Card Set Information

2012-11-15 17:31:03

exam nov
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  1. Ischaemic stroke (NICE 2010)
    • Clopidogrel 75mg alone 1st choice
    • Dipyrimadole MR+aspirin: if above not tol/CI
    • Dipyrimadole MR alone if asp+clop not tol/CI
    • Aspirin alone if dipyrimadole and clop not tol/CI
  2. Post TIA
    Dipyrimadole MR+aspirin 1st choice, treat for life, aspirin if above not tolerated
  3. PAD
    Clopidogrel  75mg daily 1st, aspirin if not tolerated
  4. Post MI
    Aspirin 1st choice
  5. Stage 1 HTN
    Initial BP >140/90 and subsequent

    • ABPM/HBPM >135/85
    • -          Lifestyle advice
    • -          Offer drug if est CVD, renal disease, diabetes or est CVD risk >20% over 10y
  6. Stage 2 HTN
    Initial BP >160/100 ABPM >150/95 offer drugs
  7. Severe HTN
    Clinic BP>180/110 immediate Tx
  8. Diagnosing HTN
    Do clinic BP twice or thrice if lowest >140/90 need ABPM
  9. DASH and low sodium diet
    Low in total and saturated fats, red meat, sugar, sodium and refined carbs, high in fruit and veg, wholegrains, fish, poultry and low fat dairy. Sodium reduce intake to <2.3g daily (5.8g salt)the lower the better.Bread breakfast cereals and table sauces high in salt, avoid high salt.
  10. Calcium channel blockers
    Step 1 in over 55 and black afros at any age.Unless unsuitable due to HF/oedema-thiazide first
  11. ACEI/ ARB (losartan)
    If <55yrs and not black afro
  12. Thiazides
    Give chlortalidone 12.5mg to 50mg or Indapamide 1.5mg modified release or 2.5mg daily If already on bendro and well controlled no need to change
  13. Investigations new HTN
    • Look for target organ damage (BP, pulses, fundoscopy)
    • ECG, proteinuria, egfr, lipids, UEC Investigate for secondary HTN if under 40  
  14. Resistant HTN
    • Consider adding further diuretic:
    • spironolactone 25mg daily if K<4.5 and egfr>60 If K> 4.5 consider inc dose of thiazide Monitor bloods Na, K and eGFR after 1m and repeat as reqd  
  15. HTN targets
    • Clinic <140/90 in pts under 80 and <150/90 if over 80
    • Type 2 DM: <140/80, <135/75 if with microalbuminaemia  
  16. Phaeochromocytoma
    Paroxsyms of palpitations, sweating, headaches and pallor, check urinary catecholamines.
  17. Statins and DM
    Small inc risk in DM but statins reduce CV risks and events so benefits outweigh the risk and so not a reason for stopping or withholding a statin
  18. Statins counselling
    • Report muscle symptoms
    • Interactions:
    •  ca channel blockers : inc myalgia risk and grapefruit juice as affects metabolism
    • macrolides and azoles: stop statin and restart 7days after last dose, consider dose reductions with ca channel blockers
  19. CK and statins
    • >10tims inc: stop statin
    • >5 times normal:  symptomatic and statin suspected then stop
    • <5 times normal:rarely significant prob rel to exercise
    • CK not raise try lower dose or change to prava/atorva, low dose and titrate, if myalgia recursà ezetimibe 10mg
  20. Simvastatin and commonly prescribed drugs
    • Itraconazole, ketoconazole, erythromycin and clarithromycin:CI
    • Amiodarone and verapamil: do not exceed 20mg simva
    • Diltiazem and amlodipine : do not exceed 40mg
  21. Raised triglycerides
    Check for common secondary causes-DM, impaired gluc tolerance, hypothyroidism, liver and kidney disease and excessive alcohol.
  22. Triglycerides>10
    • Refer lipid clinic (risk of pancreatitis)
    • Triglycerides 5-10
    • Simvastatin 40
    • if <5 after 8w continue, if still raised replace with omega3acid or fenofibrate, if still high at 8w refer, if high risk(>20%10yr) or CVD add statin to second agent
  23. Triglycerides 3-5
    Only treat if pre-existing CVD or >20%5yr risk
  24. Familial hypercholesterolaemia
    • Consider if fasting cholesterol >7.5, check FH, exclude secondary c auses
    • Check for tendon xanthomata
    • Cascade testing first degree relatives
    • High intensity statin  (atorva 40mg) aim to reduce LDL by 50%
    • Refer to specialist clinic if fail to reach targets, children and adults at high risk.
  25. Risk assessment for osteoporosis
    • FRAX (low-reassure,lifestyle;med-BMD and redo;high greater than 10% in over 50>8%under 50           ->treat)
    • Osteoporosis risk factors
    • Prev fragility fracture
    • Low BMI<18.5
    • Smokers
