Flashcards in GP rotation Deck (96):
do we give amoxycillin for a patient with swollen oedematous tonsils?
No! bc it may be EBV virus and giving amoxycillin and augmentin may bring out a rash
what criteria do we use for a child with possible strep pharyngitis?
FACEL (centor criteria)
A- age less than 14
C- cough absent
E- exudate on tonsils
what criteria do we use for headscanning post head injury?
Seizure, LOC, amnesia, vomiting greater than 5 times ( for children)
how do we surgically manage an ingrown toenail?
what are murtagh's 7 masquerades?
depression, diabetes, drugs, anaemia, thyroid, UTI, referred pain from spine
Impaired fasting glucose means?
IFG is when you have impaired fasting glucose (higher than 6 mmols/L) but the glucose levels do NOT abnormally rise with 75g of glucose drink (OGTT)
Impaired glucose tolerance means?
IGT is when the blood glucose levels at 2hrs in the OGTT is higher than normal, but not high enough to be classified as diabetes
a 35 yr old patient first presents with reflux symptoms. What is your first line of action? when is endoscopy indicated?
First line- trial of PPI for 1 month. If it improves with PPI then this is good enough for a diagnosis of reflux.
If reflux continues post PPI for 1 month, or there are other red flag symptoms such as dysphagia, LOW, iron deficiency anaemia etc then order a gastroscope
what are the aus cardio risk cut offs for high/med/low risk?
high greater than 15, med greater 10, low less than 10%
who do we consider to be automatically at high risk of a CVD event in the next 5 years?
· Familial hypercholesterolemia
· Diabetes + >60
· Diabetes + microalbuminuria
· Mod-severe CKD
· BP > 180 or >110
· Total cholesterol >7.5
Existing CVD (previous event, symptomatic CVD), stroke,TIAs or CKD
when do we start cardiovascular risk assessments and how often do we do them?
at age 45 and every 2 years or at 35 year old for aboriginal patients
how do we manage patients with high cvd risk scores?
intensive lifestyle advice SNAP
Commence cholesterol lowering therapy simultaneously with antihypertensives
how do we manage patients with moderate CVD risk scores
Intensive lifestyle advice SNAP
Consider pharmacotherapy if not reaching target after 6 months or if FHx of premature CVD or from Aboriginal/South Asian descent.
Consider meds if not reaching target 140/90 or 130/80 (CKD), 125/75 (diabetes/proteinuria) after 3-6 months.
Or if always greater than 160/100, FHx etc.
how do we manage low risk CVD score patients
what sort of lifestyle advice would you provide for nutrition?
dietary salt restriction ≤4 g/day, don't add any to cooking
reduce fats, cheese, meats, portions
trim off excess fats,
use olive oil
Avoid takeaway food
Avoid processed foods
what are some standard lifestyle advice for alcohol consumption
limit alcohol intake to ≤2 standard drinks per day for males and ≤1 standard drink per day for females
with at least 2 alcohol free days
what can we advise for the amount of physical activity done per day for a patient we are counselling about CVD risk?
at least 30 minutes of moderate-intensity physical activity on most, if not all, days
what are the normal waist circumferences for females and men
waist measurement less than 94cm for men
waist measurement less than 80cm for women
what do we prescribe for sore throat that fits the centor criteria?
phenoxymethylpenicillin 500mg for 10 days every 12 hours or cephalexin
a patient comes in with a hx of sore throat and voice change. what do you think of?
abscess e.g. quinsey abscess
what are the pathogens that cause acute otitis media and their incidence?
1. viruses 25%
2. strep pneumoniae 35%
3. haemophillis 25%
4. moraxella cataralis 15%
what are some sequelae of acute otitis media?
2. facial nerve paralysis
3. intracranial abscess
how might we manage chronic suppurative otitis media?
ciprofloxacin ear drops
first line treatment for allergic rhinitis?
how might we test for chlamydia?
first void urine sample (better for men)
or self collected vaginal swab
or endocervical swab (usually taken opportunistically after pap smear)
a patient presents to his GP with purulent urethral discharge. You suspect he has a STI and has taken the appropriate swabs. How will you manage him in the meantime whilst waiting for the results?
needs to be treated right away
ceftriaxone 500mg IM + 1g azithromycin
(treatment for gonorrhoea, but will also cover chlamydia)
how do we diagnose diabetes in a GP setting?
