Primary Care Core Conditions Flashcards
1
Q
List the 12 most prevelant long-term conditions in the UK
A
Hypertension Diabetes AF Stroke TIA Coronary Heart Disease/ IHD Heart failure Chronic Kidney Disease Asthma COPD Epilepsy Cancer
2
Q
A 72 y/o during a GP appointment has a BP of 149/87.
What would you do next?
A
- Retake blood pressure 2X
2. Ask him to do Ambulatory BP monitoring (ABPM) OR HBPM for 7days BD
3
Q
What clinic and home BP values would indicate HTN stage 1?
A
Clinic BP > 140/90
Home BP >135/85
4
Q
After diagnosing the 72 y/o man with stage 1 HTN after a Home BP of 142/85. You explain the diagnosis of HTN, the implications of it, give leaflets and recommend starting an anti-hypertensive medication.
What do you recommend and what side effects do you warn him of?
A
CCB
Dizzyness
Ankle swelling
Facial flushing
Headache
5
Q
What questions would you ask in thr history when a diagnosis of HTN is given?
A
CV history:
- HPC: chest pain, SOB, palpitations, orthopnoea, PND, ankle swelling, fatigue
- PMH: Diabetes, AF, previous MI, Renal, Hyperthyroid
- Social hx: Alcohol, smoking, Diet: salt, fatty foods, coffee, exercise
6
Q
What scoring tool can you use to assess the risk of a stroke or MI in the next 10 years?
A
QRisk2
7
Q
You have taken the History for HTN and done a cardiovascular examination inclusing BMI and Fundoscopy.
What investigations would you order?
A
BEDSIDE- Urinalysis
BLOODS: Cholesterol
HbA1c, U&Es, (TFTs)
IMAGING: ECG
8
Q
When should you ask the patient to have blood tests for U&Es in HTN?
A
2 weeks after starting a new anti-hypertensive medication
After increasing dose
9
Q
When is it appropriate to NOT take anti-hypertensive medications?
A
AKI
Shock
10
Q
Annual reviews for HTN are nurse-led and occur in the 1st 6 months then annually.
What are the BP targets for the following:
- HTN only
- HTN + DM + CVD/PVD/CVA/CKD
- HTN + >80yrs
A
- <140/90
- <130/85
- <150/90
11
Q
Clinic BP > 160/100 + HBPM > _________ = Stage 2 HTN
A
HBPM >150/95
12
Q
An Afro-Caribbean 56 y/o man has HTN and has already tried Amlodipine. What medication would you give next?
A
Change to Bendroflumethiazide
OR
Amlodipine + ARB
13
Q
Name are the differentials of essential HTN
A
White coat HTN Hyperthyroid Anxiety Sinus tachycardia - walking, fever WPW syndrome Acute - MI, stroke, AF Secondary HTN - renal
14
Q
At what point would you seek cardiology advise for HTN?
A
On 4 different antihypertensives
(Resistant HTN)
OR secondary cause
OR Stage 1 HTN + <40yrs with no complications
15
Q
The complications of HTN are ____________
A
CVD
Stroke
End-organ damage - CKD, retinopathy, LVH
16
Q
AF is caused by abnormal electrical activity in the atria caused by atrial remodelling. What acronym is used to list the common causes/ associations of AF?
A
MITRAL
Mitral Valve Disease IHD, HTN Thyrotoxicosis RF Alcohol, Obesity LVH
(PE)
17
Q
Define:
1. Acute AF
- Paroxysmal AF
- Recurrent AF
- Persistent AF
- Permanent/ Long-standing AF
A
- < 48hrs
- Terminates within 1 week
- 2+ episodes (paroxysmal or persistent)
- > 1 week or >48hrs requiring cardioversion to stop
- > 12m with unsuccessful cardioversion
18
Q
A 64 year old lady comes into the GP complaining of a 3 day hx of dizziness, SOB and palpitations.
What are the possible differentials?
A
Tachyarrhythmias - AF, SVT CV - Acute Heart failure, Dehydration Resp - Pneumonia Psych - anxiety Haematological - Anaemia
19
Q
The 64 y/o lady requires investigations to exclude AF.
You have one bedside tests of BP and request the HCA in the GP to perform an ECG. What other imaging and blood tests would you order?
A
BLOODS - FBC (anaemia), U&Es, Ca, Mg (electrolyte disturbances). TFTs, Coagulation
IMAGING - ECHO (mitral VD), CXR
20
Q
What are the 4 main steps in treating AF?
A
- Treat underlying cause - infection, hyperthyroid, HTN, IHD
- Conservative (lifestyle): reduce coffee, reduce alcohol, diet, exercise, smoking cessation
- Medical:
- Rate: B-blocker +/- CCB +/- Digoxin (HR <110 or 80)
- Stroke prevention - CHADS2VASC2, HASBLED –> Oral anticoagulant
- (Rythmn control - if rate not controlled - Amiodarone) - Surgical cardiac ablation
21
Q
The main complications of AF are _________ and _________ ___________
A
Stroke
Heart failure
22
Q
Infections can be an underlying cause of which tachycarrythmia present in ~1.5% of population?
A
AF
23
Q
Acute Coronary Syndrome = acute presentation of occlusion of coronary arteries, compromising of 2 conditions:
_________________
__________________
A
MI
Unstable Angina
24
Q
Which ACS is an incomplete occlusion of the coronary arteries?
How does the Hx differ from the complete occlusion?
A
Unstable angina
Presentation: More frequent angina episodes or angina at rest
25
Broadly speaking ACS can present with typical features of "PULSE" or atypical features in the elderly, diabetics and some women.
