Cardio Flashcards
AS
Significant negs
Infective endocarditis
LVF
Indicators of severity (narrow PP, quiet A2, S4)
AS
Causes
- Senile calcification
- Bicuspid valve
- Rheumatic heart disease
AS
Triad of symptoms
Dyspnoea
Angina
Syncope
AS
Investigations
ECG (LVH, arrhythmia)
Bloods (FBC, U+E, BNP, lipids, glucose)
CXR (LVH)
Echo (severity, LV function, cause)
Coronary angiogram
AS
Echo features of severe
Valve area <1cm2
Pressure gradient >40mmHg
Jet velocity >4m/s
AS
Mx
General (MDT, optimise CV risk, monitor)
Surgical (valve replacement +/- CABG) - if symptomatic or
severe
Other (TAVI)
MR
Significant negs
Infective endocarditis
AF
LVF
MR
Causes
Functional: LV dilatation
Annular calcification
Rheumatic heart disease
Valve prolapse e.g. pap muscle rupture
MR
Investigations
ECG (arrhythmias, LVH, P-mitrale)
Bloods (FBC, U+E, BNP, lipids, glucose)
CXR (LA/LV hypertrophy, oedema, calcification)
Echo (severity, LV function)
Coronary angiogram
MR
Echo features of severe
Jet width >0.6cm
Systolic pulmonary flow reversal
Regurgitant volume >60ml
MR
Mx
General (MDT, optimise CV risk, monitor)
Specific (AF, emboli, reduce after load)
Surgical (valve replacement/repair) if symptomatic
AF
Significant negs
Murmur
Evidence of thyrotoxicosis
LVF
Bruising from warfarin
AF
Cardiac causes
IHD
Rheumatic heart disease
Hypertension
Mitral valve pathology
AF
Non-cardiac causes
Thyrotoxicosis
Alcohol
Pneumonia
Hypokalaemia
RA
Post-op
PE
AF
Investigations
ECG (confirm Dx, look for cause e.g. ischaemia)
Bloods (FBC, U+E (K), TFTs, trops, D-dimer)
CXR (oedema, pneumonia)
Echo (valves, LV function)
Acute AF (<48h)
Mx
If adverse signs: DC shock, seek help, amiodarone 300mg over 10-20 mins, repeat shock, amiodarone 900mg over 24h
If stable: control rate with b-b or diltiazem, consider digoxin or amiodarone if in heart failure, assess thromboembolic risk and consider anticoagulation
Paroxysmal AF
Mx (need to clarify)
Pill in pocket
Prevention (b-b)
Persistent AF
Rhythm control
Younger pts
>3w anticoagulation with warfarin, exclude thrombus with TOE
Cardioversion (DC/medical)
Persistent AF
Rate control
b-b or rate limiting CCB
Can add digoxin
AF
Other mx
Radiofrequency ablation of the AV node
Maze procedure
Pacing
What are the causes of LEFT heart failure?
- Ischaemic heart disease
- Idiopathic dilated cardiomyopathy
- Hypertension
- Mitral and aortic valve disease
What are the causes of RIGHT heart failure?
Left ventricular failure
Cor pulmonale
Tricuspid and pulmonary valve disease
What is the NYHA classification?
- No breathlessness
- Breathless with moderate exertion
- Breathless with mild exertion
- Breathless at rest
How do you investigate chronic heart failure?
ECG: ischaemia, hypertrophy, arrhythmia
Bloods: FBC, U+E, BNP, lipids glucose
CXR: ABCDEF
Echo - gold standard
What do you look for in an echo for heart failure?
Global systolic and diastolic function
Focal/global hypokinesia
Hypertrophy
Valve lesions
What is the management of heart failure?
General: MDT, optimise CV risk (conservative and medical), monitor
Specific (medical): b-b + ACEi, spiro, digoxin, cardiac resynchronisation therapy
Surgical: LVAD, heart transplant
What are the three clinical signs of hyperexpansion?
Reduced cricosternal distance
Loss of cardiac dullness
Palpable/displaced liver edge
What are the significant negatives in a COPD exam?
CO2 retention flap
Cor pulmonale i.e. signs of right heart failure
Clubbing (could indicate cancer)
Differentials for COPD?
