Revision Flashcards
when should you never prescribe the combined oral contraceptive pill
FHx of thrombophilia
when should you never prescribe doxycycline
if patient< 12
what condition should you consider before prescribing furosemide
gout
what condition should you consider before prescribing an NSAID
hypertension
what should you consider before considering prochlorperazine
if patient pregnant
when should you not prescribe naproxen
if patient on warfarin- increased risk of GI bleeding
when in pregnancy is trimethoprim contraindicated
first trimester- folate antagonist
what antibiotic is first line for UTI in pregnancy
nitrofuratoin
give examples drugs you should monitor (4)
ACEi (BP, renal function, electrolytes)
warfarin
DMARDs
chemotherapy
how long is exclusive breastfeeding recommended for
first 6 months
what supplements should babies get
vit d from birth (not if on formula)
vit A,C and D from 6 months
what BMI decile would mean a child is overweight
> 91st
98th obese
99.6th clinically obese
what is the treatment for a baby with a suspected cows milk intolerance
2-4week lactose exclusion with extensively hydrolysed infant formula followed by a reintroduction of cows milk (if symptoms return then confirms diagnosis)
what condition is dermatitis herpetiformis associated with
coeliac disease
what percentage weight loss is recommended for BMIs of 25-35
5-10%
>35 15-20%
what does an insulin ratio mean
insulin to carb
e.g. 1:10 will need 1 unit for 10g of CHO
should T1DM patients carb count alcohol
no as increased risk of hypo following consumption of alcohol
does high fibre reduce CVD risk
yes
how does fibre reduce colon cancer risk
fibre fermentation creates short chain fatty acids which have anti-proliferative effect
what GI condition can exclusive enteral nutrition induce remission
crohns disease in paediatric patient
what is parenteral nutrition
the provision of all nutrients, fluids and electrolytes directly into a central or peripheral vein (indicated for an inadequate or unsafe oral and/or enteral nutritional intake or a no functional inaccessible or perforated GI tract.
what are the red flags for spinal pain
thoracic pain fever and unexpected weight loss bladder of bowel dysfunction ill health/ presence of other medical illness progressive neurological deficit disturbed gait, saddle anaesthesia age of onset <20 or >55
what are the yellow flags of pain
psychosocial factors shown to be indicative of long term chronicity and disability (predictors of response to treatment)
- negative attitude that back pain is harmful or potentially severely disabling
- fear avoidance behaviour and reduced activity levels
- expectation that passive treatment will be beneficial rather than active treatment
- tendency to depression, low morale, and social withdrawal
- social or financial problems
- compensation issues
what are the reds flags for cauda equina
bilateral sciatica
severe/ progressive neurological deficit of the legs (major weakness)
difficulty initiating micturition or impaired sensation of urinary flow- may lead to irreversible retention with overflow incontinence
loss of sensation of rectal fullness- may lead to reversible faecal incontinence
perianal, perineal or genital sensory loss (saddle anaesthesia/ paraesthesia)
laxity of anal sphincter
what are the red flags for a spinal fracture
sudden onset severe central spinal pain which is relieved by lying down
Hx of trauma/ strenuous lifting in people with osteoporosis/ corticosteroid users
structural deformity
point tenderness
what are the red flags for cancer associated spinal pain
> 55y/o
gradual onset of symptoms
severe unremitting paint hat remains when supine, aching night pain that prevents/ disturbs sleep and aggravated by straining
thoracic pain
localised tenderness
no symptomatic improvement after four-six weeks of conservative low back pain therapy
unexplained weight loss
PHx of cancer (esp breast, lung, prostate, GI, renal, thryoid)
what are the red flags for infection associated back pain
fever TB recent UTI diabetes Hv of IVDU HIV infection immunosuppressants
what are the trigger words for neuropathic pain
shooting numb stabbing electric feel pain tingling burning traditional pain killers don't help emotional impact
what is anticholinergic syndrome
when antocholinergic drugs (e.g. amitriptyline) blocks M3 muscarinic receptors (parasympathic nervous system) causing anorexia, blurry vision, constipation/ confusion, dry mouth, sedation/ stasis of urine, drowsiness and QT prolongation
