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4th Year CCC > GP > Flashcards

GP Flashcards

1
Q

What to do with adult with high probability asthma?

A

Trial of treatment

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2
Q

What to do with adult with intermediate probability of asthma?

A

FEV1/FVC <0.7 –> trial of treatment

FEV1/FVC >0.7 –> futher investigation/referral

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3
Q

Adult with suspected asthma

A

Clinical assessment including spirometry (or PEF if not available)

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4
Q

Zones of peak flow?

A 
Green = 80-100% of usual - good control
Yellow = 50-79% of usual - caution, additional medication
Red = <50% of usual - medical emergency, immediate action needs to be taken
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5
Q

Adults asthma ladder?

A

Step 1 = SABA + ICS (200-800 mcg)

Step 2 = Add a LABA. if response, continue. Benefit but not complete –> increase ICS to 800. No response –> stop LABA, increase ICS to 800, consider other treatments)

Step 3 = Increase ICS (2000 mcg) or add a fourth drug (LTRA, theophylline, beta agonist tablet)

Step 4 = add daily steroid tablet, conisder other treatments, refer for specialist care

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6
Q

When should you consider moving up the adult ladder?

A

If using SABA 3x per week

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7
Q

Kids asthma ladder?

A

Step 1 = SABA + very low dose ICS (200-400 mcg) or LTRA if <5

Step 2 = Add a LABA. if response, continue. Benefit but not complete –> increase ICS to low dose (400). No response –> stop LABA, increase ICS to 400, consider other treatments)

OR LTRA if <5

Step 3 = Increase ICS to medium dose (800 mcg) or add a fourth drug ( theophylline)

Step 4 = add daily steroid tablet, maintain medium dose ICS, consider other treatments, refer for specialist care

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8
Q

How do you step down treatment in asthma?

A

Consider every 3 months, 25-50% each time

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9
Q

Side effects of SABAs?

A

Tremor, headache, muscle cramps, palpitations, hypokalaemia

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10
Q

Side effects of ICS?

A

Oral candidiasis
Sore mouth
Dysphonia/hoarseness

Long term = osteoporosis, adrenal suppression

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11
Q

Doses of ICS for children?

A

> 12 = 200 mcg BD

5-12 = 100 mcg BD

<5 = 100 mcg BD (lower = 40 mcg BD)

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12
Q

Examples of combination inhalers? (LABA and ICS)

A

Symbicort = budesonide + formoterol

Seretide = fluticasone + salmeterol

Fostair = beclometasone + formoterol

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13
Q

Examples of LTRA?

A

Montelukast, zafirlukast

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14
Q

Complications and side effects of montelukast?

A

Associated with liver toxicity

Well tolerated and have few class-related adverse effects

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15
Q

Side effects of theophylline? How often should levels be taken?

A 
(At high plasma concentrations)
Nausea/Vom
Tremor
Palpitations
Arrhythmias

Every 6-12 months

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16
Q

Side effects of oral steroids?

A

(Long-term)

Osteoporosis
Hypertension
Diabetes
Hypothalamic-pituitary-adrenal axis suppression
Weight gain
Cataracts
Glaucoma
Skin thinning
Easy bruising
Muscle weakness
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17
Q

Self-management in asthma?

A

Education
Personalised asthma action plan (PAAP) - regular review
Trigger avoidance, smoke-free environment

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18
Q

Secondary prevention of asthma

A

Stopping smoking support
Weight loss support
Breathing exercise programmes (can improve QoL and reduce symptoms)

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19
Q

Signs and symptoms of AF?

A

Palpitations, tired/breathless, angina, ankle oedema, syncope, dizziness

Irregularly irregular pulse, loss of association between cardiac apex beat and radial pulsation

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20
Q

Diagnosis of AF?

A

ECG if irreg irreg pulse felt

If paroxysmal suspected –> 24 hour tape

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21
Q

ECG in AF?

A

No P waves
Chaotic baseline
Irregular ventricular rate

Rate often 160-180 but can be lower

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22
Q

Classifications of AF?

