GP Key Conditions Flashcards

(113 cards)

1
Q

Hypertension
Diabetes
Heart failure
Angina
Asthma
Fatigue
Polymyalgia
Fibromyalgia
COPD
Pneumonia
GORD
Crohn’s/UC/IBS
Osteoarthritis/rheumatoid/joint pain
Gout
Polymyalgia rheumatica
UTIs
MI/AF
DKA
ACS

A

S

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2
Q

What are the three stages of hypertension?

A

Stage 1- 140/90
Stage 2- 160/100
Stage 3- 180/120

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3
Q

What is defined as hypertension?

A

Over 140/90 in clinic

Over 135/85 outside of clinic

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4
Q

What are the investigations for hypertension?

A

Ambulatory blood pressure monitoring (ABPM)
`
Home blood pressure monitoring (HBPM)

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5
Q

What is the management of hypertension?

A

Lifestyle- salt, exercise, smoking, drinking

1st ACEi/ARB in U55/DM or CCB in O55, african with no DM

Then both

Then thiazide diuretic- bendroflumethiazide

if potassium < 4.5 mmol/l add low-dose spironolactone
if potassium > 4.5 mmol/l add an alpha- or beta-blocker

Refer if not controlled with 4 drugs

Treat stage 2 whatever

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6
Q

General management of COPD?

A

Lifestyle changes- smoking cessation, flu vaccine

SABA or SAMA

Asthma features?
Yes- LABA+ICS
No- LABA+LAMA

SABA+LABA+LAMA+ICS

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7
Q

What is type 1 diabetes?

A

Autoimmune disorder where the insulin-producing beta cells of the islets of Langerhans in the pancreas are destroyed by the immune system

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8
Q

Signs of type 1 diabetes?

A

Weight loss
Polydipsia
Polyuria

May present with diabetic ketoacidosis
abdominal pain
vomiting
reduced consciousness level

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9
Q

Signs of type 2 diabetes?

A

Often picked up incidentally on routine blood tests
Polydipsia
Polyuria

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10
Q

Diagnostic thresholds for diabetes?

A

If the patient is symptomatic:

Fasting glucose greater than or equal to 7.0 mmol/l

Random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test)

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11
Q

HbA1c diabetes level?

A

Over 48 mmol/mol (6.5%)

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12
Q

T1DM management?

A

HbA1c monitored every 6 months

Self monitor glucose levels at least 4 times a day

offer multiple daily injection basal–bolus insulin regimens, rather than twice‑daily mixed insulin regimens, as the insulin injection regimen of choice for all adults
twice‑daily insulin detemir is the regime of choice. Once-daily insulin glargine or insulin detemir is an alternative
offer rapid‑acting insulin analogues injected before meals, rather than rapid‑acting soluble human or animal insulins, for mealtime insulin replacement for adults with type 1 diabetes

Add metformin if BMI over 25

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13
Q

T2DM management?

A

Dietary/lifestyle advice

1st- Metformin

2nd- metformin + DPP-4 inhibitor
metformin + pioglitazone
metformin + sulfonylurea- gliclazide
metformin + SGLT-2 inhibitor (if NICE criteria met)

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14
Q

DKA features?

A

Abdominal pain

Polyuria, polydipsia, dehydration

Kussmaul respiration (deep hyperventilation)

Acetone-smelling breath (‘pear drops’ smell)

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15
Q

Diabetes investigations?

A

Urine should be dipped for glucose and ketones

Fasting glucose and random glucose (see below for diagnostic thresholds)

HbA1c is not as useful for patients with a possible or suspected diagnosis of T1DM as it may not accurately reflect a recent rapid rise in serum glucose

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16
Q

Features of chronic heart failure?

A

dyspnoea
cough: may be worse at night and associated with pink/frothy sputum
orthopnoea
paroxysmal nocturnal dyspnoea
wheeze (‘cardiac wheeze’)
weight loss (‘cardiac cachexia’): occurs in up to 15% of patients. Remember this may be hidden by weight gained secondary to oedema
bibasal crackles on examination
signs of right-sided heart failure: raised JVP, ankle oedema and hepatomegaly

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17
Q

What is the investigation for heart failure?

A

N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test first-line

if levels are ‘high’ arrange specialist assessment (including transthoracic echocardiography) within 2 weeks

if levels are ‘raised’ arrange specialist assessment (including transthoracic echocardiography) echocardiogram within 6 weeks

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18
Q

Management of chronic heart failure?

