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Year 4 CCC > GP Core Conditions > Flashcards

GP Core Conditions Flashcards

1
Q

Dx asthma

1) Gold standard
2) Others (X2)

A

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

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2
Q

Asthma annual review- what 4 things do you cover?

A

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

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3
Q

Step wise treatment of chronic asthma (BTS guidelines)

~6 steps

A

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

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4
Q

What are 4 signs of poor asthma control; indicating escalation to ICS therapy from SABA?

A

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

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5
Q

COPD- How are these signs/symptoms different in Emphysema and bronchitis?

1) SOB
2) Cyanosis
2) Weight loss

A

1) SOB early and severe in Emphysema
2) Bronchitis cyanosed
3) Emphysema more likely to have muscle wasting and significant weight loss

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6
Q

Role of spirometry in COPD?

FEV1/FVC?

A

1) Dx
2) Monitor progression w/ other factors

FEV1?FVC <0.7

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7
Q

Staging of COPD using FEV1- what are the stages?

A

% of predicted

1) >80%
2) 50-79%
3) 30-49%
4) < 30% (<50% + risk factors)

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8
Q

Comment on the uses of the below in COPD Dx

1) Reversibility testing
2) Key signs
3) Post-bronchodilator spirometry
4) FBC, BMI, CXR

A

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

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9
Q

In COPD what should happen to FEV1/FVC with inhaled therapy?

A

Should NOT normalise- NO reversibility

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10
Q

5 grades of the Medical Research council dyspnoea scale

A

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.

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11
Q

COPD management

1) What vaccine are needed? (2X)
2) Lifestyle advice
3) Criteria for Rehabilitation?

A

1) Pneumococcal/Influenza
2) Stop smoking, encourage mobility, Good diet to ameliorate Wx loss
3) MCP >/= 3 or symptoms infringe on QoL

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12
Q

Chronic COPD management

1) 1st line
2) The presence of what feature decides how you should escalate
3) 2nd Line
4) Triple therapy?

A

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

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13
Q

Chronic COPD management- What 2 drugs should you never use together?

A

SAMA and LAMA

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14
Q

ECG signs of AF

A

Irregularly irregular PR

Absent P waves

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15
Q

Indications for a transthoracic echo in AF?

A

Check for emboli before cadioversion

Suspicion of structural/functional abnormality

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16
Q

When is a transoesophageal Echo needed in AF?

A

After transthoracic shows an abnormality
Transthoracic technically difficult
TRO guided cardioversion

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17
Q

Treating chronic AF- RATE control

1) Monotherapy?
2) Intensification?

A

1) Beta blocker or diltiazem (CCB)

2) Combine the above or add digoxin

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18
Q

Treating chronic AF- RATE control

1) What specific type of AF is digoxin best for?

A

Non-paroxysmal and pt is sedentary

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19
Q

Treating chronic AF- RATE control

1) HR target?
2) What does this change to if symptomatic?

A

1) <90 (Consider <110)

2) <80

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20
Q

Treating chronic AF- Rhythm control

1) When is this indicated?

A

1) Symptomatic, young, 1st presentation with lone AF, rate control is inadequate

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21
Q

Treating Chronic AF- Rhythm control

1) 1st line for rhythm control
2) Alternatives to above

A

1) Beta blocker (CI if asthmatic!)

2) Dronedarone or Amiodarone

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22
Q

Treating chronic AF- Rhythm control

1) Indications for Dronedarone

A

1) Successful Cardioversion, Paroxysmal/persistent AF, if 1st line rhythm control fails, IHD/TIA/DM/HTN/>70

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23
Q

Treating chronic AF- Rhythm control

1) Why would you consider Amiodarone> Dronedarone

A

1) LV impairment or HF

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24
Q

Treating chronic AF- Pill in the pocket

1) Indications?
2) CI?

A

1) Known precipitants, infrequent attacks

2) LVD, VHD, IHD in PMHx

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25
Q

Treating chronic AF- Anticoagulation

1) What scoring systems do you use? (2)
2) What do they assess?

A

CHA2DS2- VAD- Stroke risk

HAS-BLED- Bleeding risk

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26
Q

Treating chronic AF- Anticoagulation

1) CHA2DS2- VAD score needed for anticoagulation
2) HAS-BLED score that indications caution

A

1) Males= 1 Females = 2

2) Greater than or equal to 3

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27
Q

Treating Acute AF- What is indicated when…

1) < 48hrs + Haemodynamic instability
2) < 48 hrs + stable
3) > 48 hours

A

1) Electric cardioversion
2) Consider managing as >48 hrs
3) Cardioversion (DC or flecoinide) +/- Amiodarone (stating 4 weeks before)

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28
Q

Most common duration of TIA symptoms?

