GP-chronic Disease Flashcards
65 year old man newly diagnosed angina…
What medication should he be taking ? What would be the next stage?
NICE -
Aspirin, statin, GTN + one of beta blocker / Calcium channel blocker (verapamil)
Combination therapy but swap Ca to nifedipine
Which of these drugs is not recommended for second line angina mx? Digoxin Ivabradine Isosorbide mononitrate Nicorandil
After combining b-blocker and CCB at maximum dose
Nice recommends any of the 3 bar
DIGOXIN - that is for AF and HF
Which of these drugs do many patients develop a tolerance to? Nifedipine Atenolol Isosobide mononitrate Verapamil
Isosobide mononitrate
[BNF says they should take second daily dose after 8 hours if this happens]
Patient with long standing angina comes to A&E with a funny feeling in her chest along with presyncope
Most likely finding on ECG?
AF
What 3 questions should be asked to assess asthma control
Difficulty sleeping
Do you get sx during day
Interfering with activities
25 year old man poorly controlled asthma
Currently taking salbutamol PRN and beclomethasone 200mcg BD
What should be done?
Trial a leukotriene receptor antagonist
Steps of asthma management
1 - short acting beta agnoist
2 - SABA + inhaled corticosteroid
3 - SABA + IC + LABA
4 - SABA + IC + LABA
- Increase corticosteroid to max dose
- add Leukotrine receptor antagnoist OR theophylline
5 - SABA + IC + LABA + LRA/T
-Oral corticosteroids
Refer to a respiratory specialist
4 year old girl has poorly controlled asthma
Currently taking salbutamol PRN and beclomethasone 200mcg BD
What should be done ?
Trial montelukast
Stages of paediatric asthma management
1 - as required SABA
2 - Regular preventer + Inhaled corticosteroids 200-400mcg daily
- if IC cannot be used -> Leukotrine receptor antagonist
3- aged 2-5 -> trial LRA or if already on LRA reconsider IC
Under 2 -> refer to respiratory physician
4 - refer to respiratory physician
26 year old woman recently found out she is pregnant
Asthma well controlled on salbutamol, beclomethasone 400mcg BD and salmeterol 50mcg bd
She is worried how the medication will affect her baby, what should she do?>
Continue as she is
There is no evidence asthma drugs are harmful in pregnancy
Which of these would indicate diabetes
Radom BM of 12 in patient with polydipsia
2 fasting BM of 7.5 in aSx pt
Random BM of 13 in asx
2 fasting BM of 6.5 in pt with polyuria and polydipsia
2 random BM of 10 in polyuria
A HbA1C > 48 in asx
Random BM of 12 in pt with polydipsia
2 fasting BM of 7.5 in asx
Hba1c >48
Diagnosis of diabetes?
Sx - fasting BM of >7.0mmol OR random >11.1 (or following GTT)
Asx - same but on 2 occasions
Or
HBA1C >48 - [ lower than his does not exclude Diabetes]
Which drug used in type 2 diabetes can cause hypoglycaemia ?
Gliclazide (sulphonylurea)
Diabetes side effect... Metformin Sulphonyureas Pioglitazone DD-4 inhibitors
M- GI upset and lactic acidosis
S - hypoglycaemia
P - weight gain
DD4i - rarely cause pancreatitis
What is DDP - 4 ? Eg?
Enzyme that destroys incretin which usually helps the body produce insulin and reduces liver glucose production
Sitagliptin
75 year 80kg woman presents with 3 days of
Confusion, polyuria, polydipsia
O/E she is dehydrated has a blood glucose of 42 and her serum osmolarity is 400mmol/L (high)
What should you do?
