GP Flashcards
what happens when you take clozapine (antipsychotic) and carbamazepine - BAM ZAP
agranulocytosis
drug causes of gastric ulcers
nsaids
ssri’s
alendronic acid
steroids
order of potency of topical steroids
least
hydrocortisone
betamethasone 0.025%, butyrate (eumovate)
betamethasone 0.1%
propionate (Dermovate)
most
side effects of bisphosphonates
GI and headache reflux and indigestion alopecia anaemia arthraliga/myaglia asthenia (lack of energy) peripheral Aedema atypical fractures - new onset hip pain osteonecrosis of jaw - should maintain good physical hygiene
should you stop statins if suffereing from muscle pain
if ck is 5x upper limit of normal
or if raised but not that much but are severely impacted by the muscle pain
NB it is common to have muscle pain, but uncommon overall for CK to be so high that they have to stop it
dose of statin for primary vs secondary prevention
and when is it used for primary prevention
atorvastatin 20mg for primary
atorvastatin 80mg for secondary
QRISK ≥10% - risk of heart attack or stroke in 10 years
most T1DM
CKD if eGFR <60
increase dose if non-HDL has not reduced by >40%
statins interactions
- CI in pregnancy
- Macrolides (azithromycin etc.) are an important interaction - statins should be stopped until patient has completed the course
which diabetic drugs cause weight gain
sulphylureas - gliclazide
pioglitazone
insulin
which diabetic drugs cause weight loss
GLP-1 agonist - given by weekly injection e.g. exenatide
sglt-2 inhibitors (flozin)
side effects of sulphonulureas (NB are good for rapid glucose correction)
hypoglycaemia weight gain GI side effects SIADH - low sodium peripheral neuropathy
should take in morning to reduce risk of nocturnal hypo
side effects of metformin
lactic acidosis GI effects altered taste anorexia decreased b12 absorption
can switch metformin to modified release if getting bad GI effects (as opposed to immediate release)
The symptoms of lactic acidosis include abdominal or stomach discomfort, decreased appetite, diarrhea, fast, shallow breathing, a general feeling of discomfort, muscle pain or cramping, and unusual sleepiness, tiredness, or weakness
side effects of pioglitazone
weight gain fluid retenion (not good in HF) liver impairement bladder cancer - report dysuria anaemia increase risk of fractures
CI = haematuria
side effects of dpp-4 inhibitors (sitagliptin)
GI upset Headache painful muscles - Myalgia pulmonary - Interstitial lung disease Pancreatitis peripheral oedema
is liscensed in liver and kidney failure
side effects of sglt-2 inhibitors
GI - constipation Euglycemia DKA UTI + thrush risk Increased thirst Dyslipidaemia Ineffective if eGFR<60 Affects genitalia
very cardioprotective
example of long acting insulins
lantus - glargine
levemir - detemir
onset in 30 mins - 1 hour and last for 24 hours
example of short acting insulins
human - actrapid
DMARD side effects examples
methotrexate - pulmonary fibrosis
leflunamide - HTN, peripheral neuropathy
hydroxchlorquirne - nightmares, reduced visual acuity
rituximab - night sweats, low platelets
sulfalazine - male infertiliy
effect of drinking alcohol with warfarin
a binge increases INR so increases chance of bleeding
chronic alcohol use decreases INR
if drinkning - should be occassional and limited amount
should stick to guidelines of 14 units a week - spread over at least 3 days
missed warfarin dose
do not double to make up for a missed dose
what things enhance effect of warfain
wight loss smoking cessation acute illness cranberry juice grapefruit juice alcohol binge
avoid st johns wart, aspirin and ibuprofen due to increased bleeding risk
what things decrease effect of warfarin
diarrhoea
vomiting
green leafy vegetables and green tea
can you take paracetamol on wafarin
o But only take 1 tablet (500mg) at a time
o Do not take more than 4 tablets over a 24 hours period
o Taking more = increases bleeding risk / higher INR
RIPE for tb management
rifampicin
isoniazid
pyrazinamide
ethambutol
NICe recommend treatment in those <65 w evidece of latent tb and been in contact w someone - treat w 6m of isoniazid or 3m of isoniazid and rifampicin
ACTIVE TB
notfiable disease - public health
no CNS involvemtn - then RIPE for 2 months then RI for 4 months
with CNS involvement - RIPE for 2 months, then RI for 10 months
patients with CNS may also have adujavent steroids for first 1-2 months