Chronic asthma
Bronchiectasis
What is the definition of chronic bronchitis?
Cough productive of sputum for >/= 3months on >/= 2 consecutive years
What is the definition of emphysema?
Histological description of alveolar wall destruction with airway collapse and air trapping
Investigations in COPD?
Bedside: PEFR, BMI, sputum mc&s
SPIROMETRY: obstructive
Bloods: FBC (polycythaemia), ABG (T2 resp failure), CRP (infective exacerbation), Albumin (malnutrition), a1-AT
Imaging: CXR, echo (cor pulmonale)
What do you find on spirometry with COPD?
Obstructive pattern Increased total lung capacity and residual volume FEV1 <80% FEV1/FVC <0.7 Reduced transfer factor
What are you looking for on a CXR in COPD?
Acute: consolidation, pneumothorax
Chronic:
- Hyperinflation (>10 posterior ribs), flat diaphragm
- PHT (prominent pulmonary arteries, peripheral oligaemia)
- Bullae
What is the general management of COPD?
MDT: dietician, physio, resp physician, specialist nurses
SMOKING CESSATION: specialist nurse and support programme, nicotine replacement therapy (varenicline = partial nicotinic agonist)
Pulmonary rehab therapy: tailored exorcise programme, disease education and psychosocial support
Comorbidities: nutrition, CV risk, vaccination (pneumococcal and seasonal flu)
What is the medical management of COPD?
Anti muscarinics
b2 agonists
ICS
Theophylline
Home emergency pack for exacerbations
LTOT (aiming for PaO2 >8 for >15h/day) if stable non smokers with PaO2 <7.3 OR <8 with cor pulmonale or polycythaemia
What is the GOLD classification?
Based on mMRC dyspnoea score (1-5) and airflow limitation (based on FEV1) and no. of exacerbations per year
What is the mMRC dyspnoea score?
- SOB on vigorous exertion
- SOB on hurrying or walking up stairs
- Walks slowly or has to stop for breath
- Stops for breath after <100m / few mins
Too breathless to leave the house or SOB on dressing
How is airflow limitation classified?
Mild >80%
Moderate 50-79%
Severe 30-49%
Very severe <30%
What are the significant negatives for pulmonary fibrosis exam?
Cyanosis
Cor pulmonale
Specific cause e.g. rheumatoid hands or sclerodactyly
What are some differentials for pulmonary fibrosis?
Bronchiectasis
Chronic lung abscess
What are the causes of UPPER zone fibrosis?
APENT
Aspergillosis (ABPA) Pneumoconiosis (coal, silica) EAA/hypersensitivity pneumonitis Negative sero-arthropathy (ank spond) TB
PPFE
What are the causes of LOWER zone fibrosis?
STAIR
Sarcoid (mid zone) Toxins: BANS ME Asbestosis IPF Rheum: RA, SLE, SS, sjogren's PM/DM
What are the drug causes of pulmonary fibrosis?
BANS ME
Bleomycin Amiodarone Nitrofurantoin Sulfasalazine Methotrexate
What are the investigations for pulmonary fibrosis?
Bedside: PEFR, ECG (RVH)
Bloods: FBC, ABG, ESR and CRP (IPF)
Imaging: CXR (reticulonodular shadowing and reduced lung volume), HRCT (fibrosis and honeycomb lung)
SPIROMETRY: restrictive
Other: echo (PHT), BAL (for disease activity), biopsy
What is the management of pulmonary fibrosis?
MDT: GP, pulmonologist, palliative care, physio, psych, specialist nurses, family
Rx specific cause: STEROIDS for EAA, sarcoid and CTD
Supportive care: STOP SMOKING, pulmonary rehab, LTOT, symptomatic tx e.g. anti tussives (codeine) and heart failure medication
Surgery: Lung transplant is only cure in IPF
What are the significant negatives in a bronchiectasis exam?
cor pulmonale
specific causes e.g. RA hands, yellow nails, CF, IBD
What is the differential for bronchiectasis?
IPF
Chronic lung abscess
How can you classify the causes of bronchiectasis
Congenital or acquired
What are the CONGENITAL causes of bronchiectasis?
