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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
What is the chronic management of COPD?
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
What causes T1DM?
Autoimmune destruction of insulin-producing beta cells of pancreatic islets of Langerhans-> absolute insulin deficiency
27
What causes T2DM?
Diminished effectiveness of endogenous insulin/insulin resistance
28
What is the presentation of T1DM?
Weight loss, polydipsia, polyuria, acutely unwell with DKA
29
What is the presentation of DKA?
Abdo pain Vomiting Reduced consciousness level
30
What is the presentation of T2DM?
Incidental finding or polydipsia/polyuria
31
How is diabetes diagnosed in a symptomatic and asymptomatic patient?
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
What is impaired fasting glucose?
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
What needs to be checked annually in a T1DM patient?
BP, renal function, eye check, foot check | Target HBA1C <48
34
What is the target HBA1C in a T2DM patient?
Target BP <140/80mmHg OR 130/80 if end-organ damage Give Atorvastatin if Q risk is >10%
35
What are 1st line intervention in T2DM?
Dietary advice, 5-10% weight loss advised in an overweight person Smoking cessation
36
What if HbA1c remains above 48 after lifestyle interventions?
give metformin- increases hepatic gluconeogenesis and GI absorption of CHO
37
What are the positives and negative of metformin?
+ Weight neutral - GI upset, risk of lactic acidosis if impaired renal function CI- recent tissue hypoxia
38
If HbA1c remains >58 after metformin, what are the options?
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
What of the additional medications for diabetes cause weight differences?
Sulfonylurea- weight gain SGLT2 inhibitors- weight loss DPP4 inhibitors- weight neutral
40
If HbA1c stays above 58...?
Triple therapy or insulin Use insulin if BMI less than 35 (causes weight gain) Use GLP1 agonist if BMI >35 e.g. exenatide
41
What are the risk factors for chronic kidney disease?
Hypertension, DM, RAS, glomerulonephritis, adult PKD, SLE
42
What are the different stages of CKD?
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
What is the management of CKD?
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
What are the characteristic features of asthma?
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
What are the symptoms of asthma?
``` 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
What are the symptoms of severe asthma vs life-threating asthma?
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
What are the investigations for asthma?
``` PEFR Spirometry CXR Trial of B-agonists Trail of steroids ```
48
What is step-wise management for asthma?
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
What is the management of an acute asthma attack?
Give O2 Nebulised salbutamol Nebulised ipratropium bromide Oral predisolone
50
What is the difference between Type 1 and Type 2 respiratory failure?
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
What are the causes of type 1 vs type 2 resp failure?
Type 1- COPD, pneumonia, asthma, pneumothorax, pulmonary oedema Type 2- COPD, severe asthma, drug OD, myasthenia gravis, polyneuropathy, poliomyelitis
52
What are risk factors for a DVT?
>60, prior DVT, surgery, obesity, malignancy, prolonged travel, immobility, pregnancy, FH, COCP and HRT, dehydraion
53
What are the clinical features of a DVT?
Limp pain and tenderness along the deep veins Unilateral oedema Distension of superficial veins Hot, red leg
54
What are the investigations for DVT?
Wells score USS D-dimer
55
What is the management of DVT?
LMWH Warfarin NOAC Fondaparinux
56
How does warfarin work? What are some side effects?
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
How do NOACS work? What are some side effects?
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
What are some side effects of LMWH? What is the antidote?
SE- thrombocytopenia, bleeding, osteoporosis CI- severe thrombocytopenia, when you can't monitor regularly Antidote= protamine sulphate

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