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1
Q

cause of angina

A

mostly atheroma

mismatch of o2 demand and supply

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2
Q

why are cold fingers a side effect of beta blockers?

A

they dilate coronary arteries but constrict skin and muscle ones –> cold fingers

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3
Q

what does negatively chronotropic mean?

A

decrease in heart rate

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4
Q

what does negatively inotropic mean?

A

decrease in LV contractility (force of contraction)

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5
Q

Side effects of beta blockers

A

erectile dysfunction, cold hands + feet, bradycardia

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6
Q

How do nitrates work?

A

they are ventilators

increase venous capacity –> reduction in preload

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7
Q

how does aspirin work?

A

cyclo-oxygenase inhibitor
reduces prostaglandin synthesis, results in decreased platelet aggregation.
Is antipyretic, anti-inflammatory, analgesic

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8
Q

what does angiotensin II do?

A

increased sympathetic activity
release of aldosterone
vasoconstriction. ACEi block the conversion of angiotensin I to angiotensin II

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9
Q

what are the most sensitive + specific markers of MI?

A

cardiac troponin levels (T and I)

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10
Q

1st line management for ACS (pre-hospital)

A

MONA

morphine, oxygen, nitrate, aspirin

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11
Q

what do anticoagulants target?

A

formation and/or activity of thrombin

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12
Q

Medical treatment after MI

A 
primary angioplasty/thrombolysis
BBs (atenolol)
ACE-i (lisinopril) or ARB (candesartan)
Statin
Dual anti platelet therapy: aspirin and a P2Y12 inhibitor (clopidogrel)
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13
Q

LT rx angina

A

CCB/B-blocker/long acting nitrate e.g. amlodipine, atenolol, nicorandil

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14
Q

Post MI what should pts do

What is contraindicated

A

Attend cardiac rehab – advice on activity etc.
Lifestyle changes
NSAIDS absolute CI for 2/12 post STEMI

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15
Q

Ix AF

A

ECG, echo

CHADS-2-VASC

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16
Q

CHADS-2-VASC

rx level?

what rx?

A 
CHF
HTN
Age 65-74 – 1
DM
Stroke/TIA/VTE -2
Vascular disease
Age >75 2 point
Sex – female - 1

Low risk – men 0, women 1 –> not for AC
Moderate risk – men 1 ?AC
High risk – 2 or above –> AC

Can give warfarin or NOAC

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17
Q

target inr

A

2-3

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18
Q

HAS-BLED

A

Risk of major bleeding in AF with oral anticoagulation:
HTN (Uncontrolled)
Abnormal renal/liver function (up to 2pts)
Stroke history
Bleeding predisposition/history
Labile INR
Elderly >65
Drugs (anti plts) or alcohol (up to 2 pts)
≥3 high risk – use AC with caution

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19
Q

Rx AF

A

New onset – consider cardioversion (AC 4/52 first)
Rate control – B-blocker or rate limiting CCB (diltiazem), digoxin
OR…
Rhythm control – amiodarone, or flecainide (not if IHD)
Do not do both

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20
Q

the 3 aspects to atrial fibrillation management

A

a. rate control
b. rhythm control
c. thromboprophylaxis

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21
Q

SABA

A

salbutamol

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22
Q

LABA

A

salmeterol

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23
Q

SAMA

A

Ipratropium bromide

short acting muscarinic antagonist (anticholinergic)

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24
Q

LAMA

A

Tiotropium bromide

long acting muscarinic antagonist (anticholinergic)

Adverse effects are mainly related to its antimuscarinic effects. Common adverse drug reactions (≥1% of patients) associated with tiotropium therapy include: dry mouth and/or throat irritation. Rarely (<0.1% of patients) treatment is associated with:urinary retention,

