gp 3B Flashcards
list some risk factors for non alcoholic fatty liver disease
METABOLIC SYNDROME- obesity, hypertension, diabetes, hypertriglyceridaemia, hyperlipidaemia
secondary to drugs (NSAIDS, corticosteroids, methotrexate), PCOS, hypothyroidism, hep C virus
Name the stages of non alcoholic fatty liver disease
steatosis–> steatohepatitis–> fibrosis–> cirrhosis
insulin resistance leads to build up of fat in liver cells, causes inflammation (steatohepatitis), stellate cells lay down fibrous tissue, and eventually whole architecture of liver is changed (cirrhosis)
signs and symptoms NAFLD
Typical blood test pattern
often asymptomatic and picked up incidentally on blood tests
fatigue and malaise. significant damage- hepatomegaly, jaundice, RUQ pain, ascites
LFTs- AST and ALT raised persistently for 3 months
Bigger rise in ALT (L= liver, L=lipids)
(in alcoholic hepatitis AST more raised (s= shit loads of alcohol)
management of NAFLD
steatosis and steatohepatits reversible
- reverse factors causing insulin resistance- diet, exercise, medication to control blood glucose
- optimise hypertension, hyperlipidaemia, diabetes management
fibrosis and cirrhosis irreversible
- need for specialist surveillance for hepatocellular cancer (ultrasound scans and AFP
- liver transplant
diagnosis of NAFLD
LFTs
ultrasound scan
biopsy and fibroscan (transient elastography)
complications of NAFLD
direct liver complications- portal hypertension, variceal haemorrhage, liver failure, hepatocellular carcinoma, sepsis
metabolic complications- hypertension, CKD, impaired glucose regulation, diabetes type 2
likely cause of LTF results:
raised AST> ALT
AST- Cirrhosis or alcohol (Shit loads of alcohol)
likely cause of LTF results:
Raised ALT> AST
ALT- acute or chronic liver disease (L=liver specific)
likely cause of LTF results:
raised ALP> ALT
ALP- cholestasis (plug)
likely cause of LTF results:
raised ALT> ALP
ALT - hepatocellular injury
likely cause of LTF results:
ALP raised, GGT normal
ALP, normal GGT- likely bone cause (bp, no GGT in bone)
check calcium
bony mets, primary bone tumour, vit d deficiency, recent bone fracture
likely cause of LTF results:
ALP and GGT raised
ALP and GGT- likely liver cause
causes of acute hepatocellular injury
paracetamol overdose
infection- hep a, hep B
liver ischaemia
causes of chronic hepatocellular injury
alcoholic fatty liver disease
NAFLD
chronic infection (hep B/ C)
primary biliary cirrhosis
(alpha 1 antitrypsin deficiency, wilsons disease haemochromatosis
what are the BMI cut off points
Healthy weight- 18.5-24.9 overweight 25-29.9 obesity 1- 30-34.9 obesity 2 35-39.9 obesity 3- 40 or more
what is the recommended amount of exercise people should do a week
30 mins 5 days a week. activities can be in 10 min bursts. 2x weight bearing sessions
summarise the management of type 1 diabetes
- INSULIN- 2x daily background medium acting insulin and pre-meal quick acting insulin
- monitor blood glucose to determine pre-meal insulin
- measure carbohydrate intake
- awareness of blood glucose lowering effect of exercise
- DAFNE- insulin treatment education programme- dose adjustment for normal eating
summarise the management of type 2 diabetes
lifestyle- exercise, diet, weight loss
medication to conrol BP< blood glucose, lipids
identification and prevention of long term microvascular complications
1st line drug treatment- metformin
- opposes insulin resistance
- modest improvement in HbA1c
- no weight gain
- reduces cardiovascular risk
side effects and risk of metformin
diarrhoea, N+V, abdo pain
risk of lactic acidosis if renal function impaired- do not prescribe if eGFR < 30