A

Paroxysmal = >2 episodes that terminae within 7 days

Persistent = >7 days of AF >48h in which decision made to perform cardioversion

Long standing persistent = consistent SF of >12 months duration

Permanent = decision made to cease attempts to restore sinus rhythm

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23
Q

Causes of AF?

A

Cardiac = hypertension, valvular, heart disease, heart failure, IHD

Resp = chest infections, PE, lung cancer

Systemic = alcohol, thyrotoxicosis, electrolyte depletion, infections, CKD

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24
Q

Investigations in AF?

A

TFTs, FBC, U&E, calcium, magnesium, glucose

TT echo if structural or functional heart disease suspected

CXR if lung pathology suspected

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25
Q

Criteria for urgent referral in AF?

A

Rapid pulse (>150) and/or low BP (<90 systolic)
LoC, severe dizziness, ongoing chest pain, increasing breathlessness
Complication of AF - stroke, TIA, acute HF

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26
Q

Rate control in AF?

A

Beta blockers/rate limiting CCB
Digoxin if sedentary

Combination often required

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27
Q

Target rate in AF?

A

<110 bpm

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28
Q

Chemical cardioversion drugs?

A

Flecainide, propafenone

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29
Q

Who should be referred for cardioversion?

A

New onset AF
Reversible cause
HF primarily causes, or worsened by AF
Atrial flutter suitable for ablation to restore SR

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30
Q

When to do cardioversion if haemodynamic instability?

A

Within 48 hours - immediate cardioversion (no anticoagulation)

> 48 hours - start rate control and therpaeutic anticoagulation for 3 weeks and then 4 weeks afterwards

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31
Q

Beta blockers used in AF?

A

Atenolol (50-100mg)

Acebutolol, metoprolol, nadolol, oxprenolol, propanolol

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32
Q

Side effects and contraindications of beta blockers/

A

Bradycardia
Cold extremities/paraesthesiae
Sleep disturbance
Can mask hypoglycaemia

Asthma
Severe bradycardia or hypotension
Uncontrolled HF
2nd/3rd degree heart block

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33
Q

Side effects and contraindications of digoxin?

A 
Cardiac = SA/AV block, PR prolongation, premature ventricular contractions, ST depression
Non-cardiac = nausea, vomiting, visual abnormalities, CNS effects
SV arrhythmias
Heart conduction problems
VT
HOCM
Avoid TCAs/venlafaxine (proarrhythmic)
St John's Wort decreases conc.
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34
Q

Side effects/contraindications of rate limiting CCBs?

A 
Diltiazem = dizziness, palpitations
Verapamil = constipation

CCF, aortic stenosis, severe hypotension, AV block, LVF, pregnancy

Metabolised by P450

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35
Q

What is catheter ablation?

A

Electrical isolation of pulmonary veins –> creates electrically inexcitable scare around them which blocks PV ectopic from entering LA.

Good for paroxysmal.

Percutaneous access via femoral veins

70% success, 2-3% complications (stroke, tamponde, PV stenosis)

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36
Q

Componenents of CHA2DS2VASc

A 
Congestive HF/LV dysfunction
Hypertension (>140/90)
Age > 75
Diabetes
Stroke/TIA
Vascular disease (MI, PAD, aortic plaque)
Age 65-74
Sex category (female)
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37
Q

Interpretation of CHADSVASC?

A

> 2 for females

>1 for men

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38
Q

Components of HASBLED?

A 
Hypertension
Abnormal renal function
Abnormal liver function
Stroke
Bleeding tendency
Labile INRS
Elderly (>65)
Drugs or Alcohol
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39
Q

Examples of NOACS?

A 
Dabigatran = thrombin 
Rivaroxaban = FXa
Apixaban = FXa
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40
Q

What to prescribed in AF if anticoagulation contraindicated?

A

Aspirin + clopidogrel combination

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41
Q

NOACs v Warfarin?

A

NOACs are just as good and have reduced risk of intracerebral haemorrhage.

NOACs have shorter half life so adherence more important.

NOACs don’t need monitoring.

No reversal agent for NOACs yet (except dabigatran)

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42
Q

Follow up after starting rate control for AF?

A

Within 1 week

Check tolerating, review symptoms, HR and BP

If not tolerating, change drug

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43
Q

Follow up after starting anticoagulation treatment?