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25
Inhaled corticosteroid
beclametasone, budesonide, fluticasone
26
Leukotriene antagonist
montelukast
27
4 key Qs to assess asthma severity
In the last four weeks.. 1. How many days did you have daytime asthma symptoms? 2. How often did you need to use your reliever? 3. How many days were activities limited by asthma? 4. How often did asthma symptoms occur at night or on waking?
28
Asthma rx pathway in adults
1. inhaled SABA PRN 2. Inhaled corticosteriod 200-800 3. inhaled LABA. Up steroid to 800 4. Increase ICS to 2000/d. Add montelukast 5. daily oral steroids
29
Stage 1 COPD
Mild | FEV1>80%
30
Stage 2 COPD
Mod | FEV1 50-79%
31
Stage 3 copd
severe | fev1 30-49%
32
Stage 4 copd
v severe | fev1 <30%
33
type 1 resp failure
pink puffers low o2 norm co2
34
type 2 resp failure
blue bloaters low o2 high co2 become unresponsive to high co2 drive and only breathe in response to hypoxia
35
mx of COPD
1. SABA + SAMA e.g. salbutamol and ipratropium bromide 2. ICS e.g. beclametasone/budesonide 3. If SAMA used QDS  change to LAMA once a day e.g. tiptropium bromide 4. If unstable consider LABA or LAMA 5. Combined inhaler with LABA and ICS e.g. seretide/symbicort 6. If still symptomatic add LAMA
36
other mx of copd
Smoking cessation Pneumococcal vaccine and yearly influenza vaccine Prompt abx for infective exacerbations Pulmonary rehabilitation
37
T1 DM mx
Insulin – mixture of short and long acting insulin e.g. Novorapid boluses and Detemir BD Individual care plan Review annually – includes BP, renal function, eye check, foot check If poor control refer to Diabetologist Target HbA1c <48 mmols/mol
38
T2 DM mx stepwise
1. Lifestyle Modifications – recheck HbA1c in 2-3 months 2. Biguanide e.g. Metformin – titrate upwards to max. dose as needed (monitor renal function) 3. If HbA1c still >58 add second agent - sulphonylurea (gliclazide, glibenclamide), pioglitazone or DPP4 inhibitor (e.g. sitagliptin) 4. Add a third agent (another of those listed in step 3) 5. BMI <35 = commence insulin therapy BMI >35 = GLP1 agonist e.g.exenatide T2 diabetics require the same annual review as type 1 diabetics
39
what is the target hba1c for t2dm
48 If on an oral hypoglycaemic agent target = 53 to avoid hypos.
40
BP targets in someone with htn
Aim clinic BP >140/90 in people <80 Aim 150/90 if ≥80 Aim 130/80 if diabetic
41
drug for obesity
orlistat | if bmi >50 proceed to surgery immediately
42
bariatric surgery criteria
- BMI >35 and recent dx of T2DM - Asian and recent dx of T2DM with BMI >25 - BMI >40 or BMI >35 with sig. assoc. disease + all non surgical methods failed + seen by specialist + fit for anaesthetic and surgery + patient commits to long term follow up
43
bariatric surgery
Gastric banding Gastric bypass Sleeve gastrectomy
44
53yr old Jamaican, BP in clinic 152/97, and APBM of 140/80, eGFR 100, T1DM. Does he need treatment? If so what is first line?
CCB e.g. amlodipine, lifestyle changes
45
73yr old lady, currently on lisinopril and felodipine, her clinic and ABPM are consistently >150/90. What should be added next?
Thiazide like diuretic e.g. bendroflumethiazide
46
Stage 1 HTN
BP (clinic) ≥140/90 & ABPM ≥135/85
47
Stage 2 HTN
BP (clinic) ≥160/100 & ABPM ≥150/95
48
Severe HTN
BP (clinic) Systolic ≥180 or Diastolic ≥110
49
After establishing someone has high blood pressure what should be done next
Assess CV risk e.g. QRISK2 Assess target end organ damage: Urine AC ratio, U&E, plasma glucose, serum cholesterol, fundoscopy ?HTN retinopathy, ECG
50
HTN mx
1. Lifestyle advice 2. Offer antihypertensives if <80 with stage 1 HTN if at least 1 of: - Target organ damage - Established CVD - CKD - T1/T2DM - QRISK 2 ≥20% 3. Offer antihypertensives to anyone with stage 2 or severe HTN
51
BP meds
STEP 1 over 55y or black - C under 55 - A STEP 2 C + A STEP 3 C + A + D (thiazide like) STEP 4 consider further diuretic or alpha/beta blocker consider expert advice
52
example of CCB
amlodipine
53
example of ACEi
lisinopril
54
example of thiazide like diuretic
bendroflumethiazide
55
SE ACEi
dry cough
56
SE CCB
swollen ankles
57
SE thaizide like diuretic
hypokalaemia / sexual dysfunction
58
what do thiazides do?
block reabsorption of sodium at distal convoluted tubule of kidney
59
name 4 medications every patient should be on post-MI?
B blocker, aspirin, ACE/ARB (e.g. candesartan), statin e.g. atorvastatin, ?warfarin
60
What agent reverses warfarin? give an example of a NOAC?
