Basics Flashcards
Indications for renal transplant
(Congential/Obstuctive/Inflammatory/Systemic)
Diabetic nephropathy
PKD
Hypertensive nephropathy
Cogential eg Alports
Glomuleronephritis/pyelonephritis
Obstructive uropathy e.g prostate
Causes of hepatomegaly
3Cs, 4Is
Carcinoma
Cirrhosis
CCF
Immune (PBC, PSC, Hepatitis)
Infiltrative (amyloid, myeloproliferative)
Iron - haemochromatosis
Infective - viral hepatitis
What bloods would you want to Ix hepatomegaly?
FBC, U+E, LFTS
INR
Glucose
Iron studies
NI liver screen
HIV
Autoimmue (Anti mitochondrial, anti smooth muscle)
Caeruloplasmin
What Ix would you want for hepatomegaly?
(not bloods)
USS
ascitic tap
biospy
CT/MRI
Fibroscan - fibrosis/cirrhosis
How would you manage ALD
Alcohol cessation
Chlordiazepoxide/pabrinex
Nutrition
OGD ?varices (only band if hx of haemorrhage)
How would you manage (chronic) pancreatitis?
Creon
PPI
What inhalers can you use for COPD?
short acting beta - salbutamol
short acting mucs - ipratropium
long acting beta - salmeterol
long acting musc - tioptropium
What are the respiratory causes of clubbing?
ILD
CF
Lung abscess
Bronchiectasis
Lung ca
How do you treat asthma?
BTS guidelines
1st - SABA
2nd - inhaled steroid
3rd - LABA
4th - LRA
Causes of wheeze?
Asthma
COPD
Pulmonary edema
Causes of lower zone fibrosis
SAB IPM
Systemic sclerosis/RA/SLE
Alpha 1 anti tryspin, ABPA
Bronchiectasis
Infection
Medications - bleomycin, nitro, hydralazine, methrotrexate, amiodarone
Clubbing + >50 suggests IPF
Causes of apical fibrosis
(CASH RAT)
Silicosis
Coal workers pneumoconiosis
Histiocytosis
Ank spond
ABPA
Radiation
TB
What are the most common indications for lung transplant?
CF
Bronchiectasis
pulmonary vascular disease
pulmonary fibrosis
COPD (single lung)
Scars that indicate lung transplant
Clamshell - double
Median sternotomy and/or lateral thoracotomy - single lung/heart
Drains
Central line
trache
Criteria for lung transplant
- > 50% risk death from lung disease within two years if transplant is not performed
- > 80% likelihood of surviving at least 90 days post-transplant
- > 80% likelihood of a 5-year post-transplant survival from a general medical perspective provided there is adequate graft function.
Median surival is around 6 years, worse in COPD and PF
i.e sick enough to need transplant but well enough for it to work
What are the common indications for aortic valve replacement?
Severe symptomatic AS/AR
Infective endocarditis
What further investigations would be appropriate in murmur/AF?
ECG
FBC, bloods, cultures
CXR
24hr tape
Echo
Complications of prosthetic valves?
Infective endocarditis early/late
thromboembolism
Anticoagulation complications
Anaemia (from haemolysis/ endocarditis/bleeding)
Valve failure (heart failure from dehisence, leaking, calcification or stiffening of leaflets)
What are the advantages of mechanical valves?
Longer lifespan
but require lifelong anticoag
so better in younger patient
What are the advantages of tissue valves?
anticoag not needed
but shorter lifespan so better in older patients
can be used in IE as more resistant to infection
If aortic valve replacement and no signs of LVH/HTN/CCF, what was likely reason for valve replacement?
Likely aortic regurg
If aortic valve replacement and with signs of LVH/HTN/CCF, what was likely reason for valve replacement?
AS
Long term management of valve replacement
Anticoag (if metallic)
Serial echos
Indications for mitral valve replacement
Mitral stenosis
Mitral regurgitation
Infective endocarditis
IE prophylaxis with metallic valve replacement
Prophylactic ABx for dental, abdo surgery or sigmoidoscopy with biopsy
Can carry cards
Not for routine dental
Can you tell me the indications for mitral valve replacement?
symptomatic
features of PHTN or fluid overload
declining
acute mitral regurg following MI
Causes of mitral regurg
papillary muscle rupture from rheumatic fever or IE
Post MI
from MVP eg from connective tissues eg Ehler Danos
Common valve pathology in Marfans
aortic regurg
Cardiac features of Marfans
Aortic root dilatation
Aortic dilatation at any point
aortic regurg
mitral valve prolapse
Causes of clubbing
Cardiac - subacute IE, congenital cyanotic heart disease
Resp - ca, TB, bronchiectasis, CF, ILD
GI - IBD
Familial
How would you manage AF?
