GP Core Conditions Flashcards
Dx asthma
1) Gold standard
2) Others (X2)
1) Spirometry FEV1:FVC <0.7
2)
Clinical Dx- recurrence, wheeze, diurnal variation, Atopy in FHx
PEFR- Best of 3 within 40L/min; 2 readings/day for 2 weeks
Asthma annual review- what 4 things do you cover?
1) Symptom control- sleeping? Symptoms during day? Interference with activities and cotrico use/time off
2) Lung function- PEFR/Spiro if needed
3) Check inhaler function/Compliance
4) Asthma action plan- 2 cans of Salbutamol/Month is poor control- intensify therapy
Step wise treatment of chronic asthma (BTS guidelines)
~6 steps
1) Short acting B2 agonist
2) ICS- Beclometasone 200-800mg
3) + LABA (Salmetrol)
4) Increase ICS dose to max 800mg
5) Leukotriene R antagonist or sustained release theophylline
6) Referral, 4th drug? Inc ICS
What are 4 signs of poor asthma control; indicating escalation to ICS therapy from SABA?
1) 3+ Uses of SABA/week
2) Symptoms 3+ times/week
3) Waking >1 time a week
4) An exacerbation in the last 2 years
COPD- How are these signs/symptoms different in Emphysema and bronchitis?
1) SOB
2) Cyanosis
2) Weight loss
1) SOB early and severe in Emphysema
2) Bronchitis cyanosed
3) Emphysema more likely to have muscle wasting and significant weight loss
Role of spirometry in COPD?
FEV1/FVC?
1) Dx
2) Monitor progression w/ other factors
FEV1?FVC <0.7
Staging of COPD using FEV1- what are the stages?
% of predicted
1) >80%
2) 50-79%
3) 30-49%
4) < 30% (<50% + risk factors)
Comment on the uses of the below in COPD Dx
1) Reversibility testing
2) Key signs
3) Post-bronchodilator spirometry
4) FBC, BMI, CXR
1) Not needed; only useful if ?Asthma
2) Accessory muscle use, cricosternal distance <3cm, Dec sounds, no diurnal variation
3) Reconsider Dx if marked improvement in symptoms
4) PCV, Anaemia
Low
Exclude other Dx
In COPD what should happen to FEV1/FVC with inhaled therapy?
Should NOT normalise- NO reversibility
5 grades of the Medical Research council dyspnoea scale
Grade 1: not troubled by breathlessness except on strenuous exertion.
Grade 2: short of breath when hurrying on level ground or walking up a slight incline.
Grade 3: walks slower than contemporaries because of breathlessness, or has to stop for breath when walking at own pace.
Grade 4: stops for breath after walking about 100 metres or stops after a few minutes of walking on level ground.
Grade 5: too breathless to leave the house or breathless on dressing or undressing.
COPD management
1) What vaccine are needed? (2X)
2) Lifestyle advice
3) Criteria for Rehabilitation?
1) Pneumococcal/Influenza
2) Stop smoking, encourage mobility, Good diet to ameliorate Wx loss
3) MCP >/= 3 or symptoms infringe on QoL
Chronic COPD management
1) 1st line
2) The presence of what feature decides how you should escalate
3) 2nd Line
4) Triple therapy?
1) SABA or SAMA (Ipratropium)
2) Asthmatic features (PEFR/diurnal variation) as this indicates ICS responsiveness
3) No asthmatic features add LAMA (Tiotropium) Or LABA
Asthmatic features= LABA + ICS
4) LABA +LAMA + ICS
Chronic COPD management- What 2 drugs should you never use together?
SAMA and LAMA
ECG signs of AF
Irregularly irregular PR
Absent P waves
Indications for a transthoracic echo in AF?
Check for emboli before cadioversion
Suspicion of structural/functional abnormality
When is a transoesophageal Echo needed in AF?
After transthoracic shows an abnormality
Transthoracic technically difficult
TRO guided cardioversion
Treating chronic AF- RATE control
1) Monotherapy?
2) Intensification?
1) Beta blocker or diltiazem (CCB)
2) Combine the above or add digoxin
Treating chronic AF- RATE control
1) What specific type of AF is digoxin best for?
Non-paroxysmal and pt is sedentary
Treating chronic AF- RATE control
1) HR target?
2) What does this change to if symptomatic?
1) <90 (Consider <110)
2) <80
Treating chronic AF- Rhythm control
1) When is this indicated?
1) Symptomatic, young, 1st presentation with lone AF, rate control is inadequate
Treating Chronic AF- Rhythm control
1) 1st line for rhythm control
2) Alternatives to above
1) Beta blocker (CI if asthmatic!)
