Primary care Flashcards
Cardiac differentials for chest pain
ACS - crushing, radiating, nausea/SOB, risk factors
- ECG, troponin, coronary angiography
- manage with MONAC and PCI
Aortic dissection - sudden tearing, radiate to back, unequal pulses
- CXR, CT angio or TOE
- surgical repair or bp control
Pericarditis - retrosternal relieved leaning forward, viral prodrome, pericardial rub
- ECG (saddle), CXR, echo
- NSAIDs, treat cause
Myocarditis - palpitations, fever, fatigue, congestive cardiac failure, S1/S4 gallop
- ECG, inflammatory markers, troponin, serology, biopsy
- supportive, bed rest
Respiratory differentials for chest pain
Pulmonary embolism - pleuritic, dyspnoea, haemoptysis, risk factors
- D-dimer, CTPA, ECG, ABG, CXR
- LMWH, thrombolysis?
Pneumonia - fever, SOB, productive, coarse creps, dullness
- CXR, inflammatory markers, sputum culture, urinary antigens, blood culture
- antibiotics
Pneumothorax - sudden pleuritic, risk factors, absent breath sounds/hyperresonance
- CXR
- monitoring / aspirate / chest drain
Pleurisy - pleuritic, dry cough, fever, pleural rub
- CXR
- NSAIDs, treat cause + complications
Other causes of chest pain
Anxiety/panic attack - tightness, SOB, palpitations, doom, stimulus
- ECG, troponin, CXR (exclusionary)
- reasurrance, CBT
Oesophageal spasm - intermittent crushing, GTN relieves, dysphagia
- oesophageal manometry, barium swallow
- diet, PPI / other drugs
+ also gastritis, peptic ulcer disease, acute cholecystitis, pancreatitis, fibromyalgia etc
Angina
= symptomatic reversible myocardial ischaemia
- constricting/heavy discomfort to chest, jaw, neck, shoulders, arms; brought on by exertion; relieved within 5 minutes by rest or GTN. (all three symptoms = typical, two = atypical angina, 0-1 = non-anginal chest pain)
- also precipitants - emotion, cold weather, heavy meals
- associated dyspnoea, nausea, sweatiness, faintness
- caused by atheroma or rarely coronary artery spasm, aortic stenosis, tachyarrythmias
Types of angina
- stable – induced by effort, relieved by rest, good prognosis
- unstable – angina of increasing frequency or severity, occurs at minimal exertion/at rest, increased risk of MI
- decubitus angina – precipitated by lying flat
- variant (vasospastic) angina
Investigations and management of angina
Ix
- ECG usually normal – may show ST depression/flat or inverted T waves (signs of past MI)
- bloods - FBC, U+Es, LFTs, lipids, HbA1c
- consider echo and CXR
- confirm with exercise ECG, angiography, functional imaging eg stress echo
Management
- address exacerbating factors - anaemia, tachycardia, thyrotoxicosis
- secondary prevention - stop smoking, exercise, diet, optimise HTN and diabetes control
- 75mg daily aspirin if not C/I
- address hyperlipidaemia
- consider ACEi
- symptom relief with GTN spray or sublingual tabs – repeat dose if pain not gone in 5mins, then call ambulance if still not gone 5 mins after second dose
Medication
- B blockers and/or calcium channel blocker – atenolol/bisoprolol, amlodipine/diltiazem
- long acting nitrate eg isosorbide mononitrate
- consider revascularisation if inadequate control (PCI or CABG)
- if post MI – beta blocker, aspirin, statin, ?ACEi
Acute coronary syndromes
- pain lasts more than 20 mins of rest, then not angina
- includes unstable angina, STEMI, NSTEMI
- need 2/3 of: history of cardiac chest pain, ECG changes, troponin change
Myocardial infarction
= prolonged cardiac ischaemia, due to occlusion of coronary arteries, resulting in myocardial necrosis
- LAD, left circumflex, right coronary most important
- ECG - ST elevation, new LBBB, T wave inversion, ST depression, pathological Q waves
- troponin raise >20%
Acute – MONAC • Morphine – pain, and vasodilation • Oxygen • Nitrates – vasodilation • Aspirin – antiplatelet • Clopidogrel – antiplatelet - if STEMI, need to go to cath lab for reperfusion (primary PCI) or thrombolysis (alteplase), may require CABG
Chronic • Aspirin/clopidogrel • B-blocker • ACEI • Statins • Lifestyle changes (MDT – cardiac rehab)
Complications post MI
- cardiac arrest, arrhythmias – AF, VT, further MI/IHD, heart failure, valvular dysfunction – mitral valve prolapse, pericarditis (Dresslers syndrome), heart block (from SA node knock out)
Cardiovascular disease risk
Non-modifiable
- Age
- Male sex
- Family history
- Ethnicity
- Socioeconomic deprivation
- Genetic factors
Modifiable
- Smoking
- High bp
- High cholesterol
- Obesity
- Diabetes
- Physical inactivity
Q risk calculated (accounts for other factors including comorbidities, BMI, deprivation, fhx, ethnicity)
- initiate treatment if
Q risk >10% (10 year risk)
A particularly high risk factor (eg very high bp)
Other risk factors (eg diabetes)
Target organ damage
Management of hypertension
- prevalence around 30%
- half of all HTN is undetected, half of those with known HTN are untreated, half of those treated still have HTN!
