6/10/21

Question 1

Factors involved in Absolute Cardiovascular Risk - 8 points

Answer 1

1. Gender
2. Age
3. Systolic Blood Pressure
4. Smoking Status
5. Total Cholesterol
6. HDL Cholesterol
7. Diabetes
8. ECG LVH

Question 2

How do you determine who requires lipid-modifying therapy? Using this, explain who will benefit from lipid-modifying therapy and who will not?

Answer 2

• Patients with established CVD and those at high absolute CVD risk → require lipid-modifying drug therapy in addition to lifestyle modification
• Patient with moderate or low absolute CVD risk → benefit of drug therapy is not so great so initial drug therapy is not recommended routinely. Provide lifestyle advice and consider drug therapy if a period of lifestyle modification does not improve CVD.

Question 3

Non-pharmacological management of Elevated Lipids: Lifestyle Changes (7 points - 4 diet and 3 other)

Answer 3

1. Reduce intake of saturated and transaturated fats
2. Replace saturated fats with monounsaturated or polyunsaturated fats
3. Increased intake of soluble fibre
4. Introduce plant-sterols - milk, margarine or cheese products
5. Limited alcohol intake
6. Losing weight (if overweight or obese)
7. Increase physical activity

Question 4

Patients clinically determined to be high absolute CV risk WITHOUT calculator (6 points)

Answer 4

1. Diabetes + Age >60yo
2. Diabetes with microalbuminuria (urinary ACR >2.5mg in male and >3.5mg in female)
3. Moderate or Severe CKD → persistent proteinuria or eGFR <45)
4. Previous diagnosis of Familial Hypercholesterolaemia
5. Systolic Blood Pressure ≥ 180mmHg or Diastolic Blood Pressure ≥ 110 mmHg
6. Serum Total Cholesterol > 7.5mmol/L

Question 5

Management of patient with High Absolute CV Risk. Lifestyle - 2 points, Pharmacological - 2 points + 1 bonus

Answer 5

Lifestyle Management
    - Frequent and sustained specific advice regarding diet and physical activity → with referral as needed
    - Smoking Cessation
Drug Therapy
    - BP and Lipid Lowering Therapy
    - No Aspirin

Question 6

What is Coronary Artery Calcium Scoring?

Answer 6

Non-invasive quantitation of coronary artery calcification using CT → marker of atherosclerotic plaque burden

Independent predictor of future myocardial infarction and mortality

Question 7

Who should and who should Calcium scores not be considered in? (2 should, 3 should not)

Answer 7

Patient groups TO CONSIDER CAC

1. Intermediate Absolute Risk patients + Asymptomatic + No known coronoary artery disease + Age 45-75 → in order to reclassify into the lower or higher groups
2. Low Risk but family history of premature CVD and possibly in patients with diabetes + age 40-60yo

Patient groups NOT TO CONSIDER CAC

1. At very low risk
2. High risk when CAC will not alter management including the patients that are automatically considered high risk
3. Symptomatic or previously documented coronary artery disease

Question 8

Acute and Chronic CV Complications of Cocaine Use.(5 Acute, 4 Chronic - given me 3 all up)

Answer 8

Acute cocaine use → CV conditions:

• Myocardial Ischaemia
• Myocarditis + Development of Cardiomyopathy
• Arrhythmias
• Stroke
• Aortic Dissection

Chronic Cocaine Use

• Accelerated atherogenesis + LV Hypertrophy
• Coronary Artery Aneurysm
• Dilated Cardiomyopathy
  
  • cardiomegaly with otherwise unexplained heart failure in a young person - ?cocaine related

Question 9

Classic Triad for Retroperitoneal Haematoma.

Answer 9

• acute abdominal and/or flank pain
• anaemia
• hypotension

Question 10

Aetiology of Retroperitoneal Haematoma ( 5 in notes - give 2)

Answer 10

• pelvic abdominal or lumbar trauma → pelvic fractures
• blood dyscrasia
• rupture arterial aneurysm (AAA)
• interventional or surgical procedures
• spontaneous retroperitoneal haemorrhage (SRH) → anticoagulation

Question 11

Classic Triad of Symptoms for Aortic Stenosis

Answer 11

Heart Failure, Angina and Syncope

Question 12

Type of murmur Aortic Stenosis.

Answer 12

ejection systolic murmur

Question 13

Investigation of choice in Aortic Stenosis. How to assess severity if unsure.

Answer 13

Primary test in diagnosis - ECHOCARDIOGRAM (transforacic)

• if severity is uncertain → for exercise stress testing, CT quantifications of valve calcifications, transoesophageal echocardiography

Question 14

Initial management of Euvolaemic HFrEF - medications and progress.

Answer 14

• ACEi or ARB + Heart Failure Beta-Blocker
• Add MRA
• Uptitrate heart failure therapy to max tolerated dose → start with beta-blocker
  
  • Difference between euvolemic and congested is the commencement of beta-blocker only when euvolemic.