2) Dronedarone or Amiodarone
Treating chronic AF- Rhythm control
1) Indications for Dronedarone
1) Successful Cardioversion, Paroxysmal/persistent AF, if 1st line rhythm control fails, IHD/TIA/DM/HTN/>70
Treating chronic AF- Rhythm control
1) Why would you consider Amiodarone> Dronedarone
1) LV impairment or HF
Treating chronic AF- Pill in the pocket
1) Indications?
2) CI?
1) Known precipitants, infrequent attacks
2) LVD, VHD, IHD in PMHx
Treating chronic AF- Anticoagulation
1) What scoring systems do you use? (2)
2) What do they assess?
CHA2DS2- VAD- Stroke risk
HAS-BLED- Bleeding risk
Treating chronic AF- Anticoagulation
1) CHA2DS2- VAD score needed for anticoagulation
2) HAS-BLED score that indications caution
1) Males= 1 Females = 2
2) Greater than or equal to 3
Treating Acute AF- What is indicated when…
1) < 48hrs + Haemodynamic instability
2) < 48 hrs + stable
3) > 48 hours
1) Electric cardioversion
2) Consider managing as >48 hrs
3) Cardioversion (DC or flecoinide) +/- Amiodarone (stating 4 weeks before)
Most common duration of TIA symptoms?
10-15 mins
Must be less than 24 hours to be TIA
Different categories of symptoms to consider for TIA/Stroke
Motor Sensory Meningism Pain Speech Cognition Consciousness Sight
What global symptoms make TIA less likely as the aetiology?
Unsteadiness
Dizzy
Syncope
Key stroke mimics?
Hypoglycaemia Migraine Seziure Bell's palsy MS ?Sepsis
CT target if stroke likely?
1 hr
What anti-platelet is indicated, and for how long, in TIA
300mg aspirin for 14 days
then an assessment within 24hrs by a specialist
TIA secondary prevention?
Lifestyle- Smoking and alcohol reduction. Encourage exercise.
Atorvastatin 20-80mg
BP lowering if HTN
Anticoagulation ONLY if AF
Briefly outline acute stroke management
Exclude haemorrhage
<4.5 hours then alteplase
300mg Aspirin
75 mg Clopidogrel
Define CKD
Abnormal renal function for > 3months
Progressive and Irreversible
What are the metabolic complications of CKD?
Normochromic normocytic anaemia Renal osteodystrophy Renal dysfunction (Nocturia, polyuria, salt retention/oedema) Accelerated CVD Platelet abnormalities, skin pigmentation, Pruritis Hyperkalaemia Metabolic acidosis Neuropathy
What symptoms help differentiate CKD from AKI?
CKD more likely if Wx loss, anorexia, pruritis and nocturia
Could be an Acute-on-chronic presentation
4 key investigations of CKD
eGFR (Superior to creatinine and urea)
Proteinuria
Haematuria
Renal USS (Small echogenic kidneys)
How is proteinura useful for CKD?
Best way to detect this? GIVE VALUES!
Assessment and prognostic info (presence and quantity is a RF for progression)
Albumin:Creatinine ratio (ACR)
> 3mg/mmol is clinically significant
ACR in CKD
1) How do you measure ACR?
2) What value indicates no need to repeat? When do you repeat?
1) 24hr urine collection or morning urine
2) > 70 mg/mmol= no repeat needed as excessively high
3-70 then repeat
(Anything > 3 suggests CKD)
Best way to detect Haematuria in CKD?
What result warrants further evaluation?
Reagent strips not urine microscopy
Greater than or equal to 1+
Indications for a Renal USS in CKD?
Accelerated progression Haematuria Symptoms of obstruction GFR< 30 Polycystic KD in FHx
What are the eGFR values for the different stages of CKD?
1- > 90 NORMAL 2- 60-89 (Other evidence of CKD required) 3a- 45-59 (Moderate) 3b- 30-44 (Moderate) 4- 15- 29 (Severe) 5- <15 (Failure)
If the eGFR value is 60-90 in ?CKD what other evidence is required for a Dx?
Persistent microalbuminaemia/proteinuria/haematuria
Structural abnormalities
Biopsy proven glomerulonephritis
In CKD are the following likely to be raised or decreased? Na K Bicarb Alk Phos Ca Phos PTH Lipids
Na-Norm or Inc K- Inc Bicarb- Dec Alk Phos- Increased indicating bone disease Ca- ANY Phos- inc PTH- Inc with progressively declining function Lipids- Dyslipidaemia is commonn
3 key RF for CKD progression
1) Uncontrolled BP
2) Advanced stage/ Declining eGFR
3) Proteinuria
BP target in CKD if HTN?
What factors reduce this further and to what level?
Typically < 140/90
If DM or ACR of 70mg/mmol then <130/80
Indications for an ACEi for BP control in CKD?
DM + ACR >3 mg/mmol
HTN + ACR >30 mg/mmol
ACR >70 mg/mmol
If ACR< 30mg/mmol and there is HTN + CKD what is indicated?