List features of each presentation
PULSE
- Persistent chest pain +/- radiation to neck/jaw/shoulder/arm
- Upset stomach - N/V
- Light-headed
- SOB
- Excessive sweating
Atypical: Epigastric pain, Vomiting, Hyperglycaemia, Delirium, Syncope, Unresponsiveness, Pulmonary oedema...
26
A 80 year old man comes into A&E with crushing chest pain and vomiting for the last 2 hrs. You are concerned he may be having an MI. Which investigations are the most important to order?
- Troponin (3 tests total. Appears 3-12hrs post-MI)
- ECG
- Glucose
27
What are the differentials of chest pain?
V - ACS, PE, Aortic dissection, Stable angina, Fast AF
I - Pneumonia, TB, Shingle, Cellulitis, Costochondritis, GORD
T - Pneumothorax, Chest wall injury, Cardiac temponade
A
M - Anaemia
I - Anxiety
N - Lung cancer
28
The 80 year old man had high troponins and ST elevation in Leads 2,3, AVF with LBBB and no reciprcol changes. You want to send him for coronary angiography with PCI. What initial management should you do before this?
What is the location of the MI?
ROMANCE:
- Reassurance
- 02 - if SATS <94%
- Morphine - IV
- Aspirin - 300mg
- GTN (if have chest pain)
- Clopidogrel - 300mg
- Enoxiparin (HASBLED score 1st)
Inferior MI
29
If PCI is contraindicated then Streptokinase in used in Acute MI.
What further management would you do once he has recovered?
Conservative - diet, exercise, smoking cessation, Cardiac rehab
Medical - ACE-In (if DM), B-Blockers, Statins, Aspirin 75mg, Clopidogrel 75mg
Follow-up in a few weeks
30
What acronym is used to describe the complications of MI?
DARTH VADER
31
What investigations would you do if a 49 year old man complained of heart attack episode 3 days ago?
```
Troponin
ECG (pathological Q waves, ischaemic changes)
```
32
What does cardiac rehab entail?
Which patients would this be suitable for?
Weight loss programs, dietary advice education and stress management in the community, home or hospital
Post-MI
Heart failure
33
A 78 y/o gardener comes into the GP complaining of a 1 week history of chest and shoulder discomfort when doing her gardening.
It is better when she sits down. What is the likely diagnosis?
Stable angina
Presentation similar to ACS but on exertion +/- relieved by rest or GTN within 5 mins
34
Stable angina is a clinical diagnosis.
True or False
True
Investigations if unsure:
- FBC (anaemia exacerbates angina)
- Resting ECG
- CT coronary angiography (if non-anginal pain but ECG or clinical assessment points to it)
35
You are unsure if the 78 y/o has angina and you arrange a resting ECG. What ECG changes may you see?
Pathological Q waves (previous MI)
LBBB (previous MI)
ST depression
T inversion
36
The ECG of the gardener shows ST depression. You are now sure that she has stable angina.
How would you manage this?
Conservative - Lifestyle: diet, exercise, stop smoking, reduce alcohol, relaxation
Medication:
1. B-Blockers or CCB (if both don't work or contra --> IMN)
2. Episodic relief - GTN spray
3. Manage CV risk factors - ACE-In, Statins, Aspirin
(Surgical - CABG or PCI if appropriate)
37
What counsel do you need to give when prescribing the GTN spray?
GTN spray is for relief from episodes of chest pain.
Symptoms should resolve within 5 mins of using the spray. If not, have another spray.
If symptoms STILL PERSIST after those 5 mins or they are getting WORSE then call 999
Common SE: facial flushing, headache, light-headedness
38
Stable angina can be classification into typical, atypical or non-angina pain?
How many for 3 core symptoms need to be present in each classification?
3 = typical angina
2 = atypical angina
1 = non-angina pain
(chest/jaw/shoulder/arm pain +/- on exertion +/- relieved by rest or GTN within 5 mins)
39
Chest pain at rest with no CV risk factors is defined as _________ _________
Variant Angina
40
Besides atherosclerosis, stable angina can be caused by ___ _____ & ______
Aortic stenosis
Vasospasm
41
Heart failure is a syndrome of signs & symptoms caused by the heart pumping mechanism being impaired.
What is the most common cause of Heart failure?
State causes of LVH & RVH
MI**
LVH
- dysfunction: MI
- pressure: Aortic stenosis, HTN
RVH:
- LVHF
- MI
- Cor pulmonale, PE
42
The prognosis of heart failure is good. ~40% diagnosed with HF die within 5 years.
True or False?
False
PROGNOSIS OF HEART FAILURE IS POOR
~40% diagnosed die within 1yr
(important to have end of life care discussions)
43
Heart failure can be acute or chronic.
List the key signs & symptoms of LVHF which is the most common HF.
Symptoms:
- Fatigue
- Cyanosis
- SOB
- Pulmonary oedema: Orthopnoea, PND, sputum
Signs:
- Cold peripheries
- Low SATS
- High HR, High RR
- Low BP
- Chest - displaced apex beat, dull to percuss, bilateral inspiratory creps
- Ankle oedema
44
How do signs & symptoms of RVHF contrast with those of LVHF?
Symptoms: CAW HEAD + urinary retention
Signs:
- Same as LVHF
- Raised JVP
- Hepatosplenomegaly
45
Congestive HF develops when the heart is not able to meet to body's demand leading to fluid retention, cardiomegaly, chamber dilation and hypertrophy.
