GP Flashcards
(32 cards)
Which NSAID is best for patients with previous stomach ulcers? [1]
Celocoxib is a selective COX-2 inhibitor or coxib (their names usually end in -ib). Coxibs have a lower risk of GI ulceration than regular NSAIDs because they inhibit COX-1 to a far lesser extent. COX-1 is protective for gastric mucosa
Describe the asthma tx pathway [+]
Step 1 NICE
* a low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler to be taken as needed for symptom relief
* this is termed anti-inflammatory reliever (AIR) therapy
* if the patient presents highly symptomatic (for example, regular nocturnal waking) or with a severe exacerbation:
* start treatment with low-dose MART (maintenance and reliever therapy, see below)
* treat the acute symptoms as appropriate (e.g. a course of oral corticosteroids may be indicated)
Step 2 NICE
* a low-dose MART
* MART describes using an inhaled corticosteroid (ICS)/formoterol combination inhaler for daily maintenance therapy and the relief of symptoms as needed, i.e. regularly and as required
Step 3
* a moderate-dose MART
Step 4
* check the fractional exhaled nitric oxide (FeNO) level if available, and the blood eosinophil count NICE
* if either of these is raised, refer to a specialist in asthma care
* if neither FeNO nor eosinophil count is raised, consider a trial of either a leukotriene receptor antagonist (LTRA) or a long-acting muscarinic receptor antagonist (LAMA) used in addition to moderate-dose MART
* if control has not improved, stop the LTRA or LAMA and start a trial of the alternative medicine (LTRA or LAMA)
Step 5
* refer people to a specialist in asthma care when asthma is not controlled despite treatment with moderate-dose MART, and trials of an LTRA and a LAMA
How do you treat a myodixal coma? [2]
IV thyroxine and hydrocortisone
How would you manage a women who presents with frequent UTIs? [1]
Give prophylaxis abx for post-coital events
How do you investigate UTI with haematuria? [1]
Need to conduct MSU
Name a side effect of amlodopine (not oedema) [1]
Gingivial hyperplasia
Management for BPH x troublesome sx? [2]
1. Tamulosin (smooth muscle relaxant)
2. Finasteride (5 alpha reductase inhibitor) - will decrease prostate size
AOM x tympanic membrane perforation mx? [1]
Amoxicillin for 7 days
Which DMT2 drug can cause oedema? [1]
Which condition is it therefore CI in ? [1]
Pioglizatone
- CI in HF
Describe the cremasteric reflex [1]
Which condition does it help to support? [1]
Stroke inner thigh - testicles should move up
- Indicates TT
What is the over 80s BP target? [1]
> 150/90 or 145/85
State the different CKD levels [+]
Proteinuria is an important marker of chronic kidney disease, especially for diabetic nephropathy. NICE recommend using the albumin:creatinine ratio (ACR) in preference to the protein:creatinine ratio (PCR) when identifying patients with proteinuria as it has greater sensitivity.
How would you manage patients depending on their A:CR and comorbidities? [+]
ACE inhibitors (or angiotensin II receptor blockers) are key in the management of proteinuria
* they should be used first-line in patients with coexistent hypertension and CKD, if the ACR is > 30 mg/mmol
* if the ACR > 70 mg/mmol they are indicated regardless of the patient’s blood pressure
State the HTN medication pathway
A macrocytic anaemia in the presence of hyper-segmented neutrophil polymorphs on the blood film is likely to be a megaloblastic anaemia
The patient has symptoms of anaemia, glossitis, a macrocytosis and hyper-segmented neutrophils on the blood film. This is typical of a megaloblastic anaemia such as B12 or folate deficiency anaemia. Another key feature of a megaloblastic anaemia is the presence of megaloblasts and giant metamyelocytes within the bone marrow. Following a full blood count, a blood film is the suggested second-line test for megaloblastic anaemia (as per BMJ best practice). It is also common practice to test for haematinics as this may reveal low B12 or folate levels and hence identify the cause of macrocytosis.