    • Falls
    • FH
    • Heavy alcohol use
    • Frequent steroids
    • Under 50- prem men/oral steroids >7.5mg pred over 3/12)
  26. Calcium in Osteoporosis
    • Advise >800mg calcium daily
    • 4+ servings of dairy daily small pot youghurt, matchbox cheese, 1/3 pint milk, if compliant give vit D alone fultium D3 800IU daily
    • If not able to do this for calcium and vit Dif no CI (active stones orCKD5)
  27. Bisphosphonates
    • Women main trials show approx half risk compared to placebo
    • NNT postmentopausal with BMD<2.5 over 3yrs: 14 for vertebral fracture, 25 for non vertebral, 90 for a hip fracture
    • ALENDRONATE first line
  28. Risks of bisphosphonates
    • Indigestion/heartburn-consider for referral for IV zolendronic acid
    • Do not give if oesophageal disease/non compliance
    • SE- muscular pain/Rash/headache common, rare osteonecrosis jaw in poor dental health, can cause atypical femoral fractures
    • CI- in severe renal impairment egfr<35, correct hypocalcaemia before starting them
  29. Bisphosphonates how long to continue?
    • Measure BMD after 3-5 yrs: if low or fracture during tx continue, if normal- drug holiday for 2 to 3 years
  30. Back pain red flags
    • Age under 20 and over 55, systemic illness, known cancer/HIV/steroids and immune suppression, cauda equine symptoms, morning/nocturnal stiffness). MRI and or referral only if specific diagnosis suspected e.g. ankylosing spondylitis.
  31. Examine for nerve root problem
    • SLR test (L4-s1 roots)
    • Reflexes AJ (S1), KJ (L3/4)
    • Sensation lateral (S1) and medial (L5)toes
    • Power extension big toe (L5), stand on tip toes (S1)
  32. Treatment acute back pain
    • Reassurance and explanation – advice to stay active, discourage rest back book
    • Medication as required (fixed dosing intervals)
    • Consider muscle relaxants (e.g. tizanidine) or short term opioid
    • Consider spinal manipulation (for pain relief)
  33. Chronic low back pain
    • Short term NSAID and weak opioids for flares
    • Consider TCA and antidepressants
    • Manipulation, acupuncture, exercise therapy, massage may be helpful
  34. Spondyloarthropathies
    • Inflammation in the spine. 2-5 per 1000.
    • AS- adolescence early adulthood, spinal and peripheral joint damage, 25%spinal fusion, inc CVD risk.
    • 50% episodic anterior uveitis, psoriasis, IBD
    • Anti TNF and specialised physio improve the prognosis
  35. Inflammatory back pain
    • Back pain of >3months duration is inflammatory with 4 of these criteria:
    • Age less than 40
    • Insidious onset
    • No improvement with rest
    •  improved by exercise
    • Pain at night (improves on getting up)
    • Pain and stiffness worse first thing in the am and may improve with stretching and light exercise.
    • If suspected refer to rheumatology they will do HLA-B27 and MRI scan 
  36. What is the S factor?
    • Encourage patients to present if they have:
    • Early morning stiffness in their joints lasting >30min
    • Swelling- persistent swelling of one or more especially hand joints
    • Squeezing joints is painful
    • If squeezing across the MCP or MTP joints causes pain this should trigger concern, referral should not be delayed awaiting tests
  37. Management OA
    • Education, hip and knee book
    • Exercise activity and weight loss
    • Acupuncture!!
  38. Torticollis mx
    • Severe, sudden onset unilateral neck pain with deviation of neck to that side
    • Exclude drug reactions-antipsychotics, metoclopramide
    • Reassure rapid resolution is common (24-48hrs), simple analgesia and advise against collars
    • Intermittent heat or cold pad, gentle stretching within comfort limit, low firm pillow, good posture
  39. Whiplash
    • Assess and exclude red flags
    • Urgent xray to exclude subluxation or fracture is indicated if unable to laterally rotate the neck left and right more than 45degrees, they have paraeasthsiae in the extremities, focal neuro deficit or RF for fracture over 65 or OP
  40. Non specific neck pain
    • Encourage mobilisation, return to normal activity, gentle exercises
    • Reassure exercises may be painful but don’t make it worseLow firm pillow, consider physio
  41. Cervical radiculopathy
    • Neck pain with shooting pain, numbness or paraeasthesiae in the arm caused by irritation or entrapment of the lower cervical roots by a herniated disk or degenerative disc disease.
