ࡱ> q` 0bjbjqPqP .::wU%"S"S"S8ZSlSzhTT"TTTTTT.z0z0z0z0z0z0z$;|h~rTz9VTTVVTzTTzgggV TT.zgV.zggrrTsTT 0Q?#"ScsvTz0z"szetssJsT>&U,gRU$vUTTTTzTzgXTTTzVVVVCH H BMJ reading Jan 11th Medical abortion Used up to 63 days gestation (9/40) Mifepristone 200mg orally follwed 24 hours later by Misoprostol SL 800mcg. Most women abort 2 to 6 hours after taking the Misoprostol Women should seek medical help id:vaginal bleeding more than two sanitary towels for two consecutive hours, temp persistently > 38 C, severe abdo pain unrelieved by analgesia, or D&V lasting > 24 hours after taking misoprostol Causes of polydipsia Common (>1in 10) Diuretics, caffeine & alcohol DM Lithium Heart Failure Infrequent (1 in 100) Hypercalcaemia Hyperthyroidism Rare Psychogenic polydipsia Hypokaleamia Jan 4th Cardio-selective beta-blockers for patients with COPD who have an MI provide substantial survival benefits so use them! Interesting paper on IGR and the risk of progression to diabetes when using statins, diuretics or betablockers. Surprisingly beta-blockers did not increase that risk whereas statins and diuretics did. Oral rehydration in diarrhoea (if no signs of dehydration) <2 years = 50 to 100mls after each loose stool >2 years = 100-200mls after each loose stool But if signs of dehydration use 75mls/kg over four hours then revert to the regime above. Dec 14th Duration of common childhood illness 90% will be better within: Cough = 3 weeks Brochiolitis = 3 weeks Cold 2 = 1 week Otitis media = 1 week Dec 7th Age over 50 (usually > 70) with ESR usually > 40 proximal mylagia and stiffness (struggles to get off toilet or bath and/or raise arms over shoulder height). They may struggle to turn over on bed. Morning stiffness usually lasts about an hour. Screen for TA symptoms = admit PMR base line invx FBC, ESR/CRP, Cr&Es, LFTs, adj calcium, plasma electrophoresis and Rh factor. Rx Oral pred 15 a day should have symptom resolution within 3 to 5 days Reduce by 1mg per week until at 10mg and then 1mg a month If symptoms recur, revert Back to prior dose. Consider periodic screening for DM and osteoporosis prophylaxis Nov 30th Idiopathic Hyperhidrosis Life style advice avoid alcohol, spicy food, stress/emotional triggers. Use loose fitting clothes made wit natural fibres, use antiperspirant spray rather than deodorant. If that fails try topical aluminium chloride (axillae or hands only) Other options ionyophoresis. Oral anticholinergics e.g. oxybutinin (unlicensed) or second line glycopyrrolate Botox injections (last 6 to 9 months) Sympathectomy Nov 23rd Erythrocytosis = HB >185 and PCV >0.52 in a man and 165 & 0.48 in a woman. Secondary causes alcohol, smoking, and obesity but does remedying the PCV & HB make any difference to morbidity & mortality?? Chronic hypoxia of any cause will cause erythrocytosis e.g. attitude, respiratory disease e.g. sleep apnoea, copd etc, heart failure etc Drugs diuretics, anabolic steroids and erythropoietin. Cancer renal cell carcinoma, hepatocellular carcinoma Renal stage renal disease Primary causes Polycythaemia Rubra Vera due to the JAK2 mutation Risks of erythrocytosis = VTE due to increased viscosity Hyperviscosity symptoms myalgia, weakness, paraesthesia, blurred vision, fatigue and headache Invx in primary care = rpt FBC after 2 weeks, Cr&Es and LFTs re ? renal or hepatic disease, serum ferritin, Pox re ? hypoxia, TTU for haematuria Correct secondary causes if possible and re-check FBC Refer! PCR Rx = aspirin, venesection and cytoreductive drugs e.g. hydroxyurea, busulfan and JAK inhibitors. Nov 16th Secondary Prevention of MI NICE summary All patients should be offered cardiac re-hab benefits = reduced hospital admissions, reduced rate of second MI, reduced death rate and better quality of life. It should commence within 10 days of discharge. Do not recommend routinely eating oily fish. Do recommend, smoking cessation, Mediterranean diet, weight management, moderate alcohol and regular physical activity. Low dose aspirin should be offered to all patients. If allergic use clopidogrel. Clopidogrel and aspirin for 12 month in: NSTEMI or ST elevation MI & stent / medical (no Rx or fibrinolytic Rx) treatment. Ticagrelor and aspirin for 12 months is an alternative in: NSTEMI or patients with ST elevation in whom the cardiologist is going angio. Offer