GP Flashcards
Caution in ACEI is in which condition
Bilateral renal artery stenosis
Which CCB can you give it heart failure and which one you cant
Dihydropyridine- caution in HF and non-Dihydropyridine(verapamil and diltiazem)- can give
In which condition thiazide diuretics should be cautious used
Gout
What are the contraindications for beta-blocker
asthma, bradycardia, second or third-degree heart block, uncontrolled heart failure
Prazosin is contraindicated in
aortic stenosis
Which anti-HTN combination cant you give
1) BB + CCB (increase risk of heart block)
2) ACE and ARB
3) ACE +spironolactone(due to risk of hyperkalaemia)
Absolute CV risk assessment recommendation
age 35 for ATSI
normal people-45-74
Absolute CV risk assessment factors
sex, age, BP, smoking, total cholesterol, HDL cholesterol, T2DM and LVH on ECG
What makes adults are already known to be at increased absolute risk of cardiovascular disease
Diabetes and age > 60 years
Diabetes with microalbuminuria (> 20 mcg/min or urinary albumin:creatinine ratio > 2.5 mg/mmol for males, > 3.5 mg/mmol for females)
Moderate or severe chronic kidney disease (persistent proteinuria or estimated glomerular filtration rate < 45 mL/min/1.73 m2)
A previous diagnosis of familial hypercholesterolaemia**
Systolic blood pressure ≥ 180 mmHg or diastolic blood pressure ≥ 110 mmHg
Serum total cholesterol > 7.5 mmol/L
What are 2rd causes of HTN
Cushing’s, renal artery stenosis and thyroid disease
CKD, sleep apnea, CoA, Pheochromocytoma and primary adolsteronism
3 conditions to rule out if pt got metabolic syndrome
antipsychotic use, PCOS and OSA
Metabolic syndrome criteria- how many need to fulfil
3/5
Waist circumference- 102, 88 and 90 and 80
Raised triglycerides ≥1.7mmol/L (or drug treatment for elevated triglycerides)
Reduced HDL cholesterol <1.0mmol/L in men, <1.3mmol/L in women.
Elevated blood pressure (or drug treatment for hypertension) ≥ 130 systolic or ≥85 diastolic.
Elevated Fasting glucose (fasting plasma glucose) ≥5.6 mmol/L or previously diagnosed type 2 diabetes.
Diabetes which risk assessment tool
AUSDRISK
AUSDRISK- when can we use it
what is the numbers for high risk
- high risk- from age 40- every 3 years
- ATSI- from age 18- every 3 years
High risk is greater than 12
What are the screening rates for low and high risk T2DM
Those considered at high risk should have an FBG or HbA1c test every three years.
people with low individual risk or who are from a community with low prevalence (<5%) may be screened for risk with AUSDRISK every three years
What are some symptoms of T2DM
Lethargy polyuria polyphagia polydipsia pruritis Blurred vision frequent bacterial or fungal infections peripheral neuropathy poor wound healing
What are some signs of insulin resistance
Acanthosis Nigricans Skin tags central obesity PCOS(menstrual irregularities) Hirsutism
What are the criteria to be met for diagnosing someone with T2DM
If they are symptomatic: reading of RBG>11mmol/L or HbA1C greater than 7 is adequate
If asymptomatic:
fasting blood glucose(FBG) >7mmol/L(on two separate occasions)
RBG greater than 11.1 with additional FBG or second HBA1C>6.5
HbA1C>6.5 - on two separate occasions
OGTT:2 hours postprandial >11mmol/L(on two separate occassions)
If diabetes unlikely, repeated test in 3 years
What tool can we use to identify distress in T2DM
PAID tool
Which drugs can increase glucose
1) Glucocorticoids
2) Immunosuppressants
3) Cytotoxic drugs
4) Antipsychotics
What are the medical emergencies with diabetes(3)
Hypoglycemia, DKA and HHS
What are the microvascular complications of diabetes
Diabetic nephropathy, retinopathy and neuropathy
What are the macrovascular complications of diabetes
CVD, PVD and cerebrovascular disease
HbA1C- what is the cut-off
6.5%, if > 6.5 on two separate ocassions diabetes
Diabetes cycle of care
- every 6 months(4)
- annually(6)
- special one
Every 6 months
- weight, height and BMI
- BP
- HbA1c
- waist circumference
Annual
- Measure total cholesterol, triglycerides and HDL-C
- Foot exam( high risk- every 6 months)
- Microalbuminuria
- eGFR
- self-care education diet, physical activity and smoking evaluation
- medication review
Ensure that a comprehensive eye examination is carried out at least once every 2 years
What are the 4 indications for insulin
- HbA1c >8.5
- Nil improvement of BSL 3 months after being on glucose-lowering medications
- Gestational diabetes
- If an end-stage renal failure(oral meds are contraindicated)
What are the care plans available for T2DM in GP land
NDSS, GPMP+ chronic disease management plan and team care management(TCA)