A

INR should be between 2 and 3

Possible factors for poor control are - impaired cognitive function, poor adherence, illness, concurent medications interactions, lifestyle factors (diet and alcohol)

Consider switching to a NOAC if poor control

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44
Q

What is taken into account in QRISK2?

A

Age, sex, ethnicity, postcode, smoking status, medical and family history

BP and BMI

Cholesterol-HDL ratio from non-fasting sample

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45
Q

How often to repeat Qrisk?

A

Every 5 years or if any significant changes occur

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46
Q

Who is Qrisk not used in?

A 
Pre-existing CVD
Type 1 diabetes
CKD (eGFR <60 + hyperalbuminaemia)
Familial hypercholesterolaemia
Age > 85
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47
Q

Threshold for primary prevention of CVD in Qrisk?

A

10% - offer atorvastatin 20mg OD

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48
Q

Adverse effects of statins?

A

Myopathy and rhabdomyolysis

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49
Q

What can you do before starting a statin for primary prevention?

A

Consider delaying if committed to lifestyle changes

Counsel on risks and benefits of statin treatment

Baseline bloods - lipid profile, CK, LFTs, U+Es, HbA1c

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50
Q

Monitoring of statin therapy?

A

Monitor total cholesterol, HDL and non-HDL cholesterol after 3 months

AIM = 40%reduction in baseline non-HDL cholesterol levels

LFTs - 3 months and 12 months

Regularly monitor for adverse effects

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51
Q

Symptomatic relief in angina?

A

Sublingual GTN

Beta blocker or rate limiting CCB

(if BB and CCB contraindicated, can use isosorbide mononitrate, nicorandil ivabridine or ranolazine - specialist advice)

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52
Q

Advice for people with chest pain and GTN?

A

STOP and rest, use GTN as instructed

Take second dose after 5 minutes if pain not eased

Call 999 if pain not eased in 5 minutes

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53
Q

Best BB for angina?

A

Bisoprolol - long 12 hour half life

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54
Q

Secondary prevention in angina?

A

Low dose aspirin (75mg OD) - clopidogrel if strok or PAD

ACE-i - if DM

Statin/antihypertensive

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55
Q

Routine review in angina?

A

6 months to 1 year depending on stability and comborbidities

Symptoms
Risk factors
Complications - HF and depression
Compliance - drug interactions and side effects

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56
Q

Secondary prevention of MI

A

ACE-i - titrate up to maximum tolerated dose (10mg)

Beta blocker/CCB - bisoprolol (max tolerated dose - 10mg)

Statin - atrovastatin 80mg for life

Antiplatelet - dual for 12 months (aspirin + clopidogrel/ticagrelor/prasugrel) - aspirin indefinitely after 12 months

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57
Q

Who to test for CKD?

A 
Diabetes
HTN
AKI
CVD
Structural renal disease
Multisystem (rheumatological) disease
FHx
Haematuria
Long term nephrotoxic drugs
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58
Q

When is urea high and low?

A

High = catabolic state, high protein intake, GI bleed, glucocorticoids, dehydration, cardiac failure

Low = low protein intake, liver failure

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59
Q

In whom is creatinine high and low?

A

High = large muscle mass (young, muscular, male)

Low = elderly, wasting, amputees, female

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60
Q

How do you test for CKD?

A

Serum creatinine (eGFR)

Early morning urine for ACR

Urine dip (haematuria - insensitive for protein)

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61
Q

Diagnostic criteria for CKD?

A

eGFR <60

AND/OR

ACR > 3mg/mmol

for over 3 months

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62
Q

Categories of urinary ACR in CKD?

A

Normal to mildly increase = < 3

Moderately increased = 3- 30

Severely increased = >30

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63
Q

Stages of CKD?

A

Stage 1 = >90

Stage 2 = 60-89

Stage 3a = 45-59

Stage 3b = 30-44

Stage 4 = 15-29

Stage 5 (kidney failure) = <15

64
Q

How to explain CKD?