A

10-15 mins

Must be less than 24 hours to be TIA

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29
Q

Different categories of symptoms to consider for TIA/Stroke

A 
Motor
Sensory
Meningism 
Pain
Speech
Cognition
Consciousness 
Sight
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30
Q

What global symptoms make TIA less likely as the aetiology?

A

Unsteadiness
Dizzy
Syncope

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31
Q

Key stroke mimics?

A 
Hypoglycaemia
Migraine 
Seziure
Bell's palsy
MS
?Sepsis
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32
Q

CT target if stroke likely?

A

1 hr

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33
Q

What anti-platelet is indicated, and for how long, in TIA

A

300mg aspirin for 14 days

then an assessment within 24hrs by a specialist

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34
Q

TIA secondary prevention?

A

Lifestyle- Smoking and alcohol reduction. Encourage exercise.
Atorvastatin 20-80mg
BP lowering if HTN
Anticoagulation ONLY if AF

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35
Q

Briefly outline acute stroke management

A

Exclude haemorrhage
<4.5 hours then alteplase
300mg Aspirin
75 mg Clopidogrel

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36
Q

Define CKD

A

Abnormal renal function for > 3months

Progressive and Irreversible

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37
Q

What are the metabolic complications of CKD?

A 
Normochromic normocytic anaemia 
Renal osteodystrophy 
Renal dysfunction (Nocturia, polyuria, salt retention/oedema)
Accelerated CVD
Platelet abnormalities, skin pigmentation, Pruritis 
Hyperkalaemia
Metabolic acidosis 
Neuropathy
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38
Q

What symptoms help differentiate CKD from AKI?

A

CKD more likely if Wx loss, anorexia, pruritis and nocturia

Could be an Acute-on-chronic presentation

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39
Q

4 key investigations of CKD

A

eGFR (Superior to creatinine and urea)
Proteinuria
Haematuria
Renal USS (Small echogenic kidneys)

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40
Q

How is proteinura useful for CKD?

Best way to detect this? GIVE VALUES!

A

Assessment and prognostic info (presence and quantity is a RF for progression)

Albumin:Creatinine ratio (ACR)
> 3mg/mmol is clinically significant

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41
Q

ACR in CKD

1) How do you measure ACR?
2) What value indicates no need to repeat? When do you repeat?

A

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)

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42
Q

Best way to detect Haematuria in CKD?

What result warrants further evaluation?

A

Reagent strips not urine microscopy

Greater than or equal to 1+

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43
Q

Indications for a Renal USS in CKD?

A 
Accelerated progression
Haematuria 
Symptoms of obstruction 
GFR< 30
Polycystic KD in FHx
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44
Q

What are the eGFR values for the different stages of CKD?

A 
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)
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45
Q

If the eGFR value is 60-90 in ?CKD what other evidence is required for a Dx?

A

Persistent microalbuminaemia/proteinuria/haematuria
Structural abnormalities
Biopsy proven glomerulonephritis

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46
Q 
In CKD are the following likely to be raised or decreased?
Na
K
Bicarb
Alk Phos
Ca
Phos
PTH
Lipids
A 
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
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47
Q

3 key RF for CKD progression

A

1) Uncontrolled BP
2) Advanced stage/ Declining eGFR
3) Proteinuria

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48
Q

BP target in CKD if HTN?

What factors reduce this further and to what level?

A

Typically < 140/90

If DM or ACR of 70mg/mmol then <130/80

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49
Q

Indications for an ACEi for BP control in CKD?

A

DM + ACR >3 mg/mmol
HTN + ACR >30 mg/mmol
ACR >70 mg/mmol

50
Q

If ACR< 30mg/mmol and there is HTN + CKD what is indicated?

A

Normal BP guidelines!

51
Q

Before starting an ACEi in CKD what is important to check?

A

K+< 5 mmol/L and eGFR

Check before starting and 1-2 weeks after

52
Q

When should fluid be restricted in CKD?