A

1st- ACE-inhibitor and a beta-blocker

2nd- aldosterone antagonist- spironolactone

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19
Q

Treatment of acute heart failure?

A

IV loop diuretics- furosemide, bumetanide

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20
Q

Stable angina management?

A

All patients recieve aspirin and statin

Siblingual glyceral trinitrate to abort angina attacks

BB or calcium channel blocker first line

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21
Q

Asthma management adults?

A

SABA

SABA + low dose ICS

SABA + ICS + LTRA

SABA + ICS + LABA (can continue LTRA)

SABA+- LTRA + MART low dose ICS

SABA+- LTRA + MART med dose

SABA+- LTRA
and either
Increase to high dose ICS not as part of MART
Trial theophylline
Specialist help

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22
Q

Signs and symptoms of asthma?

A

Symptoms
cough: often worse at night
dyspnoea
‘wheeze’, ‘chest tightness’

Signs
expiratory wheeze on auscultation
reduced peak expiratory flow rate (PEFR)

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23
Q

How long for chronic fatigue to be diagnosed?

A

After 3 months of disabling fatigue affecting mental and physical function more than 50% of the time in the absence of other disease which may explain symptoms

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24
Q

Investigations of chronic fatigue syndrome?

A

NICE guidelines suggest carrying out a large number of screening blood tests to exclude other pathology e.g. FBC, U&E, LFT, glucose, TFT, ESR, CRP, calcium, CK, ferritin, coeliac screening and also urinalysis

