Monday 15/09/2021 Flashcards
1
Q
What are some points in the principles of prescribing?
A
doctors with full registration may prescribe all medicines, but not those drugs in Schedule 1 of the Misuse of Drugs Regulations 2001
you should only prescribe drugs to meet identified needs of patients and never for your own convenience or simply because patients demand them
avoid treating yourself and those close to you
2
Q
Which age group no point urine dipstick?
A
Over 65s
3
Q
What can antibiotics cause elderly people especially?
A
GI upset -> diarrhoea etc.
4
Q
Mnemonic to help remember causes of delirium?
A
PINCHES ME
5
Q
What does PINCHES ME stand for?
A
Pain Infection Nutrition Constipation Hydration Endocrine Stroke Medication Environment
[also retention]
6
Q
Big four systems when it comes to infection
A
UTI
Lungs
Gastro
Skin
7
Q
Why aren’t XR useful in people over 70 of the neck?
A
Need CT scan due to arthritis
8
Q
Type of brain injury concerned about elderly?
A
Subdural haematomas -> due to increased adherance dura tot he skull -> underlying bridging veins daamged
9
Q
What can CK look for in the blood?
A
Signs of rhabdo
10
Q
What is a colles fracture?
A
Distal radial fracture [soemthing about pointing downwards too]
11
Q
What is deconditioning?
A
- Deconditioning is a complex process of physiological change following a period of inactivity, bedrest or sedentary lifestyle. It results in functional losses in such areas as mental status, degree of continence and ability to accomplish activities of daily living
12
Q
What is frailty?
A
- Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves. Around 10 per cent of people aged over 65 years have frailty, rising to between a quarter and a half of those aged over 85 -> slow gait, decreased muscle mass, other
13
Q
What is the ceiling of treatment?
A
Limit to how aggressively going to treat the patient
14
Q
3 broad categories of ceiling of treatment
A
- Full escalation - you will do everything that can be done
- Ward-based - you will do everything that happens on a conventional medical ward but will not send the patient to an intensive care unit, regardless of how unwell they become
- Palliative - you will do everything you can to make the patient comfortable but will not actively treat their illness
15
Q
Difference between ITU and HDU
A
Single organ support can happen HDU, multiple organ support ITU.
16
Q
What is in a respect form?
A
- discussing and reaching a shared understanding of the person’s current state of health and how it may change in the foreseeable future,
- identifying the person’s preferences for and goals of care in the event of a future emergency,
- using that to record an agreed focus of care (either more towards life-sustaining treatments or more towards prioritising comfort over efforts to sustain life),
- making and recording shared decisions about specific types of care and realistic treatment that they would want considered, or that they would not want, and explaining sensitively advance decisions about treatments that clearly would not work in their situation,
- making and recording a shared decision about whether or not CPR is recommended
17
Q
Way of assessing frailty?
A
Clinical frailty scale - Rockwood
18
Q
SE of canagliflozin [SGLT2 inhibitor]?
A
SGLT-2 inhibitors are associated with an increased risk of urinary tract infections, making this the correct answer.
19
Q
Which antidioabetic drug is associated with fluid retention?
A
Fluid retention is linked to thiazolidinediones (e.g. pioglitazone).
20
Q
Which antidiabetic drug is associated with hypoglycaemia?
A
Sulfonureas [e.g. glicazide]]
21
Q
Which antidiabetic drug is associated with lactic acidosis?
A
Metformin
22
Q
Which antidiabetic drug is associated with pancreatitis??
A
Pancreatitis is associated with both DPP4 inhibitors (e.g. sitagliptin) and GLP1 agonists (e.g. exenatide)
23
Q
How do SGLT-2 inhibitors work?
A
SGLT-2 inhibitors reversibly inhibit sodium-glucose co-transporter 2 (SGLT-2) in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion.
Examples include canagliflozin, dapagliflozin and empagliflozin.
24
Q
Adverse effects of SGLT-2 inhibitors
A
Important adverse effects include
urinary and genital infection (secondary to glycosuria). Fournier’s gangrene has also been reported
normoglycaemic ketoacidosis
increased risk of lower-limb amputation: feet should be closely monitored
25
A positive effect of taking SGLT-2 inhibitors
Patients taking SGLT-2 drugs often lose weight, which can be beneficial in type 2 diabetes mellitus.
