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GP Core Conditions Flashcards

1
Q

Dx asthma

1) Gold standard
2) Others (X2)

A

1) Spirometry FEV1:FVC <0.7
2)
Clinical Dx- recurrence, wheeze, diurnal variation, Atopy in FHx
PEFR- Best of 3 within 40L/min; 2 readings/day for 2 weeks

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2
Q

Asthma annual review- what 4 things do you cover?

A

1) Symptom control- sleeping? Symptoms during day? Interference with activities and cotrico use/time off
2) Lung function- PEFR/Spiro if needed
3) Check inhaler function/Compliance
4) Asthma action plan- 2 cans of Salbutamol/Month is poor control- intensify therapy

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3
Q

Step wise treatment of chronic asthma (BTS guidelines)

~6 steps

A

1) Short acting B2 agonist
2) ICS- Beclometasone 200-800mg
3) + LABA (Salmetrol)
4) Increase ICS dose to max 800mg
5) Leukotriene R antagonist or sustained release theophylline
6) Referral, 4th drug? Inc ICS

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4
Q

What are 4 signs of poor asthma control; indicating escalation to ICS therapy from SABA?

A

1) 3+ Uses of SABA/week
2) Symptoms 3+ times/week
3) Waking >1 time a week
4) An exacerbation in the last 2 years

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5
Q

COPD- How are these signs/symptoms different in Emphysema and bronchitis?

1) SOB
2) Cyanosis
2) Weight loss

A

1) SOB early and severe in Emphysema
2) Bronchitis cyanosed
3) Emphysema more likely to have muscle wasting and significant weight loss

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6
Q

Role of spirometry in COPD?

FEV1/FVC?

A

1) Dx
2) Monitor progression w/ other factors

FEV1?FVC <0.7

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7
Q

Staging of COPD using FEV1- what are the stages?

A

% of predicted

1) >80%
2) 50-79%
3) 30-49%
4) < 30% (<50% + risk factors)

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8
Q

Comment on the uses of the below in COPD Dx

1) Reversibility testing
2) Key signs
3) Post-bronchodilator spirometry
4) FBC, BMI, CXR

A

1) Not needed; only useful if ?Asthma
2) Accessory muscle use, cricosternal distance <3cm, Dec sounds, no diurnal variation
3) Reconsider Dx if marked improvement in symptoms
4) PCV, Anaemia
Low
Exclude other Dx

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9
Q

In COPD what should happen to FEV1/FVC with inhaled therapy?

A

Should NOT normalise- NO reversibility

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10
Q

5 grades of the Medical Research council dyspnoea scale

A

Grade 1: not troubled by breathlessness except on strenuous exertion.
Grade 2: short of breath when hurrying on level ground or walking up a slight incline.
Grade 3: walks slower than contemporaries because of breathlessness, or has to stop for breath when walking at own pace.
Grade 4: stops for breath after walking about 100 metres or stops after a few minutes of walking on level ground.
Grade 5: too breathless to leave the house or breathless on dressing or undressing.

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11
Q

COPD management

1) What vaccine are needed? (2X)
2) Lifestyle advice
3) Criteria for Rehabilitation?

A

1) Pneumococcal/Influenza
2) Stop smoking, encourage mobility, Good diet to ameliorate Wx loss
3) MCP >/= 3 or symptoms infringe on QoL

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12
Q

Chronic COPD management

1) 1st line
2) The presence of what feature decides how you should escalate
3) 2nd Line
4) Triple therapy?

A

1) SABA or SAMA (Ipratropium)
2) Asthmatic features (PEFR/diurnal variation) as this indicates ICS responsiveness
3) No asthmatic features add LAMA (Tiotropium) Or LABA
Asthmatic features= LABA + ICS
4) LABA +LAMA + ICS

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13
Q

Chronic COPD management- What 2 drugs should you never use together?

A

SAMA and LAMA

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14
Q

ECG signs of AF

A

Irregularly irregular PR

Absent P waves

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15
Q

Indications for a transthoracic echo in AF?

