Block 31 Week 1 Flashcards

Question

resp differentials for chest pain ?

Answer 1

* pleuritis * pneumothorax * PE * pulm hypertension * asthma exacerbation

Answer 2

* GORD * oeseophagitis * oeseophageal spasm * gastritis * gastric ulcer

Answer 3

* rib fractures * costochondritis

Answer 4

* panic attacks * somatisation

Answer 5

aortic dissection

Answer 6

pericarditis, myocarditis

Answer 7

* lumen diameter reduced by around 50% so coronary blood flow is unable to respond to an inc in metabolic demand

Answer 8

* resting flow affected when lumen diameter reduced by ~80%

Answer 9

* sudden complete occlusion

Answer 10

* ECG can have ST depression and/or T wave inversion * troponin negative

Answer 11

* ECG can be normal or have ST depression and or T wave inversion * troponin positive

Answer 12

* troponin positive

Answer 13

* massive GI bleed can precipitate MI from hypovolemia and myocardial hypoerfusion

Answer 14

* chest pain on exertion * less severe partial occlusion w plaque

Answer 15

* chest pain on progressively less exertion and now episodes at rest * partial occlusion * increasing plaque and thrombus

Answer 16

* sudden onset chest pain at rest * partial occlusion

Answer 17

* sudden onset chest pain at rest * total occlusion * plaque rupture and thrombus

Answer 18

Angina and NSTEMI can have ST depression/ T wave inversion

Answer 19

* coronary artery spasm * SCAD * Takosubo's

Answer 20

* different tissues attenuate the beam to varying degrees depending on atomic constituents * The image starts all white. If x-rays reach the detector that part of the image turns black.

Answer 21

* bones have a high atomic denstity so white as lots of X rays are abs so only a few pass through

Answer 22

* radiological sign * alveoli and small airways fill up with material * Larger airways remain air-filled giving rise to an ‘air bronchogram’ sign

Answer 23

* Pus (e.g. in pneumonia) * Fluid (e.g. in pulmonary oedema) * Blood (e.g. in traumatic contusions)

Answer 24

* black areas within the area of inc density * these are larger airways that remain air filled so you can see them clearly - key part of consolidation

Answer 25

* can be partial - collapse of one lobe of the lung * or total which is collapse of an entire lung

Answer 26

(e.g. due to fluid or air in the pleural space around the lung in an effusion or pneumothorax respectively)

Answer 27

* or obstruction of a bronchus e.g. by tumour or an inhaled foreign body (where the lung distal to the obstruction will collpased)

Answer 28

* lung collapse in a child is often due to inhalation of a foreign body or mucus obst in asthma

Answer 29

* Lung collapse in an older person raises concern for an underlying tumour (e.g. primary lung cancer) and further investigation is often required (e.g. with CT and/or bronchoscopy).

Answer 30

* area of homogenous increased density without air bronchograms (vs consolidation). * There are no air bronchograms as all the airways are collapsed distal to the obstruction and do not contain air.

Answer 31

- left lower lobe collapse - creates triangle of increased density behidnt he heart - makes it look like there are 2 heart borders

Answer 32

* accumulation of fluid in the pleural space * appears as an area of homogenous increased density (whiter than the normal lungs)

Answer 33

* If the CXR is taken with the patient sat up or stood up, the fluid will settle dependently and will obscure the diaphragm.

Answer 34

* It can be unilateral (typical in malignant causes) or bilateral (typical in heart failure)

Answer 35

* an effusion as large as this is v concerning for a malignant cause like lung cancer, mesothelioma etc

Answer 36

* complete collapse of the left lung * signs of colume loss in the left hemithorax - trachea is pulled to the left and the D is pulled up - stomach bubble seen high on left side

Answer 37

* massive left pleural effusion * this is bc there are signs of increased volume in the left hemithorax due to the fluid - trachea and heart are shifted away to right side

Answer 38

* Working out whether there is volume loss or increased volume in the hemithorax is key to differentiating between a large effusion or collapse.

Answer 39

* primary LC appears as a solid mass on CXR usually * This will usually not contain air bronchograms (like consolidation does) * Sometimes you will not see the actual mass but will see the result of the mass such as collapse of the lung or one lobe of the lung, or a pleural effusion.