Normal BP guidelines!
Before starting an ACEi in CKD what is important to check?
K+< 5 mmol/L and eGFR
Check before starting and 1-2 weeks after
When should fluid be restricted in CKD?
End-stage disease
Oliguria
What complication of CKD aggravates hyperkalaemia and renal osteodystrophy
Metabolic acidosis
2 key drugs in preventing CVD in CKD
Statin- Antorvastatin Antiplatelet therapy (Anticoagulate if AF)
3 stages of HTN
1) >140/90
2) 160/100
3) >180/110
(-5 from Sys and Dia if ABPM/HBPM)
What is accelerated HTN
> 180/110
+ Papilloedema + Retinal haemorrhage
? Phaeochromocytoma (If headaches and postural hypotension)
Explain how ABPM and HBPM is used in HTN Dx
ABPM- Min 2 measurements/hr, waking hours. > 14 total
HBPM- 2x/day morn and evening, 4-7 days and discard 1st, two readings each a minute apart
Explain how QRISK2 is used to determine CVD risk and prevention
How would you explain a 10% risk to a patient?
> 10%= Intermediate risk ?Statin
“If we lined 100 of you up and watched you over 10 years, 10 would have a CV event”
List non-idiopathic causes of HTN
Hypertenisve crisis ( >200/130, end organ damage)
Phaeochromocytoma (Headaches and post.hypotension)
Renal disease (ACR from urine sample)
Thyroid disease
Diet
BP target for <80 years, > 80 years and those with DM
<80= <140/90 >80= <150/90 DM= < 130/80
When would you offer pharmacological intervention for HTN?
Stage 2 (>160/100) S1 + End organ damage/CKD/CVD/DM/QRISK2>20%
1st line for HTN + <55 yrs/Non-black
ACEi or ARB
1st line for HTN >55yrs
CCB like Amlodipine or Nifedipine
2nd line pharmacological treatment for resistant HTN
ACEi/ARB + CCB
3rd line pharmacological treatment for resistant HTN
ACEi/ARB + CCB + Thiazide diuretic (Indapamide)
When would you refer HTN to a specialist?
Underlying cause, Accelerated HTN, <40 yrs, Pregnancy, Triple therapy resistant
What NTproBNP level is indicative of an urgent HF referral?
WHat NTproBNP level is suspicious?
> 2000
400-2000
If an ECG and/or NTproBNP is abnormal in ?HF what do they get sent for?
Transthoracic Echo (6 weeks if 400-2000, 2 weeks if >2000) +Bloods/Urine etc
Signs of HF on CXR
Alveolar oedema (BAT WINGS) Kerley B lines Cardiomegaly Dilated upper lobe vessels Pleural effusion
HF classification-
1) What is the NYHA
1- No SOB on activity
2- SOB on activity
3- Less then ordinary activities cause SOB
4- SOB at rest
What is the Framingham Criteria for congestive HF
2 major simultaneously or 1 major + 2 minor
Major: PND, crepitations, Neck vein distension, S3 gallop, Hepatojug reflex, Sig Wx loss 4.5Kg/5 days
Minor: Bi-ankle oedema, SOB on norm activity, HR>120, Nocturnal cough, Hepatomegaly, Pleural effusion, 1/3rd decrease in VC
General pharmacological management of HF with decreased EF
ACEi + Beta blocker -> Add spironolactone or Digoxin
In CKD with eGFR <45 W/ Comorbid HF what is the patient at increased risk of if on Digoxin?
Hyperkalaemia
Lower dose and slower titrations
Describe the role of the below in the treatment of congestive HF Diuretics CCB Anticoagulation Amiodarone Vaccinations
Diuretics- Relief of congestive symptoms, FUROSEMIDE (LOOP) 1st line K+ sparing if <3.2 mmol/l
CCB- Treat comorbid HTN/Angina (Avoid non-dihydropyridines if Dec.EFHF)
Anticoagulation- Comorbid AF, Hx VTE, LV aneurysm
Amiodarone-Specialist
Vaccinations- Annual influenza, Pneumococcal
If a pt is symptomatic what blood results would be diagnostic of DM
Random >11.1
Fasting> 7
HbA1C >48 (re-check in 3 months)
If a pt is asymptomatic how many abnormal blood results are needed for DM diagnosis
2
Pre-diabetes HbA1C range and what intervention for this?
42-47
Lifestyle changes
HbA1C target in DM
Aim <53
48 if on metformin and lifestyle changes
What HbA1C level indicates that therapy should be intensified?
>48= can start single agent (aim for target of 48 if lifestyle controlled and on met)
First Intensification: MONO to DUAL RX
If HbA1c >58mmol/mol/7.5%
AIM for 53mmol/mol/7.0%
Second Intensification: DUAL to TRIPLE
If HbA1c >58mmol/mol
AIM for 53mmol/mol/7.0%Which T2DM medications pose a hypoglycaemia risk?
