ILA/GP Flashcards
Tunica intima
Innermost layer of blood vessel
Endothelial cells
Smooth layer for seamless blood flow
Tunica media
Middle layer of blood vessel
- Smooth muscle cells = contract and relax.
- Elastic fibers = withstand pressure changes.
Tunica adventitia
Outermost layer of artery.
- Collagen and elastic fibers = support and structure.
- Vasa vasorum - network of small blood vessels that supply the outer layers of larger blood vessels.
- Anchors the vessel to the surrounding tissue.
Primary prevention for atherosclerosis?
- Cut alcohol - 14 units/ week for men and women
- Improve diet - reduce cholesterol
- Increase exercise - reduce weight
- Stop smoking
- Take prescribed medications
Secondary prevention for atherosclerosis?
- Manage diabetes risk —> review again
- Statins (side effects: muscle cramping)
- Low dose aspirin - 75mg - enough to inhibit platelet clotting (thrombus formation)
- Manage hypertension and other conditions
Define anaphylaxis
Severe, life-threatening, generalised or systemic hypersensitivity reaction.
Caused by asevere type 1 hypersensitivityreaction (IgE-mediated)
Stages/pathophysiology of anaphylaxis?
- Sensitisation phase - first encounter with allergen = IgE Abs produced by B cells
- Re-exposure: allergen binds to IgE Abs on mast cells + basophils.
=> production of histamine, tryptase, chymase, leukotrienes, interleukins and cytokines. - Histamine causes vasodilation = SHOCK
Signs and symptoms of anaphylaxis?
- Skin reactions (hives)
- Breathing difficulties
- Swelling
- Cardiovascular symptoms due to vasodilation = rapid, weak pulse + shock + prlonged cap refill time
- GI symptoms
- Neurological (disorientation, LOC)
Treatment for anaphylaxis?
- IM adrenaline (300 microgram EPIPEN or 500 micrograms in hospital)
- Repeat after 5 mins if required
- ABCDE
- High flow oxygen
- IV fluids
- IV antihistamines (for skin symptoms)
- Beta-agonists
Mode of action of adrenaline in treatment of anaphylaxis?
Activates sympathetic response
= B2 adrenoreceptors (bronchodilation) = A1 receptors (vasoconstriction to increase BP)
= B1 receptors (increased cardiac contractility)
Confirmatory blood test for anaphylaxis?
Tryptase (due to mast cell degranulation)
What characteristics should drug have to put patient to sleep quickly?
- Pass through cell membranes - lipophilic (lipid-soluble)
- Low protein binding - bioavailable - high amount of free drug
Oral bioavailability of morphine?
50%
Hence need double dose if given orally
What is the metabolite of morphine?
Morphine-6-glucoronoide
More potent than morphine - can cause toxicity in renal impairment
Metabolised by CYP2D6
Signs of ARTERIAL vs venous thrombosis?
ARTERIAL:
Peripheral vascular disease
6Ps
VENOUS:
DVT/PE
Virchow’s triad
6PS of arterial thrombosis?
Pulselessness
Pallor
Pain
Perishingly cold
Paralysis
Paraesthesia
Virchow’s triad?
- Stasis of blood flow - immobilisation - long haul flights etc
- Endothelial injury - i.e. smoking, cellulitis, AF, LV dysfunction
- Hyper-coagulability - i.e. dehydration, meds (oestrogen), polycythaemia, thrombocytosis, inflammation, IBD, autoimmune diseases, pregnancy, immobilisation, malignancies (esp. blood cancers), sickle cell anaemia, sepsis
Signs of venous thrombosis? DTV/PE
Unilateral swelling]
Oedema
Tender
Erythematous
Distension of superficial veins
Pre-renal causes of AKI?
Insufficient blood supply reduces filtration of blood
= dehydration, shock (i.e. sepsis, anaphylaxis, or acute blood loss), heart failure, renal artery stenosis, AF/arrhythmias, MI, diarrhoea, diuretics, burns
Complications of AKI?
- Chronic kidney disease
- Heart failure
- Hyperkalaemia
- Metabolic acidosis – which can cause nausea, vomiting, drowsiness and breathlessness
- Fluid overload - peripheral or pulmonary oedema
Renal causes of AKI?
Glomerulonephritis
Acute interstitial nephritis
Acute tubular necrosis
Haemolytic uraemic syndrome
Rhabdomyolysis
Post-renal causes of AKI?
- Kidney stones
- Tumours (retroperitoneal, bladder or prostate)
- Strictures of the ureters or urethra
- Benign prostatic hyperplasia
- UTIs
- Neurogenic bladder
Cushing’s triad?
Body response to raised ICP due to intracranial bleed (haemorrhagic stroke):
- Bradycardia
- Irregular respirations
- Hypertension
Causes of ischaemic stroke?
