ASTHMA: how can you use PEFR to diagnose?
PEFR improves after administration of a SABA
ASTHMA - adult: first line treatment (symptom relief)
SABA
ASTHMA - adult: first line treatment + prevention
SABA + low-dose ICS
ASTHMA - adult: next step from SABA + low-dose ICS
+ LTRA
ASTHMA - adult: next step from SABA + low-dose ICS + LTRA
+ LABA (keep or take away LTRA)
ASTHMA - adult: next step from SABA + low-dose ICS + LTRA + LABA
incorporate MART routine
ASTHMA - adult: next step from SABA + low-dose ICS + LTRA + LABA (MART routine)
increase ICS to medium dose
ASTHMA - adult: next step from SABA + med-dose ICS + LTRA + LABA (+/-MART routine)
increase ICS to high dose
ASTHMA - adult: next step from SABA + high-dose ICS + LTRA + LABA (+/-MART routine)
+ 4th drug theophylline/oral beta agonist/anti-muscarinic
ASTHMA - adult: next step from SABA + high-dose ICS + LTRA + LABA (+/-MART routine OR 4th drug)
oral corticosteroid (also keep high dose ICS)
ASTHMA - 5-16yo: first line treatment (symptom relief)
SABA
ASTHMA - 5-16yo: next step from SABA + paed low dose ICS
+ LTRA
ASTHMA - 5-16yo: next step from SABA + paed low dose ICS + LTRA
+ LABA (consider stopping LTRA)
ASTHMA - 5-16yo: next step from SABA + paed low dose ICS + LABA (+ LTRA)
incorporate MART routine
ASTHMA - 5-16yo: next step from SABA + paed low dose ICS + LABA (+ LTRA; +/- MART routine)
increase to medium dose ICS
ASTHMA - 5-16yo: next step from SABA + paed med dose ICS + LABA (+ LTRA; +/- MART routine)
refer to specialist paed clinic + consider increasing to high dose ICS
ASTHMA - 5-16yo: next step from SABA + paed med dose ICS + LABA (+ LTRA; +/- MART routine)
refer to specialist paed clinic + consider increasing to high dose ICS
ASTHMA - <5yo: first line treatment (symptom relief)
SABA
ASTHMA - <5yo: first line treatment with maintenance therapy
SABA + 8-week trial of paed mod-dose ICS
ASTHMA - <5yo: after 8 week paed mod-dose ICS trial if symptoms recur within 4 weeks
low dose ICS and SABA
ASTHMA - <5yo: after 8 week paed mod-dose ICS trial if symptoms recur within & after 4 weeks
med dose ICS and SABA
COPD FVC <0.7, FEV1 >80%
mild, mod, severe, v severe?
mild
COPD FVC <0.7, FEV1 50-79%
mild, mod, severe, v severe?
moderate
COPD FVC <0.7, FEV1 30-49%
mild, mod, severe, v severe?
severe
COPD FVC <0.7, FEV1 <30%
mild, mod, severe, v severe?
v severe
MRC dyspnoea scale 1 = not troubled by breathlessness OR too breathless to leave house?
not troubled by breathlessness
MRC dyspnoea scale 5 = not troubled by breathlessness OR too breathless to leave house?
too breathless to leave house
name 2 lifestyle management things for COPD
smoking cessation
vaccinations
pulmonary rehab
COPD - inhaled meds - step-up if no improvement FEV1 >/=50% (already on SABA/SAMA + LABA)
LABA + ICS
COPD - inhaled meds - short acting relief
SABA salbutamol or
SAMA ipatropium bromide
COPD - inhaled meds - long acting if FEV 1 >/=50%
LABA (salmeterol) or LAMA (tiotropium bromide)
remove SAMA if using LAMA
COPD - inhaled meds - long acting if FEV 1 <50%
LABA + ICS combi inhaler or LAMA
COPD - inhaled meds - second line if no improvement for both FEV1 measurements
LABA + ICS combo AND LAMA
COPD - combined inhaled and oral therapy
beta-2 agonist + theophylline OR
anticholinergic + theophylline
COPD - if chronic cough
mucolytic (carbocristine)
COPD - abx for purulent sputum
amoxicillin
doxycycline
erythromycin
COPD - when would you give PO corticosteroids?
