GP/public health Flashcards
Causes of HTN
- Essential/primary = no cause
- Secondary = Renal disease, Obesity, Pregnancy induced/pre-eclampsia, Endocrine - particularly Conns (renin:aldosterone blood test)
Diagnosis of HTN
- Measure blood pressure in both arms in clinic
- If BP above 140/90, take 2nd measurement. If 2nd substantially lower, take 3rd.
- Ambulatory bp monitoring to confirm diagnosis (could be white coat HTN or stress)
= 2 measurements/per hr during waking hours. Use average of atleast 13 measurements. - If home blood pressure monitoring preferred (or ABPM not tolerated) record 2 consecutive BP, atleast 1 minute apart. Recorded in morning and evening and taken for atleast 4 days.
HTN diagnosis confirmed in people with clinic BP of 140/90 mmHg AND ABPM/HBPM of 135/85mmHg+.
- Stage 2 hypertension: Clinic BP > 60/100 mmHg and subsequent ABPM daytime average or HBPM average BP > 150/95 mmHg
- Severe hypertension: Clinic BP >180/120 admit for specialist assess if:
signs of retinal haemorrhage or papilloedema (accelerated hypertension) or
life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury.
Mx of HTN
- Lifestyle: healthy diet, stopping smoking, reducing alcohol, caffeine and salt intake and taking regular exercise.
- Medical management is offered to:
All patients with STAGE 2 hypertension (140/90)
All patients UNDER 80 years old with stage 1 hypertension that ALSO have a Q-risk score of 10% or more, diabetes, renal disease, cardiovascular disease or end organ damage.
Step 1: Aged less than 55 and non-black use A. Aged over 55 or black of African or African-Caribbean descent use C.
Step 2: A + C. (Alternatively A + D or C + D.) If black then use an ARB instead of A.
Step 3: A + C + D
Step 4: A + C + D + additional (see below)
For step 4, if the serum potassium is less than or equal to 4.5 mmol/l consider a potassium sparing diuretic such as spironolactone. If the serum potassium is more than 4.5 mmol/l consider an alpha blocker (e.g. DOXAZOSIN) or a beta blocker (e.g. atenolol).
A – ACE inhibitor (e.g. ramipril 1.25mg up to 10mg once daily)
B – Beta blocker (e.g. bisoprolol 5mg up to 20mg once daily)
C – Calcium channel blocker (e.g. amlodipine 5mg up to 10mg once daily)
D – Thiazide-like diuretic (e.g. INDAPAMIDE/METOLOAZONE 2.5mg once daily)
ARB – Angiotensin II receptor blocker (e.g. candesartan 8mg to up 32mg once daily)
Angiotensin receptor blockers are used in place of an ACE inhibitor if the person does not tolerate ACE inhibitors (commonly due to a dry cough) or the patient is black of African or African-Caribbean descent. ACE inhibitors and ARBs are not used together.
Further tests for HTN
- End Organ Damage -> heart attack, heart failure, kidney problems, eye problems, dementia, metabolic syndrome
NICE recommend all patients with a new diagnosis should have:
- Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess for kidney damage
- Bloods for HbA1c, renal function and lipids
- Fundus examination for hypertensive retinopathy
- ECG for cardiac abnormalities
S/E of antihypertensives
- All = Erectile dysfunction
- ACEi = Dry cough, low BP, Kidney damage, hyperkalaemia. CI by renal artery stenosis and hyperkalaemia.
- Ca2+ blockers = Ankle oedema, flushed, constipation, headache
- Thiazides = hyponatremia, hyperkalaemia - kidney damage, gout
Complications of HTn
MI, HF,Stroke
PVD
CKD, dementia, metabolic syndrome, eye damage
Px of heart failure
- Dyspnoea + fatigue
- Paroxysmal nocturnal dyspnoea
- Signs: tachycardia, tachynpoea, gallop rhythm (S3 present), narrow pulse pressure, displaced apex
- LHF Sx: pulmonary oedema, orthopnoea (accum in lungs), cough - may have pink, frothy sputum.
Signs: Pleural effusion - RHF Sx: Liver enlargement, nausea, peripheral oedema/ankle swelling/bloating.
Signs: Raised JVP, hepatomegaly
Dx of HF
- NT-proBNP:
High -> specialist assessment in 2 weeks.