CF
PCD/Kartagener’s
Young’s: azoospermia and bronchiectasis
Hypogammaglobulinaemia: XLA, CVID, SAD
What are the ACQUIRED causes of bronchiectasis?
Idiopathic
Post infectious: pertussis, TB, measles
Obstruction: tumour, foreign body
Associated: RA, IBD (UC), ABPA
What are investigations for bronchiectasis?
Bedside PEFR and urine dip (proteinuria - amyloid)
Bloods: FBC (ACD), serum Ig, Aspergillus (RAST, precipitins, IgE, eosinophilia), RA (anti CCP, RF)
CXR: tramlines and ring shadows (grapes)
HRCT: SIGNET RING SIGN: thickened dilated bronchi and smaller adjacent vascular bundle. Pools of mucus in saccular dilatations
Spirometry: obstructive
Other: bronchoscopy and mucosal biopsy, CF sweat test, aspergillum skin prick testing
What are the complications of bronchiectasis?
Cachexia PHT Massive haemoptysis T2 respiratory failure Amyloidosis
What is the CONSERVATIVE management of bronchiectasis?
MDT: GP, resp consultant, physio, dietician, immunologist
Physio: postural drainage, active cycle breathing, rehab
What is the MEDICAL management of bronchiectasis?
ABX for exacerbations
Bronchodilators: nebuliser b-agonists
Tx underlying cause: CF (creon, ADEK), ABPA (steroids), Immune deficiency (IVIG)
Vaccination: flu, pneumococcus
What is the SURGICAL management of bronchiectasis?
Indicated in severe localised disease or obstruction
Significant negs for pleural effusion exam?
Absence of:
- Fever
- Clubbing
- Raised JVP and peripheral oedema
- Features of CTD
Causes of pleural effusion (transudate)?
CCF Renal failure Reduced albumin Hypothyroidism Meig's syndrome
Causes of pleural effusion (exudate)?
Infection: pneumonia, TB Malignancy Inflammation: RA, SLE Infarction: PE Trauma
Investigations for pleural effusion?
Sputum MC&S and cytology
Imaging: CXR, US to guide pleurocentesis, volumetric CT
Bloods: FBC (low Hb), U+E (high Cr), LFTs: (low albumin), TFT (high TSH), ESR (CTD), raised Ca
Diagnostic pluerocentesis
Expand on diagnostic pleurocentesis
Percuss upper border and go 1-2 spaces below, infiltrate town to pleura with lignocaine and aspirate with a 21G needle
Send for
- Chemistry: protein, LDH, pH, glucose, amylase
- Bacteriology: MCS, auramine stain, TB culture
- Cytology
- Immunology: RF, ANA, complement
Features of empyema?
turbid fluid
low glucose
pH <7.2
What is the management of pleural effusion?
Tx underlying cause
Drainage if symptomatic (<2L/24h) - repeated aspiration or ICD
Pleurodesis with talc if recurrent malignant effusion
Persistant effusions may require surgery
Indications for lobectomy/pneumonectomy?
90% for non-disseminated bronchial carcinoma
Bronchiectasis
COPD (lung reduction surgery)
TB
Operative mortality of lobectomy/pneumonectomy?
7% / 12%
Location of lung Ca?
SCC: central
Adeno: peripheral
Small cell: central
Complications of lung Ca?
RLNP Phrenic nerve palsy SVCO Horner's AF
Lung cancer paraneoplastic syndromes? ENDO
ADH –> SIADH
ACTH –> cushings syndrome
Serotonin –> carcinoid
PTHrP –> raised Ca
Lung cancer paraneoplastic syndromes? RHEUM
Dermato/polymyositis
Lung cancer paraneoplastic syndromes? NEURO
Cerebellar degeneration
Peripheral neuropathy
Lung cancer paraneoplastic syndromes? DERM
Acanthosis nigerians
Trousseau’s syndrome: thrombophlebitis migrans
Features of metastatic lung Ca?
Pathological #
Hepatic failure
Confusion, fits, focal neuro
Addison’s
Ix in lung cancer?
Bloods
Dx of mass: CXR + volumetric CT
Determine cell type: cytology and histology
Staging: CT (neck, thorax, abdo brain), PET, radio nucleotide bone scan, thoracoscopy, mediastinoscopy and LN sampling
Pulmonary function tests
Blood tests in lung cancer?
