GP notes Flashcards
1
Q
(7)
Who is at an increased risk of AKI?
A
CKD, other organ failure/chronic disease, history of AKI, use of drugs with nephrotoxic potential within the last week, use of iodinated contrast agents within the last week, >65 years, oliguria
2
Q
What are drugs with nephrotoxic potential?
A
NSAIDs, aminoglycoside, ACE inhibitors, angiotensin II receptor antagonists, diuretics
3
Q
What are the ways that AKI may present?
A
Reduced urine output (oliguria), fluid overload, a rise in molecules that the kidney normally excretes/maintains a balance of
4
Q
What is the definition of oliguria?
A
Urine output of less than 0.5ml/kg/hour
5
Q
What symptoms are seen in AKI?
A
Reduced urine output, pulmonary and peripheral oedema, arrhythmias, features of uraemia
6
Q
What are features of uraemia?
A
Pericarditis, encephalopathy
7
Q
What is the diagnostic criteria for AKI?
A
50% or greater risk in serum creatinine known or presumed in last 7 days, rise in serum creatinine of 26 mmol/L or greater within 48 hours, fall in urine output to less than 0.5ml/kg/hr
8
Q
What is the treatment in hyperkalaemia for stabilisation of the cardiac membrane?
A
IV calcium gluconate
9
Q
What is the treatment in hyperkalaemia for short term shift in potassium from extracellular to intracellular fluid compartment?
A
Nebulised salbutamol, combined insulin/dextrose infusion
10
Q
What is the treatment in hyperkalaemia for removal or potassium from the body?
A
Calcium resonium (orally or enema), loop diuretics, dialysis
11
Q
What are possible complications of severe AKI?
A
Hyperkalaemia, pulmonary oedema, acidosis or uraemia (pericarditis, encephalopathy)
12
Q
What is acute tubular necrosis?
A
Damage and death of the epithelial cells of the renal tubules. Damage occurs due to ischaemia due to hypoperfusion or due to nephrotoxins
13
Q
What is the commonest intrinsic cause of AKI?
A
Acute tubular necrosis
14
Q
What is seen on urinalysis in acute tubular necrosis?
A
Muddy brown casts
15
Q
Is acute tubular necrosis reversible?
A
Yes: epithelial cells can regenerate, though this takes between 1 and 3 weeks
16
Q
What are the investigations in AKI?
A
Urinalysis for protein, blood, leucocytes, nitrites and glucose. Ultrasound can be done to assess for obstruction when suspected post renal cause
17
Q
What is the tx for AKI?
A
- IV fluids
- withhold medications that may worsen condition, and without medications that can accumulate in reduced renal function
- relieve obstruction in post-renal AKI
- dialysis if severe
18
Q
What are risk factors for CKD?
A
Diabetes, HTN, certain nephrotoxic medications, glomerulonephritis, polycystic kidney disease
19
Q
What are the symptoms of CKD? When do they present?
A
Symptoms often present very late. It is often non specific: fatigue, pallor (due to anaemia), foamy urine (proteinuria), nausea, loss of appetite, pruritus (ithching), oedema, HTN, peripheral neuropathy
20
Q
What is the ratio that quantifies proteinuria?
A
Urine albumine:creatinine ratio
21
Q
What is the diagnosis criteria for CKD?
A
For over 3 months:
- estimated glomerular filtration rate is sustained below 60ml/min/1.73m2
- urine albumin:creatinine ratio is sustained above 3mg/mmol
22
Q
What is the estimated decline in eGFR annually in CKD?
A
15ml/min/1.73m^2
23
Q
What are the potential complications of CKD?
A
anaemia, renal bone disease, cardiovascular disease, peripheral neuropathy, end stage kidney disease, dialysis related complications
24
Q
When should someone be referred for renal specialist assessment in CKD?
A
- eGFR <30ml/min/1.73m^2
- urine ACR >70 mg/mmol
- accelerated progression
- uncontrolled hypertension despite 4 or more hypertensives
25
What are medications that can slow the disease progression of CKD?
ACE inhibitors (or ARBs), and SGLT-2 inhibitors (specifically dapagliflozin)
26
Why can CKD cause anaemia?
Healthy kidneys produce erythropoietin, which stimulates RBC production. In CKD, erythropoietin production reduces, which causes normocytic normochromic anaemia
27
Why can CKD cause renal bone disease?
