Week 18- GP

Question 1

Procainamide

Answer 1

Antirrythmic sodium channel blocker. Dont use with complete heart block, myasthenia gravis nor K+ changes. Most common side effects are nausea, D+V, bitter taste, flushing, rash. Has been used for ventricular tachycardia.

Question 2

Theophylline

Answer 2

Bronchodialator for COPD and asthma, not a steroid. Orally given. Now prefer inhaled ones, can cause D+V, arrhythmia and CNS excitation. Other bronchodialators singulair, albuterol, montelukast, ventoline. Its toxicity is increased by erythromycin, cimetidine, ciprofloxcin/fluoroquinolone. X use with fluvoxamine SSRI nor beta blockers.

Question 3

Quinidine

Answer 3

For Afib and flutter, antiarrhythmic. Nausea, D+V, heartburn, fever and dizzy, incs risk of ventricular arrythmia.

Question 4

Cor pulmonale

Answer 4

Describes impairment in right ventricular function as a result of respiratory disease, inc pulmonary resistance over > 20mmhg, if > 40 -> complete right ventricular failure. Its thought chronic hypoxia leads to pulmonary arteriolar constriction via acts to maintain v/q. Also pulmonary fibrosis, or acutely from causes of pulmonary HTN, usually pul embolism.

Question 5

Symptoms cor pulmonale

Answer 5

Worsening tachynoea and at rest, lassitude, ankle swelling, worsening dyspnoea with deterioration in exercise tolerance. Angina pain x responding to nitrates, haemoptysis, hyper expanded chest, intercostal recession, crackles/wheeze, systolic bruits over lung fields, left parasternal heave (indicates right ventricular hypertrophy) 3-4th heart sounds and pansystolic murmur of tricuspid regurgitation (indicates systolic ejection murmur with click over PA). Hepatomegaly.

Question 6

Causes of cor pulmonale

Answer 6

COPD, myasthenia gravis, motor neurone disease, kyphoscoliosis, neonatal pulmonary disease and the lead to bronchopulmonary dysplasia.

Question 7

Management of cor pulmonale

Answer 7

Long term oxygen therapy + diuretics like furoside or bumetanide- risk hypokalemia metabolic alkalosis. Can also use methylxanthine bronchodialators. Indicated therapy comes when paO2 < 55mmHg or SaO2 < 88%. Oxygen therapy can be at night too with risk of combustion with smokers near gas cylinders.

Question 8

Alpha- 1 antitrypsin deficiency and symptoms

Answer 8

A1AT produced by hepatocytes is missing with mutation in SERPINA1 so disrupts production of elastin. Onset of lung symptoms at 20-50 and liver issues from birth.

Symptoms sob, wheezing, jaundice, emphysema/copd young, sputum production. Risk of cirrhosis. Also associated with vasculitis, psoriasis, bronchietasis, asthma, aneurysms, arterial fibromuscular dysplasia associated with necrotising panniculitis . Normal A1AT 1-2.7 g/L. Can be 40-60% higher 1.4-4.8 G/L.

Question 9

Alpha 1 antitrypsin deficiency management

Answer 9

Recombinant a1at augmentation and copd-like management.
Short acting Beta agonists saba eg salbutamol and terbutaline or a short acting antimuscarinic eg ipatropium firstline if breathless or reduced exercise capacity.

If not enough, add long acting versions laba eg formoterol, salmoterol and indaccaterol, olodaterol or vilanterol. Or give lama eg . Sfter that, combine saba, sama, laba, lama.

After, still bad then switch to theophylline with saba or laba and sama or lama. Watch out for macrolides with theophylline.

If asthmatic symptoms (having asthma or atopy, eosinophilia, change in fev1 over 400ml or variation of pefr over 20%)- laba and inhaled corticosteroid eg fluticasone, budesonide, beclometasone.

If x solve asthmatic symptoms, fev1 less than 50 or 2+ attacks in a year then try roflumilast.

Oxygen therapy

Question 10

O2 therapy for A1AT deficiency

Answer 10

O2 should be for 15+ hours per day, cyanosis, polycythemia vera, pul htn, peripheral oedema, raised jvp, O2 sat 92% or less on air, fev1 less than 30% ( consider up to 40) or when stable, paO2 is less than 7.3kpa.

Inappropriate use can give respiratory depression, hypercapnic metabolic acidosis

Question 11

Asthma guidelines for diagnosis

Answer 11

Ask about wheeze, cough, breathlessness, triggers, seasonal change, personal or family history of atopy. Spirometry and reverse test. Over 17 diagnose with feno more or at 35ppb then pefr if uncertain. Can also use direct bronchial challenge with histamine ir methacholine. If spirometry, fev1/fvc less than 70% is pos. in reversibility, change of 12% or more with inc vol 200ml minimumis positive.