directly observed therapy to improve adherence in those that would benefit eg alcoholics, homeless
isoniazide is given with pyridoxine to reduce the risk of polyneuropathy
why chose apixaban over rivaroxaban
rivaroxaban has to be taken with food
when do DOACs vs warfarin reach therapeutic levels
doacs = 3-4 hours warfarin = 3-7 days
BUT effects fade after 12-24 hours with DOACs vs 48-72 hours with warfarin (something to think about w poor adherence)
side effect of ethambutol
optic neuritis
drugs at risk of toxic build up in AKI
ACEi, ARB diuretics stop statins if aki due to rhabdomyolsis or muscle pain metofrmin lithium digoxin - reduce dose trimethoprim and co-amox aciclovir - reduce dose morphine consider witholoding DOACs
should either reduce doses or stop
sick day rules for preventing AKI
- When vomiting of diarrhoea (unless minor) should stop certain triggering medication to avoid an AKI
- ACEi/ARBs, NSAIDs, diuretics
- Note - not one fits all, should be stated on an individual basis
conversion of oral morphine to SC morphine or SC oxycodone
divide by 2
example of bulk forming laxative
fybogel - ispaghula husk
blood pressure targets
<140/90
if >80 then <150/90
T1DM <135/85 (if accompanied by albuminuria (kidney disease) or 2+ features of metabolic syndrome then ≤130/80)
CKD <140/90 (if also accompanied by CVD or diabetes or high urine creat ratio then lower than this)
3 stages of htn
- Stage 1 hypertension - BP in surgery/clinic is ≥140/90 mm Hg AND ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) from 135/85 mm Hg
- Stage 2 hypertension - BP in surgery/clinic is ≥160/100 mm Hg AND ABPM or HBPM is ≥150/95 mm Hg
- Stage 3 or severe hypertension - systolic BP in surgery/clinic is 180 mm Hg or higher or diastolic BP is 120 mm Hg or higher
I.e. confirm readings with ABPM OR HBPM for stage 1 and 2!!
<55 or with type 2 diabetes first and second line for anti-HTN
ace or arb
then a + c OR a + d
(then a plus c plus d)
> 55 or black first and second line for anti-HTN
CCB
then c + a OR c + d
(then a plus c plus d)
4th line anti-htn management
spironolactone if potassium <4.5
alpha or beta blocker if potassium >4.5
what stage to start anti-htn treatment
STAGE 1
treat if <80 AND any of following apply organ damage, established CV disease, renal disease, diabetes, QRISK >10
STAGE 2
offer regardless of age
STAGE 3
investigate for end-organ damage
urine dip, urine ACR, HbA1c, UE, creatiine, eGFR, opthalm, ECG
if all normal, repeat BP in 7 days
ABPM vs HBPM
abpm measures at least 2 per hour in persons normal waking hours - if not tolerated or declined then offer hbpm
hbpm - 2 readings taken 1 min apart with person seated - at least twice daily - ideally for 7 days
when to take first dose of acei
before bed because of first dose hypotension
monitoring and stopping acei
measure renal function and electrolytes before starting
POTASSIUM
if rises to 5 - investigate and treat other causes like stop potassium sparing drugs (amiloride, spironolactone) or nephrotoxic drugs
if persists 5-5.9 - reduce dose and recheck in 5-7 days
if >6 - stop and switch to amlodopine
can also do ECG if raised
OVERALL - refer immediately to A+E if K >6.5 or >5.5 with ECG changes
EGFR AND CREATININE
o If >25% reduction in eGFR or rise of >30% of creatinine - check for another cause, then stop or reduce for a week then recheck
o If >15% reduce in eGFR or rise of >20% in creatinine - remeasure in 2 weeks
ACEi SEs
- Dry cough
- High potassium
- Angioedema
- GI discomfort, nausea, constipation, vomiting
- Renal artery stenosis
- Low glucose
- First dose hypotension
DHP CCBs
amlodipine
nifedipine
side effects of CCBs
peripheral oedema flushing palpitaitons headaches constipation HF bradycardia or heart block for verapamil HF (verapamil and diltiazem can worsen HF)
interactions with CCBs
non-dhps (diltiazem and verapamil) with BB - can cause brady or heart block (are both negative inotropic and chronotropic)
lower dose of simvastatin - they increase dose
sodium and potassium levels with thiazide or indapamide use and loop diuretic use
low sodium and low potassium
side effects of thiazide like diuretics
- GI
- Hypokalaemia – as a result of low sodium
- Hyponatraemia
- Can exacerbate diabetes
- Impotence
may precipitate gout attakes - reduces uric acid excretion
their effectiveness can be reduced by NSAIDs
increases liklihood of digoxin toxicity
best time to take diuretics
