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Phase 3a AW > GP 2 > Flashcards

GP 2 Flashcards

1
Q

What are the differentials of an irregular rhythm on ECG?

A

AF
Sick sinus syndrome
Ventricular ectopics
Heart block

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2
Q

What is acute AF and what are the causes of it?

A

Onset within 48 hours

May be precipitated by acute infection, high alcohol intake, surgery, MI, pericarditis, PE or hyperthyroidism

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3
Q

What are the causes of chronic AF?

A 
No cause
Hypertension
Coronary heart disease
Cardiomyopathy
Valvular heart disease
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4
Q

What are the symptoms in AF and what investigations would you do?

A

Symptoms- Palpitations, chest pains, stroke/TIA, dyspnoea, fatigue, lightheadedness, and/or syncope

Investigations- ECG, ECHO, Bloods, CXR

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5
Q

What are the 2 approaches to treatment?

A

Rhythm control and rate control

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6
Q

What is involved in rhythm control?

A 
Amiodarone or flecainide (if no IHD)
Consider referral for DC or chemical cardioversion if:
- symptomatic or CCF
- first presentation with lone AF
- age <65

Consider digoxin for sedentary elderly patients

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7
Q

What is involved in rate control?

A

Aim is to reduce the myocardial metabolic demand

Consider controlling ventricular rate with a beta-blocker
e.g. atenolol or rate-limiting calcium antagonist e.g. verapamil if age >65, CAD, no CCF, duration >1 year

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8
Q

When would you consider anti-coagulation in treatment of AF?

A

In all rate control strategies

In rhythm control strategies prior to cardioversion

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9
Q

What score is used to make the decision about anti-coagulation in AF?

A

CHADSVASC
This is the risk of stroke in patients with AF

Consider AC in men with 1 point, and women with 2 points

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10
Q

What anticoagulation would be considered in AF?

A

Warfarin or NOAC e.g. apixaban, rivaroxaban

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11
Q

What is the antidote to a NOAC?

A

Beriplex

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12
Q

What is the HAS-BLED score?

A

The risk of major bleeding in AF with oral anticoagulation

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13
Q

What is HAS-BLED?

A

Hypertension
Abnormal renal function or liver function
Stroke history

Bleeding predisposition
Labile INRs
Elderly
Drugs predisposing to bleeding or alcohol

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14
Q

What are the 3 features of angina?

A
  1. Episodic central crushing chest pain or band-like chest pain that may radiate to the jaw/neck and/or one or both arms
  2. Precipitated by physical exertion, cold, emotion and/or heavy meals
  3. Releived by rest or GTN in about 5 mins

3/3 typical angina
2/3 atypical angina
1/3 non-anginal pain

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15
Q

What investigations should you do for a patient with angina?

A

Bloods- fasting lipid profile, having blood glucose, ESR, TFTs
12 lead resting ECG

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16
Q

What is the management in angina?

A

Lifestyle advice
GTN spray for symptomatic relief
1st line- BB e.g. atenolol
2nd line- add a long-acting dihydropyridine CCB e.g. amlodipine
3rd line- add long acting nitrate or nicorandil

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17
Q

What is the risk of combining a BB and rate-limited CCB e.g. verapamil?

A

Risk of bradycardia/stroke

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18
Q

What is secondary management of angina?

A

Statin
Aspirin (all patients should have statin and aspirin)
Ace inhibitors

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19
Q

What are the risk factors for COPD?

A

Smoking
Occupational disease
Air pollution
A1AT deficiency

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20
Q

What are the symptoms of COPD?

A 
SOBOE
Chronic cough with sputum
Wheeze
Bronchitis
Apnoea
Fatigue
Weight loss
Haemoptysis
Recurrent infections
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21
Q

What would show on spirometry for COPD?

A

FEV1/FVC <0.7 and FEV1 <70% predicted and <15% reversibility to a reversible test

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22
Q

What other investigations can be done in COPD?

A 
CXR and FBC
PHQ9
O2 sats
ECG and ECHO
Sputum culture
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23
Q

What scale is used in COPD?

