GP ILAs Flashcards
What are the causes of hypertension?
Essential/primary hypertension Secondary hypertension- - Cushings Disease - Conns Syndrome -Renal artery stenosis - Coarctation of the aorta - Phaeochromatoma- postural HT, headache, palpitations, pallor, sweating - Renal disease (PKD, glomerulonephritis)
How is hypertension diagnosed?
Suspect if clinical BP >140/90
Confirm it with ABPM >135/85
What are the stages in severity of hypertension?
Stage 1- Clinic BP >140/90 or ABPM >135/85
Stage 2- Clinic BP >160/100 or ABPM >150/95
Severe- Systolic >180 or >110
(all =< rather than 20% = Stage 2
What is the management of hypertension?
Stage 1: Lifestyle modification- weight, salt, exercise, alcohol, stress
Stage 2:
<55 = ACEi or ARB
>55 or Afro-Caribbean = CCB (amlodipine or verapamil)
Then combine
Then add thiazide- like diuretic e.g. indapamide
Then refer for expert advice and add spironolactone if potassium <4.5, or a-blocker or BB if above >4.5
What investigations would you do in hypertension?
End organ damage (12 lead ECG, U&Es, eGFR and urine dip, renal USS)
CVD risk- BG, fasting lipids
Secondary causes- dexamethasone suppression, 24 urinary metanephrines
What is target BP in
a) >80 year old
b) under 80
c) diabetes with signs of end-organ damage
a) <150/85
b) <140/85
c) <135/85
What are the causes of chronic heart failure?
High output and low output
High output means the needs of the body have increased beyond that which the heart can supply e.g. hyperthyroidism, anaemia, Paget’s, AV malformation
Low output means decreased heart function. This can either be:
- Increased pre-load (mitral regurg, fluid overload such as CKD)
- Pump failure (cardiac muscle disease, decreased expansion of the heart)
- Chronic excessive overload or aortic stenosis
What are the symptoms of heart failure?
Breathlessness, fluid retention, fatigue, syncope, orthopnoea, PND
What are the signs of heart failure?
Tachycardia, hypertension, tachypnoea, basal creps, oedema, displaced apex beat, raised JVP, hepatomegaly, ascites
What is the classification system for HF?
NYHA
Talks about limitations to physical activity
What are the investigations for acute HF?
ECG, CXR
Bloods- U&Es, eGFR, TFTs, LFTs, fasting glucose, FBC, fasting lipids
Diagnosis by BNP or NT-pro-BNP
> 400pg/ml- urgent TTE (trans-thoracic echo)
100-400- TTE within 2 weeks
What are the investigations for chronic HF?
Same as acute
Except refer to cardiology and organise ECHO within 2 weeks if no history of MI
What can reduce BNP?
Obesity Diuretics ACEi BBs/ ARBs Aldosterone antagonists
What else can raise BNP?
LVH Ischaemia Tachycardia Sepsis COPD
What does an ECG show for HF?
Ischaemia or hypertrophy
What does a CXR show for HF?
Alveolar oedema Kerley B lines Cardiomegaly Dilated upper vessels/ upper lobe diversion Pleural effusion
When would you refer HF to an MDT?
1st diagnosis, severe case, failure to manage in primary care, comorbid vascular disease
Who is involved in the management of HF in primary care?
GP, ANPs, district nurses, third sector (BHF), family, counselling services, palliative care, CMHTs
What are non-pharmacological measures of HF?
Educate, diet and exercise, stop smoking, reduce alcohol intake, restrict fluid intake, vaccination- annual flu and once-only pneumococcal
What are the pharmacological measures in HF?
1st line- ACEi and BB, loop diuretic for symptomatic relief
2nd line- Refer
If NYHA 3/4 or MI in last month, begin spironolactone
Consider hydralazine with nitrate for Afro-Caribbean patients
3rd line-
Digoxin
Ivabradine- decrease HR (AEs= luminous phenomena, visual effects)
Other drugs to consider- anticoagulation (if AF), aspirin (if athersclerotic arterial disease), statins (anti-cholesterol), amlodipine (treatment for angina and hypertension)
What diuretic is used in HF? How do they work?
