GP Clinic 3 Flashcards
Clarify is it one leg or both, risk factors for cardiovascular disease SOCRATES
Peripheral vascular exam, pulse, cap refill, abpi (Less than 0.9 is arterial disease, less than 0.5 is critical limb iscahemia)
What is peripheral arterial disease?
How to calculate ABPI?
With the person resting and supine (if possible): Record systolic blood pressure in both arms and in the posterior tibial, dorsalis pedis, and, where possible, peroneal arteries. Take measurements manually using a Doppler probe of suitable frequency in preference to an automated system. Calculate the index in each leg by dividing the highest ankle pressure by the highest arm pressure. An ABPI ratio of less than 0.9 indicates the presence of peripheral arterial disease (with some classifications using a threshold value of less than 0.5 for critical limb ischaemia), but a resting ABPI of more than 0.9 does not mean that peripheral arterial disease is not present. If the ABPI is high (1.3 or more), consider the possibility of peripheral arterial disease, particularly if the person has diabetes. The measured ankle cuff pressure may be falsely elevated in patients with calcified arteries (particularly occurs in diabetic and renal patients). An ABPI of >1.3 has been suggested as a strong indicator of calcification
6ps of acute limb ischaemia:
Don’t need all of these
Peripheral arterial disease classification:
What stage is he at?
=Intermittent claudication
What to discuss about management of intermittent claudication?
Conservative-lose weight, supervised exercise programmes, stop smoking
Medical-naftidrofuryl oxalate-vasodilator
History
- When it started
- Any changes in vision
- For falls history, cover before (chest pain, dizziness, triggers-eg any new medication), during (banged head, neck or hip) and after (confused)
- Ask about whether he had any prior injury which could have caused a foot drop
- How many falls has he been having?
what exactly happens around each fall (before, during and after – approach to falls hx)? • do you hit your head or have any other injuries? (and examine) Head injury, neck/c-spine/hip • did anything trigger the falls to start? did you bang your knee before the falls began? (i.e. foot drop causing falls from a prior CPN traumatic injury) • do you get any light-headedness? • how do you find getting about at home normally? • How many falls? Recurrent? Falls clinic referral etc
Unlateral tremor-parkinsons
Parkinsonism vs Parkinsons
Parkinsonism is a triad of symptoms: bradykinesia, tremor (pill rolling, 4-6Hz) and rigidity
Parkinson’s disease is the most common cause of parkinsonism but other things can cause this eg cerebrovascular disease, lewy body dementia, drugs etc.
Other symptoms of Parkinson’s
Motor complications of parkinson’s or parkinson’s management=falls, immobility, wearing off fluctuations, communication issues, slowness
Non-motor complcations-depression, anxiety, dementia, hallucinations, psychotic symptoms, sleep difficulties
Wait for confirmation of parkinson’s disease by specialist rather than giving treatment at GP. Don’t delay referral and don’t change medication as can induce akinesia or neuroleptic malignant syndrome.
Falls
Multifactorial risk assessment if had more than 2 falls and over 65, or hospitalised for fall etc.
GP head injury referral guide to A and E if any of the following
These are the questions to ask in a head injury history.
Read guidelines
- Could she be pregnant
- Loin pain-pyelonephritis from UTI
- Colour and smell
- Sexual history
- Suggest to pass urine after sex
- Do an exam if worried about sepsis and to look for loin pain/renal angle tenderness (pyelonephritis)
- Do an MSU as she is having frequent urinary infections and you want to check she isn’t having any resistance. Do MSU and start them on broad spectrum antibiotics.
Management options for recurrent UTIs:
When do we say it is recurrent?
Recurrent-2 or more in last 6 months or 3 in a year
Consider for underlying cause-HbA1c, residual volume bladder scan (urine stasis is more likely to get infected), HIV/immunosuppression test.
-dark urine cause-passing small amounts due to irritation, or bacteria can change colour and smell, or dehydrated which could be the cause in the first place.
UTI
-Older age-less able to communicate symptoms, catheters insitu
Risk factors in post-menopausal women and elderly women - Hx UTI pre-menopause - Urinary incontinence - Atrophic vaginitis - Cystocele - Increased post-void urine volume - Urine catheterisation and reduced functional status in elderly institutionalised women
Cough less than 3 weeks is acute
- viral-cold or flu or covid
- LRTI
Chronic cough
- Asthma
- post nasal drip
- Reflux
Most likely to be community acquired pneumonia. Would want to risk stratify her using CURB-65. In GP so Urea is not included.
Would be 2 as BP less than 90 or diastolic of 60 or less. So age and diastolic BP. But beyond CURB we are worried about other factors eg high heart rate and low BP-edging towards danger/sepsis, especially as she is a not smoker.
Can send her to A and E, treat in community or in the middle we could send her to ambulatory care.
Prescribing for CAP:
What antibiotic would you prescribe? For moderate severity (based on clinical judgement and guided by CRB65 score 1-2) and guided by microbiological results when available: 1st line amoxicillin 500mg tds for 5 days If penicillin allergic: clarithromyicin 500mg bd for 5 days
Take a full history. In particular, ask about: Onset of symptoms. Duration of cough. Frequency of cough. Type of cough (dry or productive). Precipitating or exacerbating factors. Associated symptoms – throat, chest, gastrointestinal. Diurnal variation. Smoking history. Environmental factors. Occupational history. Family history. Recent respiratory tract infection. Recent travel history.
NSAIDs-important risk of asthma
Viral illness, exercise, season change, cold weather, extreme emotion, damp, pets, smoking
Asthma diagnostic tests:
Asthma:
Now gold standard is low dose
Chronic cough red flags:
BTS Asthma guidelines
Inhalers and carbon footprint:
Asthma acute exacerbation
Assessing asthma severity
Community management of acute asthma exacerbation
Hospital management of acute asthma exacerbation