A 
GOLD scale- to assess FEV1
<0.3 is very severe
0.3-0.49 is severe
0.5- 0.79 is moderate
>0.8 is mild
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24
Q

What is the acute management of COPD?

A

Increase dose of SABA/ SAMA
Oral corticosteroids for 1-2 weeks
Antibiotics if purulent sputum- amoxicillin usually
O2 if FEV1 <30%

25
Q

What is the chronic management of COPD?

A

SABA e.g. salbutamol or SAMA anticholinergic e.g. ipratropium

Combine them

Consider adding a LABA e.g. salmeterol or LAMA e.g. tiotropium

Use and LAMA/LABA and inhaled corticosteroid e.g. beclomethasone

Consider adding theophylline

REFER

26
Q

What causes T1DM?

A

Autoimmune destruction of insulin-producing beta cells of pancreatic islets of Langerhans-> absolute insulin deficiency

27
Q

What causes T2DM?

A

Diminished effectiveness of endogenous insulin/insulin resistance

28
Q

What is the presentation of T1DM?

A

Weight loss, polydipsia, polyuria, acutely unwell with DKA

29
Q

What is the presentation of DKA?

A

Abdo pain
Vomiting
Reduced consciousness level

30
Q

What is the presentation of T2DM?

A

Incidental finding or polydipsia/polyuria

31
Q

How is diabetes diagnosed in a symptomatic and asymptomatic patient?

A

Symptomatic-
Fasting glucose >7mmol/L
Random blood glucose >11.1 mmol/L
HBA1C >48 (6.5%)

Asymptomatic-
One of the above must be demonstrated on 2 separate occasions

32
Q

What is impaired fasting glucose?

A

Greater or equal to 6.1 but less than 7.0mmol/L

They should be offered an OGTT to rule out a diagnosis of diabetes

33
Q

What needs to be checked annually in a T1DM patient?

A

BP, renal function, eye check, foot check

Target HBA1C <48

34
Q

What is the target HBA1C in a T2DM patient?

A

Target BP <140/80mmHg OR 130/80 if end-organ damage

Give Atorvastatin if Q risk is >10%

35
Q

What are 1st line intervention in T2DM?

A

Dietary advice, 5-10% weight loss advised in an overweight person
Smoking cessation

36
Q

What if HbA1c remains above 48 after lifestyle interventions?

A

give metformin- increases hepatic gluconeogenesis and GI absorption of CHO

37
Q

What are the positives and negative of metformin?

A

+ Weight neutral
- GI upset, risk of lactic acidosis if impaired renal function

CI- recent tissue hypoxia

38
Q

If HbA1c remains >58 after metformin, what are the options?

A

Sulfonylurea- binds to beta cell receptors and stimulate insulin release so only effective if you have functioning beta cells left
Pioglitazone
SGLT2 inhibitors- flozins e.g. dapaglifozin
DPP4 inhibitors- gliptins e.g. sitagliptin

39
Q

What of the additional medications for diabetes cause weight differences?

A

Sulfonylurea- weight gain
SGLT2 inhibitors- weight loss
DPP4 inhibitors- weight neutral

40
Q

If HbA1c stays above 58…?

A

Triple therapy or insulin
Use insulin if BMI less than 35 (causes weight gain)
Use GLP1 agonist if BMI >35 e.g. exenatide

41
Q

What are the risk factors for chronic kidney disease?

A

Hypertension, DM, RAS, glomerulonephritis, adult PKD, SLE

42
Q

What are the different stages of CKD?

A

Stage 1- greater than 90ml/min with some signs of kidney disease on other tests (abnormal U&Es, proteinuria, haematuria)

Stage 2- 60-90ml/min

Stage 3a- 45-59 ml/min
Stage 3b- 30-44

Stage 4- 15-29ml/min- a severe reduction in kidney function

Stage 5- <15ml/min- established kidney failure, dialysis or kidney transplant may be needed

43
Q

What is the management of CKD?

