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302 > Case of the GP under Pressure > Flashcards

Case of the GP under Pressure Flashcards

1
Q

high blood pressure affects people in UK?

A

1 in 4

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2
Q

hypertension is?

A

3 rd biggest risk factor

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3
Q

every 10mmHg reduction in BP reduces?

A

CAd- 17%
Stroke- 27%
HF-28%
all cause mortality- 13%

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4
Q

Blood pressure equation

A

BP=CO x PR

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5
Q

cardiac output equation?

A

CO= HR x SV

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6
Q

pathogenesis of HTN?

A

increased sympathetic tone
increased peripheral vascular resistance
RAAS activation
Increased cardiac output

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7
Q

causes of HTN?

A

primary-90%
secondary- 10% underlying disease
younger patients, hypertensive crises, abnormal blood results, signs and symptoms

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8
Q

Causes of HTN?

A

PKD, glomerulonephritis, renal artery stenosis
High aldosterone, cushings, phaechromocytoma, hypo/hyperthyroidism, hyperparathyroidism, acromegaly

Steroids, COCP, NSAIDs, cocaine, antidepressant, EPO,

obstructive sleep apnoea

pregnancy

congenital-coarction of the aorta

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9
Q

risk factors of HTN?

A

male, age, FH, ethnicity (south asian, black african), smoke, high lipids, diabetes, socioeconomic status

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10
Q

RAAS?

A

Renin from juxtaglomerular apparatus released and will act on angiontensinogen released from liver. this will produce angiotensun 1, which is converted angiotensin II by ACE enzyme.

angiotensin II increases sympathetic activity, aldosterone secretion, tubular Na/Cl absorption and K excretion, H20 retention, arteriolar vasoconstriction, ADH secretion-H2O reabsorption

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11
Q

hyperaldosteronism?

A

low plasma renin
40%- Conns
bilateral adrenal hyperplasia- 60%

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12
Q

key investigation for hyperaldosteronism?

A

high plasma aldosterone/ renin ratio

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13
Q

pH in hyperaldosteronism?

A

metabolic alkalosis

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14
Q

how to check for what type of hyperaldosteronism?

A

CT/MRI adrenals

Adrenal vein sampling- lesion is functional

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15
Q

how to treat hyperaldosteronism?

A

laparoscopic adrenalectomy

radiofrequency ablation

mineralocorticoid receptor antagonist- spironolactone/eplerinone

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16
Q

causes of hyperaldosteronism with high plasma renin?

A

secondary hyperaldosteronism- kidneys detect low kidney blood flow

renal artery stenosis

coarction of the aorta

reninoma
hereditary disorders

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17
Q

diagnosis of high plasma renin hyperaldosteronism?

A

HTN
low plasma aldosterone: renin ratio
high creatinine
MR renal angiogram
CT renal angiogram/ renal dopplers

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18
Q

gold standard of high renin aldosterinism?

A

renal angiogram

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19
Q

10% of renal artery stenosis?

A

fibromuscular dysplasia- beading

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20
Q

treatment high renin hyperaldosteronism?

A

medical- control BP
renal angioplasty
stent insertion
surgical repaire

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21
Q

ateriosclerosis?

A

blood vessels become thicker

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22
Q

atherosclerosis?

A

inflammatory process and high cholesterol leading to plaque, which could narrow the artery

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23
Q

how to diagnose target organ damage?

A

fundoscopy for retinopathy
ECG- LVH, AF
Urinalysis- proteinuria
Bloods- U/Es

24
Q

acute target organ damage due to hypertensive crisis?

A

eyes- retinal haemorrhage/ papilloedema
brain-encephalopathy, stroke
heart- pulmonary oedema, MI
Kidneys- AKI
aortic dissection
pre-eclampsia

25
Q

causes of secondary hypertension CHAPS?

A

Cushings
Hyperaldosteronism
Aortic Coarctation
Pheochromocytoma
Stenosis of renal arteries

26
Q

phaechromocytoma?

A

adrenal medullary tumour that secretes excess catecholamines from chromaffin cells

27
Q

paraganglioma?