She is hyperglycaemic, hyperosmolar state which has a 50% mortality rate
Rehydrate with 0.9% saline
Which of these drugs does not improve mortality in chronic heart failure ? ACEI B blockers Aldosterone agonists (spironolacotne) Loop diuretics
Loop diuretics - improve sx but no effect on life expectancy
4 things on chest ray that indicate heart failure
ABCDE Alveolar oedema (bats wing) Kerley B lines Cardiomegaly Dilated upper lobe vessels Pleural Effusion
Patient with hx of HTN
Worsening SOB over 2 months
Never had an MI
CXR, spirometers and basic bloods are all normal
What is appropriate next investigation ?
B-type natriuretic peptide
ECG
Important DDx of first seizure
Febrile convulsion
Alcohol withdrawal
Psychogenic non-epileptic seizures
How can you avoid white coat syndome?
Ambulatory blood pressure monitoring
Home BP monitoring
Stage 1/2/severe HTN?
> 135/85
150/95
180/110
Taken either ambulatory / home BP
What factors would mean stage 1 hypertension was treated as stage 2?
End organ damage - ECG, U&Es, haematuria, fundoscopy
Established CVD
Diabetes
Renal pathology
10 year CVD risk >20% according to QRISK2
Mx of stage 1 HTN?
Lifestyle
Smoking, exercise, diet, alcohol, relaxation
Mx of stage 2 HTN? 1/2/3/4/5 line
1st Line
≤55 years = ACEi (Ramipril, Lisinopril)
>55 years or Afro-Carribean = CCB (Amlodipine, Verapamil)
2nd Line
Add the other
3rd Line
Add thiazide-like diuretic
4th line
Potassium <4.5mmol/l -> spironolactone
Potassium >4.5mmol/l -> increase dose of thiazide like diuretic
5th line
Refer for expert advice
In GP surgery, person comes in saying they feel their heart is racing, a bit more breathless than usual., pulse is irregular and you do an ECG and see this:
Absent p waves, variability in the R-R intervals irregularly irregular QRS complexes
Likely cause? RF?
Other cause of irregular pulse?
AF
HTN, coronary artery disease, valvular heart disease, sepsis, alcohol, PE, thyrotoxicosis
Ventricular ectopics, sinus arrhythmia
2 parts of AF treatment in a haemodynamically stable patient? What is the aim of these?
Rate control - b blockers or CCB (diltiazem > verapamil)
-to reduce the myocardial metabolic demands
Rhythm control
- young patients, new AF -> cardioversion
- IV amiodarone or fleicanide (CI in structural heart disease)
- DC cardioversion
Worrying features in AF?
What would you do if haemodynamically unstable?
Heart failure, decreased BP, chest pain, decreased GCS
Haemodynamically unstable: O2, DC Cardioversion
What important consideration at all rate control strategies in AF? Why? When else do you consider it? How to decide?
In all control strategies and prior to cardioversion must consider anticoagulation as risk of embolism is highest during switch from AF to sinus
CHA2DS2 Vasc Score
When can people have cardioversion in AF?
If they have had a short duration of Sx (<48HRS)
Or if they have been anticoagulated first
Parts of CHADSVASc
Congestive heart failure - 1 Hypertension >140/90 - 1 Age >75 - 2 Diabetes melitus -1 Prior TIA / Stroke - 2 Vascular disease (MI, aortic plaque...) -1 Age - 65-74 - 1 Sex category - female - 1
Mx of scores in CHA2DS2VASC
1 - consider anticoagulation if male
>2 - offer anticoagulation: NOAC / warfarin (INR 2-3)
Egs of NOAC ?
Novel anti coagulation
Rivaroxaban, apixaban, dabigantran
Score for bleeding risk on anticoagulants? What do the parts stand for? When is there a high risk of bleeding?
HAS BLED
Hypertension >160
Abnormal renal function (dialysis / creatinine >200)
OR Abnormal liver function (cirrhosis, bilirubin >2 times normal, ALT,ASP,ALP >3 times normal
Stroke - Hx of
Bleeding - tendency to bleed
Laiable INR - unstable / high
Elderly >65
Drugs for bleeding - antiplatelets, NSAIDs
Or Alcohol >8 drinks / week
All score 1 point
>3 = high risk
Patient presenting with heart failure… What would you do it they have had a previous MI? Had not?
