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My General Practise > Oxford summary 2 > Flashcards

Oxford summary 2 Flashcards

1
Q

Abnormal ABPM

A

Average day time ≥135/85

Average night-time ≥120/70

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2
Q

HTN causes

A
  1. Essential/ unknown- alcohol, obesity
  2. Renal disease
  3. Endocrine disease- cushings, conns, Phaeochromocytoma, acromegaly, hyperparathyroidism
  4. Pregnancy
  5. Coaractation of aorta
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3
Q

HTN assessment

A

Examination: heart size, Heart Sound, heart failure examine fundi for silver wiring, AV nipping, flame haemorrhage, cotton wool spots
Blood tests: creatinine, U&E, eGFR, HbA1c, lipid profile
Urine: RBC and protein and albumin: creatine ratio
Cardiovascular risk estimation
ECG ± echo if LVH

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4
Q

HTN Dx stages

A

Stage 1: clinic ≥140/90 and av daytime ≥135/85

Stage 2: clinic ≥160/100 and av daytime ≥150/95

Severe: clinic systolic ≥180 or diastolic ≥110

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5
Q

HTN Tx
step 1
if under 55

A

ACEi

ARBs

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6
Q

HTN Tx
step 1
if over 55 or AA

A

Ca Channel blocker

Thiazide

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7
Q

HTN Tx

step 2

A

ACEI
ARB
Ca channel blocker
thiazide

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8
Q

HTN Tx

step 3

A

ACEI + CCB + Thiazide

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9
Q

HTN Tx
step 4
Resistant HTN

A

Spironolactone 25mg od if K under 4.5 mmol/L
Thiazide if K over 4.5 mmol/
A or B blocker

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10
Q

Hyperlipidemia drug causes

A
  1. Steroids
  2. BB, thiazides
  3. OCP, Tamoxifen
  4. Isotretinonin
  5. Antipsychotics
  6. Antiretrovirals
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11
Q

Before starting statins

A

Bloods
Fasting total cholesterol, LDL, HDL, TG
Fasting blood glucose
LFT, renal function, TSH

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12
Q

statin doses hyperlipidemia

A

Simvastatin 40mg
or
atorvastatin 20mg

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13
Q

Statin SE:

A

Myositis: muscle pain/ weakness
Peripheral neuropathy
Abnormal LF

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14
Q

Statins contraindicated in

A

pregnancy, breastfeeding, acute liver disease (AST/ALT >3x normal)

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15
Q

Statin drug interactions

A

increased warfarin effect
increased mysositis when with lipid- lowering drugs,
Erythromycin, CCB, ciclopsorin

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16
Q

Polygenic hypercholesterolaemia:

A

FH premature CHD + total cholesterol >6.5mmol/L

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17
Q

Familial combined hyperlipidemia:

A

a/w obesity, IR, FM, HT, xanthelasma, corneal arcus, premature IHD.

Total cholesterol 6.5-10, TG 2.3- 12

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18
Q

Familial hypercholesterolemia type IIa: AD

A

o Tendon xanthomata and FH premature IHD

o LDL >4.9, total >7.5 and normal TG

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19
Q

Familial hypertriglyceridemia type IV/V: AD

A

A/w obesity, DM, gout, eruptive xanthomas, pancreatitis

Normal/ slightly  total cholesterol, TG 2-3->10

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20
Q

Angina causes

A 
CAD
HOCM
valve disease
hypoperfusion during arrhythmia
arteritis
anaemia
thyrotoxicosis
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21
Q

stable angina investigations

A
  • Bloods: FBC, lipids, fasting blood glucose, ESR, TFT

* 12- lead ECG

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22
Q

stable angina drug tx

A

As required: GTN spray. SE- flushing, headache, lightheadedness

Regular treatment:
1. Β-blocker or CCB
2. Long- acting nitrates, ivabradine, nicrorandil, ranolazine
• Monotherapy or in combination with first-line

Secondary prevention
• Aspirin 75mg or clopidogrel 75mg
• Statin
ACEI

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23
Q

stable angina surgical tx

A

• CABG or PCI
• If not controlled with 2 drugs
CABG better if DM, >65, LAD, 3 vessel disease

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24
Q

unstable angina Management:

A

refer to cardiology,
admission if severe,
at rest or >10min even with GTN

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25
Q

Dihydropyridine CCB:
eg
Contraindications:

A

amlodipine, delodipine
AS,
<1month post MI, uncontrolled HF

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26
Q

Rate- limiting CCB:
eg
Contraindications:

A

diltiazem, verapamil
HB or HF
Don’t combine with BB

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27
Q

Cardiac syndrome X
what is it
tx

A

angina despite normal angiogram = microvascular angina

BB ± CCB

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28
Q

Β-blocker:

A

can accumulate in renal disease
Monitor HR- resting ≤65, post-exercise ≤90 (indicates successful beta blockade)
Warn to not stop suddenly-taper off over 4 weeks
Asthma/ COPD: use atenolol, bisoprolol, metoprolol, nebivolol- cardio-selective (usually start from A-M)
LVH: start at low dose and increase

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29
Q

Long acting nirates: isosorbide mononitrate (ISMO)

Oral and patch ≥10mg/24hrs

SE
Tolerance
Contraindications

A

SE: headache, postural hypotension, dizziness, reflex tachy= decrease coronary BF worsen angina

Tolerance develops rapidly- nitrate- free period 4-8hrs overnight by removing patch or give 2nd dose at 4pm

HOCM, AS, constrictive pericarditis, MS, severe anemia, closed- angle glaucoma

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30
Q

Potassium channel activator: nicorandil (venous vasodilator)

SE:
Contraindications:

A

headache

LVF, hypotension

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31
Q

Ivabradine
Lower HR by acting at sinus node
Contraindications:

A

HR <60, HB, HF

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32
Q

Ranolazine: sodium-dependent calcium channels
Contraindications:

A

RenalF, LiverF, caution with CCF and weight <60kg

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33
Q

Drugs after an MI

A

ACEI: decrease myocardial work

Antiplatelet: aspirin 75mg od for life
Add clopidogrel 75mg od:
• For 12 months if NSTEMI/ unstable
• For 1 month STEMI with no stenting
• For 3 months STEMI w/ bare metal stenting
• For 12 months STEMI with drug- eluting stenting

Anticoagulation: if AF, LV aneurysm or if cant use antiplatelet

HF/ LV dysfunction: spironolactone 25mg od

34
Q

when can you return to work after an MI?

A

sedentary 4-6wks later,
light 6-8 wks,
heavy 3mo

35
Q

Dressler syndrome:
2-10wks post MI or heart surgery
Autoantibodies to myocytes

Presentation?
Tx:

A

recurrent fever, chest pain ± pleural/ pericardial effusion

steroids and NSAIDS

36
Q

Causes of high output HF:

A

hyperthyroidism,
anemia,
Pagets,
AV malformation

37
Q

Causes of low output:

A

increased preload: MR, fluid overload

Pump failure
i. Cardiac muscle disease- IHD, cardiomyopathy
ii. decreased heart expansion/restricted filling: restrictive CM, constrictive pericarditis, tamponade
iii. Inadequate HR: BB, HB, post-MI
iv. Arrhythmia- AF
v. decreased power: negative inotropes- verapamil- diltiazem
Chronic excessive afterload: HT, AS

38
Q

causes of Falsely elevated ANP:

A 
Structural/ functional cardiac disease (including MI)
Baseline high in males and >70 
Lung disease- COPD, PE 
Renal and liver impairment 
DM 
Sepsis
39
Q

HF Severity- New York heart association (NYHA)

1-4

A
  1. No limitation, ordinary exercise doesn’t cause SOB, palpitations, fatigue
  2. Slight limitation: comfortable at rest but ordinary activity causes symptoms
  3. Marked limitation: comfortable at rest but less than ordinary activity causes symptoms
  4. Symptoms at rest and worse with any activity
40
Q

Prognosis HF

A

50% die suddenly- due to arrhythmia

Mild/ moderate: 20-30% 1year mortality

Severe: >50% 1 year

41
Q

HF meds

3 main meds

A

diuretics
ACEi
BB

42
Q

HF meds

diuretics

A
  • Loop: furosemide 20-40mg or bumetanide 1-2mg od
    • thiazide if continued problems with odema or HT
  • Monitor for hypokalemia treat with amiloride or K+ supplements
43
Q

HF meds

LV systolic dysfunction:

A

ACEI (repipril 1.25mg od) + BB (bisoprolol 1.25mg mane)