Cause
?sx
Rate control or rhythm control
CHADXSVAC ?anti coag to avoid thrmobus ?1 anticoagulate with DOAC/warfarin
Describe rate control AF options?
Can use drug options like flecanide if no structural heart disease
Or DC cardiovert if they are sufficiently anticoagulated
CHADS2VASC
CCF
HTN
AGE >65 OR >75
DIABETES
STROKE/TIA =2
VASCULAR DISEASE
AGE
SEX
Causes of mitral regurg
RF
IE
chronic dilatation in AF (annular dilatation)
LAD
Endocrine causes of HTN
Adrenal - phaechromocytoma, Conns
Cushings
Acromegaly
Hyperthyroidism
Renal causes of HTN
Renal artery stenosis
Polycystic kidney disease
Chronic glomerulonephritis
Diabetic nephropathy
Nephrotic syndrome
Chest causes of HTN
Coarctation of aorta
OSA
Autoimmune causes of HTN
Systemic sclerosis
SLE
Wegners granulomatosis
Drug causes of HTN
NSAIDs
EPO
Cyclosporin/tacrolimus
Steroids
COCP
ETOH/liquorice
What are the common indications for aortic valve replacement?
Severe symptomatic AS/AR
Infective endocarditis
What are the advantages of mechanical valves?
Longer lifespan
but require lifelong anticoag
so better in younger patient
What are the advantages of tissue valves?
anticoag not needed
but shorter lifespan so better in older patients
can be used in IE as more resistant to infection
Endocrine causes of HTN
Adrenal - phaechromocytoma, Conns
Cushings
Acromegaly
Hyperthyroidism
Chest causes of HTN
Coarctation of aorta
OSA
Drug causes of HTN
NSAIDs
EPO
Cyclosporin/tacrolimus
Steroids
COCP
ETOH/liquorice
Autoimmune causes of HTN
Systemic sclerosis
SLE
Wegners granulomatosis
Renal causes of HTN
Renal artery stenosis
Polycystic kidney disease
Chronic glomerulonephritis
Diabetic nephropathy
Nephrotic syndrome
Causes of mitral regurg
RF
IE
chronic dilatation in AF (annular dilatation)
LAD
CHADS2VASC
CCF
HTN
AGE >65 OR >75
DIABETES
STROKE/TIA =2
VASCULAR DISEASE
AGE
SEX
Describe rhythm control AF options?
Can use drug options like flecanide if no structural heart disease
Or DC cardiovert if they are sufficiently anticoagulated
How would you manage AF?
Cause
?sx
Rate control or rhythm control
CHADXSVAC ?anti coag to avoid thrmobus ?1 anticoagulate with DOAC/warfarin
Causes of clubbing
(Cardiac/Resp/GI)
Cardiac - subacute IE, congenital cyanotic heart disease
Resp - ca, TB, bronchiectasis, CF, ILD
GI - IBD
Familial
Cardiac features of Marfans
Aortic root dilatation
Aortic dilatation at any point
aortic regurg
mitral valve prolapse
Common valve pathology in Marfans
aortic regurg
Causes of mitral regurg
papillary muscle rupture from rheumatic fever or IE
Post MI
from MVP eg from connective tissues eg Ehler Danos
Can you tell me the indications for mitral valve replacement?
symptomatic
or
features of PHTN or fluid overload
declining
acute mitral regurg following MI
IE prophylaxis with metallic valve replacement
Prophylactic ABx for dental, abdo surgery or sigmoidoscopy with biopsy
Can carry cards
Not for routine dental
Indications for mitral valve replacement
Mitral stenosis
Mitral regurgitation
Infective endocarditis
Long term management of valve replacement
Anticoag (if metallic)
Serial echos
If aortic valve replacement and with signs of LVH/HTN/CCF, what was likely reason for valve replacement?
AS
If aortic valve replacement and no signs of LVH/HTN/CCF, what was likely reason for valve replacement?