26
44-year-old man presents to his GP complaining of weakness in his hands and legs and numbness in his feet. He first noticed some problems with walking in his late teens and reports that he’s always been “clumsy” and will often trip over. He is otherwise well and takes no regular medications. On examination, he has a high-stepping gait with wasting of the lower legs and high arches. Power is reduced in all limbs and reflexes are difficult to elicit. There is a reduction in sensation which is more pronounced distally. Coordination is intact
Charcot-Marie-Tooth disease
27
Which nerves does Charcot-Marie-Tooth disease effect?
Charcot-Marie-Tooth disease is a hereditary sensory and motor peripheral neuropathy. UMN signs are not present in these patients. Patients can present with lower motor neurone signs in all limbs and reduced sensation (more pronounced distally)
28
What is DMD? Progression of disease and is motor/sensation effected?
Duchenne muscular dystrophy is an inherited myopathy. It is caused by progressive degeneration and weakness of specific muscle groups. Most patients lose the ability to walk by 12 years of age and require ventilatory support by the age of 25. Sensation is intact in these patients
29
What is cervical spondylosis?
Cervical spondylosis is the term used for osteoarthritis of the spine and can result in compression of the spinal cord
30
Signs of cervical spondylosis
This is more likely to result in LMN signs at the level of the compression (ie. upper limb if the lesion is below C5) with UMN signs below (in the lower limb). Patients usually complain of neck pain and stiffness
31
LMN signs
Signs of LMN damage include weakness, muscle atrophy (wasting), and fasciculations (muscle twitching)
32
UMN signs
Signs of UMN disease usually include spasticity of the muscles (a stiffness and resistance to movement), brisk reflexes and a Babinski sign, (a reflex that is a sign of damage to the nerve paths connecting the brain to the spinal cord)
33
How does GBS present and what is it caused by?
Guillain-Barre syndrome (GBS) is an inflammatory peripheral sensory and motor neuropathy. It typically presents over the course of days to weeks, not years. There is often a recent bacterial or viral infection in the history
34
How do patients with SCDC present? What will happen first?
Patients with subacute combined degeneration of the cord (SCDC) classically have an ataxic gait (due to degeneration of the dorsal columns) and mixed UMN and LMN signs (due to degeneration of lateral motor tracts and peripheral nerves). The history will typically be subacute, occurring over months rather than decades. Patients with SCDC often notice sensory symptoms before weakness.
35
Most appropriate Mx of a possible TIA?
Give 300mg aspirin and refer for specialist review within 24 hours
36
Possible CI to taking aspirin for a TIA
As there is no contraindication he should also be given an immediate 300mg dose of aspirin. Haemorrhage does not need to be ruled out in this case as a TIA is ischaemic by definition and the patient is not taking any anticoagulant medication
37
Original vs new definition of a TIA
The original definition of a transient ischaemic attack (TIA) was time-based: a sudden onset of a focal neurologic symptom and/or sign lasting less than 24 hours, brought on by a transient decrease in blood flow. However, this has now changed as it is recognised that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new 'tissue-based' definition is now used: a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction.
38
What wass the old way of Tx a TIA? WHy no longer used?
The ABCD2 prognostic score has previously been used to risk stratify patients who present with a suspected TIA. However, data from studies have suggested it performs poorly and it is therefore no longer recommended by NICE Clinical Knowledge Summaries.
39
Tx for a TIA according to NICE
Immediate antithrombotic therapy:
give aspirin 300 mg immediately, unless
1. the patient has a bleeding disorder or is taking an anticoagulant (needs immediate admission for imaging to exclude a haemorrhage)
2. the patient is already taking low-dose aspirin regularly: continue the current dose of aspirin until reviewed by a specialist
3. Aspirin is contraindicated: discuss management urgently with the specialist team
40
Further Mx for patient who's had a TIA?