    • Wait 6 weeks of not resolving refer for specialist+-MRI, may need op
  42. Nerve roots cervical radiculopathy-C5
    • elbow flexion, biceps, sensory-lateral arm
  43. C6
    elbow flexion/wrist extension, biceps, supinator, sensory- lateral forearm thumb and index
  44. C7
    • elbow extension, triceps,  s- middle finger
  45. c8
    • finger flexion, s- medial forearm/little and ring
  46. T1
    • finger abduction and adduction,s- medial side upper forearm
  47. Tennis elbow
    • Lateral epicondylitis
    • 6-12months recovery
    • Eccentric exercises
    • NSAID symptom relief
    • Injection- reduces short term pain increases risk of recurrence and overall duration
    • GTN patches- RCT- cut patches quarter of 5mg matrix directly applied to the site use for 3m.Surgery/botox for resistant cases
  48. Temporal arteritis
    • Suspect in anyone over aged 50 with headache, scalp tenderness, transient visual symptoms or unexplained facial pains.
    • Start steroids immediately 40mg prednisolone unless ischaemic symptoms (jaw claudication) visual symptoms admit for IV methylprednisolone. Urgent referral for assessment and biopsy within 2w
    • Start aspirin unless CI, bone protection also
  49. PMR step 1- inclusion
    • Diagnose based on bilateral shoulder and/or pelvic girdle pain
    • Morning stiffness >45min
    • Abrupt onset, aged over 50 duration >2weeks
    • Raised ESR/CRP but can be diagnosed without raised markersàif classic symptoms and responds to steroids
  50. Step 2- need to exclude clinically
    • Active GCA (common 16-21% of PMRs)
    • Active cancer/infection(if present cannot diagnose)
    • Exclude active inflammatory rheumatic diseases (RA/SLE) and non inflammatory (fibromyalgia)
  51. Investigations for PMR
    • Protein electrophoresis and bence jones protein
    • RF, ANA
    • Dipstick urine and consider CSR if prominent systemic symptoms.
  52. Step 3- low dose steroids
    • Pred 15-20mg daily expect a clinical response in 1w
    • Aim for at least 70% global symptoms improved, lab resolution 3-4w
    • Usually 1-2 y required
  53. Prednisolone dose for polymyalgia
    • 15mg daily for 3w
    • 12.5mg for 3w
    • 10mg 4-6 w
    • Reduce by 1mg every 4-8w
    • BONE PROTECTION important
    • Monitor every 3m and check FBC/ESR/CRP/UEC/gluc
  54. Medications associated with gout
    Diuretics 1st, BBlockers, ACEI and non-losartan ARBs
  55. What causes gout?
    • Overproduction of urate-due to excessive purine intake or cancer treatments causing tumour lysis
    • Underexcretion- due to renal impairment e.g. hypertension
  56. Factors predisposing to gout?
    Male, overweight, HTN, DM, CKD, metabolic syndrome
  57. Triggers for gout
    • Drugs
    • Alcohol-beer/spirits
    • Red meat
    • Shellfish/seafood
    • Fructose sweetened drinks
  58. Acute gout Tx
    • NSAID-e.g. indomethacin
    • Colchicines- 500mcg TDS
    • Steroid-prednisolone 50mg daily reduced over 10days
    • Rest and ICE packs (QDS)
    • Some weak evidence for VITAMIN C
  59. When do we give allopurinol?
    • If pts have 2 attacks PA, and high serum uric acid persists despite non-drug measures
    • Dose start at 50-100mg daily, inc by 50-100mg every few weeks until uric acid level reaches target, max 900mg daily
  60. Allopurinol
    • Do not start in acute attack, wait until resolved (usually 1 or 2 weeks later)
    • When starting may trigger gout flares (esp if not titrated up slowly)-consider prophylactic treatment with colchicines 500mcg BD for up to 6 months, if cannot tolerate due to diarrhoea use NSAID with PPI
  61. Atopic eczema
    • Affects 20% children 10%adults Aqueous cream as a soap substitute not as an emollient
    • Continuing the emollient with steroid for flare up increases the efficacy of the steroid, steroid should be applied 30mins after the emollient to aid absorption
  62. Eczema and food allergy
    • Consider food allergy in infants with moderate/severe eczema which has not been controlled esp if associated with GI symptoms-colic, diarrhoea, reflux, under 6m 6-8 week trial of hypoallergenic hydrolysed formula for those bottle fed. With possible CMPI.
    • Avoid irritants – shower gels, bio washing powders, fabric conditioner.
  63. Acne
    Grading assessment:

    Predominantly comedonal (non inflammatory whiteheads/blackheads)

    Inflammatory(- erythematous papules/pustules)
  64. Rosacea
    • Exacerbating factors- alcohol, exercise, heat
    • Tx –topical metronidazole and azelaic acid
  65. Psoriatic arthritis
    • Suspect if:
    • Early morning stiffness >30m
    • Spinal stiffness improved with exercise
    • Joint swelling/tenderness
    • Dactylitis (acutely swollen tender digit)
    • If suspected refer to rheumatology for DMARD to reduce joint damage
  66. Psoriasis
    • Assess vascular risk and comorbidities and psychosocial impact.
    • Psoriasis treatment
    • 1.  Emollient
    • 2.  Plaque psoriasis- short intermittent potent steroid or steroid-calcipotriol ointment for rapid improvement
  67. Facial psoriasis
    • And flexural use- moderate potency steroids for short term
    • If fail then use vit D or tacrolimus
  68. Long term- use psoriasis
    • vit D analogue calcipotriol first line but alternative if causes irritation coul use:
    • coal tar
    • tazarotene gel
    • short contact dithranol (30min exposure with few large plaques)
  69. scalp psoriasis
    • thick scaling scalp – use overnight application salicylic acid, tar preparations or oil (olive or coconut) to remove thick scale.
    • Nail-topical steroids/calcipotriol/tazarotene
  70. Anterior uveitis
    • Red eye with pain, photophobia and blurred vision-refer
    • Circumcorneal rednes s is an early sign, consider if pt prev diagnosed with conjunctivitis and not responding to treatment
  71. Blepharitis symptoms
    • Gritty, uncomforatable ‘tired’ eyes
    • If severe- sticky eyes on waking
    • Lid margins have crusting and red rimmed appearance
  72. Management of blepharitis
    • Twice daily lid hygiene on a long term basis
    • If severe or if associated roseacea- doxycycline 100mg daily or lymecycline 408mg daily for 3m, erythromycin if pregnant or children
  73. Iron deficiency anaemia-NICE
    • Refer if Hb< 11g/dl men or
    • HB<10g/dl women
  74. If Hb low what do you need to check?
    • Serum ferritin (13-15)
    • Microcytosis?
    • Hypochromia?
    • Exclude haemoglobinopathy by doing Hb electrophoresis
    • Check transferrin and RBC indices
  75. Iron deficiency history
    • Ask about dietary intake
    • NSAID use if so stop
    • FH blood disorders- thalassemia/bleeding disorder/iron deficiency
    • Hx of non occult blood loss or blood donation
    • Significant FH colorectal cancer (1 relative under age 50 or 2 affected first degree relatives)
  76. Iron deficiency investigations
    • Urine for blood and celiac serology (1%renal tract malignancy)
    • Do upper and lower GI investigations for confirmed IDA-colonoscopy first choice then Ct colography , V frail do CTscan
  77. Premenopausal and IDA
    Screen for celiac, other investigations only necessary if >50yrs, GI symptoms or sig FH colorectal cancer
  78. Management of IDA
    Monitor with monthly FBC, and continue treatment until 3m after iron def is corrected.  E.g. ferrous sulphate 200mg BD

    • Follow up with 3 monthly FBCs for one year and a further test after another year. If poor response to iron and Hb not maintained consider ref for further investigations e.g. repeat OGD
  79. Iron deficiency in pregnancy
    • Iron requirements 3x higher in pregnancy
    • Vit Cinc iron absorbption, tea, coffee, wholegrains, calcium and antacids decrease iron absorption when consumed with or after a meal/oral iron
    • Definition Hb<11g (1st trimester), Hb <10.5 (2nd and 3rd trimester)
  80. Colorectal cancer
    • 1 in 18 men and 1 in 20 women will develop it, in 80% cases occurring over aged 60.
  81. Risk factors for colorectal cancer
    • Increasing age especially in men
    • Obesity
    • Consumption of red and processed meat and alcohol
    • Diet low in fruit, vegetables and fibre
    • Genetic conditions such as FAP and HNPCC
  82. Family history of colorectal cancer-another risk factor what is significant?
    -family history in a first degree relative <45years or in 2 first degree relatives diagnosed at any age gives rise to an increased lifetime risk  reaching 16-25% in men and 10-15% women.

    • -a single first degree relative diagnosed >65 years gives rise to only a slightly increased risk
  83. NICE referral guidelines for suspected cancer 2005
    >40years with rectal bleeding and change in bowel habit to looser stools and/or increased stool frequency for 6 weeks or more

    >60 years with rectal bleeding for 6 weeks or more without change in bowel habit or anal symptoms

    >60 years with persistent change in bowel habit to looser and/or more frequent stools for 6 weeks or more

    Abdominal or rectal mass

    Unexplained iron deficiency anaemia (<11 men <10 non menstruating women)
  84. New department of health guidelines 2012 guidelines associated to colorectal cancer suggest?
    • Direct GP referral for flex sigmoidoscopy for those:
    • >40years – unexplained rectal bleeding for 6 weeks
    • >55yrs  with any rectal bleeding (unexplained)
    • >40 with change in bowel habit for 6 weeks
  85. FOB screening
    • England 60-74 offered screening 2 yearly, over 75 can request a test kit
    • Current uptake is 50%

    Sensitivity 55-92% in one study- important to tell patient this is not 100% effective and so to report any bowel symptoms

    May cause distress if falsely positive result and need to warn about complications of colonoscopy if they go on to have this after a positive result

    Reduces mortality from CRC in those screened
  86. Irritable bowel syndrome
    • Affects 5-20%
    • Proposed mechanism- abnml GI motility, enhanced visceral perception, immune activation and altered gut flora as well as psychosocial, genetic and env factors
  87. Consider IBS in anyone with 6 month history of ABC
    • Abdominal pain/discomfort
    • Bloating
    • Change in bowel habit
  88. Red flags to check in IBS
    Unexplained or unintentional weight loss, rectal bleeding, +FH ovarian/colorectal cancer