A

Check for emboli before cadioversion

Suspicion of structural/functional abnormality

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16
Q

When is a transoesophageal Echo needed in AF?

A

After transthoracic shows an abnormality
Transthoracic technically difficult
TRO guided cardioversion

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17
Q

Treating chronic AF- RATE control

1) Monotherapy?
2) Intensification?

A

1) Beta blocker or diltiazem (CCB)

2) Combine the above or add digoxin

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18
Q

Treating chronic AF- RATE control

1) What specific type of AF is digoxin best for?

A

Non-paroxysmal and pt is sedentary

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19
Q

Treating chronic AF- RATE control

1) HR target?
2) What does this change to if symptomatic?

A

1) <90 (Consider <110)

2) <80

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20
Q

Treating chronic AF- Rhythm control

1) When is this indicated?

A

1) Symptomatic, young, 1st presentation with lone AF, rate control is inadequate

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21
Q

Treating Chronic AF- Rhythm control

1) 1st line for rhythm control
2) Alternatives to above

A

1) Beta blocker (CI if asthmatic!)

2) Dronedarone or Amiodarone

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22
Q

Treating chronic AF- Rhythm control

1) Indications for Dronedarone

A

1) Successful Cardioversion, Paroxysmal/persistent AF, if 1st line rhythm control fails, IHD/TIA/DM/HTN/>70

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23
Q

Treating chronic AF- Rhythm control

1) Why would you consider Amiodarone> Dronedarone

A

1) LV impairment or HF

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24
Q

Treating chronic AF- Pill in the pocket

1) Indications?
2) CI?