A

neuroendocrine tumours that arise from sympathetic and parasympathetic ganglia

28
Q

common signs and symmptoms of phaechromocytoma/paraganglioma?

A

headache
sweating
high blood pressure
tachycardia
anxiety
palpitation
abdominal pain
dizziness
blurry vision
diabetes symptoms
Heart failure

29
Q

phaechromocytoma affects

A

0.01 to 0.1%

30
Q

investigate phaechromocytoma if?

A

signs/ symptoms
severe HTN, HTN crisis
refractory HTN>3 drugs
HTN at young age
adrenal lesion
FH

31
Q

phaechromocytoma 5 Ps?

A

pain
pressure
palpitation
perspiration
pallor
paroxysms spells

32
Q

mechanism of hypotension in phaechromocytoma?

A

loss of postural reflexes due to prolonged catecholamine stimulation

release of adrenomedullin (vasodilatory neuropeptide)

33
Q

catecholamines cause?

A

dilated cardiomyopathy so affect systolic dysfunction

34
Q

HTN causes?

A

hypertrophic cardiomyopathy so affects systolic function

35
Q

other features of phaechromocytoma?

A

lipolysis
mild glucose intolerance
hypercalcaemia- MEN2, PTHrP secreted by pheo

36
Q

adrenaline is produced in?

A

only adrenals because phenyethanolamine n-methyltransferase is present only there

37
Q

if clinical suspicion of PPGL first check?

A

urine metanephrines then imaging

38
Q

why might you get a false positive for high metanephrines in urine?

A

extreme stress, critical illness, non supine position, sympathoadrenergic activity, renal insufficiency, diet (coffee, tea, bananas, chocolate), medication

39
Q

what is a really good scan for phaechromocytoma?

A

galium dotatate

40
Q

preoperative treatment?

A

7-14 days

alpha adrenergic receptor blocker- phenoxybenzamine, doxazocin

propanolo- if tachycardic
calcium channel blocker
metyrosine- sympathtic

41
Q

familial phaechomoctoma?

A

40%- bilateral, paragnaglioma, unilateral with FH, uinlateral and young age of onset, metastasis

42
Q

familial phaechromocytoma could be due to?

A

MEN 2a, MEN 2b, Von Hippel-landau, NF1, familial paraganglioma, familial pheo and islet cell tumout

43
Q

men 2 a?

A

pheochromocytoma, medullary thyroid carcinoma, parathyroid hyperplasia

44
Q

men 2b?

A

pheochromocytoma, medullary throid carcinoma, marfanoid habitus, mucosal neuroma

45
Q

NF1?

A

cafe au lait spots, neurofibroma and optic glioma

46
Q

von hipple landau?

A

pheochromocytoma, retinoblastoma, cerebellar hemangioma, nephroma, renal/pancreas cysts

47
Q

familial pheochromocytoma gene

A

succinate dehydrogenase mutation

48
Q

WHO healthcare quality dimensions?

A

effective- adherent to an evidence base and results in improved health outcomes

efficient- maximises resource use and avoids waste

accessible

acceptable- takes into account preferences and aspirations of individual service users/ cultures of their community

equitable-

safe

49
Q

sustainability?

A

outcome for patients and populations divided by environmental social and financial impacts

50
Q

components of healthcare (donabedian model)?

A

structure- facilities, equipment, human resources,

process- care seeking behaviour, diagnosis, treatment

outcome- patient knowledge, behaviour, health status and satisfaction

51
Q

audit?

A

way to find out if healthcare is being provided in line with standards and let care providers and patients know where their service is doing well and where there could be improvements

52
Q

stimulus for quality improvement?

A

reflective case, large scale data, feedback, learning event analysis

53
Q

research?

A

creating new knowledge that can be generalised beyond the participant sample or setting

54
Q

difference in clinical audit vs quality improvement?

A

audit- evaluating service against a benchmark

QI- find out something about that service which can be used to improve that service

55
Q

which cycle is pertinent to improvent?

A

plan do study act

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