Healthy kidneys metabolise vitamin D into its active form. Active vitamin D is essential in calcium absorption in the intestines and reabsorption in the kidneys. It is also responsible for regulating bone turnover and promoting bone reabsorption to increase the serum calcium level. Chronic kidney disease leads to less vitamin D activity and low serum calcium. There is also high serum phosphate due to reduced excretion. Parathyroid gland reacts by excreting parathydoid hormone, which stimulates osteoclast activity, increasing calcium absorption from bone.
All of this leads to osteomalacia (soft bones) and osteosclerosis (
28
What is a characteristic xray finding in CKD?
Rugger jersey spine: this involves sclerosis of both ends of each vertebral body (denser white) and osteomalacia in the centre of the vertebral body (less white). The name refers to the stripes found on a rugby shirt.
29
What is osteomalacia?
Softening of bones, occurs because of a problem with vitamin D
30
What is osteosclerosis?
A disorder that is characterised by abnormal hardening of bone and an elevation in bone density
31
What is the best way to differentiate between AKi and CKD?
Ultrasound: most patients with CKD have bilateral small kidneys.
CKD is also more likely to have hypocalcaemia
32
What UTI causative organism is most linked to renal stones?
Proteus sp.
33
What is the management if someone presents with queried PE but there is a delay for scan?
Start treatment (rivaroxaban)
34
What is the first line management of hypertension in diabetics?
ACE-I/ARBs
35
What is the recommended treatment for all patients in acute heart failure?
IV loop diuretics (furosemide or bumetanide)
36
What are the features of pericarditis?
Chest pain, relieved by sitting forwards, non-productive cough, dyspnoea, flu-like symptoms, pericardial rub
37
What ECG changes are seen in pericarditis?
Saddle shaped ST elective, PR depression (most specific)
38
What investigation should be done for all patients with pericarditis?
Transthoracic echocardiography
39
What is the management of pericardial effusion?
NSAIDs, and colchicine (reduces risk of recurrence)
40
What is the management for a patient who has a stroke whilst on warfarin?
Give IV vitamin K and prothrombin complex concentrate
41
What is done if there is a high INR of >8.0 and minor bleeding for a patient on warfarin?
Give IV vitamin K
42
What is the management for high INR of >8.0 but no bleeding for a patient on warfarin?
Give oral vitamin K
43
What is the target range of warfarin?
2.5, action needed if more than 5
44
What drug commonly interacts with statins to raise creatine kinase levels?
Clarithromycin
45
Who is it recommended should take statins?
Anyone with a 10-year cardiovascular risk >10%
46
What is first line therapy in chronic heart failure?
ACE inhibitor/ARBi and beta blocker
47
What is second line therapy in heart failure?
Aldosterone antagonist (spironolactone)
48
What is the risk factor tool for whether to anticoagulate a patient in AF?
CHA2DS2-VASc
49
What is first line treatment of AF?
Bisoprolol
50
What is a common contraindication for beta blockers?
Asthma
51
What is chronic heart failure?
Refers to the clinical features of impaired heart function, specifically the left ventricle
52
How does left ventricular failure in heart failure lead to pulmonary oedema?
Leads to a chronic backflow of blood waiting to flow through left side of heart. LA + pulmonary veins + lungs experience increased volume and pressure blood. Fluid leaks -> pulmonary oedema
53
What is a normal ejection fraction?
>50%
54
What is heart failure with reduced ejection fraction?
When the ejection fraction is less than 50%
55
What causes heart failure?
Ischaemic heart disease, valvular heart disease (mostly aortic stenosis), hypertension, arrythmias, cardiomyopathy
56
What is the presentation of chronic HF?
- breathlessness, worsened by exertion
- cough (frothy)
- orthopnoea (breathless when lying flat)
- PND
- peripheral oedema
- fatigue
57
What signs are seen on examination in heart failure?
Tachycardia, tachypnoea, HTN, murmurs, 3rd heart sound, bilateral basal crackles (pulmonary oedema), raised JVP (due to backlog to right heart), peripheral oedema
58
What is done to establish a diagnosis of heart failure?
- N-terminal pro-B-type natriuretic peptide
- ECG
- ECHO
- CXR + lung function tests
- bloods
59
What is the New York Heart Association Classification?