BSL recommendations for T2DM
6-8mmol/L-fasting
8-10-posrprandial
T2DM lipid profile should be
Total cholesterol <4
LDL -<2
Triglycerides <2
HDL- >1
4,2,1, rule
Urine albumin excretion T2DM should be
male-<2.5
female-<3.5
Metformin 3 SE
Lactic acidosis, vitamin b12 deficiency +N/V
Sulfonylurea-insulin secretagogue-SE
Hypoglycemia, Weight gain, cannot consume alcohol(Can cause disulfiram-like effect
Thiazoloiniodione(insulin sensitizer)—tazone
fluid retention, edema, weight gain, increase heart failure, bone fracture
T2DM in the ward, what is the most important thing
diabetes sliding scale
which type of diabetics needs to inform RTA
ones who are taking sulphonylureas or insulin
What is the most common cause of visual loss in diabetics
Maculopathy
What are 3 causes of sudden blindness
central retinal artery, retinal reattachment and vitreous hemorrhage
What are the ddx we should consider for neuropathy
Non-diabetic causes of peripheral neuropathy:
b12 deficiency, hypothyroidism, renal disease, excess alcohol consumption and neurotoxic drugs(chemotherapy)
Treatment for diabetic neuropathy
antidepressants, anticonvulsants(pregabalin and gabapentin) for neuropathic pain
Autonomic neuropathy is T2DM
orthostatic hypotension, gastroparesis and ED and retrograde ejaculation in males
Kidney status in people with T2DM should be assessed how:
- annual screening for albuminuria(note that dipstick is not adequate to identify albuminuria)
- annual eGFR
Screening for microalbuminuria- how, what are the ranges
Urine albumin to creatinine ratio(UACR) in a random spot collection-preferred method
Any positive UACR needs to be confirmed with a repeated collection and also mid-stream urine to exclude UTI as a contributor proteinuria
2.5
2.5-25
>25
DO NOT DRIVE UNDER 5
check your BSL every 2 hours
Hypoglycemia is below
4mmol/L
Things to do in diabetic foot exam
neuropathy- 10g monofilament, vibration perception and normal neuro exam
circulation- feel pulses and ABI
foot deformities-
- small muscle wasting
- Charcot foot deformity
- bony prominence
- prominent metatarsal hands
- hammer of claw toes limited joint mobility
Biochemical criteria for DKA
BSL >11
venous pH <7.3
bicarbonate- <15
presence of blood ketones or urinart ketones
HHS-hyperosmolar hyperglycemic state, what should you lookout
> 25mmol/L
hyperosmolar
dehydration
change in mental state with little or no ketoacidosis
Tell me about RULE OF 15 with hypoglycemia
provide 15g of carbs, wait 15 min
Severe hypo, <2 can result in
hypoglycemia coma, resuscitation protocols and injection of glucagon
Non-proliferative changes in Diabetic retinopathy
doy haemorrhages, blot haemorrhages, microaneurysms and hard exudates and soft exudates
Proliferative changes diabetic retinopathy
neovascularization
unilateral wheeze think
inhaled foreign body
When to begin ICS preventer in adults
symptoms occur twice per month or more
waking up due to asthma symptoms a least once in the past month
2 conditions which have expiratory wheeze in children
asthma and bronchiolitis
Management of COPD exacerbation in GP
start using more SABA via MDI and spacer every 3-4 hours, titrate response
Not helping–> oral pred 30-50mg daily for 5 days then stop. If infection present oral antibiotics(augmentin duo) for 5 days
If more than 2 or more exacerbations in a year concerning
Which cancers are reduced by OCP
endometrial, ovarian and bowel cancer(BOE)
What are the contraindications for OCP
- VTE(including obesity)
- Stroke(includes migraine with aura)
- Ischemic heart disease
- Breast cancer
- Liver disease
other important considerations- breastfeedings and drug interactions
UpToDate:
●Age ≥35 years and smoking ≥15 cigarettes per day
●Multiple risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, and hypertension)
●Hypertension (systolic ≥160 mmHg or diastolic ≥100 mmHg)
●Venous thromboembolism
●Known thrombogenic mutations
●Known ischemic heart disease
●History of stroke
●Complicated valvular heart disease (pulmonary hypertension, risk for atrial fibrillation, history of subacute bacterial endocarditis)
●Current breast cancer
●Severe (decompensated) cirrhosis
●Hepatocellular adenoma or malignant hepatoma
●Migraine with aura
●Diabetes mellitus of >20 years duration or with nephropathy, retinopathy, or neuropathy
What is the mechanisms of action of COCP-remember there is estrogen and progesterone
The main contraceptive efficacy of COCs is suppression of ovulation by inhibition of gonadotropin-releasing hormone (GnRH), luteinizing hormone (LH), follicle-stimulating hormone (FSH) and the mid-cycle LH surge.
