GP Flashcards
After how many days do you give a sick note?
6 days
Who should be treated for hypertension?
BP over 160/100
Or over 140/90 with:
Diabetes
End organ damage: past stroke, MI, angina, peripheral vascular disease, LVH
Cardiovasc risk
What indicates end organ damage in hypertension?
Rx if BP over 140/90 if
Heart: LVH, past MI or angia
Vessels: stroke, TIA, peripheral vascular disease
Kidney disease
45 year old man has BP of 165/103 and low K+.
Likely cause?
Secondary hypertension due to Conn’s
Hyperaldoesteronism from adrenals
What are the grades of hypertensive retinopathy?
1- silver wiring (tortuous thick walled arteries)
2- AV nipping
3- flame haemorrhage + cotton wool spots
4- papilloedema
What is considered stage 1 and stage 2 HTN with ambulatory BP?
Take off 5/5 from clinic readings so
Stage 1 > 135/85
Stage 2 > 150/95
What viruses can cause a LRT symptoms along side the common cold?
Particularly in children and older adults
Respiratory syncytial virus + parainfluenza (bronchiolitis + croup)
= bronchitis (phlegm + wheeze), bronchiolitis or pneumonia
Commonest cause of URTI?
Common cold
Rhinovirus
How can you investigate a patient with the flu to confirm your clinical diagnosis?
Serology- takes 2 weeks
Culture- nasopharyngeal swab takes 1 week
PCR- quick
What can you give to children with the flu?
Oseltamivir PO
Can cause GI upset, stevens-Johnson
Given if symptoms started in last 48 hours
When might you consider giving Oseltamivir prophylactically for someone coming into contact with the flu?
If
HLA associated with type 1 diabetes?
DR3
3 Little Pigs + a Straw Shack
liver- autoimmune hepatitis
pancreas- type 1 DM
Sjogrens, SLE
Which is more associated with progression to diabetes:
Impaired fasting glucose (between 6-7)
Or Impaired glucose tolerance (between 7.8-11)
Impaired glucose tolerance
Drug causes of diabetes?
Steroids
Anti-HIV drugs
Anti-psychotics- clozapine, atypicals
Thiazides
Which auto-antibodies may be found in type 1 diabetes?
Islet cell antibodies
Glutamic acid decarboxylase
BP target if stroke, MI, retinopathy or microalbuminaemia?
130/80
Patient is on metformin, but HbA1c is above 53 after 16 weeks of it, how do you decide the next medication to add in?
BMI below 35: gliclazide
BMI above 35 or hypoglycaemia is an issue: gliptins (DPP4 inhibitors)
DPP4 breaksdown GLP1, a hormone that augments insulin release
Patient is taking metformin, gliclazide and after 6 months, HbA1c is still >57mmol
What are the options now?
Insulin
Or glitazone
How do you decide whether to give PCI or thrombolysis to someone with MI?
If patient can be at a PCI centre within 2 hours of first medical contact
After how long is fibrinolysis no longer worth giving to someone following an MI?
CI after 24 hours
CI to thrombolysis?
PC: Aortic dissection, cerebral malignancy or AV malformation,
LP or liver biopsy in last 24 hours
PMH: brain bleed, GI bleed (
If giving thrombolysis what should be given after the tissue plasminogen activator?
After alteplase/ reteplase/ tenecteplase
Unfractionated heparin infusion
What features should be present to warrant giving clopidogrel in suspected NSTEMIs?
Chest pain with ECG changes- ST depression or raised troponin
What features in a patient would make you opt for an invasive approach in treating an NSTEMI? Aka that make them high risk so conservative approach won’t work?
- Rise in troponin
- Dynamic ST or T waves changes
- PMH: diabetes, CKD, angina post MI, LVEF
Rx of high risk patients with suspected NSTEMI?
Aspirin + clopidogrel
Fondaparinux
IV nitrate
High risk: GPIIb/IIIa infusion (tirofiban) + inpatient angiography
How soon should angiography be delivered in someone with ongoing pain and an NSTEMI?
- URGENT: if ongoing angina + evolving ST changes or signs of shock/life threatening arrhythmias = within 2 hours
- EARLY: if high risk patient with GRACE score >140 = within 24 hours
- If lower risk patient = within 72 hours
Which features are associated with the worst prognosis in NSTEMI?
Age > 70
PC: ST depression or widespread T wave inversion
Raised troponin
PMH: unstable angina, previous MI, poor LV function, DM
Causes of angina that are not from atheroma?
Aortic stenosis, HOCM
Arteritis
Anaemia
Tachyarrhythmias
How does management differ between Prinzmetal angina (due to coronary artery spasm) and angina pectorus?
Prinzmetal- aggravated by aspirin, treat with calcium channel blockers ± long acting nitrates
CI to beta-blockers in angina?
Asthma, COPD
LVF, bradycardia
Coronary artery spasm (variant Prinzmetal angina)
Give diltiazem or verapamil instead
What can be given as prophylaxis against angina?
Regular oral nitrate or slow-release nitrate
What are the pro’s and cons of stenting vs percutaneous transluminal coronary angioplasty Vs medical therapy?
PTCA controls symptoms better than drugs but has a higher rate of cardiac events (MI)
Stenting reduces restenosis rates and need for CABG compared to PTCA
How can the risk of coronary artery disease (CAD) be used to stratify choice of imaging to confirm diagnosis?
