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Phase 3a > GP/community 3 > Flashcards

GP/community 3 Flashcards

1
Q

what is the recommended alcohol intake per week?

A

14 units per week for both men and women

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2
Q

what are some risk factors for alcohol misuse?

A

more common in men
combination of social, psychological and environmental
previous history, family history, emotional/family problems, drug issues

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3
Q

what are some problems associated with alcohol misuse?

social, physical, mental health

A

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

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4
Q

what are some clinical presentations of alcohol misuse?

A
  • Increased and uncontrolled blood pressure
  • Excess weight
  • Recurrent injuries/accidents
  • Non-specific GI complaints
  • Poor sleep
  • Tremore
  • Sweating, slurring of speech
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5
Q

what screening tool can be used for alcohol misuse?

A

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

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6
Q

what test can be done for alcohol misuse?

A

elevated serum gamma GT, AST and ALT

raised red cell mean corpuscular volume (MCV)

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7
Q

when does alcohol withdrawal start?

A

10-72 hours after the last drink

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8
Q

what is delirium tremens?
what are the symptoms
how is it managed?

A

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
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9
Q

how do you manage alcohol withdrawal?

A

IV vitamin B
reducing regimen - benzos - chlordiazepoxide over 1 week period
correct dehydration and electrolyte imbalance

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10
Q

what are the contraindication to detoxification in the community?

A

confusion/hallucinations
history of previously complicated withdrawal e.g. delirium tremens
epilepsy or fits

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11
Q

what is an addiction?

A

Craving, tolerance, compulsive drug-seeking behaviour, physiological
withdrawal state

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12
Q

what are the physical, social and psychological effects of dependent drug use?

A

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

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13
Q

how does heroin work and how often does in need to be used?

A

acts on opiate receptors

appox 8 hourly

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14
Q

how is heroin taken?

A 
smoking 
snorting 
oral 
IV 
SC
IM
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15
Q

what are the effects of heroin?

A

euphoria
intense relaxation
miosis
drowsiness

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16
Q

what are the adverse effects of heroin ?

A

dependence and withdrawal symptoms
physical complications - nausea, itching, sweating, constipation
overdose

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17
Q

what is the mode of action of crack cocaine?

A

blocks reuptake of mood enhancing neurotransmitters (serotonin and dopamine) at the synapses resulting in an intense pleasurable sensation

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18
Q

how can cocaine/crack cocaine be taken?

A

oral
snorting
smoking
IV

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19
Q

what are the effects of cocaine?

A

confidence, well being, euphoria, impulsivity, increased energy, alertness, impaired judgement, decreased need for sleep

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20
Q

what are the adverse effects of cocaine?

A

may produce anxiety, hypertension and arrhythmias
subsequent crash- dysphoria
chronic effects: depression, panic, paranoia, psychosis, damaged nasal septum, CV event

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21
Q

what is the basic harm reduction actions to prevent deaths in drug users?

A
  • not injecting or injecting more safely
  • not mixing respiratory depressants
  • not using drugs alone
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22
Q

what are the basic harm reduction actions to prevent blood borne virus transmission?

A

not sharing needles etc
safer sex
provision of hepatitis A and B vaccination blood bourne virus screen including hep C

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23
Q

how is quick detoxification of drugs carried out?

A

for younger users, using heroin or other opiates, less time addicted, often not injecting use BUPRENORPHINE

for sta

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24
Q

how is stabilisation and maintenance detoxification done?

A
  • 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
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25
Q

how do you treat crack cocaine addiction?

A

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

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26
Q

how is drug addiction relapse prevented?

A

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

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27
Q

what are the withdrawal symptoms of opiates/opiods?

A

profuse sweating, tachycardia, dilate pupils, leg cramps, diarrhoea and vomiting may be reduced by giving methadone

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28
Q

what is the clinical presentation of an opioid overdose?

A

pinpoint pupils
reduced respiratory rate
coma
in severe cases there may be hypothermia, hypoglycaemia and convulsions

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29
Q

how do you manage an opioid antagonist ?

A

give an opioid antagonist every 2 minutes until breathing is adequate

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30
Q

what is CKD?

A
  • 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
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31
Q

what is the classification of CKD?

A

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

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32
Q

what is suggestive of renal damage?

A

proteinuria, haematuria or evidence of abnormal anatomy or systemic disease

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33
Q

what are some causes of CKD?

A
  • 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
34
Q

what are some risk factors for CKD?

A
  • DM
  • HTN
  • old age
  • CVD
  • renal stones
  • recurrent UTIs
  • proteinuria
  • AKI
  • smoking
  • African, afro-Caribbean or Asian origin
  • chronic use of NSAIDs
35
Q

how might CKD present?

A
  • 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,
36
Q

what are the complications of CKD?

A

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
37
Q

how is CKD diagnosed?

A

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
38
Q

what are the aims of CKD treatment?