VIT K, Beriplex
61
What should be considered when deciding between warfarin and NOAC?
Risk of fall/bleeding, how easy it will be to monitor, dietary changes
62
1. Name two groups of medications that can be used in the rate control of AF and an example of each? 2. Which drug is contraindicated for rhythm control in AF if the patient has IHD?
1. B blocker , Rate limiting CCB (non-dihydropyridine) e.g. diltiazem, cardiac glycoside e.g. digoxin 2. Flecainide
63
Two examples of an inhaled corticosteroid
Beclametasone, budesonide, fluticasone
64
33 yr old with uncontrolled asthma. Currently taking terbutaline PRN, beclametasone 400mcg/day and they have recently completed a trial of formeterol which provided some relief. What is the next step?
Continue formeterol and increase ICS to 800mcg/day. Then add 4th drug or increase to 2000.
65
``` Intepret this ABG: 65 yr old gentlemen brought into A&E with COPD exacerbation. On 28% oxygen via simple facemask. pH 7.35 PaO2 7.3 PaCO2 11.2 HCO3 36.0 ```
Type 2 resp failure. Chronic – as bicarbonate has increased
66
What oxygen saturations are the target for COPD patients on oxygen therapy?
88-92%
67
69 yr old pt with COPD on salbutamol and ipratropium bromide, they take both at least 4 times a day. What is the next step in management?
Change ipratropium bromide to tiotropium (LAMA) and add ICS
68
Three things that require annual review in a diabetic?
Renal function, hba1c, bp, eyes, feet
69
If an asymptomatic patient has an incidental random plasma glucose test done with a result of 12.0 what does the result of his glucose tolerance test have to be to be diagnosed as diabetic?
>11.1
70
If a 68 year old morbidly obese lady has a HbA1c of 60 and is been considered for insulin therapy. What medications should they have already tried?
Metformin, 2 others (sulphonylurea/glitazone/gliptin) and GLP1 agonist e.g. exanatide
71
If a 76 yr old gentlemen is found to have an eGFR of 38, what stage CKD does he have?
3B
72
Following lifestyle changes which treatment option is the most appropriate next step for a patient with BMI 52?
Surgery
73
paget's disease of the nipple
``` sign of intraductal breast cancer unilateral, red, scaly, crusted nipple dx: biopsy. DDx: eczema Surgery: mastectomy or lumpectomy + surgery ```
74
ABCDE of malignant melanoma
``` A - asymmetry B - borders irregular C - colour change D - diameter >6mm E - evolving quickly. bleeding bad ```
75
rx malignant melanoma
excision with margin of normal skin
76
pathology of psoriasis
``` epidermal proliferation inflammatory infiltration (T-cell driven in the dermis & epidermis) ```
77
what is the signal for hyperprofliferation in psoriasis?
tumour necrosis factor | which is why infliximab is a logical therapy
78
signs psoriasis
symmetrical well defined red plaques with silvery scale on the extensor surfaces nail changes - pitting, onycholysis (separation from nail bed) generalised psoriasis = systemic symptoms eg fever, inc WCC, dehydration
79
systemic signs in psoriasis
7% develop athropathy
80
Dds psoriasis
eczema | fungal infection
81
mx psoriasis
- EDUCATION - remove possible triggers - strep infection, drugs, stress, alcohol - potent corticosteroid applied once daily plus vitamin D e. g. betamethasone + calcipotriol (Dovobet)
82
mx severe psoriasis
methotrexate - helps athropathy | infliximab (anti tnf)
83
cause of cellulitis
strep infection - B haemolytic strep
84
px cellulitis
systemic upset and lymphadenopathy, badly defined and affecting the legs
85
rx cellulitis
benzylpenicillin + flucloxacillin
86
what rx for cellulitis if penicillin allergic
erythromycin
87
cause of acne vulgaris
abnormality of keratinisation within the follicle = blockage of secretions = blackhead and white heads (comedones) increased sebum production (regulated by androgens and CRH)
88
what is the ddx for acne
acne rosacea - no comedones, diffusely red nose, cheeks, chin - flushing. Eye involvement. rx - topical metronidazole
89
signs & rx moderate acne
``` signs = inflammatory lesions, face +/- chest and back rx = erythromycin PO with topical benzoyl peroxide ```
90
signs & rx mild acne
signs = mainly comedones on face rx = topical benzoyl peroxide
91
signs & rx severe acne
signs = nodules, cysts, scarring rx = the synthetic retinoid isotretinoin - v teratogenic so good contraception needed. High success rates but psychosis and depression.

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