Estrogen suppression of FSH, which in turn prevents folliculogenesis, is likely the most important mechanism
Progestin-related mechanisms that contribute to the contraceptive effect include:
●Effects on the endometrium, rendering it less suitable for implantation. Long-term cyclic or daily progestin exposure leads to endometrial decidualization and eventual atrophy.
●Thickening of cervical mucus, which becomes less permeable to penetration by sperm.
●Impairment of normal tubal motility and peristalsis.
Side effects of COCP
headache nausea breast tenderness unscheduled bleeding amenorrhea acne(usually improves) bloating mood changes reduced libidio weight gain
When should the pill be started
An active hormonal pill should be started on day 1-5 of the menstrual cycle(when bleeding occurs) in order to be immediately effective-the pill is often started >5 days after the onset of menses.
REMEMBER TO EXCLUDE PREGNANCY- do a URINE Beta-hCG
and make sure to
1)TAKE A BP READING
2)MEASURE THEIR BMI–> increased risk of VTE
quick method- will take 7 days for it to start working. IT TAKES 7 DAYS FOR IT TO WORK :) so use other methods of contraception-like condoms or abstinence
Before starting any contraception what should you exclude
PREGNANCY!!!
Why post-partum women should not be recommended to use COCP
Postpartum women should not use combined hormonal contraceptives for at least the first 21 days after delivery because of the increased risk for venous thromboembolism during this time period
Breastfeeding women should avoid combined hormonal contraceptives until 30 days postpartum due to theoretical effects on lactation.
Doctor, I missed (COCP) one pill today, what should I do?
If a single pill is missed anywhere in the packet, women should be instructed to take the missed pill as soon as it is noticed and then continue taking one pill each day as prescribed. Depending on when she remembers her missed pill, she may end up taking two pills on the same day. No additional contraception is required because one missed pill does not reverse ovarian suppression
Doctor, I missed more than 2 pills, what should I do (more than 24 hours)
Abstinence from sex or use condoms.
Have unprotected sex after 7 active pills
What does the morning after pill contain
levonorgestrel-A synthetic progestogen
The hormone levonorgestrel, at a dose of 1500 micrograms, is taken as soon as possible after unprotected sex. This is supplied as either two tablets (two x 75mg).
GP conditions that are often missed
- Addison’s disease
- Haemochromatosis
- Thyroid disease
- Menopause
- Pregnancy
- Diabetes
What are the seven masquerades
- Depression
- Diabetes mellitus
- Drugs–> Iatrogenic and self-abuse
- Anaemia
- Thyroid and other endocrine disorder
- Spinal dysfunction
- UTI
What are some drugs that can be used to control obesity
Duromine
Orlistat
What is the best treatment for obesity
Bariatric surgery
CVD risk assessment of <10%, review in
BP every 2 years
CVD risk assessment of 10-15%, review in
BP every 6-12 months
CVD risk assessment of >15%, review in
BP every 6-12 weeks
What are some yellow flags of lower back pain
- The belief that pain and activity are harmful
- “Sickness behaviour(like extended rest)
- Low or negative mood, social withdrawal
- History of back pain, time-off and other claims
- Overprotective family vs lack of support
Menopause
diagnosed after 12 months of amenorrhea.
Benefits vs the risk of HRT
cons: risk of breast cancer and endometrial , CHD, stroke, DVT and PE
pros: reduce osteoporotic fracture
What are some examples of bisphosphonates
Alendronate, risedrionate and zoledronic acid
What are the 4 important side effects of bisphosphonates
hypocalcemia
renal impairment
aseptic osteonecrosis of the jaw
esophageal inflammation and increase risk of cancer
What advice do you need to give to patient taking bisphosphonates
Bisphosphonates should be taken in the morning with sufficient water and in an upright position at least 60 minutes before eating!
and SHOULD NOT be taken with calcium supplementation
What are some contraindications for bisphosphonates
Reduced GFR (< 30–35 ml/min)
Hypocalcemia
Esophageal abnormalities (e.g., strictures)
Pregnancy/lactation period: no clear contraindications, individual risks/benefits must be weighed
Prolia (Denosumab Injection)
Denosumab is recommended for osteoporosis in post-menopausal women at increased risk of minimal trauma fracture
Every 6 months
if treatment stops, osteoporosis will come back
What is the gold standard for measuring the bone mineral density in Australia
DXA
DXA is a diagnostic tool for osteoporosis or osteopenia, enabling doctors to determine the extent of bone loss for
clinical decision making
If suspected of a vertebral fracture, when should refer it on
Refer for spinal X-ray when:
– Height loss of 3cm or more
– Thoracic kyphosis
– New onset back pain suggestive of fracture
if the fracture is confirmed then do a DXA scan
What does T score signify
The T-score compares the patient’s bone density to the peak bone density of young adults. It is the number of standard deviations (SDs) of the BMD measurement above or below that of young healthy adults of the same sex. According to definitions agreed by the World Health Organisation, a T-score of -2.5 or lower at the spine or hip is indicative of osteoporosis
-reference with a healthy 30-year-old
What does Z score signify
The Z-score compares the patient’s bone density to that of
adults of the same age. It is the number of SDs of the BMD
measurement above or below that of adults of the same age and sex. Z-score is a useful indicator of possible secondary osteoporosis. A Z-score of -2.0 or below should trigger investigations for the underlying disease to exclude other causes of bone mineral loss.
