Primary Care Update form 3rd year Flashcards
Asthma: diagnostic tests? (3) why are objective tests important in asthma? (1) when can't you diagnosis asthma? (1) what to do in this age group? (2)
Objective asthma tests: 1- spirometry 2- FeNO 3- peak flow VARIABILITY - get diary (more on which to do when on another card)
- commonly misdiagnosed
- <5 years
- treat symptoms based on clinical judgement
- review on a regular basis
- if they still have Sx at 5, do objective tests
if get to 5 and still unable to do test, then repeat every 6-12 months until satisfactory results obtained OR consider referral to specialise
Asthma:
what to ask in history? (7)
what will you hear on examination? (1)
- wheeze
- cough
- SOB
- diurnal variation
- seasonal variation
- triggers
- PMH or FH of atopic disorders
- occupation–> are Sx better on holiday/ away from work
- expiratory polyphonic wheeze
(if exam normal may still have asthma)
Ashtma:
what do FeNO tests do? (1)
positive spriometry test result for asthma? (2)
- fractional exhaled nitric oxide (FeNO)
- FEV1/FVC < 70%
- bronchodilator reversibility test if obstructive spirometry,improvement of FEV1 of 12% is positive test
Asthma diagnosis: diagnosis (2) which test to do first? (1) when to do FeNO? (1) when to do PEFR variability? (1) when might skin prick or specific IgE be appropraite? (1)
- symptoms of asthma
AND
1- FeNO 35+ (kids) 40+ (adults) AND PEFR variability
OR
2- obstructive spirometry (FEV1/FVC<0.7) AND positive BDR
(no other tests diagnostic e.g. total serum IgE/ skin prick!) - spirometry and bronchodilator reversibility (BDR)
FeNO if diagnostic uncertainty:
- normal spirometry but symptoms
- obstructive spirometry but negative BDR test
- refer to specialist if negative FeNO and BDR, but positive spirometry (basicualy if the tests don’t match up)
- do skin prick once diagnosis made to identify triggers
Asthma:
when to consider alternative diagnoses? (2)
differential diagnosis? (9)
if symptoms of asthma but
- normal spirometry
- FeNO <35ppb
- negative peak flow variability
if any of these positive then still consider asthma as DD , repeat tests every 6 weeks & review symptoms
- COPD
- Bronchiectasis: sputum, coarse lung crepitations
- Cystic fibrosis: moist cough, GI symptoms, clubbing, failure to thrive, Sx present from birth
- Foreign body aspitations: acute, stridor, diminished breath sounds
- GORD: cough, food-related symptoms, vomiting
- Heart failure
- TB
- PE: acute, pleuritic pain, haemoptysis, crackles, sinus tacycardia, calf
- Pertussis: paroxysms of coughing, vomiting, inspiratory whoop
- Lung cancer: hoarse voice, haemoptysis, weight loss
- Interstitial lung disease: dry cough, fine lung crepitations
- Dysfunctional breathing: breathless, dizzy, light-headed, peripheral tingling
Asthma:
how does smoking affect FeNO? (1)
- smoking lowers FeNO levels
Uncontrolled asthma:
what to consider? (5)
how often to review after starting new asthma medications? (1)
key points for prescribing ICS? (1)
1- alternative diagnosis 2- poor adherence 3- inappropriate inhaler technique 4- smoking (active or passive) 5- occupational exposures 6- psychosocial factors 7- seasonal/ environmental factors (e.g. triggers) THEN consider adding drugs
- review in 4-8 weeks after starting medicines
- adjust daily ICS dose over time; aim for lowest dose for effective control
(to reduce side effects)
Asthma:
when to check they can use their inhaled? (5)
what is self-management in asthma? (3)
- at every consultation relating to an asthma attack, in all care settings
- when there is deterioration in asthma control
- when the inhaler device is changed
- at every annual review
- if the person asks for it to be checked.