A

1) Known precipitants, infrequent attacks

2) LVD, VHD, IHD in PMHx

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25
Treating chronic AF- Anticoagulation 1) What scoring systems do you use? (2) 2) What do they assess?
CHA2DS2- VAD- Stroke risk HAS-BLED- Bleeding risk
26
Treating chronic AF- Anticoagulation 1) CHA2DS2- VAD score needed for anticoagulation 2) HAS-BLED score that indications caution
1) Males= 1 Females = 2 | 2) Greater than or equal to 3
27
Treating Acute AF- What is indicated when... 1) < 48hrs + Haemodynamic instability 2) < 48 hrs + stable 3) > 48 hours
1) Electric cardioversion 2) Consider managing as >48 hrs 3) Cardioversion (DC or flecoinide) +/- Amiodarone (stating 4 weeks before)
28
Most common duration of TIA symptoms?
10-15 mins | Must be less than 24 hours to be TIA
29
Different categories of symptoms to consider for TIA/Stroke
``` Motor Sensory Meningism Pain Speech Cognition Consciousness Sight ```
30
What global symptoms make TIA less likely as the aetiology?
Unsteadiness Dizzy Syncope
31
Key stroke mimics?
``` Hypoglycaemia Migraine Seziure Bell's palsy MS ?Sepsis ```
32
CT target if stroke likely?
1 hr
33
What anti-platelet is indicated, and for how long, in TIA
300mg aspirin for 14 days | then an assessment within 24hrs by a specialist
34
TIA secondary prevention?
Lifestyle- Smoking and alcohol reduction. Encourage exercise. Atorvastatin 20-80mg BP lowering if HTN Anticoagulation ONLY if AF
35
Briefly outline acute stroke management
Exclude haemorrhage <4.5 hours then alteplase 300mg Aspirin 75 mg Clopidogrel
36
Define CKD
Abnormal renal function for > 3months | Progressive and Irreversible
37
What are the metabolic complications of CKD?
``` Normochromic normocytic anaemia Renal osteodystrophy Renal dysfunction (Nocturia, polyuria, salt retention/oedema) Accelerated CVD Platelet abnormalities, skin pigmentation, Pruritis Hyperkalaemia Metabolic acidosis Neuropathy ```
38
What symptoms help differentiate CKD from AKI?
CKD more likely if Wx loss, anorexia, pruritis and nocturia | Could be an Acute-on-chronic presentation
39
4 key investigations of CKD
eGFR (Superior to creatinine and urea) Proteinuria Haematuria Renal USS (Small echogenic kidneys)
40
How is proteinura useful for CKD? | Best way to detect this? GIVE VALUES!
Assessment and prognostic info (presence and quantity is a RF for progression) Albumin:Creatinine ratio (ACR) > 3mg/mmol is clinically significant
41
ACR in CKD 1) How do you measure ACR? 2) What value indicates no need to repeat? When do you repeat?
1) 24hr urine collection or morning urine 2) > 70 mg/mmol= no repeat needed as excessively high 3-70 then repeat (Anything > 3 suggests CKD)
42
Best way to detect Haematuria in CKD? | What result warrants further evaluation?
Reagent strips not urine microscopy | Greater than or equal to 1+
43
Indications for a Renal USS in CKD?
``` Accelerated progression Haematuria Symptoms of obstruction GFR< 30 Polycystic KD in FHx ```
44
What are the eGFR values for the different stages of CKD?
``` 1- > 90 NORMAL 2- 60-89 (Other evidence of CKD required) 3a- 45-59 (Moderate) 3b- 30-44 (Moderate) 4- 15- 29 (Severe) 5- <15 (Failure) ```
45
If the eGFR value is 60-90 in ?CKD what other evidence is required for a Dx?
Persistent microalbuminaemia/proteinuria/haematuria Structural abnormalities Biopsy proven glomerulonephritis
46
``` In CKD are the following likely to be raised or decreased? Na K Bicarb Alk Phos Ca Phos PTH Lipids ```
``` Na-Norm or Inc K- Inc Bicarb- Dec Alk Phos- Increased indicating bone disease Ca- ANY Phos- inc PTH- Inc with progressively declining function Lipids- Dyslipidaemia is commonn ```
47
3 key RF for CKD progression
1) Uncontrolled BP 2) Advanced stage/ Declining eGFR 3) Proteinuria
48
BP target in CKD if HTN? | What factors reduce this further and to what level?
Typically < 140/90 If DM or ACR of 70mg/mmol then <130/80
49
Indications for an ACEi for BP control in CKD?
DM + ACR >3 mg/mmol HTN + ACR >30 mg/mmol ACR >70 mg/mmol
50
If ACR< 30mg/mmol and there is HTN + CKD what is indicated?
Normal BP guidelines!
51
Before starting an ACEi in CKD what is important to check?
K+< 5 mmol/L and eGFR | Check before starting and 1-2 weeks after