Class I: no limitation on activity
Class II: comfortable at rest but symptomatic with ordinary activity
Class III: symptomatic with any activity
Class IV: symptomatic at rest
60
How does NT-proBP result guide ECHO?
If 400-2000 ng/litre: ECHO within 6 weeks, >2000 ng/litre within 2 weeks
61
What are the four pillars of heart failure treatment?
ACEI, beta blocker, aldosterone antagonist, SGLT2i
62
How do SLGT-2i work in heart failure?
Reduce glucose reabsorption and increase urinary glucose excretion (increased risk of UTI)
63
What vaccines should be given in heart failure patients?
Influenza annually and one off pneumococcal vaccine
64
What should be monitored if ACEI and aldosterone antagonists taken together?
Renal function: both can cause hyperkalaemia (tall tented t waves)
65
What is diagnostic of hypertension?
Blood pressure above 140/90 in a clinical settings, confirmed with ambulatory or home readings above 135/85
66
What are potential secondary causes of hypertension?
Renal disease, obesity, pregnancy induce (pre-eclampsia), endocrine, drugs (alcohol, steroids, NSAIDs, oestrogen)
67
What investigation should be done for very high blood pressure that is not responding to treatment?
Duplex ultrasound or MRI/CT angiogram, for renal artery stenosis
68
How often does NICE recommend measuring blood pressure for HTN?
Every 5 years, or every year in T2DM
69
What is stage 1 vs 2 vs 3 hypertension?
1: >140/90, 2: >160/100, 3: 180/120
70
What investigations should be done for end organ damage on diagnosis of HTN?
Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria, bloods for HbA1c/renal function, fundus examination, ECG (especially left ventricular hypertrophy)
71
What is starting dose of statin?
20mg
72
What is step 1 anti HTN?
If <55 years of T2D<: ACEI or ARB
If >55 + no T2DM, or Afro caribbean + no T2DM: CCB
73
Why should renal function be checked 2-3 weeks after starting ACE-I?
May worsen kidney function intially
74
What are the common s/e of ACE-I?
COUGH, angioedema, hyperkalaemia
75
What is second line drug treatment of HTN?
ACE-I + CCB or ACE-I + diuretic
76
What is an alternative to CCB?
thiazide diuretic if not tolerated
77
What is the common complaint for CCB?
Ankle oedema
78
What is the preferential drug in black patients out of ACE-I or ARB?
ARB
79
What is step 4 hypertension management?
Spironolactone or alpha blocker or beta blocker
80
When is spironolactone used in step 4 HTN management?
If serum potassium less than 4.5 mmol, then spironolactone. If >4.5, then alpha or beta blocker
81
Is nitrites or leucocytes a better indicator of UTI?
Nitrites
82
What patients is a urine dipstick not a valid investigation for UTI?
Women >65, men, and anyone catheterised
83
What are the most common causes of UTI?
E.coli. Also: Klebsiella pneumoniae, enterococcus, pseudomonas
84
What is the first line management of UTI?
Trimethoprime or nitrofurantoin for 3 days
85
What is the management for UTI in men?
7 days abx (tri or nitro)
86
What eGFR should nitrofurantoin be avoided in?
<45
87
What is the management of symptomatic UTI in pregnant women?
Nitrofurantoin, amoxicillin 2nd line
88
What is the management of acute pyelonephritis?
- consider hospital admission
- local guidelines abx
- broad spectrum cephalosporin or quinolone for 7-10 days
89
What is the cells in oesophagus vs stomach?
Oesophagus: squamous epithelial, stomach: columnar epithelial
90
What is the symptoms of dyspepsia?
Heartburn, acid regurg, retrosternal or epigastric pain, bloating, nocturnal cough
91
What is red flag symptoms in GORD?
Dysphagia, >55 years, weight loss, upper abdo pain, reflux, treatment resistance, N+V, upper abdo mass, low haemoglobin
92
What is management for GORD proven with endoscopy?
Full dose PPI for 1-2 months. If no response double
93
What is the management for endoscopically negative reflux disease?
Full dose PPI for one month. If no response then H2RA or prokinetic
94
What does H.pylori cause?
Can damage epithelial lining of the stomach, leading to gastritis, ulcers and increase stomach cancer
95
Who should be tested for H.pylori?
Anyone with dyspepsia
96
What should be done before H.pylori testing?
Stop PPI for 2 weeks
97
What is the investigation for H.pylori?
