GP👨🏽⚕️ Flashcards
1
Q
What are the thresholds for diagnosis of hypertension?
A
140/90 clinic BP 135/85 ambulatory BP
2
Q
What is the main cause of hypertension?
A
Essential hypertension - unknown cause
3
Q
What are the secondary causes of hypertension? (3)
A
ROPED R - renal failureO - obesity P - pre-eclampsiaE - endocrine D - drugs - NSAIDs, alcohol, steroids, oestrogen
4
Q
What is the most common cause of secondary hypertension?
A
Renal failure
5
Q
What are the risks of high blood pressure? (3)
A
Increased risk of:- Stroke - IHD - Heart failure - Left ventricular hypertrophy - Hypertensive retinopathy - Kidney failure- Vascular dementia
6
Q
What is stage 1 hypertension?
A
Clinic BP >140/90 Ambulatory BP > 135/85
7
Q
What is stage 2 hypertension?
A
Clinic BP > 160/100Ambulatory BP > 150/95
8
Q
What is stage 3 hypertension?
A
Clinic BP > 180/120
9
Q
What investigations should all those with a new diagnosis of hypertension have? (5)
A
Urine albumin:creatinine ratio Urine dipstick HbA1cRenal function LipidsFundoscopy ECGCalculate Q riskTFTs - check for secondary causes
10
Q
What medications are used in the management of hypertension?
A
Under 55:- 1st line - ACE inhibitor - 2nd line - ARB Over 55:- 1st line - calcium channel blockerBlack or afro-carribean background:- 1st line - CCB Type 2 diabetes patients - 1st line - ACE inhibitor Alternative medications:- Beta blockers + potassium sparing diuretics - 4th line - Thiazide like diuretic - 3rd line
11
Q
What is malignant hypertension?
A
Hypertension above 180/120 with papilloedema
12
Q
What is the treatment of malignant hypertension?
A
Same day referral for IV antihypertensives:- Sodium nitroprusside - Labetolol- GTN - Nicardipine
13
Q
What lifestyle changes can patients make to manage their hypertension? (3)
A
Stop smoking Reduce alcohol intake Reduce caffeine intake Reducing dietary salt Diet and exercise
14
Q
What should be monitored in patients on antihypertensives? (3)
A
Serum electrolytes Kidney functionCheck blood pressure
15
Q
Which thiazide like diuretic is most commonly used in hypertension?
A
Indapamide
16
Q
What is heart failure?
A
Impaired heart function, usually of the left ventricle - blood can’t get out to the body
17
Q
What is the pathophysiology of heart failure?
A
Impaired left ventricular function resulting in blood backing up into the left ventricle and the rest of the heart The left atrium, pulmonary vein and lungs are increased in volume and pressure This results in pulmonary oedema
18
Q
What is a normal ejection fraction?
A
Above 50%
19
Q
What is ejection fraction?
A
The proportion of blood in the left ventricle that is pumped out of the heart with each contraction
20
Q
What are the causes of heart failure? (4)
A
Ischaemic heart diseaseValvular heart disease - aortic stenosis Hypertension Arrhythmias - AFCardiomyopathy
21
Q
What is the presentation of heart failure? (5)
A
BreathlessnessCough with frothy pink/white sputumOrthopnoea Paroxysmal nocturnal dyspnoea Peripheral oedema Fatigue
22
Q
What signs of heart failure would be seen on examination? (5)
A
TachypnoeaTachycardia Hypertension Murmurs (if caused by valvulvar heart disease)3rd heart sound Bilateral basal cracklesRaised JVPPeripheral oedema
23
Q
What investigations are used to diagnose heart failure? (5)
A
ECGEchocardiogram BNP Bloods - LFT, TFT, U&E, FBC, lipids, HbA1c, inflammatory markersChest XR
24
Q
What are the differentials of heart failure? (3)
A
COPD
Pulmonary fibrosis
Pneumonia
Ageing/physical inactivity
25
What are the NYHA classes of heart failure?