- diagnose by taking 3 in GP, then confirm with 24 hour ambulatory BPs or home measures
- discuss risk factors, secondary causes, complications
- check peripheral pulses, signs of HF, bruits, fundoscopy
- dipstick urine for blood, protein, glucose
- bloods for renal function, lipids, HbA1c
- 12 lead ECG
Classifications
- Stage 1: clinic BP ≥140/90 mmHg, 24-hour / home BP ≥135/85
- Stage 2: clinic BP ≥160/100 mmHg, 24-hour / home BP ≥150/95
- Severe: clinic BP ≥180/110 mmHg
- Specialist help if accelerated HTN (bp > 180/10 + papilloedema) or secondary causes
- Lifestyle advice – smoking, exercise, salt, alcohol
- Medication – for all stage 2 HTN and stage 1 HTN if high risk (Q risk >10%, diabetes, end organ damage), aiming for <140/90:
1. if <55 and non-black ethnicity - ACEi (lisinopril)
1. if >55 or black - calcium channel blocker (nifedipine)
2. ACEi + CCB
3. + thiazide
4. + b-blocker or alpha-blocker or alternative diuretic
Management of hypercholesterolaemia
- 3/5 adults have elevated total cholesterol
Diagnose
- serum blood sample for total, HDl, non-HDL, triglycerides (no need to fast)
- consider secondary causes – alcohol, diabetes (uncontrolled), hypothyroidism, liver disease, nephrotic syndrome, familial hypercholesterolaemia
- specialist assessment if >9.0mmol/l, or >7.5mmol/l and premature or family history CVD
Treatment
- lifestyle – smoking, diet (soluble fibre, reduce sat fats), exercise, weight loss, moderate alcohol
- statin treatment (inhibits HMG-CoA reductase). SEs - GI upset, muscle problems, liver dysfunction, diabetes. Atorvastatin first line, aiming for 40% reduction in non-HDL cholesterol at 3 months second most commonly prescribed drug
Smoking cessation
- personal advice – GP, NHS website, consultation skills to initiate behaviour change
- stop smoking support services
- pharmacotherapy – nicotine replacement (gums/patches etc), varenicline or bupropion if commit to stop date
- national campaigns – public ban, stopping adverts, plain packaging – EFFECTIVE
Diet and exercise advice
- change most likely if built into routine – get off a bus one stop early, use smaller plates etc
- maybe offer social prescribing for lifestyle, eg communal kitchens, gym courses
Cardioprotective diet (Mediterranean)
- reduce sat fats and dietary cholesterol
- increase mono-unsaturated fats (olive oil, rapeseed oil)
- use wholegrain varieties of starchy food
- reduce sugar intake
- > 5 portions of fruit and veg per day
- > 2 portions of fish per week
- > 4 portions of unsalted nuts, seeds and legumes per week
- limit alcohol consumption to 14 units per week
Physical activity
- important for weight loss, lower BP, improved lipid profile
- improvement in mood, increased exercise tolerance
- aerobic exercise and muscle-strengthening activities
Secondary prevention post MI
- lifestyle – diet, exercise, stop smoking
- pharmacotherapy (for indefinite period)
• ACE inhibitors
• Low dose aspirin (+ clopidogrel for 1st 12 months)
• Beta blockers
• Statins - cardiac rehabilitation – exercises, education, stress management
- annual flu vaccine, one-off pneumococcal vaccine
- no clear guidelines re return to work
- DVLA guidance on driving – none for 4 weeks (6 if bus or lorry)
- treat depression
- consider sexual activity – complicated by fear, medication SEs, depression – but can resume as soon as patient comfortable
Asthma
= recurrent episodes of dyspnoea, cough and wheeze, caused by reversible airway obstruction
- associated with other atopic disease – eczema, hayfever, allergy, family history
- PEFR and keep as diary
Management:
Step 1: mild intermittent asthma - Salbutamol [SABA] when needed
Step 2: mild persistent asthma - Salbutamol when needed plus; 1st line = fluticasone [ICS] (100-300mg/day), 2nd line = montelukast [LTRA] or theophylline [OB]
Step 3: moderate persistent asthma - All above drugs and; Add salmeterol [LABA]
Step 4: severe persistent asthma - fluticasone (300-500mg/day)
Step 5: severe persistent asthma with no response to medium dose inhaled corticosteroid – higher dose of fluticasone (>500mg/day)
Step 6: severe persistent asthma with no response to high dose inhaled corticosteroid - Add prednisolone and Immunomodulator (e.g. omalizumab = anti-IgE antibody)
+ yearly flu jab, lifestyle advice
Chronic obstructive pulmonary disease