nowadays a diagnosis of diabetes can be made with a HbA1c >6.5%
how might we start metformin?
start off with 250mg then increasing with weekly intervals to 500mg twice daily and finally 850mg-1000mg
what AUSDRISK score indicates possible type 2 diabetes
12 or more
at what eGFR would we not recommend metformin?
less than 30
what are some standard ix we need to do to assess diabetes control in diabetics?
eGFR + urine albumin creatinine ratio
Fasting lipids- TG, LDL, HDL, total chol
what health assessments/checks would we consider in a diabetic patient?
regular eye checks
Absolute cardiovascular risk assessment
what are some allied health providers we can get involved with a diabetic patient?
what should LDL levels be less than?
less than 2.0 ideally
who can we prescribe a statin/fibrate for any cholesterol level?
-symptomatic cardiovascular/cerebrovascular/PVD disease
-Diabetes in over 65 yrs, aboriginal/torres strait islanders, with microalbuminuria
a patient gets routine bloods done by is GP and is found to have a total cholesterol level of 5.5mmols/L. What is your management as a GP?
trial non-pharmacological approach first: attempt a change in diet/increase physical activity/reduce alcohol intake
retest and if still high, commence statin/fibrate + diet/activity modifications
how might we manage diabetic neuropathy pharmacologically? what is first/second line?
first line is amitriptyline, second line is pregabalin/gabapentin
how might you manage a patient who has just been diagnosed with non-valvular AF in the GP setting?
Rate control- beta blocker like metoprolol
Rhythm control- sotalol
Calculate CHADS2 + HAS-BLED score for anti-coagulation
first line: warfarin/dabigatran
2nd line: apixaban/rivaroxaban
what is good about rivaroxaban (xarelto) in gp land?
only once a day dosing
what is good about apixaban (eliquis) compared to other NOACs
can be used at a higher level of renal impairment than dabigatran and xarelto
what type of AF do we have to use warfarin for?
how should we monitor a patient who we have just commenced on spironolactone as a GP?
check potassium and renal function 1 week after commencement, then monthly for 6 months. After that 6 monthly until stabilised
what are some non-pharmacological management options/advice we can give as GPs to a patient with heart failure?
-reduce salt and fluid intake
-health prevention- vaccination against influenza and pneumovax
-referral to dietician
-once symptoms stable, increase physical activity
a patient comes in to see the GP contemplating whether to quit smoking. What would you do/advise as a GP?
Employ motivational interviewing techniques- follow 5As
Encourage calling Quitline
Pharmacotherapy such as nicotine patches/Champix may be prescribed
how might you identify high risk patients and implement assessment of absolute CVD risk in the GP clinic?
1. Ensure you enter in relevant patient details into patient file e.g smoking status, BP, weight height etc over a number of GP visits
2. Collect missing health information from previous GPs, hospital discharge summaries etc.
3. You can opportunistically identify eligible patients- patients who are over 45 yrs or 35 yrs if Aboriginal/Torres Strait Islander; also identify those who are already at high risk of CVD event in next 5 yrs.
4. On a practice level, multiple staff members e.g. practise nurse/receptionist/pathology can also audit patients who are eligible for a CVD risk assessment and put into a recall system. Can also use audit programs like PENCAT to identify eligible patients.
A 17 year old patient sees you for a repeat script for asthma inhalers. As a GP, what health prevention strategies might you opportunistically screen for/employ in this consultation?
1. Can get BMI from weight and height
2. 2 yearly BP measurements from 18 yrs of age
3. Establish vaccination status
4. SNAP!!! Assessment. Motivational interviewing if required
5. HEADSS mental health screen (home, education/employment, activities, drugs, sexuality, suicidality)
One of your patients has just had a heart attack, and was managed with a drug eluting stent. As a GP, what medications would you like your patient to continue on post heart attack? What are some other management/health prevention options for this patient?
1. Review discharge summary from hospital and review current medications
2. Medications for secondary prevention: aspirin + clopidogrel (aspirin indefinitely, clopidogrel for at least 1 year), if AF- commence anti-coagulation, statins now indicated as patient is at high risk of another CV event occurring, ACE inhibitors +/- beta blockers may be used for HT as they have been proven to have a role in cardiac remodelling, GTN PRN as required. Need to explain the SE of each medication.