    In pt over 60 change in bowels towards loose stools over 6 weeks

    Anaemia, masses (inc rectal- therefore PR recommended), inc inflammatory markers

    Consider OVARIAN pathology in women with new onset IBS like symptoms esp if >50 – do a Ca 125 blood test as this would be raised in ovarian pathology
  89. How to make + diagnosis IBS
    • Abdominal pain/discomfort relieved by defecation or associated with altered bowel frequency/form with at least two of:
    • Altered stool passage ~(straining, urgency, incomplete)
    • Abdominal bloating/distension
    • Symptoms worse with eating
    • Passage of mucusLethargy, nausea, backache and bladder symptoms are common and may support the diagnosis
  90. Investigations for IBS- bloods
    CRP, FBC, celiac
  91. Management IBS
    Healthy eating and lifestyle-ask about  dietary fibre, fatty foods, fluid,caffeine, alcohol

    Regular meals take time to eat, drink 8 cups at least fluid per day, restrict tea,coffee, fizzy drinks, advise exercise and relaxation

    • Check for food intolerance esp milk/lactose
    • Probiotic might help e.g. youghurts
  92. Wind/bloating in IBS
    Limit fruit to 3 portions daily

    Reduce resistant starches- pulses, wholegrains, bran, processed foods

    Oats and golden linseeds may help 1tbsp daily
  93. Diarrhoea in IBS

    • Limit alcohol and insoluble fibre- wholegrains, brans, cereals and nuts,seeds)
    • Limit fruit to 3 portions daily
    • Avoid sugar free sweets
    • Try lower fat diet

    • Probiotics may help
  94. Constipation in IBS
    Wholegrains fruit and vegetables up to one extra portion every 2 days

    • Oats and golden linseed may help, probiotics may help
  95. Antispasmodics in IBS
    • Peppermint oil and dicyclomine (merbentyl)
    • SSRIs and TCAs (low dose at night max amitrip 30mg)  for pain in IBS
  96. Other treatments for IBS
    Hypnotherapy and CBT- offer after 12m ongoing symptoms.

    • Mindfulness- training to focus on the present and uses breathing or another object as a focal point, to avoid thoughts about the past/future or judgement about the sig of physical symptoms.
  97. Coeliac disease
    1% prevalence

    • Prev is 4-22% in 1st dgree relatives so they should be offered testing
    • Presentation of coeliac

    • Pain, bloating, IBS type symptoms
    • Also fatigue, WL, arthralgia, myalgia, depression, itchy rash/dermatitis herpetiformis, apthous ulcers
  98. Diagnosis of Coeliac
    Offer serological testing with anti-TTg to:

    • Persistent and unexplained GI symptoms
    • Prolonged fatigue
    • Unexpected weight loss or in children FTT
    • Unexplained anaemia
    • 1st degree relative with celiac
    • Autoimmune disease- DM type 1, thyroid

    Consider in those who have amenorrhea, apthous stomatitis, depression, metabolic bone disease and fractures, abnml LFT, unexplained infertility and alopecia
  99. Testing for coeliac
    Need gluten in diet for 6 weeks prior to test

    Check anti TTg and IgA

    Refer if positive for confirmation of diagnosis with small bowel biopsy
  100. What are the risks of coeliac?
    • Osteoporosis- need bone scan at diagnosis
    •  advice about dietary calcium intake

    Vaccination as 30% have functional hyposplenism- need haemophilus, pneumococcal and annual influenza

    • Advise that risk of malignancy and small bowel lymphoma is greater in coeliacs, absolute risk is small and diminishes with time from diagnosis, autoimmune disease is more common.
  101. Management of coeliac
    Dietitian- for gluten free advice and advice on iron, folate, vit D and calcium

    Annual follow up

    Supply of GF food

    Annual bloods- FBC, ferritin, B12, folate, calcium, glucose, TSH +/- tTGA, LFT, vit D
  102. Gilberts
    Hereditary – autosomal recessive

    5-10% western populations

    Is due to a genetic variation in the way the pigment bilirubin is metabolised resulting in slightly higher circulating levels than average

    • Reassure not a disease jaundice will resolve in a few days without treatment, does not indicate liver damage
    • Tell staff if admitted and if jaundice persists over a few days needs to see GP
  103. Red flags dyspepsia
    • GI bleeding –change in bowel habit/stool colour
    • IDA
    • Prog unintentional WL/dysphagia
    • Persistent vomiting
    • Epigastric mass
    • High Rf for cancer- prev gastric surgery/ulcer, barretts, fh upper gi cancer)
  104. Referral for endoscopy
    If over 55 new onset persistent dyspepsia despite lifestyle and drug modification and 4 weeks treatment

    • If under 55 and symptoms unresponsive to full dose PPI, h pylori and lifestyle, where concern exists about diagnosis.
  105. Testing for h pylori
    13C urea breath test, stool antigen test