Antithrombotic therapy
clopidogrel is recommended first-line (as for patients who've had a stroke)
aspirin + dipyridamole should be given to patients who cannot tolerate clopidogrel
these recommendations follow the 2012 Royal College of Physicians National clinical guideline for stroke. Please see the link for more details (section 5.5)
these guidelines may change following the CHANCE study (NEJM 2013;369:11). This study looked at giving high-risk TIA patients aspirin + clopidogrel for the first 90 days compared to aspirin alone. 11.7% of aspirin only patients had a stroke over 90 days compared to 8.2% of dual antiplatelet patients
41
Who to give carotid artery endarterectomy?
recommend if patient has suffered stroke or TIA in the carotid territory and are not severely disabled
should only be considered if carotid stenosis > 70% according ECST* criteria or > 50% according to NASCET** criteria
42
AST/ALT blood result from patient with alcoholic hepatitis
AST/ALT ratio is 2:1
43
Characteristic clinical features of alcoholic hepatitis?
jaundice, anorexia, fever, and tender hepatomegaly
44
Labatory results of alcoholic hepatitis?
Laboratory tests reveal moderately elevated transaminases ie. AST and ALT (typically <300U/mL), with an AST:ALT ratio of 2 or greater - as seen in this patient
45
MCV of a patne twith alcoholic hepatitis?
A haemoglobin of 125g/L and mean corpuscular volume (MCV) of 81fl is a borderline microcytic anaemia. If anaemia was to be present in this patient, it would most likely cause an increased MCV, due to defective synthesis of red blood cells as a result of excess alcohol intake and likely concurrent malnutrition
46
Why is AST/ALT 2:1?
An AST of 310IU/L and ALT of 300IU/L gives an AST:ALT ratio of ~1:1. This is not the correct answer as a ratio of >2:1 is seen in alcoholic hepatitis. The disproportionate rise in AST relative to ALT is due to alcohol-induced deficiency of the cofactor pyridoxine-phosphate, the active form of vitamin B6, which limits the rise in ALT
47
82 year old women with hypothyroidism taking thyroxine has high T4 in bloods. Risk of developing what?
Over-replacement with thyroxine increases the risk for osteoporosis
48
Key points to managing hypothyroidism well
initial starting dose of levothyroxine should be lower in elderly patients and those with ischaemic heart disease. The BNF recommends that for patients with cardiac disease, severe hypothyroidism or patients over 50 years the initial starting dose should be 25mcg od with dose slowly titrated. Other patients should be started on a dose of 50-100mcg od
following a change in thyroxine dose thyroid function tests should be checked after 8-12 weeks
the therapeutic goal is 'normalisation' of the thyroid stimulating hormone (TSH) level. As the majority of unaffected people have a TSH value 0.5-2.5 mU/l it is now thought preferable to aim for a TSH in this range
women with established hypothyroidism who become pregnant should have their dose increased 'by at least 25-50 micrograms levothyroxine'* due to the increased demands of pregnancy. The TSH should be monitored carefully, aiming for a low-normal value
there is no evidence to support combination therapy with levothyroxine and liothyronine
49
Which two types of patient should be wary of managing hypothyroidism? How to change their management?
1. initial starting dose of levothyroxine should be lower in elderly patients and those with ischaemic heart disease. The BNF recommends that for patients with cardiac disease, severe hypothyroidism or patients over 50 years the initial starting dose should be 25mcg od with dose slowly titrated. Other patients should be started on a dose of 50-100mcg od
2. women with established hypothyroidism who become pregnant should have their dose increased 'by at least 25-50 micrograms levothyroxine'* due to the increased demands of pregnancy. The TSH should be monitored carefully, aiming for a low-normal value
50
SE of thyroixine therapy
hyperthyroidism: due to over treatment
reduced bone mineral density
worsening of angina
atrial fibrillation
51
Interactions of thyroxine therapy?
iron, calcium carbonate
| absorption of levothyroxine reduced, give at least 4 hours apart
52
A 56-year-old man presents to the emergency department with haematemesis. He has been vomiting bright red blood for the past hour. He has never experienced anything like this before. On questioning about alcohol consumption, he reveals that he previously had an alcohol addiction, and has now been diagnosed with liver cirrhosis.
He does not currently take any medication, prescribed or over the counter.
You assess the patient using the ABCDE method and order an urgent oesophago-gastro-duodenoscopy (OGD). You give him terlipressin, but he is still bleeding and his platelet count is 47 x 109/L (150 - 400). Therefore, a platelet transfusion is performed. Despite this, he continues to vomit blood. The OGD is still being prepared and will be another 30 minutes.
```
His observations are:
Heart rate: 110 beats per minute.
Respiratory rate: 22 breaths per minute.