Stool antigen test, urea breath test, rapid urease test
98
What is eradication for H.pylori?
PPI + amoxicillin + clarithromycin/metronidazole (7 days)
99
What is the management for H.pylori if pencillin allergic?
PPI + metronidazole + clarithromycin
100
What is the RF for peptic ulcer disease?
H.pylori, NSAIDs/SSRIs/steroids/bisphosphonates
101
What makes up CURB-65?
Confusion, urea >7mmol, resp rate >30, blood pressure <90/60, age over 65
102
What does CURB-65 predict?
Mortality with pneumonia
103
What does 0/1 CURB-65 score suggest?
Treatment at home
104
What does CURB-65 2 or more suggest?
Consider hospital admission
105
What does CURB-65 3 or more suggest?
Consider intensive care
106
What are the most common causes of pneumonia?
S.pneumoniae, h.influenzae
107
What is a possible cause of pneumonia in COPD patients?
Moraxella catarrhalis and H.influenzae
108
What are potential causes of pneumonia in cystic fibrosis?
Pseudomonas aeruginosa and S.aureus
109
What complication can legionella pneumophilia cause?
SIADH and hyponatraemia
110
How is legionella pneumophilia diagnosed?
Urine antigen test
111
What pneumonia may occur in HIV/immunocompromised patients, and what is the prophylaxis?
Pneumocystis jirovecii. Co-trimoxazole is treatment/prophylaxis
112
What is the treatment for COVID-19 pneumonia?
Respiratory support, dexamethasone, monoclonal antibodies
113
What is the treatment for CAP?
5 days of oral abx, such as amoxicillin, clarithromycin
114
What is the treatment for moderate/severe pneumonia?
IV tazocin, or doxycycline
115
What are two causes of atypical pneumonia?
Mycoplasma pneumoniae, legionella pneumophilia
116
What are risk factors for pneumonia?
Under 5 or over 65, smoking, recent viral URTI, chronic respiratory diseases, immunosuppression, IVDU
117
What pneumonia is classically seen in alcoholics?
Klebsiella pneumoniae
118
What type of pneumonia does influenza infection precede?
S.aureus
119
What is the scoring system for severity of LUTS symptoms in men?
International prostate symptom score
120
What categories can LUTS be separated into?
Voiding symptoms, storage symptoms, post micturition, complications
121
What investigations are done for men with LUTS?
- DRE
- abdo exam
- urinary frequency volume chart for 3 days
- urine dipstick
- PSA
122
What are possible causes of raised PSA?
Prostate cancer, BPH, prostatitis, UTIs, vigorous exercise, recent ejaculation or prostate stimulation
123
What are the two medical options for BPH?
- alpha blockers (tamsulosin) to relax smooth muscles. Rapid improvement in symptoms
- 5-alpha reductase inhibitors (finasteride) to gradually reduce size
124
What is first line BPH tx?
Alpha blockers: tamsulosin
125
What are potential s/e of tamsulosin?
Dizziness, postural hypotension, dry mouth, depression
126
When is 5-alpha reductase inhibitors indicated?
Significantly enlarged prostate at high risk of progression
127
What are potential s/e of 5-alpha reductase inhibitors?
Erectile dysfunction, reduced libido, ejaculation issues, gynaecomastia
128
What type of tumours are the majority of prostate cancers?
adenocarcinomas
129
What are the risk factors for prostate cancer?
Increasing age, FHx, black african, tall stature, anabolic steroids
130
What is the initial drug therapy for ACS?
Aspirin (300mg), oxygen (if <94%), morphine if severe pain, nitrates. (MONA)
131
What should be offered in smoking cessation?
Nicotine replacement therapy, varenicline, or bupropion
132
What is the advice for smoking cessation and pregnant women?
- test with carbon monoxide detectors
- CBT first line. Can use nicotine replacement therapy
- varenicline and buprorion contraindicated
133
What unfavourable side effect can spironolactone cause?
gynaecomastia
134
What is the typical presentation of COPD, and what symptoms should not be attributed to COPD and lead to further investigations?
COPD: dyspnoea, cough, sputum production, wheeze, recurrent resp infections
Further Ix: clubbing, haemoptysis, chest pain
135
What is the MRC dyspnoea scale?
