GP Flashcards
What is polypharmacy?
The concurrent use of multiple medications by one patient
What is concordance?
The agreement reached after negotiation between a patient and doctor that respects the beliefs and wishes of the patient in determining whether, when and how medicines are taken
Why might a patient struggle to stick to medication?
- Lack of motivation
- Lack of understanding of drug
- Fear of side effects
- Misconceptions about drug
- Language barrier
Benefits of breastfeeding for the baby
- Immunity
- Reduces risk of infection
- Reduces risk of SIDS
- Reduces risk of obesity and CVD
- Reduces risk of diarrhoea and vomiting
Benefits of breast feeding for the mother
- Creates bond with baby
- Reduces risk of breast cancer and ovarian cancer
- Reduces risk of osteoporosis
- Reduces risk of CVD and obesity
Complications after vaginal delivery
- CVD
- Infection or sepsis
- Hemmhoragic stroke
- Thrombotic pulmonary embolism
- Hypertensive disorders of pregnancy
- Anaesthesia problems
- Post natal depression (10-20%)
- Perineal scarring
- Back pain
How to check brain damage in a baby after ventouse suction delivery
- Examine motor movements
- Hydrocephalis measurements
What would class as an abnormal growth chart result?
- Lower than the 2nd percentile
- Higher than the 98th percentile
- Not consistent (deviation of 2 centiles is worrying)
Red reaction test
- Done at birth to check for retinoblastoma
- For adults, its used to test for cataracts
- Looking for red reflection of the retina
Which vaccines are given under 1 years old?
- 6-in-1
- Rotavirus
- MenB
- Pneumococcal
Which vaccines are given age 1-15?
- MenB
- Hib/MenC
- MMR
- Pneumococcal
- Flu vaccine every year (2-10)
- 4-in-1 preschool booster
- 3-in-1 teenage booster
- HPV
- MenACWY
What vaccines are included in the 6-in-1?
- Diphtheria
- Hepatitis B
- Hib
- Polio
- Tetanus
- Pertussis (whooping cough)
What vaccines are included in the 4-in-1?
- Diphtheria
- Tetanus
- Pertussis (whooping cough)
- Polio
What vaccines are included in the 3-in-1?
- Tetanus
- Diphtheria
- Polio
Vaccines given to adults
- 50+ years - Flu
- 65 years - Pneumococcal
- 70 years - Shingles
Vaccines given to pregnant women
- During flu season - flu from 16 weeks pregnant
- Pertussis
What condition should you be worried about if a newborn’s growth is abnormally fast?
Gigantism
What condition should you be worried about if a newborn’s growth is abnormally slow?
Hypothyroidism
What is the most common cause of a heart murmur in a baby in the first 24 hours which goes within 3 days?
Patent ductus arteriosis - lasts for about 5 days. 1/3 close spontaneously, if it is significant, it can lead to heart failure.
What would splenomegaly in newborns be a sign of?
Haemolytic disease of the newborn
Sign of hypothyroidism in a baby
A large anterior fontanelle and anything more than a fingertip breadth posterior fontanelle
What are some major risk factors for postnatal depression?
- History of mental health problems
- Psychological disturbance during pregnancy
- Poor social support
- Poor relationship with partner
- Recent major life event
- Baby blues
What is the recommended treatment for mild to moderate post natal depression?
Facilitated self-help strategies
What is the recommended treatment for mild post natal depression with a history of severe depression?
Antidepressant
What is the recommended treatment for moderate to severe post natal depression?
- CBT
- Antidepressant treatment
What are some complications children can face due to postnatal depression in their parent?
- Marked changes in behaviour
- Cognitive impairment
- Insecurity in forming attachments
- Early onset depression
- Negative effects in Language skills and IQ
Baby checks
- First 72 hours of life - heel prick test (CF, sickle cell, congenital hypothyroid)
- 6-8 weeks - check arms, eyes, heart, hips
General routes of administering paracetamol
- Oral (PO)
- Rectal (PR)
- Intravenous (IV)
- Intramuscular (IM)
- Subcutaenous (SC)
- Topical (TOP)
- Intranasal (IN)
- Sublingual (SL)
- Nebulised (NEB)
- Inhaled (INH)
How can paracetamol be given to a patient of any age (including neonates)?
- PO via tablet, capsule, suspension tablet or effervescent tablet
- PR via suppository
- IV via solution or infusion
Describe the 3 stages of lochia
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What percentage of people have at least one further depressive episode after their initial episode?