-age-matched normal
Only patients over 70 need a bone density test with DXA, is it true doc?
Clinical risk factors – not age – should determine referral for DXA, targeting the 50+ patient population is important.
Prevention is key
Please draw out the osteoporosis treatment algorithm
https://www.osteoporosis.org.au/
sites/default/files/files/RACGP%20Osteoporosis%20Summary%20
Guideline%204428%20Nov%202017.pdf
What are the 2 fracture calculator Australia uses
Garvan Fracture Risk Calculator or FRAX
When should a full falls risk assessment be done
Any person who has fallen twice or more in the previous 12 months or having difficulty with walking or balance.
A multifaceted falls prevention program should be tailored to individual needs.
What type of exercise is recommended for improving bone density
Not leisure walking, swimming or cycling
prescribed regular, varied, high-intensity resistance training and progressive balance training.
programs should be individualized
Which glaucoma presents as acute onset
closed-angle glaucoma
Osteoporosis- what is the most common site for fractures–> go from most to least
vertebral (most common) > femoral neck > distal radius (Colles) fracture, fractures of the long bones (e.g., humerus)
How would you detect a vertebral factures-Osteoporosis
Vertebral compression (crush) fractures are commonly asymptomatic but may cause acute back pain and possible point tenderness without neurological symptoms
Long-term findings after repeated vertebral compression fractures
→ Decreased height (loss of 2–3 cm with each fracture)
→ Thoracic hyperkyphosis → stooped posture with a “dowager’s hump”
4 ddx for osteoporosis
Osteomalacia
Hyperparathyroidism
Metastases
Multiple myeloma
What is first-line for osteoporosis
1st-line treatment: bisphosphonates (alendronate, risedronate); inhibit osteoclasts and therefore bone resorption
Why should you give raloxifene to a woman who has osteoporosis
Raloxifene (selective estrogen receptor modulator, SERM) for patients with contraindications to bisphosphonates or those who also require breast cancer prophylaxis (but increases the risk of thromboembolism
State some things you would consider in the management as a GP
Primary prevention - GP centered
implement strategies to prevent falls
- improving vision
- adjusting drug therapy if possible (eg drugs causing sedation, altered gait or postural hypotension)
- minimising household risks (preferably under the guidance of an occupational therapist)
- providing aids for daily living (eg walking aids, rails)
- minimising periods of immobilisation
- promoting exercise to maintain mobility, balance and strength.
increase weight-bearing exercise and balance training
ensure adequate calcium intake
ensure vitamin D sufficiency
stop smoking
limit alcohol intake to two standard drinks per day
maintain ideal body weight.
What is the frequency of
- prolia injection
- bisphosphonates
- bisphosphonates is once week tablet
- Denosumab- SC injection/ 6 monthly
eTG
What are the causes of falls in the elderly
Motor problems: gait or balance impairment; muscle weakness
Sensory impairment: peripheral neuropathy, vestibular dysfunction, vision impairment
Cognitive or mood impairment: dementia, depression, delirium
Orthostatic hypotension
Polypharmacy or certain medicines (particularly psychotropic medicines)
Impairment of activities of daily living
Environmental hazards (e.g., loose rugs, poor lighting, clutter)
Additional factors such as age or comorbid illnesses.[
Falls history should assess
Location
Activity at the time of the fall
Injury realted to the fall
Any change in level, or LOC
Cardiovascular symptoms–> chest pain, palpitations, dizziness, vertigo or lightheadedness
Symptoms related to change–> spine to sitting, sitting to standing
Pain or neurological symptoms( headache, weakness/tingling/numbness or acute change in mental status), which may indicate an underlying acute condition such as stroke
Medicines should be reviewed (with particular reference to psychotropic medications and narcotics
falls with related head injury should prompt a re-evaluation of risk for individuals taking anticoagulants or antiplatelet therapy).
A history of comorbidities such as diabetes, Parkinson’s disease or osteoporosis should be elicited.
Coordination and cerebellar function testing is useful when looking for focal deficits related to cerebrovascular disease or neurodegenerative disorders such as corticobasal degeneration.
Consider Romberg’s sign and tests for proprioception when the patient complains of balance problems or if there are underlying causes of peripheral neuropathy (e.g., diabetes, B12 deficiency).