Question 12

Asthma treatment guidelines

Answer 12

Saba, then if symptoms are over 3 weeks, saba is not enough or waking at night add ICS. Then LRTA with review 4-8 weeks later. Then instead give ICS ( fluticasone, budesonide, beclometasone) and LABA (formoterol, salmeterol,olodaterol, vilanterol) , then mart regimen, then theophylline.

If -5yrs 8 week trial ICS, if returns within 4 weeks following, continue ICS as firstline. Next add LTRA, then next is to stop and refer.

Question 13

Antibiotics per region

Answer 13

Lungs- amoxicillin, doxicycline
Skin- flucloxacillin
Bladder- trimethoprim or nitrofurantoin
Kidneys- ciprofloxacin, levofloxacin, sulfamethoxazole+trimethoprim combo
GI- Amoxicillin, piptaz, ampicillin, ceftriaxone, ceftazidime, imipenem, meropenem

Question 14

Cholestyramine

Answer 14

Bile sequestrant and cholesterol regulator. Side effects include chronic constipation;
a thyroid disorder;
diabetes;
kidney disease;
liver disease; or
coronary artery disease

Question 15

Diabetic vagal neuropathy

Answer 15

Autonomic neurpathy- Loose bowel movements (diarrhea)
Hard bowel movements (constipation)
Feeling less hungry or full after only a few bites of food.
Nausea.
Throwing up undigested food.
Trouble swallowing.
Heartburn.

Question 16

Bowens disease

Answer 16

A very early form of skin cancer that’s easily treatable. The main sign is a red, scaly patch on the skin. It affects the squamous cells, which are in the outermost layer of skin, and is sometimes referred to as squamous cell carcinoma in situ. On the anterior tibia, finger, face. Itchy, oozing, bleeding, tender. Can look like AK if early on or pale.

Question 17

Mirtazapine

Answer 17

Atypical antidepressant as alpha2 adrenoreceptor antagonist. Side effects = drowsiness, dizziness, anxiety, confusion, weight gain, dry mouth, constipation. Its the choice for major depressive disorder.

Question 18

Chondrodermatitis nodularis helicis

Answer 18

Affects skin of the ear, commonly the helix. Inflammatory, benign, painful. Sudden onset, painful bump on the ear. Affects the cartilage and overlying skin, may or may not have a scab.

Question 19

Prurigo nodularis

Answer 19

Arms or legs get pruritic papules and nodules, excoriation from stratching. Often symmetrical firm nodules. May first appear in the hair follicles, itching occurs later. The excoriated lesions are flat, umbilicated and can have a crusted top. Can become scarred and thickened.

Prednisone or azathioprine is given. Can also give thalidomide, UVB, cryosurgery.

Question 20

Betnovate

Answer 20

Topical corticosteroid for itchy eczema, psoriasis and dermatitis.

Question 21

Lentigo

Answer 21

Dark dot on skin thats melanocyte hyperplasia over the epidermal basement membrane. More melanocytes, not more melanin produced (freckles)

Question 22

Pigmentary dispersion syndrome

Answer 22

When pigment rubs off the back of the iris, then floats to other parts of the eye and blocks drainage that gives raised intraoccular pressure.

Question 23

Glaucoma

Answer 23

Open angle = slow onset, painless, peripheral vision loss or central. Closed angle glaucoma can present gradual or suddenly. Sudden - eye pain, blurred vision, mid dialated pupil, red eyes, nausea, vision loss from glaucoma.

Question 24

Ocular HTN

Answer 24

Any raised intraoccular pressure that gives halos, blurred vision, pain. Can lead to Glaucoma.

Question 25

Latanoprost

Answer 25

An eyedrop for open angke glaucoma and ocular HTN. Prostaglandin F2 alpha antagonist.

Question 26

Bence jones proteins

Answer 26

Indication for multiple myeloma

Question 27

Metoclopramide

Answer 27

D2/ 5HT3 receptor antagonist for nausea, migrane, gastroparesis and Gord. Stimulates prolactin release.

Question 28

Sever’s disease

Answer 28

Swelling and irritation of growth plate in the heel. Has achilles strain. Its the most common cause of heel pain in growing children and youths. Give nsaids or naproxen.

Question 29

Chlorphenamine

Answer 29

Antihistamine

Question 30

Chloramphenicol

Answer 30

Antibiotic for conjunctivitis, meningitis, cholera and typhoid.