A

Common condition (nearly 10% adults) which increases in prevalence as you get older

A lot of people don’t realise they have it and it has no effect on their lives

Kidney damage causes leakage of protein and/or blood into urine

Kidney function deteriorates resulting in worsening ability to regulate fluid/electrolyte balance and calcium metabolism

65
Q

Potential complications of CKD?

A 
Renal disease requiring RRT
CV disease
Renal anaemia
Renal bone disease
Malnutrition
Neuropathy
Lipid abnormalities
66
Q

Causes of CKD?

A

Intrinsic - HTN, DM, glomerulonephritis, HF

Nephrotoxic drugs - NSAIDs, lithium, aminoglycosides, mesalazine, ciclosporin

Obstruction - bladder voiding dysfunction, urinary surgery, recurrent stones

Multi-system disease - SLE, vasculitis, myeloma, polycystic kidney disease

67
Q

Management of CKD?

A

Refer to nephrology eGFR <30 (stage 4)

Monitor for progression and complications

Manage causes and risk factors

Manage blood pressure and/or proteinuria

Statin

68
Q

Monitoring in CKD?

A

eGFR/ACR at least annually

FBC - exclude renal anaemia

Serum calcium, phosphate, vitamin D, PTH (stage 4/5)

69
Q

Self-management in CKD?

A

Smoking

Avoid NSAIDs

Diet - salt intake restriction, calories, phosphate/potassium restriction if needed

Increased risk of AKI - what to do if they become ill

70
Q

Functions of kidney of CKD?

A

Excretory - inorganic substances, organic, larger molecules

Homeostasis - fluid balance, blood pressure, acid-base

Endocrine - EPO, bone metabolism

71
Q

potential complications of CKD?

A

Anaemia (EPO)

Bone mineral disorder (low serum Ca, high PO4, high PTH to normalise calcium)
Lack of vitamin D hydroxylation
Phosphate retention

Metabolic acidosis (low serum bicarbonate)

Hyperkalaemia

72
Q

Definition of COPD?

A

Progressive disorder

Airway obstruction, no reversibility, chronic bronchitis and ephysema

73
Q

Definition of chronic bronchitis and emphysema?

A

CB = productive cough on most days for 3 monhts of 2 successive years

Emphysema = histologically - enlarged air spaces distal to terminal bronchioles and destruction of alveolar walls

74
Q

Risk factors for COPD?

A

Smoker
Occupation exposure to dusts and chemicals
Exposure to fumes from burning fuel
Age
Genetics (alpha-1-antitrypsin deficiency)

75
Q

Lifestyle advice in COPD?

A

Encourage exercise at own level

Aim to walk 20-30 minutes 3-4 times per week (if mobile)

Upper limb activities (if immobile)

Annual influenza vaccine, pneumoccocal vaccine, smoking cessation advice

76
Q

Investigations in COPD?

A

Spirometry - FEV1:FVC ratio <0.7 = airway obstruction

CXR - rule out cancer and HF

Bloods - anaemia or polycythaemia (due to chronic hypoxia)

ECG - cor pulmonale

BMI

77
Q

Signs of COPD on CXR?

A 
Hyperinflation
Flat hemidiaphragms
Large central pulmonary arteries
Reduced peripheral vascular markings
Bullae
78
Q

Differentiating COPD from asthma?

A

Reversibility testing

Serial peak flow measurements (asthma has diurnal variation)

79
Q

Grading of COPD?

A

BODE Index

MRC breathlessness scale

FEV1 as percentage of predicted

80
Q

What is BODE index?

A

BMI
Obstruction (FEV1 percentage of predicted)
Dyspnoea
Exercise capacity index

81
Q

COPD stages?

A 
1 = mild = 80% predicted
2 = moderate = 50-79%
3 = severe = 30-49%
4 = very severe = below 30%
82
Q

Side effects of SAMA?

A

Dry mouth
GI motility disorder
Cough
Headahce

83
Q

Side effects of LABA?