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25
Management of chronic fatigue syndrome?
Specialist CFS service Energy management Physical activity and exercise CBT
26
What are the features of polymyalgia rheumatica?
Typically patient > 60 years old Usually rapid onset (e.g. < 1 month) Aching, morning stiffness in proximal limb muscles Weakness is not considered a symptom of polymyalgia rheumatica Also mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats
27
Investigations for polymyalgia rheumatica?
Raised inflammatory markers e.g. ESR > 40 mm/hr Note creatine kinase and EMG normal
28
What is the treatment for polymyalgia rheumatica?
Prednisolone e.g. 15mg/od Patients typically respond dramatically to steroids, failure to do so should prompt consideration of an alternative diagnosis
29
What is fibromyalgia?
Fibromyalgia is a syndrome characterised by widespread pain throughout the body with tender points at specific anatomical sites. The cause of fibromyalgia is unknown. Women 5x Between 30-50
30
What are the features of fibromyalgia?
Chronic pain: at multiple site, sometimes 'pain all over' Lethargy Cognitive impairment: 'fibro fog' Sleep disturbance, headaches, dizziness are common
31
Diagnosis and management of fibromyalgia?
Diagnosis is clinical and sometimes refers to the American College of Rheumatology classification criteria which lists 9 pairs of tender points on the body. If a patient is tender in at least 11 of these 18 points it makes a diagnosis of fibromyalgia more likely Explanation Aerobic exercise: has the strongest evidence base Cognitive behavioural therapy Medication: pregabalin, duloxetine, amitriptyline
32
What are the features of COPD?
Cough: often productive Dyspnoea Wheeze In severe cases, right-sided heart failure may develop resulting in peripheral oedema Smoking is the cause
33
COPD investigations?
Post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70% Chest x-ray hyperinflation bullae: if large, may sometimes mimic a pneumothorax flat hemidiaphragm also important to exclude lung cancer Full blood count: exclude secondary polycythaemia Body mass index (BMI) calculation
34
COPD management?
General advice: >smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion annual influenza vaccination one-off pneumococcal vaccination pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above) 1st- SABA or SAMA as required Determine if steroid response- previous asthma/atopy, raised eosinophil etc Yes- SABA + LABA+ ICS No- SABA + LABA + LAMA SABA + LABA + LAMA + ICS
35
Pneumonia signs and symptoms?
Symptoms cough sputum dyspnoea chest pain: may be pleuritic fever Signs signs of systemic inflammatory response fever tachycardia reduced oxygen saturations auscultation: reduced breath sounds bronchial breathing
36
Management pneumonia?
Patients with pneumonia require the following: antibiotics: to treat the underlying infection supportive care, for example: oxygen therapy if the patient is hypoxaemic intravenous fluids if the patient is hypotensive or shows signs of dehydration Most common organism Streptococcus pneumoniae
37
CURB-65?
C Confusion (abbreviated mental test score <= 8/10) U urea > 7 mmol/L R Respiration rate >= 30/min B Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60 mmHg 65 Aged >= 65 years consider home-based care for patients with a CURB65 score of 0 or 1 - low risk (less than 3% mortality risk) consider hospital-based care for patients with a CURB65 score of 2 or more - intermediate risk (3-15% mortality risk) consider intensive care assessment for patients with a CURB65 score of 3 or more - high risk (more than 15% mortality risk)
38
Features crohns vs uc?
Crohns Diarrhoea usually non-bloody Weight loss more prominent Upper gastrointestinal symptoms, mouth ulcers, perianal disease Abdominal mass palpable in the right iliac fossa Lesions may be seen anywhere from the mouth to anus Skip lesions may be present Inflammation in all layers from mucosa to serosa increased goblet cells granulomas Small bowel enema UC Bloody diarrhoea more common Abdominal pain in the left lower quadrant Tenesmus Inflammation always starts at rectum and never spreads beyond ileocaecal valve Continuous disease No inflammation beyond submucosa (unless fulminant disease) - inflammatory cell infiltrate in lamina propria neutrophils migrate through the walls of glands to form crypt abscesses depletion of goblet cells and mucin from gland epithelium granulomas are infrequent Barium enema