Class 1 - no limitation of activity
Class 2 - comfortable at rest but symptomatic with moderate/high exertion
Class 3 - comfortable at rest but symptomatic with slight exertion
Class 4 - symptomatic at rest
26
What is the first line medical management of heart failure?
ACE inhibitor
Beta blocker
Aldosterone antagonist- spironolactone (if symptoms are not controlled by A+B)
Loop diuretics
27
What are haemorrhoids?
Enlarged anal vascular cushions
28
What are the risk factors for haemorrhoids? (3)
Straining Constipation Pregnancy Obesity Increased age Increased intra-abdominal pressure
29
What is an anal cushion?
Submucosal tissue in the anus that contains connections between arteries and veins, making it very vascular
30
What is the classification of haemorrhoids?
Class 1 - no prolapse
Class 2 - prolapse on straining and return on relaxation
Class 3 - prolapse on straining with no return on relaxation, but that can be pushed back
Class 4 - prolapsed permenantly
31
What is the presentation of haemorrhoids? (3)
Bright red bleeding upon wiping or after opening bowels Blood not mixed with stool Sore/itchy anus Intermittent protrusion
32
What are the differentials of haemorrhoids? (3)
Anal fissure Crohn's diseaseUlcerative colitis Bowel cancerAnal fistulaDiverticulosis
33
What is the first line investigation of haemorrhoids?
Inspection and PR exam
34
What other investigations may be performed in the diagnosis of haemorrhoids? (2)
FBC Colonoscopy (to exclude other conditions)
35
What is the management of haemorrhoids? (3)
Topical treatments - anusol Rubber band ligation Sclerotherapy Surgical treatment - haemorrhoidal artery ligation or haemorrhoidectomy
36
What is a thrombosed haemorrhoid?
Where there is strangulation at the base of the haemorrhoid which causes thrombosis in the haemorrhoid
37
What lifestyle advice should be given to someone with haemorrhoids?
More dietary fibre Good fluid intake Using laxatives where required Avoid straining
38
What is the most effective emergency contraception?
Copper IUD
39
How long after sex is a copper IUD effective for emergency contraception?
120 hours (5 days)
40
How does the copper IUD work?
It prevents implantation as it is toxic to both egg and sperm
41
How long can a copper IUD stay in place?
Up to 10 years
42
What are the contraindications to the copper IUD? (3)
Pregnancy Repeated history of STIs Current pelvic infection or STI Distorted uterus Abnormal cervix Unexplained bleeding Wilson’s disease
43
What is the UKMEC criteria?
UKMEC1 - no restriction in use UKMEC2 - benefits outweigh risksUKMEC3 - risks outweigh benefits UKMEC4 - absolute contraindication
44
What contraception should women with breast cancer avoid?
Any hormonal contraception - Copper IUD or barrier methods are best choice
45
What contraception should women with Wilson's disease avoid?
Copper IUD
46
What contraception should women with cervical or endometrial cancer avoid?
IUS
47
What are diaphragms and cervical caps?
Silicone caps that fit across the cervix to prevent semen from entering the uterus
48
How is a diaphragm/cervical cap used?
Fitted before sex, and left in for 6 hours after sexUsed alongside spermicide gel
49
How effective is the COCP?
99% with perfect use 91% with typical use
50
How does the COCP prevent pregnancy?
Prevents ovulation (primary method)Progesterone thickens cervical mucus Progesterone inhibits proliferation of the endometrium
51
How does the COCP prevent ovulation?
Oestrogen and progesterone have negative feedback on the release of GnRH from the hypothalamus In turn, less FH and LSH is released from the anterior pituitary, without which ovulation cannot occur
52
What are the first line choices of progesterone for the COCP?
Levonorgestrel or norethisterone
53
Why are levonorgestrel and norethisterone the first line choices of progesterone?
They have a lower VTE risk
54
What is the first line COCP for PMS?
Yasmin - containing drospirenone
55
Which is the first line COCP for acne and hirtuism?
Dianette - containing cyprotenone acetate
56
What are the three regimes for COCP use?