increased dyspnoea or reduced ADLs
DM classic triad
polyuria
polydipsia
weight loss
DM2 - HbA1c target if not on hypoglycaemics
<48
DM2 - HbA1c target if on hypoglycaemics
53
DM1 routes of insulin
SC injections - short acting before meals, long acting in the evening
SC pump - continuous/regular
DM2 - first line meds
metformin
DM2 - metformin SEs
reduced appetite + weight, cardio protective, reduced risk of hypo
DM2 - metformin CI
cannot be used if eGFR <30
DM2 - what to add to metformin if HbA1c >58
DPP4 (sitagliptin) OR
sulfonylurea (gliclazide) OR
pioglitazone
DM2 - out of sitagliptin, gliclazide and pioglitazone, which is best in kidney impairment?
sitagliptin
DM2 - sulfonylurea SEs
increased weight, increased risk of hypo
DM2 - pioglotazone CIs
HF, DKA, bladder ca, haematuria
DM2 - third line treatment
metformin + sulfonylurea + DPP4(sitagliptin)/pioglitazone
DM2 - 4th line treatment
insulin
DM2 - if metformin resistant…
skip metformin and use one of the other adjuncts
DM2 - when to measure HbA1c
3 monthly until stable then 6 monthly
DM2 - non glycaemic treatments
statin (reduce CVD risk)
antihypertensives if >140/90
DM2 - annual check
weight + BMI serum creatinine BP smoking HbA1c cholesterol urinary ACR eye exam foot exam
DM - microalbuminuria - ACR ratio over ?
> 3
+ urine dip + for protein
DM - microalbuminuria management
ACE-i or ARB even if BP normal - protects kidneys
CHD - what type of angina?
induced by effort, relieved by rest
stable
CHD - what type of angina?
caused by coronary artery spasm
variant
CHD - what type of angina?
increasing in freq or severity, after minimal exertion/at rest, high risk of MI
unstable/crescendo
CHD - what type of angina?
precipitated by lying flat
decubitus
QRISK2 score - what does it calculate?
10 year risk of having MI or stroke (based on RFs and demographics)
CHD - step 0 - symptom relief
inhaled GTN
CHD - step 1 - regular medicines
BB or CHB
amlodipine, felodipine
OR diltiazem + verapamil (rate limiting)
CHD - step 2 - monotherapy
long acting nitrate (isorbide mononitrate)
specific anti-angina drugs (ivabrandine, nicorandil, ranolazine)
CHD - when step 2 monotherapy insufficient
combine with BB or CCB
then can add GTN
CHD - secondary prevention in stable angina
aspirin 75mg to all
statin to all
ace-i if also have DM
CHD - secondary prevention after an MI
BRA-AC bisoprolol ramipril aspirin atorvostatin clopidogrel
HF - investigations
BNP
echo
ECG
CXR
HF - acute management
diuretics - frusemide or bendroflumethiazide if already on loop
do not offer opiates or nitrates
HF - first line chronic management
ACE-i and BB
ARB if ACE-i intolerant
hydralazine + nitrate if afro-caribbean
HF - second line chronic management
aldosterone antagonist (spironolactone), ARB or hydralazine + nitrate
OR
sacubitril valsartan
HF - 3rd line management
digoxin or ivabradine
implantable cardiac defib
investigation in suspected AF
ambulatory ECG
AF - acute management
cardioversion
flecainide or amiodarone
AF - management - anti-coagulation
CHADSVASC or HASBLED
if anti-coag
warfarin or NOAC
AF - management - rate control
beta blocker or rate limiting CCB
digoxin if sedentary
next stage is to combine 2 of the above
AF - management - rhythm control
only if rate control has been unsuccessful
cardioversion + amiodarone
score for stroke prevention in AF
CHA2DS2VASC stroke risk based on congestive heart failure HF age diabetes stroke sex (female) vascular disease if score >/= 7 = 10% stroke risk