= progressive airway obstruction
- due to smoking (95%) as irritant, paralyses cilia and scars lung (normal response to this irritant)
- emphysema = breakdown of lung tissue, alveolar tissue fusion (enlarged air spaces distal to terminal bronchioles, bullae)
- chronic bronchitis = chronic inflammation (cough, sputum production on most days for three months of two successive years)
- loss of elasticity, so bronchi close on inspiration (air trapping, long term leads to barrel chest and hyperinflation of CXR) and reduce capacity of lung
- FEV1 <80% of predicted, FEV1/FVC <0.7, with little or no reversibility
- do FBC, CXR, CT, ECG, ABG, spirometry
Management of COPD
Smoking cessation! Exercise, weight optimisation, respiratory nurses
Inhalers
- salbutamol SABA/SAMA
- LABA
- LABA + steroids if FEV1 <50%
- muscarinic antagonists – SAMA (ipratropium bromide) and LAMA
Nebulisers
After acute exacerbation, refer to pulmonary rehabilitation via physio (strength exercises, percussion exercises etc)
Flu jab (and other immune status measures)
Types of anaemia
Low MCV – microcytic anaemia (IN)
- iron-deficiency (treat with oral iron/ferrous sulfate – beware SEs nausea, abdo pain, black stool, diarrhoea or constipation – for at least 3 months)
- thalassaemia
Normal MCV – normocytic anaemia (ABC How Pretty)
- acute blood loss
- bone marrow failure
- chronic disease
- haemolysis
- pregnancy
High MCV – macrocytic anaemia (Big Foot Hettie)
- B12
- folate deficiency
- haemolysis
Heart failure
= inadequate cardiac output for body’s requirements
Systolic failure
- inability of ventricle to contract normally
- ejection fraction <40%
- caused by ischaemic heart disease, MI, cardiomyopathy
Diastolic failure
- inability of ventricle to relax and fill normally, so increased filling pressures
- ejection fraction >50% (HFpEF)
- caused by ventricular hypertrophy, constrictive pericarditis, tamponade, restrictive cardiomyopathy, obesity
Left ventricular failure
- dyspnoea, poor exercise tolerance, fatigue, orthopnoea, paroxysmal nocturnal dyspnoea, nocturnal cough (with pink frothy sputum), nocturia, cold peripheries, weight loss
Right ventricular failure
- peripheral oedema, ascites, nausea, anorexia, facial engorgement, epistaxis
- caused by LVF, pulmonary stenosis, lung disease (cor pulmonare)
Low-output HF
- low CO that fails to increase normally on exertion
- caused by excessive preload (mitral regurg, fluid overload), pump failure (systolic and diastolic HF, low HR, antiarrhythmic drugs), chronic excessive afterload (aortic stenosis, HTN)
High-output HF
- rare – output normal or increased in face of very high demands, occurs in a normal heart
Diagnosis needs symptoms above, + objective evidence of cardiac dysfunction at rest. Staged class I-IV based on impact on daily living
Investigations and management of heart failure
- ECG
- BNP (higher BNP = higher mortality)
Management:
Acute HF – medical emergency! Sit upright, high flow oxygen, IV access, treat any arrythmias, slowly administer diamorphine and durosemide, GTN spray, catheter + monitor fluid balance and weight (aim to lose kgs a day, offloading water), fluid restriction, B blockers, ACEis
Chronic
- usually can’t reverse disease only ease symptoms
- lifestyle essential – stop smoking, stop drinking alcohol, eat less salt, optimise weight and nutrition
- diuretics – loop eg furosemide, + potassium sparing eg spironolactone if hyperkalaemia
- ACEi
- B blockers
- treat the cause (AF). Rate – B blockers, digoxin (avoid CCB in HF), rhythm – amiodarone, fleccainide, cardioversion
- anticoagulation (use CHADS2VASC score)
Lung cancer symptoms and risk factors
Send for two week wait if 2 of cough, fatigue, SOB, weight loss!
Symptoms
- specific - cough, haemoptysis, dyspnoea, chest pain
- systemic - weight loss, night sweats, fatigue, recurrent laryngeal nerve palsy / Horner’s syndrome
- from mets to liver (N+V, RUQ pain, jaundice, clotting, ascites, varices), to bone (fractures, bony swelling, pain, hypercalcaemia), to adrenals (fatigue, anorexia, weight loss, postural hypotension), to brain (ICP rise, personality change, seizures)
- lymphatic spread
Risk factors
- smoking
- asbestos, occupational exposure, smoke pollution (consider mesothelioma if asbestos and pain, recurrent pleural effusions, clubbing)
- age
- family history