Likely aortic regurg
What are the possible complications of prosthetic valves?
Infective endocarditis early/late
thromboembolism
Anticoagulation complications
Anaemia (from haemolysis/ endocarditis/bleeding)
Valve failure (heart failure from dehisence, leaking, calcification or stiffening of leaflets)
What further investigations would be appropriate in murmur/AF?
ECG
FBC, bloods, cultures
CXR
24hr tape
Echo
What are the common indications for aortic valve replacement?
Severe symptomatic AS/AR
Infective endocarditis
Indications for liver transplant
Cirrhosis - most commonly ETOH
Acute hepatic failure - viral hepatitis, paracetamol/other drugs
Hepatic malignancy - hepatocellular carcinoma
Hereditary - Haemochromatosis
Autoimmune - PBC
Indications for SPK transplant
Diabetics (renal failure from diabetic nephropathy)
Usually type 1 but can be type 2
How do you diagnose pulmonary hypertension?
Echo - suggests
Right heart catherisation - definitive
What are some causes of PHTN?
(Lung/Heart/Hereditary/Drug/Idiopathic)
Idiopathic
Hereditary, congential heart defects
Drug induced
Left sided heart disease - valves, LVSD
Lung - COPD, PF, OSA, chronic PE
Causes of massive splenomegaly
CML
Myelofibrosis
Malaria
Indications for splenectomy
Rupture
ITP
Hereditary Spherocytosis
Causes of enlarged kidneys
PKD
RCC
Simple cysts
Hydronephrosis
Tuberous sclerosis/amyloidosis (bilateral)
Causes of bronchiectasis
(Congential/Infective/Immune/GI)
ABPA
Rheumatoid
Cystic Fibrosis
Kartageners
IBD
Recurrent infection
Yellow nail Syndrome
Extra articular features of RA
Pulmonary fibrosis/pleural effusions
Pericarditis
Epi/scleritis
Splenomegaly
Carpal tunnel
Anaemia
Amyloid kidney
Causes of dupetryns
Smoking
Diabetes
ALD
Idiopathic
Anti epileptics
Causes of Ascites
1) portal HTN - cirrhosis, CCF, Budd Chiari
2) Peritoneal disease - peritonitis, Meigs
3) Hypoalbuminaemia - nephrotic syndrome
Causes of palmar erythema
Pregnancy
Hyperthyroid
Rheumatoid
Polycythaemia
Cirrhosis
Gynaecosmastia
Puberty/senility
Kleinfelters
Cirrhosis
Drugs - spironlactone, digoxin
Thyroid,
Addisons
Transudative causes of pleural effusion
Heart Failure
Liver failure
Renal failure
Exduative causes of pleural effusion
Infection
Malignancy
Lung infarct
Differentials of aortic stenosis
HCOM
VSD
Aortic sclerosis
Aortic flow murmur
Complications of aortic stenosis
Endocarditis
LVSD
Causes of AS
Congential - bicuspid vavle
Age - calcification
Rheumatic
Dukes crtieria
Major:
- Typical organism in two blood cultures
- Echo: abscess* , large vegetation* , dehiscence*
Minor:
- Pyrexia >38°C
- Echo suggestive
- Predisposed, e.g. prosthetic valve
- Embolic phenomena*
- Vasculitic phenomena (ESR↑, CRP↑)
- Atypical organism on blood culture
2 maj/1 maj 2 minor/ 5 minor
Eponymous signs of Aortic regurg
⚬ Corrigan’s: visible vigorous neck pulsation
⚬ Quincke’s: nail bed capillary pulsation
⚬ De Musset’s: head nodding
⚬ Duroziez’s: diastolic murmur proximal to femoral artery compression
⚬ Traube’s: ‘pistol shot’ sound over the femoral arteries
Causes of aortic regurg
Endocarditis
Rheumatic fever
Diatation: Marfans, HTN
Ank splond, vasculitis
Causes of collapsing pulse
Pregnancy
PDA
Aortic regurg
Pagets
Anaemia
Thyrotoxicosis
When do you replace valve in Aortic Regurg
Symptomatic
OR
. wide pulse pressure >100mm Hg/ECG changes (on ETT) 3/echo: LV enlargement >5.5cm systolic diameter or EF <50%
Causes of mitral stenosis
Congenital
Rheumatic fever
Age
IE
Causes of mitral regurg
IE/rheumatic
Connective tissue
LV dilatation
Calcification
Post MI - papillary muscle rupture
MVP
What how do you assess MR severity on echo?
size/density of MR jet
LV dilation
reduced EF
Who gets mitral valve prolapse?