score for predicting risk of bleed on anti-coags in AF
hasbled
FAST screen for stroke
face
arms
legs
TIME TO CALL 999 muvafuka
acute stroke management - thrombolysis
alteplase thrombolysis in <4.5hrs
acute stroke management - pharmacological
antiplatelets
aspirin 300mg for 2 weeks
then clopidogrel 75mg long term
warfarin if AF
acute stroke management - possible surgical interventions
carotid artery imaging <1 week to see if there is carotid artery narrowing
carotid endarectomy
stroke management longterm
clopidogrel 75mg
warfarin if AF
statin
score for TIA
ABCD2 age BP clinical features (unilateral weakness or speech disturbance) duration of symptoms
TIA - ABCD2 score meanings
>/= 4 - urgent 24hr see neurologist <4 - 1 week referral ALSO hospitalise if... persistant signs/sx <45yo crescendo TIA patient has AF
TIA - management
ABCD2 score >/=4 (or <45, crescendo or AF)
aspirin 300mg & urgent neurologist appt in 24hrs
ABCD2 score <4
aspirin 300mg within 1 week
DVLA rules post stroke or TIA
1 month
what classification system used for stroke
oxford
CKD investigations
creatinine based eGFR
urine ACR
renal USS + biopsy
CKD - microalbuminaemia
raised ACR
CKD - stages
1 = eGFR >90 (review annually) 2 = 60-90 (review annually) 3 = 30-60 (review 6 monthly) 4 = 15-30 (review 3 monthly) 5 (end stage) = <15 (review 6 weekly)
CKD - managment
BP control (aim <140) ACE-I or ARB
CKD - end stage management
haemodialysis / some form of dialysis
CKD - prevention of CVD
statin
antiplatelet (apixiban or warfarin)
epilepsy - initial investigation for all
ECG
epilepsy - when to start treatment
after diagnosis confirmed (usually 2nd seizure)
epilepsy - absent/tonic clonic or atonic management
sodium val
lamotrigine
epilepsy - myoclonic management
sodium valproate
leviteracetam, topiramate
epilepsy - focal management
carbamazepine
lamotrigine
epilepsy - non-pharma management
surgery
vagal stimulation
ketogenic diet
deep brain stimulation
epilepsy - coming off anti-epileptics
wean down over 3 months
epilepsy - annual review
seizures
medications
bloods
lifestyle/eduction
epilepsy - DVLA
can drive car/bike if seizure free for over a year
can drive lorry/bus if seizure free for 10 years
epilepsy - sodium val side effects
weight gain, N+V
epilepsy - lamotrigine side effects
anti-cholinergic
epilepsy - carbemazapine side effects
headache, blurred vision, dizzy drowsy ataxic
HT - diagnosis
blood pressure in GP
ambulatory blood pressure
HT - score for risk of cardiac event
qrisk2
% risk of heart attack or stroke in 10 years
HT - first line management - non-pharmacological
lifestyle and diet
HT - first line - pharmacological
<55yo
ACE-i (ARB if not tolerated)
>55 or afro-caribbiean
CCB (thiazide diuretic if not tolerated)
HT - second line pharma treatment
ACE-i + CCB
HT - third line pharma treatment
ACE-i + CCB + thiazide diuretic
HT - 4th line pharma treatment
add:
a blocker (tamusolin)
diuretic (spironolactone or indapamide)
beta blocker
HT - ACE-i side effets
postural HT
dry cough
can’t use in pregnancy
HT - ARB Side effects
dizzy
can’t use in pregnancy/breast feeding
HT - CCB side effects
ankle oedema
headaches
palpitations
N+V
HT - thiazides side effects
hypokalaemia
headache
HT - K+ sparing diuretics side effects
gynaecomastia
impotence
menstrual irregular
HT - annual review
BP, weight, height BMI
medicines
COPD - exacerbation management in the community
oral prednisolone for 2 weeks
abx if needed
COPD - what is in a rescue pack?
corticosteriods, bronchodilator, abx