FBC: anaemia, raised WCC
U+E: low Na
LFTs: deranged due to mets
Bone profile: raised Ca
CXR and CT findings in lung cancer?
CXR: coin lesions, effusions, consolidation or collapse, hilar LNs, bony mets
Determining cell type in lung cancer?
Cytology: induced sputum and US guided pleurocentesis
Histology: percutaneous FNA (adenocarcinoma), endoscopic transbronchial biopsy (SCC)
General management for ALL lung cancers?
MDT
STOP SMOKING
Optimise nutrition and CV function
NSCLC management?
Surgery if no mets - wedge resection, lobectomy, pneumonectomy
Curative radio: if poor cardio/resp function
Chemo
SCLC management?
Usually disseminated at presentation
Some benefit with chemo
Palliative care in lung cancer?
Analgesia: opiates for pain and cough
Radiotherapy: haemoptysis, bone or CNS mets
SVCO: dex and radio or intravascular stent
Persistent effusions: chemical pleurodesis
Parkinsons examination, inspection?
Asymmetrical resting tremor: 5Hz (exacerbated by counting backwards)
Hypomimia
Extrapyramidal posture
Parkinsons examination, ARMS?
Demonstrate bradykinesia
Tone: cogwheel
NORMAL power and reflexes
Coordination: abnormal in MSA
Parkinsons examination, EYES?
Movements: nystagmus (MSA), vertical gaze palsy (PSP)
Saccades: slow initiation and movement
Parkinsons examination, EXTRAS?
Glabellar tap
GAIT (make sure you walk with them and support): slow initiation, shuffling, hurrying (festination), absent arms swing
Write sentence and draw spiral
BP lying and standing
Parkinsons examination, COMPLETION?
MMSE
Causes of parkinsonism?
Idiopathic PD
Parkinsons plus: MSA, PSP, CBD
Multiple infarcts in substantia nigra
Wilson’s disease
Drugs: neuroleptics, anti-emetics (metoclopramide)
PD history?
Symptoms: tremor, rigidity, bradykinesia
Autonomic: post hypotension, urinary probs
ADLs: handwriting, buttons etc
Sleep: turning in bed, insomnia, daytime sleepyness
Complications: depression, drug SEs esp. motor fluctuations
Cause: sudden onset, eye or balance problems
Parkinsons investigations?
Bloods: caeruloplasmin (reduced in Wilsons)
Imaging
- CT/MRI to exclude vascular cause
- DaT scan if unsure about diagnosis (ioflupane123 injection which ends to dopaminergic neurons and allows visualisation of the substantia nigra)
GENERAL management of parkinson’s?
MDT: neurologist, PD nurse, physio, OT, social worker
Assess disability e.g. unified PD rating scale
Physiotherapy: postural exercises
Depression screening
SPECIFIC management of parkinson’s?
L DOPA + carbidopa
Da agonists
MOA-O inhibitor
COMT inhibitors
Adjunctive therapy in parkinson’s?
Domperidone for nausea
Quetiapine for psychosis
Citalopram for depression
Features of parkinson’s? TRAPPS PD
Tremor Rigidity Akinesia Postural instability Postural Hypotension Sleep disorder
Psychosis
Depression
Sleep disorder in parkinson’s?
Affects 90%
Insomnia and frequent waking leading to EDS
REM sleep disorder (loss of muscle atonia and violent enactment of dreams)
Da side effects: insomnia, drowsiness, EDS
Autonomic dysfunction seen in PD
Postural hypotension Constipation Hypersalivation Urgency, nocturia, frequency ED Hyperhidrosis
L-DOPA SEs (DOPAMINE)
Dyskinesia On-off phenomena Psychosis ABP reduced Mouth dryness Insomnia N/V EDS
MSA pathology
Papp-lantos bodies: a-synuclein inclusions in glial cells
MSA features
Autonomic dysfunction: postural hypotension
Parkinsonism
CEREBELLAR ataxia
NB: if autonomic features predominate, may be referred to as Shy Drager Syndrome
PSP features?