Answer 40

* CXR usually done as first Ix as it is readily available and involves little radiation exposure * CT is more sensitive for lung cancer than CXR - so if high clinical suspicion do a CT

Answer 41

* normal cardiothoracic ratio: 50%

Answer 42

* cardiomegaly * pleural effusions (due to fluid leak into the pleural space) * septal thickening - due to fluid leak into the intersitial space * consolidation due to fluid leak into the alveoli

Answer 43

* cardiomegaly, * small pleural effusions, * some septal thickening * and bilateral consolidation

Answer 44

* 1 in 6 male deaths and 1 in 9 female deaths * most common cause of death in under 75s in the UK

Answer 45

* ACS are caused by rupture of lipid rich atheroma plaques. * -> platelet adhesion * activation and thrombin activation with resultant occlusion / partial occlusion of the coronary artery and ischaemia/infarction.

Answer 46

* stable angina is usually caused by plaques which sig reduce lumen of the artery so ischemia occurs on exertion

Answer 47

* the character, duration, severity and radiation of the pain. * relieving/exacerbating factors * associated symptoms (eg nausea) * and consider differential diagnoses (eg varying with respiration - pleurisy or pericarditis, upper GI symptoms such as indigestion, weight loss).

Answer 48

* previous vascular disease * RF for coronary artery disease - smoking, diabetes, obesity, hypertension, FHx

Answer 49

* Any potential co-morbidities that might indicate a contra-indication to the medications required for ACS treatment eg recent GI bleed when taking aspirin therapy

Answer 50

* haemodynamic status - pulse, BP, resp rate, O2 sats * signs of cardiac failure: * crackles in the lung bases * elevated JVP * gallop rhythm * peripheral oedema * underlying cardiac disease e.g. murmur of aortic stenosis

Answer 51

* make the diagnosis (ECG and cardiac enzymes) * exclude exacerbating factors (eg anaemia) * identify complications (eg pulmonary oedema on CXR) * evaluate left ventricular function (echocardiography) * in some cases exclude other diagnoses (eg amylase-acute pancreatitis)

Answer 52

Antiplatelets and statins

Answer 53

* meds - antiplatelets, statins * pain relief e.g. opiates + anti-emetics * nitrates - sublingal GTN or IV infusion * consider oxygen

Answer 54

* PCI * aspirin 300mg stat * proximitiy to defibrillator requiredc

Answer 55

eg: arrhythmia, cardiac arrest, LV failure, recurrent ischaemia

Answer 56

LV function prior to discharge - echo

Answer 57

* aims to restore blood flow by using a soft wire to cross the occluded coronary segment and perform intervention to open the narrowing * thrombus may be extracted and procedure relies on pharm - anti-thrombotic and anti-platelets to treat the thrombus

Answer 58

* stent inserted to maintain vessel lumen then dual anti-platelet therapy required

Answer 59

* early treatment with aspirin, statin, and low molecular weight heparin to reduce the risk of AMI/death * second anti-platelet agent should also be given (eg clopidogrel, ticagrelor or prasugrel)

Answer 60

* Consider IV glycoprotein IIb/IIIa inhibitor for high risk/ unstable ppts

Answer 61

BBs, nitrates (CCBS, nicorandil, ivabradine, ranolazine)

Answer 62

* Identify risk factors for atheroma * eg glucose and cholesterol * Identify factors that exacerbate angina * eg haemoglobin (anaemia), thyroid function (hypothyroid / thyrotoxicosis)

Answer 63

* ECG (often normal in patients with angina) * Echocardiogram if needed (eg suspicion of LV dysfunction, cardiac murmur)

Answer 64

* those with recent onset angina should be seen within 2 weeks of referral in a rapid access chest pain clinic

Answer 65

e.g beta-blockers, calcium channel blockers, nicorandil, ivabradine, ranolazine, long-acting nitrates

Answer 66

- aspirin, statins - management of diabetes and hypertension, smoking cessation, encourage exercise (assuming symptoms are stable)

Answer 67

* those w ongoing symptoms despite medical therapy should be considered for revascularization - either PCT or CABG

Answer 68

* EA starts at SA node * spreads through atrium to AV node where it is delayed * travels down BoH * down right and left bundle branches

Answer 69

electrical signal from SA node spread through atria and cause them to depolarise

Answer 70

time signal travels through AV node

Answer 71

depolarisation of intraventricular septum

Answer 72

depolarisation of bulk of ventricle

Answer 73

last phase of ventricular depolarisation

Answer 74

plateau in myocardial action potential (when ventricles contract and pump blood)

Answer 75

ventricular repolarisation

Answer 76

Lines that connect waveforms

Answer 77

* TP segment is the least affected by pathology so can be used as the baseline within the ECG

