Amir Sam Flashcards
Structure to HPC
Ask about presenting symptoms- socrates
Associated symptoms to that system
Then questions relating to your differential diagnoses
Associated symptoms with MI
Nausea
Sweating
Breathlessness
Chest pain investigations
ECG
Troponin
Echo
DDx of chest pain
Cardiac - IHD - aortic dissection - pericarditis Resp - PE -Pneumothorax -Pneumonia GI - oesophagitis - gastritis - oesophageal spasm Musculoskeletal - costochondritis
Important investigation forgotten about in chest pain
BP both arms to check for aortic dissection
Anterior MI ecg
LAD
V1-V4
Lateral MI ecg
Circumflex
V5-6
aVL
Inferior MI ecg
Right coronary artery
II, III
avF
Which enzymes get elevated acutely MI
CK isoform
What happens in seizure cause of collapse after event
Confused
Important thing to ask to ask about in family history with collapse
Sudden death in family
How to check for postural hypotension collapse
Change in BP lying vs standing
DDx collpase
Glucose Cardiac - valves - arrythmia - outflow obstruction - postural hypotension Neurological
Forgotten cause of outflow obstruction
PE
Investigations for cardiac causes
ECG
Pulse, ESM, echo
Lying and standing BP
What is long QT syndrome
Abnormal ventricular repolarisation
Acquired causes of long QT
Low K+, Mg+, Ca+, hypothermia
MI
Raised ICP
Drugs
Genetic cause of Long QT
Change in K+ channel
Family history sign of long QT
Sudden death
Cardiac causes of collapse
Reduced outflow
Arrythmia either brady or tachy
Postural hypotension
Vasovagal
What does long QT syndrome predispose you to
Tachyarrythmias
What does murmur louder on inspiration say about murmur
Murmur on right side
What are signs on examination of tricuspid regurg
Hepatomegaly
DDx of JVP
R heart failure
Tricuspid regurg
Constrictive pericarditis
Causes of JVP
R HF - pulmonary HTN -PE, COPD - secondary to left failure Tricuspid regurg - R ventricle dilation - vegetations - hepatomegaly Constrictive pericarditis - infection TB - autoimmune sarcoid - maligancy
Questions to ask self about murmur
Where loudest
Where radiate
DDx of sinus tachycardia
Caffeine Alcohol Sepsis Hypovolaemia Endocrine Anxiety
DDx of SVT
Re-entry circuit
Difference between AVNRT and AVRT
AVNRT at level of node
AVRT goes into ventricles and back up bundle of kent
Is there an upstroke in AVNRT
No
AVRT on ECG
SR
Short PR interval
Delta wave
Causes of AF
Thyrotoxicosis
Alcohol
Heart- muscle, valve, pericardium
Lung- PE, pneumonia, Cancer
Causes of VT
Iscaemia
Electrolyte
Long QT
Drugs
Managment of haemodynamically stable SVT
- Valsalva
2. adenosine
Acute fast AF management
Rythm and rate control
Causes and complications
Categories of ECG abnormaliites
Iscaemia
Arrythmia or block
Vent strain or hypertrophy
What causes third heart sound
Associated with ventricular filling- very common in HF
What causes fourth HS
Associated with ventricular hypertrophy
Management of HF patient
Initially sit them up and give high flow oxygen
Furosemide
GTN infusion
What cant you do when a patient is hypothermic
Any cardioversion
Classify SOB
Seconds P embolism Pneumothorax FB Mins airway disease chest infection acute HF Hours chronic above Fibrosis NMJ Anaemia Malignancy Effusions
Iatrogenic
Caused by treatment
What would cause SOB after chest drain
Pulnomary odema
When is pain worse pericarditis
Lying down
Breathing in
Recent history for pericarditis
RTI
When is aortic regurg murmur heard best
Leaning forward
Murmur for aortic dissection
Aortic regurg
What done if patient comes in with stemi
PCI
Difference in echo between MI and myocarditis
MI regional wall abnormality where event occurred whereas myocarditis globally
Treatment for NSTEMI
MONOBASH and angiogram
Outflow obstruction causes of collapse
Aortic stenosis
PE
Hypertrophic obstructive cardiomyopathy
What to ask about when querying neuro cause of collpase
Aura
Confusion afterwards
Tongue biting
Shaking
Which drugs can lead to long QT syndrome
Arrythmics Psycotics Depressants Histamines Biotics Methadone