A

Headache

Dizziness

84
Q

Side effects of LAMA

A

Dry mouth
GI motility disorder
Cough
Headache

85
Q

COPD treatment ladder? (>50% predicted)

A

STEP 1 = SAMA or SABA

STEP 2 = add LABA or LAMA (stop SAMA in LAMA)

STEP 3 = LABA + ICS or LAMA and LABA (not SAMA)

STEP 4 = add LAMA (SABA + LABA + ICS + LAMA)

86
Q

COPD treatment ladder? (<50% predicted)

A

STEP 1 = SABA or SAMA

STEP 2 = add LABA + ICS or LAMA + LABA

Step 3 = add LABA + ICA + LAMA

87
Q

When to consider home nebs in COPD?

A

When not responding to maximum therapy

88
Q

When to consider home oxygen?

A

PaO2 < 7.3 when stable
or
PaO2 = 7.3 - 7.8 with other features

89
Q

Management of acute exacerbation in primary care?

A

Prednisolone 30mg OD for 7-14 days

Amoxicillin 500mg TDS for 5 days (or doxy 100mg OD 5 days)

Can write action plan and prescribe rescue pack. Advise on how to recognise exacerbations.

90
Q

When should COPD patients have pulmonary rehab?

A

MRC 3 or above, or recent hospitalisation for exacerbation

Programmes 2-3 sessions/week, last 6-12 weeks

Physical training, disease, education, nutritional, psychological and behavioural interventions tailored to the patient’s needs

91
Q

Diagnosis of diabetes?

A

Symptoms plus…

Random glucose > 11.1 mmol/L
Fasting > 7.0 mmol/L
OGTT > 11.1 mmol/L (2 hours after 75g anhydrous glucose)
HbA1c > 48 mmol/L

If asymptomatic, should have at least one additional glucose test result.

92
Q

What is HbA1c not used for?

A

T1DM
Children
Pregnancy

93
Q

Health promotion/education in diabetes?

A

Diet - high fibre, low glycaemic index sources of carbs. Personalised diabetes management plan.

Physical activity - 150 minutes moderate activity per week. Time spent sedentary should be minimised.

Alcohol - don’t drink on empty stomach. Can make you more hypo and mask symptoms of hypos.

Smoking - cessation support/advice

94
Q

How often should HbA1c be monitored in TIIDM?

A

3-6 monthly intervals until on stable unchanging therapy

6 monthly intervals once HbA1c level and sugars are stable

95
Q

Targets in TIIDM?

A

Lifestyle only/monotherapy = 48 mmol/L

Hypoglycaemia drug = 53 mmol/L

Multiple drugs and above 58 mmol/L = 53 mmol/L

96
Q

When should HbA1c targets be relaxed?

A

Frail
Unlikely to achieve long term risk reduction benefit
High risk of hypoglycaemia (HGV, falling, low awareness of hypos)
Intensive management inappropriate

97
Q

Self-monitoring in TIIDM?

A

Not necessary unless…

on insulin
Evidence of hypos
On medication which would increase risk of hypos while driving, operating machinery
Pregnant

98
Q

Example, mechanism of biguanide? Side effects?

A

Metformin

Decreases glucose production by liver and increases insulin sensitivity of body tissues.

Bowel problems

Not if eGFR < 35

99
Q

Example, mechanism of sulfonylurea? Side effects?

A

Gliclazide, glimepiride

Depolarises pancreatic beta cells, which opens voltage gated Ca2+ channels, leading to increased secretion of insulin.

Causes weight gain. Better than metformin at reducing blood glucose quickly – good if patient experiencing symptoms.

100
Q

Example, mechanism of DDP-4 inhibitor? Side effects?

A

Sitagliptin, alogliptin, linaliptin

Increase incretin levels, which inhibits glucagon release, which increases insulin release, decreases gastric emptying and decreases blood glucose levels

101
Q

Example, mechanism of Thiazolidinedione ? Side effects?

A

Pioglitazone

Reduces insulin resistance in the liver and peripheral tissues, decreases gluconeogenesis in the liver –> reduces blood glucose.

Contraindicated in heart failure, hepatic impairment, DKA, history of bladder cancer, uninvestigated macroscopic haematuria.

102
Q

Example, mechanism of SGLT2 inhibitor? Side effects?

A

Dapagliflozin, canagliflozin, empagliflozin

Inhibits reabsorption of glucose in the kidney –> lower blood sugar because peeing out glucose.

