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Phase 3a > GP Key Conditions > Flashcards

GP Key Conditions Flashcards

1
Q

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

A

S

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2
Q

What are the three stages of hypertension?

A

Stage 1- 140/90
Stage 2- 160/100
Stage 3- 180/120

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3
Q

What is defined as hypertension?

A

Over 140/90 in clinic

Over 135/85 outside of clinic

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4
Q

What are the investigations for hypertension?

A

Ambulatory blood pressure monitoring (ABPM)
`
Home blood pressure monitoring (HBPM)

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5
Q

What is the management of hypertension?

A

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

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6
Q

General management of COPD?

A

Lifestyle changes- smoking cessation, flu vaccine

SABA or SAMA

Asthma features?
Yes- LABA+ICS
No- LABA+LAMA

SABA+LABA+LAMA+ICS

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7
Q

What is type 1 diabetes?

A

Autoimmune disorder where the insulin-producing beta cells of the islets of Langerhans in the pancreas are destroyed by the immune system

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8
Q

Signs of type 1 diabetes?

A

Weight loss
Polydipsia
Polyuria

May present with diabetic ketoacidosis
abdominal pain
vomiting
reduced consciousness level

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9
Q

Signs of type 2 diabetes?

A

Often picked up incidentally on routine blood tests
Polydipsia
Polyuria

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10
Q

Diagnostic thresholds for diabetes?

A

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)

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11
Q

HbA1c diabetes level?

A

Over 48 mmol/mol (6.5%)

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12
Q

T1DM management?

A

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

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13
Q

T2DM management?

A

Dietary/lifestyle advice

1st- Metformin

2nd- metformin + DPP-4 inhibitor
metformin + pioglitazone
metformin + sulfonylurea- gliclazide
metformin + SGLT-2 inhibitor (if NICE criteria met)

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14
Q

DKA features?

A

Abdominal pain

Polyuria, polydipsia, dehydration

Kussmaul respiration (deep hyperventilation)

Acetone-smelling breath (‘pear drops’ smell)

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15
Q

Diabetes investigations?

A

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

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16
Q

Features of chronic heart failure?

A

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

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17
Q

What is the investigation for heart failure?

A

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

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18
Q

Management of chronic heart failure?

A

1st- ACE-inhibitor and a beta-blocker

2nd- aldosterone antagonist- spironolactone

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19
Q

Treatment of acute heart failure?

A

IV loop diuretics- furosemide, bumetanide

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20
Q

Stable angina management?

A

All patients recieve aspirin and statin

Siblingual glyceral trinitrate to abort angina attacks

BB or calcium channel blocker first line

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21
Q

Asthma management adults?

A

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

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22
Q

Signs and symptoms of asthma?

A

Symptoms
cough: often worse at night
dyspnoea
‘wheeze’, ‘chest tightness’

Signs
expiratory wheeze on auscultation
reduced peak expiratory flow rate (PEFR)

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23
Q

How long for chronic fatigue to be diagnosed?

A

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

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24
Q

Investigations of chronic fatigue syndrome?

A

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

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25
Q

Management of chronic fatigue syndrome?

A

Specialist CFS service

Energy management

Physical activity and exercise

CBT

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26
Q

What are the features of polymyalgia rheumatica?

A

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

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27
Q

Investigations for polymyalgia rheumatica?

A

Raised inflammatory markers e.g. ESR > 40 mm/hr
Note creatine kinase and EMG normal

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28
Q

What is the treatment for polymyalgia rheumatica?

A

Prednisolone e.g. 15mg/od

Patients typically respond dramatically to steroids, failure to do so should prompt consideration of an alternative diagnosis

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29
Q

What is fibromyalgia?

A

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

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30
Q

What are the features of fibromyalgia?

A

Chronic pain: at multiple site, sometimes ‘pain all over’

Lethargy

Cognitive impairment: ‘fibro fog’

Sleep disturbance, headaches, dizziness are common

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31
Q

Diagnosis and management of fibromyalgia?

A

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

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32
Q

What are the features of COPD?