A

Treat reversible causes
Limit progression/ complications- target BP 130/80, renal osteodystrophy, CVD
Symptom control- anaemia, oedema, restless legs
Refer to nephrology when eGFR <30
Give stain and antiplatelet
Avoid foods with high K+ or phosphate

44
Q

What are the characteristic features of asthma?

A
  1. Airflow limitation which is usually reversible spontaneously or with treatment
  2. Airway hyper-responsiveness to a wide range of stimuli
  3. Inflammation of the bronchi
45
Q

What are the symptoms of asthma?

A 
Wheeze
SOB
Chest tightness
Cough
Symptoms are variable, intermittent, worse at night and in the morning and/or provoked by triggers e.g. exercise, pollen
46
Q

What are the symptoms of severe asthma vs life-threating asthma?

A

Severe asthma- Unable to complete sentences, intercostal recession, PEFR <50%, RR <25, HR >110

Life-threatening- Central cyanosis, silent chest, confusion or exhaustion, PEFR <33%, hypotension, bradycardia

47
Q

What are the investigations for asthma?

A 
PEFR
Spirometry
CXR
Trial of B-agonists
Trail of steroids
48
Q

What is step-wise management for asthma?

A

Step 1- SABA (salbutamol)
Step 2- SABA + low-dose ICS (budenoside)
Step 3- SABA + ICS + leukotriene receptor agonist (Montelukast)
Step 4- SABA + ICS + Montelukast + MART (Maintenance and reliever therapy- combination of ICS and LABA)
Step 5- SABA +/- Montelukast + medium-dose MART
Step 6- SABA +/- Montelukast + ICS increased dose. Trail of long-acting muscarinic receptor antagonist or theophylline

Refer for specialist care

49
Q

What is the management of an acute asthma attack?

A

Give O2
Nebulised salbutamol
Nebulised ipratropium bromide
Oral predisolone

50
Q

What is the difference between Type 1 and Type 2 respiratory failure?

A

Type 1- hypoxia with a normal or low CO2
PaO2 <8kPa
“Blue bloater- chronic bronchitis- chronic, productive cough, purulent sputum, haemoptysis, cyanosis, obese”

Type 2- hypoxia and hypercapnia PaCO2 >6kPa
“Pink puffer- emphysema- dyspnoea, minimal cough, pink-skin, pursed breathing, accessory muscle use, cachexia”

51
Q

What are the causes of type 1 vs type 2 resp failure?

A

Type 1- COPD, pneumonia, asthma, pneumothorax, pulmonary oedema

Type 2- COPD, severe asthma, drug OD, myasthenia gravis, polyneuropathy, poliomyelitis

52
Q

What are risk factors for a DVT?

A

> 60, prior DVT, surgery, obesity, malignancy, prolonged travel, immobility, pregnancy, FH, COCP and HRT, dehydraion

53
Q

What are the clinical features of a DVT?

A

Limp pain and tenderness along the deep veins
Unilateral oedema
Distension of superficial veins
Hot, red leg

54
Q

What are the investigations for DVT?

A

Wells score
USS
D-dimer

55
Q

What is the management of DVT?

A

LMWH
Warfarin
NOAC
Fondaparinux

56
Q

How does warfarin work? What are some side effects?

A

Inhibits vitamin K
Stops production of clotting factors II, VII, IX, X and protein C

SE- haemorrhage, teratogenic, skin necrosis, purple toes

CI- NSAIDS, SSRIs, allergy, haemorrhage, pregnancy

Antidote- Vitamin K

57
Q

How do NOACS work? What are some side effects?

A

Rivaroxaban, apixaban
Direct Xa inhibitor

SE- bleeding and anaemia, dizzy spells, headache and syncope, N&V

CI- severe renal impairment, pregnancy, lactation

Antidote- beriplex

58
Q

What are some side effects of LMWH? What is the antidote?

A

SE- thrombocytopenia, bleeding, osteoporosis

CI- severe thrombocytopenia, when you can’t monitor regularly

Antidote= protamine sulphate

Phase 3a AW (7 decks)

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