Previous MI - urgent trans thoracic echo
Not - measure serum BNP
>400pg/ml -> urgent transthoracic echo
100-400 - transthoracic echo within 6 weeks
Heart failure ix and what is seen?
12 lead ECG - ischaemia, hypertrophy
CXR - Alveolar oedema, kerley B lines, cardiomegaly, upper lobe Diversion, pleural Effusion
Bloods - FBC, U&E, LFTs, TFT, eGFR, lipid profile, glucose
Urinalysis
Peak flow / spirometers
When would you refer heart failure to MDT ?>
New Diagnosis
Severe
Unable to manage in primary care
Co morbid vascular disease
What should you screen for at diagnosis of HF
Depression
NYHA classification of heart failure ?
1 - No symptoms or limitation to daily activities
2 - Mild symptoms and slight limitation of daily activities
3 - Marked symptoms, limitation on daily activities, only comfortable at rest
4 - Severe symptoms, uncomfortable at rest
1st, 2nd, 3rd line mx of heart failure? Any things to remember? What combination is good for Afro-carribean pt?
1 - ACEi + B-blocker (measure eGFR and U&Es before starting ACEi)
2- begins spironolactone
-ARB may be used in unresponsive cases
Hydralazine + nitrate may be good for Afro-Caribbean
3- digoxin
Ivabradine
What other aspects of management are needed in heart failure? Who is involved in community support?>
Yearly flu vaccine, pneumococcal vaccine
Manage ischemic / valvular co morbidity
Consider defibrillator if arrhythmic
Advance care planning
Community support
- named go
- advanced nurse practitioners
- district nurses
- third sector
- family
- counselling
- palliative services (worse prognosis then most cancers)
- community mental health teams
Factors which would make angina unlikely?
Continuous / prolonged pain
Unrelated to activity
Brough on by breathing in
Associated wit dizziness, palpitations, tingling or difficulty swallowing
1 / 2 mx of angina ? What else to consider in 2ndary?
3rd? What else can you consider
1- sublingual glyceryl trinitrate
+b-blocker / CCB
May add or switch 1st line
2 - If combining a b blocker and CCB -> use long acting CCB eg modified release nifedipine
3- ivabradine
[long acting nitrates, nicorandil, ranolazine, trimtazine]
Consider angiogram -> PCI stenting / CABG
[percutaneous coronary intervention, coronary artery bypass graft]
How does ivabradine work? Side effects?
Acts on ion channels in SA node -> reduces heart rate
Visual effect especially luminous phenomena, headache, bradycardia
Which drugs cant be prescribed together in angina and why?
Verapamil + b-blocker
Risk of complete heart block
Bar managing the angina what other aspect of treatment is there for angina and what do you use?
Prevention of ACS
Lifestyle, risk factors and education
Aspirin, statin [consider ACEi / ARB]
Should receive asprin and statin if no CI
Sx of COPD
SOBOE Chronic cough w sputum Wheeze Bronchitis (more than two winters) Apnea Fatigue Weight Loss Haemoptysis Recurrent infections
When would you perform spirometery in COPD? What is the key measure of diagnosis? What scale is used and what score?
> 35, current / ex-smoker, chronic cough
FEV1 to FVC ratio
GOLD Scale: 1 - Mild - ≥0.8 2 - Moderate - 0.5-0.79 3 - Severe - 0.3-0.49 4 - Very Severe - <0.3
Medical research council scale of SOB levels?
1 - With strenuous activity 2 - With vigorous walking 3 - With normal walking (level at which NICE recommends rehab) 4 - After walking for several minutes 5 - On changing clothing
COPD early management? Acute? When to use ABx? Common infections?