52
When should fluid be restricted in CKD?
End-stage disease | Oliguria
53
What complication of CKD aggravates hyperkalaemia and renal osteodystrophy
Metabolic acidosis
54
2 key drugs in preventing CVD in CKD
``` Statin- Antorvastatin Antiplatelet therapy (Anticoagulate if AF) ```
55
3 stages of HTN
1) >140/90 2) 160/100 3) >180/110 (-5 from Sys and Dia if ABPM/HBPM)
56
What is accelerated HTN
>180/110 + Papilloedema + Retinal haemorrhage ? Phaeochromocytoma (If headaches and postural hypotension)
57
Explain how ABPM and HBPM is used in HTN Dx
ABPM- Min 2 measurements/hr, waking hours. > 14 total HBPM- 2x/day morn and evening, 4-7 days and discard 1st, two readings each a minute apart
58
Explain how QRISK2 is used to determine CVD risk and prevention How would you explain a 10% risk to a patient?
> 10%= Intermediate risk ?Statin | "If we lined 100 of you up and watched you over 10 years, 10 would have a CV event"
59
List non-idiopathic causes of HTN
Hypertenisve crisis ( >200/130, end organ damage) Phaeochromocytoma (Headaches and post.hypotension) Renal disease (ACR from urine sample) Thyroid disease Diet
60
BP target for <80 years, > 80 years and those with DM
``` <80= <140/90 >80= <150/90 DM= < 130/80 ```
61
When would you offer pharmacological intervention for HTN?
``` Stage 2 (>160/100) S1 + End organ damage/CKD/CVD/DM/QRISK2>20% ```
62
1st line for HTN + <55 yrs/Non-black
ACEi or ARB
63
1st line for HTN >55yrs
CCB like Amlodipine or Nifedipine
64
2nd line pharmacological treatment for resistant HTN
ACEi/ARB + CCB
65
3rd line pharmacological treatment for resistant HTN
ACEi/ARB + CCB + Thiazide diuretic (Indapamide)
66
When would you refer HTN to a specialist?
Underlying cause, Accelerated HTN, <40 yrs, Pregnancy, Triple therapy resistant
67
What NTproBNP level is indicative of an urgent HF referral? | WHat NTproBNP level is suspicious?
>2000 | 400-2000
68
If an ECG and/or NTproBNP is abnormal in ?HF what do they get sent for?
Transthoracic Echo (6 weeks if 400-2000, 2 weeks if >2000) +Bloods/Urine etc
69
Signs of HF on CXR
``` Alveolar oedema (BAT WINGS) Kerley B lines Cardiomegaly Dilated upper lobe vessels Pleural effusion ```
70
HF classification- | 1) What is the NYHA
1- No SOB on activity 2- SOB on activity 3- Less then ordinary activities cause SOB 4- SOB at rest
71
What is the Framingham Criteria for congestive HF
2 major simultaneously or 1 major + 2 minor Major: PND, crepitations, Neck vein distension, S3 gallop, Hepatojug reflex, Sig Wx loss 4.5Kg/5 days Minor: Bi-ankle oedema, SOB on norm activity, HR>120, Nocturnal cough, Hepatomegaly, Pleural effusion, 1/3rd decrease in VC
72
General pharmacological management of HF with decreased EF
ACEi + Beta blocker -> Add spironolactone or Digoxin
73
In CKD with eGFR <45 W/ Comorbid HF what is the patient at increased risk of if on Digoxin?
Hyperkalaemia | Lower dose and slower titrations
74
``` Describe the role of the below in the treatment of congestive HF Diuretics CCB Anticoagulation Amiodarone Vaccinations ```
Diuretics- Relief of congestive symptoms, FUROSEMIDE (LOOP) 1st line K+ sparing if <3.2 mmol/l CCB- Treat comorbid HTN/Angina (Avoid non-dihydropyridines if Dec.EFHF) Anticoagulation- Comorbid AF, Hx VTE, LV aneurysm Amiodarone-Specialist Vaccinations- Annual influenza, Pneumococcal
75
If a pt is symptomatic what blood results would be diagnostic of DM
Random >11.1 Fasting> 7 HbA1C >48 (re-check in 3 months)
76
If a pt is asymptomatic how many abnormal blood results are needed for DM diagnosis
2
77
Pre-diabetes HbA1C range and what intervention for this?
42-47 | Lifestyle changes
78
HbA1C target in DM
Aim <53 | 48 if on metformin and lifestyle changes
79
What HbA1C level indicates that therapy should be intensified?
``` >48= can start single agent (aim for target of 48 if lifestyle controlled and on met) First Intensification: MONO to DUAL RX If HbA1c >58mmol/mol/7.5% AIM for 53mmol/mol/7.0% Second Intensification: DUAL to TRIPLE If HbA1c >58mmol/mol AIM for 53mmol/mol/7.0% ```
80
Which T2DM medications pose a hypoglycaemia risk?
SU (Gliclazide), Thiazolidinesdiones (Pioglitazone), Gliptins
81
Common SE of metformin? | When should it be avoided?