routine clinical investigations for tired all the time
FBC ESR and CRP LFTs U+E TFT glucose/ HbA1c IgA TTB (coeliac)
what is the risk of using sulphonylurea to treat DM type II
hypoglycaemia
weight gain
how should pain management be stepped up in a dying patient
WHO analgesic pain ladder
1) non opioid analgesics- NSAIDs, paracetamol
2) weak opioids- cocodamol, codeine, tramadol
3) strong opioids-morphine, fentanyl, methadone, oxycodone
what should be prescribed with an opioid
laxatives
softening- docusate
stimulant- senna, bisacodyl
opioid toxicity signs
drowsiness, myoclonic jerks, itching, pinpoint pupils, confusion, agitation, cognitive impairment, hallucinations, vivid dreams, respiratory depression
main symptoms to control in dying patient
N+V breathlessness respiratory secretions pain agitation
what anti-emetic should be used in a patient with parkinsons
domperidone- doesn’t cross BBB so cant cause extrapyramidal side effects
5 reversible/ treatable causes of nausea and vomiting
drugs- opioids, PPIs, NSAIDs, SSRIs, antibiotics (stop drug)
pain- analgesia
anxiety- explore fears, anxiolytic- lorazepam
constipation- laxatives
raised ICP- dexamethasone
electrolyte disturbances
infection- antibiotic
bowel obstruction- surgery, steroids, antiemetics
Suitable antiemetic for chemical/ drug causes of N+V
haloperidol- inhibits chemoreceptor trigger centre
suitable antiemetic for gastric stasis
metoclopramide (pro-kinetic agent)
antiemetic used in chemotherapy
ondansetron
what is the DS1500 form?
form for immediate release of certain funds eg disability living allowance, incapacity benefts etc, for a patient with a terminal illness
fast track to certain welfare benefits
pre- emptive medication prescribed for ‘death rattle’
hyoscine butylbromide
main locations lung cancer metastases to
bone brain liver lymph nodes adrenal glands
4 main features of CXR suggesting lung cancer
hilar enlargement
peripheral opacity (visible lesion in lung field
pleural effusion- usually unilateral
lobar collapse
presentation of AF
asymptomatic irregularly irregular pulse syncope/ dizziness breathlessness palpitations chest discomfort TIA/ stroke
pathology of AF
irregular atrial rhythm between 300-600bpm.
The AV node is unable to transmit beats as quickly as this, and thus does so intermittently, resulting in an irregular ventricular rhythm.
This irregular stimulation of the ventricles reduces cardiac output by up to 20%, as well as allowing stasis of blood in the heart chambers.
causes of AF
cardiac- hypertension, heart failure, MI, valve disease, congenital heart disease
pulmonary- PE, pneumonia, bronchocarcinoma
other- alcohol, hyperthyroidism, sepsis, hypokalaemia, hypermagnesaemia
ECG findings in AF
irregular QRS complexes/ R-R intervals
absent P waves
investigations of AF
ECG
bloods- U+Es, TFTs, cardiac enzymes
echo- structural abnormalities
management of acute AF
emergency electro-cardioversion if haemodynamically unstable
if haemodynamically stable
-rate control- betablockers, then digoxin
-rhythm control- pharmalogical cardioversion (amiodarone, flecainide)
anticoagulation- heparin
management of chronic AF
rate control
- betablocker (CCB if asthma) 1st line
- digoxin monotherapy only if sedentary
- combination therapy (betablocker, digoxin, diltaziem) if uncontrolled
rhythm control
- if symptoms continue after rate control
- cardioversion- electrical/amiodarone
pace and ablate strategy
- left atrial ablation
- if permanent atrial fibrillation with symptoms or left ventricular dysfunction thought to be caused by high ventricular rates.