Blood pressure: 90/65 mmHg.
Temperature: 36.4ºC.
```
What is the best next step in managing this patient?
Insert a Sengstaken-Blakemore tube
53
What should give first to variceal bleed to stop bleeding?
This man is most likely to have a variceal bleed given the nature of fresh red blood and history of alcoholic liver disease (portal hypertension). To stop the bleeding, you should give vasopressors (terlipressin) and correct any clotting abnormalities
54
When is a platelet transfusion considered in patient actively bleeding?
A platelet transfusion is performed when the platelet count is less than 50 x 109/L and the patient is actively bleeding.
55
Definitive Mx of variceal bleeds?
Endoscopic banding during OGD
56
What to do with variceal bleeds whilst awaiting for the OGD?
A Sengstaken-Blakemore tube has oesophageal and gastric balloons which can be inflated to tamponade the variceal bleeding. It is inserted through the nose. This is is the best management step in this situation whilst waiting for the OGD.
57
Which drug used long term to prevent further variceal bleeds?
IV propranolol is used to prevent further variceal bleeds in the long term, after initial management during OGD
58
Acute Mx of variceal haemorrhage
Acute treatment of variceal haemorrhage
- ABC: patients should ideally be resuscitated prior to endoscopy
- correct clotting: FFP, vitamin K
- vasoactive agents:
+ terlipressin is currently the only licensed vasoactive
agent and is supported by NICE guidelines. It has
been shown to be of benefit in initial haemostasis
and preventing rebleeding
+ octreotide may also be used although there is
some evidence that terlipressin has a greater
effect on reducing mortality
- prophylactic IV antibiotics have been shown to reduce mortality in patients with liver cirrhosis. Quinolones are typically used. NICE support this in their 2016 guidelines: 'Offer prophylactic intravenous antibiotics for people with cirrhosis who have upper gastrointestinal bleeding.'
- both terlipressin and antibiotics should be given before - endoscopy in patients with suspected variceal haemorrhage
- endoscopy: endoscopic variceal band ligation is superior to endoscopic sclerotherapy. NICE recommend band ligation
- Sengstaken-Blakemore tube if uncontrolled haemorrhage
- Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail
+connects the hepatic vein to the portal vein
+exacerbation of hepatic encephalopathy is a common complication
59
Prophylaxis of variceal hameorrhage
propranolol: reduced rebleeding and mortality compared to placebo
endoscopic variceal band ligation (EVL) is superior to endoscopic sclerotherapy. It should be performed at two-weekly intervals until all varices have been eradicated. Proton pump inhibitor cover is given to prevent EVL-induced ulceration. This is supported by NICE who recommend: 'Offer endoscopic variceal band ligation for the primary prevention of bleeding for people with cirrhosis who have medium to large oesophageal varices
60
A 23-year-old male presents to the emergency department with a single episode of haemoptysis. He had COVID-19 four weeks ago and has had a negative lateral flow test at home and in the department upon arrival. He has no other past medical history and takes no regular medications. His observations show a respiratory rate of 26/min, oxygen saturation of 97% in room air, heart rate of 101/min, a temperature of 36.5ºC, and blood pressure of 115/80 mmHg.
Considering the likely diagnosis, what is the most appropriate diagnostic test?
CT pulmonary angiogram - diagnostic test for a PE
61
most common clinical sign of a PE?
Tachpnoea [96%]
62
Signs of a PE
This patient has symptoms (haemoptysis) and signs (tachypnoea and a mild reduction in oxygen saturations) of a pulmonary embolism (PE)
63
Why does COVID increase risk of a PE?
The likelihood of this diagnosis is compounded by the recent diagnosis of COVID-19 which is associated with an increased risk of coagulopathy
64
Wells score for a PE
Clinical signs and symptoms of DVT (deep vein thrombosis) (3 points).
PE is the number 1 diagnosis or equally likely (3 points).
Heart rate > 100/min (1.5 points).
3-day history of immobilisation or surgery within the past 4 weeks (1.5 points).
Previous DVT or PE (1.5 points).
Haemoptysis (1 point).
Malignancy within 6 months of treatment or palliative (1 point)
65
What is Buerger's disease [Thromboangiitis obliterans]?
The combination of Raynaud's syndrome, intermittent claudication and finger ulcerations in a young smoker is consistent with thromboangiitis obliterans (Buerger's disease).