SU (Gliclazide), Thiazolidinesdiones (Pioglitazone), Gliptins
Common SE of metformin?
When should it be avoided?
N&V
eGFR<30/Before GA
Benefits of metformin?
Increases insulin sensitivity to counter resistance
Cardio-protective, reduces appetite, no hypo risk!
SE of gliclazide?
Does it counter insulin resistance?
Hypoglycaemia, Weight increase as appetite increases,
Notably does not counter insulin resistance only increases insulin secretion
Benefits of gliptins?
Wx neutral
Good if poor kidney function
Good Alt. to gliclazide if BMI>35 or Hypo risk
SE of gliptins?
Pancreatitis risk!
HF risk!
Hypo risk
Se of pioglitazone
Fractures
Fluid retention
LFTs
Hypos
When is Pioglitazone CI?
Osteoporosis, CCF
Avoid if bladder cancer or impaired renal function
What is a requirement for SGLT-2 inhibitors (Empagliflozin)
Needs adequate kidney function as it reduces renal glucose reabsorption
SE of SGLT-2 inhibitors?
UTI, thrush, Wx loss, polyuria, nocturia
Unique risk of Canagliflozin?
DKA
When should gliclazide be avoided?
Elderly (at least monitor regularly)
GLP-1 mimetics mechanism
Inhibit glucagon secretion
Slow gastric emptying
(By inc incretin levels)
GLP-1 mimetics (-tide) benefits? Disadvantages?
Good impact on reducing CV risk
Usually need injecting…
What is Acarbose?
Chewed at the start of a meal Decreases starch (+ sugar) Causes wind and abdo pain
What confirms the Dx of CHD/Angina in primary care
Exercise testing
What should be done if a pt has a QRISK2 > 10%?
Atorvastatin 20mg
Indications for 80mg Atorvastatin? What should be checked?
Hx MI/CHD T2DM ACS symptoms Total cholesterol> 4 LDL >2
CHECK LFTs before/ 3 months/ 12 months (+ CI if pregnant)
Treatment steps for stable angina
GTN spay (2 doses 5 mins apart then 999)
Beta blocker or CCB (Non-dihydro)
Dual therapy (add isorbide mononitrate or nicorondil)
Refer if on max doses
secondary prevention in CHD?
Antiplatelet Low dose aspirin 75mg or clopidogrel (PVD or stroke)
ACEi if angina + DM
Statin if QRISK > 10%
RF for frailty
Old, slow walking, Hx falls, confusion, dementia, cannot leave house, polypharmacy, need helps doing common tasks
Frailty definition
Weak. Delicate. Vulnerable. Not able to bounce back from an event. Associated with multimorbidity.
How do you calculate BMI?
weight (kg)/Height (m2)
BMI values for overweight and obesity
Obesity > 30 (>40 morbidly)
Overweight >25
What waist circumference values confer high risk of obesity?
M= >94cm F= >80cm
Normal cholesterol range for... Total chol HDL LDL T chol/HDL
Total chol- <5mmol/L
HDL >1.2 mmol/L
LDL <3 mmol/L
T chol/HDL <4.5mmol/L
How would you explain what cholesterol is to a patient
A fatty substance needed for healthy functioning of the body
Part of every cell in the body
Examples for non-dihydropyridines CCB
Verapamil
Diltiazem
MORE INOTROPIC
Examples for Dihydropyridines CCB
Amlodipine
Nifedipine
Felodipine
POTENT VASODILATORS
Common SE of CCB (5)
Swelling, dizziness, headaches, flushing, Nausea
Common SE of ACEi
Cough, Hypotension (Take at night), Impotence
Rarely HYPERKALEMIA
What is indapamide
Thiazide like diuretic
Thiazides SE?
Polyuria, Hypokalaemia, Hyponatraemia Impotence Inc glucose, inc TG
Three key HBA1C values to remember for DM management
48- 53- 58
>48= 1st drug >58= Add 2nd drug >58= 3rd drug
Aim for <53 on 2nd and 3rd steps
What can cause a raised urea
Inc protein
BLEED
CKD
(low in liver failure)
When can creatinine values appear falsely abnormal
High muscle mass (too high)
Frail/Elderly (Too low)
Why is creatinine not the best marker for renal impairment
Insensitive marker of early impairment
When is dialysis indicated in CKD
eGFR <10
Discuss when <20
What is paroxysmal AF
> 2 episodes terminating in 7 days
What is persistent AF
Continues > 7 days
Long standing AF is what
Continues >12 months
Permanent AF is when
There are not further attempts to restore sinus rhythm
When is rate control not 1st line in AF
Reversible cause (hyperthyroidism)
AF induced HF
New onset paroxysmal AF where rhythm control is more suitable
