GP Key Conditions Flashcards
Hypertension
Diabetes
Heart failure
Angina
Asthma
Fatigue
Polymyalgia
Fibromyalgia
COPD
Pneumonia
GORD
Crohn’s/UC/IBS
Osteoarthritis/rheumatoid/joint pain
Gout
Polymyalgia rheumatica
UTIs
MI/AF
DKA
ACS
S
What are the three stages of hypertension?
Stage 1- 140/90
Stage 2- 160/100
Stage 3- 180/120
What is defined as hypertension?
Over 140/90 in clinic
Over 135/85 outside of clinic
What are the investigations for hypertension?
Ambulatory blood pressure monitoring (ABPM)
`
Home blood pressure monitoring (HBPM)
What is the management of hypertension?
Lifestyle- salt, exercise, smoking, drinking
1st ACEi/ARB in U55/DM or CCB in O55, african with no DM
Then both
Then thiazide diuretic- bendroflumethiazide
if potassium < 4.5 mmol/l add low-dose spironolactone
if potassium > 4.5 mmol/l add an alpha- or beta-blocker
Refer if not controlled with 4 drugs
Treat stage 2 whatever
General management of COPD?
Lifestyle changes- smoking cessation, flu vaccine
SABA or SAMA
Asthma features?
Yes- LABA+ICS
No- LABA+LAMA
SABA+LABA+LAMA+ICS
What is type 1 diabetes?
Autoimmune disorder where the insulin-producing beta cells of the islets of Langerhans in the pancreas are destroyed by the immune system
Signs of type 1 diabetes?
Weight loss
Polydipsia
Polyuria
May present with diabetic ketoacidosis
abdominal pain
vomiting
reduced consciousness level
Signs of type 2 diabetes?
Often picked up incidentally on routine blood tests
Polydipsia
Polyuria
Diagnostic thresholds for diabetes?
If the patient is symptomatic:
Fasting glucose greater than or equal to 7.0 mmol/l
Random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test)
HbA1c diabetes level?
Over 48 mmol/mol (6.5%)
T1DM management?
HbA1c monitored every 6 months
Self monitor glucose levels at least 4 times a day
offer multiple daily injection basal–bolus insulin regimens, rather than twice‑daily mixed insulin regimens, as the insulin injection regimen of choice for all adults
twice‑daily insulin detemir is the regime of choice. Once-daily insulin glargine or insulin detemir is an alternative
offer rapid‑acting insulin analogues injected before meals, rather than rapid‑acting soluble human or animal insulins, for mealtime insulin replacement for adults with type 1 diabetes
Add metformin if BMI over 25
T2DM management?
Dietary/lifestyle advice
1st- Metformin
2nd- metformin + DPP-4 inhibitor
metformin + pioglitazone
metformin + sulfonylurea- gliclazide
metformin + SGLT-2 inhibitor (if NICE criteria met)
DKA features?
Abdominal pain
Polyuria, polydipsia, dehydration
Kussmaul respiration (deep hyperventilation)
Acetone-smelling breath (‘pear drops’ smell)
Diabetes investigations?
Urine should be dipped for glucose and ketones
Fasting glucose and random glucose (see below for diagnostic thresholds)
HbA1c is not as useful for patients with a possible or suspected diagnosis of T1DM as it may not accurately reflect a recent rapid rise in serum glucose
Features of chronic heart failure?
dyspnoea
cough: may be worse at night and associated with pink/frothy sputum
orthopnoea
paroxysmal nocturnal dyspnoea
wheeze (‘cardiac wheeze’)
weight loss (‘cardiac cachexia’): occurs in up to 15% of patients. Remember this may be hidden by weight gained secondary to oedema
bibasal crackles on examination
signs of right-sided heart failure: raised JVP, ankle oedema and hepatomegaly
What is the investigation for heart failure?
N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test first-line
if levels are ‘high’ arrange specialist assessment (including transthoracic echocardiography) within 2 weeks
if levels are ‘raised’ arrange specialist assessment (including transthoracic echocardiography) echocardiogram within 6 weeks
Management of chronic heart failure?
1st- ACE-inhibitor and a beta-blocker
2nd- aldosterone antagonist- spironolactone
Treatment of acute heart failure?
IV loop diuretics- furosemide, bumetanide
Stable angina management?