A

End-stage disease

Oliguria

53
Q

What complication of CKD aggravates hyperkalaemia and renal osteodystrophy

A

Metabolic acidosis

54
Q

2 key drugs in preventing CVD in CKD

A 
Statin- Antorvastatin 
Antiplatelet therapy (Anticoagulate if AF)
55
Q

3 stages of HTN

A

1) >140/90
2) 160/100
3) >180/110
(-5 from Sys and Dia if ABPM/HBPM)

56
Q

What is accelerated HTN

A

> 180/110
+ Papilloedema + Retinal haemorrhage
? Phaeochromocytoma (If headaches and postural hypotension)

57
Q

Explain how ABPM and HBPM is used in HTN Dx

A

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

58
Q

Explain how QRISK2 is used to determine CVD risk and prevention
How would you explain a 10% risk to a patient?

A

> 10%= Intermediate risk ?Statin

“If we lined 100 of you up and watched you over 10 years, 10 would have a CV event”

59
Q

List non-idiopathic causes of HTN

A

Hypertenisve crisis ( >200/130, end organ damage)
Phaeochromocytoma (Headaches and post.hypotension)
Renal disease (ACR from urine sample)
Thyroid disease
Diet

60
Q

BP target for <80 years, > 80 years and those with DM

A 
<80= <140/90
>80= <150/90
DM= < 130/80
61
Q

When would you offer pharmacological intervention for HTN?

A 
Stage 2 (>160/100)
S1 + End organ damage/CKD/CVD/DM/QRISK2>20%
62
Q

1st line for HTN + <55 yrs/Non-black

A

ACEi or ARB

63
Q

1st line for HTN >55yrs

A

CCB like Amlodipine or Nifedipine

64
Q

2nd line pharmacological treatment for resistant HTN

A

ACEi/ARB + CCB

65
Q

3rd line pharmacological treatment for resistant HTN

A

ACEi/ARB + CCB + Thiazide diuretic (Indapamide)

66
Q

When would you refer HTN to a specialist?

A

Underlying cause, Accelerated HTN, <40 yrs, Pregnancy, Triple therapy resistant

67
Q

What NTproBNP level is indicative of an urgent HF referral?

WHat NTproBNP level is suspicious?

A

> 2000

400-2000

68
Q

If an ECG and/or NTproBNP is abnormal in ?HF what do they get sent for?

A

Transthoracic Echo (6 weeks if 400-2000, 2 weeks if >2000) +Bloods/Urine etc

69
Q

Signs of HF on CXR

A 
Alveolar oedema (BAT WINGS)
Kerley B lines
Cardiomegaly
Dilated upper lobe vessels 
Pleural effusion
70
Q

HF classification-

1) What is the NYHA

A

1- No SOB on activity
2- SOB on activity
3- Less then ordinary activities cause SOB
4- SOB at rest

71
Q

What is the Framingham Criteria for congestive HF

A

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

72
Q

General pharmacological management of HF with decreased EF

A

ACEi + Beta blocker -> Add spironolactone or Digoxin

73
Q

In CKD with eGFR <45 W/ Comorbid HF what is the patient at increased risk of if on Digoxin?

A

Hyperkalaemia

Lower dose and slower titrations

74
Q 
Describe the role of the below in the treatment of congestive HF
Diuretics
CCB
Anticoagulation
Amiodarone
Vaccinations
A

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

75
Q

If a pt is symptomatic what blood results would be diagnostic of DM

A

Random >11.1
Fasting> 7
HbA1C >48 (re-check in 3 months)

76
Q

If a pt is asymptomatic how many abnormal blood results are needed for DM diagnosis

A

2

77
Q

Pre-diabetes HbA1C range and what intervention for this?

A

42-47

Lifestyle changes

78
Q

HbA1C target in DM

A

Aim <53

48 if on metformin and lifestyle changes

79
Q

What HbA1C level indicates that therapy should be intensified?

A 
>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%
80
Q

Which T2DM medications pose a hypoglycaemia risk?

A

SU (Gliclazide), Thiazolidinesdiones (Pioglitazone), Gliptins

81
Q

Common SE of metformin?

When should it be avoided?

A

N&V

eGFR<30/Before GA

82
Q

Benefits of metformin?

A

Increases insulin sensitivity to counter resistance

Cardio-protective, reduces appetite, no hypo risk!

83
Q

SE of gliclazide?

Does it counter insulin resistance?

A

Hypoglycaemia, Weight increase as appetite increases,

Notably does not counter insulin resistance only increases insulin secretion

84
Q

Benefits of gliptins?

A

Wx neutral
Good if poor kidney function
Good Alt. to gliclazide if BMI>35 or Hypo risk

85
Q

SE of gliptins?

A

Pancreatitis risk!
HF risk!
Hypo risk

86
Q

Se of pioglitazone

A

Fractures
Fluid retention
LFTs
Hypos

87
Q

When is Pioglitazone CI?

