GP Flashcards
(94 cards)
1
Q
What is atrial fibrillation?
A
Chaotic irregular atrial arrhythmia
2
Q
What are the different types of atrial fibrillation?
A
Permanent: Cardioversion ineffective
Persistent: >7 days
Paroxysmal: <7 days
3
Q
What is the clinical presentation of atrial fibrillation ?
A
IRREGULARLY IRREGULAR PULSE
Dyspnoea
Chest pain
Hypotension and tachycardia: palpitations
Syncope
4
Q
What are the investigations for atrial fibrillation?
A
ECG: F fibrillatory waves, absent P and a waves, irregularly irregular narrow QRS complexes
CHADVASc score: assesses risk of stroke in AF + when to start anticoagulation
- 0: no anticoagulation + Aspirin alone
- 1: consider anticoagulation + Aspirin
- >1: offer anticoagulation (Warfarin) + Aspirin
5
Q
What is the management for atrial fibrillation ?
A
- Rate control: beta-blocker (e.g. bisoprolol), CCB (not in HF) and digoxin (BCD)
- Rhythm control: return to normal sinus rhythm through cardioversion
Anticoagulation: asprin and Warfarin
Thrombin or Factor 10A inhibitor
Reduce Stroke risk
6
Q
What are the 2 types of Cardioversion in AF?
A
Electrical DC
Pharmacological: Amiodarone
7
Q
What are the risks of Cardioversion?
A
Embolism
Only attempt if symptomatic for >48 hours + long period of anticoags
8
Q
How do you measure Stroke risk in AF?
A
CHA2DS2VASc
Score (/9):
- Congestive heart failure
- Hypertension
- Age
- 65-74 =1
- ≥75=2
- Diabetes
- Stroke/TIA
- Vascular disease
- Female
9
Q
What is hypertension?
A
> 140/90: clinic
> 135/85: ambulatory
10
Q
What are the causes of hypertension?
A
Primary (essential): no known cause
Secondary: a known underlying cause
ROPE
Renal disease
Obesity
Pregnancy
Endocrine (primary hyperaldosteronism, most common cause)
White coat syndrome
11
Q
What are the causes of paediatric HTN?
A
Renal parenchymal disease (majority)
CoA
12
Q
What type of HTN is most common?
A
Essential
13
Q
How is HTN measured?
A
BP reading:record BP in both arms
Ambulatory blood pressure monitoring (ABPM)
Home blood pressure monitoring (HBPM)
14
Q
How would you perform a HBPM?
A
Two consecutive measurements 1 minute apart
Patient seated
BD for 1 week
DO NOT INCLUDE 1ST DAY MEASUREMENTS (INACCURACY)
15
Q
How would you perform a ABPM?
A
2/hr during waking hours
14 readings a day
16
Q
What are the 3 stages of hypertension?
A
1 =
Clinical- >140/90
ABPM - >135/85
2=
Clinical- >160/100
ABPM - >150/95
3 = 180/110
17
Q
How would you assess for end organ damage in hypertension?
A
Fundoscopy: hypertensive retinopathy
ECG: LVH or IHD
Urine dip: renal disease
18
Q
What is the management for hypertension?
A
ABCD
Step 1
> 55 & stage 2 or above → ACEi
> 55 OR of black/African Caribbean → CCB
Step 2
ACEi / ARB + CCB (ACEi ARE CONTRAINDICATED IN BLACK/AFRICAN CARRIBEAN PEOPLE)
Step 3
ACEi/ARB + CCB + Thiazide diuretic
Step 4
Resistant HTN
Consider other drugs: sodium nitroprusside in emergencies
19
Q
What would you do if a patient reaches stage 4 of hypertension management?
A
Resistant HTN:
Confirm elevated BP
Assess for postural Hypotension
Discuss Adherence
Potassium <4.5: low dose spironolactone
Potassium >4.5: AB or BB
20
Q
How is hypertension monitored?
A
Treatment targets:
* < 80 yrs: <140/90
* > 80 yrs: 150/90
* CKD, previous stroke and diabetes: >130/80
Monitor U&Es regularly when using ACEi and diuretics
21
Q
What are the side-effects of ACEi?
A
Cough
Angioedema
Hyperkalaemia
22
Q
What are the side-effects of CCB?
A
Ankle swelling
Headache
Flushing
23
Q
What are the side-effects of thiazide diuretics?
A
Hyponatraemia
Hypokalaemia
Dehydration
24
Q
What are the side-effects of ARB?
A
Hyperkalaemia
25
What is the clinical presentation of pericarditis?
Pleuritic chest pain: eased by leaning forwards
Worsened by lying flat
Pericardial rub
Fever
Myalgias
26
What are the investigations for pericarditis?