Can cause weight loss because of lost calories, but can cause UTI/thrush.

103
Q

Example, mechanism of GLP-1 agonist? (Incretin mimetic)

A

Works on same pathway as DPP-4 inhibitors but are more potent.

Injectable - good for weight loss

Expensive. Need to have lost certain weight or reduced HbA1c over 6 months to continue.

Better than insulin for HGV drivers etc.

104
Q

Treatment pathway for TIIDM?

A
  1. Healthy eating, weight control, increased physical activity and diabetes education
  2. Monotherapy (MTF/SU if MTF not tolerated)
  3. Dual therapy
  4. Triple therapy or insuln
105
Q

Drugs with hypo risk?

A

Sulfonylureas

SGLT-2 inhibtors

106
Q

HGV drivers and insulin?

A

Need to stop driving whilst established on insulin.

Need to record sugars and prove not had hypo - see consultant and reapply.

107
Q

CV risk reduction in TIIDM?

A

BP - control with medications. Target = 140/90, or 130/80 if end organ damage

Antiplatelet - do not routinely offer

Lipids - atorvastatin 20mg if >10% risk on QRISK

normal secondary prevention

108
Q

Complications of diabetes?

A 
Gastroparesis
Painful diabetic nephropathy
Autonomic neuropathy
Erectile dysfunction
Diabetic foot problems
Diabetic nephropathy
Diabetic retinopathy
109
Q

Components of diabetic annual review?

A

Retinopathy screening
Diabetic foot check
Nephropathy screening
Cardiovascular risk factors

110
Q

Insulin and driving?

A

Inform DVLA
Check levels before driving and 2 hourly intervals
<5 DON’T DRIVE

111
Q

Investigations and diagnosis of HF>

A

Transthoracic Echo! within 2 weeks, and assessment by specialist MDT

BNP
ECG
CXR
Bloods - U+E, eGFR, TFTs, LFTs, lipids, glucose, FBC
Urinalysis
EPFR/spirometry
112
Q

Scores for HF?

A

Frammingham

NYHA classification (I = mild, II = mild, III = moderate, IV = severe)

113
Q

First line treatment for HF?

A

ACEi
Beta blocker
Furosemide (symptomatic relief)

114
Q

Second line for HF?

A

Spironolactone
ARB
Hydralazine with nitrate
Sacubitril valsartan

115
Q

Implantable devices in HF?

A

Recommended in previous serious ventricular arrhytmia

Cardiac arrest (VT/VF)
Spontaneous sustained VT --> syncope/haemodynamic compromise

CRT with defib (CRT-D) or pacing (CRT-P)

116
Q

Self-management plan in HF?

A

Monitor own symptoms
Monitor weight at home at same time every day (2kg in 3 days is substantial)

Avoid excessive salt intake

Restrict fluid intake (30 ml/Kg/day) - if D+V, maintain fluid intake and stop treatments until recover and eating and drinking normally.

Regular low intesity physical activity

Smoking cessation/alcohol/nutritional advice

117
Q

Annual review in HF?

A

6 monthly

Signs/symptoms - examine the heart - ECG

Assess fluid status

Functional capacity

Cognitive status and psychosocial needs (MOOD)

Assess nutriitonal status

Review of medication/side effects

Bloods (urea, electrolytes, creatinine, eGFR)

118
Q

Diagnosis of hypertension?

A

If BP persistently above 140/90 –> ambulatory BP monitoring or home BP monitoring

119
Q

Ambulatory BP monitoring?

A

Two measurements per hour during normal waking hours - average of at least 14 measurments

120
Q

Home BP monitoring?

A

Two measurements at least `1 minute apart, with person seated.

Record twice daily for at least 4 days, ideally 7. Discard the first day, average the rest.

121
Q

What is stage 1 hypertension?

A

Clinic BP above or equal to 140/90

ABPM average above or equal to 135/85

122
Q

What is stage 2 hypertension?

A

Clinic BP above or equal to 160/100

ABPM average above or equal to 150/95 OR there is isolated systolic hypertension with systolic BP of 160 or higher.

123
Q

Causes of secondary hypertension?