What criteria is used to formally diagnose congestive HF?
Framingham
| combination of LVHF & RVHF presentations
46
A 56 year old lorry driver who is overweight and has diabetes and a previous MI 3 years ago comes into the GP complaining of having to sleep on several pillows at night, sleeping more during the day and ankle swelling.
What is the initial management?
Urgent referral to Heart failure community team:
- Doppler 2D ECHO + Cardiology assessment within 2 weeks
(If suspect HF + previous MI)
47
A 87 year y/o retired lawyer with long-standing HTN comes to the GP complaining of feeling short of breath, cold, swollen ankles and coughing pink foam.
What is the initial management?
BNP
- If >400 --> Urgent referral to Heart failure team (ECHO + cardiology assessment within 2 weeks)
- If 100-400 --> Same as above but done within *6 weeks
48
There are various causes that can raise a BNP.
List possible causes.
CARDIAC - LVH, Tachycardia, RV overload
RENAL: eGFR <60 (CKD stage 3a)
SEPSIS
LONG-TERM CONDITIONS: COPD, Cirrhosis, Diabetes
49
Given that the 87 y/o lawyer may have other causes for raise BNP, what further investigations would you like to order?
```
FBC
U&Es, Urinalysis, eGFR
LFTs
HbA1c
Spirometry
```
50
Name the 3 other standard imaging ordered in suspected HF.
| What signs will you see?
ECHO (LVEF <40%)
ECG (IHD changes)
CXR (cardiomegaly, Kerley B lines, pleural effusion, dilated hilum)
51
High [BNP] carries a poor prognosis.
True or False?
What does it stand for?
True
B-type Natriuretic peptide (released by atria stretched)
52
What classification system is used in chronic HF & how many domains are there?
New York Heart Association Classification of HF
```
4 classes:
I - no limitation to activities
II - mild limitation
III - marked limitation, symptoms on exertion
IV - symptoms at rest
```
53
What acute presentation can occur in chronic Heart Failure?
Acute pulmonary oedema
54
Chronic heart failure has several strands to its management.
How is it managed?
Conservative - Lifestyle advice: abstain alcohol, smoking cessation, diet, exercise - CARDIAC REHAB, vaccines
Medication - ACE-In + B-Blocker (refer for 2nd/3rd line)
Diureitcs (if fluid retention/ congestive HF/ preserved EF)
CCB to treat co-mordbities
Surgical - Heart transplant, defib
55
Reviews for chronic heart failure occur how frequently?
You assess their clinical status, medication review, bloods (U&Es, eGFR)
What should you screen for?
Depression
56
What anti-hypertensive medications are contraindicated in heart failure?
Rate-limiting CCB
- Verapimil
- Diltiazem
57
In Heart failure you are giving an ACE-In & B-clocker, should you start them at the same time?
NO
Start low, go slow. Monitor U&Es, BP, Pulse
58
At what point would you refer a heart failure patient to cardiology?
Initial diagnosis
Managing Severe HF
HF not responsive to medical Rx
Patient not able to manage at home
59
TIAs & Stroke present with the same symptoms & signs of acute focal neuro deficit.
How do you differentiate between the two?
TIA = temporary cerebral/retinal ischaemia, <24hrs
Stroke = cerebral/ retinal ischaemia/bleed, >24hrs
60
15% of strokes are preceded by TIAs.
True or False
True
| TIA can be sign of MI
61
List the causes/risk factors of TIAs based on location.
Carotid catheroembolism
Cardioemblism: mural thrombus - post-MI, AF, Valvular D, Infective Endocarditis
Hyperviscosity states: polycythaemia, Sickle cell, Myeloma, COCP
62
TIA & stroke present similarly.
What are the key aspects of the presentation?
Unilateral motor weakness/ sensory loss
Speech - dysarthria
Vision - homonymous hemianopia, amaurosis fugax
Other: Delirium, Collapse
63
A 68 y/o teacher who has AF had an episode 2 days ago of sudden arm weakness, slurred speech and confusion. This has now resolved. You have taken cardiovascular and neuro history and asked about stroke risk factors.
What examinations would you do?
CV - Irregularly irregular pulse (AF), Carotid bruits (atheroma), Heart murms (Valvular D, IE)
Fundoscopy - retinal artery emboli
Neuro exam - CNS + PNS
64
Differentials of the 68 y/o lady with sudden right arm weakness, slurred speech and confusion include...
```
V - Stroke, TIA, post-MI, GCA, retinal bleed
I - Meningitis, Encephalitis
T- head trauma
A
M - hypoglycaemia
I - hemiplegic migraine, focal epilepsy
N - brain mets + other lesion
```
Psych - conversion disorder, hyperventilation
65
Should those with a TIA avoid driving?
Yes
66
If you suspect a TIA what score should be used to assess risk of stroke in the next few days?
ABCD2
A - Age >60yrs
B - BP >140/90
C - Clinical features. Unilateral weakness (2), Speech (1)
D- Duration of symptoms. >60 mins (2). 10-60 mins (1). <10 mins (0)
D - Diabetes
67
Is a TIA a medical emergency?
YES
| Likely to have stroke within 1 month
68
What score of the ABCD2 for TIA is considered high risk of stroke?
4 +
Automatically high risk if have crescendo TIAs (2+ in a week)
69
What is the pathway for managing those with a TIA + high risk of stroke?