3. Organise an action plan- give written information about heart attacks and when to use GTN spray. Refer to self-management resources e.g. websites etc
4. Refer to dietician for nutritional planning/advice
5. Intensive SNAP advice
6. Screen for depression/anxiety post MI
7. Organise follow up and ongoing review
A patient presents to the GP for a pre-travel consult. He is going to India for a business trip. As a GP, what do you need to cover in this consultation/subsequent consultations prior to his travel?
1. Where in India/how long is the trip/when is he going
2. What activities is he likely to be undertaking?
3. Establish vaccination status- may require checking serology
4. Look up which travel vaccinations are required (e.g. hep A and typhoid), and administer them prior to travel
5. Other prophylactic medications as required e.g. anti-malarials if in malarial region, loperamide for traveller's diarrhoea
6. Provide general health prevention advice such as drinking bottled water, eating thoroughly cooked food, avoiding animal bites, insect repellents
7. Provide travel information pamphlet on management of traveller's diarrhoea/gastroenteritis and when to seek medical help overseas.
8. Provide GP letter regarding travel medications for the pt to take with him on the plane
what are some GP management options for a patient who has chronic alcoholic liver disease?
Early referral to specialist gastroenterologist/hepatologist
Encourage alcohol abstinence- promote support groups such as AA or other drug and alcohol service; look out for alcohol withdrawal symptoms
Ensure vaccinations up to date- annual influenza, pneumovax, hep A, hep B vaccine
Screen for concurrent HIV/Hep C infection
Refer to dietician for nutritional advice
Thiamine supplementation to prevent Wernicke's encephalopathy
Reduce salt intake if ascites present
Screen for alpha-feto protein +/- liver u/s if HCC suspected
how might we assess a patient's alcohol dependence in a GP setting?
Audit C questionaire
what special tests do we order for suspected coeliac disease?
tissue transglutaminase antibody
deamidated gliadin antibody
total IgA level
gold standard for diagnosis= small bowel biopsy looking for villous atrophy, crypt hyperplasia etc
For children under 2 yrs old with asthma (but older than 12 months), what is the preventer of choice?
for children between 2-5 yrs old with asthma, what is the preventer of choice
montelukast 4mg daily
when should we consider preventer medication in children with asthma
when they are requiring their reliever more than twice a week
what is included in an asthma action plan?
- a list of the child's usual allergy and asthma medications
-clear information outlining how to change medications or increase the number of reliever puffs and when to commence oral corticosteroids, and how to seek medical help during asthma exacerbations/emergencies.
when should a child with asthma be reviewed by their GP?
Generally every 3-6 months if symptoms/medications stable.
4 weeks after commencement of new asthma medications
2-4 weeks after hospital discharge for asthma exacerbation.
what are some key GP management priorities for a patient with COPD?
1. Strongly encourage cessation of smoking
2. Regular influenza/pneumoccocal vaccination
3. Ensure patient is compliant with medication and uses the inhalers correctly
4. COPD exacerbation action plan
5. Ongoing monitoring/follow up via chronic disease management plan
6. Referral to pulmonary rehabilitation/specialist care in moderate-severe cases
7. screen for medical and psychosocial comorbidities
what is spiriva?
tiotropium bromide (LAMA)
what is seretide?
fluticasone + salmeterol
do you need a DEXA scan to prove osteoporosis if a patient comes in with a hx of previous minimal trauma fracture and needs to start anti-resorptive therapy?
No you don't need to perform a DEXA scan to begin prescribing anti-resorptive therapy in this setting as a minimal trauma fracture is diagnostic of osteoporosis regardless
what investigations would you need to order in a patient who you believe is at risk of osteoporosis?
1. FBE, UEC, PTH, CMP, vitamin D
2. DEXA scan
3. thoracolumbar spine plain x-ray looking for fractures
4. +/- myeloma screen/coeliac screen/LFTs if indicated
what are some key management priorities for a GP who has a patient with osteoporosis?
Exclude secondary causes of osteoporosis/ remove exacerbating factors
1. Anti-resorptive therapy- ongoing monitoring for SE etc
2. Address falls risk- gait aids, podiatrist, physiotherapist, occupational therapist, environmental modifications etc
3. Calcium and vitamin D supplementation if required
4. Weightbearing exercises with physiotherapist
you start a patient with CKD on ACEi. After a few subsequent consultations you feel their high blood pressure is not improving. what drug would you add next?
when would you urgently refer a patient with CKD to a nephrologist/hospital?