A

Cough: often productive

Dyspnoea

Wheeze

In severe cases, right-sided heart failure may develop resulting in peripheral oedema

Smoking is the cause

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33
Q

COPD investigations?

A

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

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34
Q

COPD management?

A

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

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35
Q

Pneumonia signs and symptoms?

A

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

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36
Q

Management pneumonia?

A

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

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37
Q

CURB-65?

A

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)

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38
Q

Features crohns vs uc?

A

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

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39
Q

Crohn’s investigations?

A

Bloods- CRP
MC&S
Faecal calprotectin
Colonoscopy, bowel biopsy
MRI to assess Cx

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40
Q

Crohn’s treatment?

A

Stop smoking, optimise nutrition

Induce and maintain remission

Oral prednisolone

Severe - IV fluids, IV steroids

Azathioprine (immunosuppressant)

Infliximab

Surgery - not curative

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41
Q

Crohn’s presentation?

A

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

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42
Q

UC presentation?

A

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

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43
Q

UC investigations?

A

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

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44
Q

UC management?

A

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

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45
Q

OA features?

A

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

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46
Q

OA investigations?

A

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

47
Q

OA management?

A

Exercise, wt loss
Physio/occ therapy, walking aids
Analgesia- topical/oral NSAIDs
Joint steroid injections
Surgery - joint replacement / fusion

48
Q

RA features?

A

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

49
Q

RA investigations?

A

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)

50
Q

RA management?

A

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

51
Q

Gout features?

A

hot, swollen joints
shiny red, taut
pain
inflammation, fever, malaise
tophi - long-term (large crystal deposits)

52
Q

Gout investigations?

A

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

53
Q

Gout management?

A

NSAIDs, colchicine (inhibits phagocyte activation, inflammation),
Oral steroids

Lose weight, reduce diet factors

Allopurinol / febuxostat (inhibits purine conversion into uric acid by xanthine oxidase)

54
Q

Polymyalgia rheumatica features?

A

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

55
Q

Polymyalgia rheumatica investigations?

A

Clinical history
ESR/CRP raised
ANCA negative
serum ALP raised
Mild anaemia (normocytic, normochromic)
Temporal artery biopsy - GCA
Creatinine kinase normal - distinguish from myopathies

56
Q

Polymyalgia rheumatica management?

A

Prednisolone long-term- big response

lansoprazole and alendronate to prevent osteoporosis and GI upset

57
Q

HTN presentation?

A

Asym

Retinal haemorrhage, papilloedema, headaches - malignant htn

58
Q

HTN invvestigations?

A

24hr ABPM

Urinalysis, bloods, fundoscopy, ECG, echo

59
Q

HTN Mx

A

Lifestyle

ACEi (under 55yo)/CCB (55+, afro-caribbean)
Then the other one
Then thiazide
Then another diuretic (spironolactone), alpha/beta blockers

60
Q

HF presentation?

A

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

61
Q

HF Ix

A

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

62
Q

HF Mx

A

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

63
Q

DM Ix

A

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)

64
Q

DM complications

A

Macrovascular - atherosclerosis, stroke, IHD, PAD

Microvascular - diabetic retinopathy, nephropathy, neuropathy, infections

DKA, HHS, hypoglycaemia

65
Q

DM presentation

A

signs
ketonuria (ketoacidosis) - pear drop breath (T1)
complications (eg retinopathy)

symptoms
polyuria/nocturia
polydipsia
weight loss

T1 - leaner than T2

66
Q

T1DM Mx

A

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

67
Q

T2DM Mx

A

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

68
Q

DKA overview

A

Ketonaemia (/ketonuria)
Hyperglycaemia
Acidosis

69
Q

DKA presentation

A

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

70
Q

DKA Ix

A

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)

71
Q

DKA Tx

A

ABCDE
Replace fluid loss with 0.9% saline
Restore electrolye (K) loss and acid-base balance
Insulin-glucose

72
Q

Stable angina Px

A

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
73
Q

Stable angina Ix

A 
ECG - may be normal, ST depression, flat/inverted T waves
Treadmill test/exercise ECG
Bloods - FBC to exclude anaemia
ECHO
CXR
Coronary angiography
74
Q