1. Aspirin 300mg STAT
2. Seen by Stroke Dr for investigations & assessment within 24hrs of onset of symptoms
3. Once TIA confirmed --> 2" prevention of CV risk factors: Statins, DM control, BP meds, lifestyle
4. If specialist says patient candidate for carotid endarectomy --> Do carotid Doppler within 1 week
5. If Doppler shows stable neuro symptoms + carotid stenosis > 50-99% or 70-99% --> endardectomy within 2 weeks of onset
70
List the investigations that the stroke Dr would order as part of their assessment in suspected TIA.
BEDSIDE: BP, Fundoscopy
BLOODS: FBC, U&Es, LFTs, Lipids, cholesterol, glucose, Coagulation, TSH
IMAGING: MRI (urgent if high risk of stroke or uncertain pathology). ECG
71
An ABCD2 score of ___ or less equates to a low risk of stroke.
There is also a low risk of stroke if ______
3
Low risk of stroke if patient presents late with TIA i.e > 1 week
72
How does the management of a low risk of stroke differ from high risk with a patient within suspected TIA?
Low risk - Stroke Dr investigations & assessment within 1 week
73
Stroke is defined as an acute focal neurological deficit caused by cerebral _________ or __________ in the brain, lasting over _____
Infarction
Bleeding
24hrs
74
Ischaemic strokes account for 85% of strokes and the causes are the same as of TIA.
What are the causes of haemorrhagic stroke?
```
HTN
Head trauma
Aneurysm rupture - SAH
Anticoagulation
Thrombolysis
```
75
a 56 y/o teacher comes into A&E with 4 hour history of left facial palsy with frontal sparing and left tingling in her hand. You want to use a tool to quickly assess if it is likely to be a stroke. What tool is this?
ROSIER
76
The symptoms of an ischaemic stroke are the same as a TIA.
How would a haemorrhage present?
Meningism - Severe Headache, Photophobia, Neck stiffness
Collapse/Syncope
Raised ICP signs - seizure, N/V
CNIII palsy
77
The 56 y/o teacher with left facial palsy with frontal sparing and left hand tingling has been clerked in. What examinations were formed?
What investigation would you order urgently?
CV, Neuro, Fundoscopy
OBS
BEDSIDE: ABCDE OBS, glucose (EXCLUDE HYPO), ECG
IMAGING: CT head (rule out bleed)
78
The 56 y/o teacher has the CT head which shows no bleed. She had her onset of symptoms 4 hrs ago.
How would you manage her stroke?
Alteplase
| <4.5hrs
79
If a patient has a CT head showing no bleed but the onset of stroke symptoms was over 4.5 hrs ago. What treatment would you give?
Aspirin 300mg PO/Rectal daily for 2 weeks +/- PPI
80
If a stroke was caused by Warfarin, what treatment would you give?
PCC (Prothrombin Complex Concentrate + IV Vit K
81
With sudden onset of neuro symptoms, what condition must you always exclude?
HYPOGLYCAEMIA
82
You have given aspirin 300mg + Lansoprazole daily to the 56 y/o teacher with the stroke.
List the next important components of her further management after she has been admitted to the stroke ward.
1. 02 (if <94%)
2. GLUCOSE target 4-11 (otherwise treat)
3. HTN - if haemorrhagic stroke +systolic > 200 or hypertensive crisis + end-organ damage
4. NUTRITION/ HYDRATION- Swallow assessment by SALT within 24hrs. If risk --> Dietetics to discuss nutrition + NG tube within 24hrs. Review hydration regularly
5. BOWEL/ BLADDER- Assistance toileting (often incontinent)
6. MOBILITY- sit upright ASAP to prevent hypostatic pneumonia. Physio assessment
83
Stroke is the leading cause of disability in the UK & 3rd leading cause of death.
What 3 key areas does a stroke cause complications in?
1. MOBILITY - Disability, Hemiplegic gait, falls risk, pressure sores, constipation
2. PSYCH - Depression (think carer too!). Vascular Dementia
3. NEURO - Aspiration pneumonia, Neglect, Incontinence, Seizures
84
Define non-disabling stroke.
Acute focal neuro deficit for > 24hrs where symptoms later resolve with no permanent disbaility
85
Those with disability after stroke embark on Stroke Rehab using SMART goals approach.
Where is the rehab conducted?
In-patient unit
+ Community
(consists of MDT with educational program, assess to various services)
86
Stroke rehab involes assessments and interventions for:
Visual Neglect, Vision, Cognition, Emotional functioning, Swallowing, communication, Mobility/gait.
Name types of gait
Hemiplegic* - circumduction of pathological leg + arm flexed, pronated
Diplegic - "scissoring", cerebral palsy
Parkinsons - shuffling, gaining speed, no arm swing, steps for turning corner
Ataxic - broad base, uncoordinated
Foot drop - perineal nerve damage
87
Who is it important to involve in the care & rehab of stroke patients?
Patient
Families
Carers
88
Diabetes is defined as a medical syndrome of high blood glucose from insulin ineffectiveness or deficiency causing vascular complications.
What are the ranges for:
- normoglycaemia
- hypoglycaemia
- hyperglycaemia
Normal: 4-7
Hypoglycaemia: < 4
Hyperglycaemia: > 11
89
The pancreas secretes insulin and causes liver & muscle cells to present the Glut4 channels to allow glucose to enter the cells.
Glycogenesis then occurs.
True or False?
True
90
A 43 y/o baker comes into GP complaining of weight loss in the last 6 weeks, drinking more water than usual and having frequent episodes of thrush.
She has no signs of malignancy and her calcium is within the normal range. She weighs 99kg.
What investigations do you decide to do?