Raised -> specialist assessment within 6 weeks. - Echocardiogram = gold standard -> Ejection fraction less than 40%
- ECG (MI, arrhythmias, old MI = Q wave)
- CXR
CXR of HF
A mnemonic to remember chest x-ray findings in heart failure is ABCDE:
A: alveolar oedema (perihilar/bat-wing opacification)
B: Kerley B lines (interstitial oedema)
C: cardiomegaly (cardiothoracic ratio >50%) – may be difficult to assess on an AP film
D: dilated upper lobe vessels
E: effusions (i.e. pleural effusions – blunted costophrenic angles with meniscus sign)
Causes of HF
- Ischaemic Heart Disease
- Valvular Heart Disease (commonly aortic stenosis)
- Hypertension
- Arrhythmias (commonly atrial fibrillation)
- High output cardiac failure: pregnancy, anaemia
Tx of HF
- ACE inhibitor (e.g. ramipril)
- Beta Blocker (e.g. bisoprolol)
- Aldosterone antagonist when symptoms not controlled with A and B (spironolactone)
- Loop diuretics (e.g. furosemide)
Extra;s:
- ARB if dont tolerate ACEi (e.g. cough)
- Cautious of beta blocker in asthmatics, PAD, bradycardic pts
-If have pre-existing IHD will need extra meds - aspirin, Calcium channel blocker
- U&Es monitored whilst on diuretics, ACE inhibitors and aldosterone antagonists as all three medications can cause electrolyte disturbances.
What is the mental capacity act 5 principles
- Adults assumed to have capacity unless proven
- Must be given all possible help to assess and communicate capacity
- Making an unwise decision does not mean a person lacks capacity
- Decisions made for someone who lacks capacity must be done in their best interests
- Should be the least restrictive of basic rights/freedom
What is a deprivation of liberty
- person is under continuous supervision and control and is not free to leave, and the person lacks capacity to consent to these arrangements.
- provide pt with a representative, give pt right to challenge a DOL through court of protection
- provide mechanism for DOLS to be reviewed and monitored regularly
Delirium vs dementia
Factors favouring delirium over dementia:
-impairment of consciousness
- fluctuation of symptoms: worse at night, periods of normality
- abnormal perception (e.g. illusions and hallucinations)
- agitation, fear
- delusions
Rules of Gillick competency regarding giving contraception to under 16 year old
- Girl under 16 will understand advice
- Cannot persuade to tell parents
- Likely to continue having intercouse w/wout
- Unless she recieves contraceptive advice her physical +/- mental health will suffer
- Best interests require contraception without parental consent
- girl under 13 always considered too young for gillick competence
When to alert police regarding sexual activity of minor
You should usually share information about abusive or seriously harmful sexual activity involving any child or young person, including that which involves:
a) a young person too immature to understand or consent
b) big differences in age, maturity or power between sexual partners
c) a young person’s sexual partner having a position of trust
d) force or the threat of force, emotional or psychological pressure, bribery or payment, either to engage in sexual activity or to keep it secret
e) drugs or alcohol used to influence a young person to engage in sexual activity when they otherwise would not
f) a person known to the police or child protection agencies as having had abusive relationships with children or young people
Notifiable disease
Measles, Malaria, Encephalitis/meningococcal septicaemia/meningitis, cholera, diphtheria, haemolytic uraemic syndrome, Rubella, TB, Whooping cough, Yellow fever, Scarlet fever
Types of TB
- Primary: first infection of lungs. Usually can kill and clear infection. Immune system may encapsulate sites = latent TB.
- Secondary: If host becomes immunocompromised, initial infection may become reactivated.
- Miliary TB: disseminated, severe disease
Px of TB
- progressive, worsening of symptoms
- Lungs (most common): Cough with or without haemoptysis, dyspnoea
- Lymph nodes: lymphadenopathy
- Systemic: Fever, Lethargy, Night sweats
- CNS: Spinal pain
- Skin: Erythema nodosum
Dx of TB
- prev, latent or active TB: Mantoux test and interferon‑gamma release assay.
- Active disease:
-CXR
-Sputum smear - +ve in Ziehl Neelsen
- Sputum culture (gold)
- NAAT
Tx of TB
The standard therapy for treating active tuberculosis is:
first 2 months (RIPE)
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
Continuation phase - next 4 months
Rifampicin
Isoniazid
Complications of Tx of TB
- rifampicin:
hepatitis, red/orange secretions - isoniazid
peripheral neuropathy: prevent with pyridoxine (Vitamin B6) - pyrazinamide
hyperuricaemia causing gout - ethambutol
optic neuritis: check visual acuity before and during treatment - Rifampicin, isoniazid and pyrazinamide are all associated with hepatotoxicity