21 days on, 7 days off 63 days on, 7 days offContinuous use
57
What are the common side effects of the COCP? (3)
Unscheduled bleeding in first 3 months Breast pain and tendernessMood changes and depression Headaches
58
What are the risks of the COCP? (3)
Hypertension Small increase in risk of breast cancer, and cervical cancerVTE Small risk of MI and stroke
59
What are the contraindications to the COCP? (5)
Over 35 and smoking more than 15 cigarettes per day Migraine with aura History of VTEUncontrolled hypertensionIshcaemic heart diseaseHistory of vascular disease or strokeLiver cirrhosis SLE
60
What extra protection is required when starting the COCP?
Up to day 5 of period- no extra protection requiredDay 5 onwards - condoms for the first 7 days of pill taking
61
What extra protection is required in the case of a missed COCP?
If it is less than 72 hours since the last pill taken: - Take the missed pill as soon as possible - No extra action requried
62
What extra protection is required in the case of more than 1 missed COCP?
Take the missed pill as soon as possible Additional contraception needed for 7 days Day 1-7 of packet - emergency contraception neededDay 8-14 - no emergency contraception neededDay 15-21 - no emergency contraception required, but skip 7 day pill free period
63
Can the COCP be used during a major operation?
No - the COCP should be stopped 4 weeks before a major operation
64
What is the only absolute contraindication to the POP?
Breast cancer
65
What are the two types of POP?
Traditional POPDesogestrel only pill
66
What is the time window for taking the traditional POP?
3 hours
67
What is the time window for taking the desogestrel only pill?
12 hours
68
What is the mechanism of action of the traditional POP? (3)
Inhibits proliferation of the endometrium Thickens cervical mucus Reduces ciliary action in the fallopian tubes
69
What is the mechanism of action of the desogestrel only pill?
Inhibits ovulationInhibits proliferation of the endometrium Thickens cervical mucus Reduces ciliary action in the fallopian tubes
70
What extra protection is needed when starting the POP?
No extra protection needed if started on days 1-5Day 6 onwards - additional contraception required for 48 hours
71
What are the side effects of the POP? (3)
Unscheduled bleeding during first three months Breast tendernessHeadaches Acne
72
What are the risks of the POP? (2)
Increased risk of ovarian cystsRisk of ectopic pregnancy with traditional POPIncreased risk of breast cancer
73
What extra protection is required in the case of a missed POP pill?
Take the missed pill as soon as possible Use additional contraception for the next 48 hours
74
How often is the progestogen-only injection given?
Every 12 to 13 weeks
75
How long can it take for fertility to return after stopping the progestogen-only injection?
12 months
76
What are the two types of progestogen-only injection given in the UK?
Depo-provera - IM injection
Sayana Press - self administered SC injection
(Medroxyprogesterone)
77
What are UKMEC3 contraindications to the POP? (3)
Ischaemic heart disease and stroke
Liver disease
Unexplained vaginal bleeding
78
What is the main mechanism of action of the depo injection?
Inhibits ovulation(also works by inhibiting proliferation of the endometrium and thickening cervical mucus)
79
When is extra protection required when starting the depo injection?
No extra protection required before day 5 After day 5 - additional protection required for 7 days
80
What are the side effects of the depo injection? (3)
Weight gain Acne Reduced libidoMood changesHeadaches Flushes Hair lossSkin reactions at injection sites
81
What is the most important side effect of the depo injection?
Reduced bone mineral density
82
What is the progestogen only implant?
A small 4cm plastic rod that is inserted underneath the skin, above the subcutaneous fat
83
How long does the implant last for?
3 years
84
What is the only UKMEC4 criteria for the implant?
Active breast cancer
85
How does the implant work?
Inhibits ovulation Makes the endometrium less accepting of implantation Thickens cervical mucus
86
What are the two types of coils?
IUD - copper containing coil IUS - levonorgestrel containing coil
87
What are the contraindications to the coil? (3)
PID Immunosuppression Pregnancy Unexplained bleeding Pelvic cancerDistortion of the uterus by fibroids
88
What are the risks relating to insertion of the coil? (3)
Bleeding Pain on insertion Vasovagal reactions Uterine perforationPIDExpulsion
89
What are the types of IUS and how long can they be used for?