    If positive 7 day twice daily full dose ppi

    plus metronidazole 400mg and clarithromycin 250mg or

    amox 1g and clarithryomycin 500mg
  106. Diagnosis of COPD criteria
    IF FEV1/FVC ratio is <0.7 even if FEV1 is >80% predicted in the presence of symptoms such as cough/breathlessness
  107. NICE guidelines COPD
    • Smoking cessation
    • Pulmonary rehabilitation
  108. Drug management COPD
    1st short acting beta agonist as required

    • 2nd if remain breathless or frequent exacerbations: tiotropium (spiriva-powder formulation-LAMA) or salmeterol (LABA)
    •  if FEV1>50% predicted

    If FEV<50% predicted use LABA+ICS in combination inhaler or LAMA

    Inhaled corticosteroids and LABA combinations for all patients with severe disease FEV1<50% not just in exacerbations
  109. Diagnosing COPD
    • Based on hx, ex and
    • airflow obstruction defined as FEV1/FVC ratio<0.7
    • When to consider COPD
    • age over 35 smoker or exsmoker with:
    • exertional dysponea, cough or wheeze
    • frequent sputum production
    • recurrent winter bronchitis
    • In patients without typical asthma symptoms- chronic non productive cough, sig diurnal or day to day variability, night time waking with wheeze
  110. Spirometry reversibility testing
    • Asthma present if there is a 400ml response to bronchodilators or 30mg pred for 2w or
    • Serial peak flows show a >20% day to day variability

    Initially do CXR, FBC (to identify anaemia/polycythaemia) and do BMI
  111. Severity of COPD stages
    • All post bronchodilator FEV1/FVC <0.7
    • FEV1%predicted:
    • Stage 1 mild>80%
    • Stage 2 moderate 50-79%
    • Stage 3 severe 30-49%
    • Stage 4 v severe <30%
  112. MRC dysponea score grade 1
    Not troubled by dysponea except on strenuous exercise
  113. MRC dysponea score grade 2
    SOB when hurrying or walking up a steep hill
  114. MRC dysponea score grade 3
    • Walks slower than contemporaries on level ground due to SOB, or has to stop for breath when walking at own pace
  115. MRC stage 4
    • Stops for breath after approx 100m or a few mins on level ground
  116. MRC grade 5
    Too breathless to leave house or SOB when dressing/ undressing
  117. When to refer for Oxygen therapy
    • Pulse ox <92% on air
    • If sever <50%predicted
    • Cyanosis/polycythaemia
    • Signs of right sided heart failure
  118. Exacerbation of COPD
    ABx and oral steroids pred 30mg for 7-14 days, do pulse oximetry, admit if sats<90%, severe dysponea, poor general condition/not coping
  119. Moderate asthma exacerbation
    • PEFR>50-75% best or predicted and increasing symptoms
  120. Acute severe asthma
    • PEFR 33-50% predicted, inability to complete sentences, RR>25, HR>110
  121. Life threatening asthma
    PEFR<33% best predicted, Sats<92%, silent chest, poor resp effort, arrthymia, exhaustion or altered conscious level
  122. Treatment acute asthma
    • Oxygen to all hypoxaemics- aim spo2 94-98%
    • Nebulised high dose beta agonists or beta 2 agonist by spacer
    • Steroid 40-50mg for at least 5 days
  123. Asthma

    Review 3 monthly and step down if control adequate
    • Step 1- mild intermittent asthma
    • Short acting beta agonist as required
  124. Step 2- regular preventive therapy
    Add ICS 200-800mcg daily (400 starting dose)
  125. Step 3 initial add on therapy
    Add LABA and assess response: if good continue LABA, if benefit but still not controlled inc ICS to 800mcg daily, if no response stop LABA, if control still inadequate trial LTRA/SR theophylline
  126. Step 4 persistent poor control
    • Increase ICS to 2000mcg daily
    • Add fourth drug-LTRA, SR theophylline, oral beta agonistStep 5 refer
  127. Pre pregnancy counselling
    Folic acid (decreases NTD by 72%) – for 12weeks

    • 5mg if prev NTD, DM, sickle cell,anticonvulsants
  128. Smoking in pregnancy
    Decreases fertility, causes birth defects, preterm and stillbirth, SIDS. Growth restriction, infants are 170g lighter on average

  129. Alcohol in pregnancy
    • Heavy intake-growth restriction and preterm. Binge may affect neurodevelopment. May inc risk of miscarriage
  130. Chronic kidney disease
    All patients should be informed of their diagnosis leading to increased involvement in their care, inc risk of vascular disease
  131. Advise patients CKD
    Adequate hydration, temporary cessation of medications e.g. ACEI/ARB in intercurrent illness, avoid NEPHROTOXIC drugs (NSAIDS),

    care with opiods, hypoglycaemics, digoxin, lithium, high dose statins

    Control BP target <140/90
  132. Interpreting and investigation of proteinuria?
    1.       Check persistent- defined as dip positive proteinuria>2samples, send MSU to ex infection repeat at least 2 wks after uti resolved