80%
Most common barriers for receiving effective care for a mental health condition
- Lack of resources
- Lack of trained healthcare providers
- Social stigma of mental disorderer
How many people who experience a major depressive episode recover within 6 months?
50%
How many people who experience a major depressive episode recover within a year?
75%
Why can depression cause fatigue?
- It affects neurotransmitters in the brain that control awakeness
- It disrupts sleeping patterns
- The stress the patient is dealing with doesn’t allow them to sleep
Mortality rate for major depressive disorder
About 10%
Common differential diagnoses for ‘feeling tired all the time’
- Hypothyroidism
- Anemia
- Anxiety disorder
- Depression
- Cancer
- CFS
- Diabetes
- Chronic kidney disease
- Fibromyalgia
- COVID …and more
Classes of antidepressants
- Selective serotonin reuptake inhibitors
- Selective noradrenaline reuptake inhibitors
- Tricyclic antidepressants
- Tetracyclic anti depressants, eg: mirtazapine
- Monoamine oxidase inhibitors (inihibit reuptake of serotonin, dopamine and noradrenaline), eg: selegeline
- Serotonin receptor and reuptake inhibitors, eg: trazodone
What non pharmacological treatment for depression has the highest strength of evidence?
CBT
In CBT, what 5 main areas are problems broken down into?
- Situations
- Thoughts
- Emotions
- Physical feelings
- Actions
Exceptional circumstances that mean antidepressants can be prescribed in mild depression
- Past medical History of moderate to severe depression
- Mild depression that has been present for two years
- Continued presence of Mild depression after other interventions
How long does it usually take for antidepressants to provide benefit?
3-6 weeks
Potential side effects of antidepressants
- Sexual dysfunction
- Weight gain
- Hyponatraemia
- Agitation
- Risk of self harm
- Serotonin syndrome
Cycle of change
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When does diabetic ketoacidosis occur?
More common in T1DM but can occur at severe stages of T2DM/T1.5
What is diabetic ketoacidosis characterised by?
Need all 3 of the following to be diagnosed:
1. Hyperglycaemia
2. Metabolic acidosis
3. Ketonaemia
What is the leading cause of death for people with T2DM?
- Macrovascular issues
- Atherosclerotic CVD
- Stroke
- Peripheral arterial disease
Diabetic kidney disease can be caused by and is first identified by:
Caused by:
1. Diabetic neuropathy
2. Hypertension
3. Renal atheroma or ischaemia
First sign:
1. Proteinuria
Diabetes is the most common cause of CKD and end stage renal disease
Risk of diabetic vision problems
- 2x increased risk of cataracts
- 1.5x increased risk of glaucoma
- Diabetes is the leading cause of prevetable sight loss in the UK
Diabetic peripheral neuropathy epidemiology and presentation
- Estimated to affect up to 50% of people with diabetes
- Common presentation: Distal and symmetrical polyneuropathy
Risk of depression in people with diabetes
2x increase
What should be tested in a diabetic annual review?
- BMI
- BP
- HbA1c
- Cholesterol
- Smoking status
- Foot examination
- Albumin:Creatinine ratio
- Serum Creatinine measurement
Examples of primary diabetes prevention
- Exercise
- Dietary modification
- Smoking cessation
Examples of secondary diabetes prevention
- Home blood glucose monitoring
- Routine annual diabetic review
Example of tertiary diabetes prevention
Screening for diabetic retinopathy and other complications
Key symptoms of diabetic retinopathy
- Seeing floaters
- Blurred or patchy vision
- Eye pain or redness
- Difficulty seeing in the dark
- Worsening vision/sudden vision loss
What is MODY?
- Autosomal dominant condition - single gene
- Reduced insulin produced by the pancreas
- Usually develops in late adolescence
- Treated with sulfonylureas
- Tend to be non-obese
What is LADA/Type 1.5 diabetes
- Latent onset Diabetes in adults
- Patients Tend to have a healthy Weight
- Slow progressing form of autoimmune disease, pancreatic cells are damaged
Symptoms of lactic acidosis (sometimes caused by metformin)
Muscle cramping - vomiting to remove acids
Diabetic foot examination - inspection
- Discolouration
- Swelling
- Cuts, bruising, scarring etc
- Asymmetry
- Diabetic foot ulcer
Diabetic foot examination - palpation
- Foot pulse
- Temperature
- Check for crepitis (bubblewrap feeling)
Charcot arthropathy definition and clinical features
Progressive degeneration of weight-bearing joint due to peripheral neuropathy
Clinical features:
1. Effusion
2. Distortion
3. Overlying erythema
4. Loss of joint function
Special tests for diabetic foot examination
Monofilament test - Vibration test with tuning fork
What is permanent neonatal diabetes?