Young tall women
Connective tissue eg Marfans, HCOM
Asx, or chest pain/syncope/palps
Mid ES murmur, louder when standing from squatting
Presentation of tricuspid regurg
Raised JVP
Giant C waves
Thrill LSE
Pan systolic murmur, reverse split S2
Causes of triscuspid regurg
Ebsteins anomaly (atrialisation of RV and TR)
IE
Reumatic, Cariconoid syndrome
Presentation of Pulmonary stenosis
Riased JVP with giant a waves
Left parasternal heave
Thrill in pulmonary area
ES murmur, widely split S2
Ax conditions pulmonary stenosis
Tetralogy of Fallot
Noonans
Carcinoid syndrome
Management of pulmonary stenosis
- Pulmonary valvotomy – if gradient >70mm Hg or there is RV failure
- • Percutaneous pulmonary valve implantation (PPVI)
- • Surgical repair/replacement
Indications for an ICD
Primary prevention
- post MI > 4/52 + LVSD with VT/ widerned QRS
- Familial eg LQTS, ARVD, Brugada, HCM, complex congenital heart disease
Secondary prevention
- cardiac arrest due to VT/VF or
- haemodynamically compromising VT/VT with LVEF < 35%
Indication for CRT Bivent PPM
Severe heart failure or widened QRS
Types of ASD
Primum - ax w AVSD and cleft mitral valve, seen in Downs
Secundum commonest
Complication of ASD
Paradoxial emoblus
Artiral arrythmias
RV dilatation
When do you close an ASD?
Sx or significant shunt
Causes of VSD
Congenital = Tetralogy
Acuqired: trauma/post MI/ post op
Blalock–Taussig (BT) shunts
Partially corrects the Fallot’s abnormality by anastomosing the subclavian artery to the pulmonary artery • Absent radial pulse and scar
Complications of PDA
IE
Eisenmengers
Causes of cerebellar syndrome
PASTRIES
Paraneoplastic cerebellar syndrome
Alcoholic cerebellar degeneration
Sclerosis (MS)
Tumour (posterior fossa SOL)
Rare (Friedrich’s and ataxia telangiectasia)
Iatrogenic (phenytoin toxicity)
Endocrine (hypothyroidism)
Stroke (brain stem vascular event)
Cerebellar syndrome
+
Internuclear opthalmoplegia, spasticity, female, younger age
MS
Cerebellar syndrome
+
Oprtic atrophy
MS
Friedrichs Ataxia
Cerebellar syndrome
+
Clubbing, tar‐stained fingers, radiotherapy burn
Bronchial carcinoma
Cerebellar syndrome
+
CLD
ETOH
Cerebellar syndrome
+
Neuropathy
ETOH
Fredreichs Ataxia
Cerebellar syndrome
+ Gingival hypertrophy
Phenytoin
Causes of tremor
(Resting, Postural, Intention)
1) Resting - Parkinsons
2) Postural - Benign, Anxiety, Thyroid, Drugs, Alcohol, Co2, Hepatic
3) Intention - Cerebellar
Causes of ptosis
1) Unilateral - Horners, 3rd nerve palsy, MG, Congenital
2) B/L - Myasthenia, Congential, Muscular dystrophy
Systolic murmur in young person differentials
ASD
VSD
HCOM
MVP
PS
Clinical findings Marfans exam
Mitral Regurg
Aortic regurg
Valve replacement
Scars from aneurysm repair
High arched palate
Extra intestinal features of IBD
Eyes - uvetits, episcleritis, iritis
Mouth - apthous ulcers
Skin - eryhthema nodosum, pyogangrenosum
Clubbing Joint - arthritis
Liver - PSC Systemic amyloidosis
Drugs causing pulmonary fibrosis
bleomycin
nitro
hydralazine,
methrotrexate
amiodarone
CN I
Olfactory
Ask about smell
CN II
Optic nerve
(vision not motor)
- pupils
- visual acuity (distance/line read)
- pupillary reflfex (direct, consensual, swinging, accommodation)
- fundoscopy
- inattention
CN III
Oculomotor
Ptosis
CN IV
Trochlear
supplies superior oblique
palsy causes vertical diplopia
CN VI
CN VI Abducens
controls lateral rectus
palsy causes oncvergent squint
worse on looking towards affected side
CN V
CN V Trigeminal nerve