clopidogrel instead of aspirin to patients 12 months post MI who have TIA, CVA, PVD etc. If patients are on an anticoagulant prior to MI then aspirin or clopidogrel is added for 12 months. Ace inhibitor uptitrated to max dose within four weeks of discharge. If intolerant use an ARB. Start spironlactone or eplerenone within 3 to14 days if evidence of LV dysfunction/HF. Start betablocker as soon as possible after MI and titrate to the maximum tolerated dose and continue for at least 12 months. If LVD/HF continue long term. Oct 26th Invx of suspected SLE If SLE suspected GP tests should be FBC, ESR, CRP, LFTs, Cr&Es, urine dip test (?nephritis), antinuclear antibody, antinuclear antigen antibodies Most patients with positive antinuclear antibodies do not have SLE. Antinuclear antibodies may be positive in: Crohns, autoimmune hepatitis, PBC and lympho proliferative disorders. Specificity is also low at 57%. Clinical features (joint pain/swelling, Raynaulds, malar rash, Sicca syndrome, lymphadenopathy, splenomegaly, anaemia etc) + a positive rest increase the positive predictive value. Normochromic, normocytice anemia with lymphopaenia and neutropaenia are common. A disproportionate rise in ESR to CRP is common . Oct 21st New generation antianginals The antianginal drugs recommended for initial treatment are  blockers and calcium channel blockers, which reduce myocardial ischaemia by heart rate reduction and vasodilatory mechanisms, respectively. Either or both of these drug classes should be prescribed, together with a short acting nitrate for prompt alleviation of angina attacks. However, if these drugs are not tolerated, are contraindicated, or fail to correct symptoms, alternative antianginals are available. Alternative antianginal drugs include older less familiar ones such as nicorandil, which has been available for the past 20 years, and newer antianginal drugs such as ivabradine and ranolazine. Antianginal drugs reduce myocardial ischaemia by augmentation of oxygen delivery, reduction of oxygen demand, or a combination of both. Nicorandil augments oxygen delivery through coronary vasodilatation. Ivabradine reduces myocardial oxygen demand by reducing heart rate, whereas both ranolazine and trimetazidine are thought to do so through metabolic modulation, increasing the efficiency of myocardial energy production. Side effects Ivabradine Adverse effects include visual flashing lights known as phosphenes in up to 16% of patients, which are usually only mild to moderate in intensity and transient. Nicorandil Common adverse effects include headache (>10% of cases) (especially on initiation of treatment), flushing, dizziness, decreased blood pressure and/or increase in heart rate, and gastrointestinal side effects. Ranolazine Undesirable effects with ranolazine tend to be mild to moderate in severity and often develop within the first two weeks of treatment.The most common are constipation, nausea, and weakness. Oct 5th Gout review interesting points Effects 1-2% of population (men >40 and women > 65) But only 10% of patients with hyperuricaemia develop gout There is progressive urate crystal deposition in the cartilage, periarticular tissues and the acute attack occurs when crystals are shed from the cartilage into the joint space It usually resolves within 2 weeks if untreated Uricacid is derived for degredation of purines (70% endogenous and 30% dietary origin) and levels increase with decreased renal excretion or increased production. Metabolic syndrome is strongly associated with gout Beer and spirits >> risks than wine Meat, seafood and fructose containing drunks increase risk Gout co-morbidity HT 74%, Obesity 53%, DM 26%,CKD 20%, IHD 14% During an acute attack serum urate levels may be normal Blood invx FBC (myeloproliferative??), HBa1c, fasting lipids, Cr&Es Ask re smoking (CVD risk) and alcohol (causation) Rx options Naproxen 500mg for 5 days Oral pred 30mg a day for 5 days Colchicine 1.2mg stat and 600mcg after one hour (low dose regime) Prophylaxis commence if pt has 2 or more attacks over 12 months Start 2 to 4 weeks afte acute attack Start allopurinol at 100mg and uptitrate monthly with colchicine cover 600mcg bd Measure FBC, Cr&Es lfts and uric acid monthly during uptitration Allopurinol hypersensitivity syndrome (liver & kidney