BEDSIDE: glucose, urinalysis (glucose, ketones, protein), fundoscopy
BLOODS: HbA1c, cholesterol/lipids, U&Es, LFTs (fatty liver), TFTs
91
The 43 y/o baker with weight loss in the last 6 weeks, drinking more water than usual and having frequent episodes of thrush has a random cap glucose tested.
It is 10.4mmol/L.
What information would give a diagnosis of diabetes?
Random glucose > 11 + symptoms
| Fasting glucose >7 + symptoms
not in kids as risk of DKA
92
List the symptoms of Diabetes
Polyuria
Polydipsia
Fatigue
Weight loss
Thrush
Frequent/prolonged infections
Blurry vision
Acanthosis nigricans (Type ")
93
Type 1 Diabetes is an autoimmune condition. Besides taking injectable insulin daily. What must they do daily?
Finger prick glucose tests (5X/day)
94
An HbA1c of > _____ is a diagnosis of Diabetes?
What is HbA1c?
> 48
Measure how glycosylated the haemoglobin is in the blood for the last 3 months.
95
How would you manage the following with a diagnosis of diabetes:
1. HbA1c >48
2. HbA1c >48 despite lifestyle changes
3. If HbA1c >58 despite lifestyle + 1 drug
4. If HbA1c still > 58 despite listyle + 2drugs
5. If HbA1c >58 (uncontrolled) despite 3 drugs
1. Lifestyle modifications: diet, exercise (to maintain at 48)
2. 1st drug - Metformin (or Gliclazide if contra or severe DM symptoms). Aim for HbA1c ~48
3. Add 2nd drug. Aim for HbA1c <53.
4. Add 3rd drug. Aim for HbA1c <53
5. Swap 1 of the drugs for another OR consider insulin. Lifestyle
96
A 68 y/o new diagnosis od diabetes was started on Gliclazide as he has Stage 4 CKD.
What HbA1c value should the patient aim to be below?
Why?
HbA1c < 53
Risk of hypo with Sulphonylureas
97
A 78 y/o retired lady who has had 2 previous MIs, heart failure and has on-going diabetes has attended her 6 monthly review at the GP for Diabetes. She often stays in the house.
Given her comorbidities and frailty. What target should her HbA1C be?
HbA1c 70 max
If elderly/ frail/ significant comorbidities
98
A 60 y/o lady has diabetes and new diagnosis of hypertension. You want to start her on an anti-hypertensive.
1. Which is the best to use?
2. Why?
3. What is her BP target?
1. Ace-In
2. Protective of kidneys
3. BP <140/90 (<130/85 if end-organ damage)
99
A 45 y/o lady with type 2 diabetes comes into A&E with chest sepsis.
Her sugars are normally well-controlled with Metformin & Gliclazide & Dapagliflozin.
Her sugars are now 14.
Why is this?
Hyperglycaemia can worsen in acute intercurrent illness
100
What class, mechanisms of action, SE & contraindications do each of the following anti-diabetic medications have?
1. Metformin
2. Gliclazide
1. Metformin - increases insulin sensitivity.
SE: weight loss. Contra: eGFR <30 (increase risk of acidosis)
2. Gliclazide - Sulphonylurea. Stimulates pancreas to release insulin.
SE: hypo. Contra: severe hepatic/renal failure. Use if metformin contra or very symptomatic at presentation.
101
What class, mechanisms of action, SE & contraindications do each of the following anti-diabetic medications have?
1. Liraglutide
2. Pioglitazone
3. Sitagliptin
4. Dapagliflozin
1. Liraglutide. GLP-1 agonist. Stimulates pancreas to make B cells, released when eat sugar + slows gastric empyting (fuller).
SE: weight loss. Contra: BMI <35. EXPENSIVE INJECTION
2. Pioglitazone - Glitazones. Increase insulin sensitivity.
SE: osteoporosis. Contra: Heart failure
3. Sitagliptin - DDP-4 In. Inactivate GLP-1 inhibitors. Few SE.
4. Dapagliflozin - SGLT-2 In. Stop kidneys from reabsorbing glucose in PCT --> wee it out. SE: thrush, UTI, loose weight.
102
75% of those with diabetes with have a stroke or MI.
How often arte their reviews with diabetic nurses?
What do they review?
What advise do they give?
6 monthly
Review: Medication, BP, Feet, Retinopathy, Bloods: HbA1c, U&Es, cholesterol.
Advise: daily checks on feet & glucose
103
What are microvascular complications of diabetes?
What are macrovascular complications of diabetes?>
Micro - retinopathy, nephropathy, neuropathy
Macro - PVD - ulcers, claudication, limb ischaemia, stroke/MI
Other: infections/healing, impotence, psych
104
Life expectancy can be reduced by as much as 10yrs in type 1 Diabetes.
True or False?
False
By 20 yrs
105
Chronic Kidney Disease (CKD) is defined as impaired renal function from abnormal structure or function for > _______ months.
3 months
Often irreversible + progressive
106
CKD can present in any age. At what age does it peak?
> 60yrs
107
The two top causes of CKD are _____________ and __________.
Name other causes of CKD>
Diabates**
HTN*
CV - heart failure, renal artery stenosis
Urinary obstruction - prostate cancer, BPH
Autoimmune - glomerulonephritis
Systemic - SLE, Myeloma, Vascultis
Congenital - VUR, PKD
Idiopathic
108
A 56 y/o lady with diabetes since 18 years old from CF. Has no symptoms but during her 6 monthly review has proteinuria ++ on urinalysis.
There are several ways that CKD can present in signs & symptoms. What are they?