Question 15

NYHA Classification of Heart Failure - explanation of classes (4 classes)

Answer 15

Class 1 → no limitation of ordinary physical activity

Class 2 → slight limitation of ordinary physical activity + no symptoms at rest

Class 3 → marked limitation of ordinary physical activity + no symptoms at rest

Class 4 → symptoms on any physical activity or at rest

Question 16

Variants of HFE Gene in hereditary haemochromatosis. (4 points)

Answer 16

1. C282Y Homozygote
2. Compound Heterozygote - C282Y/H63D
3. C282Y Heterozygote, H63D Heterozygote or Homozygote
4. No change in HFE gene

Question 17

For C282Y Homozygote in hereditary haemochromatosis - risk of overload and management (3 points of management including with and without iron overload)

Answer 17

• Risk of Overload: 40-60% in Females, 75-100% in males
• If iron overload present → lifelong venesection is required
• If iron overload not present → need iron studies every 2-5 years
• Test all first degree relatives is recommended once they turn 18yo. Those with C282Y homozygosity wanting to test their child when they turn 18yo, should first test the partner as if they do not carry the C282Y gene, then child will not be affected by hereditary haemochromatosis.

Question 18

Risk of overload in compound heterozygote (C282Y/H63D) and management.

Answer 18

• Risk of Overload: 1%

- Monitor iron every 2-5 years

Question 19

Timeline/Progression of a Tonic Clonic Seizure + potential associated features.

Answer 19

• sudden loss of consciousness → followed by stiffening (tonic) and then rhythmic jerking (clonic) of the muscles
• often associated with shallow or “jerky” breathing bluish tinge of the skin and lips, drooling of saliva and often loss of bladder or bowel control generally occur
• Seizures usually last a couple of minutes → breathing and consciousness return to normal following this → person is usually tired and confused following the seizures

Question 20

Diagnostic Criteria of Childhood Absence Epilepsy (4 points)

Answer 20

1. Age of onset 4-10 years
2. Normal neurological and developmental state
3. Brief (4-20 seconds) and frequent (tens/day) absence seizures with abrupt and severe loss of consciousness
4. Generalised rhythmic spikes or double spikes wave discharges at around 3 Hz

Question 21

Prognosis + Mx of Childhood Absence Epilepsy

Answer 21

Prognosis is favourable → seizures usually respond well to first line monotherapy + remit before puberty without cognitive sequelae

Question 22

Behaviour modifications of constipation (paediatrics) - (5 points - give me 3)

Answer 22

• Position → knees above hips. lean forwards with elbow on knees
• Toilet Sits → up to 5 mins, 3 times/day, after meals, encourage child to bulge out their abdomen
• Reinforce positive behaviour
• Increase Exercises
• Delay toilet training attempts until child is passing soft stools

Question 23

How does Mitral Stenosis present commonly? What are also some less common presentations of mitral stenosis? (1 point, 7 points - give me 2)

Answer 23

Presents with exertional dyspnoea and/or decreased exercise tolerance

Less common presentations: haemoptysis, chest pain, fatigue, ascities, lower extremity oedema, stroke or other thromboembolic event

Question 24

In what situations can the symptoms associated with mitral stenosis be worse and why? (6 causes)

Answer 24

Any situation that increases cardiac output or causes tachycardia → increases transmitral pressure → can worsen symptoms like dyspnoea or haemoptysis.

• fevers, stress, exertion, pregnancy, pulmonary infection, atrial fibrillation
  
  • AF → elevation of left atrial pressure and enlargement of left atrium

Question 25

Examination findings of mitral stenosis (2 points definite, 2 bonus)

Answer 25

• low pitched diastolic rumble most prominent at the apex → heard when patient lies on their left side
• can also hear an opening snap of the mitral valve
• if MS is severe → pulmonary hypertension + diminished cardiac output can result → cutaneous vasodilation resulting in pinkish-purple patches on the cheeks (mitral facies)
• prominent “a” wave (atrial contraction or systole) in JVP

Question 26

Symptomatic Therapy for Rhinosinusitis (5 points)

Answer 26

1. Regular Oral Analgesia → paracetamol + NSAIDs
2. Saline Nasal Preparations → sprays, rinses and drops
3. Intranasal Corticosteroids
4. Intranasal and Systemic Decongestants → recommended for short-term use for up to 5 days
5. Intranasal Ipratropium → beneficial if rhinorrhoea is main symptoms

Question 27

ABx therapy for Rhinosinusitis. For bonus points, 1) if BD dosing? 2) allergy to penicillins?

Answer 27

• amoxicillin 500mg (child 15mg/kg up to 500mg) orally, 8hrly for 5/7
• if BD dosing → amoxicillin 1g (child 30mg/kg up to 1g) orally, 12 hrly for 5/7
• if allergy to penicillins → cefuroxime 500mg orally, 12 hourly for 5/7