Answer 78

* QRS = duration of QRS complex alone, should be less than 120ms long

Answer 79

* PR interval = 120-200ms * P wave and PR segment

Answer 80

* QRS + ST segment + T waveform * dependent on heart rate * < 1/2 RR

Answer 81

* everything within 1 cardiac cycle

Answer 82

Right arm: red Left arm: yellow arm Left leg: green Right leg: black

Answer 83

* avR: right shoulder * avL: left shoulder * avF: floor

Answer 84

* positive P wave as a positive deflection reflects electrical activity going towards the positive pole * R and T wave also positive

Answer 85

* aligned w electrical activity of atrial and ventricular depolarisation * so strongly positive P wave and R wave in a normal lead 2 - tall waves

Answer 86

* Positive P wave and R wave

Answer 87

* positive P waves and R waves in leads 1, 2, aVF

Answer 88

* Reads opposite direction to electrical activity of the heart * so the waves are upside down!!

Answer 89

* Reads at right angles to EA

Answer 90

* 1 small box = 40ms * 1 big box (5 small boxes) = 200ms * 5 big boxes = 1 second

Answer 91

* rhythm strip (at the bottom) is often lead 2 * use this for rate * 300 big big boxes in 1 minute * 300/ number of big boxes between the 2 QRS complexes e.g. 300/4 = 75 for a regular rhythm

Answer 92

* for an irreg rhythm take number of complexes in the 10s x 6 to get the rate

Answer 93

represents the average direction of electrical activity in the heart during ventricular depolarisation (projected onto frontal plane)

Answer 94

- positive lead 1, negative lead 2 - negative AVF

Answer 95

- Negative lead 1 - positive in lead aVF

Answer 96

positive in both lead 1 and lead aVF

Answer 97

- LAD: positive in lead 1 and RAD is negative in lead 1 - LAD is negative in AVF and RAD is positive in aVF

Answer 98

* positive in lead 1 * negative in lead 2 * negatIve in aVF

Answer 99

* negative in lead 1 * positive in aVF

Answer 100

* Short and obese: QRS close to 0 * young age: right axis at birth * tall and thin: QRS close to +90

Answer 101

* INCOMPLETE OCCLUSION * but enough to cause some myocardial ischaemia * Angiogram, but does not need to be within 12hours * troponin +ve

Answer 102

* complete occlusion * angiogram ASAP within 12 hrs (PPCI) * trop +ve

Answer 103

* treat sepsis: blood loss or other prec factors * troponin +ve

Answer 104

* may have ST depression and/or T wave inversions

Answer 105

* ST elevation in 2 or more leads * may have ST depression and or T wave inversions

Answer 106

* T wave inversion and hyperacute T waves

Answer 107

* ST depressions and elevations

Answer 108

* pathological Q wave

Answer 109

- Supplies anterior wall of left ventricle - Supplies intraventricular septum - Supplies apex

Answer 110

* Supplies the left atrium * Supplies lateral wall of left ventricle

Answer 111

* lateral wall * circumflex artery * 1 * aVL * V5 and V6

Answer 112

* Supplies right ventricle * Supplies the right atrium * Usually supplies posterior descending artery and therefore the posterior and inferior walls of left ventricle

Answer 113

* 2 * 3 * aVF * posterior descending artery, inferior wall

Answer 114

* anterior wall * left anterior descending (LAD) * V3 and V4

Answer 115

* intraventricular septum * LAD * V1 and V2

Answer 116

(LAD) can give ST in V2 - V5 or more

Answer 117

* High lateral wall (I; aVL) can be supplied by either LAD or Cx * V1 & V2 can show posterior changes

Answer 118

the junction between QRS complex and the ST segment

Answer 119

* ST elevation >1mm in contigous limb leads * ST elevation >2mm in contigous chest leads * new LBBB

Answer 120

* inflammation of rib cartilage in chest wall * one of the most common chest pains in adults * self limiting and benign

Answer 121

* sharp aching or pressure like pain in the chest wall * worsens w deep breath, cough, activity involving upper body * and lying on affected side

Answer 122

* noted in more than 1 location and typically felt between 2nd and 5th ribs

Answer 123

- pressure pain - substernal - dysponea, sign of inc venous pressure including oedema and venous distention

Answer 124

- pleuritic pain - unilateral often localised - dyspnea, cough, fever, occassional rub