All patients recieve aspirin and statin
Siblingual glyceral trinitrate to abort angina attacks
BB or calcium channel blocker first line
Asthma management adults?
SABA
SABA + low dose ICS
SABA + ICS + LTRA
SABA + ICS + LABA (can continue LTRA)
SABA+- LTRA + MART low dose ICS
SABA+- LTRA + MART med dose
SABA+- LTRA
and either
Increase to high dose ICS not as part of MART
Trial theophylline
Specialist help
Signs and symptoms of asthma?
Symptoms
cough: often worse at night
dyspnoea
‘wheeze’, ‘chest tightness’
Signs
expiratory wheeze on auscultation
reduced peak expiratory flow rate (PEFR)
How long for chronic fatigue to be diagnosed?
After 3 months of disabling fatigue affecting mental and physical function more than 50% of the time in the absence of other disease which may explain symptoms
Investigations of chronic fatigue syndrome?
NICE guidelines suggest carrying out a large number of screening blood tests to exclude other pathology e.g. FBC, U&E, LFT, glucose, TFT, ESR, CRP, calcium, CK, ferritin, coeliac screening and also urinalysis
Management of chronic fatigue syndrome?
Specialist CFS service
Energy management
Physical activity and exercise
CBT
What are the features of polymyalgia rheumatica?
Typically patient > 60 years old
Usually rapid onset (e.g. < 1 month)
Aching, morning stiffness in proximal limb muscles
Weakness is not considered a symptom of polymyalgia rheumatica
Also mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats
Investigations for polymyalgia rheumatica?
Raised inflammatory markers e.g. ESR > 40 mm/hr
Note creatine kinase and EMG normal
What is the treatment for polymyalgia rheumatica?
Prednisolone e.g. 15mg/od
Patients typically respond dramatically to steroids, failure to do so should prompt consideration of an alternative diagnosis
What is fibromyalgia?
Fibromyalgia is a syndrome characterised by widespread pain throughout the body with tender points at specific anatomical sites. The cause of fibromyalgia is unknown.
Women 5x
Between 30-50
What are the features of fibromyalgia?
Chronic pain: at multiple site, sometimes ‘pain all over’
Lethargy
Cognitive impairment: ‘fibro fog’
Sleep disturbance, headaches, dizziness are common
Diagnosis and management of fibromyalgia?
Diagnosis is clinical and sometimes refers to the American College of Rheumatology
classification criteria which lists 9 pairs of tender points on the body. If a patient is tender in at least 11 of these 18 points it makes a diagnosis of fibromyalgia more likely
Explanation
Aerobic exercise: has the strongest evidence base
Cognitive behavioural therapy
Medication: pregabalin, duloxetine, amitriptyline
What are the features of COPD?
Cough: often productive
Dyspnoea
Wheeze
In severe cases, right-sided heart failure may develop resulting in peripheral oedema
Smoking is the cause
COPD investigations?
Post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70%
Chest x-ray
hyperinflation
bullae: if large, may sometimes mimic a pneumothorax
flat hemidiaphragm
also important to exclude lung cancer
Full blood count: exclude secondary polycythaemia
Body mass index (BMI) calculation
COPD management?
General advice:
>smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
annual influenza vaccination
one-off pneumococcal vaccination
pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)
1st- SABA or SAMA as required
Determine if steroid response- previous asthma/atopy, raised eosinophil etc
Yes- SABA + LABA+ ICS
No- SABA + LABA + LAMA
SABA + LABA + LAMA + ICS
Pneumonia signs and symptoms?
Symptoms
cough
sputum
dyspnoea
chest pain: may be pleuritic
fever
Signs
signs of systemic inflammatory response
fever
tachycardia
reduced oxygen saturations
auscultation:
reduced breath sounds
bronchial breathing
Management pneumonia?
Patients with pneumonia require the following:
antibiotics: to treat the underlying infection
supportive care, for example:
oxygen therapy if the patient is hypoxaemic
intravenous fluids if the patient is hypotensive or shows signs of dehydration
Most common organism Streptococcus pneumoniae
CURB-65?
C Confusion (abbreviated mental test score <= 8/10)
U urea > 7 mmol/L
R Respiration rate >= 30/min
B Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60 mmHg
65 Aged >= 65 years
consider home-based care for patients with a CURB65 score of 0 or 1 - low risk (less than 3% mortality risk)
consider hospital-based care for patients with a CURB65 score of 2 or more - intermediate risk (3-15% mortality risk)
consider intensive care assessment for patients with a CURB65 score of 3 or more - high risk (more than 15% mortality risk)
Features crohns vs uc?