    2.       Send urine for albumin:creatinine ratio/protein : creatinine ratio

    • 3.       If confirmed significant proteinuria: do U+E, FBC, ESR, lipids, check USS renal tract, refer nephrology if above referral threshold
  133. Referral threshold for proteinuria?
    ACR >70 or >30 concomitant haematuria 

    PCR>100 or >50 concomitant haematuria
  134. What is the clinical significance of proteinuria?
    Clinically significant proteinuria PCR>30 indicates glomerular rather than tubular pathology e.g. glomerulonephritis+ diabetic retinopathy,

    isolated proteinuria PCR<30 just needs monitoring
  135. Renal USS in CKD when?
    • If patient has obstructive symptoms, FH polycystic kidneys, haematuria, progressive CKD or stages 4
  136. Stages of CKD 1+2
    Stage 1 – kidney damage and normal eGFR (proteinuria, haematuria, anatomical abml) eGFR>90

    Stage2- kidney damage and mild reduction egfr 60-89
  137. stages 3 to 5 CKD?
    • Stage 3a- moderate reduction in egfr 45-59,
    • 3b 30-44

    Stage 4- reduction in gfr 15-29

    Stage 5- established kidney disease.
  138. CKD rate of progression
    • Progressive if rate of decline is greater than average of 5ml/yr over years or >10ml/min over one year
  139. Refer CKD
    If stages 4+5

    • High proteinuria (ACR>70)
    • Proteinuria (ACR>30)with haematuria
    • Rapidly declining egfr (>10ml/min in one year or aveof>5ml/min pa over a few years)
    • Poorly cont HTN despite at least 4 drugs . Or suspected Renal artery stenosis or rare genetic cause of CKD.
  140. CKD when to give ACEI or ARB?
    Diabetes + ACR>30 irrespective BP/egfr

    ACR>70 irrespective of HTN/CVD

    CKD+HTN with clinically sig proteinuria (ACR>30)

    • Use max tolerated dose ACEI check renal function after 1-2w if declines >25% stop + look for cause.
  141. Managing CVD risk in CKD
    Statins if otherwise indicatied e.g. est vascular disease,1prev after SHARP consider

    Antiplatelets for secondary prevention CVD only

    • Identify anaemia if 3b, 4 or 5+ex other cause check haematinics
  142. Bones and CKD
    Check PTH, Ca, Phos only in 4+5

    • Bisphosphonates if indicated ergo/cholecalciferol in stages1-3B, alfacalcidol +ca monitoring stage4 or 5.
  143. Haematuria >+ blood on dipstick what do I do?
    Exclude transient(UTI/exercise) or spurious (menstruation, dietary,sex)cause

    Send MSU to exclude infection

    Persistent- repeat twice more at intervals 2-3 w, if 2/3 positive then manage further ignore’ trace’

    • No UTI but symptomatic? Refer likely urological cause
  144. Assymptomatic NON VISIBLE haematuria (NVH)/microscopic haematuria what do I do?
    Do baseline renal – BP, blood for creatinine eGFR, urine for ACR

    PCR to look for possible glomerular disease-nephropathy and GN
  145. NVH + under 40
    If eGFR<60, urine ACR>30 (PCR>50) or BP >140/90 – REFER NEPHROLOGY

    If normal for primary care monitoring – annual renal function refer if sig change
  146. NVH+ over 40
    • REFER NEPHROLOGY to exclude cancer
  147. Primary care monitoring of continued NVH?
    Annual assessment recommended

    • Refer back to urology if symptomatic/visible
    • Refer nephrology if worsening eGFR >5ml/min/yr or proteinuria
  148. Hypomagnesemia causes
    PPI, antidepressants-citalopram and escitalopram, diuretics

    Hypomagnesemia can cause torsades de points/QT prolongation
  149. Prediabetes study Lancet 2012
    IGT 5-12% will develop diabetes

    • Reduction prog to diabetes after 3 yrs lifestyle intervention by 58% compared to placebo, metformin by 31% compared to
    • placebo

    • 150mins/week aerobic exercise reduces risk by 52%
  150. Prediabetes for patients identified as high risk?
    Offer bloods (fasting gluc/HBa1c) :

    if FBG>7 or hba1c>48(6.5%)repeat tests to look for DM

    FBG 5.5-6.9 Hba1c 42-47 (6-6.4) offer intensive lifestyle programme

    • FBG<5.5 Hba1c <42 reassess risk every 3y
  151. Intensive lifestyle change programme
    • Group based prog min 8 times meet over 18m
    • Focus exercise, weight loss inc whole grains vegetables, reduce fat, annual blds and assessments
  152. Metformin and IGT
    Offer to pts prog to DM despite intensive programme

    Start 500mg daily gradually inc to 1500mg to 2000mg daily

    • Orlistat if BMI>28, 12 w then review need to lose 5% body  weight
  153. Diagnosing DM
    Random FBG>11.1