assess stroke and bleeding risk
stop smoking, limit caffeine and alcohol
how to assess stroke risk in AF
CHA2DS2 VASc
1 year risk of stroke
congestive heart failure hypertension age >75 diabetes stroke/ TIA/ TE Vascular disease age 65-75 sex (female)
1- low- moderate risk, consider antiplatelet or anticoagulation
2+ moderate-high risk- start anticoagulant
how to assess the risk of bleeding in those starting anticoagulation for AF
HASBLED
risk of major bleeding for patients on anticoagulant
Hypertension abnormal liver/ renal function stroke bleeding history/ predisposition labile INR elderly >65 drugs/ alcohol
3+ high risk of bleeding
if patients were at a high risk of stroke, how could this be managed?
anticoagulation
apixaban, rivaroxaban, warfarin, dabigatran
risk of stroke following TIA
ABCD2 score
age >60 BP > 140/90 clinical features- unilateral weakness (2), speech difficulties (1) duration (>60 mins (2), 10-59 min (1) ) diabetes
definition of CKD
reduction in kidney function or structural damage (or both) present for more than 3 months, with associated health implications.
- eGFR <60mL/min
- > 3 months
- evidence of structural/ functional abnormalities: proteinuria, ultrasound, biopsy, U+Es
risk factors of CKD
diabetes hypertension smoking AKI chronic use of NSAIDS Cardiovascular disease
causes of CKD
diabetes
pre-renal- renal artery stenosis
renal- diabetic nephropathy, hypertension, glomerulonephritis, myeloma, polycystic kidney disease
post renal- urinary obstruction (enlarged prostate, stone, neurogenic bladder, constipation)
presentation of CKD
asymptomatic
Ureamic state: anorexia loss of appetite nausea oedema muscle cramps peripheral neuropathy pallor hypertension nocturia and polyuria restless legs amenorrhoea
who to screen for CKD
diabetes hypertension cardiovascular disease structural renal disease recurrent UTIs SLE FHx
investigations of CKD
UEs –> eGFR
eGFr- 2 tests 3 months apart
urine dipstick- haematuria/ proteinuria
FBC- normochromic, normocytic anaemia- anaemia oc CKD (decreased erythropoietin production
early morning urine sample- albumin creatine ratio
BMI, glucose, lipid, BP profile
renal tract ultrasound
kidneys often small
CKD complications
ABCDEF
Anaemia
blood pressure
calcium phosphate loading + cardiovascular disease
vit D- poor bone metabolism- renal bone disease
electrolyte derangements- acidosis, hyperkalaemia
fluid overload- pulmonary oedema
management of CKD
identify and treat reversible causes
limit progression/ complications
-BP- ACE-I
-renal bone disease- check PTH, vit D analogues and calcium supplements
-cardiovascular risk- statin, aspirin
-diet- mdt involvement
symptom control
-anaemia- give iron/ b12/ folate and human epo
-acidosis- give sodium barcarbonate
-oedema- loop diuretics, fluid and sodium restriction
renal replacement therapy
red flags of a vomiting child
not keeping down any food- pyloric stenosis, intestinal obstruction
-projectile vomiting- pyloric stenosis
-bile stained vomit- intestinal obstruction
-haematemesis or melaena- peptic ulcer, oesophagitis
-abdo distension- intestinal obstruction
-reduced consciousness, bulging fontanelle, neurologic signs- meningitis
-respiratory symptoms- aspiration, infection
blood in stool- gastroenteritis, cow milk protein allergy
-rash, angioedema- cows milk protein allergy
common causative agents of gastroenteritis
norovirus, rotavirus, ecoli, salmonella
signs and electrolyte disturbance of pyloric stenosis
projectile vomiting, no bowel movements
olive shaped mass RUQ, peristaltic waves L-R dehydration
metabolic alkalosis- hypochloraemic, hypokalaemic
management: correct electrolyte disturbances. Pylomyotomy
premature baby, distended stomach, vomited, temperature, refusing feeds, green vomit, fresh blood in stools
likely diagnosis
nec- necrotising enterocolitis
diagnosis: transilumination of abdo
AXR: distended loops of bowel, thickened bowel wall, intramural gas, gas in portal venous tract
