (Fostair ****if asthmatic)
- LABA + LAMA + ICS (Trimbo)
Stop smoking
When should long term oxygen therapy be offered in COPD?
O2 for ≥ 15 hours per day if:
- pO2 < 7.3
OR pO2 7.3 – 8 AND:
- Secondary polycythaemia
- Peripheral oedema
- Pulmonary hypertension
- Non-smoker
What is a major complication of COPD?
Cor Pulmonale
What is Cor Pulmonale?
Pulmonary hypertension from chronic lung disease that can cause right sided HF
What is the clinical presentation of cor pulmonale?
- Peripheral oedema
- Increased JVP
- Parasternal heave
- Loud P2
What is the management of Cor pulmonale in COPD?
Loop Diuretic Furosemide
Long term O2
What are features of an acute COPD exacerbation?
Worsening of:
- Dyspnoea
- Cough
- Wheeze
- Sputum
- Hypoxia
- Confusion
Name 2 exacerbation organisms of COPD
Haemophilus Influenzae
Strep Pneumoniae
Moraxella Catarrhalis
What is the management of acute exacerbation in COPD?
Prednisolone for 7-14 days
Increased nebulised salbutamol dose
Oral Abx if purulent sputum or signs of pneumonia:
- Amoxicillin
What is Gout?
Hyperuricaemia and deposition of monosodium urate crystals causing attacks of acute inflammatory arthritis- crystal arthropathy
Usually affects small joints and kidneys
What causes hyperuricaemia and thus gout?
Idiopathic: Majority
Increased production: psoriasis, genetics, diet (shellfish, red meat and alcohol)
Decreased excretion from the kidneys: CKD, NTN, thiazides and alcohol
What is the clinical presentation of gout?
Rapid-onset severe pain
Flares
Joint stiffness and tenderness
1st metatarsophalangeal and carpo-metacarpal joint
Monoarticular
Swelling and joint effusion
Tophi: subcutaneous deposits near the ears island fingers
Erythema and warmth
What can precipitate Gout?
Diuretics
Cold
Alcohol
What are the investigations for Gout?
Arthrocentesis (aspiration) synovial fluid analysis:
-High WBC
-Presence of needle shaped monosodium urate crystals with negative birefringence
X-ray shows:
1) Soft tissue swelling
2) Peri-articular erosions
3) Norma joint space
Serum urate
What is the management of Gout?
NSAID: for acute episodes
Corticosteroids
Allopurinol: lowers uric acid levels (long term)
Colchicine: anti-gout and reduces inflammation and pain (aCute)
Lose weight
Stop drinking
Avoid meats with high purines (red meat, shellfish)
What is pseudogout?
Calcium pyrophosphate deposition causing synovitis (arthritis)
What investigations are ordered for the diagnosis of pseudogout?
Arthrocentesis with synovial fluid analysis:
Presence of rhomboidal, weakly positively birefringent crystals under polarized light microscopy
Joint X-ray: crystals
What is the management of pseudogout?
Intra-articular corticosteroids
NSAIDs
DMARD: methotrexate