what dosing technique should you use with anticholinergic drugs
start low go slow and be aware of side effects
dont use post MI or in the manic stage of BPAD
when is creatine most effective in showing kidney function
when patient underweight or elderly
what BP medication can cause a cough
ACEi (e.g. lisinopril- increases bradykinin levels)
name a side effect of amlodipine
ankle swelling
what is edoxaban
anti-coagulant: inhibits factor 10a
prescribed based on patient weight
what is a coagulopathy
tendency to bleed due to inability to coagulate blood
doacs vs warfarin go
doacs cause less major bleeds, dont need monitoring and have faster onset
but cant be reversed unlike warfarin (vit K) and cant be given to patients with mechanical heart valves
name the doacs
dabigatran
apixaban
edoxaban
rivoroxaban
what is leucopenia
reduction in leukocytes (WBC)
what happens when steroids are stopped too quickly
adrenal insufficiency/ crisis
how is gentamicin given
IV only
how could you clinically differentiate intracranial heamorrhages
subdural- subclinical, slow deterioration
extradural- lucid period, quick deterioration
subarachnoid- thunderclap headache
treatment pathway asthma
SABA as required
consider low dose ICS to diagnose- if helps symptoms prescribe as regular
if >3 times a week use of SABA or disturbing sleep add in LABA to ICS and SABA
increase ICS or add LTRA
when should you do peak flow
3-4x a day to look for diurnal variation, low value usually in morning, cough at night
can you give SAMA and LAMA at the same time
no
how many puff of salbutamol should you take in suspected asthma attack
10
what does PRHrP released by Sqclc cause
hypercalcaemia with normal PTH
what can pancoast tumour cause
SVC syndrome, horners, vocal cord palsy (recurrent larhyngeal nerve)
how long should you give DOACs in DVTS
provoked- 3 months
unprovoked 6 months
more than 2 unprovoked lifelong
if renal impairement give LMWH
what scoring system for DVT and PE
wells score (>2 DVT >4 PE)
Tx for PE
calculate wells score (if <4 do d dimer, if +ve immediate CTPA)
if >4 admit for CTPA with interim DOAC if needed
if unstable unfractionated heparin and thrombolysis (alteplase/ streptokinase)
if stable CTPA and DOAC
continue anticoagulation for at least 3 months (DOAC)
what are the features of horners
anhidrosis
ptosis
miosis
what is in the paediatric sepsis 6
give high flow oxygen
obtain IV or IO access for: blood cultures, blood glucose (treat if low), blood lactate/ gas
give IV/IO abx
if shocked
fluid resus
consider early inotropic support
involve seniors early
how should you start child CPR
5 rescue breaths then 15 to 2
what drugs do you stop in AKIs
nephrotoxics- ACEi, ARBs, NSAIDs, aminoglycosides (gent, -micins)
drugs that increase comps: duiretics, metformin, anti-hypertensives
what are the indications for anticoagulants
venous thrombosis, AF, prophylaxis
what factors is def the haemophilias
a- 8
b- 9
what does APPT measure and what raises it
intrinsic system (8+9) raised in heparin, haemophilias, DIC and liver dissease
what does PT measure and what raises it
extrinsic (2,7)
measured as INR (0.9-1.2)
raised by warfarin, vit k def, liver disease and DIC
what is the anticoagulation after DVT or PE
offer apixaban or rivaroxaban for at least 3 months
if provoking factor no longer presence can stop after 3
if active cancer 6 months
if unprovoked or risk factors remain then calculate has bled score (stop anticoag if >4) and chadvasc score if risk of stroke to decide on lifelong anticoagulation
what drugs should be stopped before surgery
acei, arbs
nsaids,
warfarin 5 days before (INR<1.5)
DOACS- 24hrs if low risk, 48hrs if high bleeding- dont stop if op no bleeding risk)
all diabetic meds (except long acting insulin)
contraceptive pill and HRT if major op
what antiemetics are best post op
5HT3 receptor antagonists (odansetron)
dexamethasone, prochlorperazine
Cyclizine for opioid nausea
what antiemetic is best for chemo
ondansetron
dexamethasone
what antiemetics for motion sickness
cyclizine
hyoscine hydobromide
promethazine (sedating)
what are mild opioids
codeine
dihydrocodeine
what are strong opioids
morphine
oxycodone
what score for DVT
wells (calculate before doing dimer)
if 2 or more DVT likely do USS then d dimer if that is negative. if cant to USS in 4 hours do d dimer then intermin coagulation.