1. nephrotic syndrome
2. abrupt rise in creatinine
3. severe hyperkalemia
5. signs of end organ failure
what are some management priorities for a GP managing a patient with CKD?
Remove nephrotoxic drugs or dose adjust renally cleared meds including metformin
1. Management of BP and good diabetes control (if diabetes is cause of CKD)
2. Encourage cessation of smoking/reduce alcohol intake etc
3. Annual influenza vaccination. Also pneumoccocal/hep B and varicella vaccine as required
4. Encourage patient to reduce salt intake in diet, and increase protein in diet especially if CKD is severe
5. Manage secondary complications- anaemia, metabolic bone disease etc
6. Early referral to nephrologist/dialysis service if deteriorating renal function
a young patient is brought in by his mother to the GP clinic appearing very unwell. You suspect he has DKA. What are some critical assessments you must make prior to sending him off to hospital urgently?
1. Assess fluid status (cap refill, tissue turgor etc)
2. Assess airways + GCS
3. If possible, put in IV drip. While there- get venous blood gas, get blood sample for BSLs, blood ketones, UEC, and if required a septic work up including blood cultures
4. Urine ketones
5. Early referral to hospital, arrange transport ASAP
6. Make a note to ix anti-GAD, anti islet antibodies, coeliac screen etc
how do you pharmacologically manage a patient who has genital HSV ulcers?
Acyclovir 200mg TDS, 7-10days
OR Valaciclovir BD 7-10 days
+ analgesia for pain relief
what type of tests do we order for possible chlamydia/gonorrhoea samples?
(nucleic acid amplification test- PCR)
Microscopy and culture
Do we need a secondary test of cure for gonorrhoea/chlamydia infection?
No, as cure rates are very high with appropriate antibiotic treatment. Do need to test for reinfection three months later though.
what are some GP management priorities for a patient who presents with a STI?
1. Gonorrhoea + Chlamydia are notifiable to the NNDSS (national notifiable disease surveillance system). Other diseases like HIV and syphillis are also notifiable diseases
2. Need to either inform sexual partners on behalf of patient or encourage them to inform themselves
3. Organise outstanding vaccinations including HPV/Hep B/hep A
4. Encourage safe sex practices including using condoms for protection against STIs
5. If patient is in high risk (e.g. M2M sex), then put in recall system for 3 monthly STI screens. If not at high risk- then annual STI screens are sufficient.
how might a GP manage an elderly patient with polypharmacy use?
1. take a thorough medication history
2. carefully remove medications that are not indicated/interact with other drugs/predispose high bleeding or falls risk etc
3. take care not to start a 'prescribing cascade' for side effects of drugs
4. try and use combination tablets as much as possible (reduces number of pills, increases compliance)
5. talk about administration options- webster/dosette
6. refer to pharmacist for home medicines review
a patient comes to see their GP with urinary incontinence? what is something you might suggest?
take a bladder diary for 2-3 days and return to GP for further assessment and delineation of type of urinary incontinence
a mother brings her child to see the GP. She says her child is sick and is 'burning up'. There aren't any localising symptoms of infection. What is your management?
1. Take a good history from the child + mother
2. General observation- does the child look well or unwell?
e.g. unwell might be not responding to social cues, weak high pitched cry
3. Assess vitals. Look for tachycardia, tachypnoea, reduced O2 saturation, dry mucous membranes. Take a temperature.
4. Top to toe examination looking for possible causes of infection.
5. If no localising signs are present and child clearly looks unwell, and or there are signs that suggest haemodynamic compromise/respiratory instability, document in notes and advise admission to hospital.
6. call RCH and advise that the child will be arriving soon. If possible, handover to the ED registrar on call.
7. call for patient transport- e.g. ambulance 000
8. using the clinical notes and the child's medical history, write a succinct but detailed referral letter to expedite their admission through ED
9. Explain and reassure both parent and child
a heterosexual couple comes to see their GP to talk about infertility. What are the examinations you would want to do for both male and female partner?
• Look for secondary sexual characteristics
• Female= Pelvic--> speculum and bimanual exam
Male- height weight BMI, testicular and scrotal examination, prostate exam
what are some mx options a GP can suggest for a couple with infertility?