ASYMPTOMATIC
Renal - ankle swelling, pulmonary oedema, bone pain, anaemia, polyuria/retention, nocturia
Uraemic - itchy, restless legs, tremors, N/V, delirium
GI - N/V, anorexia
CV - pulmonary oedema, LVH, (from fluid retention)
109
What investigations would you do in the 56 y/o lady with diabetes since 18 years old from CF and asymptomatic proteinuria
BEDSIDE: Urinalysis
BLOODS: FBC (anaemia), U&Es, eGFR (<60), Albumin:Creatinine ratio (ACR). HbA1C. Biochem: Ca, Pi, ALP, PTH
IMAGING: USS +/- Biopsy (if unknown)
110
Why is proteinuria & ACR an important marker in CKD?
Proteinuria correlates with poorer prognosis - esp for CVD.
Its a sign of endothelial damage which is likely to be reflected in other vessels eg heart, hence CVD
111
Why do you need to biochemical tests in CKD, i.e Ca, Pi, PTH, ALP?
3" hyperparathyroidism (chronic low Vit D)
Renal osteodystrophy
112
In CKD, urea & creatinine are chronically increased. They can be more elevated in AKI.
Where is urea produced?
When would urea be raised in isolation?
Liver - protein catabolism
Urea raised in dehydration, high protein meal, malnutrition, GI bleed, Heart failure
113
Increase in creatinine has a linear relationship with eGFR.
true or false?
False
Non-linear relationship ie small increase in creatinine could indicate a significant change in eGFR
114
What type of anaemia is seen in CKD?
Normocytic normochromic anaemia
115
A 70 y/o hunter with stage 1 HTN for 10 yrs has an eGFR of 40 during his CKD annual review.
What stage of CKD does he have?
Stage 3b - Moderate/severe CKD
116
What stages of CKD are the following?
At what point is a patient eligible for RRT?
- eGFR: 19
- eGFR:62
- eGFR:12
- eGFR: 49
- eGFR: 39
- Stage 4 (15-30)
- Stage 2 (60-90/ mild or normal)
- Stage 5 (<15, kidney failure, RRT)
- Stage 3a (45-60, mild/moderate)
- Stage 3b (30-45, mild/severe)
117
There are 4 main components to managing a patient with CKD.
What are they?
1. Treat underling cause - DM, HTN etc
2. Conservation - lifestyle advice (smoking, diet, exercise), education (avoid nephrotoxic drugs, monitoring, plans if function declines)
3. Limit progression - Manage HTN (ACE-In for proetinuria), Renal bone D: Calcichew (red absorption of Ca), Vit D
4. Treat symptoms:
Anaemia - Iron tablets, Erythropeitin injections
Acidosis - Sodium bicarbonate
Oedema - Furosemide
118
A 67 y/o lady with PKD has significant proteinuria and an eGFR of 29.
At what point would you refer to Renal for management?
```
Stage 4/5 CKD
Signficant proteinuria
Rapidly falling eGFR
Poorly controlled HTN
Suspect renal artery stenosis/ genetic causes
Metabolic complications
```
119
What are metabolic complications of CKD?
Metabolic acidosis (prod less HC03-)
Hyperkalaemia (less efficient excretion)
Anaemia (prod less Erythropoietin)
120
At what eGFR is dialysis considered?
What other forms of Renal replacement therapy are there?
< 10
RRT:
- Dialysis - Haemodialysis, Peritoneal
- Renal transplant
- Palliative
121
What specific dietary advise would you give to someone with CKD?
Reduce salt
Reduce K+ intake e.g. bananas, fruit juices
Reduce Pi intake
Reduce sugar intake
122
Epilepsy is a tendency to intermittent abnormal brain electrical activity. ~1% will have a seizure by 14yrs.
What is the most common cause of epilepsy?
Idiopathic (2/3, often FH)
123
Non-epileptic causes of seizures include....
```
V - Brain haemorrhage
I - Meningitis, Encephalitis,
T- Head trauma (raised ICP)
M - hypoglycaemia, hypercalcaema, hypoxia, alcohol/drugs
N - tumour (other + SOL)
```
124
Epilepsy is a clinical diagnosis. ALL SUSPECTED SEIZURES SHOULD BE SEEN BY NEUROLOGIST WITHIN HOW MANY WEEKS FOR DIAGNOSIS?
2 weeks
125
Epilepsy presentation can be divided into:
- Before
- During
- After
List features within each category
Before - behavioural changes, aura (dejavu, smells, flushing lights)
During - head turning, eye turning/ rolling, limb movements, silence, lip smacking, LOC**
After - "post-ictal" - headache, lethargic, confusion, tongue-biting, incontinence, temporary weakness, dysphagia
126
You are a neurologist in an out-patient clinic. A 6 y/o child has been referred to you by the GP a week ago about a child with possible absent seizures.
What investigations would you order?
BEDSIDE: glucose
BLOODS: FBC (infection), U&Es (electrolytes), Ca
IMAGING: EEG
127
What investigations would you order if a child had seizures & was febrile and systemically unwell with no rash?
Lumbar puncture
| ?Meningitis
128
Epilepsy can be classified according to location of abnormal brain activity; partial or generalised.
Which type of seizures fall into PARTIAL seizures?
Define each.
PARTIAL = 1 hemisphere
- Simple (seizure whilst alert)
- Complex (change of awareness)
- With generalisation (begins in 1 hemisphere then spreads)
129
Epilepsy can be classified according to location of abnormal brain activity; partial or generalised.