Blood supply to brain may be disrupted by:
- Thrombusorembolus
- Atherosclerosis
- Shock
- Vasculitis
Signs of raised ICP?
- Papilloedema
- Headache (non-specific and diffuse)
- Nausea
- Pulsatile tinnitus
- Transient visual loss
- Visual disturbance (visual field defects, photophobia)
Describe the main stages involved in the formation of an atherosclerotic plaque
- Endothelial injury
- Entry of LDL and cholesterol into tunica intima
- Injured endothelial cells express adhesion molecules on surface = diapadesis of WBCs into tunica intima
- FOAM CELLS FORM (macrophages ingest oxidised LDL) - many foam cells appear as a fatty streak
- Foam cells BURST = releases LDL and cholesterol = triggers further inflammatory response
- Smooth muscle cells from artery wall migrate into the fatty streak = produce collagen
= FIBROUS CAP over the fatty streak
= known as fibrous plaque
** PLAQUE RUPTURE = thrombus formation, or can embolise.
Causes of endothelial injury (leading to atherosclerosis)
High blood pressure
Chemical irritants (smoking)
High levels of cholesterol and triglycerides
Define concordance
INFORMED patients having an active role in treatment decisions.
Respects the beliefs and wishes of a patient in determining whether, when and how medicines are to be taken.
Define compliance
PASSIVE behaviour, following a list of instructions from the doctor
Define adherence
The active choice of patients to follow through with the prescribed treatment, while taking responsibility for their own well-being
Types of adverse drug reactions?
A - AUGMENTED
B - BIZARRE
C - CHRONIC USE
D - DELAYED
E - END OF USE (WITHDRAWAL)
F - FAILURE OF TREATMENT
G - GENETIC
Explain - AUGMENTED adverse drug reaction?
Exaggerated effect at recommended dose - reversible upon withdrawing the drug
i.e bradycardia with beta blockers / bleeding with anti-coagulants
Explain - CHRONIC USE adverse drug reaction?
ADR continues even after the drug has stopped
Explain - DELAYED adverse drug reaction?
ADR becomes apparent after stopping the drug
Explain - END OF USE (WITHDRAWAL) adverse drug reaction?
ADR develops after the drug has been stopped
i.e. insomnia with benzodiazepines / rebound tachycardia w beta blockers
Explain - FAILURE adverse drug reaction?
Unexpected treatment failure due to drug-drug interaction, drug-food interaction or poor compliance
Explain - GENETIC adverse drug reaction?
Drug causing irreversible changes to genome (thalidomide)
DOTS classification of adverse drug reactions
Do - dose relatedness
(ADRs can occur at either subtherapeutic doses, therapeutic doses or supratherapeutic doses)
T - timing
(ADRs can be time-dependent or independent)
S - susceptibility
(age, gender, disease state, physiological state like pregnancy)
What is green prescribing?
Green social prescribing - supporting people to engage in nature-based interventions to improve physical and mental wellbeing.
- Local walking schemes
- Community gardening projects
- Conservation volunteering
- Open water swimming
- Arts and cultural activities
Blue prescribing?
Blue social prescribing - supporting people to engage in water-based activities to improve physical and mental wellbeing.
Examples: swimming, sailing, surfing + canoeing
Benefits of breastfeeding?
- All necessary vitamins, minerals and fats for first 6 months.
- Antibodies
- Also reduces risk of breast cancer, endometrial cancer, ovarian cancer, CV diseease and T2DM in mothers.
- Convenient and quickly available
- Cheaper than formula milk
- Emotional bond between baby and mother
Screening tool for domestic abuse?
HARK
H – Humiliation
A – Afraid
R – Rape
K – Kick
SCOFF questionnairre for anorexia nervosa
Sick - do you make yourself sick
Control over food - do you worry you’ve lost control
One stone - lost more than one stone in a 3-month period?
Fat - do you believe yourself to be fat when others say you’re too thin?
Food - would you say food dominates your life?
Risk factors for osteoporosis?
- Age
- Sedentary lifestyle
- Corticosteroid use
- Hormonal (diabetes, hyper/hypothyroid)
- Dietary deficiencies (vit D, calcium, excess protein, excess alcohol, ANOREXIA)
T scores from DEXA scan
Normal: more than -1
Osteopenia: -1 to -2.5
Osteoporosis: less than -2.5
Severe Osteoporosis: less than -2.5 plus a fracture
Define the T-score (DEXA scan)
Number of standard deviations the patient is from an average healthy young adult.
Define the Z-score (DEXA scan)
Number of standard deviations the patient is from the average for their age, sex and ethnicity.
Behaviour change cycle?
- Pre-contemplation
- Contemplation
- Planning
- Action
- Maintenance
- Relapse
Annual diabetic review
- Foot check
- Changes in lifestyle or any side effects?