- written personal action plan
- education
- when to seek emergency help
- importance of asthma review
Asthma:
how to decrease maintenance therapy? (4)
drugs order? (5)
when to step up? (1)
- step down in order stepped up
- only reduce is Sx free for 3 months
- discuss risks and benefits
- follow-up
- SABA (PRN)
- low-dose ICS
- LABA
- high-dose ICS
- OTHERS: theophyline, LTRA, LAMA and refer to specialist care
- if 3+ SABA a week
NICE guidelines lung cancer 2-week referral:
- urgent specialist referral (2)
- urgent CXR
- CXR findings suggesting of lung cancer
- over 40 and unexplained haemoptysis
if over 40 and 2+ of the following unexplained symptoms or have smoked and 1 or more:
- cough
- fatigue
- SOB
- weight loss
- chest pain
- appetite loss
consider if:
- presistent or recurrent chest infection
- clubbing
- supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
- chest signs consistent with lung cancer
- thrombocytosis
NICE guidelines mesothelioma 2-week referral:
key symptoms?
- asbestos exposure
- cough
- fatigue
- SOB
- chest pain
- weight loss
- appetite loss
- finger clubbing
- chest signs/ pleural disease
NICE guidelines oesophageal cancer 2-week referral:
urgent referral for what one symptom? (1)
other red flag features? (concerning if a couple)
NB urgent means 2-weeks in guidance terms
- dysphagia (URGENT REFERAL EVEN IF JUST DYSPHAGIA!)
weight loss and aged 55+ with:
- upper abdo pain
- reflux
- dyspepsia
- haematemesis
- treatment-resistent dyspepsia non-urgent referral
- upper GI pain
- nausea
- vomiting
- reflux
NICE guidelines pancreatic cancer 2-week referral:
urgent referral for what one symptom? (1)
when to consider urgent CT (or US if CT unavailable)? (7)
- aged 40+ and JAUNDICE
aged 60+ with weight loss and one of the following:
- diarrhoea
- back pain
- abdo pain
- nausea
- vomiting
- constipation
- new-onset diabetes
NICE guidelines stomach cancer 2-week referral:
urgent referral for what one symptom? (1)
when to offer upper GI endoscopy?
- upper abdo mass consistent with stomach cancer
- same as oesophageal
(dysphagia, upper abdo pain, reflux, dyspepsia, haematemasis, treatment-resistent dyspepsia, anaemia etc)
NICE guidelines colorectal cancer 2-week referral:
urgent referral symptoms?
- 40+ and unexplained weight loss + abdo mass
- 50+ and real bleeding
- iron-deficiency anaemia +changes in bowel habit
- mass
(vague)
NICE endometrial cancer:
red flag features?
- post-menopasual bleeding (especially if 12 months post last bleed)
US if:
- unexplained vaginal discharge
- haematuria
- anaemia
- high blood glucose levels
NICE prostate cancer:
red flag features?
- lower urinary tract symptoms
- erectile dysfunction
- haematuria
NICE bladder cancer:
red flag features?
- haematuria
- unexplained non-visable haematuria and dysuria or raised WCC
- recurrent, unexplained UTI
renal cancer has very similar symptoms
NICE melanoma:
urgent referal for pigmented skin lesions?
weighted 7-point checklist of 3 points or more
MAJOR FEATURES (2 points each) - change size - irregular shape - irregular colour MINOR FEATURES (1 point each) - >7mm - inflammation - oozing - change in sensation
NICE laryngeal cancer red flags? (2)
over 45 and:
- persistent unexplained hoarseness or
- unexplained lump in neck
NICE leukaemia referral pathway:
urgent FBC red flags?