Crohns
Diarrhoea usually non-bloody
Weight loss more prominent
Upper gastrointestinal symptoms, mouth ulcers, perianal disease
Abdominal mass palpable in the right iliac fossa
Lesions may be seen anywhere from the mouth to anus
Skip lesions may be present
Inflammation in all layers from mucosa to serosa
increased goblet cells
granulomas
Small bowel enema
UC
Bloody diarrhoea more common
Abdominal pain in the left lower quadrant
Tenesmus
Inflammation always starts at rectum and never spreads beyond ileocaecal valve
Continuous disease
No inflammation beyond submucosa (unless fulminant disease) - inflammatory cell infiltrate in lamina propria
neutrophils migrate through the walls of glands to form crypt abscesses
depletion of goblet cells and mucin from gland epithelium
granulomas are infrequent
Barium enema
Crohn’s investigations?
Bloods- CRP
MC&S
Faecal calprotectin
Colonoscopy, bowel biopsy
MRI to assess Cx
Crohn’s treatment?
Stop smoking, optimise nutrition
Induce and maintain remission
Oral prednisolone
Severe - IV fluids, IV steroids
Azathioprine (immunosuppressant)
Infliximab
Surgery - not curative
Crohn’s presentation?
signs
bowel ulceration
abdo tenderness
perianal abscess/fistulae
mouth ulcers
finger clubbing
conjunctivitis, episcleritis, iritis
associated with spondyloarthropathies
symptoms
diarrhoea
abdo pain
wt loss
fatigue, fever, malaise, anorexia
UC presentation?
signs
during attack - fever, tachycardia, tender distended abdo, anorexia, malaise, wt loss
extraintestinal signs - clubbing, oral ulcer, erythema nodosum, inflammatory pustule, conjunctivitis, episcleritis, iritis, large joint arthritis, ankylosing spondylitis, primary sclerosing cholangitis
symptoms
episodic/chronic diarrhoea +/- blood, mucus
bowel urgency
tenesmus
crampy abdo discomfort
UC investigations?
Bloods - FBC, ESR, CRP, U+E, LFT, culture
Stool MC&S
Faecal calprotectin - test for GI inflammation
AXR - no faecal shadows, mucosal thickening, colonic dilatation
Lead-pipe colon on barium X ray
Lower GI endoscopy
UC management?
Avoid foods that cause flare ups
mild
Aminosalicylate - mesalazine/mesalamine
topical steroid - prednisolone
moderate
oral prednisolone
5-ASA
severe
IV fluids
IV steroids
Maintain remission- Azathioprine, mesalazine
Surgery - colectomy
OA features?
signs
reduced range of movt
pain on movt
joint swelling, instability
tenderness
crepitus
absence of systemic features (fever, rash)
bone swelling and deformity from osteophytes (Herbedens - DIP, Bouchards - PIP)
Asymmetrical joint involvement
symptoms
pain exacerbated by exercise, relieved by rest
reduced function
worsens with prolonged activity
stiffness in morning <30min/none
OA investigations?
A
X-ray - LOSS
Loss of joint space
Osteophyte formation
Subchondral sclerosis
Subchondral cysts
FBC - CRP maybe raised
MRI
Joint aspiration - exclude septic arthritis, gout
OA management?
Exercise, wt loss
Physio/occ therapy, walking aids
Analgesia- topical/oral NSAIDs
Joint steroid injections
Surgery - joint replacement / fusion
RA features?
signs
inflammation - red, hot, pain, swelling
symmetrical, polyarthropathy of smaller joints (MCP, PIP, wrist, MTP joints)
loss of function
deformity (swan neck, boutonniere, z-thumb, ulnar deviation, subluxation)
extra-articular involvement (see cx)
symptoms
pain worse in morning, stiffness >30min
fatigue, malaise
pain progressively gets worse
RA investigations?
Bloods - anaemia, high ESR/CRP
RF - positive in 60-70%
anti-CCP
X-ray - LESS
loss of joint space
erosions (focal)
soft tissue swelling
soft bones (osteopenia)
RA management?