Which type of seizures fall into GENERALISED seizures?
Define each.
Absence (staring/ blinking without falling)
Myoclonic (jerky bodily movements)
Tonic-clonic (falling, stiffening & jerking of whole body)
Tonic (falling, rigid body)
Atonic (falling heavily to the ground)
130
Infantile spams are also known as ___________ syndrome.
It has a poor prognosis.
What are the symptoms?
What is given to manage it?
West syndrome
Head nodding & jerking movements forwards
Steroids
131
Epilepsy can be managed conservatively, medically or surgically.
What is the management?
Conservative - education - relaxation tecniques, dangers when swimming/ driving DVLA/ heights. Call 999 if status epilepticus. Contraception
Medical
- if partial +/- generalisation: Carbamazepine or Lamotrigine
- If generalised - Valproate
Surgical: neurological resection (focal), vagal never stimulation
132
Who should start & alter anti-epileptics?
Neurologists
GP can alter if already instructed by neurologist
133
Should brand names be used when prescribing anti-epileptics?
Yes
134
Anti-epileptics are notorious for having numerous drug interactions.
What mnemonics help you remember P450 inhibitors and inducers?
Inhibitors: F0AM DEVICES
Inducers: CRAP GPS
P450 drugs metabolised: Warfarin, Phenytoin, Carbamazepine, OCP,
135
Status epilpeticus is a medical emergency. It is defined as...
Brain in persistent seizure (usually generalised tonic-clinic) for > 30 mins OR repeated seizures without recovery of consciousness within 30 mins
136
In Paediatrics, when would you start treating a seizure as "Established" status?
Why?
At 5 mins
Want to prevent status --> risk of developing epilepsy
137
State the management of "Status epilepticus" in children
1. Initially - ABCDE, time, 02, glucose
2. At 5 mins - Buccal 3. Midazolam 0.5mg/kg OR IV Lorazepam 0.1mg/kg
4. At 15 mins - IV Lorazepam (hospital)
5. At 25 mins - IV Phenytoin infusion over 20 mins. CALL ANAESTHETIST/ PICU
6. At 45 mins - Anaesthetist performed RSI --> PICU
138
State the management of status epilepticus in adults
1. Initially - ABCDE, time, 02, glucose
2. If pre-hospital - Buccal Midazolam 10mg OR rectal diazepam 10mg --> Repeat once if status threatening
3. 0-30 mins, Early - IV Lorazepam 4mg
4. 0-60 mins, Established, Repeat Lorazepam after 10 mins + Give regular AED
5. At 0-60 mins - Give IV Phenytoin infusion, CALL ANAESTETIST
6. 30-90 mins - Give to ICU. General anaesthesia eg thiopentone/ propofol
Continue anaesthesia for 12-24hrs after last clinical/ electrographic seizure ended.
139
Asthma is most common chronic disease in children in the UK.
It is defined as .....
What is the prevelance?
What are the triggers?
= chronic inflammation of the small airways causing reversible obstruction (mucus, inflamm, bronchospasm)
1 in 10 children
Drives ASTHMA
Drugs (NSAIDs, B-blockers), Allergens, Sport/Smoking, Temp (cold), Heart burn, Microbes, Anxiety
140
List the risk factors for developing asthma
FH - atopic triad
Parental smoking
Prematurity
Low birth weight
141
A 4 y/o girl comes into the GP with her parents after a 3 month history of nocturnal cough, breathlessness when playing outside. She has an occasional wheeze,
There is no sputum, no blood, no fever, no chest discomfort.
What is the likely diagnosis?
Differentials?
How would you manage this?
Asthma
Differentials: GORD, CF, Post-viral wheeze, foreign-body obstruction
Management:
- Wait for objective tests at 5yrs (if symptoms still there)
- Treat symptoms - Salbutamol inhaler
- Review regularly
142
A 7 y/o boy comes the GP with his dad after complaining of chest tightness and SOB when playing football at school.
On examination - he is not cyanotic, RR: 18. HR: 80. BP: normal. No signs of anaemia. Chest examination - expiratory wheeze bi-basally.
How would you manage him?
Give he is 5-16yrs --> Perform objective tests:
- Spirometry +/- bronchodilator reversibility (if signs of ob)
- FeNo
- Peak flow
143
What results from the investigations for asthma in a 5-16 y/o would indicate a positive diagnosis?
Spirometry - FVC/FEV < 0.7/70%
+ Bronchodilator reversibility of 12%+
- FeNO >35 ppb (more NO produced when lung inflamed - do if diagnostic uncertainty after spirometry)
- Peak flow variability>20% (for 2-4 weeks, if diagnostic uncertainty after FeNO
144
With a diagnosis of asthma, the conservative management is to encourage parental smoking cessation and writing action plans of what to do if asthma deteriorates, carrying inhaler everywhere.
How would you medically manage asthma in 5-16y/o according to the BTS guidelines?
1. SABA - Salbutamol (blue, reliever, PRN)
2. + ICS - Beclemethasone (brown, preventer, bd)
3. If < 5yrs: Leukotriene antagonist. e.g Montelukast
If > 5yrs: LABA - Salmeterol
4. Refer to Asthma specialist - increase steroids or trial Theophylline
5. Oral Prednisolone (>5yrs, MONITOR GROWTH)
145
When should you review a 5-16 y/o child who recently started/changed asthma medications?
When should you review them after an exacerbation
4-8 weeks after starting/changing meds
48hrs after exacerbation
(Annual review)
146
Complications of asthma are...
