GP/community 3 Flashcards
what is the recommended alcohol intake per week?
14 units per week for both men and women
what are some risk factors for alcohol misuse?
more common in men
combination of social, psychological and environmental
previous history, family history, emotional/family problems, drug issues
what are some problems associated with alcohol misuse?
social, physical, mental health
social - marriage breakdown, loss of work, poverty, social isolation
physical - hypertension, CVA, cancer, hepatitis, fatty liver disease, cirrhosis
mental health - anxiety, depression and/or suicidal ideas, dementia and or Wernicke’s encephalopathy
what are some clinical presentations of alcohol misuse?
- Increased and uncontrolled blood pressure
- Excess weight
- Recurrent injuries/accidents
- Non-specific GI complaints
- Poor sleep
- Tremore
- Sweating, slurring of speech
what screening tool can be used for alcohol misuse?
CAGE:
- Ever felt you ought to Cut down on alcohol?
- Have people Annoyed you by criticising your drinking
- Ever felt bad or Guilty about your drinking?
- Ever had an Eye-opener to steady nerves in the morning?
- Yes to ≥ 2 helps detect dependency
• AUDIT questionnaire - particularly sensitive to less severe drinking
problems
what test can be done for alcohol misuse?
elevated serum gamma GT, AST and ALT
raised red cell mean corpuscular volume (MCV)
when does alcohol withdrawal start?
10-72 hours after the last drink
what is delirium tremens?
what are the symptoms
how is it managed?
DELIRIUM TREMENS - 15% mortality - medical emergency: due to alcohol withdrawal
- Fever, tachycardia, raised BP, raised RR
- Visual/tactile hallucinations e.g. animals crawling all over skin
- Tremor, fits, fluctuating levels of consciousness
- Treat with oral LORAZEPAM
how do you manage alcohol withdrawal?
IV vitamin B
reducing regimen - benzos - chlordiazepoxide over 1 week period
correct dehydration and electrolyte imbalance
what are the contraindication to detoxification in the community?
confusion/hallucinations
history of previously complicated withdrawal e.g. delirium tremens
epilepsy or fits
what is an addiction?
Craving, tolerance, compulsive drug-seeking behaviour, physiological
withdrawal state
what are the physical, social and psychological effects of dependent drug use?
physical: complications of injecting, poor pregnancy outcomes, side effects of opiates (constipation, low salivary flow), side effects of cocaine (vasoconstriction, local anaesthesia), blood borne virus transmission)
social - effects on family, driven to criminality, imprisonment, social exclusion
Psychological - fear of withdrawal, craving and guilt
how does heroin work and how often does in need to be used?
acts on opiate receptors
appox 8 hourly
how is heroin taken?
smoking snorting oral IV SC IM
what are the effects of heroin?
euphoria
intense relaxation
miosis
drowsiness
what are the adverse effects of heroin ?
dependence and withdrawal symptoms
physical complications - nausea, itching, sweating, constipation
overdose
what is the mode of action of crack cocaine?
blocks reuptake of mood enhancing neurotransmitters (serotonin and dopamine) at the synapses resulting in an intense pleasurable sensation
how can cocaine/crack cocaine be taken?
oral
snorting
smoking
IV
what are the effects of cocaine?
confidence, well being, euphoria, impulsivity, increased energy, alertness, impaired judgement, decreased need for sleep
what are the adverse effects of cocaine?
may produce anxiety, hypertension and arrhythmias
subsequent crash- dysphoria
chronic effects: depression, panic, paranoia, psychosis, damaged nasal septum, CV event
what is the basic harm reduction actions to prevent deaths in drug users?
- not injecting or injecting more safely
- not mixing respiratory depressants
- not using drugs alone
what are the basic harm reduction actions to prevent blood borne virus transmission?
not sharing needles etc
safer sex
provision of hepatitis A and B vaccination blood bourne virus screen including hep C
how is quick detoxification of drugs carried out?
for younger users, using heroin or other opiates, less time addicted, often not injecting use BUPRENORPHINE
for sta
how is stabilisation and maintenance detoxification done?