N&V | eGFR<30/Before GA
82
Benefits of metformin?
Increases insulin sensitivity to counter resistance | Cardio-protective, reduces appetite, no hypo risk!
83
SE of gliclazide? | Does it counter insulin resistance?
Hypoglycaemia, Weight increase as appetite increases, | Notably does not counter insulin resistance only increases insulin secretion
84
Benefits of gliptins?
Wx neutral Good if poor kidney function Good Alt. to gliclazide if BMI>35 or Hypo risk
85
SE of gliptins?
Pancreatitis risk! HF risk! Hypo risk
86
Se of pioglitazone
Fractures Fluid retention LFTs Hypos
87
When is Pioglitazone CI?
Osteoporosis, CCF | Avoid if bladder cancer or impaired renal function
88
What is a requirement for SGLT-2 inhibitors (Empagliflozin)
Needs adequate kidney function as it reduces renal glucose reabsorption
89
SE of SGLT-2 inhibitors?
UTI, thrush, Wx loss, polyuria, nocturia
90
Unique risk of Canagliflozin?
DKA
91
When should gliclazide be avoided?
Elderly (at least monitor regularly)
92
GLP-1 mimetics mechanism
Inhibit glucagon secretion Slow gastric emptying (By inc incretin levels)
93
GLP-1 mimetics (-tide) benefits? Disadvantages?
Good impact on reducing CV risk Usually need injecting...
94
What is Acarbose?
``` Chewed at the start of a meal Decreases starch (+ sugar) Causes wind and abdo pain ```
95
What confirms the Dx of CHD/Angina in primary care
Exercise testing
96
What should be done if a pt has a QRISK2 > 10%?
Atorvastatin 20mg
97
Indications for 80mg Atorvastatin? What should be checked?
``` Hx MI/CHD T2DM ACS symptoms Total cholesterol> 4 LDL >2 ``` CHECK LFTs before/ 3 months/ 12 months (+ CI if pregnant)
98
Treatment steps for stable angina
GTN spay (2 doses 5 mins apart then 999) Beta blocker or CCB (Non-dihydro) Dual therapy (add isorbide mononitrate or nicorondil) Refer if on max doses
99
secondary prevention in CHD?
Antiplatelet Low dose aspirin 75mg or clopidogrel (PVD or stroke) ACEi if angina + DM Statin if QRISK > 10%
100
RF for frailty
Old, slow walking, Hx falls, confusion, dementia, cannot leave house, polypharmacy, need helps doing common tasks
101
Frailty definition
Weak. Delicate. Vulnerable. Not able to bounce back from an event. Associated with multimorbidity.
102
How do you calculate BMI?
weight (kg)/Height (m2)
103
BMI values for overweight and obesity
Obesity > 30 (>40 morbidly) | Overweight >25
104
What waist circumference values confer high risk of obesity?
``` M= >94cm F= >80cm ```
105
``` Normal cholesterol range for... Total chol HDL LDL T chol/HDL ```
Total chol- <5mmol/L HDL >1.2 mmol/L LDL <3 mmol/L T chol/HDL <4.5mmol/L
106
How would you explain what cholesterol is to a patient
A fatty substance needed for healthy functioning of the body | Part of every cell in the body
107
Examples for non-dihydropyridines CCB
Verapamil Diltiazem MORE INOTROPIC
108
Examples for Dihydropyridines CCB
Amlodipine Nifedipine Felodipine POTENT VASODILATORS
109
Common SE of CCB (5)
Swelling, dizziness, headaches, flushing, Nausea
110
Common SE of ACEi
Cough, Hypotension (Take at night), Impotence Rarely HYPERKALEMIA
111
What is indapamide
Thiazide like diuretic
112
Thiazides SE?
Polyuria, Hypokalaemia, Hyponatraemia Impotence Inc glucose, inc TG
113
Three key HBA1C values to remember for DM management
48- 53- 58 ``` >48= 1st drug >58= Add 2nd drug >58= 3rd drug ``` Aim for <53 on 2nd and 3rd steps
114
What can cause a raised urea
Inc protein BLEED CKD (low in liver failure)
115
When can creatinine values appear falsely abnormal
High muscle mass (too high) | Frail/Elderly (Too low)
116
Why is creatinine not the best marker for renal impairment
Insensitive marker of early impairment
117
When is dialysis indicated in CKD
eGFR <10 | Discuss when <20
118
What is paroxysmal AF
> 2 episodes terminating in 7 days
119
What is persistent AF
Continues > 7 days
120
Long standing AF is what
Continues >12 months
121
Permanent AF is when
There are not further attempts to restore sinus rhythm
122
When is rate control not 1st line in AF
Reversible cause (hyperthyroidism) AF induced HF New onset paroxysmal AF where rhythm control is more suitable

Year 4 CCC (3 decks)

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