```
Acute exacerbations - Oral Pred 40mg/day for 5 days (>5yrs)
Delayed growth/ puberty
Impaired QoL
Pneumothorax
Cor Pulmonale
```
147
At what point would you order a CXR if a child with a persistent cough?
3 weeks +
148
Management of asthma for adults is from 17 yrs.
An 18 y/o man has a nocturnal cough, wheeze and SOB on exertion and in Winter. You suspect asthma - what type of asthma do you want to exclude from this age?
How would you manage this?
OCCUPATIONAL ASTHMA
- Ask if symptoms better on days off/holidays away from work. If YES --> Refer to occupational asthma specialist.
If NO --> Do objective tests
- FeNO
- Spirometry +/- Bronchodilator reversibility
- Peak flow (2-4 weeks)
- (Direct bronchial challenge test with histamine & methacholine)
149
What results from the investigations would indicate a diagnosis of asthma in a person >17yrs
1. FeNO > 40 ppb
2. Spirometry FVC/FEV1 < 0.7 + Reversibility 12% + vol increase >200ml
3. Peak flow variability >20% (do for 2-4 weeks if diagnostic uncertainty)
150
Outline the management of asthma in >17yrs according to the BTS guidelines
1. SABA
2. ICS
3. Leukotreine anatgoanist OR LABA
4. Increase ICS
151
What are the SE of Salbutamol in children and in adults?
Children - hyperactivity, hypokaelaemia
Adults - palpitations, tremor, hypokalaemia
152
In an acute exacerbation of asthma, it may present with increased breathlessness, increase need for salbutamol inhaler.
Worrying signs are agitiation, behavioural changes, collapse, cyanosis.
How do you manage acute asthma?
ABCDE
0 SHIT
+/- hospital admission: <18yrs, poor compliance, persistent exacerbations, pregnant, PMH: life-threatening asthma/brittle
153
What are the parameters that would define a severe asthma attack and life-threatening asthma attack?
```
Severe:
Unable to complete full sentences
RR >25
HR >110
Peak flow: 33-50% predicted
```
Life-threatening
- Reduced GCS
- Low SATS,
- Cyanosis
- Bradycardia
- Hypotension
- Peak flow <33% predicted
- Tired breathing
- Silent chest (poor ventilation)
154
COPD is defined as __________ + __________ and is irreversible & progressive
Chronic bronchitis (cough most days for > 3months for 2 consecutive yrs)
Emphysema
155
COPD is a diagnosis in those >35yrs.
| What are the risk factors for developing COPD?
Smoking*
Occupation: Coal-miners, Dye factories, air pollution
Genetic: Anti-trypsin-1 def
156
A 65 y/o smoker for 30 yrs, 20 a day comes into the GP complaining of a cough for the last 6 months. There is sputum but no blood. She often feels tired, short of breath on exertion, no wheeze is heard. There are no signs of Cor Pulmonale.
What signs might you expect on examination?
```
Use of accessory muscles - SOB
Pursed lips
Low SATs
High RR
+/- raised JVP
Wheeze
Pulmonary oedema
```
157
You decide to perform Spirometry and CXR in the 65 y/o lady smoker with the chronic cough.
What findings would indicate a diagnosis of COPD?
How many stages of COPD are there?
What scale is used as an objective way of measuring degree of SOB?
Spirometry - FEV1/FVC <0.7, irreversible
CXR - hyper-inflated lungs, (signs of HF)
Stages 1-4
MRC Breathless Scale - Grade 1-5
158
Broadly speaking there are 4 main areas to manage when treating someone with COPD:
- Conservative - lifestyle
- Medical
+/- Adjuvants
+/- Other interventions
What is in each group?
LIFESTYLE -Smoking cessation**, Exercise + Weight loss, Diet, Travel, Vaccines (2)
MEDICAL - Inhalers +/- Steroids
ADJUVANTS
- Home 02 (if chronic hypoxia, 15hrs+/day)
- Mucolytics ( Carbocysteine)
- Theophyllne (if poor control, can't tolerate inhalers, 2" care)
OTHER
- Pulmonary rehab (MRC3+), NIV, benefits (OT assessment)
159
Outline the medical management of COPD.
1. SABA or SABA prn
2. FEV1 >50% --> LABA or LAMA
If FEV1 < 50% --> LABA + ICS or LAMA
3. LABA + LAMA + ICS
4. Oral steroids
160
What are the complications of COPD?
Acute exacerbations - breathlessness, increased WOB, reduced exercise tolerance, change colour/ amount sputum
```
Cor Pulmonale
Depression
Lung Cancer
2" polycythaemia
Pneumothorax
Disability
```
161
How would you manage an acute exacerbation of COPD?
ABCDE
Investigations:
- BLOODS: FBC, U&Es, CRP, ABG, Blood/sputum culture
- IMAGING: CXR,ECG
```
Treatment 0 SHI
- 02 - Venturi
- Salbutamol neb 5mg
- Hydrocortisone or Prednisolone 40mg
- Ipratropium bromide 500mcg
+/- Antibiotics
```
Do spirometry before discharge. Give Prednisolone 30mg for 7-14 days after discharge.
162
What criteria would warrant a patient with an exacerbation of COPD to need a hospital admission?
Admission if:
| severe SOB, cyanosis, delirium, rapid onset, CXR changes, lives alone
163
What presentation would make you consider end-stage COPD, appropriate for palliative care?
```
Multiple hospital admissions
Low BMI (loose weight as increased energy expenditure to breath)
Co-mordities
House-bound
Chronic hypoxia (needing home 02)
Dependant
```