- Hypoglycaemic awareness + check injection sites (if on insulin)
- BMI
- Blood pressure
- Cholesterol
- HbA1c
- LFTs (due to inc risk of NAFLD)
- Kidney function (eGFR + ACR albumin:creatinine ratio)
- Eye screening for retinopathy
DESMOND vs DAFNE courses
DAFNE - skills-based education programme in which adults with T1DM learn how to adjust insulin to suit their free choice of food, rather than having to work their life around their insulin doses
Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) is a structured group education programme for adults with type 2 diabetes.
Supports people in identifying their own health risks and responding to them by setting their own specific behavioural goals.
Three main symptoms of T1DM?
Weight loss
Polyuria
Polydipsia
Pre-diabetic values for HbA1c?
42-47 mmol/mol
Risk factors for AF?
SMITH
Sepsis
Mitral valve pathology (stenosis or regurgitation)
Ischaemic heart disease (restricted blood flow = arrhythmia)
Thyrotoxicosis
Hypertension
- LIFESTYLE CAUSES: caffeine + alcohol
- Smoking - 20/day = 1 pack year (pro-rata it)
- FAMILY HISTORY
Tests to order for patient with palpitations?
- ECG
- ECHO
- 24-hour ambulatory ECG(Holter monitor)
- Cardiac event recorder - 1-2 weeks
Heart rate calculation from ECG
- REGULAR rhythms: (300) / (count large squares between R-R)
- IRREGULAR rhythms: (count QRS complexes in 10 secs) x (6)
ECG findings in AF
- Absent P waves
- Narrow QRS complex tachycardia
- Irregularly irregular ventricular rhythm
Differential diagnoses for diarrhoea?
1) GASTROENTERITIS
(norovirus, C.diff, food poisoning, E.coli)
2) IMMUNE-MEDIATED
(lactose intolerance, IBD, coeliac)
3) MEDICATION
(Abx, SSRIs, PPIs, chemo)
4) PARASITE (guardia, amoebiasis)
Colostomy?
Stoma made from an
opening in the colon (large bowel)
Ileostomy?
Stoma made from an
opening in the ileum (small bowel)
Extraintestinal manifestations of IBD?
APIESAC
- Aphthous ulcers (mouth)
- Pyoderma gangrenosum(rapidly enlarging, painful skin ulcers)
- Iritis (eye issues; episcleritis, scleritis and anterior uveitis)
- Erythema nodosum(tender, red nodules on the shins)
- Sclerosing cholangitis (PSC - ulcerative colitis)
- Arthritis (enteropathic)
- Clubbing of fingers
Risk factors for AKI
● Age 65 years or over
● Chronic kidney disease (eGFR < 60 ml/min/1.73 m2)
● Heart failure
● Liver disease
● Sepsis
● Diabetes - glomerular damage, renal arteriosclerosis, and atherosclerosis are the
contributing factors in diabetic patients, leading to the progression of kidney damage
● Oliguria (< 0.5 ml/kg/hour)
● Neurological or cognitive impairment or disability, which may mean limited access to
fluids because of reliance on a carer
● Use of iodine-based contrast media within the past week (e.g., used during CT
scans)
● Symptoms or history of urological obstruction, or conditions that may lead to
obstruction (i.e. prostate enlargement, ovarian or bladder tumour, or kidney stones)
● Use of drugs that can cause or exacerbate kidney injury (Table 1)
Drugs that can cause or exacerbate AKI?
- ACEi/ARBs
- NSAIDs
- Aminoglycosides (gentamicin)
- Rifampicin
- Aciclovir
- Ampicillin
Causes of raised PSA levels?
- PROSTATE CANCER
- BPH
- Prostatitis
- Urine Infections
- Vigorous exercise
- Ejaculation
- Anal sex / prostate stimulation
- DRE
- Certain medicines
- Urinary catheters
Management of BPH?
- Tamsulosin (alpha blocker - relaxes smooth muscle) = may cause postural hypotension
- Finasteride (5a-reductase inhibtior)
LUTS symptoms
FUNI SHID
STORAGE SYMPTOMS: FUNI
- Frequency
- Urgency
- Nocturia
- Incontinence
VOIDING SYMPTOMS:
SHID-C
- Weak stream
- Hesitancy
- Incomplete bladder emptying
- Dribbling (post-micturition)
- Chronic retention
Investigations for UTI?
1st line: urine dipstick (nitrates, leucocytes, blood)
Gold standard: MSU/CSU microscopy, culture and sensitivity testing
Differential diagnosis for joint swelling?
- RA
- OA
- Ankylosing spondylitis
- Gout
- Septic arthritis
- SLE
- Psoriatic arthritis
Differential diagnosis for falls?