**Transthoracic echocardiogram:** pericardial effusion shows a 'dancing' heart
**ECG**: widespread ST saddle elevation and PR depression
**Bloods**: raised ESR and CRP
**Troponin**
27
What is the management for pericarditis?
Viral: NSAIDs + colchicine (anti-gout, reduces inflammation and pain)
Bacterial: antibiotics + pericardiocentesis
28
What is the clinical presentation of MSK chest pain?
Worse on movement
Worse on palpation
Precipitated by trauma or cough
29
What is shingles?
Reactivation of a measles infection (HHV-3) (normally occurring during childhood)
Causes a painful rash along a dermatome
30
What is the clinical presentation of shingles?
**Dermatomal pain:**
- Macular vesicular rash in dermatomal distribution
**Pain preceeds rash**
Malaise, myalgia, headache and fever
Disseminated infection: if immunosuppressed
31
What are the investigations for shingles?
Clinical presentation of skin lesions
Viral PCR, culture and immunohistochemistry
32
How is shingles managed?
Conservatively
Oral aciclovir: if high risk
Zoster vaccine
VZV immunoglobulin
Calamine lotion and chlorphenamine (antihistamine): itching
33
What is the clinical presentation of aortic dissection?
Sudden severe ‘**tearing**’ chest pain
May radiate to the back if type B
Does not radiate to arms
Syncope
Unequal upper limb BP
34
What are the investigations for aortic dissection?
**CT angiogram**
ECG
CXR
ECHO
35
How is Aortic Dissection treated?
Medical emergency
Type A: open surgery
Type B: TEVAR
36
What are 4 causes of transient non-visible haematuria?
- UTI
- Menstruation
- Vigorous exercise
- Sexual intercourse
37
What are 6 causes of persistent non-visible haematuria?
- Cancer
- Stones
- BPH
- Prostatitis
- Urethritis
- Renal: IgA nephropathy
38
How can you investigate haematuria?
- URINE DIP:
- Persistent = 2/3 samples 2 weeks apart
- Renal function
- Albumin:creatinine ratio:
- Protein:creatinine ratio PCR
Urine microscopy
39
When should you urgently refer haematuria?
> 45yrs+:
- Unexplained visible haematuria
- Visible haematuria persisting after UTI management
OR
>60yrs+
- Unexplained non-visible haematuria
- Dysuria
- Raised WCC
40
What is the Referral Guidance for chest pain?
Current/within 12hrs + abnormal ECG: EMERGENCY ADMISSION
12-72hrs ago: REFERRAL FOR SAME DAY ASSESSMENT
>72hrs ago: FULL ASSESSMENT, ECG + TROPONIN
41
What is venous thrombus embolism (VTE)?
Blood clot enters circulation
42
What is pulmonary embolism?
Obstruction of the pulmonary arteries 2° to an embolus
43
How many more times common are DVTs than PEs?
What percentage of DVTs lead to PE?
DVT 3x more common
16% in untreated patients
44
What is the clinical presentation of VTE?
- Paralysis/paresis
- Entire leg swollen
- Tenderness/pain
- Erythema
- Calf swelling >3cm compared to the other leg
- Pitting oedema
- Distended veins
45
What is the clinical presentation of PE?
Dyspnoea + dyspnea
**Syncope**
Pleuritic chest pain
Cyanosis: hypoxia
**Elevated JVP:** suggests cor pulmonale
DVT signs: positive Wells score
Cough +/- haemoptysis
Haemoptysis
Tachycardia + tachypnoea
Crackles
Fever
46
What is the Well's score?
Calculates risk of DVT
47
What comprises the Well's score?
PC:
- Paralysis/paresis/recent immobilisation
- Localised tenderness along the deep venous system
- Entire leg swollen
- Calf swelling > 3cm compared to other leg measured **10cm below** the **tibial tuberosity)**
- Pitting oedema confined to affected leg
- Collateral superficial veins present
- **PMH**
- Bedridden recently > 3 days or major surgery within 12 weeks
- Active cancer (treatment or palliation within 6 months)
- Previous DVT
- **DH**
- OCP/HRT
- **SH**
- Long haul flight
- Smoking
48
What are the investigations for PE/DVT if the Wells score is:
≥2?
≤1?
Well's Score:
≥2 = Duplex US of deep veins within 4hrs + D-Dimer
≤1 = D-Dimer within 4hrs
For both test:
FBC
U&E
LFTs
Antiphospholipid antibodies
49
What are the investigations for PE?
Well's Score:
- ≥2 = Duplex US of deep veins within 4hrs + D-Dimer
- ≤1 = D-dimer within 4hrs
Computed tomographic pulmonary angiography (CTPA): visualisation of clot
- ABG: Type 1 respiratory failure (O2 <8kPa)
- ECG: **S1Q3T3** (inverted T in V1-V6 and RBBB)
For both test:
- CXR
- ECHO
- FBC
- U&E
- LFTs
- Antiphospholipid antibodies
50
What is the gold standard in diagnosing PE?