A

Osteoporosis, CCF

Avoid if bladder cancer or impaired renal function

88
Q

What is a requirement for SGLT-2 inhibitors (Empagliflozin)

A

Needs adequate kidney function as it reduces renal glucose reabsorption

89
Q

SE of SGLT-2 inhibitors?

A

UTI, thrush, Wx loss, polyuria, nocturia

90
Q

Unique risk of Canagliflozin?

A

DKA

91
Q

When should gliclazide be avoided?

A

Elderly (at least monitor regularly)

92
Q

GLP-1 mimetics mechanism

A

Inhibit glucagon secretion
Slow gastric emptying
(By inc incretin levels)

93
Q

GLP-1 mimetics (-tide) benefits? Disadvantages?

A

Good impact on reducing CV risk

Usually need injecting…

94
Q

What is Acarbose?

A 
Chewed at the start of a meal
Decreases starch (+ sugar)
Causes wind and abdo pain
95
Q

What confirms the Dx of CHD/Angina in primary care

A

Exercise testing

96
Q

What should be done if a pt has a QRISK2 > 10%?

A

Atorvastatin 20mg

97
Q

Indications for 80mg Atorvastatin? What should be checked?

A 
Hx MI/CHD
T2DM
ACS symptoms
Total cholesterol> 4
LDL >2

CHECK LFTs before/ 3 months/ 12 months (+ CI if pregnant)

98
Q

Treatment steps for stable angina

A

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

99
Q

secondary prevention in CHD?

A

Antiplatelet Low dose aspirin 75mg or clopidogrel (PVD or stroke)

ACEi if angina + DM

Statin if QRISK > 10%

100
Q

RF for frailty

A

Old, slow walking, Hx falls, confusion, dementia, cannot leave house, polypharmacy, need helps doing common tasks

101
Q

Frailty definition

A

Weak. Delicate. Vulnerable. Not able to bounce back from an event. Associated with multimorbidity.

102
Q

How do you calculate BMI?

A

weight (kg)/Height (m2)

103
Q

BMI values for overweight and obesity

A

Obesity > 30 (>40 morbidly)

Overweight >25

104
Q

What waist circumference values confer high risk of obesity?

A 
M= >94cm
F= >80cm
105
Q 
Normal cholesterol range for...
Total chol
HDL
LDL
T chol/HDL
A

Total chol- <5mmol/L
HDL >1.2 mmol/L
LDL <3 mmol/L
T chol/HDL <4.5mmol/L

106
Q

How would you explain what cholesterol is to a patient

A

A fatty substance needed for healthy functioning of the body

Part of every cell in the body

107
Q

Examples for non-dihydropyridines CCB

A

Verapamil
Diltiazem

MORE INOTROPIC

108
Q

Examples for Dihydropyridines CCB

A

Amlodipine
Nifedipine
Felodipine

POTENT VASODILATORS

109
Q

Common SE of CCB (5)

A

Swelling, dizziness, headaches, flushing, Nausea

110
Q

Common SE of ACEi

A

Cough, Hypotension (Take at night), Impotence

Rarely HYPERKALEMIA

111
Q

What is indapamide

A

Thiazide like diuretic

112
Q

Thiazides SE?

A

Polyuria, Hypokalaemia, Hyponatraemia Impotence Inc glucose, inc TG

113
Q

Three key HBA1C values to remember for DM management

A

48- 53- 58

>48= 1st drug 
>58= Add 2nd drug
>58= 3rd drug

Aim for <53 on 2nd and 3rd steps

114
Q

What can cause a raised urea

A

Inc protein
BLEED
CKD

(low in liver failure)

115
Q

When can creatinine values appear falsely abnormal

A

High muscle mass (too high)

Frail/Elderly (Too low)

116
Q

Why is creatinine not the best marker for renal impairment

A

Insensitive marker of early impairment

117
Q

When is dialysis indicated in CKD

A

eGFR <10

Discuss when <20

118
Q

What is paroxysmal AF

A

> 2 episodes terminating in 7 days

119
Q

What is persistent AF

A

Continues > 7 days

120
Q

Long standing AF is what

A

Continues >12 months

121
Q

Permanent AF is when

A

There are not further attempts to restore sinus rhythm

122
Q

When is rate control not 1st line in AF

A

Reversible cause (hyperthyroidism)
AF induced HF
New onset paroxysmal AF where rhythm control is more suitable

Year 4 CCC (3 decks)

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