GP Flashcards
Explain the mechanism behind cor pulmonale
= a change in the structure of the RV secondary to a lung disorder causing pulmonary hypertension.
Pulmonary hypertension creates a back pressure, increasing afterload on R side of heart, causing RV hypertrophy. Pulmonary hypertension exists because of ventilation:perfusion matching- in less well-ventilated areas vessels will constrict to divert blood to better ventilated areas.
Normally a chronic cause (typically COPD) but can be acute from massive PE or injury due to mechanical ventilation (as in ARDS)
Signs: peripheral oedema, distended jugular veins, hepatomegaly
What are the long term effects of chronic hypoxaemia?
- EPO produced by kidney –> polycythemia
- Pulmonary HTN –> cor pulmonale
- Increased 2,3 DPG
What does hypercapnia do to blood vessels and name two clinical effects of this
Vasodilation.
Peripheral vasodilatation- warm hands, bounding pulse
Cerebral vasodilatation- headache
What does the kidney do in response to chronic hypercapnia?
Retention of HC03 to compensate
Medications that could affect lung disease/symptoms?
ACEi (e.g. ramipril)- cough
Methotrexate- pulmonary fibrosis / acute pneumonitis
Nitrofurantoin- acute (more common) or chronic pulmonary toxicity e.g. ILD, pulmonary fibrosis
Non-pharma management of COPD
- Smoking cessation
- Vaccination (pneumococcal and influenza)
- Pulmonary rehabilitation (6-12week MDT programme of supervised exercise, unsupervised home exercise, nutritional advice and disease education to break the cycle of deconditioning)
Pharma management of COPD
Breathlessness/exercise limitation:
LABA or LAMA as required
If exacerbations or persistent breathlessness:
If FEV1 >50%: LABA + ICS in combined inhaler (Fostair) + LAMA
If FEV1 <50%: LABA + LAMA, then LABA + ICS
If either category and not working try LABA + LAMA + ICS
Assess need for long-term oxygen therapy (LTOT) in patients with FEV1 <30% predicted, cyanosis, polycythaemia, peripheral oedema, raised JVP or O2 saturations ≤92% breathing air
What are the possible different drugs for COPD?
LABA - Formoterol LAMA - Tiotropium ICS - Budesonide LABA + ICS - Fostair LABA + LAMA + ICS - Trimbow
Mucolytics for chronic productive cough - e.g. Carbocysteine
How do you diagnose COPD?
Consider diagnosis if aged >35yo, smoker, with: – exertional breathlessness – chronic cough – regular sputum production – frequent winter 'bronchitis' – wheeze
Do spirometry- if obstructive (FEV1/FVC x 100 <70% = COPD).
CXR and FBC to check for other explanations.
Do MRC dyspnoea scale score.
What is the scale to score COPD?
MRC Dyspnoea scale:
Grade Description of Breathlessness
1 - I only get breathless with strenuous exercise.
2 - I get short of breath when hurrying on level ground or walking up a slight hill.
3 - On level ground, I walk slower than people of the same age because of breathlessness, or have to stop for breath when walking at my own pace.
4 - I stop for breath after walking about 100 yards or after a few minutes on level ground.
5 - I am too breathless to leave the house or I am breathless when dressing.
Management of acute exacerbations of COPD?
- Consider antibiotic: Amoxicillin 500mg TDS 5 days
- Bronchodilators +/- oxygen
- Oral corticosteroids e.g. 5-day course of oral prednisolone (40 mg/day)
Why does emphysema cause hyperinflation of lungs?
Loss of elastic tissue so lose the ability to resist the tendency of the ribs to expand outwards
How can spirometry define the airflow obstruction in COPD?
The NICE guidelines suggest the following:
● Mild airflow obstruction - FEV1 50–80% predicted
● Moderate airflow obstruction - FEV1 30–49% predicted ● Severe airflow obstruction - FEV1 <30% predicted
How do LABAs work and what are side effects?