- Opiate user, long time addict, usually injecting:
• Use METHADONE
• Titrate from a low starting dose to maintenance dose until patient is fully comfortable for 24hrs and does not need to use heroin
how do you treat crack cocaine addiction?
there is no suitable medication available like wit opiates
harm reduction: advise on risky behaviour, safe sex advice, blood borne virus advice, hepB/C vaccination, education on harms effects of drugs
how is drug addiction relapse prevented?
support is essential
avoid benzos except in very short term
constantly relapsing patients may need stabilisation and maintenance to avoid revolving door
maintenance can be an effective step to long-term abstinence
what are the withdrawal symptoms of opiates/opiods?
profuse sweating, tachycardia, dilate pupils, leg cramps, diarrhoea and vomiting may be reduced by giving methadone
what is the clinical presentation of an opioid overdose?
pinpoint pupils
reduced respiratory rate
coma
in severe cases there may be hypothermia, hypoglycaemia and convulsions
how do you manage an opioid antagonist ?
give an opioid antagonist every 2 minutes until breathing is adequate
what is CKD?
- CKD is longstanding, usually progressive, impairment in renal function ( haematuria, proteinuria or anatomical abnormality) for more than 3 months
- defined as a GFR <60 for more than 3 months with/without evidence of kidney damage
what is the classification of CKD?
stage 1: >90 GFR (normal or raised GFR with other evidence of renal damage
stage 2: 60-89 GFR - slight decrease in GFR with other evidence of renal damage
stage 3a - 45-59, stage 3b - 30-44: moderate decrease in GFR with or without evidence of renal damage
stage4: 15-29
stage 5: <15 = established renal failure
what is suggestive of renal damage?
proteinuria, haematuria or evidence of abnormal anatomy or systemic disease
what are some causes of CKD?
- Diabetes mellitus - Type II > Type 1
- Hypertension
- Atherosclerotic renal vascular disease
- Polycystic kidney disease
- Primary glomerulonephritides e.g. IgA nephropathy
- SLE
- Amyloidosis
- Small and medium-sized vessel vasculitis
- Family history of stage 5 CKD or hereditary kidney disease e.g.
polycystic kidney disease - Idiopathic - 20% cases
what are some risk factors for CKD?
- DM
- HTN
- old age
- CVD
- renal stones
- recurrent UTIs
- proteinuria
- AKI
- smoking
- African, afro-Caribbean or Asian origin
- chronic use of NSAIDs
how might CKD present?
- often asymptomatic
- serum urea and creatinine are used as surrogates of accumulating metabolites
- symptoms common when serum urea conc exceeds 40mmol/L
- malaise
- anorexia and weight loss
- insomnia
- nocturia and polyuria
- itching
- nausea, vomiting and diarrhoea
- symptoms due to salt and water retention - peripheral or pulmonary oedema
- amenorrhea in woman and ED in men
- increased risk of peptic ulceration, acute pancreatitis,
what are the complications of CKD?
anaemia - normochromic, normocytic anaemia (due to reduced erythropoietin production by diseased kidney
- bone disease (bone pain, renal osteodystrophy, renal phosphate retention and impaired 125dihydroxy VD leads to skeletal decalcification)
- neurological: occurs in almost all patients with CKD - autonomic dysfunction presents with postural hypotension and disturbed GI motility, polyneuropathy resulting in peripheral paraesthesia and weakness , in advanced uraemia there is depressed cerebral function, myoclonic twitching and seizures
- CV - MI, HF, sudden cardiac death and stoke - causes the highest mortality in CKD - due to hypertension, hyperlipidaemia and vascular calcification
- skin disease - pruritus due to nitrogenous waste products of urea’s , brown discolouration of nails
how is CKD diagnosed?
ECG - for high potassium signs
- urinalysis: haematuria (indicates glomerular nephritis), proteinuria (if heavy suggests glomerular disease but can also be caused by infection) , midstream urine sample, albumin to creatinine ration or protein to creatinine ratio
- urine microscopy - granular casts = active renal disease, red cells = glomerulonephritis
- Serum biochemistry - low eGFR, U&Es (high urea and creatinine), raised alkaline phosphatase (renal osteodystrophy), raised PTH of CKD stage 3 or more
- bloods - raised phosphate low calcium, Hb low, raised viscosity
- immunology - autoantibody screening for SLE, scleroderma and good pastures, Hep B, C, HIV and streptococcal antigen tests
- imaging - USS, CT
- biopsy
what are the aims of CKD treatment?
- therapy is aimed at the underlying cause of renal disease e.g. immunosuppressive agents for vasculitis and tight metabolic control in diabetes
- slow the deterioration of kidney function
- reduce CV risk
- treat complications
how is CKD managed?