44
Q

HF other meds

A
  • Anticoagulation if HF+ AF or history of thromboembolism, LV aneurysm, Intrathoracic thrombus
  • Aspirin 75- 150 mg if HF + atherosclerotic arterial disease
  • Statins
  • Amlodipine: angina and HT
45
Q

Atrial Fibrillation chronic causes

A

isolated,
HT,
coronary heart disease, cardiomyopathy,
Valvular heart disease

46
Q

Atrial Fibrillation acute causes

A 
infection, 
high alcohol intake, 
surgery, 
electrocution, 
MI, 
pericarditis, 
PE
hyperthyroidism
47
Q

AF investigations

A

• Routine: ECG, CXR, bloods- TFT, FBC, U&E
• Ambulatory ECG or cadiac memo if paroxysmal
• ECHO if <50 or murmur/ HF present
Exercise tolerance test if exercise related

48
Q

AF TX aims

A

B blocker
rhythm control - DC or chemical cardioversion
rate control - verapamil 40-120mg tds

49
Q

Intermittent claudication investigations

A
  • Bloods: FBC, U&E, Cr, eGFR, FBC/ HbA1c, lipids
  • ABPI <0.95
  • Duplex USS
50
Q

Intermittent claudication tx

A
  • Exercise: ideally 2h/ week for 3 months
  • Decrease risk factors
  • Aspirin 75mg od or clopidogrel 75mg od
  • Foot care
51
Q

Intermittent claudication exam

A
  • Cool, white, atrophic changes, absent pulses
  • Superficial femoral A: no popliteal and foot- calf pain
  • Aorta or ilia A: weak or no femoral pulse ± femoral bruit. Calf, thigh, buttock pain
52
Q

Critical limb ischaemia presentation

A

deteriorating claudication and nocturnal rest pain. Ulceration/ gangrene from minor trauma

53
Q

Critical limb ischaemia exam

A
  • Atrophic changes: cold, pallor, hairless, shiny
  • Elevated= pallor + venous guttering, lowered= blue- red
  • Ulceration
  • Swelling suggests sleeping on chair to avoid rest pain
  • No pulses, ABPI <0.5
54
Q

Chronic Peripheral Ischaemia vascular surgeon tricks

A

• Angiography: to assess extent and position of diease
• Percutaneous transluminal angioplasty ± stenting: if short occlusions/ stenoses of iliac and superficial femoral vessels
Surgery: longer occlusions/ multiple stenosis

55
Q

Chronic Peripheral Ischaemia drug tx

A

Naftidrofuryl

56
Q

Varicose Veins Complications

A
  • Haemorrhage
  • Varicose eczema, skin pigmentation, ulcerations, oedema
  • Atrophie blanche- white lacy scars
  • Thrombophelebitis
  • Lipodermatosclerosis- fibrosis of dermis and subcutis –> firm
57
Q

Saphena varix

A
  • Dilation of saphenous vein at confluence with femoral vein
  • Transmits a cough impulse
  • Blue tinge and gone when lying flat, lump in groin
  • No tx unless symptomatic
58
Q

Thrombophlebitis
Px
Causes
Tx

A

Px: severe pain, erythema, pigmentation + hardening of vein

Due to stasis, malignancy, thrombophilia if in normal veins

Tx
o Crepe bandaging to compress vein and minimize propagation of thrombus if ABPI >0.8
o Analgesia- NSAID>
o Ice pack + elevation
o Aspirin 75-150mg od
If in long saphenous toward SFJ- uregent duplex bc may cause ligation

59
Q

Thrombophlebitis migrans

A

Recurrent tender nodules affecting veins throughout body

A/w pancreatic carcinoma

60
Q

DVT presentation

A

Unilateral leg pain, swelling, tenderness, ± fever, pitting oedema, warmth, distended collateral superficial veins

61
Q

DVT considerations

A

with no cause found
• If <45y: thrombophilia
• If >45y: undiagnosed cancer

62
Q

DVT Immediate action

if there is delay in dx
tx with LMWH

A

Well’s diagnostic algorithm
o Low probability: do D-Dimer, if +ve assess as med/high
o Med/ high: compression USS ± D-dimer, repeat in 1 wk