A
  • 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
39
Q

how is CKD managed?

A
  • 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
40
Q

what are the indications for dialysis?

A

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

41
Q

what are the different renal replacement therapies?

A 
renal transplant 
dialysis 
hemofiltration 
haemodialysis 
peritoneal dialysis
42
Q

what is AF?

A

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)

43
Q

what is the clinical classification of AF?

A

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

44
Q

what are causes of AF?

A
  • 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
45
Q

what are the risk factors for AF

A
  • Older than 60
  • Diabetes
  • High blood pressure
  • Coronary artery disease
  • Prior MI
  • Structural heart disease (valve problems or congenital defects)
46
Q

how does AF present?

A
  • 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
47
Q

how is AF diagnosed?

A

ECG - absent P waves

irregular and rapid QRS complex

48
Q

how is AF managed ?

A
  • 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

49
Q

what scoring system can be used to calculate stroke risk and thus the need for anticoagulation ?

A 
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
50
Q

what is angina?

A

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

51
Q

what are the two types of angina?

A

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

52
Q

what can cause angina?

A 
atheroma/stenosis of coronary arteries 
valvular disease 
aortic stenosis 
arrhythmias 
anaemia 
ischaemic metabolites including adenosine
53
Q

RF for angina?

A 
smoking 
sedentary lifestyle 
obesity 
DM 
fam history 
hypercholesterolaemia
54
Q

how does angina present?

A
  • 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
55
Q

DD for angina?

A 
pericarditis/myocarditis 
pulmonary embolism 
chest infection 
dissection of the aorta 
GORD
56
Q

how is angina diagnosed?

A

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

57
Q

how is angina treated?

A 
modify risk factors 
treat underlying conditions
aspirin 
statins 
BB
GTN spray (glyceryl trinitrate)
revascularisation (PCI, CABG)
ACE inhibitors
58
Q

what is angiotensin 2 receptor blocker used for?

what are some examples ?

A 
indicated for hypertension, diabetic neuropathy and heart failure when ACE inhibitors are contraindicated 
ARB's end in sartan 
examples 
- candesartan 
- losartan
59
Q

what are the main adverse effects of ARB’s ?

A
  • systemic hypotension
  • hyperkalaemia
  • potential renal dysfunction
  • rash
  • angio-oedema
  • contraindicated in pregnancy
  • they are generally very well tolerated
60
Q

what are CCB used for and what are some examples?

A
  • indicated for hypertension, ischaemic heart disease (angina) and arrhythmias
    amlodipine
    verapamil
    nifedipine
61
Q

what are the adverse effects of CCB?

A
  • 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
62
Q

when are BB used and what are some examples of BB?

A

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

63
Q

what are the main adverse effects of BB?

A
  • Fatigue
  • Headache
  • Sleep disturbance/nightmares
  • Bradycardia
  • Hypotension
  • Cold peripheries
  • Erectile dysfunction
  • Bronchospasm
  • worsening of asthma, COPD, PVD, heart failure
64
Q

when are diuretics used?

A

hypertension and heart failure

65
Q

what are the different classes and examples of diuretics?

A

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

66
Q

what are the main adverse effects of diuretics ?

A
  • 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)
67
Q

what antibiotic would you give for exacerbation of chronic bronchitis?

A

amoxicillin or clarithromycin

68
Q

what antibiotic would you give for uncomplicated CAP?

A

amoxicillin
doxycycline or clarithromycin if penicillin allergic
ADD flucloxacillin if staphylococci suspected e.g. influenza

69
Q

what would you give for pneumonia caused by atypical pathogens?

A

clarithromycin

70
Q

what antibiotic for HAP?

A
  • WITHIN 5 days of admission - Co-amoxiclav or Cefuroxime

* MORE than 5 days after admission - Ceftazidime or Ciprofloxacin

71
Q

what antibiotic for lower UTI?

A

trimethoprim or nitrofurantoin

72
Q

what antibiotic would you give for skin? e.g. cellulitis?

A

flucloxacillin

clarithromycin or clindamycin if penicillin alergic

73
Q

what should antibiotic should you give for C.Diff infection

A

first episode - metronidazole

second or subsequent episodes - vancomycin

74
Q

what are the side effects of amoxicillin?

A

rash with infection mononucleosis

75
Q

what are the side effects of co-amoxiclav?

A

cholestasis

76
Q

what are the side effects of flucloxacillin ?

A

cholestasis - usually develops several weeks after use

77
Q

what are the side effects of ciprofloxacin?

A

lowers seizure threshold

tendonitis

78
Q

what are the side effects of metronidazole?

A

reaction following alcohol ingestion

79
Q

what are the side effects of doxycycline?

A

photosensitivity

80
Q

what are the side effects of trimethoprim ?

A

rashes
photosensitivity
suppression of haematopoiesis

Phase 3a (41 decks)

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