- Diagnosed < 6 months
- Small babes, epilepsy, muscle weakness
- Closure of K+ chennels prevented, so insulin can’t be secreted
What is maternally inherited diabetes and deafness?
- Mutation in mitochondrial DNA
- Loss of beta cell mass
- Similar presentations to Type 2
- Wide phenotype
What is lipodystrophy?
- Selective loss of adipose tissue
- Associated with insulin resistance, dyslipidaemia, hepatatic steatos, hyperandrogenism, PCOS
What is cystic fibrosis diabetes
- Features of Type 1 and 2 diabetes
- Build-up of mucus can lead to inflammation and scarring of pancreas which can damage cells producing insulin
What is the mechanism of action of beta blockers?
- Block the beta adrenoreceptors of the heart, peripheral vasculature, bronchi, pancreas and liver
- Block the effects of adrenaline, decreasing HR and blood pressure
- Also help widen veins and arteries to improve blood flow
Conditions that would contraindicate beta blockers?
- Asthma
- Hypotension
- Heart failure
- Heart block (2nd or 3rd degree)
- Hypoglycaemia
Which molecule’s metabolism do beta blockers affect?
Carbohydrates, affecting the body’s autonomic response to hypoglycaemia
Side effects of beta blockers
- Cold hands and feet (particularly in older people)
- Vivid dreams
- Fatigue
- Erectile dysfunction
Water-soluble vs lipid soluble beta blockers
- Water soluble beta blockers (eg: atenolol) are less likely to enter the brain, causing less sleep disturbance and nightmares
- They are also excreted by the kidneys so dosage reduction is often required in renal impairment
“Pill-in-the-pocket” / “PRN” approach to taking meds
- Patient with atrial fibrillation takes their antiarrhythmic medication when they experience an episode of palpitations, rather than taking regular meds
- Don’t need to go to medical facility this way
- Reduces unnecessary side effects
How is metformin excreted?
- Cleared by active tubular secretion
- Excreted unchanged in the urine
What precautions do you need to take if a patient on metformin is undergoing a radiological investigation with IV contrast?
- 30-50% risk of lactic acidosis
- Serum creatinine must be measured within the preceding month
- If normal, up to 100ml contrast can be given
- If more than 100ml contrast is used, metformin must be withheld 48 hours before
- If creatinine is raised, withhold metformin for 48 hours before and after procedure, measure creatinine again prior to restarting metformin
In what ways can a prescription be altered to mitigate the effects of reduced renal function?
- Reducing the dose
- Lengthening the dosing interval
- or both
- Some drugs will be less effective in renal impairment so should be substituted if necessary
Why is it important to know that a patient is using herbal treatments, particularly St John’s Wort?
- Drugs may interact
- eg: St John’s wort is a potent inducer of CYP450 and other enzymes involved in drug metabolism
- Makes SSRIs more potent, increasing risk of serotonin syndrome
- Other drugs can be made less potent eg: oral contraceptive, warfarin, statins, digoxin, anticonvulsants, HIV meds
In a patient with a new diagnosis of depression what class of drug would initially be used?
- SSRI such as fluoxetine
- SNRIs can be used second line but have more side effects
- Tricyclic antidepressants not prescribed first line as overdose prolongs QT interval (cardiac arrhythmias caused)
- MAOIs less commonly prescribes as they can cause interactions with certain foods and bevarages
Foods to avoid when taking MAOIs
Foods containing high levels of tyramine (an amino acid that regulates BP) eg: aged cheeses, sauerkraut, cured meats, draft beer and fermented soy products (such as soy sauce, miso and tofu)
Selective serotonin reuptake inhibitors examples and side effects
e.g. fluoxetine, sertraline
Side effects:
1. Heart burn and other GI side effects, so best not to take with food
2. Also Vivid dreams or poor sleep, so take in the morning
Tricyclic antidepressants examples and side effects
eg: lofepramine, amitriptyline
Side effects:
Anticholinergic side effects such as drowsiness, dry mouth and constipation
How long should antidepressants be taken?
- 6 months before weaning off over a period of weeks
- Patients need to be made aware of the longevity of the treatment or they may stop taking their medication too quickly once they start to feel well again
How are the 8 week immunisations administered?