Answer 125

- sudden onset: several hours - pleuritic pain - lateral to side of pneumothorax pain - dyspnea, dec breath sounds on side of pneumothorax

Answer 126

- 10-60 mins onset - burning pain, substernal/ epigastric - worsened by post prandial recumbency - relieved by antacids

Answer 127

- 2-30 min onset - pressure, tightness burning - retrostrenal pain - can closely mimic angina

Answer 128

- prolonged onset - burning/ pressure pain - epigastric/ RUQ pain, substernal - may follow meal

Answer 129

- aortic dissection - malignant pleural effusion - MI - pericarditis - pneumonia - pneumothorax - PE - TB

Answer 130

- tearing sensation - pain radiates to back/ abd - most severe at onset

Answer 131

- BP/ radial pulse discrepency - aortic murmum - possible cardiac tamponade

Answer 132

D-dimer often elevated

Answer 133

- history of malignancy - night sweats - older age - tobacco use - weight loss

Answer 134

- Locally decreased breath sounds

Answer 135

unilateral or bilateral effusions

Answer 136

- angina - headache - arm/ neck pain - nausea/ vomiting

Answer 137

- diaphoresis - hypotension - third heart sound - CXR often normal

Answer 138

- recurrent or recent viral infection

Answer 139

- diffuse conccave upward ST segments - PR segment depression w/o T wave inversion - positional chest pain

Answer 140

- possible cardiomegaly - ECG w diffuse ST elevation

Answer 141

- acute onset dysponea - history of venous thrombosis - history of malignancy - unilateral leg swelling

Answer 142

- Hypotension - hypoxia - sinus tachy - resp distress

Answer 143

- exposure - haemoptysis - fever - night sweats - weight loss

Answer 144

- Often consolidation - lymphadenopathy - and/or unilateral pleural effusion - cavitation common

Answer 145

* refers to sudden and severe chest or upper abdominal pain, typically caused by an enteroviral infection (e.g., coxsackie A, coxsackie B, and echovirus). * Pleurodynia is most commonly caused by group B coxsackie virus and typically occurs as an epidemic

Answer 146

* severe intermittent pleuritic chest pain or upper abdo pain from inflammation of ICMs * most common in younger adults and children * after exposure to enterovirus, typically unilateral

Answer 147

* knife like spasms lasting 15-30 mins * sometimes profuse sweating

Answer 148

* fever, malaise, headaches, cough, sore throat, muscle aches and pains

Answer 149

* Constitutional symptoms: fevers, anorexia, lethargy, weight loss * Dysphagia * weight loss * bleeding - haematemesis and melaena * pain: typically retrosternal

Answer 150

* aspiration - cough, SOB, fever * hoarseness - recurrent laryngeal nerve

Answer 151

* Lymphadenopathy: if local tumour spread * Cachexia * Pallor: due to anaemia * Hepatomegaly: if metastatic spread

Answer 152

* classically occurs after meals and is made worse by lying down or bending forwards

Answer 153

* Regurgitation * Dyspepsia * Chest pain * Dysphagia (difficulty swallowing) * Odynophagia (painful swallowing)

Answer 154

* Cough * Hoarse voice * Nausea and/or vomiting

Answer 155

* acute-onset chest pain and characteristic ECG features (e.g. saddle ST elevation). Multiple aetiologies. * Self-limiting without significant complications in 70-90% of cases.

Answer 156

* long standing inflammation > 3 months usually following acute episode * Complications include chronic pericardial effusion and constrictive pericarditis due to scarring.

Answer 157

* sig prop of cases

Answer 158

* short lived lasting 1-3 weeks * Often due to coxsackievirus B. * Variety of other viruses implicated (e.g. influenza, echovirus, adenoviruses, enterovirus, etc)

Answer 159

* May occur due to haematogenous spread, extension from pulmonary infection or as complication of endocarditis or trauma.

Answer 160

* high prevalence areas or high risk patients e.g. immunodeficiency * More insidious onset. * High-risk of chronic pericarditis and constrictive complications.

Answer 161

* underlying systemic inflammatory disease (e.g. rheumatoid arthritis). Features of systemic disease on clinical assessment. * May complicate chronic kidney disease (e.g. uraemic pericarditis), hypothyroidism or post-myocardial infarction

Answer 162

drugs, radiotherapy and trauma

Answer 163

* medical emergency * atherosclerosis is the most sig aetiological factor

Answer 164

ST-segment elevation or new-onset left bundle branch block and raised troponins.

Answer 165

Non-specific signs of ischaemia or normal ECG, raised troponins.