CTPA
51
What is the management of a VTE/DVT?
LMWH (e.g. enoxaparin) :
- 5 days OR INR >2.0 for 24hr
- 6 months if active cancer
Wafarin:
- 3 months
- 6 months: if unprovoked
Fondaparinux sodium: inhibits factor X
Compression stockings
IVC filters
DOAC: rivaroxaban
Unfractionated heparin: in CKD
52
What should be given if the USS is delayed when diagnosing a VTE?
LMWH
53
If the VTE is unprovoked what should be done?
Test for Malignancy:
- CXR
- Bloods (FBC,Ca,LFTs)
- Urinalysis
- Abdo CT or mammogram: - If >40yrs
54
What is the management of PE?
On clinical suspicion and only stopped once ruled out:
1) LMWH (e.g. enoxaparin):
- 5 days OR INR >2.0 for 24hr
- 6 months if active cancer
2) Wafarin:
- 3 months
- 6 months: if unprovoked
3. **DOAC:** apixaban or rivaroxaban
4. **Compression socks:** prophylaxis
5. **Inferior vena cava filter**
6. THROMBOLYSIS (e.g. e.g. alteplase) : in haemodynamic compromise e.g. alteplase
7. **Surgical embolectomy**
55
How do you monitor treatment in VTE/PE/DVT?
Anti-Xa: anti-thrombin III inhibits factor Xa and stops coagulation cascade
56
What may affect a V/Q scan?
Previous PE
AV malformations
Vasculitis
Radiotherapy
57
What are lymphomas?
Lymphoproliferative disorder (specifically B-cells) that predominantly involves the lymph nodes and extranodal sites
58
What is Hodgkin’s lymphoma?
A lymphoma associated with Reed-Sternberg cells (owl’s eye nuclei)
59
Name the 4 different types of Hodgkins Lymphoma
Nodular Sclerosing: Majority + women (lacunar cells)
Mixed Cellularity (Reed-Sternberg cells)
Lymphocyte predominant
Lymphocyte depleted
60
What is Non-Hodgkin's Lymphoma?
Malignant proliferation of lymphocytes other then Hodgkin's
61
What are the presentations of lymphomas?
Painless, asymmetrical and non-tender lymphadenopathy (**rubber**): cervical, axillary or inguinal
**B-cell symptoms:** night sweats, fever & weight loss
Itching
Pain when drinking alcohol
Recurrent infections
Alcohol induced node pain
Normocytic anaemia
62
What features may suggest a poor prognosis in lymphoma?
B-symptoms:
- Weight loss >10%
- Fever >38
- Night sweats
Poorer:
- > 45yrs
- Stage 4
- Haemoglobin < 10.5
- Lymphocytes < 600 or 8%
- Male
- Albumin
- WCC > 15000
63
What s the difference between Hodgkin's and Non-Hodgkin's in terms of:
- Histology
- B-symptoms
- Extra-nodal disease
Histology:
Hodgkins= Reed-Sternberg cells
B-symptoms:
Hodgkins = Early
Non-Hodgkins = Late
Extra-nodal disease:
Hodgkins = Less common
Non-Hodgkins = More common
64
What are the investigations for Hodgkin’s lymphoma?
Blood smear: Reed-Sternberg cells
Raised serum LDH
Diagnosis: FBC, ESR, CRP, CXR and lymph node biopsy
Staging: MRI and PET scan
65
What are the investigations for non-hodgkin’s lymphoma?
Diagnosis: FBC, ESR, CRP, CXR and excisional lymph node biopsy
Staging: MRI, CT and PET scan
66
What are laboratory signs of Hodgkin’s lymphoma?
Lymphocyte proliferation
Reed-Sternberg cells
67
What is the staging used for lymphomas?
Ann Arbor system:
1. 1 node
2. ≥2 nodes on same side of the diaphragm
3. Lymph nodes on both sides of diaphragm
4. Extra-nodal involvement
+ A: no B symptoms
+ B: present B symptoms
68
How are Hodgkin’s lymphomas managed?
**ABVD:**
Adriamycin
Bleomycin
Vinblastine sulfate
Dacarbazine
69
What is the treatment for non-hodgkin’s lymphoma?
**R-CHOP:**
Rituximab
Cyclophosphamide
Hydroxydaunorubicin hydrochloride
Vincristine
Prednisone
Stem cell transplantation
70
What is are the complications of lymphomas?
**Chemotherapy**: risk of leukaemia, infertility, nausea, vomiting, hair loss etc
**Radiotherapy**: risk of cancer and damage to tissues
71
What is COPD?