if d dimer +ve scan negative stop any interim coag and repeat USS in a week
if wells score 1 or less DVT unlikely do a d dimer, if thats +ve do USS
what score for PE
wells
>4 PE likely do CTPA, if CI offer anticoagulation
if 4 or less do d dimer, if positive do CTPA
what anticoagulation for DVT and PE
apixaban or rivaroxaban
if APS or renal impairment LMWH
what is acute cholecystitis
impaction of stone in neck of gallbladder
continuous RUQ/ epigastric pain, fever, vomiting, murphys sign positive
what causes biliary colic, how is it different to acute cholecystitis
cause by stone in cystic duct or common bile duct
doesnt have inflammatory component to cholecystitis (local peritonism, fever, increased WCC)
what are the features of chronic cholecystitis
chronic inflammation + colic
flatulent dyspepsia, nausea, distension, fat intolerance
treatment- cholecystectomy
what is ascending cholangitis
infection of bile duct
what are the features of ascending cholangitis
RUQ, fever and jaundice
rigors
tx- piperacillin, tazobactm
when is ERCP used
common bile duct clearance- stone in CBD
when should you consider antibiotics in sinusitis
when symptoms lasting for >10 days or symptoms of bacterial infection (purulent discharge, severe pain, fever) or systemically unwell
what is the centor criteria
tonsilitis: 3 or more bacterial fever anterior cervincal tender nodes no cough tonsilar exudates
what are the urgent referalls for red eye
acute closed angle glaucoma
anterior uvetitis
scleritis
acute iritis
what causes of red eye also cause decreased visual acuity
acute glaucoma
anterior uveitis
what cause of red eye causes painful eye movements
scleritis
what is the pupil like in anterior uveitis
small, may have synechiae which distort pupil via adhesions
how do you diagnose ant uveitis
slit lamp- leukocytes in anterior chamber
what is the uvea
iris, cillary body, choroid
what is the eye like in acute angle closure glaucoma
hard, fixed dilated pupil, hazy cornea
what is the treatment for acute angle closed glaucoma
urgent referal, avoid darkness (dilates pupil more)
beta blocker (timolol) - decreases aqeous production
pilocarpine- constricts pupil, opens angle
IV acetazolamide- decreases aqueous production
analgesia, antiemetic
once IOP controlled peripheral iridectomy
treatment for herpes simplex corneal ulcer
aciclovir (NOT steroids as this causes full thickness involvement)
treatment for GCA
40mg
if visual involvement 60mg pred
tapered over a year,
what is the treatment for optic neuritis
high dose methylpred for 72 hours then pred for 11 days
white retina W/ cherry red spot=?