morning so not awaken to go to loo in night
side effects of beta blockers
fatigue cold extremities bradycardia erectile dysfunction can cause hypo or hyperglycaemia - beware in diabetics with frequent hypos
beware in COPD - can cause bronchospasm - not on BNF CI list
CI in asthma
does high or low potasium precipitate digoxin toxicity
low
digoxin toxicity
confusion
nausea
arrhtymias
yellow vision or haloes
time of day to take warfarin
should take at 6pm every day so if their dose is changed it can be actioned on the same day (i.e. blood test in morning, then change dose for their evening time)
when to double dose of levonelle
if BMI >26 or weight >70kg or if taking enzyme inducer
missed pop
if >3 horus or >12 then take a pill asap
need extra contraception for next 2 days
if you have unprotected sex in the 2 days after you start taking it reliably again, you may need emergency contraception (it takes 2 days for the POP to thicken cerical mucus so sperm cannot get through)
when do you need EC when missing 2 or more combined pill
only if in first week of pack and had unprotected sex in previous 7 days
(if later then will just need extra contraception for 7 days
when to stop combined pill prior to surgery
4 weeks before major and restart 2 weeks after due to increased VTE risk
if vomit while taking combined pill
if within 3 hours of taking then take another
side effects of combined pill
- Mood swings, nausea, breast tenderness, headaches, change of periods - usually settle in a few months
- May have spotting in between periods
- No evidence for weight gain
- Serious side effects - blood clots, cervical and breast cancer
starting contraception after levonelle vs ellaone
levonella - immediate quick start but will need additional contraception for 7 days if COC or 2 days if POP
ellaone - wait 5 days before restarting contraception then same as above
ovulation with leveonella and ellaone and iud
levelonelle has to be >48 hours before ovulation
ellaone can be right up until ovulation
IUD can be 5 days after ovulation
symptoms and management of temporomandibular joint dysfunction
restricted jaw function
joint noise
facial pain
may have locking episodes - unable to open their mouth
manage by avoid yawning, singing and chewing gum, bite guards for bruxism (grinding teeth and clenching jaw), analgesia, steroid injection for some, or surgery for some
ankylosing spondylitis presentation
o Pain at night that is not relieved when person is supine
The spinal disease starts in the sacroiliac joints and may be felt as diffuse non-specific buttock pain
OE there is often tenderness of sacroiliac joints or limited range of spinal motion - later stages will get lumbar lordosis, buttock atrophy, question mark posture
o Stiffness in morning that is relieved with movement/exercise - characteristic
o Gradual onset of symptoms
o Symptoms develop over 3 months
o Usually presents before the age of 30
o Most patients have mild chronic disease or intermittent flares with periods of remission
o Systemic features are common - fever, weight loss may occur in active disease
o Peripheral enthesitis and peripheral arthritis each occur in about 1/3 (e.g. plantar fasciitis)
o Extra-articular occur in 20-30% e.g. anterior uveitis, aortic regurgitation secondary to aortitis of ascending aorta, pulmonary fibrosis…
how is pain relieved in a spinal fracture
lying down
whereas pain due to cancer typically remains when supine
symptoms of cauda equina
bilateral sciatica lower back pain neurological deficit of the legs impairment in micturition or faecal incontinence laxity of anal sphincter saddle anaesthesia sexual dysfunction
sciatica symptoms
o Unilateral pain radiating below knee
o Low back may also be present - if so, is less severe than leg pain (often though, is pain in legs without co-existing back pain)
o Numbness, tingling and muscles weakness in the distribution is suggestive of nerve root compression
types of tendinopathy
- De Quervain’s tenosynovitis
o Affects tendons that extend the thumb
o The typical symptom is pain over your wrist at the base of your thumb that is made worse by activity and eased by rest - Trigger finger
o This most commonly affects your ring finger. The condition prevents your finger from straightening fully - Tennis elbow (lateral epicondylitis)
o It is usually due to overuse of your forearm muscles - Golfer’s elbow (medial epicondylitis)
- Achilles tendinopathy