- pallor
- persistent fatigue
- unexplained fever
- unexplained/ recurrent infection
- lymphadenopathy
- unexplained bruising
- unexplained bleeding
- unexplained petechiae
- hepatosplenomegaly
What symptoms are concerning for cancer in a history? (3)
- UNEXPLAINED weight loss
- unexplained appetite decrease
- DVT
https://www.nice.org.uk/guidance/ng12/resources/suspected-cancer-recognition-and-referral-pdf-1837268071621 - this document very good list at the end of symptoms and what action to take
Type 2 diabetes: who to test for type 2? (2) who to encourage to have a risk assessment? (10) what to do if low risk score? (2) what to do if high risk score? (2)
2 stages:
1- a validated risk assessment to see who should have a test
2- those high risk get blood test and lifestyle advice
(i.e. if you’re treating a patient who you think might be at risk then do risk assessment on them)
people in high risk groups:
- cardiovascular disease
- hypertension
- obesity
- stroke
- polycystic ovary syndrome
- PMH gestational diabetes
- mental health problems
- over 40 years old
- ethnic minorities (aged 25-39)
- learning disabilities
- anyone attending ophthalmology, renal surgery, vascular surgery, and emergency assessment units
- brief advice: encouragement & reassurance, discuss any at risk factors
- reassess if condition changes, or max 5 years later
- offer blood test to see if (pre) diabetes diagnosis
Type 2 diabetes:
who to offer blood test to? (2)
what to do it moderate risk but negative for diabetes? (1)
what to do if high risk but negative? (1)
- any adult with high risk score
- aged 25 or over, Asian descent, BMI > 23 km/m2
- retest in 3 years, advice
- re-test in 1 year, advice
Type 2 diabetes diagnosis? (1)
diangosis for gestational diabetes? (2)
diabetes symptoms \+ random plasma glucose >=11.1 mmol/l OR fasting plasma glucose conc. >=7.ommol/l OR 2 hour plasma glucose conc. >=11.1 mmol/l two hours after 75g anhydrous glucose in oral glucose tolerance test (OGTT)
if no symptoms then needs two tests on two separate days
- fasting glucose 5.6mmol/l +
- 2-hour plasma glucose 7.8mmol/l+
Diabetes: key categories of management? (4) what is the HbA1c target? (2) what does it depend on? (3) whats problem with very tight glucose control in the frail? (1)
1- education!
2- monitor blood glucose
3- monitor CVD/HTN/ high cholesterol
4-monitor complications
- every 6 months
- it’s FLEXIBLE
- 3 main targets: 48, 53 and 58
- depends on the patient e.g. personal choice/ if frail
- what drugs they’re taking (if hypo risk)
- life expectancy (if going to die in 6 months let them eat cake!)
Diabeetes:
who should self-monitor blood glucose? (5)
- on insulin
- evidence hypoglycaemic episodes
- on oral medication that may increase their risk of hypoglycaemia while driving or operating machinery
- pregnant or planning to be pregnant
- starting oral/ IV corticosteroids
- to confirm suspected hypoglycaemia
- risk vs benefit of hypoglycaemia and tight glucose control
what affects drug choice? (
what non diabetic drugs would you want to consider prescribing? (2)
- BMI e.g. might want them on one that reduces weight
- HbA1c
- kidney eGFR
- age
- occupation; e.g. for hypo risk
- statin (cholesterol—> QRISK)
- blood pressure –> BP drugs
Type 2 diabetes:
HbA1c targets and managment levels? (4)
diet and lifestyle (D&L) at all levels
1 - >48mmol/mol
–> METFORMIN
2- D&L+ single drug > 48mmol/mol
or >54mmol/mol if hypo risk drug
–> ADD 2ND DRUG AND TAGET 53mmol/mol
3- D&L+ 2 drugs 58mmol/mol
–> ADD 3RD DRUG but keep target 53mmol/mol
4- D&L+ 3 drugs make personal target
Who to suspect diabetes in?
- recurrent cellulitis
- candidiasis
- dermatophyte infections
- gangrene
- pneumonia (particularly TB reactivation)
- influenza
- genitourinary infections (UTIs)
- osteomyelitis
- and/or vascular dementia