66
Strongest RF for Buerger's disease?
The single strongest risk factor for thromboangiitis obliterans is smoking.
67
You are a GP in your practice. A 25 years old male with a known history of Marfan syndrome complains of progressive shortness of breath over a few months. On examination, he notices that the pulse is collapsing and has wide pulse pressure.
Which cardiac abnormality do these findings suggest?
Aortic regurgitation is associated with Marfan syndrome
- Due to the abnormal production of fibrillin gene, the connective tissues are affected. A patient with Marfan's syndrome is likely to have aortic regurgitation
68
How does aortic stenosis typically present?
Aortic stenosis typically presents with the triad of angina, syncope and heart failure.
69
Typical sign of aortic stenosis?
The typical sign is slow rising pulse with narrow pulse pressure
70
Mitral regurgitation sign
Mitral regurgitation results in pansystolic murmur at the apex and radiates to axilla.
71
Mitral stenosis sign
Mitral stenosis results in mid-diastolic murmur which is heard best on expiration.
72
MItral valve prolapse sign
Mitral valve prolapse would result in low volume pulse and rumbling mid-diastolic murmur ie
73
Features of aortic regurgitation
Features
early diastolic murmur: intensity of the murmur is increased by the handgrip manoeuvre
collapsing pulse
wide pulse pressure
Quincke's sign (nailbed pulsation)
De Musset's sign (head bobbing)
mid-diastolic Austin-Flint murmur in severe AR - due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams
74
Causes of aortic regurgitation
```
Causes (due to valve disease)
rheumatic fever
infective endocarditis
connective tissue diseases e.g. RA/SLE
bicuspid aortic valve
```
```
Causes (due to aortic root disease)
aortic dissection
spondylarthropathies (e.g. ankylosing spondylitis)
hypertension
syphilis
Marfan's, Ehler-Danlos syndrome
```
75
A 38-year-old hiker attends the out-of-hours clinic after being bitten by a tick earlier in the day. The tick was safely removed as soon as it was noticed. He is concerned about Lyme disease as he knows it is prevalent in the area. He does not currently have any symptoms but is requesting antibiotics just in case. On examination, there is a small red mark on his left calf in the location of the bite but no rash.
What treatment is the most appropriate?
There is no need for prophylactic antibiotics for Lyme disease in asymptomatic patients bitten by a tick
76
Signs of Lyme's disease
This patient is showing no symptoms of Lyme disease e.g. no rash, lymphadenopathy or tiredness and there is no need for prophylaxis despite his concerns
77
When would chorphenamine be appropriate for Lyme's?
Chlorphenamine would be an appropriate treatment if he were to be showing signs of an allergic reaction to the bite, for example, itching or swelling, but is not used for treatment or prevention of Lyme disease.
78
First line Tx for Lyme's disease
Doxycycline would be first line in the treatment of Lyme disease however it is not used prophylactically so is not indicated here
79
First line treatment for flucloxacillin?
Flucloxacillin is first line for cellulitis infections however is not indicated in this case as there are no signs of infection i.e. swelling or erythema. It would also not be recommended for the treatment of Lyme disease or for prophylaxis
80
Early features of Lyme's disease
Lyme disease is caused by the spirochaete Borrelia burgdorferi and is spread by ticks.
Early features (within 30 days)
erythema migrans
'bulls-eye' rash is typically at the site of the tick bite
typically develops 1-4 weeks after the initial bite but may present sooner
usually painless, more than 5 cm in diameter and slowlly increases in size
present in around 80% of patients.
systemic features
headache
lethargy
fever
arthralgia
81
Late features of Lyme's disease
```
Later features (after 30 days)
cardiovascular
heart block
peri/myocarditis
neurological
facial nerve palsy
radicular pain
meningitis
```
82
Ix for Lyme's disease
NICE recommend that Lyme disease can be diagnosed clinically if erythema migrans is present
erythema migrans is therefore an indication to start antibiotics
enzyme-linked immunosorbent assay (ELISA) antibodies to Borrelia burgdorferi are the first-line test
if negative and Lyme disease is still suspected in people tested within 4 weeks from symptom onset, repeat the ELISA 4-6 weeks after the first ELISA test. If still suspected in people who have had symptoms for 12 weeks or more then an immunoblot test should be done
if positive or equivocal then an immunoblot test for Lyme disease should be done
83
Mx of asymptomic tick bites
tick bites can be a relatively common presentation to GP practices, and can cause significant anxiety
if the tick is still present, the best way to remove it is using fine-tipped tweezers, grasping the tick as close to the skin as possible and pulling upwards firmly. The area should be washed following.