- 2 IM injections (6-in-1 and MenB)
- Drops into the mouth (rotavirus)
Ideal lengths of ECG segments
PR interval: 0.12-0.2 seconds
QRS complex: 0.08-0.12 seconds
QT interval: 0.2-0.4 seconds
How to work out heart rate when rhythm is regular (from ECG)
300 ÷ number of large squares between consecutive R waves
How to work out heart rate when rhythm is irregular (from ECG)
(number of QRS complexes on 10 second rhythm strip) x 6
How long are the squares on an ecg?
1 small square = 0.04 seconds, 0.1mV
1 large square = 0.2 seconds, 0.5mV
10 large squares = 2 seconds
50 large squares = 10 seconds (typical length of rhythm strip)
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- Atrial fibrillation
- P waves absent/chaotic baseline
- Irregularly irregular
- HR of 140+bpm (tachycardic)
- Most common cardiac arrhythmia
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- Atrial flutter
- “Flutter waves” instead of P waves, “sawtooth baseline”
- HR 250-350bpm (tachycardic)
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- First degree AV block
- PR interval > 0.2 seconds (1 large square)
- Bradycardic
- Benign and may not need any treatment
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- Second degree AV block - Mobitz I
- PR interval prolonged over several beats, until a beat is missed (P not followed by QRS)
- Bradycardic
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- Second degree AV block - Mobitz II
- PR interval not prolonged progressively
- A beat missed every few beats with normal PR interval
- Conduction is slowed through Bundle of His and Purkinje fibres
- Irregularly irregular
- Bradycardic
- Requires a pacemaker
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- Third degree/complete AV block
- “AV dissociation” - no relationship between P waves and QRS complexes
- Bradycardic
- Requires dual-chamber pacemaker
Best lifestyle intervention for atrial fibrillation
Stress management
Best way to exercise if you have atrial fibrillation
- 150 mins moderate intensity activity a week - reduce if you become breathless quickly
- Try to be active 30 mins a day
- With paroxysmal AF (occasional), exercise when AF not happening
- Brisk walk suitable for almost anyone
- Warm up and cool down
Good diet for patient with AF
- Regular meals
- Foods low in sugars, saturated fats and sodium
- Plenty of fruits and vegetables
- Cut down on alcohol (Also quit Smoking)
Signs that a patient with atrial fibrillation is acutely unwell/unstable
- Syncope
- Shock
- Chest pain
- Heart failure
What drug should be taken prior to cardioversion?
An anticoagulant - as a clot may have formed before cardioversion and cardioversion treatment can cause the clot to mobilise -> stroke
Types of cardioversion
- Electrical - defibrillator
- Pharmacological - BBs, amiodarone etc
Examples of SNRIs
- Duloxetine
- Venlafaxine
- Reboxetine
Nephrotoxic drugs in prerenal AKI
- NSAIDS
- ACE inhibitors
- Diuretics - Circulatory volume depletion leads to hypoperfusion of the kidneys
Nephrotoxic drugs in intrarenal AKI
- Many types of antibiotics
- Diuretics - NSAIDS
- ACE inhibitors - Direct toxicity to, or hypersensitivity reactions involving the glomerular or interstitial tissues
Nephrotoxic drugs in post renal AKI
- Anticholinergics
- Sulphonamides
- Methotrexate - Urinary tract obstruction due to Urinary retention or stone formation (crystalluria)
What is commonly affected by having a colostomy?
- Sexual funciton
- Diet
- Ability to travel
Drugs that can be used to treat IBD
- Mesalazine
- Immunosuppressants
- Biological and biosimilar medicines
- Antibiotics
Crohn’s disease profile
- Crows NESTS
- No blood or mucus (less common)
- Entire GI tract
- Skip lesions on endoscopy (Fig.1)
- Terminal ileum affected in Transmural inflammation
- Smoking is a RF
Ulcerative colitis profile
- Closeup Continuous inflammation
- Limited to colon and rectum
- Only superficial mucosa affected
- Smoking is protective
- Excrete blood and mucus
- Use aminosalicylates
- Primary sclerosing cholangitis
Investigations for AKI
First line:
1. Basal metabolic profile - figures like urea:creatinine ratio tell you whether the cause is pre/intra/post-renal Can also do:
1. FBC
2. ECG (as hyperkalaemia is a common complication of AKIs)
3. Blood culture
Definition of AKI (NICE)
A spectrum of injury to the kidneys which can result from a number of causes. It is a clinical syndrome rather than a biochemical diagnosis
Causes of pre-renal AKI (non-drugs)
- Hypovolaemia
- Reduced CO
- Renal artery stenosis
- Shock
- Dehydration
Causes of renal AKI (non-drugs)
- Vasculitis
- Glomerulonephritis
- Tubular acidosis
- Interstitial nephritis
Causes of post-renal AKI
- Obstruction, eg: renal stones
- Blocked catheter
- Enlarged prostate
- GI tumours/masses
Risk factors for AKI
- CKD
- Heart failure
- Diabetes
- Liver disease
- 65<
- Cognitive impairment
- Nephrotoxic meds
- Contrast
How often would you empty and change stoma
Empty: Every 2-3 hours
Change: Every 2-3 days
PSA and prostate cancer
Not specific to prostate cancer, prostate biopsy needed to confirm diagnosis
What components of the prostate does BPH affect?