Describe the COPD Mx pathway
How can you tell if a sickle cell patient has aplastic crisis from their blood results? [1]
Aplastic crises in sickle cell disease are associated with a sudden drop in haemoglobin
What are DMT1 sick day rules? [+]
- if a patient is on insulin, they must not stop it due to the risk of diabetic ketoacidosis
- check blood glucose more frequently, for example, every 1-2 hours including through the night
- consider checking blood or urine ketone levels regularly
- maintain normal meal pattern if possible
- if appetite is reduced meals could be replaced with carbohydrate-containing drinks (such as milk, milkshakes, fruit juices, and sugary drinks)
- aim to drink at least 3 L of fluid (5 pints) a day to prevent dehydration
Describe sick day rules for DMT2 for:
- metformin
- sulfonylureas
- SGLT-2 in
- GLP-1 agonists
Patients with type 2 diabetes
advise the patient to temporarily stop some oral hypoglycaemics during an acute illness
* medication may be restarted once the person is feeling better and eating and drinking for 24-48 hours
metformin: stop treatment if there is a risk of dehydration, to reduce the risk of lactic acidosis.
sulfonylureas: may increase the risk of hypoglycaemia#
SGLT-2 inhibitors: check for ketones and stop treatment if acutely unwell and/or at risk of dehydration, due to the risk of euglycaemic DKA
GLP-1 receptor agonists: stop treatment if there is a risk of dehydration, to reduce the risk of AKI
if on insulin therapy, do not stop treatment, as above
monitor blood glucose more frequently as necessary
Poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a standard-dose thiazide diuretic. K+ > 4.5mmol/l - add an [1]
Poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a standard-dose thiazide diuretic. K+ > 4.5mmol/l - add an alpha- or beta-blocker
Which antihypertensive class might cause constipation? [1]
Thiazide diuretics can cause hypercalcaemia and hypocalciuria
Which organisms commonly cause AOM? [3]
Streptococcus pneumonaie, Haemophilus influenzae and Moraxella catarrhalis
Describe the treatment pathway for BPH
alpha-1 antagonists e.g. tamsulosin, alfuzosin
- considered first-line: NICE recommend if moderate-to-severe voiding symptoms (IPSS ≥ 8)
5 alpha-reductase inhibitors e.g. finasteride
* block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH
* unlike alpha-1 antagonists causes a reduction in prostate volume and hence may slow disease progression. This however takes time and symptoms may not improve for 6 months
the use of combination therapy (alpha-1 antagonist + 5 alpha-reductase inhibitor) was supported by the Medical Therapy Of Prostatic Symptoms (MTOPS) trial and is also supported by NICE: ‘If the man has bothersome moderate-to-severe voiding symptoms and prostatic enlargement’
if there is a mixture of storage symptoms and voiding symptoms that persist after treatment with an alpha-blocker alone, then an antimuscarinic (anticholinergic) drug such as tolterodine or darifenacin may be tried
Describe the treatment pathway for DMT2
Metformin remains the first-line drug of choice in type 2 diabetes mellitus.
* metformin should be titrated up slowly to minimise the possibility of gastrointestinal upset
* if standard-release metformin is not tolerated then modified-release metformin should be trialled
SGLT-2 inhibitors
* should also be given in addition to metformin if any of the following apply:
* the patient has a high risk of developing cardiovascular disease (CVD, e.g. QRISK ≥ 10%)
* the patient has established CVD
* the patient has chronic heart failure
* metformin should be established and titrated up before introducing the SGLT-2 inhibitor
* SGLT-2 inhibitors should also be started at any point if a patient develops CVD (e.g. is diagnosed with ischaemic heart disease), a QRISK ≥ 10% or chronic heart failure
Second-line therapy
* Dual therapy - add one of the following:
* metformin + DPP-4 inhibitor
* metformin + pioglitazone
* metformin + sulfonylurea
* metformin + SGLT-2 inhibitor (if NICE criteria met)
Third-line therapy
* If a patient does not achieve control on dual therapy then the following options are possible:
* metformin + DPP-4 inhibitor + sulfonylurea
* metformin + pioglitazone + sulfonylurea
* metformin + (pioglitazone or sulfonylurea or DPP-4 inhibitor) + SGLT-2 if certain NICE criteria are met
* insulin-based treatment