Answer 166

Characteristic clinical features, non-specific signs of ischaemia or normal ECG, normal troponins.

Answer 167

rupture of an atheromatous plaque in the coronary arterial wall - atherosclerosis

Answer 168

rupture of an atheromatous plaque in the coronary arterial wall - atherosclerosis

Answer 169

* High cholesterol * Hypertension * Smoking * Diabetes * Obesity

Answer 170

- Age * Family history * Male sex * Premature menopause

Answer 171

* emboli and dissection -> vessel occlusion * anaemia - oxygen supply/ demand mismatch - not total occlusion, just a lack of perfusion which leads to necrosis and troponin rise

Answer 172

* Vasculitis (e.g. Kawasaki disease) * Coronary vasospasm (e.g. spontaneous, cocaine) * Coronary dissection

Answer 173

* Anaemia * Hyperthyroidism * Severe sepsis

Answer 174

* endothelial dysfunction - LDL accumulation -> ROS * plaque formation * plaque rupture

Answer 175

* This causes a local inflammatory response. If the injury recurs or healing is incomplete, inflammation may continue leading to the accumulation of LDL. * These become oxidised by local waste products creating reactive oxygen species (ROS).

Answer 176

* endothelial cells attract monocytes which phagocytose the LDLs -> foam cells and fatty streaks

Answer 177

* continued inflammation triggers SM cell migration * This forms a fibrous cap, which together with the fatty streaks, develops into an atheroma.

Answer 178

* The top of the atheroma forms a hard plaque. * This may rupture through its endothelial lining exposing a collagen-rich cap. * Platelets aggregate on this exposed collagen forming a thrombus that may occlude or severely narrow the vessel. * Alternatively, the thrombus may break lose, embolising to infarct a distant vessel.

Answer 179

* Chest pain > 15 minutes: central crushing or pressing pain +/- radiation to neck or arm * Shortness of breath * Sweating * Nausea and vomiting * Palpitations

Answer 180

* Pale * Clammy * Tachycardia * Cardiac failure (e.g. pulmonary oedema, hypotension)

Answer 181

- may occur due to AMI or pericarditiis - can also be caused by coronary vasospasm, benign early repolarisation, BBB and ventricular aneurysm

Answer 182

* ABCDE + history and examination * ECG: ST elevation or LBBB * if absent look for other features of ischaemia e.g. ST depression, T wave inversion * cardiac enzymes: troponin

Answer 183

- ST elevation - ST depression - T wave inversion

Answer 184

seen in STEMI, may be evidence of reciprocal ST depression

Answer 185

more specific sign of ischaemia than T wave changes. Seen in NSTEMI/UA. Also seen as reciprocal change with ST elevation

Answer 186

less specific sign of ischaemia. Multiple causes. Seen in NSTEMI/UA and as part of the natural evolution of a STEMI over days.

Answer 187

- * May occur due to acute myocardial ischaemia or as a reciprocal change to ST elevation. - Other causes can include electrolyte disturbances, digoxin effect and bundle branch blocks.

Answer 188

* feature of myocardial ischamia, even in absence of ST changes * T wave inversion may be fixed, which is usually associated with a previous ischaemic event and associates with Q waves.

Answer 189

Alternatively, T wave inversion may be dynamic, which is associated with& acute myocardial ischaemia.

Answer 190

V5-V6, I, aVL

Answer 191

II, III, aVF

Answer 192

no ST elevation on routine ECG. Dominant R wave V1. May be ST elevation by placing posterior leads V7-V9.

Answer 193

* Minutes to hours: hyperacute T-waves * 0-12 hours: ST-elevation * 1-12 hours: Q-wave development * Days: T-wave inversion * Weeks: T-wave normalisation and persistent Q-waves

Answer 194

hyperacute T waves -> ST elevation -> Q waves -> T wave inversion -> T wave normalisation

Answer 195

may be signs of HF

Answer 196

- reduced EF and or valvular pathology - * also useful to look for regional wall motion abnormalities

Answer 197

if PE is suspected or needs to be excluded

Answer 198

if aortic dissection suspected or needs to be excluded

Answer 199

* morphine + anti-emetic * oxygen - if sats under <94% or under <88% in hypercapnic resp failure * nitrates * aspirin 300mg

Answer 200

* emergency reperfusion required to restore coronary flow

Answer 201

* Patients diagnosed with a STEMI, who present within 12 hours of onset of chest pain, should be referred for emergency coronary angiography +/- primary percutaneous coronary intervention (PCI). * This should occur within 120 minutes of being diagnosed with ST elevation

Answer 202

* coronary angiography involves insertion of a catheter via the femoral or radial artery * From here, the catheter can be passed to the coronary artery vessels with x-rays for guidance and contrast injected. * During the procedure a balloon catheter can be inserted to open up a blockage. A stent can be then be inserted into the blocked artery.