A

Renal - chronic pyelo, dabetic nephropathy, glomerulonephritis, polycystic kidney, obstructive nephropathy, renal cell ca

Vascular - coarctation, renal artery stenosis

Endocrine - primary hyperaldosteronism, phaeochomocytoma, Cushing’s, acromegaly, hypothyroid/hyperthyroid

Drugs - alcohol misuse (most common cause of secondary)

124
Q

how to assess target organ damage in hypertension?

A 
PCR/haematuria
Bloods
Fundoscopy
ECG
Cardio exam
125
Q

Lifestyle factors in HTN?

A 
Weight
Diet
Exercise
Cut out caffeine
Reduce sodium intake
Smoking cessation
Group therapies
126
Q

Adverse effects/contraindications of ACEi?

A

Renal function, hyperkalaemia, cough, angioedema, dizziness and headaches.

Angioedema, bilateral RA stenosis, pregnancy, breastfeeding.

127
Q

Adverse effects/contraindications of ARB?

A

Renal function, hyperkalaemia, dizziness and headache

Angioedema, bilateral RA stenosis, pregnancy, breastfeeding

128
Q

Adverse effects/contraindications of thiazides?

A

Excessive diuresis, hypokalaemia, other electrolyte imbalances (hyponatraemia –> confusion), gout, DM

Gout (hyperuricaemia), electrolyte imbalance, low eGFR, pregnancy.

129
Q

Adverse effects/contraindications of CCB?

A

Vasodilatory (flushing, headaches, ankle swelling), gingival hyperplasia.

Heart failure, cardiac outflow obstruction. Antidepressants (post hypoT), CYP450 metabolised, beta blockers.

130
Q

Adverse effects/contraindications of aldosterone antagonist?

A

Gynaecomastia, GI, renal/ electrolyte disturbances.

AKI, hyperkalaemia, Addison’s.
ACEi/ARB, heparins, potassium containing things, aspirin/NSAIDs.

131
Q

Adverse effects/contraindications of alpha blocker?

A

Uncommon – dizziness, drowsiness, headache, post hypotension.

Postural hypotension.
Phosphodiesterase-5 inhibitors, antidepressants.

132
Q

Blood pressure targets?

A

Clinic BP
Under 80 yrs – 140/90
Over 80 yrs – 150/90

ABPM/HBPM
Under 80yrs – 135/85
Over 80 yrs – 145/85

133
Q

Monitoring of HTN?

A

Lifestyle only
Every 3-4 months until BP well controlled.
Annually thereafter.

On treatment
Recheck BP at after 4 weeks.
ACEi/ARB – U&E and eGFR at baseline and 1-2 weeks after treatment and every time you increase dose.
Thiazide – U&E and eGFR at baseline and 4-6 weeks after treatment.
CCB – no specific monitoring required.

134
Q

Crietria for starting antihypertensive treatment

A 
People under 80 with stage 1 hypertension who have one or more of:
	Target organ damage
	Established CV disease
	Renal disease
	Diabetes
	10-year CV risk of 20% or greater

Anyone of any age with stage 2 hypertension.

135
Q

What is stage 3 hypertension? What is criteria for admission?

A

Systolic 180mmHg or higher or diastolic 110mmHg or higher – diagnose hypertension and start antihypertensive treatment immediately.

180/110 + signs of papilloedema and/or retinal haemorrhage – arrange same day admission.

136
Q

Types of stroke?

A

Ischaemic - Thrombotic/Embolic

Haemorrhagic - Intracerebral/subarachnoid

137
Q

FAST Test?

A

Facial weakness
Arm weakness
Speech problems

138
Q

Score for risk of stroke after TIA?

A

ABCD2 score

A - age - 60+

B - blood pressure (>140/90 = 1 point)

C - clinical features (uni weakness = 2, speech without weakness = 1)

D = duration (60 minutes = 2, 10-59 = 1)

D = diabetes (1 point)

139
Q

Management of high/low risk post-TIA?

A 
HIGH
Specialist assessment in 24 hours
Atorvastatin 20mg
Clopidogrel/aspirin 300mg (unless on anticoagulation)
No driving until seen by specialist

LOW
Specialist assessment ASAP, within 1 week
Clopidogrel/aspirin 300mg loading and 75mg after
Review CV risk factors
No driving until seen by specialist

140
Q

Driving after a stroke?

