GP 2 Flashcards
What are the differentials of an irregular rhythm on ECG?
AF
Sick sinus syndrome
Ventricular ectopics
Heart block
What is acute AF and what are the causes of it?
Onset within 48 hours
May be precipitated by acute infection, high alcohol intake, surgery, MI, pericarditis, PE or hyperthyroidism
What are the causes of chronic AF?
No cause Hypertension Coronary heart disease Cardiomyopathy Valvular heart disease
What are the symptoms in AF and what investigations would you do?
Symptoms- Palpitations, chest pains, stroke/TIA, dyspnoea, fatigue, lightheadedness, and/or syncope
Investigations- ECG, ECHO, Bloods, CXR
What are the 2 approaches to treatment?
Rhythm control and rate control
What is involved in rhythm control?
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
What is involved in rate control?
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
When would you consider anti-coagulation in treatment of AF?
In all rate control strategies
In rhythm control strategies prior to cardioversion
What score is used to make the decision about anti-coagulation in AF?
CHADSVASC
This is the risk of stroke in patients with AF
Consider AC in men with 1 point, and women with 2 points
What anticoagulation would be considered in AF?
Warfarin or NOAC e.g. apixaban, rivaroxaban
What is the antidote to a NOAC?
Beriplex
What is the HAS-BLED score?
The risk of major bleeding in AF with oral anticoagulation
What is HAS-BLED?
Hypertension
Abnormal renal function or liver function
Stroke history
Bleeding predisposition
Labile INRs
Elderly
Drugs predisposing to bleeding or alcohol
What are the 3 features of angina?
- Episodic central crushing chest pain or band-like chest pain that may radiate to the jaw/neck and/or one or both arms
- Precipitated by physical exertion, cold, emotion and/or heavy meals
- Releived by rest or GTN in about 5 mins
3/3 typical angina
2/3 atypical angina
1/3 non-anginal pain
What investigations should you do for a patient with angina?
Bloods- fasting lipid profile, having blood glucose, ESR, TFTs
12 lead resting ECG
What is the management in angina?
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
What is the risk of combining a BB and rate-limited CCB e.g. verapamil?
Risk of bradycardia/stroke
What is secondary management of angina?
Statin
Aspirin (all patients should have statin and aspirin)
Ace inhibitors
What are the risk factors for COPD?
Smoking
Occupational disease
Air pollution
A1AT deficiency
What are the symptoms of COPD?
SOBOE Chronic cough with sputum Wheeze Bronchitis Apnoea Fatigue Weight loss Haemoptysis Recurrent infections
What would show on spirometry for COPD?
FEV1/FVC <0.7 and FEV1 <70% predicted and <15% reversibility to a reversible test
What other investigations can be done in COPD?
CXR and FBC PHQ9 O2 sats ECG and ECHO Sputum culture
What scale is used in COPD?
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
What is the acute management of COPD?
Increase dose of SABA/ SAMA
Oral corticosteroids for 1-2 weeks
Antibiotics if purulent sputum- amoxicillin usually
O2 if FEV1 <30%
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
What causes T1DM?
Autoimmune destruction of insulin-producing beta cells of pancreatic islets of Langerhans-> absolute insulin deficiency
What causes T2DM?
Diminished effectiveness of endogenous insulin/insulin resistance
What is the presentation of T1DM?
Weight loss, polydipsia, polyuria, acutely unwell with DKA
What is the presentation of DKA?
Abdo pain
Vomiting
Reduced consciousness level
What is the presentation of T2DM?
Incidental finding or polydipsia/polyuria
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
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
What needs to be checked annually in a T1DM patient?
BP, renal function, eye check, foot check
Target HBA1C <48
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%
What are 1st line intervention in T2DM?
Dietary advice, 5-10% weight loss advised in an overweight person
Smoking cessation
What if HbA1c remains above 48 after lifestyle interventions?
give metformin- increases hepatic gluconeogenesis and GI absorption of CHO
What are the positives and negative of metformin?
+ Weight neutral
- GI upset, risk of lactic acidosis if impaired renal function
CI- recent tissue hypoxia
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
What of the additional medications for diabetes cause weight differences?
Sulfonylurea- weight gain
SGLT2 inhibitors- weight loss
DPP4 inhibitors- weight neutral
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
What are the risk factors for chronic kidney disease?
Hypertension, DM, RAS, glomerulonephritis, adult PKD, SLE
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
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
What are the characteristic features of asthma?
- Airflow limitation which is usually reversible spontaneously or with treatment
- Airway hyper-responsiveness to a wide range of stimuli
- Inflammation of the bronchi
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
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
What are the investigations for asthma?
PEFR Spirometry CXR Trial of B-agonists Trail of steroids
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
What is the management of an acute asthma attack?
Give O2
Nebulised salbutamol
Nebulised ipratropium bromide
Oral predisolone
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”
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
What are risk factors for a DVT?
> 60, prior DVT, surgery, obesity, malignancy, prolonged travel, immobility, pregnancy, FH, COCP and HRT, dehydraion
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
What are the investigations for DVT?
Wells score
USS
D-dimer
What is the management of DVT?
LMWH
Warfarin
NOAC
Fondaparinux
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
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
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