central retinal artery occlusion
tx for crao
occular massage, surgical removal of aqueous, treat RF
signs of CRVO
dot and flame haemorrhages
cotton wool spots
macular oedema
swelling of optic disc
treatment for open angle glaucoma
prostaglandins, pilocapine, sympathetmetics, trabeculoplasty: latanoprost increase outflow
beta blockers, alpha adrenergics (-nidine), carbonic anhydrase (azetazolamide)- decrease aqueous production
normal IOP
<21
what biochemical signs does pagets have
isolated rise of ALP
treatment for psoriasis
potent steroid + vit d once daily 4 weeks
vit d twice daily 8-12 weeks
potent steroid + vit d 2x daily/ coal tar
v potent
dithranol, phototherapy (PUVA), systemic tx (methotrexate, ciclosporin, acritrenin (oral retinoid), biologics)
(if face, flexures or genitals use mild-mod steroid)
list steroids mild to mod
hydrocortisone
betnovate
dermovate
acne treatment
mild: topical retinoid (adapalene, tretinoin) or BP or clindamycin
mod: combo of 2 of above, oral abx (doxy, tetra, erythrcycline) with topical BP
severe: isotretoin
treatment for rosacea
avoid sun and alcohol, soap substitutes
mild- topical metronidazole or azelaic acid
mod to severe: oral tetra- doxycycline, isotretinoin
lasers
what laxative for hard stools
osmotic- lactulose, laxido
softeners- docusate
what laxatives for stimulant issue
senna
what can be used to reduce ammonia is hepatic encephaopathy
lactulose
how do you take bisphosphonates
on empty stomach, sit up for thirty minutes
convert 40mg of oxycodone to morphine
80mg morphine
oxycodone is 2 times as potent as morphine, need to divide the daily dose of morphine by 2 to get oxycodone dose
daily dose of 120mg morphine, how much is breakthrough dose
20mg
breakthrough dose is 1/6th daily dose
what type of infusion is a syringe driver
subcut
500mg of morphine oral, covert this to subcut morphine
250mg
divide oral doses by 2 to get subcut doses
what electrolyte abnormality do PPIs cause
hyponatraemia
what should you prescribe is someone who is diabetic with proteinuria
ACEi
anticholinergic side effects
constipation, dry mouth, dry eyes, blurred vision, urinary retention, tachycardia, cog impairment, falls
examples of anticholinergic drugs
oxybutin, ipatopium, tolteridine, amitriptyline
what electrolyte imbalance can thiazides cause
hyponatraemia
what electrolyte imbalance can SSRIs cause
hyponatraemia
what drugs for acute confusion
haloperidol
if alcohol withdrawal benzos long acting: chlordiazepoxide
how long is an emergency detention and who can authorise it
72 hrs
fy2 and above
does not authorise tx, no right of appeal
how long is a short term detention, what does it allow and who can do it
28 days
assessment and treatment
approved mental practitioner and MHO
right of appeal
how long is a compulsory treatment order, what does it allow and who can authorise it
6 months
one medical practitioner, one MHO then report from 2 independent doctors (2x AMP or AMP + GP) who make care plan
mandatory tribunal
reviewed at 6 months, right to appeal
what does bronchial breathing suggest
consolidation or fibrosis
what electrolyte abnormalities happen in refeeding syndrome
hypophosphataemia (rhabdomyolysis, leucocyte dysfunction, respiratory failure, cardiac failure, hypotension, arrhythmias, seizures, coma, and sudden death)
hypomagnesium and hypopotassium
what order should you replace calcium and phosphate
and magnesium and potassium
replace calcium before phosphate (or will cause hypocalcaemia)
replace magnesium before potassium as potassium needs calcium to go up
what is HHS
hyperosmolar hyperglycaemic state
happens in type 2
presents with polydipsia, polyuria, dry, shock, acute cos impairment
hyperglycaemia, hyper serum osmolality, volume depletion
NO KETOACIDOSIS
treatment for HHS
IV fluids with potassium replacement
insulin
thromboprophylaxis
treatment for alzheimers
anticholinesterase inhibitors: donepezil, rivastigamine, galantamine
memantine (NMDA antagonist) in late stage
antipsychotics
what medications for incontinence should you avoid in eldery
tolterodine and oxybutin
use mirabegron
management for parkinsons
avoid levodopa as long as possible
DA ropinirole and pramipexole
antichoingerics in young, MAO-B inhibitors (-giline)
levodopa- given as co-beneldopa or co-careldopa to prevent nause and vomiting
what are the signs of spinal cord compression
pain: in spine, worse on straining, radicular (band like burning e.g. around rib cage, precedes weakness)
weakness: bi or unilateral
altered sensation: proprioception, light tough
urinary problems: retention
bowel problems: constipation
Ix for Spinal cord compression
urgent MRI of spine
Treatment for spinal cord compression
16mg IV dexamethaxone, followed by 8mg po bd (to reduce vasogenic oedema)
radiotherapy mainstay of tx
surgery if appropriate
chemo
if you suspect spinal cord compression what should you do
arrange urgent MRI and start dexamethasone 8mg bd
radicular pain= ?