- identify and treat any reversible causes (relieve obstruction, stop nephrotoxic drugs, stop smoking, achieve health weight, tight glucose control.
- limit progressions and complications - control BP with antihypertensive, manage bone disease, gove statins and aspirin for CVD
symptom control - iron/folate/folic acid for anaemia, for acidosis - give sodium bicarbonate, for oedema give furosemide
what are the indications for dialysis?
symptomatic uraemia including pericarditis or tamponade
hyperkalaemia not controlled by conservative measures
pulmonary oedema that is unresponsive to diuretics
high potassium
tall T waves, low flat p waves, broad QRS or arrhythmias on ECG
metabolic acidosis
fluid overload that is resistant to diuretics
what are the different renal replacement therapies?
renal transplant dialysis hemofiltration haemodialysis peritoneal dialysis
what is AF?
a chaotic irregular atrial rhythm at 300-600bpm - the AV node responds intermittently hence the irregular ventricular rate
it can either be paroxysmal (self terminating) or persistent (continues without intervention)
what is the clinical classification of AF?
acute - onset within the past 48 hours
paroxysmal - stops spontaneously within 7 days
recurrent - two or more episodes
persistent - continuous for more than 7 days and is not self terminating
permanent
what are causes of AF?
- idiopathic
- any condition that results in raised arterial pressure, increased atrial mass, atrial fibrosis or inflammation and infiltration if the atrium may cause AF
- hypertension - HF
- coronary artery disease
- valvular heard disease
- cardiac surgery
- cardiomyopathy
- rheumatic heart disease
- acute excess alcohol intoxication
what are the risk factors for AF
- Older than 60
- Diabetes
- High blood pressure
- Coronary artery disease
- Prior MI
- Structural heart disease (valve problems or congenital defects)
how does AF present?
- Symptoms are highly variable
- May be asymptomatic
- Palpitations
- Dyspnoea and or chest pains following the onset of atrial fibrillation
- Fatigue
- NO P WAVES on ECG
- Rapid & irregular QRS rhythm
- Apical pulse rate is greater than the radial rate
- 1st heart sound is of variable intensity
how is AF diagnosed?
ECG - absent P waves
irregular and rapid QRS complex
how is AF managed ?
- acute management - when due an acute precipitating event such as alcohol toxicity the provoking cause should be treated
- cardioversion - sinus rhythm achieved with a defibrillator - give LMWH (delteparin) to minimise risk of VTE. If this fails then achieved medically by IV infusion of antiarrhythmic drug (flecainide or amiodarone)
- ventricular control rate - CCB, BB, digoxin, anti-arrhythmic
LONG TERM and stable patient management - can either be by rate control or rhythm control
RATE: BB, CCB, if above fails try digoxin and then consider amiodarone
RHYTHM: advocated in younger, symptomatic and physically active patients - cardioversion to sinus rhythm with BB to supress arrhythmia, pharmacological cardioversion e.g. flecainide or amiodarone if there is structural heart defects
use appropriate anticoagulation e.g. warfarin
what scoring system can be used to calculate stroke risk and thus the need for anticoagulation ?
CHADSVASC • Congestive heart failure (1 point) • Hypertension (1 point) • A2ge greater or equal to 75 (2 points) • Diabetes mellitus (1 point) • S2troke/TIA/thromboembolism (2 points) • Vascular disease (aorta, coronary or peripheral arteries) (1 point) • Age 65-74 (1 point) • Scex Category: female (1 point) • If score is 1 then it merits consideration of anticoagulation and or aspirin • If score is 2 and above then oral anticoagulation is required
what is angina?
chest pain or discomfort as a result of reversible myocardial ischaemia
usually implies narrowing of one or more of the coronary arteries
tends to be exacerbated by exertion and relieved by rest
what are the two types of angina?
stable (induced by effort and relieved by rest)
unstable (crescendo) - anginal of recent onset or deterioration in previously stable angina with symptoms frequently occurring at rest o angina of increasing frequency or severity, occurs with minimal exertion or even at rest - a form of acute coronary syndrome
what can cause angina?
atheroma/stenosis of coronary arteries valvular disease aortic stenosis arrhythmias anaemia ischaemic metabolites including adenosine
RF for angina?
smoking sedentary lifestyle obesity DM fam history hypercholesterolaemia
how does angina present?