Sensory and motor
Branches into:
- Opthlamic (sensory scalp and forehead)
- Maxillary (sensory eyelid cheek
- Mandibular (sensory chin jaw)
Muscles of mastication from V3 mandibular
Jaw jerk
(corneal reflex)
CN VII
CN VII Facial nerve
motor (facial movements)
sensory - (anterior two thirds of tongue) ?any change in taste
hearing
CN VIII
CN VIII Vestibulocochlear
hearing and balance
Rinnes and Webers
CN IX
CN IX Glossopharyngeal
swallowing, taste gag
CN X
CN X Vagus
mouth, speech, gag
CN XI
CN XI accesory
motor only
sternocleidomastoid, trapezius
CN XII
CN XII hypoglossal
motor only
tongue movements
Webers test
Tuning fork in middle
Normal - hear both sides
Conductive loss - laterals to affected side
Sensorineural loss - lateralises to non affected side
Rinnes test
Tuning fork on mastoid, wait til they can’t hear it, then move in front of ear
They should be able to hear it again in front of ear
this is positive Rinnes test which is a normal result
sensorineural effects air and bone therefore will also have psoitive result
conductive hearing loss - bone is better therefore negative which is abnormal
Features of myotonic dystrophy
Face:
- long, expressionless, wasted facial muscles and sternocleidomataoid
- B/L ptosis
- frontal balding
- dysarthria
Mytonia, wasting, weakness in hands, percussion mytonia
Catarcts, cadiomyopathy, DM, dysphagia, testicular atrophy
Auto dom, anticipation
Dive bomber EMG
Causes of ptosis
B/L - myotonic dystrophy, MG, congential
Unilateral - 3rd nerve palse, Horners, Congenital
Presentation of MS
Intranuclear opthalmoplegia, reduced visual acuity, cranial nerve palsy
Spasticity, brisk reflexes
Weakness, altered sensation
Wheelchair/walking aids
Management of MS
MDT
Medical:
- Steroids (Shorten attack but no prognostic change)
- interferon/monoclonal antibodies
- anti spasmodics, neuropathic pain
- laxatives/intermittent self catheterising
MRC grade
0, none
1, flicker
2, moves with gravity neutralized
3, moves against gravity
4, reduced power against resistance
5, normal
Thrombolysis window for stroke
4.5 hours
Causes of cirrhosis
ETOH
NAFLD
Chronic viral hepatitis
Haemachromatosis
Less common
Autoimmune hepatitis/PBC/PSC/methotrexate/Wilsons/Alphs1antitrysin deficiency/constrictive pericarditis/CCF
Grades of hepatic encephalopathy
- Behaviour change, minimal conciousness change
- Gross disorientation, drowsy, asterixis, inapprorpiate behaviour
- Confusion, incoerent speech, sleeping most of the time but rousable
- Comatoase, unresponsive, decorticate/decerebrate posturing
How can you clinically examine for encephalopathy?
Asterixis
Draw a star
MMSE
Tx of ascites
- Fluid restrict/diuresis
- Drain if CV/resp comprimise, unit of albumin for every 2l
- TIPS - risk of worsened encephalopathy, coagulopathy
- Liver transplant
Causes of pancreatitis
ETOH
Gallstones
Trauma
ERCP
Hypertriglyceridaemia
Hypercalcaemia
Genetic: CF, PRSS1, SPINK1
Complications of pancreatitis
Acute:
- SIRS
- Sepsis response
- Respiratory failure
- Death
Chronic
- chronic pancreatitis
- portal/splenic vein thrombosis
- pseudocyst - can cause obstruction
*
UC Vs Crohns
Transmural inflammation
Crohns
UC Vs Crohns
Fissuring ulcers
Crohns
UC Vs Crohns
Lymphoid/neutrophil aggregates
Crohns
UC Vs Crohns
Mucosa/submucosa only
UC
UC Vs Crohns
Crypt Abcesses
UC
UC Vs Crohns
Skip lesions
Crohns
UC Vs Crohns
Continous inflammation
UC
UC Vs Crohns
Transmural/all layers inflammation
Crohns