Answer 203

* If PCI is unable to be performed within 120 minutes then fibrinolytic agents should be considered (e.g. alteplase) while arranging transfer to a PCI centre. Coronary angiography +/-

Answer 204

* PCI should be performed in the following 2-24 hours after fibrinolysis and may be required more urgently if patients develop worsening symptoms (e.g. worsening pain, haemodynamic instability, cardiac arrest).

Answer 205

* Patients should be initiated on aspirin and a second anti-platelet drug prior to PCI. * This is usually ticagrelor * clopidogrel can also be used if there's a high bleeding risk or prasugrel

Answer 206

* The combination of aspirin and a second anti-platelet agent is referred to as dual anti-platelet therapy (DAPT) and this should be continued for 12 months post-PCI.

Answer 207

* unfractionated or LMWH * usually given at time of PCI * or glycoprotein IIb/IIIa inhibitors (e.g. tirofiban) may be given at the time of PCI in the presence of a high thrombus burden.

Answer 208

* Additional antiplatelet agent (e.g. clopidogrel, ticargrelor) * Antithrombotic agent (e.g. fondaparinux, UFH) * GRACE risk of <1.5% treated w anti-platelet therapy

Answer 209

aspirin only whilst awaiting further Ix

Answer 210

* Significant delta change in troponin * Worsening/recurrent ischaemic pain * Deterioration (e.g. cardiogenic shock, arrhythmia, dynamic ECG changes)

Answer 211

- Transthoracic echocardiography - Stress echocardiography: - Cardiac MRI - CT coronary angiography

Answer 212

assessing for evidence of ischaemia (e.g. RWMAs, LV dysfunction). Also useful to investigate alternative pathologies.

Answer 213

can be considered if negative troponins, normal ECG and chest pain free for several hours.

Answer 214

can assess both perfusion and wall motion abnormalities. Able to detect recent infarction and assess for previous scars.

Answer 215

good at excluding coronary artery disease by visualisation of coronary anatomy.

Answer 216

* B - Beta-blockers (unless contraindicated) * A - Aspirin (300 mg loading, then 75 mg once daily) * T - Ticagrelor, alternatively clopidogrel if high bleeding risk * M - Morphine (titrate for analgesia) * A - Antithrombotic agent (Fondaparinux 2.5 mg subcutaneous unless contraindicated) * N - Nitrates (sublingual nitrates to relief pain - consider infusion if ongoing pain)

Answer 217

* estimates 6 month mortality risk in patients w NSTEMI/ UA

Answer 218

modifiable risk factors: smoking, dietary changes, exercise, reduce alcohol consumption

Answer 219

- DAPT - BBs - high dose statin - ACEi - consider mineralcorticoud antagonist

Answer 220

(e.g. aspirin and clopidogrel): should be continued for one year. Vital if had PCI to prevent in stent thrombosis.

Answer 221

Angiotensin receptor blocker can be an alternative if side-effects or inlolerant to ACE inhibitor)

Answer 222

reserved for patients with LV dysfunction (i.e. heart failure) following MI.

Answer 223

* atypical presentation e.g. elderly with comorbitiies or women * -> lack of knowkedge - health literacy * can present like indigestion -> GP

Answer 224

* distance * access to transport * availibility of ambulances

Answer 225

availability of proper treatment, staff shortages, waiting lists

Answer 226

* patient education on atypical presentations * early ECG/ troponin on arrival * early diagnsosis for STEMI for PPCI/ fibrinolysis

Answer 227

Nocturnal burning chest pain typical of gastro-oesophageal reflux disease

Answer 228

Pulmonary arterial hypertension

Answer 229

Thiazides reduce the clearance of uric acid, and raise the levels of uric acid in the blood. Hence they are prescribed with caution in patients with gout or hyperuricemia. Loop diuretics also produce this problem but less so.

Answer 230

Obesity hypoventilation syndrome (also known as Pickwickian syndrome) is a condition in which severely overweight people fail to breathe enough whilst asleep, resulting in high blood carbon dioxide (CO2) levels.