Stable angina Mx

A

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

75
Q

Asthma patho

A

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

76
Q

Asthma Px

A

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

77
Q

Levels of acute asthma atttack

A

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

78
Q

Asthma Ix

A

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)

79
Q

Acute Asthma Mx

A

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

80
Q

BPH Px

A

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,

81
Q

BPH Ix

A

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

82
Q

BPH Mx

A

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

83
Q

COPD Px

A

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

84
Q

COPD Ix

A

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

85
Q

COPD Mx

A

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

86
Q

COPD acute exacerbation

A

acute worsening of symptoms

commonly viral cause, also bacterial, air pollutants

Tx - nebulised bronchodilators, O2, steroids, ABs, aminophylline/theophylline, doxapram (respiratory stimulant drug), NIV

87
Q

BPH Px

A

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,

88
Q

BPH Ix

A

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

89
Q

BPH Mx

A

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

90
Q

Prostate cancer Px

A

LUTS
nocturia
hesitancy
poor stream
terminal dribbling
obstruction
wt loss, bone pain, anaemia

91
Q

Prostate cancer Ix

A

DRE - hard, irregular prostate

Raised PSA

Trans-rectal ultrasound scan (TRUSS), biopsy

Urine biomarkers, MRI

92
Q

Prostate cancer Mx

A

no spread
prostatectomy, radiotherapy, hormone therapy

metastatic
orchidectomy
LHRH agonist - goserelin/leuprorelin
Androgen receptor blockers - bicalutamide

for symptoms - analgesia, tx metastases, radiotherapy

93
Q

Hyperthyroidism

A

Excess TH

Primary - pathology in thyroid gland

Secondary - thyroid gland stimulated by excessive TSH

94
Q

Primary hyperthyroidism causes

A

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

95
Q

Secondary hyperthyroidism causes

A

TSH-secreting pituitary adenoma

TH-resistance syndrome

Gestational thyrotoxicosis

96
Q

Hyperthyroidism presentation

A

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

97
Q

Hyperthyroidism Ix

A

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

98
Q

Hyperthyroidism Tx

A

(IV methylprednisolone - for inflammation)

BBs (propanolol)

PTU (propylthiouracil) - stops T4 ->T3

Oral carbimazole - blocks TH synthesis - AGRANULOCYTOSIS risk (sore throat, fevers)

Radioactive iodine

Thyroidectomy

99
Q

Hypothyroidism

A

Lack of TH

Primary - thyroid gland disease

Secondary - hypothalamic/pituitary disease

100
Q

Hypothyroidism causes

A

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

101
Q

Hypothyroidism presentation

A

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

102
Q

Hypothyroidism Ix

A

TFTs - TSH high in primary, low in secondary, T4 low

Bloods - anaemia…

103
Q

Hypothyroidism Tx

A

Oral levothyroxine (T4)

104
Q

Acute coronary syndrome

A

STEMI, NSTEMI, unstable angina

patho - thrombus

105
Q

STEMI

A

complete occlusion of major coronary artery, full thickness damage to heart muscle, troponin release

106
Q

NSTEMI

A

complete occlusion of minor artery or partial occlusion of major artery, partial thickness damage, troponin release

107
Q

Unstable angina

A

angina of increasing frequency/severity, partial occlusion but no damage to heart, occurs on minimal exertion/at rest, no troponin

108
Q

ACS RFs

A

ABCDEF

age, BP, cholesterol, diabetes, exercise, fags, fat, family

109
Q

ACS Px

A

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

110
Q

ACS Ix

A

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,

111
Q

ACS Mx

A

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

112
Q

≥65 and on long-term steroids should be offered bone
protection even without a DEXA scan

A

Alendronic acid

Prednisolone for polymyalgia rheumatica

113
Q

AF?

A

Symptoms
palpitations
dyspnoea
chest pain

Signs
an irregularly irregular pulse

Investigations- ECG- irregularly irregular

  1. Rate control- BB or rate limiting CCB- diltiazem

Can add digoxin eventually

Phase 3a (17 decks)

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