39
Crohn's investigations?
Bloods- CRP MC&S Faecal calprotectin Colonoscopy, bowel biopsy MRI to assess Cx
40
Crohn's treatment?
Stop smoking, optimise nutrition Induce and maintain remission Oral prednisolone Severe - IV fluids, IV steroids Azathioprine (immunosuppressant) Infliximab Surgery - not curative
41
Crohn's presentation?
signs bowel ulceration abdo tenderness perianal abscess/fistulae mouth ulcers finger clubbing conjunctivitis, episcleritis, iritis associated with spondyloarthropathies symptoms diarrhoea abdo pain wt loss fatigue, fever, malaise, anorexia
42
UC presentation?
signs during attack - fever, tachycardia, tender distended abdo, anorexia, malaise, wt loss extraintestinal signs - clubbing, oral ulcer, erythema nodosum, inflammatory pustule, conjunctivitis, episcleritis, iritis, large joint arthritis, ankylosing spondylitis, primary sclerosing cholangitis symptoms episodic/chronic diarrhoea +/- blood, mucus bowel urgency tenesmus crampy abdo discomfort
43
UC investigations?
Bloods - FBC, ESR, CRP, U+E, LFT, culture Stool MC&S Faecal calprotectin - test for GI inflammation AXR - no faecal shadows, mucosal thickening, colonic dilatation Lead-pipe colon on barium X ray Lower GI endoscopy
44
UC management?
Avoid foods that cause flare ups mild Aminosalicylate - mesalazine/mesalamine topical steroid - prednisolone moderate oral prednisolone 5-ASA severe IV fluids IV steroids Maintain remission- Azathioprine, mesalazine Surgery - colectomy
45
OA features?
signs reduced range of movt pain on movt joint swelling, instability tenderness crepitus absence of systemic features (fever, rash) bone swelling and deformity from osteophytes (Herbedens - DIP, Bouchards - PIP) Asymmetrical joint involvement symptoms pain exacerbated by exercise, relieved by rest reduced function worsens with prolonged activity stiffness in morning <30min/none
46
OA investigations?
A X-ray - LOSS Loss of joint space Osteophyte formation Subchondral sclerosis Subchondral cysts FBC - CRP maybe raised MRI Joint aspiration - exclude septic arthritis, gout
47
OA management?
Exercise, wt loss Physio/occ therapy, walking aids Analgesia- topical/oral NSAIDs Joint steroid injections Surgery - joint replacement / fusion
48
RA features?
signs inflammation - red, hot, pain, swelling symmetrical, polyarthropathy of smaller joints (MCP, PIP, wrist, MTP joints) loss of function deformity (swan neck, boutonniere, z-thumb, ulnar deviation, subluxation) extra-articular involvement (see cx) symptoms pain worse in morning, stiffness >30min fatigue, malaise pain progressively gets worse
49
RA investigations?
Bloods - anaemia, high ESR/CRP RF - positive in 60-70% anti-CCP X-ray - LESS loss of joint space erosions (focal) soft tissue swelling soft bones (osteopenia)
50
RA management?
Physio/occ therapy, podiatry, surgery, stop smoking DMARDs - methotrexate, sulfasalazine, hydroxychloroquine Prednisolone- can be used in conjunction with DMARDs or for flares Biological agents - TNF inhibitors, B-cell depletion NSAIDs - ibuprofen, naproxen, diclofenac Analgesics - paracetamol, codeine CRP used to monitor
51
Gout features?
hot, swollen joints shiny red, taut pain inflammation, fever, malaise tophi - long-term (large crystal deposits)
52
Gout investigations?
X-ray - BETS Bony hooks (from erosions) Erosions - punched out Tophi - more opaque Space intact (no loss of joint space) Polarised light microscopy of aspirated synovial fluid - negative birefringent needles U+E - serum uric acid, urea, creatinine USS/CT/MRI
53
Gout management?
NSAIDs, colchicine (inhibits phagocyte activation, inflammation), Oral steroids Lose weight, reduce diet factors Allopurinol / febuxostat (inhibits purine conversion into uric acid by xanthine oxidase)
54
Polymyalgia rheumatica features?
Inflammatory condition of unknown cause, often coexists with GCA, kind of a large vessel vasculitis sub acute onset <2wks sudden onset severe pain, stiffness of shoulders, neck, hips, lumbar spine (limb girdle pattern) symptoms worse in morning mild polyarthritis of peripheral joints fatigue, fever, wt loss, depression
55
Polymyalgia rheumatica investigations?
Clinical history ESR/CRP raised ANCA negative serum ALP raised Mild anaemia (normocytic, normochromic) Temporal artery biopsy - GCA Creatinine kinase normal - distinguish from myopathies
56
Polymyalgia rheumatica management?
