Chronic Long Term Conditions

Question 1

CKD Management-

Answer 1

Treat anti-hypertension (>2drugs), 1st line is ACEi then furosemide.
Treat proteinuria- ACEi.
Optimise diabetes control
Primary CVD prevention.
Immunise against flu and pneumococcal.
Lifestyle advice.
Advice against OTC NSAIDs.

Question 2

CKD Anaemia-

Answer 2

Anaemia due to- Decreased erythropoietin, uraemia decreased erythropoiesis at BM, decreased iron absorption, decreased RBC survival due to dialysis. Check iron status first then give EPO.

Question 3

CKD- MBD

Answer 3

Kidneys usually activate Vit-D, therefore low Vit D.
Kidneys usually excrete PO4 therefore high PO4.
PO4 will sequester Ca2+ from bone therefore low Ca.

Manage with Vit-D (calcitriol), PO4 binders, reduce oral PO4.

Question 4

Hyperlipidaemia-

Answer 4

Suspect if cholesterol>7.5mM and personal FHx of early CVD death. One parent affected then test children at 10yrs old, if two then at 5yrs old.
Manage with high dose statins to reduce cholesterol by 50%.

Question 5

Statins-

Answer 5

20mg for 84yrs< + QRISK2>10%, T2DM >10yrs or age 40, CKD, FHx.
80mg for secondary prevention.
SE- Headaches, GI disturbance, muscle aches (RM).
Take in evening since short half life and cholesterol synthesised in the morning.
Before starting check baseline lipids, LFTs- since can raise with statins, renal function, HbA1c, creatine kinase, TSH.
If not tolerated give with ezetimibe.
Review annually.

Question 6

COPD-

Answer 6

Pulmonary HTN- Hypoxia due to airway narrowing-> increase pulmonary vasoconstriction and SM thickening->P-HTN.

CXR signs- Hyperinflation of the lungs (flattened diaphragm), floating heart (can see inferior border), large bullae (dark areas), consolidation (infection).

Secondary PCV- Poor kidney perfusion secondary to hypoxia-> increase EPO.
ECG- RA and RVH due to P-HTN, also maybe RBBB.
Exacerbation DDX- PE, Pul oedema, Pneumonia.

Question 7

COPD Management-

Answer 7

Smoking cessation

1) SAMA/SABA
2) LABA + LAMA (change SAMA to SABA)
2) LABA + ICS (if asthma features or steroid responsive)
3) LABA + LAMA+ ICS
4) Oral theophylline

Additional-
If sputum cough- mucolytic i.e. carbocisteine
If cor pulmonale- furosemide
LTOT (ensure non smokers)
Annual flu and one of pneumococcal vaccine
Pulmonary Rehab

Question 8

Asthma-

Answer 8

Mucus hypersecretion, SM thickening.
RF- Maternal smoking inc after birth, LMBW, atopy Hx, air pollution, FHx etc.
Before stepping up/down check adherence, technique and elimination of triggers.
Management is to ensure elimination/control of symptoms.

Question 9

Asthma Management-

Answer 9

Normal step up/step down.

Reliever-Blue-SABA-Salbutamol
Preventer-Brown-ICS-Beclometasone, fluticasone, budenoside.
LABA- Salmeterol/Formoterol- Only prescribe with ICS otherwise asthma related death.
Chewed tablet-LTRA-Montelukast (dampens inflammatory cascade)
MART- Maintenance and reliever- LABA + ICS.

Question 10

Acute Asthma Management-

Answer 10

1) O2- reach 94-98%
2) Nebulised salbutamol
3) Oral prednisolone 50mg daily for at least 5 days. If no oral access then IV hydrocortisone 100mg 6hrly until can convert to oral pred.
4) Ipratropium bromide
5) Single dose IV Mg SO4
6) Supportive care of fluids, electrolytes.
May need ITU referral.
Discharge if PEFR>75%, stable on discharge meds for 12-24hrs, correct inhaler technique.

Question 11

Stable Angina Management-

Answer 11

GTN spray
CCB/BB. Start with one then add other as dual therapy.
Add isosorbide mononitrate (second line)

Secondary prevention with dual antiplatelet aspirin + clopidogrel, statin, BB, ACEi.

Question 12

HF Management-

Answer 12

Loop diuretics for symptomatic relief.
BB/ACEi. Start one then add the other as dual therapy.
Then consider adding spironolactone- monitor K+.
Then specialists.

Consider Antiplatelets and statins. Lifestyle modifications, 5yrly pneumococcal vaccine, annual flu vaccine, supervised exercise rehab programme, depression screen etc.
Ensure every 6 months to check eGFR and U+Es.

Question 13

AF-

Answer 13

RF- Obesity, IHD, HF, HTN, DM, smoking, pneumonia, thyrotoxicosis, alcohol, CKD, male, age, FHx.
Complications- Stroke, tachycardia, mesenteric ischaemia, acute limb ischaemia.

Question 14

AF Management-

Answer 14

1) Rate/Rhythm control
2) Anti-coagulation

Rate control with BB, NDHP CCB, digoxin (if previous don’t work)
Rhythm control with DC cardioversion <48hrs presentation (with heparin), otherwise 3wks of AC first. Or with amiodarone, flecainide (if no structural heart disease). Only rhythm control if either first presentation, <65yrs, symptomatic.

Follow up 1 week within rate control. If symptoms not improved in 4wks then refer to cardiology.