Dix-Hallpike manoeuvre
Red flags to rule out in dementia
- Delirium
- Depression
- Brain tumours
- Traumatic brain injury
- Tuberculosis
- Syphilis (late)
Normal pressure hydrocephalus
MAKE SURE TO ASK ABOUT ACTIVITIES OF DAILY LIVING–> shopping, driving car, cleaning
Common ddx with dementia
Mild cognitive impairment (MCI) Delirium Depression Alzheimer's dementia Vascular dementia Lewy body dementia
CAM algorithm for diagnosis of delirium
2 of these must be present
- Acute onset or fluctuating course and
- Inattention and
Either 3. Disorganized thinking
4. Altered level of consciousness
Can you diagnose dementia
NO it is a symptom. It is under the umbrella term of Makor neurocognitive disorder. You need to find the cause of it
State some causes of dementia
Alzheimer's disease Vascular dementia Mixed(vd+ad) Frontotemporal disease--> with or without pick's bodies Dementia with Lewy bodies Parkinson's disease with dementia Huntington's disease
What are some treatable dementia-MINDWAVES
Meningioma and other tumours Infection--> neurosyphilis Normal-pressure hydrocephalus Depression Wilson's disease Alcohol and drugs Vitamin b12 deficiency Endocrine--> hypothyroidism Subdural haematoma
How can we assess for dementia
MMSE
ACE-R
FAB
RUDAS
What cognitive assessment tool can we use for dementia in ATSI
KICA-Kimberley Indigenous Cognitive Assessment (KICA)
Medications that can help with slowing down dementia
Cholinesterase inhibitors
Memantine
In general, anticholinergic substances (e.g., tricyclic antidepressants) should be avoided, as they may lead to further deterioration in cognitive functioning!
Advice on scabies on treatment to the patient
-what the difference in infants and adults in applying
irst-line treatment for scabies is topical permethrin 5% cream, which should be applied to the whole body (excluding the head and neck in patients other than infants) and washed off after eight hours.
All household contacts should be treated at the same time.
If the first application is thorough, then no repeat dose is required, as permethrin is active against all stages of the parasite’s life cycle. If symptoms persist, we recommend a repeat application 7–14 days after the first treatment.
If the 1st line treatment for scabies does not work, what is the 2nd line options
Benzyl benzoate 25% is the second-line topical agent. It commonly causes skin irritation, and should be diluted with water for children and infants It is applied and then left for 24 hours before being washed off.
The patient who has chronic kidney disease has low Hb?
What can be the cause of this and what is the management for this patient
Anemia of chronic kidney disease: ↓ hemoglobin, ↔︎ MCV
Pathophysiology: ↓ erythropoietin → decreased stimulation of RBC production → normocytic, normochromic anemia
(Additionally, uremia causes hemolysis, coagulopathies, and inhibits erythropoiesis)
Administer synthetic EPO, possibly in conjunction with iron replacement depending on serum ferritin and transferrin values.
Adverse effects: increased risk of thrombosis, increase in blood pressure
May need RBC transfusion- under consultant review
Hypocalcemia in CKD is caused by what?
Decreased production of vitamin D and hyperphosphatemia causes hypocalcemia.
Patients develop secondary hyperparathyroidism and subsequent renal osteodystrophy due to hyperphosphatemia, hypocalcemia, and the insufficient production of vitamin D!
Can monitor PTH and calcitriol
Sorethroat- if possible do what?
Do a throat swab if possible
Rapid antigen test- if available is really good too
Wha are the importances of falls
1) Disability
2) Instiutuionalization
3) Mortality
4) Socioeconomic burden
Intrinsic vs extrinsic factors for falls- what the reason
Intrinisic- patient factors
Extrinsic- environmental
The strongest predictor for falls
Prior falls
What are the geriatric syndromes
1) Cognition-3Ds
2) Bowels and bladder
3) Sleep- sleep disturbances
4) Sensory - hearing and vision
5) Mobility-immobility and gait disturbances. Falls and fragility fractures. pain(osteoarthritis)
6) Diet and weight
7) Polypharmacy
Rule out cardiac syncope
What delirium screening can I use for elderly people
The 4A Test: screening instrument for cognitive impairment and delirium
Falls prevention in older adults-5
Exercise High dose vitamin D Psychoactive medication withdrawal AND Medication review by pharmacist Occupational therapy home visit Restricted multifocal spectacle use Expedited cataract surgery Podiatry intervention
Skin cancer- what are the two main types
Melanoma–> from melanocytes
Non-melanocytic skin cancer (NMSC):
1) SCC
2) BCC
developed from keratinocytes
___________ and _________ are associated with both
amount and pattern of sun exposure, with an
intermittent pattern carrying the highest risk.
Melanoma and BCC are associated with both
amount and pattern of sun exposure, with an
intermittent pattern carrying the highest risk.