cord compression
symptoms of superior vena cava obstruction
swelling of face, neck, one or both arms distended veins SOB HA lethargy late- injected conjunctiva, sedation
Ix for SVC obstruction
cxr- is there a mass/ foreign body
venogram- is there a clot
CT chest
treatment for SVC obstruction
clot- thrombolysis with alteplase, anticoagulation (LMWH, warfarin)
extrinsic compression- steroids, chemo, radio, stent
what side of lung tumour causes SVC obstruction
right
what can cause hypercalcaemia in cancer pt
humoural (PTHrP)
bone destruction
tumour production of vit D (lymphomas)
symptoms of hypercalcaemia
nausea, anorexia thirsty polydipsia, polyuria constipated confused poor concentration, drowsy
Ix for hypercalcaemia
U+Es to look for dehydration
phosphate (low in hyperparathryoidism)
if no known malignancy myeloma screen
ts for hypercalcaemia
rehydrate first - several L of saline
bisphosphonates (pamidronate after rehydrated)
symptoms + signs of cardiac tamponade
SOB
fatigue, palpitations, pericarditis (chest pain improved by sitting forward), symptoms of advanced cancer
JVP distention, pulsus paradoxus (fall in pressure during inspiration), soft heart sounds/ pericardial rub, tachycardia with low BP
IX for tamponade
CXR
ECG
echo (rim of pericardial fluid)
cytology of fluid
tx for tamponade
pericadiocentesis
pericardial window
does perciardial tamponade cause systolic or diastolic heart failure
diastolic
what is neutropenic sepsis
sepsis in a patient with a neutrophil count less than 0.5 or <1 in cancer patients or who have had chemo in the last 21 days
tx for neutropenic sepsis
antibiotics within 1 hr of admission
give immediately before septic screen/ blood tests
what is CO2 like in a PE
low (blowing it off with tachypnoea)
Ix for Pe
CTPA ABGs O2 sats ECG bloods
tx for PE in malignancy
LWMH for 6 months
consider rivaroaban if recurrent DVTs/PE
what is 8/500 co-codamol
8mg codeine with 500 mg paracetamol
100mg of codeine = ? morphine
10
morphine is 10 times as strong as codeine
what is the pain ladder
mild- paracetamol
mod- co-codamol 30/500, dihydrocodeine, tramadol
severe- morphine, diamorphine, oxycodone, hydromorphine, methadone
adjuvants: NSAIDs, TCAs, anticonvulsants. steroids, anxiolytics, muscle relaxants, antimuscarinics
what should you prescribe with opioid
anti-emetic and laxative
what drugs can be used as muscle relaxants
diazepam, baclofen
what drugs can be used as antimuscarinics (for colicky pain)
hyoscine butylbromide
how do you convert oral tramadol dose to oral morphine dose
divide tramadol dose by 10
how do you convert oral morphine to SC diamorphine
divide by 3
what are the anticipatory care medications
Opioid for pain and/or breathlessness: morphine 2mg SC
anxiolytic or sedative for anxiety, agitation or breathlessness: midazolam 2mg sc
anti-secretory medications for resp secretions: hyoscine butylbromide 20mg sc
anti-emetic for n+v: levomepromazine 2.5-5mg sc
what are the dexa results meaning
t scores
1- -1 normal
-1 to -2.5 osteopenia
-2.5 or less osteoporosis
talk me through the bone protection guidelines girly xx
calculate Qfracture/frax score (10 year risk of fragility fracture) for all high risk (>65 women, >75 men, RFs)
if score 10% or more do DEXA
if -1 to -2.5 modify risk factors
if less than -2,5 bone protection (once weeklr bisphosphonate)
consider bone protection in those taking steroids
offer HRT to young post menopausal women
rank these from least to most potent:
methyl pred, betamethason, hyrocortisone, cortisone, prednisolone, dexamethasone
cortisone, hydrocortisone, methyl pred, pred, dex
what drug first line for delirium
haloperidol
benzos if have PD
what can be used to treat acute pulmonary oedema
high flow oxygen
IV furosemide