Mirena - 5 years Levosert - 5 years Kyleena - 5 years Jaydess - 3 years
90
What other uses is the mirena coil licensed for?
Contraception, menorrhagia and HRT
91
What other uses is the levosert coil licensed for?
Contraception and menorrhagia
92
How does the IUS work?
Thickens cervical mucus Makes the endometrium less accepting of implantation Inhibits ovulation in some women
93
What are the side effects of the IUS? (3)
Can cause spotting or irregular bleeding Pelvic pain Acne Headaches Breast tenderness
94
What are the risks of the IUS?
Ectopic pregnancies Ovarian cysts
95
What are the three types of emergency contraception?
Copper IUD Levonorgestrel (Levonelle)Ulipristal acetate (EllaOne)
96
When can levonelle be taken?
Within 72 hours of unprotected sex
97
When can EllaOne be taken?
Within 120 hours of unprotected sex
98
What are the side effects of levonelle? (3)
Nausea and vomiting Spotting and changes to the next menstrual period Diarrhoea Breast tendernessDizziness Depressed mood
99
What are the side effects of EllaOne? (3)
Nausea and vomiting Spotting and changes to the next menstrual period Back pain Mood changes Headache DizzinessBreast tenderness
100
What is the Pearl Index?
The number of pregnancies that would be seen if 100 women used that form of contraception for one year
101
At what age should a woman stop taking the COCP?
50 years
102
When can the mirena coil or IUD be inserted after childbirth?
Within 48 hours of childbirth or after 4 weeks
103
When can the COCP be started after childbirth?
After 21 daysor After 6 weeks if breastfeeding
104
When can the progestogen only pill be started after childbirth?
Can be started at any time
105
When can patients be given the copper IUD after 5 days post intercourse?
If the patient is up to 5 days after their earliest ovulation date
106
Who should EllaOne not be given to?
Patients with severe asthma
107
What is rheumatoid arthritis?
An autoimmune condition which causes chronic inflammation of the synovial lining of the joints
108
Who is rheumatoid arthritis more common in?
3 times more common in women than in men
109
What are the gene associations with rheumatoid arthritis?
HLA DR4HLA DR1
110
What antibodies may be present in a patient with rheumatoid arthritis?
Rheumatoid factor Anti-CCP- more specific than RF (Anti-cyclic citrullinated peptide) antibodies
111
What are the key symptoms in rheumatoid arthritis? (5)
Joint pain
Joint swelling
Morning stiffness < 30 minutes
Pain that gets better with exercise
Fatigue
Weight loss
Flu like illness
112
Which joints are commonly affected in rheumatoid arthritis?
Proximal interphalangeal joints (PIP)Metacarpophalangeal joints (MCP)WristsAnklesCervical spine
113
What hand signs may be present in someone with rheumatoid arthritis? (4)
Z thumb Swan neck deformity Boutonnieres deformity Ulnar deviation
114
What are the extra-articular manifestations of rheumatoid arthritis? (3)
Pulmonary fibrosis Bronchiolitis obliterans Sjogren's syndrome Anaemia of chronic diseaseCardiovascular diseaseEpiscleritis and scleritis Rheumatoid nodules
115
What investigations may be carried out in the diagnosis of rheumatoid arthritis? (4)
Rheumatoid factorAnti-CCP antibodies CRP and ESRXR hands and feetUltrasound to confirm synovitis
116
What changes may be seen on XR in someone with rheumatoid arthritis? (5)
117
What factors are indicative of a worse prognosis of rheumatoid arthritis? (3)
Younger onset Male More joints and organs affectedPresence of RF and anti-CCP antibodies Erosions seen on XR
118
What is the first line management of rheumatoid arthritis?
Monotherapy with methotrexate, leflunomide or sulfasalazine
119
What is the second line management of rheumatoid arthritis?