Physio/occ therapy, podiatry, surgery, stop smoking
DMARDs - methotrexate, sulfasalazine, hydroxychloroquine
Prednisolone- can be used in conjunction with DMARDs or for flares
Biological agents - TNF inhibitors, B-cell depletion
NSAIDs - ibuprofen, naproxen, diclofenac
Analgesics - paracetamol, codeine
CRP used to monitor
Gout features?
hot, swollen joints
shiny red, taut
pain
inflammation, fever, malaise
tophi - long-term (large crystal deposits)
Gout investigations?
X-ray - BETS
Bony hooks (from erosions)
Erosions - punched out
Tophi - more opaque
Space intact (no loss of joint space)
Polarised light microscopy of aspirated synovial fluid - negative birefringent needles
U+E - serum uric acid, urea, creatinine
USS/CT/MRI
Gout management?
NSAIDs, colchicine (inhibits phagocyte activation, inflammation),
Oral steroids
Lose weight, reduce diet factors
Allopurinol / febuxostat (inhibits purine conversion into uric acid by xanthine oxidase)
Polymyalgia rheumatica features?
Inflammatory condition of unknown cause, often coexists with GCA, kind of a large vessel vasculitis
sub acute onset <2wks
sudden onset severe pain, stiffness of shoulders, neck, hips, lumbar spine (limb girdle pattern)
symptoms worse in morning
mild polyarthritis of peripheral joints
fatigue, fever, wt loss, depression
Polymyalgia rheumatica investigations?
Clinical history
ESR/CRP raised
ANCA negative
serum ALP raised
Mild anaemia (normocytic, normochromic)
Temporal artery biopsy - GCA
Creatinine kinase normal - distinguish from myopathies
Polymyalgia rheumatica management?
Prednisolone long-term- big response
lansoprazole and alendronate to prevent osteoporosis and GI upset
HTN presentation?
Asym
Retinal haemorrhage, papilloedema, headaches - malignant htn
HTN invvestigations?
24hr ABPM
Urinalysis, bloods, fundoscopy, ECG, echo
HTN Mx
Lifestyle
ACEi (under 55yo)/CCB (55+, afro-caribbean)
Then the other one
Then thiazide
Then another diuretic (spironolactone), alpha/beta blockers
HF presentation?
SOB, fatigue, ankle swelling
signs
tachycardia
displaced apex beat (LV dilatation)
RV heave (pul HTN)
added heart sounds - gallop (S3), murmurs, raised JVP
hepatomegaly
ascites
peripheral oedema
PO
cyanosis
pleural effusions
symptoms
SOB, fatigue
cold peripheries
PND - paroxysmal nocturnal dyspnoea
nocturnal cough (maybe pink frothy sputum)
orthopnoea (SOB when lying down)
wheeze
light-headed/syncope
NYHA classification for severity I-IV
HF Ix
Bloods - brain natriuretic peptide - secreted in ventricles in response to increased myocardial wall stress - if normal, HF unlikely, and other blood tests
ECG - underlying causes - ischaemia, LVH, arrhythmia
ECHO
CXR - ABCDE
Alveolar oedema (bat’s wing shadowing)
Kerley B lines - septal lines
Cardiomegaly - cardiothoracic ratio >50%
Dilated prominent upper lobe veins (upper lobe diversion)
Pleural Effusions
HF Mx
lose weight, exercise, stop smoking
Diuretics - furosemide, thiazide, spironolactone
ACEi - ramipril, enalapril (S/E cough, hypotension, hyperkalaemia, renal dysfunction)
ARB
BB - bisoprolol
Surgery to repair cause, heart transplant
DM Ix
random plasma glucose >11.1mmol/L
fasting plasma glucose >7mmol/L
OGTT >7mmol/L (>6 for impaired glucose tolerance)
HbA1c >6.5% normal (48mmol/mol)
DM complications
Macrovascular - atherosclerosis, stroke, IHD, PAD
Microvascular - diabetic retinopathy, nephropathy, neuropathy, infections
DKA, HHS, hypoglycaemia
DM presentation
signs
ketonuria (ketoacidosis) - pear drop breath (T1)
complications (eg retinopathy)
symptoms
polyuria/nocturia
polydipsia
weight loss
T1 - leaner than T2
T1DM Mx
synthetic human insulin
short acting insulins - eg for before meals
sort-acting insulin analogues - fast onset, eg with evening meal