Prednisolone long-term- big response lansoprazole and alendronate to prevent osteoporosis and GI upset
57
HTN presentation?
Asym Retinal haemorrhage, papilloedema, headaches - malignant htn
58
HTN invvestigations?
24hr ABPM Urinalysis, bloods, fundoscopy, ECG, echo
59
HTN Mx
Lifestyle ACEi (under 55yo)/CCB (55+, afro-caribbean) Then the other one Then thiazide Then another diuretic (spironolactone), alpha/beta blockers
60
HF presentation?
SOB, fatigue, ankle swelling signs tachycardia displaced apex beat (LV dilatation) RV heave (pul HTN) added heart sounds - gallop (S3), murmurs, raised JVP hepatomegaly ascites peripheral oedema PO cyanosis pleural effusions symptoms SOB, fatigue cold peripheries PND - paroxysmal nocturnal dyspnoea nocturnal cough (maybe pink frothy sputum) orthopnoea (SOB when lying down) wheeze light-headed/syncope NYHA classification for severity I-IV
61
HF Ix
Bloods - brain natriuretic peptide - secreted in ventricles in response to increased myocardial wall stress - if normal, HF unlikely, and other blood tests ECG - underlying causes - ischaemia, LVH, arrhythmia ECHO CXR - ABCDE Alveolar oedema (bat's wing shadowing) Kerley B lines - septal lines Cardiomegaly - cardiothoracic ratio >50% Dilated prominent upper lobe veins (upper lobe diversion) Pleural Effusions
62
HF Mx
lose weight, exercise, stop smoking Diuretics - furosemide, thiazide, spironolactone ACEi - ramipril, enalapril (S/E cough, hypotension, hyperkalaemia, renal dysfunction) ARB BB - bisoprolol Surgery to repair cause, heart transplant
63
DM Ix
random plasma glucose >11.1mmol/L fasting plasma glucose >7mmol/L OGTT >7mmol/L (>6 for impaired glucose tolerance) HbA1c >6.5% normal (48mmol/mol)
64
DM complications
Macrovascular - atherosclerosis, stroke, IHD, PAD Microvascular - diabetic retinopathy, nephropathy, neuropathy, infections DKA, HHS, hypoglycaemia
65
DM presentation
signs ketonuria (ketoacidosis) - pear drop breath (T1) complications (eg retinopathy) symptoms polyuria/nocturia polydipsia weight loss T1 - leaner than T2
66
T1DM Mx
synthetic human insulin short acting insulins - eg for before meals sort-acting insulin analogues - fast onset, eg with evening meal longer-acting insulins - 12-24hrs complications - hypoglycaemia, weight gain
67
T2DM Mx
1st line - lifestyle - diet, exercise, weight loss, ramipril/statins/orlistat 2nd - oral metformin Add sulfonylurea (oral gliclazide) later - insulin/glitazone (oral pioglitazone) - increase tissue sensitivity to insulin
68
DKA overview
Ketonaemia (/ketonuria) Hyperglycaemia Acidosis
69
DKA presentation
signs Pear drop breath Kussmaul’s respiration (deep, rapid) Disturbance of consciousness symptoms Vomiting Drowsiness Abdo pain Dehydration - eyes sunken, slow cap refill, tachycardia, weak pulse, hypotension
70
DKA Ix
Bloods show: hyperglycaemia, raised plasma ketones, acidaemia, metabolic acidosis with bicarb reduced Urine stick testing - glycosuria and ketonuria Check plasma osmolality and anion gap (both elevated, plasma osmolality more elevated in HSS)
71
DKA Tx
ABCDE Replace fluid loss with 0.9% saline Restore electrolye (K) loss and acid-base balance Insulin-glucose
72
Stable angina Px
Provoked by exertion - after meal, cold, windy, exercise, angry/excited signs sweaty distressed ``` symptoms central chest tightness or heaviness pain may radiate SOB nausea, feeling faint ```
73
Stable angina Ix
``` ECG - may be normal, ST depression, flat/inverted T waves Treadmill test/exercise ECG Bloods - FBC to exclude anaemia ECHO CXR Coronary angiography ```
74
Stable angina Mx
Modify RFs - stop smoking, exercise, lose weight, atorvastatin Aspirin GTN - dilates systemic veins, reducing venous return to heart, reduces preload, also dilates coronary arteries BBs - atenolol, bisoprolol CCB - verapamil Long acting nitrates Ivabradine - HCN channel blocker, reduces HR Maybe surgery - PCI, CABG
75
Asthma patho
narrowing of airway, SM contraction, airway wall thickening by cellular infiltration, inflammation, secretions Eosinophilic - associated with allergy, subset of atopic/non-atopic Non-eosinophilic - later onset, overlaps with smoking, obesity, neutrophils instead of eosinophils RFs FHx, atopy, low SES, inner city environ, obesity, premature, viral infections in early childhood, smoking
76
Asthma Px
symptoms intermittent SOB wheeze cough (often nocturnal) sputum chest tightness signs tachypnoea audible wheeze - widespread, polyphonic hyperinflated chest hyper-resonant percussion note reduced air entry