- Rotator cuff tendinopathy
management of tendinopathy
rest ice packs ibuprofen, paracetamol, co-codamol physiotherapy steroid injection rarely - surgical release of the tendon
plantar fasciitis
under surface heel pain
is a misnomer as pathologyi is actually degenerative
thorught to be a traction and overuse injury
damage is usually in the form of micro-tears
can be bilateral
risk factors = spending time on feet, running, jumping, wearing worn-out trainers, obesity, flat feet
reproduction of pain when pressing on plantar surface - or when patient stands on toes or passive dorsiflexion
rule out referred pain from S1/s2 lesion via straight leg raise
manage with weight loss, run on a softer surface, update shoes reguarly, takes 6-8w w conservative management, deep massage of sole and foot, heal and arch support may help, night splints to keep ankle dorsiflexed and toes extended to help stretch the plantar fascia
limited evidence for steroid injection
viral vs bacterial vs allergic conjunctivitis
VIRAL
more likely watery discharge
pre-auricular lymphadenopathy
BACTERIAL
purulent discharge
more likely unilateral
ALLERGIC
itchiness more common
might be redder around the eye
may be swelling
investigations and management of conjuncitivits
visual acuity, fundocsopy if unsure (look for clouding of the anterior chamber), can swab for HSV if longer lasting
VIRAL
usually resolves within 7 days, dont share towels, cool compresses, lubricating drops, avoid contacts, avoid close contact with others (dont have to exclude from school), wash hands frequently
BACTERIAL
most resolve within 7 days wihtout treatment, same self care as above, if severe or needs rapid resolution then can use topical antibiotics , or can do a delayed strategy saying to take if not resolved in 3 days - chloramphenicol drops or fusidic acid second line, dont exclude from school, explain red flags of reduced visual acuity or photophobia
ALLERGIC
avoid allergens like pets or mould, avoid eye rubbing, cold compress, artifical tears, if non-pharmacological measures dont provide relief then topical antihistamine like antazoline drops (mast cell stabiliser second line, topical steroids if v severe)
herniated disc management
90% will resolve spontaneously – the herniatied material will become dehydrated, and be reabsorbed - within a few weeks
Encourage return to normal activities as soon as possible
Short frequent walks
Swimming is beneficial
Advise analgesics and NSAIDs - 10-14 days of regular NSAIDs
In more severe cases, physiotherapy may be beneficial
In very severe cases, you can give local steroid injections, which will provide pain relief, but do not alter the longer term course of the illness
In cases lasting longer than 12 weeks:
Further investigation may be necessary
X-ray is of virtually no use!
MRI – is the investigation of choice. It can directly show the herniation, allowing you to assess its location, size, and view any impinged structures
CT – may also be useful, but provides a lower resolution image, and has been mainly superceeded by MRI
Most cases are still managed conservatively
Consider some of the treatment options for chronic pain
e.g. Amitriptyline 10-25mg nocte, increasing to a maximum of 75-100mg daily
Operative treatment is given in some cases. The main procedure is called microdiscectomy. It is performed thrugh a small inscisional windows cut in the laminae and ligamentum flavum. In 90% of cases, patients can return to work within 6 weeks
presentation of glandular fever
low-grade fever, fatigue, headache, tired all the time, myalgia and prolonged malaise
may have nausea or vomiting
sore throat
tonsillar enlargement (often meet in midline) - classically exudative
palatal petechiae and uvular oedema
bilateral cervical lymphadenopathy
snoring or even sleep apnoea due to significant tonsillar enlargement
neck may be swollen
may seen splenomegaly (+/- abdo pain) and even hepatmegaly
feverish/tired symptoms/swollen lymph glands may persist for several months after acute infection has resolveed, whereas the sore throat typically lasts 7-10 days
investigations for glandular fever (EBV)
FBC - atypical lymphocytosis - i.e. a relative raised lymphocyte count within the raised WCC
ESR - raised
LFTs - mildly raised in around 75%
monospot test is primary technique but relies on generation of non-specific heterophile IgM autoantibodies which may take a week to appear (NICE say to do this in second week of illness)