IV diamorphine (vasodiltor, reduces CO)
digoxin
what is a modified release preparation
12 hourly tablets
who should adenosine not be given to
asthmatics
what are the signs of brugada syndrome on ECG
st change - coved/ saddle
which brain bleed has a period of lucidity
extradural lemon shaped (lens shaped), MMA, associated with skull fractures, young men, LOC following lucidity after injury
who gets subdural haematomas
old people on blood thinners, slow decline in cognition
what is laryngomalacia
congenital cause of stridor in infants
resolves usually by 12-24 months
what are the features of epiglottitis
dsypnoea, dysphagia, drooling, dysphonia (muffled voice)
stridor is a late sign
tripod position
distinguished from retropharyngeal abscess by xray
what is seen on cray in croup
steeple sign of subglottis
what is quinsy
peritonsilar abscess
what occurs sooner physiological or breast feeding jaundice
physiological- after 24 hours
breast feeding- usually in 2-3 weeks, can be in first
in sufficient intake- first week not getting enough calories
what are the alarm symptoms of dyspepsia
anaemia loss of wight anorexia recent progression malaena/ haematemesis swallowing difficulties (dysphagia) (think malignancy)
how does phenytoin affect COCP
induces liver enzymes, reduces efficacy of CoCP
what are the features of osteomalacia
bony pain
vit d and calcium def (calcium can be normal)
high PTH
what is the most important step in HHS
IV fluids first
insulin when rehydrated
what contraception for dysmenorrhoea
COCP
what causes CNIII palsies
intracranial anuerisms, diabetes and extradural haematomas
difference between somatosism and conversion disorder
Conversion disorder is characterised by voluntary motor or sensory function deficits that suggest neurological or medical conditions but are rather associated with clinical findings that are not compatible with such conditions. Somatic symptom disorder is characterised by one or more somatic symptoms that are distressing or result in significant disruption of daily life.
tender mass in RIF- UC or crohns
crohns
how do you tell the difference between an indirect and a direct inguinal hernia
indirect goes down towards scrotum
direct above pubic tubercle
indirect can be controlled by pressure at the internal ring (halfway between pubic tubercle and ASIS)
what type of incontinence does oxybutin help with
OAB
what type of incontinence does duloxetine help with
stress
treatment for STEMI
300 mg aspirin - continue indefinitely unless CI
presenting in 12 hours: reperfusion therapy (PCI or fibrinolysis)
-PCI available in 120 mins: prasugrel if not on AC, clopidogrel if on anti coagulant, if >75 and high bleeding risk offer tricagrelor or clopidogrel instead of prasugrel
- PCI not available in 120 mins: fibrinolysis= alteplase, streptokinase, antithrombin (fondaparinux) at same time, ECG 60-90 mins after fibrinolysis, give tricagrelor (or clopidorgrel if high bleeding risk)
medical management:
-tricagrelor or clopidogrel if high bleeding risk
treatment for NSTEMI/ unstable angina
300mg aspirin and continue indefinitely
antithrombin (fondaparinux) unless high bleeding risk or immediate angiography
calculate grace score (6 month mortality), ECG, troponin I/ T
intermediate or high risk (>3%): if unstable offer immediate angiography +/- PCI, if stable offer in 72 hours
give prasugrel with aspirin (or clopidogrel if on AC), give unfractionated heparin if getting PCI
low risk: <3%
(young people may still benefit from PCI)
tricagrelor (or clopigrel if high bleeding risk)
what drugs used for secondary prevention following an MI
ACEi (arb if intolerant) indefinitely dual antiplatelet (aspirin + another e.g. clopidogrel) for 12 months beta blockers 12 months/ indefinitely if LVEF reduced statin (atorvastatin 80mg)