D-dimer
o Degradation product of fresh venous thrombus
o Normal = high negative predictive value
o Causes of  DD: malignancy, pregnancy, trauma, inflammation, sepsis, liver impairment

63
Q

DVT Management if confirmed DVT

A

Initially LMWH then warfarin or other oral anticoagulant

Continue LMWH for 4 days until INR is 2-3 for ≥2 days

Continue oral anticoagulants for 3-6months

Wear elastic compression stockings for >2 y to reduce post- thrombotic leg syndrome

64
Q

DVT complications

A

• PE
• Post- thrombotic syndrome: chronic venous HT pain, swelling, hyperpigmentation, dermatitis, ulcers, gangrene, lipodermatosclerosis
Recurrent venous thromboembolism

65
Q

cause of falls in elderly

A 
•	Physical: 
o	Neurological: stroke, visual loss 
o	Cardiac- arrhythmia, postural hypotension 
o	Muscular: steroid- induced myopathy 
o	Skeletal: OA 
o	Infection: pneumonia, UTI 
Environmental
66
Q

Falls Assessment

A
  • Frequency and causes
  • Medications: hypnotics, sedatices, diuretics, antihypertensives
  • Gait and balance
  • Neurological function: vision, mental status, muscle strength, LE peripheral nerves, proprioception, reflexes
  • CV status: BP, HR, rhythm
  • Assessment of environmental risks
67
Q

Incontinence Hx

A 
•	How long 
•	Urgency, frequency, nocturia, volume
•	Stress- cough, sneezing, standing 
•	Past obstetric and medical hx
Medications
68
Q

Incontinence Dx

A

Intake/ out put diary
Urinalysis
Bloods: U&E, eGFR, FBC, HbA1c

69
Q

Incontinence medication causes

A 
diuretics
antihistamines
anxiolytics
α-blockers
sedatives
hypnotics
anticholinergics
TCA
70
Q

Stress incontinence
Loss with cough/ exercise
Causes:
Tx

A

prostatectomy, childbirth, pelvic floor muscles

pelvic floor exercises >3months, vaginal cones, electrical stimulation

71
Q

Functional incontinency
No urological problem
Caused by

A

immobility,

inaccessible toilets, behavioral

72
Q

Overflow
Dribbling is constant
Causes:
Tx:

A

BPH, prostate ca, urethral stricture, faecal impaction, neuro- LMN, SE of meds

Tx: relieve obstruction

73
Q

Urge incontinence: detrusor instability or hyperreflexia
Sx

Causes:

Tx:

A

Sx Frequency, urgency, large loss, nocturia

Causes: idiopathic, neurological, local irritation, obstruction, surgery

Tx: bladder retaining , oxybutynin

74
Q

Urinary fistula: communication between bladder and outside
Constant dribbling

Causes:

A

congenital,
malignancy,
complication of surgery

Refer to gynecology/ urology

75
Q

GP management of incontinence

A

• Fluid intake- amount, timing, type- avoid coffee/tea/caffeine
• Promote weight loss
• Alter medications, treat UTI and chronic respiratory conditions
• Avoid constipation
HRT if estrogen deficiency

76
Q

Dementia definition:

A

Generalized impairment of intellect, memory, and personality without impairment of consciousness

77
Q

Dementia Investigations

A
  • FBC, U&E, eGFR, LFTs, TFT, Ca2+, B12, folate, glucose

* MSU, CXR, ECG

78
Q

Dementia DDx

A
  • Acute delirium
  • Depression
  • Communication probz- deaf, dysphagia, language difficulties
79
Q

Alzheimers drug tx

A

Mild/ moderate: anticholinesterase inhibitors- donepezil, galantamine, rivastigmine

Moderate/ severe: memantine

80
Q

Vascular dementia

A

Multiple lacunar infarcts or larger strokes
Generalized intellectual impairment
Clinically: dementia, pseudobulbar palsy, shuffling gait
Tx: secondary prevention of TIA/ stoke

81
Q

Picks dementia

A
  • Personality change a/w frontal lobe signs (gross tactlessness)
  • Lack of restraint  stealing, practical jokes, unusual sexual adventures
  • Tx: supportive
82
Q

Lewy body dementia

A
  • Fluctuating but persistant cognitive impairement, parkinsonism, and hallucinations
  • No tx, can use benzodiazepines as tranquillization
  • Avoid antipsychotics- can be fatal

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