damage with skin rash) is more common with CKD, diuretic use and higher dose allopurinol at initiation hence low start with uptitration. Once target uric acid level achieved it should be checked 6 to 12 monthly to ensure in the lower half of the normal range but after 2 years this can be relaxed to upper half of normal range with bi-annual uric acid level checks Sept 28th Rational testing - acute cardiac? Chest pain ECG still 1st line test CK testing is no longer recommended Tropinin assays are the test of choice The new Highly Sensitive Troponin tests have much greater sensitivity Levels are measures on admission and 3 hours after admission irrespective of timing of onset of pain Beware heart failure, septicaemia and renal failure can increase troponins September 21st Cows Milk allergy Effects 2 to 7.5% of children under 12 months Whereas lactose intolerance is very rare Symptoms- prurtius, erythema, eczema, reflux, colic, diarrhoea etc after cows milk ingestion NB Breast fed babadies can get cows milk allergy from cow milk proteins transferred from mother to chils in breast milk! Rx- exclusion of cows milk protein from diet note soya based formulas are not the answer you have to recommend an extensively hydrolysed formula e.g. Aptamil Pepti Most children out grow it by 3 years of age Urinary incontinence in women NICE Hx Define whether they have stress, urgency (Overactive Bladder) or mixed urinary incontinence A bladder diary over 3 days is helpful Ex Abdominal exam and pelvic exam - confirm pelvic muscle contractions before progressing to pelvic floor training Absorbent products or handheld urinals should not be considered primary Rx option just a coping strategy adjunct pending definitive therapies. SI or Mixed 1st line = 3 months pelvic floor training (which should involve at least 8 contractions 3x a day) SI do not use duloxetine 1st line! SI refer to urogyneacologist or specialist incontinence service if pelvic floor training fails OB 1st line = bladder training before oral Rx (e.g. Oxybutinin or tolterodine immediate release preps or Darifenacin) which should be a trial for 4 weeks prior to dose increase or medication change. Newer Rx OB Botulinus toxin and percutaneous nerve stimulation August 24th DKA in type 2 can occur = type 2 ketosis prone diabetes Can be the 1st presentation of the patients diabetes More common on non Caucasians e.g. Afro-Caribbeans, Africans, Hispanics etc Often an older and may be obese Due to intercurrent illness reducing pancreatic insulin output in a patient with insulin resistance August 3rd 1 in 8 adults will have CKD as per the eGFR based CKD classification system.but only 1 in 3000 to 5000 develop end stage renal failure per year. The value of early detection and Rx of generic CKD remains to be proven. Useful review re CKD Patients > 65 without HT or DM, in the absence of macro albuminuria, and a stable eGFR between 45 and 59 are very unlikely to have significant progression in their CKD and the value of coding it and treating it is very debateable. July 27th NICE guidance on VVs Compression hosiery as a sole Rx options is no longer indicated unless the patient is not suitable for any other intervention Symptomatic or VVS with complications = refer to vascular service E.g. Patients recommended for referral include Patient with pain, swelling or heaviness of the legs. Associated skin changes Bleeding from VVs Venous ulcer i.e. a break in the skin below the knee which has nit healed after 2 weeks 1st line invx in hospital is duplex uss to confirm the diagnosis of VVS and truncal reflux 1st line Rx = radio frequency or laser ablation 2nd line Rx = USS guided foam scherotherapy NB compression hosiery post Rx is only worn for a maximum of 7 days July 20th NSAIDS review NSAIDS are second line agents on the Rx of arthritis Naproxen has no excess risk for CVD Diclofenac has the highest risk NSAIDs negate the effect of aspirin so use COX2 inhibitors in patients on aspirin Use PPI cover when using SSRIs or Corticosteroids with nsaids Use PPI cover with nsaids in the > 65s If you have to use nsaids in > 65 consider eGFR 1 to 2 weeks after start and then periodically Avoid nsaids in CCF and CKD NSAIDS increase BP in hypertensives, especially for patients on ACE inhibitors, ARBs, diuretics and betablockers