if LVEF reduced start aldosterone antagonist 3-14 days after MI
what lifestyle changes for secondary prevention following an MI
exercise, stress, Mediterranean diet, alcohol, smoking
cant drive with unstable angina
stop driving for a week after PCI
when should a statin be started for primary prevention
in those with a QRISK2 score >10%, CKD, T1DM, >85 who smoke/ HPTN, severe obesity
(atorvastatin 20mg)
management of AF
if unstable DC cardioversion (+ amiodarone if unsuccessful)
heparin for anticoagulation in the acute setting
treat underlying cause: HPTN, valvular disease, HF, IHD, infection, cancer, alcohol, hyperthyroid, electrolytes
if <48 hrs: rate (BB, RL CCB (verapamil/ diltiazem), digoxin if sedentary)/ rhythm (cardioversion, flecainide, amiodarone)
if >48 hours: rate control, need to be anticoagulated for 3 weeks before rhythm control
assess CHA2DS2VASc score (stroke risk) and ORBIT bleeding risk
anticoagulation if CV score 2 or more, 1 if man: apixaban, dabigatran, rivaroxaban (if DOAC CI warfarin) (do not offer anticoagulation to those <65 with 0 (men) or 1 (women) CHV score)
rate control: beta blocker or diltiazem/ verapamil or digoxin if sedentary
(do not offer amiodarone long term)
rhythm control if rate control unsuccessful: flecainide, amiodarone, electrical cardioversion, ablation
amiodarone not flecainide if ischaemic or structural HD
what can you not prescribe verapamil and ditiazem with
alpha blockers, ACEis, arbs, antipyschotics, amiodarone, beta blockers, digoxin, NSAIDS LOADS
how is heart failure diagnosed
HX, exam, ECG, NT-proBNP, if high echo (>2000 in 2 weeks, 400-2000 in 6 weeks)
management for chronic HF
diuretics- mineralocorticoid receptor antagonist (spironolactone) if reduced ejection fraction: -ACEi (or ARB) (if intolerant to both hydralazine and nitrate) -BB if still symptoms: -sacubitril if EF <35% or -ivabridine sinus rhythm EF<35% or -hydralazine and nitrate or -digoxin
treatment for stable angina
GTN (2nd dose after 5 mins, ambulance 5 mins after 2nd dose)
BB/ CCB (combo of two if not helped- must be -dipine ones (dihydropyridine))
if not helping: long acting nitrate (isosorbide), ivabradine, nicorandil
if still not helping referral for revascularisation surgery (CBG)
consider aspirin 75 mg
consider ACEi
Statin
what should you do for people with BPs in clinic between 140/90- 179/119
ABPM
if 135/85-149/94 : lifestyle advice + tx if >80 or CVD/ organ damage/ high CVD risk (>10%)
150/95 lifestyle + tx
what should you so for people with BP in clinic of 180/120
refer same day if papilloedema/ life threatening symptoms or suspected pheochromocytoma
anti hypertensives immediately
what are the BP targets
<80 140/90 clinic 135/95 ABPM
>/= 80 150/90 clinic 145/95 ABPM
what is the tx pathway for HPTN
hypertension with type two diabetes or <55: ACEi/ ARB -> A + CCB or thiazide (indapamide) -> A + C + T
>55 or black african or african-caribean : CCB + C + A/T -> C + A + T
resistant: spironolactone if potassium <4.5
alpha (sin) or beta blocker if >4.5
what bugs usually cause infective endocarditis
commonest- staph aureus: amox + gent / fluclox if sepsis
prosthetic valve/ abnormal valves/ IVDU- staph epidermidis: vancomycin and gent
dental- viridans ( beta lactam (penicillin, cephalosporins) +/- gent, vancomycin
what is S1
closure of mitral and tricuspid valves
start of systole, pulse felt at same time
what is S2
closure of aortic and pulmonary valves
start of diastole
what causes a split S2
inspiration, pulmonary stenosis
what grade of murmer has a thrill
4-6
Murmur: ejection systolic, crescendo decrescendo, radiates to carotids, loudest on expiration when patient sitting forward, slow rising pulse
AS