_____________ and ________ are
associated with the total amount of sun
exposure accumulated over a lifetime
Premalignant actinic keratosis and SCC are
associated with the total amount of sun
exposure accumulated over a lifetime
Risk factors for melanoma
• Personal history of melanoma
• Multiple dysplastic naevi (>5)
• Multiple naevi (>100 or >11 on arm)
• Family history of melanoma/Personal
history of NMSC
• Having fair or red hair and blue or green eyes
• Fair skin that burns easily, freckles and does
not tan
• High levels of intermittent sun exposure (e.g.
during outdoor recreation or sunny holidays)
• Immune suppression and/or transplant recipients
• Increasing age
5 S to prevent from skin cancer
Slip-on sun-protective clothing – that covers as much skin as possible.
Slop on SPF30 (or higher) sunscreen – make sure it is broad-spectrum and water-resistant.
Slap on a hat – that protects the face, head, neck and ears.
Seek shade.
Slide on sunglasses
Check the daily sun protection times on the free
SunSmart app
The ABCDE acronym can help distinguish a superficial spreading melanoma from a normal mole:
Asymmetry: the lesion is irregular in shape or pattern.
Border: the border or outline of a melanoma is usually irregular
Colour: there is variation in colour within the lesion
Diameter: the lesion is usually greater than 6 mm across. However, suspect lesions of smaller diameter should also be investigated
Evolving: the lesion changes over time (size, shape, surface, colour, symptoms e.g. itch).
What is an aggressive form of melanoma
This is an aggressive form of melanoma that grows quickly.
The ABCDE acronym cannot be used
to aid diagnosis of nodular melanoma;
however, the following features can be
of help:
Elevated: the lesion can appear as a small, round
and raised lump on the skin. Colour may be
uniform throughout the lesion and may be black,
brown, pink or red.
Firm: the lesion feels firm to touch.
Growing: a nodule that has been growing
progressively for more than a month should be
assessed as a matter of urgency
Is nodular melanoma a GP emergency
YES, If nodular melanoma is suspected, the diagnosis should not be delayed, and urgent referral to a dermatologist or immediate excision is recommended.
NM can become life-threatening in 6–8 weeks.
Selecting appropriate primary treatment will
depend on the
Breslow thickness (vertical depth) of the tumour
Treatment options for non-melanoma
skin cancer include:5
• Surgical excision of the tumour and surrounding tissue • Curettage and cautery • Application of topical agents (imiquimod cream, fluorouracil cream, photodynamic therapy) • Cryotherapy • Radiotherapy
Bowen disease
Squamous cell carcinoma in situ, or Bowen disease, is an early form
of skin cancer that begins in the top layer of the skin (epidermis). It
looks like a red, scaly patch and can develop into invasive squamous
cell carcinoma if left untreated. The diagnosis and treatment of
squamous cell carcinoma in situ is similar to BCC and SCC.
Sunspots (solar or actinic keratoses) - are they a risk factor
Anyone can develop sunspots, but they occur more often in people over 40, generally on skin that’s frequently exposed to the sun,
such as the head, neck, hands, forearms and legs.
They are a warning sign that the skin has had too much
sun exposure, increasing the risk of skin cancer.
imiquimod
(brand name, Aldara)
- what can it be used for
Sunspots
superficial BCCs
squamous cell carcinoma in situ (Bowen disease)
You apply imiquimod directly to the affected area once a day at night, usually five days a week for six weeks
Arborizing vessels (AVs)
Arborizing vessels (AVs) are dermoscopically defined as telangiectasias with distinct treelike branching, and are a characteristic feature of basal cell carcinoma (BCC).
Intraepidermal squamous cell carcinoma (SCC)
Intraepidermal squamous cell carcinoma (SCC) is a common superficial form of skin cancer. It is also known as Bowen disease, intraepidermal carcinoma (IEC) and carcinoma in situ (SCC in situ).
BCC margin
3mm
SCC margin
4mm
the only treatment for SCC
surgery only
idara and efudix which ones can we use it on- BCC/SCC and where can we use on the body
NOT ON THE FACE
ONLY FOR BCC and bowen disease
melanoma is _____ mm
equal or >6mm
solar and actinic kertaosis- treatment of option
Cryotherapy
Tell me the NHMRC margins for these melanoma
in-situ
<1mm
1-2mm
2-4mm
greater than 4
in-situ- 5m mmargin
1-4– 1cm margin
4+ is 2 cm margin
Misoprostol actions on the female reproductive system?
It causes uterine contractions AND cervical ripening (dilation).
3 main causes of CKD
1) T2DM
2) HTN
3) glomerulonephritis
State some clinical features of CKD
Patients are often asymptomatic until later stages.