July 13th AF 10 minute consultation Although still part of QOF and NICE guidelines, the use of aspirin has been dropped from the European Society of Cardiology guidelines for AF in 2012. CHADS2 score 0 = no Rx , 1 = no Rx or anticoagulation, >1 = anticoagulation These rate controlling drugs are combined warfarin (target INR = 2.5 ) or one of the newer generation anticoagulants, such as Dabigatran 150mg bd (but reduced to 110mg bd in patients > 80 years). NB There are now alternatives to Dabigatran e.g. Rivaroxaban 20mg with evening meal (reduced to 15mg if eGFR < 50) or Apixaban 5mg a day (changed to 2.5mg bd if eGFR < 30 or patient > 80 years or patient < 60kg). Start bisoprolol 2.5mg (1.25mg in elderly) and uptitrate in increments of 1.25mg every one to two weeks until target pulse rate is achieved or the maximum dose of 10mg has been reached. If unable to tolerate betablockers then use diltiazem slow release starting at 90mg bd increasing to 120mg bd if pulse rate uncontrolled. Verapamil is an alternative starting at 40mg tds and uptitrating in increments of 40mg every 1 to 2 weeks. June 29th - Myeloma review Newly diagnosed patients are projected to live for five years wit with newer Rx regimes Median age of diagnosis is 70 BUT 2% of cases occur < 40 years More common in men and Afro-Caribbeans Usual IGA or IGN monoclonal antibody IGM is more likely Waldenstroms macroglubulinaemia Polyclonal antibodies suggests inflammation At presentation 75% have anaemia 70% have bone pain/disease e.g. pathological fracture 30% hypercalcaemia 25% renal impairment (due to light chains blocking renal tubules) Invx of suspected myeloma in GP FBC, ESR, Calcium, Cr&Es, Plasma electrophoresis and urinary BJP MGUS 1% per year chance of converting to myeloma Patients with myeloma have reduced renal reserve sp nephrotoxic drugs should be used with caution June 22nd Post Circulation stroke Account for 20% of strokes Diagnosis often delayed or missed Symptoms Diplopia or homonymous hemianopia Unilateral or bilateral sensory loss Vertigo Ataxia Dysarthria Dyspahagia Diagnosis MRI better thav CT June 8th Managing unscheduled vaginal bleeding in non pregnant pre-menopausal women Under the age of 30 malignant causes are rare and under 24 very, very rare! The peak incidence for Cx cancer is 30 to 34 years. The peak incidence of endometrial cancer is 55 and is very rare < 40 years. Uterine fibroids occur in of women and half of these will causes symptoms (heavy or irregular bleeding) Endometrial polyps are also associated with heavy and irregular bleeding but the incidence of cancer in polyps is low (<2%). PCB about 1/2 have no identifiable cause, 1/3 Cx ectropion, 1/5 CIN or rarely Cx cancer, only 2% have chlamydia BTB on cocp most common cause is missed pills. If you want to change increase the oestrogen to 35 mcg in preference to changing the progesterone June 1st Management of recurrent UTI in non-pregnant healthy women Definition 2 or more UTIs in 6 months or 3 or more in 1 year. 1/3 to of women who has a UTI will have a recurrence in 3 months Risk factors: Prior recent UTI Sexual intercourse Postmenopausal When to refer Hx of urinary tract surgery Known anatomical abnormality Calculi Asymptomatic haematuria after successful antibiotic Rx Persistent gross haematuria Things that might help ? regular use of cranberry products debated Post coital voiding debated Lactobacilli vaginal pessaries Things that do help Prophylactic use of antbx (daily, 3x a week or postcoital) for 6 month trial Use of hone supply of 3 days courses of antbx e.g. Trimethoprim Vaginal oestrogen in post menopausal women Things that dont help Direction of wiping Loose or cotton underwear May25th Rx of sinusitis Increasing symptoms (but systemically well) after 5 days or persistent symptoms after 10 days = 7 to 14 days of inhaled nasal steroids. If improvement after 48 hours fails to materialise consider a 5 day course of antbx with added nasal decongestants. Increasing symptoms (and systemically unwell) after 5 days or persistent symptoms after 10 days 5 days = 5 day trial of antbx, nasal decongestant and possible inhaled nasal steroids BUT if no improvement after 48 hours refer ENT. May 11th Acne review surprises! Topical retinoids are now a mainstay of treatment Avoid prolonged antibiotic courses