repeat this a week later if negative and suspicions are high
patients who remain heterophile-neg after 6 weeks with IM are considered to be heterophile-negative and should be tested for EBV specific antibodies (also useful if a false positive monospot is suspected) - via ELISA for IgM viral capsid antigen
abdominal US may be required to assess for splenomegaly
management for glandular fever
arrange hospital admission if stridor, dehydration or difficulty swallowing, suspected splenic rupture
avoid contact sports for 4 weeks because of splenic rupture risk - risk is highest 14 days after
avoid alcohol for illness duration - can feel much worse than usual due to effect of glandular fever on the liver
paracetamol for fever and pain
bacterial superinfection is present in as many as 30% and so penicillin-based antibiotics (usually benzylpenicillin/penicillin V) are often prescribed - remember to avoid ampicillin and amoxicillin
advise that symptoms usually last 2-4w
tiredness is common and often last thing to resoslve
dont have to exclude from work or school
avoid kissing and sharing eating utensils
advise to seek medical help if develop stridor, become systemicall yunwell, develop abdo pain (may indicate splenic rupture)
assessing breathlessness in COPD
mrc dyspnoea scale
2 types of chest infection
ACUTE BRONCHITIS normal cxr less unwell may or may not have temp may or may not have sputum, wheeze, breathlessness
PNEUMONIA
fever
more fatigue
more productive cough
management of acute bronchitis
increase fluids, paracetamol, ibuprofen
seek medical help if symptoms worsen rapidly or do not improve after 3 to 4 weeks
do not routinely offer an antibiotic in people who are not systemically very unwell
–> advise people that antibiotics do not make a large difference to the duration of symptoms, only shortening cough duration by about half a day on average + about adverse effects including diarrhoea and nausea
offer an immediate antibiotic prescription if the person is systemically very unwell
consider an immediate antibiotic prescription or a back-up antibiotic prescription for a person at higher risk of complication e.g. comorbid lung condition or something or elderly using steroids etc
if CRP has been done can be a guide to abx prescribing
o CRP less than 20 mg/L — do not routinely offer antibiotics
o CRP 20–100 mg/L — consider a delayed antibiotic prescription
o CRP greater than 100 mg/L — offer antibiotic therapy
- If antibiotics are indicated, for adults 18 years of age and older:
o First-line choice is oral doxycycline
causes of palpitations
- Arrhythmias o SVT, AF, bradyarrhythmias (AV block, sinus bradycardia) - Structural heart disease o Mitral valve prolapses, aortic or mitral regurgitation, cardiomegaly, HF - Psychosomatic o Anxiety, depression - Systemic causes o Hyperthyroidism, hypoglycaemia, fever, anaemia, pregnancy, menopause, hypovolaemia - Medication, recreational drugs o Beta-2 agonists, vasodilators o Withdrawal of beta blockers o Alcohol o Nicotine o Cocaine, MDMA, cannabis, speed, heroin o Caffeine - cola, coffee, tea, red bull
histroy/investigations for palpitations
- Ask the patient to tap out the beat
- Ask if accompanying chest pain - = more sinister
- Onset associated with exercise is a red flag
- Ask about family history of sudden cardiac death <40 years
- General exam, BP
- Gold standard is ECG taken at the time of the palpitations
- Blood tests - FBC, U&Es, TFTs, LFTs and HbA1c
- 24-hour or 48-hour Holter monitor (types of ambulatory ECGs) - if not can use an event monitor or self-activated recorder for less frequent symptoms
- Echo if cardiomyopathy is suspected
- Exercise testing: if the problem is related to exercise then a treadmill ECG or stress echocardiogram is required
diagnosis of T2DM
HbA1c >48
random blood glucose >11.1
fasting blood glucose >7
should be confirmed with repeat testing - esp if asymptomatic - is prudent for symptomatic - usually taken in 2 weeks time
pre-diabetes = 42-47 mmol/l
management of t2dm
DESMOND programme (a group of educational programmes for diabetics)
X-PERT diabetes programme (a 6w course for anyone living with a longterm health disorder inc diabetes)
lifestyle - consider dietician - it is essential that these modifications continue once antidiabetic drugs are introduced
o Control amount of carbohydrates and high-fat foods, increase fibre