Pulmonary rehab
Aim for BMI 20 - 25 (may need to increase)
Stop smoking (key intervention)
Vaccinations (yearly flu and pneumococcal)
Acute
Increase bronchodilator use
Steroid, no antibiotics unless positive sputum sample
Common organisms: H. Influenzae [key], Strep Pneumoniae, Maroxella Catarrhalis
What happens in T1DM
Autoimmune destruction of insulin-producing beta cells of pancreatic islets of Langerhans -> absolute insulin deficiency
Diagnosis of DM in Sx patient ? Asx? Why does HBA1C <48 not exclude DM?
Symptomatic patient
fasting glucose ≥ 7.0 mmol/l
random blood glucose ≥ 11.1 mmol/l (or after 75g OGTT)
HbA1c >48 (6.5%)
In an asymptomatic patient one of the above must be demonstrated on 2 separate occasions
not as sensitive test as Fasting blood glucose and results can be misleading in conditions whre there is increased RBC turnover
Management of T1DM
Individual care plan
Insulin: mixture of short and long acting insulin e.g. Novorapid boluses and Detemir BD
Annual reviews: BP, renal function, eye check, foot check
Target HbA1c <48 mmols/mol
3 main parts of T2DM management?
Blood glucose control
Monitor and treat microvascular complications
Modify RF for CVD – BP, lipids
QRISK
Usual initial weight loss target in T2DM? What dietary advice do you give?
5-10%
High fibre, low GI carbs, lower sat fat but can include low fat dairy and fish
Metformin S/E? Weight change? Hypoglycaemia risk? C/I? How does it work?
S/E: GI upset, risk of lactic acidosis if impaired renal function
Weight neutral
No risk of hypoglycaemia
C/I: recent tissue hypoxia, CT contrast within 48h
Increase insulin sensitivity, hepatic gluconeogensis and GI absorption of CHO
Metformin and HBA1C >58 next step?
Metformin + Sulfonylurea / DPP4i / SGLT2i / Pioglitazone
Sulfonylureas
Eg? S/E? Anything to remember? CI? Mechanism?
S/E: weight gain, hypoglycaemia, SIADH, peripheral neuropathy
Only effective if some functioning beta cells present
C/I: breast feeding, pregnancy
Bind to beta cell receptors and stimulate insulin release so only effective if you have some functioning beta cells left
Poiglitazone
S/E? Anything to remember? C/I? Mechanism ?
S/E: weight gain, # risk, bladder cancer
Need LFT monitoring
C/I: heart failure (fluid retention)
PPARgamma receptor aggonist – increases adipogenesis and improves insulin sensitivity
SGLT2 inhibitor Egs?
S/E? Mechanism ?
‘flozins’: dapaglifozin, canaglifozin
S/E: UTI, thrush, euglycaemic ketoacidosis
Weight loss
Block renal absorption of glucose
DPP4 inhibitors eg? Weight? Hypo? Mechanism ?
‘gliptins’: sitagliptin, vildagliptin
Weight neutral, no risk of hypoglycaemia
prevents GLP1 degradation and therefore inhibits glucagon secretion
Full T2DM treatment pathway
Metformin tolerated - HBA1C target 48
Hba1c >58
Dual therapy - HBA1C target 53
-> triple therapy
Triple therapy not tolerated / ineffective
-> BMI<35 - INSLUIN
Bmi>35 GLP1 agonist Eg exenatide
GLP1 mimetics eg Exenatide
S/E? CI? Mechanism?
S/E: nausea/vomiting, severepancreatitis
Weight loss
C/I: breast feeding, pregnancy
Preserves beta cells, increases insulin secretion and inhibits glucagon
Pathway if metformin not tolerated? HBA1C targets?
Sulphonyurea (HBA1C target 53) OR DPP4i / pioglitazone (HBA1C target 48)
IF hba1c >58
-> dual therapy
Target 53
If HBA1C >58
-> insulin
67 year old man comes into your GP surgery saying he’s been feeling under the weather and has lost his appetite.
He’s been feeling more tired and achey recently but put it down to ‘getting older’. He’s also been feeling generally itchy and has been getting twitchy legs at night.