and antibiotic monotherapy because of the risk of bacterial resistance Use topical retinoids, topical retinoids + benzoylperoxidase (different times of the day), topical retinoids and topical antbx rather than benzoylperoxidase or topical antbx in isolation General treatment algorithm according to acne severity SeverityTopical retinoidBenzoyl peroxideTopical antibioticOral antibioticHormonal agent*Azelaic acidOral retinoidMaintenanceRecommended treatmentPossible treatmentNoNoPossible treatmentNoNoMildRecommended treatmentPossible treatmentNoNoNoAlternative treatmentNoMild-moderateRecommended treatmentPossible treatmentRecommended treatmentNoNoAlternative treatmentNoModerateRecommended treatmentRecommended treatmentRecommended treatmentPossible treatmentAlternative treatmentMonotherapyModerate-severeRecommended treatmentRecommended treatmentNoRecommended treatmentPossible treatmentAlternative treatmentMonotherapySevereNoNoNoNoNoNoMonotherapy*Female patients only. Heart failure invx (May 11th BMJ) A normal ECG has 90% negative predictive value for excluding systolic heart failure. BNP is raised in heart failure and has 90% sensitivity for diagnosing heart failure (also 93% negative predictive value if level normal) it inhibits aldosterone and rennin production and sympathetic drive. The higher the level the worse the prognosis. A > 30% fall with treatment correlates with an improvement in prognosis. Normal ECG abd BNP in a non acute setting means heart failure is very unlikely Causes of non cardiac moderately raised BNP: COPD, DM, CKD, liver failure and sepsis. Levels > 400pg/ml = to be seen by a cardiologist in 2 weeks Invx of choice = ECG and BNO, echo if abnornmal. Base line bloods include FBC, Cr&Es, LFTs, Hba1c, Lipids and TSH. May 4th BMJ Repeat CVD risk calculation before 8 to 10 years is not warranted if their initial risk assessment is 15% If 15% to 20% rpt in 1 year 20% = Rx April 27th BMJ Move towards prophylactic use of tamoxifenor or raloxifene in women deemed to be high risk of breast cancer. Diabetes in the elderly American Diabetes Association guidelines Elderly with little co-morbidity Hba1c target <58.5mmol/l Elderly with multiple co morbidity or memory impairment Hba1c target <64mmol/l Elderly with end stage chronic disease or significant cognitive impairment Hba1c target < 69mmol/l Management of Hidradenitis suppurativa Smoking and obesity important risk factors Make sure you use adequate analgesia in flare not just antbx Rx aggressively with antbx early and use for 3 months to limit scarring erythromycin, lymecycline, , doxycycline or oxytet 1st line but topical clindamycin is an option you can also use both early on in the disease. Refer to dermatology if flare ups becoming frequent or evidence of scarring starting etc dermatology often use clindamycin with rifampicin and may use dapsone. March 2nd 2013 BMJ Topic: incidental thrombocytopaenia What things have you learnt which may change your practice? Other than the obvious causes such as ITP, hypersplenism, chronic liver disease and myelodysplasia there are a wealth of possible common causes. Drugs which cause thrombocytopaenia: alcohol, heparin, quinine, trimethoprim, thiazides, phenytoin and carbamazepine B12 deficiency, folate deficiency HIV and Hep C Pregnancy Recommended invx of incidental isolated thrombocytpopaenia 1st just rpt the FBC, if platelets < 20 admit, <30 urgent referral and discuss with haematologist, 30 100 and stable routine referral. Invx = Blood film, Cr&Es, B12, folate, LFTs, gamma GT, LDH, CRP, plasmaphoresis NB if platelets < 50 stop aspirin and clopidogrel and nsaids If platelets 100 to 150 recheck and do invx, if all normal rpt FBC at 6 weeks and then periodically BMJ review on bed bugs Jan 2013 What did I learn? They are 2 to 5mm long and brown in colour. They can survive up to 1 year between feeds. They exist in other places other than beds dark places such as behind curtains and in crevices. The rash does not necessarily appear in the morning but can take up to 11 days it is due to allergy to the mites saliva.    (  , N S v w x d e ļĴؓzpezaZ hThM`hM`hM`hM`5>*H*hM`hM`5>*hM`hG5>*hG hThThThThT5>* h7h{tah{tah{tah{ta>*h+Vh{tah+V>*h7h75h7 h75h7h75>*H* h75>*hPCJ aJ h`hk&5>*CJ aJ h ;5>*CJ aJ !  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