signs of appendicitis
colicky pain getting worse vomiting pain moving across abdo pain relieved by lying still pyrexic tenderness and guarding
abdo ultrasound- thickened non-compressible appendix with increased blood flow
management of GORD
small frequent meals
burping regularly to help milk settle
not over feeding
keep baby upright after feeding
if problematic cases (chronic cough, hoarse cry, distress, reluctance to feed, poor weight gain
- Gaviscon mixed with feeds
- thickened milk formula
- ranitidine- histamine 2 blocker- recued amount of acid stomach produces
risk factors of cows milk protein allergy
atopy
formula fed
<1yo
clinical features of IgE mediated cows milk protein allergy
symptoms within 2 hrs of milk consumption
• Skin reactions including itching, erythema, urticaria and acute angioedema
• Colicky abdominal pain, nausea, vomiting and diarrhoea
• Nasal itching, sneezing, rhinorrhoea and congestion
• Cough, chest tightness and wheeze
• Anaphylaxis can occur but is extremely rare
clinical features of non- igE mediated cow milk protein allergy
symptoms up to a week after ingestion
• Atopic eczema, itching and erythema
• Colicky abdominal pain, reflux, blood or mucus in stool, constipation or diarrhoea
• Cough, wheeze, breathlessness or chest tightness
• Tiredness, weight loss and faltering growth
management of cows milk protein allergy
-skin prick/ blood test for IgE
-trial exclusion of cows milk (exclude from mums diet of breast fed)
-hydrolysed milk formula
-paediatric dietician
-remission rate high- challenge every 6-12 months
milk alternatives- avoid soya (common allergen), others can be used age 2yo+
what is lactose intolerance
inability to digest lactose due to lack of enzyme lactase. problem of older childhood and adults
bloating, diarrhoea, gas
not an allergy
presentation of cluster headache
management
disabling, rapid onset excruciating pain around one eye blood shot, lid swelling, miosis, ptosis, lacrimation unilateral pain worse at night can wake person up attacks last 15-90 mins, can have several in day bouts can go on for months, then relapse
management
ACUTE- 200% o2 and sumitriptans
prophylaxis- verapamil
presentation of trigeminal neuralgia
Asian male >50 paroxysms of intense stabbing pain, lasting seconds unilateral face screws up with pain electric shock in jaw/teeth/gums triggers eg washing hair, brushing teeth
management: carbamazepine
presentation of migraine
management
vomiting photophobia aura triggers FHx
management
- acute- triptans, nsaids, paracetamol, anti emetics
- chronic- propranolol, topiramate
presentation of GCA
> 50 headache, lasting a few weeks
tender thickened pulseless temporal arteries
jaw claudication
ESR >40
treatment: steroids
metabolic causes of itch
chronic renal failure and dialysis, liver disease, cholestasis
-uraemic pruritic
haematological causes of itch
iron deficiency anaemia- do FBC (glossitis, angular cheilitis)
polycythaemia rubravera- itching after hot bath. Red face, splenomegaly, burning sensation in fingers and toes, dizziness tinnitus (JAK2 mutation)
endocrine causes of itch
graves disease
diabetes mellitus- increased risk of candida infection
paraneoplastic causes of itch
lymphoma (not usually leukaemia)
especially hodgkins lymphoma
Presentation of seborrheic dermatitis
management
chronic relapsing remitting
scalp, face and trunk
oily skin, psoriasis, immunosuppression, stress
oily and dry skin, scaly patches, scaly red eyelid margins (blephitis), flaky patches around hair line, salmon pink think scaly patches
Mx- antifungal- ketoconazole
investigating systemic causes of itch
fbc esr serum ferritin WCC FBC LFTs renal function and electrolytes thyroid function tests
signs of drug dependency syndrome
craving
difficulty controlling substance use
withdrawal state
tolerance
progressive neglect of pleasures and interests
persistent use despite clear evidence of harmful consequences
guilt, keeping drug use secret, arguments