NICE guidance does not recommend routine antibiotic treatment to patients who've suffered a tick bite
84
Mx of confirmed tick bites. Alterantive to doxycycline?
doxycycline if early disease. Amoxicillin is an alternative if doxycycline is contraindicated (e.g. pregnancy)
people with erythema migrans should be commenced on antibiotic without the need for further tests
ceftriaxone if disseminated disease
Jarisch-Herxheimer reaction is sometimes seen after initiating therapy: fever, rash, tachycardia after first dose of antibiotic (more commonly seen in syphilis, another spirochaetal disease)
85
A 68-year-old male presents to the emergency department with crushing chest pain radiating up his neck. His heart rate is 72 beats/min with a regular pulse. Electrocardiogram demonstrates sinus rhythm with no ST-elevation, however point-of-care troponin is elevated.
Although the patient is not at high-risk of bleeding, a joint decision is made that he is not for percutaneous coronary intervention at this point.
He has already received aspirin.
Which of the following medications should also be administered?
NSTEMI (managed conservatively) antiplatelet choice
aspirin, plus either:
ticagrelor, if not high bleeding risk
clopidogrel, if high bleeding risk
86
Why should not give warfarin to person with nstemi?
Warfarin is incorrect as an anticoagulant that inhibits the production of clotting factors II, VII, IX and X and not indicated for use in NSTEMIs
87
Classificaiton of ACS?
ST-elevation myocardial infarction (STEMI): ST-segment elevation + elevated biomarkers of myocardial damage
non ST-elevation myocardial infarction (NSTEMI): ECG changes but no ST-segment elevation + elevated biomarkers of myocardial damage
unstable angina
88
Common Mx for al patients with ACS?
Initial drug therapy
aspirin 300mg
oxygen should only be given if the patient has oxygen saturations < 94% in keeping with British Thoracic Society oxygen therapy guidelines
morphine should only be given for patients with severe pain
previously IV morphine was given routinely
evidence, however, suggests that this may be associated with adverse outcomes
nitrates
can be given either sublingually or intravenously
useful if the patient has ongoing chest pain or hypertension
should be used in caution if patient hypotensive
89
After initial Mx of ACS, next step?
The next step in managing a patient with suspected ACS is to determine whether they meet the ECG criteria for STEMI. It is, of course, important to recognise that these criteria should be interpreted in the context of the clinical history.
90
STEMI criteria ECG
clinical symptoms consistent with ACS (generally of ≥ 20 minutes duration) with persistent (> 20 minutes) ECG features in ≥ 2 contiguous leads of:
2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years, or ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years
1.5 mm ST elevation in V2-3 in women
1 mm ST elevation in other leads
new LBBB (LBBB should be considered new unless there is evidence otherwise)
91
Once STEMI confirmed, what is the Tx?
Once a STEMI has been confirmed the first step is to immediately assess eligibility for coronary reperfusion therapy. There are two types of coronary reperfusion therapy:
primary coronary intervention
should be offered if the presentation is within 12 hours of the onset of symptoms AND PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given (i.e. consider fibrinolysis if there is a significant delay in being able to provide PCI)
if patients present after 12 hours and still have evidence of ongoing ischaemia then PCI should still be considered
drug-eluting stents are now used. Previously 'bare-metal' stents were sometimes used but have higher rates of restenosis
radial access is preferred to femoral access
fibrinolysis
should be offered within 12 hours of the onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when fibrinolysis could have been given
a practical example may be a patient who presents with a STEMI to a small district general hospital (DGH) that does not have facilities for PCI. If they cannot be transferred to a larger hospital for PCI within 120 minutes then fibrinolysis should be given. If the patient's ECG taken 90 minutes after fibrinolysis failed to show resolution of the ST elevation then they would then require transfer for PCI
92
Further drug therapy patients with STEMI
Further drug therapy
unfractionated heparin should be given regardless of whether the patient has had fondaparinux or not
further antiplatelet ('dual antiplatelet therapy', i.e. aspirin + another drug) prior to PCI
if the patient is not taking an oral anticoagulant: prasugrel or ticagrelor
if taking an oral anticoagulant: clopidogrel
Conservative management for patients with NSTEMI/unstable angina
Further drug therapy
further antiplatelet ('dual antiplatelet therapy', i.e. aspirin + another drug)
if the patient is not at a high risk of bleeding: ticagrelor
if the patient is at a high risk of bleeding: clopidogrel
93
A 68-year-old man is seen in the emergency department after falling while getting out of bed. He appears well with no injuries from the fall, but his blood pressure shows a postural drop of 35mmHg.