What does murmur louder on expiration suggest about murmur
Its on the left side
What would you consider in patient with pan systolic murmur but no signs of valve defects
Ventricular septal defect
How to differentiate between AVNRT and AVRT
In tachycardia they look exactly the same so when slow heart down the abnormality will be seen if its AVRT, if not then will be normal. Heart slowed by vagal manoevers and adenosine
What abnormalities will be seen on ECG if AVRT
Short PR
Delta wave
When can delta wave only be seen
Sinus rythm
Differences in focus between flutter and fibrillation
Flutter- single ectopic focus which can be ablated
Fib- no focus
Management plan for haemodynamically stable SVT
Vagal maooeuvres
Adenosine with cardiac monitor
What must be treatment for anyone arrythmia haemodynamically unstable
DC cardioversion
Management Plan For A Patient With Acute Fast AF & BP: 120/80
Need to rate and rythm control Rythm - if onset less than 48 hours DC cardioversion - IV flecainide or amiodarone Rate control - digoxin or B blocker Treat underlying cause
When wouldn’t you give IV flecainide acute fast AF
Structural heart disease
What would you give for acute fast AF with structural heart abnormality
IV amiodarone
How long would you wait after acute fast AF of over 48hrs to give DC cardioversion
3-4 weeks- in mean time anticoagulate
What do you give with CHADVASC score above 1
Warfarin and LMWH
What do you give for CHAD VASC score of 1
Aspirin and LMWH
What to give for VT with no haemodynamic compromise
IV amiodarone then look for and treat cause
Implant ICD
What do you do for pulseless VT
Defibrillate as in cardiac arrest
What to give if patient goes into torsades de pointes
IV magnesium sulphate
What do when patient is in haemodynamically unstable VT
Defibrillation
Difference between defibrillate and DC cardioversion
Cardioversion has to be synced so can be delivered at any time whereas defibrillation can be at any time
DC cardioversion can be given to any haemodynamically unstable patient wheras defibrillation for people in VF
What is Votlage criteria for LVH
S in V1 + R in V5 or V6 whichever is larger > 7 large squares
What suggests ischaemia on ECG
ST elevation or depression
T wave inversion
Pathological Q waves
What do pathological Q waves look like and what do they suggest
Over 2mm deep or over 1mm wide
Suggest old infarcts
How to look for previous infarcts on ECG
Pathological Q waves
What does digoxin toxicity look like on ECG
ST depression + inverted T waves in V5-6 (‘reversed tick’) + any arrhythmia
How does hyperkalaemia appear on ECG
Tall, tented T waves, widened QRS, absent P waves, prolonged PR interval, bradycardia
How does hypokalaemia appear on ECG
Small T waves, prominent U wave
How does hypocalcaemia appear on ECG
Long QT interval
How does hypercalcaemia appear on ECG
Short QT interval, small T waves
What does fixed wide splitting of S2 suggest
Atrial septal defect
What is fixed wide splitting of S2 best heard with
diaphragm
What is third heart sound best heard with
Bell as high pitched
Management of acute HF
- Sit up
- 60-100% oxygen
- GTN infusion
- Diamorphine
- IV furosemide
- Treat underlying cause
Why give diamorphine acute HF
Anxiolytic and improves breathlessness
What are shockable causes of cardiac arrest
VF
Pulseless VT
What are unshockable causes of cardiac arrest
PEA
Asystole
What would you be thinking if cardiac arrest patient arrives hypothermic
VT or VF
Who you cant give adrenaline to
Hypothermic patients
What are 8 reversible causes of cardiac arrest
Hypoxia Hypovolaemia Hyperkalaemia (or any other metabolic disorder) Hypothermia Thrombous Toxins Tension pneumothorax Tamponade
Way to remember causes of cardiac arrest
4 ts
4 hs
Management for VF or pulseless VT
Shock CPR 2 mins Assess rythm Adrenaline every 3-5 mins(if over 30C) Amiodarone after 3 shocks Correct reversible changes
Investigations for infective endocarditis
Echo
Three sets of blood cultures