Dual therapy with methotrexate, leflunomide or sulfasalazine
120
What is the third line management of rheumatoid arthritis?
Methotrexate plus a biological therapy (usually a TNF inhibitor)
121
What is the fourth line management of rheumatoid arthritis?
Methotrexate plus rituximab
122
What anti-TNF medications are commonly used in the treatment of rheumatoid arthritis?
Infliximab Adalimumab Etanercept
123
What is the treatment of an initial presentation or a flare up of rheumatoid arthritis?
A short course of glucocorticoids - prednisolone
124
How is methotrexate taken for rheumatoid arthritis?
Methotrexate is taken orally or intramuscularlyFolic acid 5mg is given once a week, on a different day to the methotrexate
125
What are the side effects of methotrexate? (3)
Mouth ulcersLiver toxicity Leukopenia Teratogenic
126
What are the differentials of rheumatoid arthritis? (3)
Osteoarthritis SLEFibromyalgia Septic arthritis Psoriatic arthritis Polyarticular gout Reactive arthritis
127
Which medications are safe for rheumatoid arthritis patients during pregnancy?
Sulfasalazine and hydroxychloroquine
128
What is psoriasis?
A chronic inflammatory condition of the skin characterised by scaly erythematous and pruritic plaques
129
What are the 5 types of psoriasis?
Chronic plaque psoriasis Flexural psoriasisGuttate psoriasis Pustular psoriasis Generalised psoriasis
130
What is chronic plaque psoriasis?
Symmetrical plaques on the extensor surfaces of the limbs, scalp and back
131
What is flexural psoriasis?
Smooth erythematous plaques without scale in flexures
132
What is guttate psoriasis?
Multiple small, tear shaped lesions on the trunk after a streptococcal infection in children
133
What is pustular psoriasis?
Multiple petechiae and pustules on the palms and soles
134
What is generalised psoriasis?
Psoriasis with erythroderma and systemic illness
135
What are the risk factors for psoriasis? (3)
Skin trauma Withdrawal of steroids Drugs - NSAIDs- Beta blockers - Lithium - Anti-malarials Stress Alcohol Smoking Cold/dry weather
136
What signs are specific to psoriasis? (2)
Auspitz sign Koebner phenomenon Residual pigmentation after lesions resolve
137
What is the auspitz sign?
Small points of bleeding when the plaques are scraped off
138
What is the Koebner phenomenon?
The development of psoriatic lesions in an area of skin affected by trauma
139
What is the first line topical treatment of psoriasis?
Topical corticosteroid and topical vitamin D applied at different times
140
What is the second line topical treatment of psoriasis?
Stop the corticosteroid Apply topical vitamin D twice daily
141
What is the third line topical treatment of psoriasis?
Stop topical vitamin DApply corticosteroid twice daily
142
What is the first line systemic treatment of psoriasis?
Methotrexate
143
What is the second line systemic treatment of psoriasis?
Ciclosporin
144
What biologics can be used to treat psoriasis?
InfliximabEtanercept Adalimumab
145
What nail changes are seen in psoriasis?
Nailbed pitting Onycholysis - separation of nail from nailbed Subungual hyperkeratosis - thickening of nailbed
146
What is the action of metformin?
Increases peripheral glucose sensitivity and increases liver uptake of glucose
147
What are the side effects of metformin? (3)
Nausea
Vomiting
Abdominal discomfort
Diarrhoea
Lactic acidosis
148
What is the action of sulfonylureas? Give an example of one
Stimulate the pancreatic beta cells to release insulin
Glipizide
149
What are the side effects of sulfonylureas? (3)
Hypoglycaemia Weight gain Nausea and vomiting Diarrhoea Allergic reactions
150
What is the action of thiazolidinediones (glitazones)? Give an example of one.
Increase peripheral insulin sensitivity
Rosiglitazone/pioglitazone
151
What are the side effects of thiazolidinediones?
Weight gain
Fluid retention and heart failure
Increased risk of fractures
Increased risk of bladder cancer
152
What is the action of SLGT-2 inhibitors? Give an example of one.