Furosemide 20-40 mg or bumetanide 1-2mg OD
It is loop diuretic, that works by inhibiting the Na/K/Cl co-transporter
AEs- dehydration, hypotension, low electrolyte statue, hearing loss and tinnitus
CIs- Hypovolaemia or dehydration, hepatic encephalopathy, severe hypokalaemia, severe hyponatraemia, worsen gout
What is an example of a thiazide-like diuretic?
Bendroflumethazide
Name an example of an ACEi and an ARB?
ACEi- Ramipril
ARB- Candersartan
How do ACE inhibitors work?
They inhibit ACE in the lungs
- Blood pressure is decreased due to reduced blood volume, peripheral resistance and cardiac load
- They inhibit vasoconstriction and release of aldosterone which inhibits the retention of sodium and water
What are the side effects of ACE inhibitors?
Persistent dry cough (due to increased bradykinin), hypotension, angiooedema, hyperkalaemia, worsen renal failure (esp renal artery stenosis)
What are contraindications of ACE inhibitors?
Renal artery stenosis, AKI, pregnant and/or breastfeeding
What needs to be monitored when increasing dose of ACE inhibitors?
Serum urea, creatinine, electrolytes and eGFR at initiation and with every increase in dose
How do beta blockers work?
Reduce the force of contraction and speed of conduction of the heart. This relieves myocardial ischaemia by reducing cardiac work and O2 demand, and increasing myocardial perfusion
They also lower BP by reducing renin secretion from the kidneys.
What are B1 selective, non-selective and a and B blockers?
B1 selective- atenolol, metoprolol, bisoprolol
Non-selective- Proanolol, nadolol, carteolol
a and B- blockers- Labetolol, carvediolol
What conditions except HF are beta blockers used in?
Peripheral vascular disease Erectile dysfunction Diabetes Mellitus Interstitial pulmonary disease COPD
What needs to be observed after every titration of beta blockers?
HR, BP, clinical status after each titration
What are the adverse effects of beta blockers?
Fatigue, cold extremities, headaches, GI disturbance e.g. Nausea
What are the contraindications for beta blockers?
Asthma (bronchospasm), heart block, haemodynamically unstable, significant hepatic failure
Which services/ healthcare professionals would be involved in a patient with heart failure?
Named GP ANP District nurses Third sector (BHF) Family Counselling Palliative services CMHT
What is the treatment of HF under a cardiologist?
Amiodarone
Medical devices: Implantable cardioverter difibrillator or cardiac resynchronsation therapy
What is the prognosis in HF?
- Progressive deterioration to death
- Approx 50% die suddenly- probably due to arrhythmias
- Mild/moderate HF- 20-30% 1 year mortality
- Severe HF- 50% 1 year mortality
What is in the 6-in-1 vaccine?
When is it given?
Diphtheria, tetanus, pertussis (whooping cough), polio, HiB, hepatitis B
2 months, 3 months, 4 months
When is the MMR given?
1 year, 3 years 4 months
When is pneumococcal vaccine given?
2 months, 4 months, 1 year, age 65
What are the factors that reduce immunisation uptake?
Other children in household Single parent Mother is <20 or >34 Mother is more highly education, not employed or self-employed Live in a deprived area
What is the protocol for non-urgent and urgent notifiable diseases?
Notify the ‘proper office’- local council or health protection team
Written notification within 3 days if non-urgent
Verbal notification within 24 hours in urgent
When is fever a red flag in an unwell child?
temperature >38 degrees in a child 0-3
What are the signs of meningococcal disease?
Fever and non-blanching rash
When should meningitis be suspected in a child?
Neck stiffness, bulging fontanelle, LOC, status epilepticus
GP- IM BenPem
Hospital- IV Cefotaxime
When should herpes simplex encephalitis be suspected in a child?
Fever with neurological signs and seizures, or decreased consciousness
When should pneumonia be suspected in a child?
Fever, tachypnoea, chest crackles, nasal flaring
When should a UTI be suspected?
<3 months- fever
>3 months- vomiting, poor feeding, lethargy, irritability, abdo pain, urinary symptoms
What are the ‘red’ signs of an unwell child?
Pale skin No response to social cues Grunting, tachypnoea >60 Reduced skin turgour Age <3 months with temp >38 Non- blanching rash Bulging fontanelle Status epilepticus
What is safety netting?