longer-acting insulins - 12-24hrs
complications - hypoglycaemia, weight gain
T2DM Mx
1st line - lifestyle - diet, exercise, weight loss, ramipril/statins/orlistat
2nd - oral metformin
Add sulfonylurea (oral gliclazide)
later - insulin/glitazone (oral pioglitazone) - increase tissue sensitivity to insulin
DKA overview
Ketonaemia (/ketonuria)
Hyperglycaemia
Acidosis
DKA presentation
signs
Pear drop breath
Kussmaul’s respiration (deep, rapid)
Disturbance of consciousness
symptoms
Vomiting
Drowsiness
Abdo pain
Dehydration - eyes sunken, slow cap refill, tachycardia, weak pulse, hypotension
DKA Ix
Bloods show: hyperglycaemia, raised plasma ketones, acidaemia, metabolic acidosis with bicarb reduced
Urine stick testing - glycosuria and ketonuria
Check plasma osmolality and anion gap (both elevated, plasma osmolality more elevated in HSS)
DKA Tx
ABCDE
Replace fluid loss with 0.9% saline
Restore electrolye (K) loss and acid-base balance
Insulin-glucose
Stable angina Px
Provoked by exertion - after meal, cold, windy, exercise, angry/excited
signs
sweaty
distressed
symptoms central chest tightness or heaviness pain may radiate SOB nausea, feeling faint
Stable angina Ix
ECG - may be normal, ST depression, flat/inverted T waves Treadmill test/exercise ECG Bloods - FBC to exclude anaemia ECHO CXR Coronary angiography
Stable angina Mx
Modify RFs - stop smoking, exercise, lose weight, atorvastatin
Aspirin
GTN - dilates systemic veins, reducing venous return to heart, reduces preload, also dilates coronary arteries
BBs - atenolol, bisoprolol
CCB - verapamil
Long acting nitrates
Ivabradine - HCN channel blocker, reduces HR
Maybe surgery - PCI, CABG
Asthma patho
narrowing of airway, SM contraction, airway wall thickening by cellular infiltration, inflammation, secretions
Eosinophilic - associated with allergy, subset of atopic/non-atopic
Non-eosinophilic - later onset, overlaps with smoking, obesity, neutrophils instead of eosinophils
RFs
FHx, atopy, low SES, inner city environ, obesity, premature, viral infections in early childhood, smoking
Asthma Px
symptoms
intermittent SOB
wheeze
cough (often nocturnal)
sputum
chest tightness
signs
tachypnoea
audible wheeze - widespread, polyphonic
hyperinflated chest
hyper-resonant percussion note
reduced air entry
Levels of acute asthma atttack
Moderate
increasing symptoms
PEF >50-75%
no features of severe attack
Severe
cannot complete sentences
HR >110
RR >25
PEF 33-50% predicted
Life-threatening
silent chest
confusion
exhaustion
cyanosis
bradyacardia
PEF <33%
Sats <92%
hypotension
Near fatal
PaCO2 increase
Asthma Ix
Blood count - eosinophils
Atopy/allergy (SPT, RAST)
CXR
Spirometry / peak flow
Reduced FEV1, FEV1/FVC <70%
PEFR reduced, >20% variability
FeNO test
level of NO in breath - measure of inflammation
BDR test (bronchodilator reversibility)
see if obstruction gets better with bronchodilator medication
Direct bronchial challenge
see if breathing worsens worsens with provocation agent (methacholine/histamine)
Acute Asthma Mx
Acute attack
Assess severity - PEF, ability to speak, RR, HR, sats
O2
Salbutamol
Ipratropium if severe
Hydrocortisone/prednisolone
Reassess every 15 mins
ECG
Magnesium sulfate if not responding
BPH Px
signs
abdo exam - enlarged bladder
symptoms
LUTS - frequency, urgency, hesitancy, incomplete bladder emptying, need to push/strain, nocturia, poor stream/flow, post-micturition dribbling, UTI, haematuria,
BPH Ix
DRE - prostate enlarged, smooth
Serum electrolytes, renal USS - exclude renal damage
Transrectal USS - see prostate
PSA may be raised in large BPH
Biopsy, endoscopy
Low flow rate
Frequency vol chart - nocturia
BPH Mx
avoid caffeine, alcohol, void twice in a row