    Fasting gluc >7

    Plasma gluc >11.1 2hrs after a glucose load 75g in OGTT

    Asymptomatic patients need to repeat to confirm diagnosis.New – Hba1c >48( x2)= correlates with gluc over 3m prev
  154. 2nd line after metformin
    • Used to always use sulphonylurea but evidence to show GLIPTIN good as next step- less risk of hypos and does not affect body weight, expensive though!!
  155. Exentatide/Byetta
    • 3rd line for diabetes for those with BMI>35 or selected BMI<35
    • BD s/c injection
    • SE- N and V
  156. Diabetes
    • EDUCATION and LIFESTYLE- priority – smoking, diet, exercise, nutrition, high fibre, low GI, little sat fat, oily fish, low salt
    • Blood pressure in diabetes
    • Target 140/80, 130/80 if small vessel disease 
  157. Diabetes review things to ask about? 
    • Vision- any vision changes need annual retinal screening, digital images
    • Neuropathic- pain? Rx with TCA/duloxetine
    • Gastroparesis – suspect with unexplained bloating/vomiting-trial of metoclopromide/domperidone
    • ED review annual offer PDE5
    • Foot
    • Screen for depression
  158. Erectile dysfunction
    Affects 30-50%men aged 40 to 70, 80% primarily organic cause, 20% purely psychological

    Maybe the first presentation of vascular disease
  159. Assessment for ED
    • Hx and Ex
    • Examination – check genitals (DRE not essential unless history of LUTs, pain or ejaculatory problems)Blood pressure, weight
  160. Tests for ED
    Serum lipids and fasting glucose in all patients

    All men should have serum testosterone (between 8am and 11am)

    PSA only if clinically indicated but essential prior to commencing testosterone therapy
  161. Management of ED
    Lifestyle advice – some men might want ginseng/yohimbine

    First line PDE5-must receive 8 doses with appropriate advice +sexual stimulation at maximum dose before considered a non-responder.

    Tadalafil licensed at 2.5 and 5mg daily use maybe cost effective if needed >twice/wk

    Vacuum erection device- highly effective but under used 84% satisfaction rates reported

    Second line- intracavernous/intraurethral alprostadil

    3rd line refer for surgical prosthesis
  162. ED caused by hypogonadism
    • If serum total testosterone consistently <12 consider a trial for up to 6m of testosterone replacement, if satisfactory response continue, unsatisfactory- combine with PDE5
  163. Treatment of ED?
    • PDE5 inhibitors- beneficial
    • Alprostadil, intracavernous injection

    • Evidence for ginseng (58% vs placebo 0.5-2g))and yohimbine(30% improved erections in 1 study)
  164. Can I get Viagra on the NHS?
    IF DM, prostate cancer, Parkinsons, MS, prostatectomy, pelvic surgery/injury, RF treated by dialysis or implant, spinal cord injury, may if ‘severe distress’ need specialist input, one per week allowed.
  165. Premature ejaculation
    20-40% prevalence, commonest sexual dysfunction in men, stigma- therefore under-reported and under-treated.

    Definition- ejaculation which always or nearly always occurs within one minute of vaginal penetration associated with negative personal consequences

    Recently tx behavioural strategies and SSRIs

    DAPOXETINE- short acting ssri on demand dosing inc IELT by 3-4min
  166. Causes of premature ejaculation
    Lifelong PE- from first sex ono all attempts of intercourse, genetic basis, neurobiological in cause, ejaculatory control under neuronal control involves neurotransmitters inc 5HT

    Secondary- later in life more likely psychological triggers stress/adv events
  167. Current treatment options for premature ejaculation
    Psychotherapy (couple psychosexual counselling), behavioural methods to improve control

    Topical anaesthetic cream- EMLA prilocaine/lidocaine cream 1st line mx- cause genital numbness  and reduced ability to maintain erection

    • SSRIs- highly effective need to take daily e.g. paroxetine 20-40mg daily, or sertraline, fluoxetine and citalopram-daily initially then to use as needed once ejaculatory control successfully regained/clomipramine if SSRI not tolerated
  168. Restless legs syndrome
    • Ekboms, urge to move your legs
    • difficult to describe sensation
    • crawling/electric/toothache/water running
    • jumpy or twitchy legs, occur every10-60secs
    • typically symptoms occur at rest- particularly sitting/lying
    • worse in evening/sleep
    • eased by walking,moving, shaking, massaging, occ affects arms
    • 1 in10 people
  169. causes of restless legs
    • pregnancy 1 in5
    • lack of iron

    medicines-antidepressants,antipsychotics, dopamine antagonists, antihistamines,calcium channel blockers, antipsychotics,phenytoins or steroids

    As a symptom of other diseases- kidney failure, PD, diabetes, underactive thyroid

    Inv- FBC, iron, UEC

    • general measures- treat cause,  distractions, reading or watching tv if symptoms mild, sleep hygiene
    • reduce caffeine/alcohol
    • salt may affect it

    Exercise during the day 3x per week

    Tx Dopamine agonists- pramipexole, ropinirole, rotigotine,feeling sick,  lightheadedness, lack of sleep, many ppl no side effects. Others carbamazepine, gabapentin, benzodiazepines.