1. Lifestyle measures- e.g. stop smoking, lose/gain weight, nutrition, CBT
2. Optimize all other medical conditions in patient
3. Clomiphene/LHRH agonists
4. Artificial insemination
you are the GP and a child you have just given a vaccination to now has difficulty breathing and talking and the nurse comes to you worried.
what might you suspect and how would you manage it (think acute/med/long term)?
1. Reassure the patient and family and act in a calm manner. Remove allergen if known.
2. Quickly assess patient's airway and whether they are in shock
3. Ask a practice staff member to call for an ambulance
4. If in shock, put the patient into supine position and raise legs.
5. Ask the patient or family if they have an Epi-Pen on them.
6. If not, or first presentation, get the Epi-Pen from clinic stock. Check it is the right Epi-Pen (either adult or junior depending on child's age) and that the expiry is in date.
7. Administer the Epi-pen firmly into the lateral thigh and hold for 10 seconds. Remove and rub thigh.
8. Monitor symptoms. If symptoms do not improve in 5 minutes, administer another dose of adrenaline and repeat until ambulance arrives. Ask practice nurse to do this if you can.
9. Back in the office, write up what has happened and document the reaction in the allergy tab. Write up a referral to the hospital to expedite their admission through ED.
10. Assist child and family into ambulance, and handover case to paramedics. Ask the child to take the used epi-pen with them.
11. At hospital, intubation/ICU management is available if needed, and further monitoring can be provided to the patient. IV adrenaline also available as well as O2/corticosteroids
12. GP to review patient post discharge and well. Explain diagnosis to patient and family, and organise an anaphylaxis action plan. Ensure they understand how to use an Epi-pen and to carry it with them at all times, and provide them with a prescription for this. Consider referral to paediatric allergy specialist for further ix and mx.
13. Regularly follow up patient and optimise other medical comorbidities such as asthma. Consider a medic bracelet if required.
14. organise follow up, and put in recall system for expiry epipen reminders
as a GP who would you may you want to screen for osteoporosis and what ix would you order?
if osteoporosis is confirmed, what first line pharmacotherapy therapy may you trial?
postmenopausal women and older men >60 yrs with minimal trauma fractures or with risk factors for osteoporosis such as prolonged steroid use, multiple falls, prolonged thyroid hormone use etc
If minimal trauma fracture suspected- think spine x-ray
otherwise gold standard ix is a bone mineral density scan.
You may also calculate their fracture risk nomogram.
Blood ix- ca2+, vit D, ALP, GGT, UEC, FBE
if clinically indicated- myeloma screen (protein electrophoresis), Testosterone, LH, TSH to rule out other causes
May begin patient on daily or weekly bisphosphonate therapy as first line
what are some non-pharmacological approaches to preventing osteoporosis that a GP may suggest to a patient? (think health promotion)
adequate dietary calcium intake
adequate vitamin D (sunlight/supplementation
regular weight-bearing exercises
maintenance of healthy BMI
limit excessive alcohol consumption
a couple comes into their GP wishing to become pregnant.
What on history do you want to know?
What are some advice you might give and some ix you might want to order?
what are some other mx you need to consider?
History: you want to do a detailed SMOG-C screen, including maternal age etc. Want to know if there are any genetic predispositions e.g. beta thalassemia and want to know other medical comorbidites/conditions e.g. epilepsy of the parents. Up to date with pap smear??
You may advise taking multivitamins with folic acid, and to cease alcohol intake and smoking. You would want to advise to maintain a healthy diet and avoid recreational drugs. You may advise having sex every 48 hrs till ovulation and beyond for best chances at pregnancy.
Ix- you would want to check immunisation status (serology), STI screen, blood type, FBE, TFTs, BSLs etc
As a GP you want to monitor BP and BSLs. You would want to do a medication review and remove teratogenic drugs. You would want to optimise all medical comorbidities. You will discuss with the couple later down the track if they would like entire private care or shared care for their antenatal care, and the timeline of investigations and follow up.
A patient, under the advice from your fellow psychiatrist is about to commence an atypical antipsychotic. As a GP, what may be your role in monitoring for SE of this drug?