Question 31

Capsaicin

Answer 31

Releives neuralgia, RH, muscle strain or sprains.

Question 32

Von hippel lindau syndrome

Answer 32

Autosomal dominant genetic condition from delection or mutation in the VHL gene. Onset age is 26 or over. 95% are symptomatic by 65. A lot are de novo.

May experience tumours and/or cysts in the brain, spine, eyes, kidneys, pancreas, adrenal glands, inner ears, reproductive tract, liver and lungs.

Hemangioblastoma symptoms include headaches, ataxia, nystagmus, back pain, numbness, hiccups.

Retinal hemangioblastoma- floaters, retinal detatchment.

Endolymphatic sac tumour- hearing loss, tinnitus, vertigo.

Pancreatic cysts/tumours, pancreatitis, diabetes. Pheochromocytoma, paraganglioma htn. Kidney cysts/carcinoma often bilateral. Cystadenomas- pai; with rupture, haemorrhage and torsion.

Often the condition is benign, however.

Beleutifan is approved to treat.

Question 33

Takoyasu Arteritis

Answer 33

Arteritus affecting young, asian and female most. Inflammation of aorta, branches and PA = arterial stenosis, occlusion, dilation or aneurysms.

Asymmetric pulses and bp per limbs. Limb claudication, dec cerebral perfusion, visual disturbance, TIA, stroke, fever, night sweats, weight loss, arthalgia, repetitive and sustained movement is fatigued.

Stenosis from subclav to vertebral art = pca neuro symptoms or syncope when arm is used (subclavian steal syndrome)

Retrograde flow and vasodialation of upper limbs and descending aorta = signs of aortic coarctation, htn, headache, leg claudication.

Prednisone 1mg/kg/day 1-3months

Question 34

Miliaria

Answer 34

Heat rash (rubra), immature neonatal sweat ducts, humidity, exercise, fever, skin occlusion, hospitalised patients with waterproof sheets. Crystalina > profunda > rubra by depth of glands.

Question 35

Chronic spontaneous urticaria +/- angioedema CSUA

Answer 35

Itchy red weals rash with large swelling. Chronic urticaria = weals present for 6+ weeks. No external stimuli.

If skin lesions last over 24hrs, leave bruising or have systemic symptoms, urticarial vasculitis should be confirmed or eliminated with skin biopsy.

Cutaneous mastocytosis indicated if rash x settle. Treats with second gen antihistamines = loratadine, fexofenadine ( least pervasive to bbb), cetirizine.

X use H1 eg hydroxyzine nor diphenhydramine.

Question 36

Occupational dermatitis

Answer 36

Contact dermatitis from irritants or allergies in beauty therapy, food industry, healthcare, lab work, agriculture, cleaning, decorating, motor repair, construction.

Dry flaking skin with fissuring, erythematous, swollen, blistering, weeping, eroded. Risk of impetigo- presents as red, painful, swollen skin with ulceration sometimes.

Question 37

Peripheral arterial disease

Answer 37

peripheral arterial disease/peripheral vascular disease = narrowing of arteries, mainly in the legs and can be due to atheroma plaque. Main symptoms is pain in the legs on walking. Pain, aching, cramping = intermittent claudication. Most commonly affected vessel = femoral artery. If iliac artery or aorta might develop pain in the thighs and rear when walking.

Extra signs= poor hair growth below the knee, poor toenail growth, cold feet, weak or absent pulses. Severe = pain at rest, ulcers on feet/legs, gangrene.

Test with bp in ankle vs arm- ankle brachial pressure index. Clopidogrel is usually given to prevent thrombosis or aspirin. A statin also to stop worsening atheromas.

Question 38

Angelman syndrome

Answer 38

Marked by severe developmental delay, learning disabilities, poor speech, ataxia, jerking, smiling and unprovoked laughter. Altered UBE3A.

Question 39

Prader willi syndrome

Answer 39

Chr 15 lost activity. Babies show failure to thrive, children are constantly hungry from 2-8 years onset leading to obesity and T2 diabetes. Medium learning difficulties and behavioural difficulties.

Characteristic small hands/feet, short, infertile, strabismus, flexible, skin picking and anxiety. In utero mutation. Can give growth hormone therapy.

Question 40

Pregabalin

Answer 40

For epilepsy, anxiety, neuropathic pain, fibromyalgia, restless leg. An anticonvulsant and anxiolytic. Risk of allergic reaction. Dizzy/drowsy, peripheral oedema, appetite, dry mouth. Respiratory depression if used with pioglitazone, rosiglitazone or ACE inhibitor.