PMH: HTN
Diagnosis? Common features? Main complication to look out for?
CKD
Uraemic features : anorexia, vomiting, restless legs, fatigue, weakness, bone pain, oedema, pruritis, men – impotence, females – amennorhoea., yellow tinge skin – rare!
Main complications to look out for: encephalopathy,
RF for ckd
Most common causes in the UK: Hypertension, DM
Others: RAS, glomerulonephritis, adult PKD, SLE
20%: unknown cause
CKD staging?
When can you diagnose CKD in stage 1 and 2?
1 - GFR >90ml/min with signs of kidney damage on other tests 2 GFR 60-90 3a: 40-59 3b: 30-44 4: 15-29 5: <15
Can only diagnose CKD in stages 1 and 2 if abnormal U+E, proteinuria or haematuria i.e. evidence of renal damage
Eg of a reversible cause of CKD? Management considerations ? When to refer to nephrology? What do you want to check? What if CKD management part of CVD management?
Diet in CKD?
Medications, Blockage, Reduced blood flow
Limit progression/complications target BP 130/80, renal osteodystrophy, CVD
Symptom control -> anaemia, oedema, restless legs
Refer to nephrology when eGFR <30
Want to check PTH, calicum, alk phosphate.
Offer a statin and an antiplatelet to patients with CKD as part of secondary prevention of cardiovascular disease – decreased eGFR is an independent risk factor for CVD.
Diet – avoid foods with high potassium and phosphate,
73yr old lady, currently on lisinopril and felodipine, her clinic and ABPM are consistently >150/90. What should be added next?
Name two groups of medications that can be used for rate control in AF and an example of each?
What agent reverses warfarin? NOAC?
Thiazide like diuretic eg Indapamide
B blocker (any apart from SOTALOL), Rate limiting CCB (non-dihydropyridine) e.g. diltiazem, cardiac glycoside e.g. digoxin
VIT K, Beriplex
Interpret this ABG: 65 yr old man brought into A&E with an exacerbation of COPD. On 28% oxygen via simple facemask. pH 7.35 PaO2 7.3 PaCO2 11.2 HCO3 36.0
Type 2 resp failure as bicarbonate is increased
What oxygen saturations are the target for COPD patients on oxygen therapy?
Three things that require annual review in a diabetic?
If an asymptomatic patient has an incidental random plasma glucose test done with a result of 12.0 what does the result of his GTT have to be to be diagnosed as diabetic?
88-92%
Renal function, hba1c, bp, eyes, feet
>11.1
Paeds asthma >5
1 SABA
2 SABA +ICS
3 Add long acting B2 agonist (Salmeterol)
4 Consider leukotriene receptor antagonist
Increase dose of inhaled steroid
Add oral low dose steroid (prednisolone) + refer
Sodium / Acid / Alkalosis in dehydrations and causes?
Metabolic acidosis – Bicarbonate loss in diarrhoea/shock with lactic acidosis
Metabolic alkalosis – Loss of H+ ions from vomiting in pyloric stenosis
Hyponatraemia – Na high Diarrhoea– Child is lethargic and skin feels dry
Hypernatraemia – Water high Diarrhoea – Child is thirsty and skin feels doughy
Maintenence fluids
4ml/kg/hour for first 10kg
2ml/kg/hour next 10kg
1ml/kg/hour for rest
side effects of chemo
Tumour lysis syndrome – The breakdown of large numbers of malignanct cells can lead to high urate, phostpahte and potassium serum levels. Urate can cause renal failure and allopurinol/hydration should be used to prevent this.
Bone marrow suppression (can be congenital too) – Anaemia/thrombocytopenia (bruising/bleeding) can be treated with infusions. Neutropenia needs broad spec antibiotics at any sign of infection.
Long term – Subfertility, nephrotoxicity, deafness, pulmonary fibrosis, cardiomyopathy.
3 options for management of hyperthyroid?
Carbimazole
Radioactive iodine
Surgery