A

Not for 4 weeks
No need to notify DVLA unless residual neuro deficit 1 month after episode

HGV/coaches - 12 months no driving

Need to be assessed for factors that preclude safe driving

Need to inform insurance company

141
Q

Secondary prevention of stroke?

A

Aspirin 300mg OD 2 weeks
Clopidogrel 75mg OD indefinitely

If no clopidogrel –> dipyridamole 200 BD + aspirin 75

If not, aspirin alone 75mg OD

STATIN - atorv 80mg

142
Q

Follow up after TIA?

A

Within 1 month, then annually in primary care
Annual lipid/BP check
Flu vaccinations

143
Q

Secondary prevention of TIA?

A

Manage AF, diabetes, hypertension

Antiplatelet - clopidogrel 75mg OD

Statin - atorv 80mg

144
Q

DVLA rules for epilepsy? (Cars)

A

Multiple seziures while awake + LoC - need to be free for 1 year to reapply

One-off seizure while awake + LoC - need to be seizure free for 6 months and doctor deems low risk of another seizure to reapply

Attacks whilst asleep and awake - DVLA discretion

Attacks whilst asleep - DVLA discretion

Attacks that don’t affect consciousness or driving - DVLA discretion

145
Q

DVLA rules for epilepsy? (Bus, coach or lorry)

A

Multiple seizures - No attacks for 10 years and no anti-epileptic medication for 10 years, 2% or lower risk of seziure

One-off seziure - no attacks for 5 years, no AEDs for 5 years. Must have been assessed by neurologist in last 12 monhts.

146
Q

1st/2nd line for idopathic generalised epilepsy, absence seizures, generalised tonic clonic seizures, myoclonic seizures, tonic/atonic seizures?

A

Sodium valproate

Lamotrigine

147
Q

First line in focal seizures?

A

Carbamezapine or lamotrigine

148
Q

Problems with sodium valproate?

A

Teratogenic – should be avoided in pregnancy.

CYP450 inhibitor – can increase concentration of warfarin etc.

Inhibits glucuronyl transferase and epoxide hydrolase – may interact with drugs that are substrates for these enzymes or are highly protein bound.

Carbapenem antibiotics, OCP decreases valproate plasma concentrations.

149
Q

Problems with carbamezapine?

A

Teratogenic – avoid in pregnancy.

CYP450 inducer – increases concentration of drugs metabolised by this pathway.

150
Q

Other interventions in epilepsy?

A

Surgical resection

Ketogenic diet in children and young people – referral to tertiary pediatric epilepsy specialist.

Vagus nerve stimulation – in children and young people who are refractory to AEDs but who are not suitable for resective surgery.

Deep brain stimulation – patients with medically refractory epilepsy for whom surgical resection is considered unsuitable. .

151
Q

Advice in epilepsy?

A

Avoid swimming alone
Bathing alone with door locked
Climbing

152
Q

Advice for women in epilpesy?

A

Take folic acid

Contraception

Pre-conception counselling

Drugs present in breast milk

Some drugs can affect contraceptive pill - double dose

153
Q

Advice on managing seizures?

A

Protect them from injury by:
 Cushioning their head with your hands or soft material.
 Removing harmful objects from nearby, or if this is not possible, moving the person away from immediate danger.
Do not restrain them or put anything in their mouth.

When the seizure stops, check their airway and place them in the recovery position.

Observe them until they have recovered.

Examine for, and manage, any injuries.

Arrange emergency admission if it is their first seizure.

154
Q

Side effects of valproate?

A 
Weight gain
Nausea
Vomiting
Hair loss/curly regrowth
Tremor
155
Q

Side effects of lamotrigine?

A

Drowsiness
Nausea
Dizziness
Diplopia

156
Q

Side effects of carbamezapine?

A 
Nausea
Vomiting
Diarrhoea
Hyponatraemia
Rash
Itching
Urinary retetnion
Drowsiness
Headache
Blurred vision
Diplopia
Dizziness

4th Year CCC (6 decks)

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