77
Levels of acute asthma atttack
Moderate increasing symptoms PEF >50-75% no features of severe attack Severe cannot complete sentences HR >110 RR >25 PEF 33-50% predicted Life-threatening silent chest confusion exhaustion cyanosis bradyacardia PEF <33% Sats <92% hypotension Near fatal PaCO2 increase
78
Asthma Ix
Blood count - eosinophils Atopy/allergy (SPT, RAST) CXR Spirometry / peak flow Reduced FEV1, FEV1/FVC <70% PEFR reduced, >20% variability FeNO test level of NO in breath - measure of inflammation BDR test (bronchodilator reversibility) see if obstruction gets better with bronchodilator medication Direct bronchial challenge see if breathing worsens worsens with provocation agent (methacholine/histamine)
79
Acute Asthma Mx
Acute attack Assess severity - PEF, ability to speak, RR, HR, sats O2 Salbutamol Ipratropium if severe Hydrocortisone/prednisolone Reassess every 15 mins ECG Magnesium sulfate if not responding
80
BPH Px
signs abdo exam - enlarged bladder symptoms LUTS - frequency, urgency, hesitancy, incomplete bladder emptying, need to push/strain, nocturia, poor stream/flow, post-micturition dribbling, UTI, haematuria,
81
BPH Ix
DRE - prostate enlarged, smooth Serum electrolytes, renal USS - exclude renal damage Transrectal USS - see prostate PSA may be raised in large BPH Biopsy, endoscopy Low flow rate Frequency vol chart - nocturia
82
BPH Mx
avoid caffeine, alcohol, void twice in a row Alpha 1 antagonist - oral tamsulosin - relaxes SM in bladder neck. S/E drowsiness, dizziness, ejaculatory failure. CI postural hypotension 5-alpha-reductase inhibitor - oral finasteride - blocks testosterone -> dihydrotestosterone (active form, responsible for prostatic growth). S/E impotence, decreased libido Surgery - TURP, TUIP, open prostatectomy
83
COPD Px
signs tachypnoea use of accessory muscles of resp (might lean forward) hyperinflation (barrel shaped chest) decreased expansion resonant/hyper-resonant percussion note expiration through pursed lips quiet breath sounds cyanosis cor pulmonale, peripheral oedema, raised JVP cachexia symptoms SOB cough sputum wheeze minimal diurnal variation wt loss PP vs BB PP - increased alveolar ventilation, normal PaO2, breathless, not cyanosed BB - decreased alveolar ventilation, low PaO2, high PaCO2, cyanosed, not breathless, resp centres insensitive to CO2, rely on hypoxic drive
84
COPD Ix
Spirometry - FEV1/FVC < 0.7, FEV1 < 80% CXR - hyperinflation, flat hemidiaphragms, large central pulmonary arteries, bullae CT - bronchial wall thickening, scarring, air space enlargement ECG - cor pulmonale ABG - decreased PaO2 +/- hypercapnia FBC - identify anaemia / polycythaemia MRC SOB scale, NICE COPD severity classification
85
COPD Mx
Stop smoking, influenza and pneumonia vaccines, pulmonary rehab Bronchodilators SABA - salbutamol LABA - salmeterol, formoterol SAMA - ipratropium LAMA - tiotropium Theophylline - bronchodilator, suppresses airway response to stimuli ICS - beclometasone, fluticasone Combination therapy of above Oxygen therapy NIV (non-invasive ventilation) Phosphodiesterase t4 inhibitors - anti-inflammatory - eg roflumilast Mucolytics Surgery - bullectomy, lung volume reduction surgery, transplant OVERALL SABA / SAMA If steroid responsive / asthmatic = add LABA + ICS If not steroids responsive / non-asthmatic = add LABA + LAMA Oral theophylline Long term oxygen therapy Do not prescribe LAMA and SAMA together, if started on LAMA, remove SAMA
86
COPD acute exacerbation
acute worsening of symptoms commonly viral cause, also bacterial, air pollutants Tx - nebulised bronchodilators, O2, steroids, ABs, aminophylline/theophylline, doxapram (respiratory stimulant drug), NIV
87
BPH Px
signs abdo exam - enlarged bladder symptoms LUTS - frequency, urgency, hesitancy, incomplete bladder emptying, need to push/strain, nocturia, poor stream/flow, post-micturition dribbling, UTI, haematuria,
88
BPH Ix
DRE - prostate enlarged, smooth Serum electrolytes, renal USS - exclude renal damage Transrectal USS - see prostate PSA may be raised in large BPH Biopsy, endoscopy Low flow rate Frequency vol chart - nocturia
89
BPH Mx
avoid caffeine, alcohol, void twice in a row Alpha 1 antagonist - oral tamsulosin - relaxes SM in bladder neck. S/E drowsiness, dizziness, ejaculatory failure. CI postural hypotension 5-alpha-reductase inhibitor - oral finasteride - blocks testosterone -> dihydrotestosterone (active form, responsible for prostatic growth). S/E impotence, decreased libido Surgery - TURP, TUIP, open prostatectomy