Increase urinary glucose excretion
Empagliflozin
153
What are the side effects of SLGT2 inhibitors? (3)
Fungal infections UTIsEuglycaemic diabetic ketoacidosis Increased risk of lower limb amputation
154
What is the action of DPP-4 inhibitors? Give an example of one.
Inhibits the enzyme DPP-4 which breaks down incretin hormones - this leads to an increase in production of insulin
Sitagliptin
155
What is atrial flutter?
An arrhythmia caused by a re-entrant circuit, causing the atria to contact quickly
156
What heart rate is seen in atrial flutter?
Atrial rate of 300 bpm Ventricular rate of 150 bpm (but can be variable)
157
What appearance does atrial flutter given on an ECG?
Sawtooth appearance
158
Why can the ventricular rate be variable in atrial flutter?
Dependant on how many impulses from the atria conduct through to the ventricles (a 2:1 ratio would result n 150bpm, a 3:1 ratio would result in 100bpm...)
159
What are the causes of atrial flutter? (3)
COPD Obstructive sleep apnoea Pulmonary emboli Pulmonary hypertension
160
What are the symptoms of atrial flutter? (3)
Palpitations LightheadednessSyncope Chest pain
161
What is the treatment of atrial flutter in someone haemodynamically unstable? (2)
Direct current synchronised cardioversion + IV amiodarone
162
What is the first line management of atrial flutter?
Beta blocker or calcium channel blocker
163
What is the second line management of atrial flutter?
Cardioversion
164
What is atrial fibrillation?
Irregular and uncoordinated atrial contraction at a rate of 300-600 bpm
165
What are the causes of atrial fibrillation? (3)
Ischaemic heart diseaseHypertension Rheumatic heart diseasePericarditis Myocarditis
166
What are the symptoms of atrial fibrillation?
Palpitations Chest pain Shortness of breath Light headednessSyncope
167
What are the signs of atrial fibrillation on ECG?
Irregularly irregular heartrate Absent P waves
168
What is the first line management of acute atrial fibrillation in a patient that is haemodynamically unstable?
Synchronised DC cardioversion and amiodarone
169
What is the first line management of acute atrial fibrillation in a stable patient?
If onset < 48 hours ago - Rate and rhythm control If more than 48 hours ago- Rate control only
170
What is the management of chronic AF?
Rate control - 1st line - beta blocker or calcium channel blocker- 2nd line - dual therapy- Digoxin Rhythm control - Electric cardioversion - Pharmacological cardioversion
171
What joint aspiration results are seen in gout?
Negatively birefringent needles
172
What joint aspiration results are seen in pseudogout?
Positively birefringent rhomboid crystals
173
What is the presentation of pseudogout?
Acute monoarthritis - Shoulder and wrist most affected
174
What is the treatment of pseudogout?
NSAIDs (colchicine if NSAIDs are contraindicated)
175
What are the causes of megaloblastic anaemia?
B12 deficiency Folate deficiency
176
What are the causes of non-megaloblastic macrocytic anaemia? (3)
Liver disease Alcohol Hypothyroidism Pregnancy
177
What is in the childhood 6 in 1 vaccine?
'Parents Will Immunise Toddlers Because Death'
Polio
Whooping cough (pertussis)
Influenzae (haemophilus type b)
Tetanus
B (hepatitis)
Diphtheria
178
What vaccines are given to children at 2, 3 and 4 months of age?
2 months- '6-1 vaccine' (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B)
Oral rotavirus vaccine
Men B
3 months- '6-1 vaccine' (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B)
Oral rotavirus vaccine
PCV (Pneumococcal Conjugate Vaccine)
4 months- '6-1 vaccine' (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B)
Men B
179
What childhood vaccinations are given at 12-13 months of age? (4)
Hib/Men C
MMR
PCV
Men B
180
What vaccinations are given at 3-4 years of age?
'4-in-1 pre-school booster' (diphtheria, tetanus, whooping cough and polio)
MMR
181
At what age is the HPV vaccination given to children?
12-13 years