most common cause calcification, bicuspid valve, rheumatic heart disease
Murmur: pansystolic, radiating to axilla, loudest on expiration lying on left side
MR
Ax- IE, MI, rheumatic HD
murmur: early diastolic, crescendo decrescendo, left sternal border 3/4th ICS
AR
bicuspid valve, RHD, IE, aortic dissection
collapsing pulse
AR
murmur: mid diastolic, rumbling, opening click, low volume pulse, heard loudest over…
MS
congenital
… apex
mid systolic click, late systolic murmur
mitral prolapse
pan systolic murmur over left 4th ICS
tricuspid regurg
what sided murmurs are loudest on inspiration
right- tricupsid regurg, pulmonary stenosis
soft diastolic murmur, loudest at 3/4th ICS at left sternal edge, loudest on inspiration
TS
ejection systolic, loudest on inspiration, a waves
pulmonary stenosis
does smoking make UC or crohns worse
crohns
treatment for crohns
inducing remission:
- monotherapy if 1 epsiode in 12 months: steroid/ budesonide (sulfsalazine or mesalazine (5-ASA) - less effective)
- add azathioprine if 2 or more episodes (or methotrexate if CI)
-infliximab/ adalimumab if severe
maintenance:
-azathioprine/ metacaptopurine monptherapy
-methotrexate
treatment of UC
inducing remission: mild mod (max 6 stools a day, no pyrexia, pulse <90, no anaemia, ESR<30)- topical (proctitis/ proctosiggmoiditis/ left sided UC)/ oral aminosysalicylate (5-ASA/ sulfasalazine) (or both) -steroid short term -biologics severe acute: -Iv steroids/ ciclosporin/ surgery (if no improvement at 72 hours or worsening symptoms: stools >8x/day, pyrexia, tachycardia, colonic dilatation, abnormal bloods) maintaining remission: -topical/ oral aminosalicylate (5-ASA) -azathioprine
where does UC affect
distal to ileocecal valve (end of large intestine)
left sided UC common
who should you test for H pylori
uncontrolled dyspepsia with no alarm symptoms (no response to lifestyle changes, antacids, one month course of PPI)
patients at high risk, previous ulcer/bleed, unexplained IDA after endoscopy exclude malignancy
what tests for h pylori
urea 13c breath test
stool helicobacter antigen test
(not within 2 weeks of ppi and 4 weeks of abx)
treatment for H pylori
triple therapy: PPI and 2 abx (consider previous ones tried)
1st line: amoxicillin + clarithromycin/ metronidazole (depending on previous use) for 7 days
if that doesn’t work try the other one for another 7 days
if penicillin allergic
- PPI + clarithromycin + metronidazole
tx for dyspepsia
weight loss, eating (alcohol, coffee, chocolate, fatty foods), smoking
- PPI for 4 weeks, h pylori test if this doesnt help
- endoscopy if alarm symptoms/ GI bleed
- offer H2RA if still inadequate response (-tidines)
what drugs can cause dyspepsia
calcium antagonists, nitrates, theophyllines, bisphosphonates, cortitosteroids, NSAIDs
what are the alarm symptoms
nice 2 weeks:
dysphagia
>55+ weight loss with: upper abdo pain/reflux/ dyspepsia
anaemia loss of weight anorexia recent progression malaena/haematemesis swallowing difficulties
what laxatives for diverticulosis
bulk forming (high fibre diet, lots of water)
when should you suspect diverticular disease
(diverticulosis asymptomatic)
DD- intermittent abdo pain in left lower quadrant with constipation, diarrhoea and occasional large rectal bleeds
-pain triggered by eating and relieved by passage of stool/ flatus
what are the symptoms of acute diverticulitis
constant abdo pain, severe and localising to left lower quadrant with:
fever
or
sudden change in bowel habit and significant rectal bleeding/ mucus
or
Tender LLQ, Hx of DD
complicated if:
- mass palpable- abscess
- adbo rigidity and guarding- perforation
- signs of sepsis
- signs of fistula
- signs of obstruction
Ix for acute complicated diverticulitis
if inflam markers raised contrast CT within 24 hours