- Hypertension
- Peripheral edema
- Pulmonary edema (usually interstitial pulmonary edema)
Clinical features of uremia Fatigue, weakness, loss of appetite, headaches Uremic fetor Pigmented spots Pruritus Anemia Uremic pericarditis Pleuritis Asterixis Encephalopathy: seizures, somnolence, coma Peripheral neuropathy: paresthesias Gastrointestinal symptoms: nausea, vomiting
↑ Risk of infection: leukocyte dysfunction
↑ Bleeding tendency secondary to platelet dysfunction
Why does CKD increase
- anaemia
- bone damage
- bleeding problems
- immunosuppression
↑ Risk of infection: leukocyte dysfunction
↑ Bleeding tendency secondary to platelet dysfunction
Chronic kidney disease-mineral and bone disorder (CKD-MBD): abnormalities of mineral or bone metabolism in the setting of chronic renal disease
Etiology: mostly due to secondary hyperparathyroidism → high-turnover renal osteodystrophy or osteitis fibrosa cystica
Clinical features: weakness, fractures, bone pain, avascular necrosis
Anemia of chronic kidney disease: ↓ hemoglobin, ↔︎ MCV
Pathophysiology: ↓ erythropoietin → decreased stimulation of RBC production → normocytic, normochromic anemi
When do you repeat UCR and eGFR in diabetics and HTN
If urine ACR and eGFR are normal repeat Kidney Health Check in 1-2 years (annually if diabetes or hypertension present)
Tell me the normal vs mirco and macro
Normal
(urine ACR mg/mmol)
Male: < 2.5
Female: < 3.5
Microalbuminuria
(urine ACR mg/mmol)
Male: < 2.5 -25
Female: < 3.5-35
Macroalbuminuria
(urine ACR mg/mmol)
Male: > 25
Female: > 35
When do you worry about the eGFR
eGFR < 60 if less than this repeat in 7 days,
if that eGFR reduced by 20%–> ?AKI
if stable–> repeated twice in 3months
YOU NEED Minimum 3 reduced eGFR’s
present for ≥3 months for CKD
defintion of CKD
an estimated or measured glomerular filtration rate (GFR) < 60 mL/min/1.73m2
that
is present for ≥3 months with or without evidence of kidney damage
Blood Pressure Targets for patient with
1) CKD
2) CKD with diabetes+ mircoabluminuria
CKD–> 140/90
CKD with diabetes+ mircoabluminuria–> 130/80
In CKD which electrolyte levels are we worried about
In chronic renal disease, close surveillance of serum potassium values as well as calcium and phosphate values is essential!
Anemia of chronic kidney disease treatment
Administer synthetic EPO, possibly in conjunction with iron replacement depending on serum ferritin and transferrin values.
Adverse effects: increased risk of thrombosis, increase in blood pressure
What is the effect HTN has on the kidneys
Hypertensive nephrosclerosis
chronic hypertension → narrowing of afferent and efferent arterioles → reduction of glomerular blood flow → glomerular and tubular ischemia → arteriolonephrosclerosis and fibrosis (focal segmental glomerulosclerosis) → end-stage renal disease
It is a vicious cycle
HTN retinopathy- state some changes
cotton-wool spots, retinal hemorrhages (i.e., flame-shaped hemorrhages), arteriovenous nicking , marked swelling and prominence of the optic disk with indistinct borders due to papilledema and optic atrophy (end-stage disease)
Hypertensive crisis (acute severe hypertension)
Definition: acute increase in blood pressure > 180/120 mm Hg
Malignant hypertension- definition
EMERGENCY
Malignant hypertension: severe hypertension that occurs with retinopathy (flame hemorrhages, papilledema)
A person with malignant hypertension has a blood pressure that’s typically above 180/120. Malignant hypertension should be treated as a medical emergency.
Which drugs are used to treat people in hypertensive crisis(IV basically)
The most commonly used drugs to treat hypertensive emergency are nitroprusside, labetalol, and nicardipine.
Nephritic syndrome features-5
Proteinuria (< 3.5 g/day) Hematuria with acanthocytes Mild to moderate edema RBC casts in urine Oliguria Azotemia Hypertension Sterile pyuria
Nephrotic syndrome features-5
Heavy proteinuria (> 3.5 g/day) Hypoalbuminemia Generalized edema Hyperlipidemia and fatty casts in urine Hypertension ↑ Risk of thromboembolism and infection
What time of glomerular disease does T2DM cause of the kidney
Nephrotic syndrome
All glomerular diseases can lead to acute and chronic kidney failure!
Necrotizing fasciitis
Pathogen: group A Streptococcus ; frequently mixed infection (with aerobic and anaerobic gram-negative bacteria)
Gas gangrene is a type of necrotizing fasciitis caused by Clostridium perfringens
Endothelial cell dysfunction due to bacterial toxins
HUS
ADAMTS13 deficiency
TTP
Antiplatelet antibodies (Anti-GpIIb/IIIa)
ITP( diagnosis of exlcusion)
Macrolides
-thromycin
think ACE (Azithromycin, Clarithromycin, Erythromycin)
> > QT Prolongation, GI distress/C. diff
What is the most common cause of pulmonary HTN?