90
Prostate cancer Px
LUTS nocturia hesitancy poor stream terminal dribbling obstruction wt loss, bone pain, anaemia
91
Prostate cancer Ix
DRE - hard, irregular prostate Raised PSA Trans-rectal ultrasound scan (TRUSS), biopsy Urine biomarkers, MRI
92
Prostate cancer Mx
no spread prostatectomy, radiotherapy, hormone therapy metastatic orchidectomy LHRH agonist - goserelin/leuprorelin Androgen receptor blockers - bicalutamide for symptoms - analgesia, tx metastases, radiotherapy
93
Hyperthyroidism
Excess TH Primary - pathology in thyroid gland Secondary - thyroid gland stimulated by excessive TSH
94
Primary hyperthyroidism causes
Graves disease - autoimmune induced excess TH secretion, diffuse goitre, Toxic multinodular goitre - nodules that secrete TH Adenoma Thyroiditis (De Quervain’s) - transient, inflammation of thyroid Drug-induced - amiodarone, iodine, lithium
95
Secondary hyperthyroidism causes
TSH-secreting pituitary adenoma TH-resistance syndrome Gestational thyrotoxicosis
96
Hyperthyroidism presentation
signs Graves ophthalmopathy - retro-orbital inflammation, protruding eye diffuse goitre hyperkinesis muscle wasting thin hair lid lag and stare, lid retraction onycholysis (nail separation from nail bed) Hyperthyroidism Ixsymptoms palpitations diarrhoea weight loss oligomenorrhea heat intolerance irritability/anxiety
97
Hyperthyroidism Ix
TFTs - T4/3 raised (TSH raised in secondary) ABs against thyroid peroxidase and thyroglobulin (Graves) Ultrasound thyroid, thyroid uptake scan inflammatory markers TSHR-Ab raised - diagnostic of Graves
98
Hyperthyroidism Tx
(IV methylprednisolone - for inflammation) BBs (propanolol) PTU (propylthiouracil) - stops T4 ->T3 Oral carbimazole - blocks TH synthesis - AGRANULOCYTOSIS risk (sore throat, fevers) Radioactive iodine Thyroidectomy
99
Hypothyroidism
Lack of TH Primary - thyroid gland disease Secondary - hypothalamic/pituitary disease
100
Hypothyroidism causes
Autoimmine - antithyroid autoantibodies - atrophy, no goitre Thyroiditis (Hashimoto’s - is autoimmune) - atrophy, goitre Post-partum thyroiditis Thyroidectomy/radioactive iodine Drug-induced - carbimazole, lithium, amiodarone Iodine deficiency
101
Hypothyroidism presentation
signs - BRADYCARDIC Bradycardia Reflexes relax slowly Ataxia Dry, thin hair/skin Yawning/drowsy/coma Cold hands/temp drop Ascites Round puffy face Defeated demeanour Immobile/ileus (peristalsis stops) CCF symptoms hoarse voice goitre constipation cold intolerant weight gain myalgia low mood hair/eyebrow loss cold pale skin
102
Hypothyroidism Ix
TFTs - TSH high in primary, low in secondary, T4 low Bloods - anaemia…
103
Hypothyroidism Tx
Oral levothyroxine (T4)
104
Acute coronary syndrome
STEMI, NSTEMI, unstable angina patho - thrombus
105
STEMI
complete occlusion of major coronary artery, full thickness damage to heart muscle, troponin release
106
NSTEMI
complete occlusion of minor artery or partial occlusion of major artery, partial thickness damage, troponin release
107
Unstable angina
angina of increasing frequency/severity, partial occlusion but no damage to heart, occurs on minimal exertion/at rest, no troponin
108
ACS RFs
ABCDEF age, BP, cholesterol, diabetes, exercise, fags, fat, family
109
ACS Px
Silent MI - no chest pain - elderly, diabetic signs distress, anxiety pallor pulse low/high BP high/low 4th heart sound signs of HF - raised JVP, 3rd heart sound, basal crepitations pansystolic murmur maybe symptoms central chest pain N+V, fatigue sweaty SOB palpitations
110
ACS Ix
ECG STEMI - ST elevation, pathological Q waves, tall T waves, new LBBB NSTEMI - ST depression, T wave inversion, maybe normal ECG Unstable angina - normal ECG usually Troponin - I/T - raised in MI CXR ECHO Bloods - FBC, U+E, glucose, lipids,
111
ACS Mx
MONA Morphine Oxygen Nitrates - GTN spray Aspirin \+ P2Y12 inhibitor - clopidogrel, ticagrelor BBs - atenolol ACEi - ramipril Statin - atorvastatin Thrombolysis if indicated PCI/CABG if indicated Modify risk factors - stop smoking, lose weight, healthy diet, control diabetes
112
≥65 and on long-term steroids should be offered bone protection even without a DEXA scan
Alendronic acid Prednisolone for polymyalgia rheumatica
113
AF?
Symptoms palpitations dyspnoea chest pain Signs an irregularly irregular pulse Investigations- ECG- irregularly irregular 1. Rate control- BB or rate limiting CCB- diltiazem Can add digoxin eventually