- central chest tightness or heaviness
- provoked by exertion, especially after meals or in the cold windy weather
- relieved by rest of GTN spray
- pain may radiate to one or both arm, the neck, jaw or teeth
- may be dyspnoea, nausea, sweatiness and faintness
DD for angina?
pericarditis/myocarditis pulmonary embolism chest infection dissection of the aorta GORD
how is angina diagnosed?
12 lead ECG (often normal, may show ST depression, flat or inverted T waves, look for signs f past MI
treadmill test/exercise ECG
CT scan for calcium scoring
how is angina treated?
modify risk factors treat underlying conditions aspirin statins BB GTN spray (glyceryl trinitrate) revascularisation (PCI, CABG) ACE inhibitors
what is angiotensin 2 receptor blocker used for?
what are some examples ?
indicated for hypertension, diabetic neuropathy and heart failure when ACE inhibitors are contraindicated ARB's end in sartan examples - candesartan - losartan
what are the main adverse effects of ARB’s ?
- systemic hypotension
- hyperkalaemia
- potential renal dysfunction
- rash
- angio-oedema
- contraindicated in pregnancy
- they are generally very well tolerated
what are CCB used for and what are some examples?
- indicated for hypertension, ischaemic heart disease (angina) and arrhythmias
amlodipine
verapamil
nifedipine
what are the adverse effects of CCB?
- peripheral vasodilation (nifedipine and amlodipine) can lead to flusing, headaches, oedema, palpitations
due to negatively chronotropic effects (hear rate) mainly verapamil and diltiazem - brady cardia, AV block, postural hypotension
worsening cardiac failure
when are BB used and what are some examples of BB?
indicated for IHD, heart failure arrhythmias and hypertension
- BISOPROLOL
- PROPRANOLOL
- METOPROLOL
- ATENOLOL
if asthmatic use a B1 selective beta blocker as these will not act on the lungs (metoprolol or bisoprolol
what are the main adverse effects of BB?
- Fatigue
- Headache
- Sleep disturbance/nightmares
- Bradycardia
- Hypotension
- Cold peripheries
- Erectile dysfunction
- Bronchospasm
- worsening of asthma, COPD, PVD, heart failure
when are diuretics used?
hypertension and heart failure
what are the different classes and examples of diuretics?
Thiazides - (causes Na and thus water loss in the urine, they act on the distal tube) Bendroflumethiazide
loop diuretics (act on the loop of henle) - furosemide
potassium sparing diuretics - spironolactone
what are the main adverse effects of diuretics ?
- Hypovolaemia (mainly loop diuretics e.g. furosemide)
- Hypotension (mainly loop diuretics e.g. furosemide)
- Hypokalaemia
- Low serum sodium (hyponatraemia)
- Low serum magnesium (hypomagnesaemia)
- Low serum calcium (hypocalcaemia)
- Raised uric acid (hyperuricaemia - can result in gout (extremely painful)
- Erectile dysfunction (mainly thiazides e.g. bendroflumethiazide)
- Impaired glucose tolerance i.e. diabetes (mainly thiazides e.g. bendroflumethiazide)
what antibiotic would you give for exacerbation of chronic bronchitis?
amoxicillin or clarithromycin
what antibiotic would you give for uncomplicated CAP?
amoxicillin
doxycycline or clarithromycin if penicillin allergic
ADD flucloxacillin if staphylococci suspected e.g. influenza
what would you give for pneumonia caused by atypical pathogens?
clarithromycin
what antibiotic for HAP?
- WITHIN 5 days of admission - Co-amoxiclav or Cefuroxime
* MORE than 5 days after admission - Ceftazidime or Ciprofloxacin
what antibiotic for lower UTI?
trimethoprim or nitrofurantoin
what antibiotic would you give for skin? e.g. cellulitis?
flucloxacillin
clarithromycin or clindamycin if penicillin alergic
what should antibiotic should you give for C.Diff infection
first episode - metronidazole
second or subsequent episodes - vancomycin
what are the side effects of amoxicillin?
rash with infection mononucleosis
what are the side effects of co-amoxiclav?
cholestasis
what are the side effects of flucloxacillin ?
cholestasis - usually develops several weeks after use
what are the side effects of ciprofloxacin?
lowers seizure threshold
tendonitis
what are the side effects of metronidazole?
reaction following alcohol ingestion
what are the side effects of doxycycline?
photosensitivity
what are the side effects of trimethoprim ?
rashes
photosensitivity
suppression of haematopoiesis