What safety netting advice would be given to an unwell child’s parents?
It allows identification of a deteriorating child and ensures direct access to healthcare if a child needs it.
- Encourage regular fluid intake
- Calpol for temperature of 38 degrees
- Observe for signs of dehydration- sunken fontanelle, dry mucous membranes, no tears, dry nappies etc
- Monitor for rash
- Contact medical professional if unsure
What advice should you give to parents of a child with febrile seizures?
Place child on their side and a soft surface
Ring ambulance if >5 mins
>10 mins= status epilepticus- give rectal diazepam
What are the ‘triple swabs’ for STI screen?
High vaginal swab- from posterior fornix. For bacterial vaginosis, trichomas vaginalis, candida
Endocervical swab- gonorrhoea
Endocervical swab- chlamydia
How can you differentiate between normal and abnormal vaginal discharge?
pH <4.5:
White, curdy discharge- candida- emperical therapy
No other symptoms- physiological- reassurance
pH >4.5:
Thin, grey/white homogenous discharge coating the vaginal walls. Fishy odour. Not Sore- Bacterial vaginosis- emperical Rx
Yellow/green frothy fishy discharge- Trichomas vaginalis- Refer to GUM/send HSV
Physiological
Foreign body
STIs
Strep/staph infections
What are the risks of the COCP?
CIs?
VTE, MI stroke, breast cancer
Migraine with aura, smoking, obesity, hypertension
What are the fraser guidelines?
A doctor can prescribe contraceptives to a girl under 16 without parents consent if:
1) She understands his advice
2) She cannot be persuaded to tell her parents
3) She is likely to continue having sexual intercourse
4) Her physical or mental health is likely to suffer
5) It is in her best interests to receive contraceptive or treatment
What age does a child not have capacity to consent to sex?
Under 13
How can you investigate dementia in primary care?
MMSE, GPCOG, 6CIT
Bloods- FBC, U&E, LFTs, TFTs, glucose, calcium, serum B12 and folate
MSU if delirium is suspected
What is dementia?
A syndrome caused by a number of brain disorders which causes memory loss, decline in cognition (memory, language, attention, problem-solving) and difficulties with ADLs
What are the treatments for Alzheimer’s disease?
AChE inhibitors- Donepezil, galantamine, rivastigmine
NMDA antagonist- Memantine
What are the 3 core features of depression and some other symptoms?
Major symptoms- Low mood, anhedonia, fatigue
- Change in appetite or weight
- Insomnia or hypersomnia
- Poor concentration
- Psychomotor retardation or retardation
-Worthlessness
SAD PERSONS
What are the organic differential diagnoses for low mood?
MEANI
Malignancy
Endocrine- thyroid, PT disorders, cushings, addisons
Autoimmune- SLE, RA
Neurological- MS, PD, Stroke, Cerebral tumour
Infection- Hepatitis, HSV, syphilis, HIV
Name some drugs causing low mood
Antihypertensives- BB, methyldopa Steroids OCP Neuro drugs- L-dopa, carbamazepine Analgesics- opioids
What is the first line treatment for depression?
Fluoxetine (SSRIs) or citalopram
What are some side effects of SSRIs?
Dyspepsia, bleeding, sweating, sexual dysfunction
What is an example of a TCA? Side effects?
Lofepramine
SEs: Drowsiness, dry mouth, blurred vision, constipation, urinary retention, sweating
Name an example of an MAOI?
Phenylzine
What are some screening questions for depression?
1) During the last month, have you been feeling down, depressed or hopeless?
2) During the last month, have you often been bothered by having little interest or pleasure in doing things?
What are some tools for depression?
PHQ9
HAD
Becks depression inventory
What are the acute causes of a cough in an adult (<3 weeks)?
URTI Croup Acute bronchitis Pneumonia Acute exacerbation of asthma Inhaled foreign body
What are the chronic causes of a cough in an adult (>3 weeks)?
Post-nasal drip TB COPD/asthma Post viral Lung cancer Bronchiectasis GORD Pulmonary oedema
How can TB be prevented?
BCG vaccination
All infants where incidence of TB is >40:100,000 or infants whose parents or grandparents were born in a country of >40:100,000
New immigrants
Occupational workers at risk