Progressive and irreversible obstructive airway disease
72
What two conditions encompass COPD?
Emphysema and Bronchitis
73
What are the causes of COPD?
- Smoking
- Alpha-1 antitrypsin deficiency
- Occupational exposure: dusts, chemical agents and fumes
74
What is the clinical presentation of COPD?
Tar staining of fingers: **NO CLUBBING**
ESPECIALLY IF A SMOKER!
**Cough + sputum production**: **NO** haemoptysis
**Blue bloater:** chronic bronchitis
**Pink puffer**: emphysema
Dyspnea
Recurrent respiratory infections
Symptoms do not improve with salbutamol
Barrel chested
Wheezing on auscultation: from airway narrowing
Coarse crackles: sudden opening of the airways
75
What are the spirometer readings for COPD?
All FEV1/FVC ratio of <0.7
FEV1 (% of predicted):
>80 = Stage 1 Mild
50-79 = Stage 2 Moderate
30-49 = Stage 3 Severe
<30 = Stage 4 Very Severe
76
How is COPD diagnosed?
**Considered in any patient >35yrs who are current/ex-smokers with ≥1 symptoms of COPD**
Spirometry:
- FEV1/FVC ratio <0.7
- Bronchodilator does not reverse
Chest X-ray: flattened diaphragm, hyperinflation and bullae
Pulse oximetry
ABG: detects cyanosis
77
What is the management of COPD?
1. SABA(salbutamol)/ SAMA (ipratropium)
2. LABA + LAMA ((salmetrol or tiotrium) Anoro Ellipta) **or** LABA+ICS (Fostair ******if asthmatic)
3. LABA + LAMA + ICS (Trimbo)
**Stop smoking**
78
When should long term oxygen therapy be offered in COPD?
O2 for ≥ 15 hours per day if:
- pO2 < 7.3
OR pO2 7.3 – 8 AND:
- Secondary polycythaemia
- Peripheral oedema
- Pulmonary hypertension
- Non-smoker
79
What is a major complication of COPD?
Cor Pulmonale
80
What is Cor Pulmonale?
Pulmonary hypertension from chronic lung disease that can cause right sided HF
81
What is the clinical presentation of cor pulmonale?
- Peripheral oedema
- Increased JVP
- Parasternal heave
- Loud P2
82
What is the management of Cor pulmonale in COPD?
Loop Diuretic Furosemide
Long term O2
83
What are features of an acute COPD exacerbation?
Worsening of:
- Dyspnoea
- Cough
- Wheeze
- Sputum
- Hypoxia
- Confusion
84
Name 2 exacerbation organisms of COPD
Haemophilus Influenzae
Strep Pneumoniae
Moraxella Catarrhalis
85
What is the management of acute exacerbation in COPD?
Prednisolone for 7-14 days
Increased nebulised salbutamol dose
Oral Abx if purulent sputum or signs of pneumonia:
- Amoxicillin
86
What is Gout?
Hyperuricaemia and deposition of monosodium urate crystals causing attacks of acute inflammatory arthritis- **crystal arthropathy**
Usually affects small joints and kidneys
87
What causes hyperuricaemia and thus gout?
Idiopathic: Majority
Increased production: psoriasis, genetics, diet (shellfish, red meat and alcohol)
Decreased excretion from the kidneys: CKD, NTN, thiazides and alcohol
88
What is the clinical presentation of gout?
Rapid-onset severe pain
Flares
Joint stiffness and tenderness
**1st metatarsophalangeal and carpo-metacarpal joint**
Monoarticular
Swelling and joint effusion
Tophi: subcutaneous deposits near the ears island fingers
Erythema and warmth
89
What can precipitate Gout?
Diuretics
Cold
Alcohol
90
What are the investigations for Gout?
Arthrocentesis (aspiration) synovial fluid analysis:
-High WBC
-Presence of needle shaped monosodium urate crystals with negative birefringence
X-ray shows:
1) Soft tissue swelling
2) Peri-articular erosions
3) Norma joint space
Serum urate
91
What is the management of Gout?
NSAID: for acute episodes
Corticosteroids
Allopurinol: lowers uric acid levels (long term)
Colchicine: anti-gout and reduces inflammation and pain (aCute)
Lose weight
Stop drinking
Avoid meats with high purines (red meat, shellfish)
92
What is pseudogout?
Calcium pyrophosphate deposition causing synovitis (arthritis)
93
What investigations are ordered for the diagnosis of pseudogout?
**Arthrocentesis with synovial fluid analysis:**
Presence of rhomboidal, weakly positively birefringent crystals under polarized light microscopy
Joint X-ray: crystals
94
What is the management of pseudogout?
Intra-articular corticosteroids
NSAIDs
**DMARD:** methotrexate
