Diabetes: All get statins. If BP up, give ACEi for protecting diabetic kidneys. If over 75, or under 75 and CV risk, give low-dose aspirin. I.e. ACEi, statin, and possible aspirin for oldies or at risk in DIABETES.
1st-line: Metformin (if not tolerated and not fat, sulphonylurea)
2nd-line: + Sulphonylurea if not fat. If fattie, gliptins. [MSG]
3rd-line: GLP-1 antagonists or insulin (start with long-acting). .
MSG-GLP/Insulin. If fat, no sulphonyureas, give gliptins.
Under 55 = ACEi. Then ACEi + CCB. Then ACEi + CCB + Thiazide. Then further diuretic or alpha or beta blocker. Young people are ace.
Oldie or black = CCB. Then ACEi + CCB. Then ACEi + CCB + Thiazide. Then further diuretic or alpha or beta blocker.
Crumbly crumbly black.
130/80 if DM or CVD. 140/85 if high-risk.
LDL under 2, TC under 4.
NICE advise 24 hour BP management if BP is over 140/90 (same as PET threshold!!).
If over 150/95, treat.
If over 135/85 and DM or organ damage or high-risk CVD – TREAT. Else annual review.
135/85 is normal on 24 hour test.
If CVD or FH or high CVD risk –> treat with statins.
If low risk –> lifestyle advice, assess in 5 years.
COLORECTAL – red flags:
– 40+ and PR bleed AND frequent/loose stools for 6 weeks
– 60+ and PR bleed for 6 weeks OR frequent/loose stools for 6 weeks
– Fe def anamemia below 11 in MEN. 11 Hb.
– Women with no menses, Hb under 10 and Fe def
[Weight loss, bowel habit change, PR bleed, fatigue/SOB, Fhx]
Crohn’s: Mucusy poo, diarrhoea, weight loss, MOUTH ULCERS IN CROHN’S, strictures, fistulae, abscesses, skin rashs, arthritis, uveitis. Fe def anaemia, high ESR/CRP.
U/C: BLOODY DIARRHOEA of U/C, tenesmus, urgency, again skin rashes, arthritis, uveitis.
U/C – bloody diarrhoea, Crohn’s – mouth ulcers!
IBS: Constip/diarrhoea Fibre. Mebeverine anti-spasmodics. Peppermint oil before meal prevents spasms/bloats. Bulking laxatives or loperamide. TCA’s, hypnotherapy, CBT.
Diverticular: Constipation. Ache with colicky exac. Distension, farts, burps. Fibre + laxatives. If colicky, anti-spasmodics. FBC (?wcc) and barium enema.
Coeliac: Diarrhoea and steatorhoea, abdo distension and pain. Follow-up due to growth in kids, cancer risk. Endomysial antibiotics or TTG, FBC/film for iron defiency (as can be deficient in Fe, folate, Vit K, Vit D). Refer for jejunal biopsy –> villous atrophy.
Piles: Bulking laxatives e.g. husks. LA. Steroid ointments. Suppositories. Else: Sclerotherapy. Rubber bands. Surgical removal.
RA = morning stiffness. Degenerative disease = worse on activity. Many joints, early morning stiffness, systemic symptoms. [Back involvement = ank spond/psoriatic] NSAIDs, refer. Naproxen = long t1/2.
Gout = purines, psoriasis, leukaemiae, diruetics, subthryoidism, EtOh//renal impairment, aspirin, diuretics, subthryoidism, EtOH. Attacks triggered by starvation, deydration, stress. Urate can be normal. NSAID’s/Colchicine/Pred acutely. Long-term allopurinol + NSAID initially.
Stiff knee = inflammation: RA, psoriasis, ank spond
Swelling = Synovitis, effusion, bursa
Locking = meniscus fragments.
Instable/give ways = ligament injury
Dyspepsia is a symptom.
– Peptic/Gastric ulcer.
?Food (fatty foods –> bilary pain) ?Worse at night (ulcer) ?Worse on lying down or bending (GORD)
GORD worsened by smoking, obesity, chocolate, coffee, pregnancy.
NSAID’s, bisphonates, CCB worsen dyspepsia.
Red flags GI:
– Chronic GI bleeds.
– Progressive dysphagia.
– Progressive weight loss.
– Persistent vomiting
– Fe def anaemia.
– Dodgy barium meal.
– 55+ and new/unexplained/persistent dyspepsia.
H pylori: C13 urea breath test [no PPI 2 weeks pre-test, no ABX 4 weeks before testing. If test positive, PPI + amox + clarithr for a week), stool antigent, or lab serology
?FBC ?WCC ?LFT (gallstones, ca, etoh), serum amylase.
Tx: Either PPI for 1/12 or test/treat H Pylori. Then try other if no effect.
Then step down to lowest PPI dose.
Eczema – flexors (extensors in kids). Pink scaly rash with possible vesicles in eczema. Avoid triggers, emollients, topical steroids, tacrolimus, cycsporin, azathioprine.
Psioriasis – epidermal excess, Koebner’s phenomenon. Improves with Sun. Well-demarated plaques of psoriasis – extensors (PE, FE!) Guttate psiorasis after strep throat. Nails – pits, onchylosis, thickening, joints, CVD risk. Emollients, topical salicyclic acid, Vit D analogues, coal tar, diathranol, tar shampoo.
Moles = 6mm.
– BCC = rolled pearly edge, telangiectasia, ulcer in middle. Benign –> excise.
– SCC = malignant sun exposure, horny rodent ulcer. Excise. Solar kertosis are an early form of SCC.
– Seb kay’s: Black stuck on lesions. Oldies. No treatment.