He was diagnosed with Parkinson’s disease two weeks ago.
He currently takes co-careldopa
What is the most likely cause for his fall?
Parkinsonism with associated autonomic disturbance (atonic bladder, postural hypotension) points towards Multiple System Atrophy
94
What is Friedrich-Waterhouse syndrome?
Friedrich-Waterhouse syndrome is a rare complication of meningococcal sepsis involving bilateral adrenal haemorrhage. This would be a patient who is extremely unwell, or who has been recently treated for meningitis and presents with collapse and salt-wasting. It is rare and not suggested by the clinical picture
95
Two predominant types of MSA?
There are 2 predominant types of multiple system atrophy
1) MSA-P - Predominant Parkinsonian features
2) MSA-C - Predominant Cerebellar features
Shy-Drager syndrome is a type of multiple system atrophy
96
Is postural hypotension common in PD?
A fall while moving from lying to standing, and significant postural hypotension, indicates autonomic instability. Idiopathic Parkinsons disease can cause autonomic instability, but this is usually a very late development. If it rapidly follows a diagnosis of Parkinson's disease (for example, two weeks, as in the question), it is more likely due to multisystem atrophy rather than idiopathic Parkinson's. 5% of patients with idiopathic Parkinson's disease have postural hypotension, compared to 75% of patients with multisystem atrophy, making the latter more likely.
Although there are many causes of postural hypotension, the combination of early and severe autonomic instability following a recent diagnosis of Parkinson's disease means MSA should be considered. The other options are all possible causes of a fall or collapse, but based on the history and clinical findings are not as likely
97
Features of MSA
```
Features
parkinsonism
autonomic disturbance
erectile dysfunction: often an early feature
postural hypotension
atonic bladder
cerebellar signs
```
98
A 55-year-old female presents with irritability, tremors, unexplained weight loss, diarrhoea, palpitations and fatigue.
On examination, her pulse rate is 118/min and regular. Her thyroid gland is also noted to be symmetrically enlarged but non-tender.
Blood tests reveal the following:
Thyroid stimulating hormone (TSH) 0.2 mU/L (0.5-5.5)
Free thyroxine (T4) 25 pmol/L (9.0 - 18)
TSH receptor antibodies (TRAb) 15 IU/L (<1.7)
Which medication will manage the patient's symptoms quickly while she is waiting to see the endocrinologist?
Propranolol should be used in new cases of Graves' disease to help control symptoms
99
When should carbimazole be used thyroid problems?
Carbimazole is an anti-thyroid medication that should also be used in this situation but is usually initiated by the endocrinologist. It will improve her thyroid levels in the long-term and eventually improve her symptoms by blocking excess thyroid hormone synthesis, but does not achieve rapid symptom improvement compared to beta-blockers
100
ATD therapy in primary care settings
carbimazole is started at 40mg and reduced gradually to maintain euthyroidism
typically continued for 12-18 months
the major complication of carbimazole therapy is agranulocytosis
an alternative regime is termed 'block-and-replace'
carbimazole is started at 40mg
thyroxine is added when the patient is euthyroid
treatment typically lasts for 6-9 months
patients following an ATD titration regime have been shown to suffer fewer side-effects than those on a block-and-replace regime
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Radioiodine Tx for thyroid problems
often used in patients who relapse following ATD therapy or are resistant to primary ATD treatment
contraindications include pregnancy (should be avoided for 4-6 months following treatment) and age < 16 years. Thyroid eye disease is a relative contraindication, as it may worsen the condition
the proportion of patients who become hypothyroid depends on the dose given, but as a rule the majority of patient will require thyroxine supplementation after 5 years