Alpha 1 antagonist - oral tamsulosin - relaxes SM in bladder neck. S/E drowsiness, dizziness, ejaculatory failure. CI postural hypotension
5-alpha-reductase inhibitor - oral finasteride - blocks testosterone -> dihydrotestosterone (active form, responsible for prostatic growth). S/E impotence, decreased libido
Surgery - TURP, TUIP, open prostatectomy
COPD Px
signs
tachypnoea
use of accessory muscles of resp (might lean forward)
hyperinflation (barrel shaped chest)
decreased expansion
resonant/hyper-resonant percussion note
expiration through pursed lips
quiet breath sounds
cyanosis
cor pulmonale, peripheral oedema, raised JVP
cachexia
symptoms
SOB
cough
sputum
wheeze
minimal diurnal variation
wt loss
PP vs BB
PP - increased alveolar ventilation, normal PaO2, breathless, not cyanosed
BB - decreased alveolar ventilation, low PaO2, high PaCO2, cyanosed, not breathless, resp centres insensitive to CO2, rely on hypoxic drive
COPD Ix
Spirometry - FEV1/FVC < 0.7, FEV1 < 80%
CXR - hyperinflation, flat hemidiaphragms, large central pulmonary arteries, bullae
CT - bronchial wall thickening, scarring, air space enlargement
ECG - cor pulmonale
ABG - decreased PaO2 +/- hypercapnia
FBC - identify anaemia / polycythaemia
MRC SOB scale, NICE COPD severity classification
COPD Mx
Stop smoking, influenza and pneumonia vaccines, pulmonary rehab
Bronchodilators
SABA - salbutamol
LABA - salmeterol, formoterol
SAMA - ipratropium
LAMA - tiotropium
Theophylline - bronchodilator, suppresses airway response to stimuli
ICS - beclometasone, fluticasone
Combination therapy of above
Oxygen therapy
NIV (non-invasive ventilation)
Phosphodiesterase t4 inhibitors - anti-inflammatory - eg roflumilast
Mucolytics
Surgery - bullectomy, lung volume reduction surgery, transplant
OVERALL
SABA / SAMA
If steroid responsive / asthmatic = add LABA + ICS
If not steroids responsive / non-asthmatic = add LABA + LAMA
Oral theophylline
Long term oxygen therapy
Do not prescribe LAMA and SAMA together, if started on LAMA, remove SAMA
COPD acute exacerbation
acute worsening of symptoms
commonly viral cause, also bacterial, air pollutants
Tx - nebulised bronchodilators, O2, steroids, ABs, aminophylline/theophylline, doxapram (respiratory stimulant drug), NIV
BPH Px
signs
abdo exam - enlarged bladder
symptoms
LUTS - frequency, urgency, hesitancy, incomplete bladder emptying, need to push/strain, nocturia, poor stream/flow, post-micturition dribbling, UTI, haematuria,
BPH Ix
DRE - prostate enlarged, smooth
Serum electrolytes, renal USS - exclude renal damage
Transrectal USS - see prostate
PSA may be raised in large BPH
Biopsy, endoscopy
Low flow rate
Frequency vol chart - nocturia
BPH Mx
avoid caffeine, alcohol, void twice in a row
Alpha 1 antagonist - oral tamsulosin - relaxes SM in bladder neck. S/E drowsiness, dizziness, ejaculatory failure. CI postural hypotension
5-alpha-reductase inhibitor - oral finasteride - blocks testosterone -> dihydrotestosterone (active form, responsible for prostatic growth). S/E impotence, decreased libido
Surgery - TURP, TUIP, open prostatectomy
Prostate cancer Px
LUTS
nocturia
hesitancy
poor stream
terminal dribbling
obstruction
wt loss, bone pain, anaemia
Prostate cancer Ix
DRE - hard, irregular prostate
Raised PSA
Trans-rectal ultrasound scan (TRUSS), biopsy
Urine biomarkers, MRI
Prostate cancer Mx
no spread
prostatectomy, radiotherapy, hormone therapy
metastatic
orchidectomy
LHRH agonist - goserelin/leuprorelin
Androgen receptor blockers - bicalutamide
for symptoms - analgesia, tx metastases, radiotherapy
Hyperthyroidism
Excess TH
Primary - pathology in thyroid gland
Secondary - thyroid gland stimulated by excessive TSH
Primary hyperthyroidism causes