Hyperplasia of both stromal and prostatic components
Factors that can increase PSA levels
- Age
- Prostate size
- Inflammation
- Infection
- Ejaculation
- Recent prostate biopsy or examination
- Vigorous Exercise
- Testosterone
Factors that can decrease PSA levels
- Drugs used to treat BPH
- Large doses of chemotherapy meds
- NSAIDS
- Obesity
- Smoking
- Medical castration
What is the IPSS?
- International prostate symptom score
- 7 questions relating to LUTS, each scored 0-5 depending on severity
- 0-7 = mildly symptomatic
- 8-19 = moderately symptomatic
- 20-35 = severely symptomatic
Approximate size of prostate in DRE
3x3cm
How does prostate feel in BPH?
- Smooth and firm + non-tender
- May be more of a rubbery consistency
- May be assymetrical though often uniformly enlarged
What is the main finding that may be indicative of prostatitis on DRE?
Tender
Surgical management options for BPH
- TURP - Transurethral electrovaporisation of prostate (TEVAP/TUVAP)
- Holmium laser enucleation of prostate (HoLEP)
- Open prostatectomy via abdo or perineal excision
Complications of TURP
- Urethral strictures
- Urinary incontinence
- Erectile dysfunction
- Retrograde ejaculation
Lifestyle change important part of BPH treatment
- More fibre
- Avoid caffeinated/sweetened drinks
- Less water at the end of the day
Maslow’s hierarchy of needs
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What happens if the prostate is not working?
- Less testosterone (endocrine function)
- Less semen (exocrine function)
- Lose switch between mictuiriton and ejaculation
Specificity and sensitivity of rheumatoid factor
Neither specific nor sensitive lol
What happens if you give NSAIDs in late pregnancy?
Early ductus arteriosis closure
Monitoring when a patient is on methotrexate
- Full blood count, renal and liver function tests before treatment
- Every 1-2 weeks until therapy stabilised
- Every 2-3 months afterwards
Folic acid and methotrexate
Methotrexate is a very slowly reversible competitive inhibitor of dihydrofolate reductase
Folic acid is given to patients 5mg once weekly, not on the same day as methotrexate
Give an example of a carbamazepine
Tegretol (brand name) Carbamazepine is an anti-convulsant
Drug interactions of carbamazepine
- Markedly reduces efficacy of oral contraceptive pill (because it is a drug that induces hepatic enzyme activity)
- Advise patients to use parenteral progesterone-only contraceptives such as depo provera or the implant or IUD
Define ‘well controlled asthma’
Requiring reliever medication no mor than twice a week
How to prevent over reliance on asthma reliever medication
- Good patient education
- Removing relievers from the repeat prescription list (or only allowing one-two issues per year)
- Describing the medication as ‘treatment’ and ‘rescue’ to help define their use better
How can the carbon footprint of asthma meds be reduced?
- Ensure asthma is well-controlled with preventer meds
- Use 1 puff of a stronger medication instead of 2 puffs of a weaker one
- Supply an inhaler with a dose counter
- Use dry powder inhalers
- Make sure patients know to return used inhalers to the pharmacy to be recycled or incinerated
What device can be used for a child to take better control of their asthma?
Spacer
Why is doxozasin antihypertensive?
Has affects on alpha-1b adrenergic receptors present in arterioles (tamsulosin has minimal effect on these)
What should patients on alpha blockers do if they’re about to have eye surgery?
Not stop, but still inform their surgeon as there is a risk of intraoperative floppy iris syndrome in patients who are on (or have previously been on) alpha blockers
Side effects of alpha blockers
- Postural hypotension (so advise to take at night)
- Retrograde ejaculation in 30% (usually antegrade) due to failure of bladder neck to close
What questionnaire is used to test for depression?
PHQ-9
5-9 = no depression/subthreshold
10-14 = depression
15+ = major depression