o Exercise can lower blood glucose as it increases glucose use by the muscles
o Exercise daily with at least 150 minutes of moderate intensity activity over a weekly period - do strengthening activities that work all the major muscles (legs, hips, back, abdomen, chest, shoulders and arms) on at least 2 days a week
o Smoking and alcohol (alcohol can exacerbate hypoglycaemia as well)
48
metofrmin - if not then DPP-4, pioglitazone, SU, SGLT-2
aim for 48, if associated with hypo then 53
58
dual therapy
aim for 53
STILL NOT DECREASING
add a third or consider insulin (if >58 and not if obese)
STILL NOT
if on triple - consider combination of metformin, SU and GLP-1
if on insulin - seek specialist advise
BP management
<140/90, but if kidney, eye or CV damage then <130/80
GLP1 agonist can be added w su and metformin in obese patients (or where weight loss would benefit weight related comorbidites like HTN, OA, sleep apnoea) or where insulin would lead to occupational restrictions like HGV drivers
how is metformin given - how do you take it/how many times
starts just breakfast, then breakfast and tea etc. etc. to TDS - start at 500mg
example of DPP inhibitor
sitagliptin
linagliptin
things other than unusal rbcs that can affect hba1c reading
Vitamin B12/folic acid deficiency
Iron-deficiency anaemia
Splenectomy
differentiating between T1DM and T2
in some cases, it may be indicated to differentiate between T1DM and T2DM in a newly presenting patient
this involves testing for C-peptide (low in T1DM) and Autoantibodies (+ve in T1DM)
sick day rules on insulin
o Cortisol released during illness –> higher glucose levels
o Increase frequency of blood glucose monitoring and consider ketone monitoring
If no ketones, then test glucose and ketones every 2-4 hours, if ketones present or glucose is high (>15) then test glucose and ketones every 2 hours
o Never stop taking insulin - you may need an increased dose/additional doses of fast acting (even if not able to eat)
o Try keep a normal meal pattern - meals may be replaced by carbohydrate-based drinks
o Good hydration - as well as sugary drinks, also drink clear sugar free fluids to avoid dehydration
o Seek urgent medical attention if unable to tolerate oral intake, drowsy or sustained vomiting, rapid breathing (sign of DKA)
o If blood glucose is 10-13 then increase usually insulin by 10%
o If >13 or not responded to increasing insulin then give extra dose of quick acting insulin (approximately 10% of total daily insulin)
type 2
sometimes need to hold your medications - when ill still produce some insulin w type 2 so may be at risk of hypo
drink a lot of fluids and montior levels
seek help if vomiting
educational programme for t1dm
DAFNE - dose adjustment for normal eating educational programme
type 1 diabetes cap glucose targets and self monitroign
should perform at least 4 capillary blood glucoses per day - including one before each meal and one before bed
increase monitoring if frequency of hypos increases, during periods of illness, before, during and after sport, when planning pregnancy, during pregnancy and while breastfeeding
o Should be 4-7 before meals/at other times of day
o 5-9 at least 90 minutes after eating
o 5-7 on waking
type 1 diabetes hba1c target and monitoring
- HbA1c should be 48 - measured 3-6 monthly - consider more if blood glucose control is changing rapidly
management of type 1 diabetes
- DAFNE - dose adjustment for normal eating education programme
- Life-long insulin is needed to prevent complications like DKA and CKD, IHD, retinopathy
- 3 types of insulin regime
o Basal bolus
One to offer first
Injection of rapid or short-acting before meals, with 1 or more separate daily injections of intermediate or long-acting per day
Thought to best mimic physiological function of the pancreas
o Continuous subcutaneous insulin infusion (insulin pump therapy)
Patient can activate pre-meal boluses
As well as it given a regular amount of short or rapid acting
May be used in those having troubling hypoglycaemic episodes
o One, two or three injections per day
These are usually injections of short acting insulin or rapid acting insulin analogue mixed with intermediate acting insulin (or injected separately)
It may be difficult to achieve optimal glycaemic control and the regimen can be complicated by hypoglycaemic episodes
E.g. 4 units for small meal, 8 for large