1. need to regularly monitor weight/BMI and weight circumference; may need to refer to dietician and encourage regular exercise
2. baseline ECG and FBE
3. Need to check blood glucose levels (or diabetes control), BP, lipids, LFTs regularly- once stable, every 6 months at least
4. Look out for EPSE and other SE such as galactorrhoea etc
5. Advise about orthostatic hypotension and drowsiness
A 3 yr old child comes in and you suspect acute otitis media. They have an uncomplicated past medical history and do not seem too overly distressed with their ear pain, only some ear tugging + fever noted. what is your management as a GP?
if greater than 1 yr old and immunocompetent,
no treatment other than panadol for fever and pain
if symptoms do not resolve in 48 hrs then commence amoxycillin for 5 days
if symptoms persist, then change to amoxycillin + clavulanic and consider referring to ENT if repeated infections and speech/learning delays suspected
a 4 yr child comes in to the GP with their parents, who say that they have been vomiting everything they have given her. What is your no 1 differential and what would you need to exclude? what questions would you ask?
what are some things you might want to do?
what are some things to advise the parents?
1. no 1 differential = gastroenteritis
2. need to exclude ketoacidosis/septicaemia/poisoning/surgical obstruction
3. ask specifically about bedwetting, rate of decline, weight loss, check immunity status.
4. assess the child's fluid status! tissue turgor, cap refill etc
5. Advise parents about fluid rehydration and signs that require admission to ED. Also talk about reducing risk of infection such as good handwashing technique and avoiding public swimming pools etc
6. Ensure the child is up to date with their vaccinations
as a GP, what ix might you want to do for a febrile toddler who has an otherwise unremarkable physical exam and normal behaviour, but is a little bit miserable?
urine dipstick and MSU
organise follow and review
what might you advise for a febrile baby less than 3 months as a GP
advise the baby should go to hospital, as there is a higher risk of bacteraemia
a 60 year old lady wonders why she needs to continue having pap smears, given that she is no longer sexually active and all previous smears have been normal. what might you tell her as a GP?
Women are advised to continue biennial Pap tests until 70 years of age, at which time they can stop if they have had two negative tests within the previous 5 years.
What medication do you use for HSv
Acyclovir 200mg tds 7-10 days or valaciclovir bd
What are some components of the six-week GP newborn consultation
Addressing parental concerns and assessing whether they are coping.
Top to toe examination looking at general appearance, weight height head circumference, fontanelles, hip dysplasia, check for organomegaly, neuro exam, listen to heart and lungs
What is the next investigation for suspected hip dysplasia
Ultrasound of hips
Woman comes into the clinic indicating that she would like to become pregnant. What are some things you may do as a GP?
Take a thorough history including previous obstetric history, organize a medication review and optimize pre-existing medical conditions including STI + pap smears.
Also inquire about genetic conditions which may run in the family.
Ensure the patient has good mental health prior pregnancy.
Assess vaccination status, particularly rubella and Varicella. If she hasn't been immunized against these communicable diseases, advise her to take these immunizations prior to pregnancy as they are contraindicated during pregnancy. Influenza vaccination should be up to date.
Advise lifestyle measures including taking folate and iodine supplements as well as maintaining a healthy diet and weight and to cease smoking, and reduce alcohol intake.
Advise against eating cheese to prevent listeria infection and avoiding handling cat litter to prevent toxoplasmosis. Also advise good hand hygiene particularly when in contact with children who are sick all may have CMV.
what should a GP routinely check on examination during an antenatal visit?
At each GP appointment check:
Fetal heart rate from 20 weeks
Fundal height from 24 weeks.
Fetal movements from 24 weeks.
what should a GP advise a patient prior to commencing carbimazole or PTU for their hyperthyroidism?
1. in the first 8 weeks- look out for signs of agranulocytosis such as infection (e.g. pharyngitis), malaise and acute fever. If it occurs, stop the drug and check neutrophil count.
2. itch and rash is a common SE of these drugs.
3. If using PTU, look out for signs of abdominal pain/jaundice/anorexia/dark urine--> stop drug and check LFTs
how might we manage isolated systolic hypertension pharmacologically?
calcium channel blocker or low dose thiazide diuretic
in a patient with ESRF and has gout, what pharmacological management might you suggest?
short course of prednisolone
define resistant hypertension?
blood pressure that remains above 140/90 mmHg in spite of concurrent use of three antihypertensive drugs from different classes (including a diuretic) for at least 1 month.
exclude white coat hypertension and non-compliance with meds
when is a gastroscopy indicated?
red flags including LOW/FE anaemia/dysphagia
persistent symptoms in a >50yr old
FMH of gastric cancer
persistent dyspepsia despite PPI
recent NSAID use in at risk patients