CARDIOVASCULAR
* Arrhythmias
* Orthostatic Hypotension
* Bradycardia
* Valvular Heart Disease
NEUROLOGICAL
* Stroke
* Epilepsy
* Peripheral Neuropathy
GENITOURINARY
* Incontinence
* UTI
ENDOCRINE
* Hypoglycaemia
MUSCULOSKELETAL
* Arthritis
* Disuse Atrophy
ENT
* Benign Paroxysmal Positional Vertigo
Driving + epilepsy?
You must stop driving immediately
and tell the DVLA if you have a seizure, even if
you have not been diagnosed with epilepsy yet.
You will only be able to apply for a license again if:
* You’ve been seizure free for 12 months.
* You’ve had an awake seizure in the past and in the last 3 years you’ve only had sleep seizures.
* You’ve never had an awake seizure, and in the last 12 months you’ve only had sleep seizures.
GRAND MAL
(generalised tonic-clonic)
Sudden loss of consciousness, stiffening of muscles (tonic phase), followed by rhythmic jerking of limbs (clonic phase).
Prolonged post-ictal period
Partial seizures(focal seizures)
- Isolated area of brain
Simple focal seizures - person remains conscious but experiences unusual sensations or feelings (aura) that may involve emotions, sensory changes, or distorted perceptions.
Complex focal seizures - alterations in consciousness or awareness. The person may exhibit repetitive behaviours like lip-smacking, fumbling with objects, or walking in circles.
Focal to bilateral tonic-clonic seizures
Start in one area of the brain (focal onset) but then spread to involve both sides of the brain, leading to a tonic-clonic seizure.
Tonic seizures
- Last only a few seconds, or at most a few minutes.
- Sudden onset of increased muscle tone - entire body stiffens.
- This results in a fall if the patient is standing, usually backwards.
Atonic seizures (drop attack)
Loss of muscle tone
Febrile seizures
In children <5 years
Tonic-clonic seizures due to HIGH FEVER
6-in-1 vaccine?
Diptheria, tetanus, polio
Pertussis (whooping cough)
Haemophilus influenzae type B + hepatitis B
Monitoring tests whilst on anti-epileptic drugs? (carbamazepine, tegretol in this example)
FBC, U&E’s and LFTs – there is a risk of leucopenia, thombocytopenia, hyponatraemia and hepatic dysfunction. Carbamazepine levels 1-2 weeks after starting the drug.
Repeated every 1-2 weeks until therapy stabilised, thereafter patients should be monitored every 2-3 months.
Patient/carer needs to be warned to report immediately the onset of any feature of blood disorders (e.g. sore throat, bruising, and mouth ulcers), liver toxicity (e.g. nausea, vomiting, abdominal discomfort, and dark urine), and respiratory effects (e.g. shortness of breath).
Maria is prescribed Tegretol, is it ok if she is given generic Carbamazepine at her next prescription?
Different formulations of Carbamazepine may vary in bioavailability. Patients being treated for epilepsy should be maintained on a specific manufacturer’s product. If Maria is taking Tegretol as a named brand then she should continue on that brand.
What is the mechanism of action of Methotrexate?
FOLATE ANTAGONIST
Inhibits dihydrofolate reductase (DHFR)
⇒ reduced thymine, adenine and guanine production
⇒ impaired nucleic acid synthesis
⇒ cell death (T CELL APOPTOSIS) = immunosuppression
Why is folic acid given to patients on Methotrexate?
Methotrexate can cause normocytic megaloblastic anaemia.
Folic acid supplementation during methotrexate therapy can reduce the risks of adverse effects including nausea, vomiting, abdominal pain, mouth ulcers, raised liver enzymes and bone marrow toxicity.
FOLIC ACID NEEDED FOR HEALTHY RBCs = can cause megaloblastic anaemia without
Which two laboratory tests can be used to assess renal function? Why would one be used over the other?
- eGFR (estimated glomerular filtration rate) - most commonly used - single blood test and therefore simplest and cheapest.
- Creatinine clearance should be used in preference when using toxic drugs, in elderly patients and in patients with very low or very high muscle mass.
A creatinine clearance test uses both a blood and urine sample in order to see how well the kidneys are functioning. Creatinine is created as a waste byproduct of normal muscle activity.
What class of drug is mesalazine?
Aminosalicylate
Contraindications for beta blockers?
asthma
COPD
HF
Low BP
Peripheral vasc disease
Diabetes mellitus
People who wear contact lenses (reduced secretion of lacrimal fluid).
What is the ‘pill in the pocket’ method of prescribing? Who is it useful for?
Where a patient with paroxysmal (intermittent) atrial fibrillation takes their antiarrhythmic medication when they experience an episode of palpitations, rather than taking regular medication every day. The idea is to terminate the suspected episode of AF without having to present to a medical facility.
The ‘prn’ method of use avoids side effects from taking tablets on days when they may not be necessary and is helpful for patients who are averse to taking regular medications.