E.g. formoterol
Agonist to B2-adrenergic receptor, cause relaxation of SM in airway –> bronchodilation
Also cardiac Rs –> tachycardia
Also skeletal Rs –> tremor & hypokalaemia (from K+ uptake in skeletal)
Anxiety, palpitations
What is the mechanism of anticholinergics? Include side effects
Act on cholinergic muscarinic Rs in airway smooth muscle
Synergistic with B2-agonists
E.g. ipratropium, tiotropium
Can’t see (blurred vision), can’t pee, can’t spit, can’t shit
Side effects:
- dry mouth and cough, pharyngitis, sore throat, URTI, bitter taste, nausea
- tachycardia, AF
- Urinary retention, constipation
Tell me about long term oxygen therapy (LTOT)
Prevents problems from hypoxia (renal and cardiac damage). Need 16/hours a day for any survival benefit. Offered if pO2 consistently <7.3kPa or <8kPa with cor pulmonale. Must be non-smoker and assessed for fire risk.
When should you consider non-invasive ventilation (NIV i.e. BIPAP)?
During acute exacerbations of COPD with type II resp failure and mild acidosis (7.25-7.35), must be conscious, must not have upper airway secretions +++, facial injury, vomited, agitated or untreated pneumothorax.
Outline management of an acute exacerbation of COPD
Check sats and do ABG
Controlled O2 therapy
Bronchodilators - formoterol nebulised
Steroids - prednisone 30mg orally 7-14 days
Antibiotics if infective features (Hx purulent sputum) e.g. doxycycline
Repeat ABG regularly, if no better consider BIPAP
Consider physio for sputum clearance
Patient presents with unilateral headache, jaw claudication, amaurosis fugax, neck stiffness. What will you do?
GCA/temporal arteritis (a large cell vasculitis).
Eye threatening condition.
Give PO prednisolone (for many months, slowly taper)
Seek urgent attention if develop visual symptoms
Start aspirin
Arrange temporal artery biopsy (skip lesions, giant cells, panarteritis, found in SM, macrophages, T cells)
CRP and ESR raised
Adult presents with bulging tympanic membrane..
Otitis media. If no signs of mastoiditis/meningitis then will not need Abx. Should take 4 days to self resolve
Adult presents with itchy ear and otorrhea…
Otitis externa. Give acetic acid 2% 1 spray TDS for 7 days (an antibacterial and anti fungal, component of vinegar)
Adult presents with cervical lymphadenopathy, sore throat, temp of 37.8, cough, and tonsillar exudate. What will you do?
Centor criteria for strep pharyngitis is 2. This is not 3-4, so no Abx needed because unlikely to be strep pyogenes so Abx (Penicillin V) will not help and can cause side effects e.g. rash, diarrhoea). It is probably viral and will resolve in 1 week.
When should you offer Abx for URTIs?
Systemically very unwell, signs of complications e.g. mastoiditis, peritonsillar abscess, meningitis, pneumonia; co-morbidities e.g. IC, DM, CHF, CF
For sinusitis give amoxicillin, for pharyngitis/tonsilitis give penicillin V
When should you send for urine culture in UTIs?
Any haematuria (visible or non-visible) Complicated UTI (IC, DM, pregnancy, reflux, obstruction)
Give examples of complicated and uncomplicated UTIs
Uncomplicated- female, no abnormalities of urinary tract, no co-morbidities
Complicated- male, children, elderly, pregnant, abnormalities of urinary tract, co-morbidities (IC, DM)
Treat a UTI in a young female
Trimethoprim BD 3 days OR nitrofurantoin QDS 3 days
Treat a UTI in a male
Trimethoprim BD 5 days OR nitrofurantoin QDS 5 days
A pregnant lady comes in with dysuria, polyuria, haematuria- what will you do?
UTI in pregnancy is complicated. Send MSU for culture.
If 1st trimester- nitrofurantoin 7 days
2nd- nitro or trimethoprim 7 days
3rd- trimethoprim 7 days
A young female presents with dysuria, polyuria, costovertebral angle tenderness and fever…
Acute pyelonephritis. Send MSU for culture.
Co-amoxiclav 625mg TDS 14 days.
Difference between bronchitis and pneumonia?
Bronchitis is affecting the bronchi, pneumonia is lung parenchyma
Definition of an LRTI
<21days cough main symptom with one other LRT symptom e.g. septum, fever, SoB, wheeze, chest pain with no alternative more likely explanation (sinusitis, asthma)
Organisms and treatment for CAP
CAP- strep pneumonia, H. influenzae.
Calculate CURB-65 score for mortality risk (confusion MMSE <8, urea nitrogen >7, RR >30, low BP sys <90 or did <60), age over 65.
Score 0: low risk (less than 1% mortality risk)
1 or 2: intermediate risk (1‑10% mortality risk)
3 or 4: high risk (more than 10% mortality risk).