Grade 1: breathless on strenuous exercise
Grade 2: breathless on walking uphill
Grade 3: breathless that stops them walking on the flat
Grade 4: breathlessness stopping them walking more than 100m on the flat
Grade 5: unable to leave the house
136
How is COPD dx? Results?
Spirometry: obstructive picture, FEV1:FVC ratio <70%. No response to reversibility testing
137
What vaccines should be given in COPD?
Pneumococcal and annual flu vaccine
138
What is initial medical tx for COPD?
SABA (salbutamol) and SAMA (ipratropium bromide)
139
What are the two types of COPD treatment?
Determined by whether asthmatic/steroid responsive features, or not
140
What is the management of steroid responsive COPD, 2nd stage?
LABA (tiotropium) + ICS
141
What is the management of COPD not steroid responsive, 2nd stage?
LABA + LAMA
142
What is the final stage management of COPD?
Combination of LABA/LAMA/ICS
143
When is long term oxygen therapy used in COPD?
If chronic hypoxia (sats <92%), though C/I from smking
144
What is cor pulmonale?
Right sided heart failure. Due to increased pressure in pulmonary arteries, causes back pressure into right atrium, vena cava
145
What is the most common cause of cor pulmonale?
COPD
146
What is seen in an arterial blood gas in COPD exacerbation?
Acidosis: low PH, low PO2, raised CO2 (retention), raised bicarb
147
What is the first line management of acute exacerbation of COPD?
Steroids (pred for 5 days), regular meds
148
what prophylaxis is given in COPD?
azithromycin
149
What is the most common infective cause of exacerbation of COPD?
H.influenzae
150
What is prophylaxis of DVT in hospital? What are the C/I?
LMWH (such as enoxaparin). C/I: active bleeding, existing anticoagulation
151
What can cause a raised d-dimer?
PE, pneumonia, malignancy, heart failure, surgery, pregnany
152
What Wells score indicates a DVT is likely?
2 points or more
153
What should be done if Well score =2 or more?
Doppler ultrasound within 4 hours. If positive, start treatment
154
What should be done if Wells score =1 or less?
D dimer within 4 hours
155
What is first line management of DVT?
Apixaban or rivaroxaban (DOACs), for at least 3 months if provoked, 6 months if unprovoked
156
What is an example of LMWH?
enoxaparin, dalteparin
157
What are examples of DOACs?
Apixaban/rivaroxaban
158
What can be investigated for in a completely unprovoked DVT?
Antiphospholipid syndrome, hereditary thrombophilias
159
What is first line imaging for PE?
CTPA (first line)
160
What ABG is often seen in PE?
Respiratory alkalosis: hypoxia leads to tachypnoea, and blowing off extra CO2, meaning blood becomes alkalotic
161
What Wells Score indicates PE is likely? What step should be taken?
4 or more. Do a CTPA
162
What are the baseline investigations for angina?
Physical exam, ECG, FBC, U+Es, LFTs, lipid profile, TFTs, HbA1c
163
What is the management for immediate symptomatic relief of angina?
GTN spray. Take GTN when symptoms start, second dose 5 mins later if symptoms remain, 3rd dose 5 mins later if remain, call ambulance after 5 mins is symptoms remain
164
What are key s/e of GTN?
Dizziness and headaches
165
What are the long term medications for angina?
Aspirin, statin, beta blocker or CCB
166
When is a statin offered to patients?
- QRISK >10%
- CKD <60 eGFR
- T1DM for more than 10 years or are over 40years
167
How do statins work?
Reduce cholesterol production in the liver by inhibiting HMG CoA reductase
168
What is secondary prevention of CVD?
Antiplatelet (aspirin/clopidogrel), atorvastatin (80mg), atenolol, ACE-I
169
What ABGs indicate someone with COPD should receive O2 therapy?
2 measurements of <7.3 kPA
170
What are investigations for target organ damage in HTN?
- albumin:creatinine ratio
- urinalysis (haematuria+proteinuria)
- HbA1c
- electrolytes
- eGFR
- cholesterol
- fundoscopy
- 12 lead ECG
171
What pathogen are you worried about in a child presenting in GP with tonsilitis?
Group A Strep (S.pyogenes)
172
What are methods of ensuring people with communication difficulties are understanding during a consultation? (5)
- chunking (breaking information down into smaller sections)
- visual support
- large text/pictures
- stop and check the person has understood at regular intervals
- slow + don't rush