> 90% assume CAD
60-90% angiography (aka women over 70, without RFs)
30-60% functional imaging (stress echo, MRI, scintigraphy)
10-30% CT- coronary artery calcification score
Which types of troponin are most sensitive and specific for myocardial necrosis?
T and I
Someone has had an NSTEMI, when would you give Fondaparinux and when LMWH?
Low bleeding risk, no angiography planned for 24 hours: fondaparinux
High bleeding risk or angiography planned within 24 hours: LMWH
In patients with an anterior MI what additional medication should be considered?
Warfarin to protect against a LV mural thrombus causing a thromboembolism
Patient with an MI is taking statin, ACEi, b-blocker and clopidogrel. On an ECG you notice the PR interval is 6 squares long and occasionally a dropped beat, what should you change?
Stop b-blocker = 2nd degree AV block
After MI’s some patients develop ventricular tachycardia, how long does it need to go on for to be sustained vs non-sustained?
30 seconds
Non-sustained: do electrophysiological studies if after 48 hours of MI
Sustained: DC shock or amiodarone if stable
Rx for pericarditis?
NSAIDs
Saddle shaped ST elevation
After an MI a patient presents with angina and persistent St elevation. Likely diagnosis and Rx?
LV aneurysm
Anticoagulate + consider excision
Rx for Dressler’s syndrome: pericarditis, fever, pleural effusions 1-3 weeks post MI
NSAIDs + steroids if severe
IHx for a patient who has an MI and develops a raised JVP and low cardiac output/failure?
Echo
Can diagnose RV failure, ventricular septal defect, cardiac tamponade
Name for oesophageal rupture caused by vomiting?
Boerhaave syndrome
During an endoscopy a patient becomes short of breath and BP drops, a crackling sensation is felt on palpation of the neck. Diagnosis + Rx?
Oesophageal rupture- surgical emphysema
As iatrogenic cause, conservative management of:
Antibiotics, PPIs + NG tube
Primary sclerosing cholangitis predisposes you to what kind of cancer?
Adenocarcinoma of bile duct + gallbladder
Associated with ulcerative colitis
What would prompt an ABG in asthma?
When sats drop below 92%
What rx do you add in for asthma treatment in adults if life-threatening?
More regular salbutamol (check ECG for arrhythmias)
Ipratropium NEB
Magnesium sulphate IV
What features indicate asthma on a peak flow diary?
Diurnal variation of >20% (between morning and evening) on 3 days a week for 2 weeks
What change in spirometry results would you expect in someone taking b2 agonists who was asthmatic?
15% improvement in FEV1
Which vasculitis are associated with asthma?
Name 2
- Churg Strauss (eosinophilia + vasculitis- looks like sepsis)
- Polyarteritis nodosum (rash + ulcers + renal disease)
Kawasaki is a version of which vasculitis?
Polyarteritis nodosum
Signs of aminophylline toxicity (used for asthma)?
Fits
GI upset
Arrhythmia
Clinical definition of chronic bronchitis?
Cough + sputum most days of 3 months for 2 successive years
Which are the different dangers faced by being a pink puffer with COPD or a blue bloater?
Pink puffer- breathless not cyanosed, risk type 1 respiratory failure (low O2)
Blue bloater- cyanosed not breathless, risk cor pulmonale from CO2 retention + polycythaemia
What is the pKa of oxygen that makes someone eligible for long term oxygen therapy in COPD, assuming they are not currently smoking?
7.3pKa
Despite O2 therapy
Measurements taken 3 weeks apart
When can someone have long term oxygen therapy (15hr a day for benefit) for their COPD if their pO2 is between 7.3-8kPa?
If they also have: pulmonary hypertension (RVH, loud S2) Polycythaemia Peripheral oedema Nocturnal hypoxia
Patient is on long term oxygen therapy and hypercapnic. What might you consider?
Non-invasive ventilation
How many pack years makes COPD less likely?
Under 10
What parameters of a patient’s COPD would make air travel risky?
FEV1
Which organisms occur commonly in hospital acquired pneumonia? (Within 48 hours)
G -ve enterobacteria or staph aureus
Pseudomonas, klebsiella, bacteroides, clostridia
A patient has a pneumonia, what features would prompt you to do an CXR to see if it is persisting at all?
CRP or persistent symptoms
Which conditions require re-vaccination with the pneumococcal vaccine after 6 years?
Conditions where pneumococcus could be fatal:
Nephrotic syndrome, post renal transplant
Asplenia, sickle cell
What type of influenza is responsible for avian flu?
H5N1 strain of Influenza A
When would you think about transferring a patient with pneumonia to ITU?
If O2 sats not improving with O2
If kPa of CO2 rose above 6kPa (type 2 resp failure)
Patient with resolving pneumonia develops recurrent fevers, what would you expect you might drain on pleural fluid aspiration and the features of this aspirate?
Empyema-
Yellow turbid fluid
Low pH
Why do people get bronchiectasis?
Permanent dilatation of airways from chronic infection
Congenital: CF, primary ciliary dyskinesia etc
Post infection: measles, pertussis, penumonia, TB
Patient has wet cough for a long time, haemoptysis, coarse creps. Likely diagnosis and IHx?
Bronchiectasis (secondary to post-infection, obstruction or congenital)
IHx: sputum culture
CXR
Definitive: High res CT chest
Additional: bronchoscopy to look for obstruction, get culture samples and find haemoptysis site
In patients with cystic fibrosis what easy and non-invasive test can be used to screen for exocrine pancreatic dysfunction?
Faecal elastase