Chronic damage due to lung disease –> cor pulmonale
i.e. COPD
What is grade 1 hypertensive retinopathy?
Thickening of arterioles
What is grade 2 hypertensive retinopathy?
Focal arteriolar spasms (AV nipping)
What is grade 3 hypertensive retinopathy?
Haemorrhages (flame shaped)
Exudates (cotton wool)
Waxy exudates
What is grade 4 hypertensive retinopathy?
Papilloedema
What does the pattern of oedema suggest about the side of the heart affected?
Right sided failure = peripheral oedema
Left sided failure = pulmonary oedema
What does the pattern of oedema suggest about the side of the heart affected?
Right-sided failure = peripheral oedema
Left-sided failure = pulmonary oedema
What are the modifiable CVD risk factors
Smoking status Nutrition and diet Alcohol intake Level of physical activity BP Waist circumference and BMI Serum lipids
Other related condition that increase your CVD risk-4
- Diabetes
- Chronic Kidney Disease (albuminuria ± urine protein, eGFR)
- Familial hypercholesterolaemia#
- Evidence of atrial fibrillation (history, examination, electrocardiogram)
Other related condition that increases your CVD risk-4
- Diabetes
- Chronic Kidney Disease (albuminuria ± urine protein, eGFR)
- Familial hypercholesterolaemia#
- Evidence of atrial fibrillation (history, examination, electrocardiogram)
Warfarin MoA
-pre-op
Vitamin K antagonists (coumarins
Vitamin K antagonists inhibit the enzyme vitamin K epoxide reductase, thereby blocking hepatic synthesis of the active, reduced form of vitamin K (needed for carboxylation of coagulation factors II, VII, IX, and X, protein C, protein S).
Can give vitamin K PO if INR is not less than 1.5 prior to surgery
pre-op
Warfarin – usually stopped 5 days prior to surgery due to bleeding risk and commenced on therapeutic dose low molecular weight heparin
Surgery will often only go ahead if the INR <1.5, so you may have to reverse the warfarinisation with PO Vitamin K if the INR remains high on the evening before
Dabigatran moa
Direct thrombin inhibitors
rivaroxaban and apixaban-MoA
Factor Xa inhibitor
Aspirin- anticoagulation MoA
Inhibits thromboxane A2 synthesis by irreversibly acetylating cyclooxygenase-1 in platelets and megakaryocyte
IRREVERSIBLE inhibition of COX-1
Preoperative bridging therapy
- Stop coumarin administration 5–6 days before surgery.
- Administer a therapeutic dose of the bridging drug 3 days before surgery, with the last dose administered 24 hours before the procedure.
- Resume the bridging drug and warfarin after surgery ; administer the bridging drug for 4–6 days post-surgery
NSAIDs (general) MoA
Inhibit cyclooxygenase 1 & 2 (COX-1/COX-2), thus preventing the conversion of arachidonic acid to prostaglandin, a key mediator in inflammation
and Inhibits thromboxane A2 synthesis by irreversibly acetylating cyclooxygenase-1 in platelets and megakaryocyte
aspirin is a type of NSAIDs
Aspirin is considered an anticoagulant or NSAIDs
BOTH
the anticoagulant effect due to the antiplatelet effect
Anticoagulants such as heparin or warfarin (also called Coumadin) slow down your body’s process of making clots. Antiplatelet drugs, such as aspirin, prevent blood cells called platelets from clumping together to form a clot.
Aspirin overdose (salicylate toxicity
tinnitus, tachypnea, vomiting, and a characteristic mixed respiratory alkalosis and metabolic acidosis on ABG.
What is clopidogrel used for
P2Y12 receptor antagonists (clopidogrel, prasugrel, ticagrelor) are mainly used in conjunction with aspirin (dual antiplatelet therapy) in the management of acute coronary syndrome and to prevent rethrombosis in patients after percutaneous coronary intervention (PCI) and/or stenting.
Aspirin
Irreversible COX-1 inhibition → inhibition of thromboxane (TXA2) synthesis in platelets → inhibition of platelet aggregation (antithrombotic effect)
Irreversible COX-1 and COX-2 inhibition → inhibition of prostacyclin and prostaglandin synthesis → antipyretic, anti-inflammatory, and analgesic effect
Signs and symptoms specific to DKA
Rapid onset (< 24 h) in contrast to HHS Abdominal pain Fruity odor on the breath (from exhaled acetone) Hyperventilation: Kussmaul respirations: deep breaths at a normal respiratory rate
DKA chart- what is the special blood test you do
Blood culture
beta-hCG( if women and pregnant)–> can do this with urine–> cause pregnant with DKA–> immediate ICU admission
Eyes in diabetics
1) diabetic retinopathy
2) cataract
The most common cause of AKI
Pre-renal failure
The most common cause of pre-renal failure
Acute tubular necrosis
Muddy brown casts