If more than 2 hospitalise.
Low risk: Amoxicillin 500mg TDS 5 days.
Mod-high risk: Amoxicillin 7-10 days + macrolide e.g. azithromycin
Treatment for acute bronchitis
No Abx unless muco-purulent sputum
In which case Amoxicillin 500mg TDS 5 days
How to manage HAP (including definition and common and uncommon causes)
Acquired >48hours after admission.
Causes: staph aureus, pseudomonas aeruginosa, escherichia coli, klebsiella pneumoniae
Uncommon causes: viridians streptococci, Neisseria
Severe HAP: confusion, CXR multi lobular shadowing, RR >30, hypoxia <8, need for ventilatory support, shock (sys <90 did <60)
Co-amoxiclav PO 635mg if mild/mod TDS 5 days, or 1.2g if severe
A patient is concerned about how long their pneumonia symptoms will last. Please advise.
1wk fever 4wk reduced chest pain and sputum 6wk cough and SoB reduced 3 months most symptoms gone but still fatigued 6 months back to normal
What organisms are most common from infected birds, CF and COPD with pneumonia:
Infected birds- chlamydia psittaci
CF- pseudomonas aeruginosa
COPD- haemophilus influenzae
Should you prescribe Abx if you do not have a clear clinical diagnosis of pneumonia?
If unclear clinically test CRP.
<20 = no abx
20-100 = delayed prescription
>100 = abx
What investigations are useful in HAP
CXR- may take 48hrs post-symptoms for consolidation and can last up to 6 weeks
Blood cultures
Sputum culture
CRP, FB, ESR
If legionella suspected can test urine for legionella antigen
May be hypoalbuminaemia (a negative inflammatory marker)
Patient presents with red, swollen purulent eyelids.
Blepharitis- a chronic, intermittent condition, no cure but self-care measures can control. Warm compress for 5-10mins BD, avoid eye makeup and contact lenses.
Normally staph is cause.
Try hygiene first, Abx are 2nd line. e.g. chloramphenicol eye ointment BD 6 weeks
A 25yo M presents with LBP. Should you refer to rheum?
Refer to rheum if 4 or more: <35yo, waking in second half of night, improves with movement, 1st degree relative, improves within 48hrs of NSAIDs, buttock pain, current/past arthritis/enthesitis, psoriasis.
If only 3 points, do HLA-B27 test
Manage 40yo presenting with LBP, no red flags.
Use the STarT back screening tool:
how bothersome is pain, it’s not safe to be active, it’s never going to get better, not enjoying activities, slow dressing, worrying thoughts, affects walking distance.
Tool identifies modifiable risk factors to see if they need more support.
Low risk - encourage activity, reassure, advise self-management
High risk- offer referral to group exercise programme, consider physiotherapy referral, CBT, promote return to work/normal activities
Offer NSAID + PPI
Consider diazepam 2mg TDS 5 days if muscle spasm
You consider testing a patient’s HLA-B27 for ?ank spond. The patient asks what this is?
Seronegative spondylitis affecting spine and sacroiliac joints
Risk factors are recent genitourinary infection and FH of spondyloarthritis/psoriasis
On examination may have limited lumbar movement
Males 3:1
Often young people
Mortality x1.5
Can lead to ankylosis which is new bone formation in spine causing fusion in immobile position
May have arthritis/enthesitis in other sites
Manage with physio, NSAIDs, paracetamol in order to reduce pain/stiffness and associated fatigue/poor sleep/anxiety
Initially offer XR of sacroiliac joints
If negative do MRI
A patient presents with burning retrosternal pain post-eating. What drugs should you consider stopping?
NSAIDs
Alpha-blockers (Tamsulosin for BPH)
Anticholinergics (chlorphenamine, loratadine, atropine, cyclizine, TCAs)
Benzodiazepines (lorazepam, diazepam)
Beta-blockers (bisoprolol)
Bisphosphonates (alendronic acid)
Calcium-channel blockers (amlodipine, verapamil)
Corticosteroids (pred)
Nitrates (GTN)
Theophyllines
Tricyclic antidepressants (amitryptyline)
Patient presents with GORD and you send for H pylori stool antigen test and prescribe 4 week trial PPI.
What are 1st and 2nd line treatments for the GORD and positive H pylori test
1st Omeprazole 20mg OD
2nd H2RA Ranitidine
H pylori-
7 day Clarithomycin BD + amoxicillin BD
