A4 page corrections

Question 1

HF Mx

Answer 1

Treat underlying cause
Treat conservative: salt intake, smoking, aspirin, statins
Specific Mx- ACEi, β-B and spiro → ↓ mortality

1st line: ACEi/ARB + β-B + loop diuretic
•ACEi/ARB: e.g. lisinorpil or candesartan
•Hydralazine + ISDN if not tolerated

• β-B: e.g. carvedilol or bisoprolol (licensed)
• Start low, go slow
• β-B therapy may be particularly good in COPD

•Loop diuretic: frusemide or bumetanide

2nd line: get specialist advice
• Spironolactone / eplerenone - Watch K (esp on ACEi too)
•ACEi + ARB
•Vasodilators: hydralazine + ISDN
•Additional Rx in Blacks

3rd line
• Digoxin
• Cardiac resynchronisation therapy ± ICD

Question 2

HF Ix

Answer 2

Bloods: FBC, U+E, BNP, TFTs, glucose, lipids
CXR: ABCDE
•	Alveolar shadowing
•	Kerley B lines
•	Cardiomegaly (cardiothoracic ratio >50%)
•	Upper lobe Diversion
•	Effusions
•	Fluid in the fissures
ECG
•	Ischaemia
•	Hypertrophy
•	AF
Echo: the key investigation
•	Global systolic and diastolic function
−	Ejection fraction normally ~60%
•	Focal / global hypokinesia
•	Hypertrophy
•	Valve lesions
•	Intracardiac shunts

Question 3

Acute AF (<48 hrs)

Answer 3

Haemo unstable → emergency cardioversion
• (IV amiodarone 2nd line)

If stable, control ventricular rate, start LMWH and cardiovert.

Control ventricular rate with:
• 1st line: diltiazem or verapamil or metoprolol
• 2nd line: digoxin or amiodarone
Start LMWH
• Electrical cardioversion or pharmacological
• 1st: Flecainide (if no structural heart disease)
• 2nd: Amiodarone

Question 4

Rhythm control in AF

Answer 4

Rhythm Control
• TTE first: structural abnormalities
• Anticoagulate ¯c warfarin for ≥3wks
• or use TOE to exclude intracardiac thrombus.
• Pre-Rx ≥4wks ¯c sotalol or amiodarone if ↑ risk of failure
• Electrical or pharmacological cardioversion
• ≥ 4 wks anticoagulation afterwards (target INR 2.5)

Maintenance antiarrhythmic
•	Not needed if successfully treated precipitant
•	1st: β-B (e.g. bisoprolol, metoprolol).
•	2nd: amiodarone
Other options
•	Radiofrequency ablation of AV node
•	Maze procedure
•	Pacing

FIRST LINE IN:
•	Symptomatic or CCF
•	Younger (<65)
•	Presenting first time
•	Secondary to treated precipitant

Question 5

COPD definition

Answer 5

• Airway obstruction: FEV1 <80%, FEV1:FVC <0.70

* Chronic bronchitis: cough and sputum production on most days for 3mo of 2 successive years.

Question 6

blue boaters vs pink puffers?

Answer 6

Emphysema and Chronic Bronchitis are two of the most common conditions that contribute to
COPD.
Pink puffers/emphysema- alveoli are destroyed, usually because of cigarette smoking, they lose their elasticity which causes air to become trapped inside them. They get progressive dyspnoea and late productive cough.
*breathless but not cyanosed (near normal o2)-> T1RF

Blue bloaters/Chronic bronchitis - inflammation and Mucus build up in the lining of the bronchial tubes
The body does not take in enough oxygen, resulting in
cyanosis. This increases strain on the heart > RHF
*decreased alveolar ventilation, cyanosed but breathless, rely on hypoxic drive -> T2RF

Question 7

COPD conservative measures

Answer 7

Stop smoking
•	Specialist nurse
•	Nicotine replacement therapy
•	Bupropion, varenicline (partial nicotinic agonist)
•	Support programme
Pulmonary rehabilitation / exercise
Screen and Mx comorbidities
•	e.g. cardiovasc, lung Ca, osteoporosis
Influenza and pneumococcal vaccine
Air travel risky if FEV1<50%
Mucolytics - •	E.g. Carbocisteine (CI in PUD)

Question 8

Infective Endocarditis diagnosis

Answer 8

Dx: Duke Criteria
Major
1. +ve blood culture
• Typical organism in 2 separate cultures, or
• Persistently +ve cultures, e.g. 3, >12h apart
2. Endocardium involved
• +ve echo (vegetation, abscess, valve dehiscence) or
• New valvular regurgitation

Minor

1. Predisposition: cardiac lesion, IVDU
2. Fever >38
3. Emboli: septic infarcts, splinters, Janeway lesions
4. Immune phenomenon: GN, Osler nodes, Roth spots, RF
5. +ve blood culture not meeting major criteria

Dx if:
• 2 major
• 1 major + 3 minor
• All 5 minor

Question 9

What is decompensated liver failure

Answer 9

An acute deterioration in liver function in a patient with cirrhosis and is characterised by jaundice, ascites, hepatic encephalopathy, hepatorenal syndrome or variceal haemorrhage.
Common precipitants of hepatic decompensation include infections, gastrointestinal (GI) bleeding, high alcohol intake / alcohol-related hepatitis or drug-induced liver injury although no specific cause is found in approximately 50% of cases

Question 10

Pneumothorax management

Answer 10

Primary:
2cm or SOB -> needle aspirate -> if unsuccessful, chest drain
<2cm and no SOB -> OPD r/v

Secondary, lung disease or 50+ old smoker ->
2cm or SOB -> chest drain
1-2cm -> needle aspirate -> chest drain
<1 - observe and o2

If traumatic -> Large bore Venflon into 2nd ICS, mid-clavicular line
If tension -> Chest drain
If sucking -> 3 sided wet dressing

Whenever you needle aspirate - observe with oxygen after
Needle thoracocentesis - 2nd ICS MCL, just above 3rd rib
Chest drain - 5th ics mid axillary line