Graves disease - autoimmune induced excess TH secretion, diffuse goitre,
Toxic multinodular goitre - nodules that secrete TH
Adenoma
Thyroiditis (De Quervain’s) - transient, inflammation of thyroid
Drug-induced - amiodarone, iodine, lithium
Secondary hyperthyroidism causes
TSH-secreting pituitary adenoma
TH-resistance syndrome
Gestational thyrotoxicosis
Hyperthyroidism presentation
signs
Graves ophthalmopathy - retro-orbital inflammation, protruding eye
diffuse goitre
hyperkinesis
muscle wasting
thin hair
lid lag and stare, lid retraction
onycholysis (nail separation from nail bed)
Hyperthyroidism Ixsymptoms
palpitations
diarrhoea
weight loss
oligomenorrhea
heat intolerance
irritability/anxiety
Hyperthyroidism Ix
TFTs - T4/3 raised (TSH raised in secondary)
ABs against thyroid peroxidase and thyroglobulin (Graves)
Ultrasound thyroid, thyroid uptake scan
inflammatory markers
TSHR-Ab raised - diagnostic of Graves
Hyperthyroidism Tx
(IV methylprednisolone - for inflammation)
BBs (propanolol)
PTU (propylthiouracil) - stops T4 ->T3
Oral carbimazole - blocks TH synthesis - AGRANULOCYTOSIS risk (sore throat, fevers)
Radioactive iodine
Thyroidectomy
Hypothyroidism
Lack of TH
Primary - thyroid gland disease
Secondary - hypothalamic/pituitary disease
Hypothyroidism causes
Autoimmine - antithyroid autoantibodies - atrophy, no goitre
Thyroiditis (Hashimoto’s - is autoimmune) - atrophy, goitre
Post-partum thyroiditis
Thyroidectomy/radioactive iodine
Drug-induced - carbimazole, lithium, amiodarone
Iodine deficiency
Hypothyroidism presentation
signs - BRADYCARDIC
Bradycardia
Reflexes relax slowly
Ataxia
Dry, thin hair/skin
Yawning/drowsy/coma
Cold hands/temp drop
Ascites
Round puffy face
Defeated demeanour
Immobile/ileus (peristalsis stops)
CCF
symptoms
hoarse voice
goitre
constipation
cold intolerant
weight gain
myalgia
low mood
hair/eyebrow loss
cold pale skin
Hypothyroidism Ix
TFTs - TSH high in primary, low in secondary, T4 low
Bloods - anaemia…
Hypothyroidism Tx
Oral levothyroxine (T4)
Acute coronary syndrome
STEMI, NSTEMI, unstable angina
patho - thrombus
STEMI
complete occlusion of major coronary artery, full thickness damage to heart muscle, troponin release
NSTEMI
complete occlusion of minor artery or partial occlusion of major artery, partial thickness damage, troponin release
Unstable angina
angina of increasing frequency/severity, partial occlusion but no damage to heart, occurs on minimal exertion/at rest, no troponin
ACS RFs
ABCDEF
age, BP, cholesterol, diabetes, exercise, fags, fat, family
ACS Px
Silent MI - no chest pain - elderly, diabetic
signs
distress, anxiety
pallor
pulse low/high
BP high/low
4th heart sound
signs of HF - raised JVP, 3rd heart sound, basal crepitations
pansystolic murmur maybe
symptoms
central chest pain
N+V, fatigue
sweaty
SOB
palpitations
ACS Ix
ECG
STEMI - ST elevation, pathological Q waves, tall T waves, new LBBB
NSTEMI - ST depression, T wave inversion, maybe normal ECG
Unstable angina - normal ECG usually
Troponin - I/T - raised in MI
CXR
ECHO
Bloods - FBC, U+E, glucose, lipids,
ACS Mx
MONA
Morphine
Oxygen
Nitrates - GTN spray
Aspirin
+ P2Y12 inhibitor - clopidogrel, ticagrelor
BBs - atenolol
ACEi - ramipril
Statin - atorvastatin
Thrombolysis if indicated
PCI/CABG if indicated
Modify risk factors - stop smoking, lose weight, healthy diet, control diabetes
≥65 and on long-term steroids should be offered bone
protection even without a DEXA scan
Alendronic acid
Prednisolone for polymyalgia rheumatica
AF?
Symptoms
palpitations
dyspnoea
chest pain
Signs
an irregularly irregular pulse
Investigations- ECG- irregularly irregular
- Rate control- BB or rate limiting CCB- diltiazem
Can add digoxin eventually