Postural instability: FALLS
Vertical gaze palsy
Pseudobulbar palsy: speech and swallowing problems
Parkinsonism: symmetrical and tremor is unusual
CBD features?
Unilateral parkinsonism ESPECIALLY RIGIDITY
Aphasia
Astereognosis: cortical sensory loss –> alien limb phenomenon: autonomous arm movements
Lewy body dementia pathology?
a-synuclein and ubiquitin lewy bodies in brainstem and neocortex
Features of lewy body dementia?
Fluctuating cognition
Visual hallucinations
Parkinsonism
Vascular parkinsonism features?
Sudden onset
Parkinsonism worse in LEGS
Pyramidal signs
Prominent gait abnormality
Causes of tremor?
Resting: parkinsonism
Intention: cerebellar
Postural - worse with arms outstretched: endocrine (hyperthyroid), alcohol withdrawal, Toxins (b-agonists), sympathetic (anxiety)
Benign essential tremor features?
AD
Occur on movement and worse with anxiety or caffeine
Doesn’t occur with sleep
Better with alcohol
UMN signs?
Increased tone
Pyramidal distribution of weakness: legs - extensors > flexors, arms - flexors > extensors
Hyper-reflexia
Extensor plantars
Common causes of spastic paraparesis?
MS
Cord compression
Cord trauma
Cerebral palsy
Less common causes of spastic paraparesis?
Familial
Vascular e.g. aortic dissection –> beck’s syndrome
Infection: HTLV1
Tumour: ependymoma
Syringomyelia
Causes of mixed upper and lower motor neurone?
Friedrich’s ataxia
Tabes dorsalis
Cord compression/conus
SCDC
MND
Also polio (anterior horn cells)
Causes of spastic hemiparesis?
Stroke
MS
SOL
Cerebral palsy
Investigation of UMN signs
MRI cord and brain
Further Ix depends on cause e.g. MS (LP, Abs, evoked potentials), compression (FBC, CXR, DRE), SCDC (B12 level, PA Abs)
Mx of UMN stuff
Supportive:
MDT: GP, neurologist, radiologist, neurosurgeon, specialist nurses, physio, OT
Orthoses
Mobility aids
Urinary: ICSC
Contractures: baclofen, botulinum injection, physio
Causes of cerebellar syndrome? DAISIES
Demyelination Alcohol Infarct: brainstem stroke SOL Inherited Epilepsy meds: phenytoin System atrophy, multiple
Cerebellar syndrome, key causes?
LMS Vestibular schwannoma VHL Friedrich's ataxia Ataxia telangiectasia Wilson's
Definition of MS?
Chronic inflammatory condition of the CNS characterised by multiple plaques of demyelination disseminated in time and space
Presentation of MS?
TEAM
Tingling
Eye: optic neuritis, bilateral INO
Ataxia and other cerebellar signs
Motor: usually spastic paraparesis
Optic neuritis in MS?
Pain on eye movement, rapid loss of central vision
Uhthoff’s phenomenon: vision worsens with heat
O/E: reduced acuity and colour vision, white disc, central scotoma, RAPD
Tell me about INO?
Disruption of MLF connecting CN6 to CN3
Weak adduction of IPSILATERAL eye
Nystagmus of contralateral eye
Convergence is preserved
Diagnosis?
Clinical using McDonald criteria: demonstration of lesions disseminated in time and space
Investigations in MS?
MRI: Gd enhancing can show active inflammation, typically plaques are in the periventricular white matter
LP: IgG oligoclonal bands
Abs: Anti MBP, NMO IgG (Devic’s syndrome)
Evoked potentials: delayed auditory, visual and sensory
Differentials for MS?
CNS sarcoidosis
SLE
Devic’s: Neuromyelitis optica
- MS variant with transverse myelitis and optic atrophy
- Distinguished by presence of NMO IgG
Principles of treatment?
MDT: neurologist, radiologist, GP, specialist nurses, physio, OT, family
Acute attack
Preventing replace
- DMARD
- Biologicals
Symptomatic
MS acute attack Mx?
Methylpred, doesn’t influence long term outcomes but reduces duration and severity of attacks
MS preventing attack mx?
DMARDs:
- INF-b
Biological
- Natalizumab
Symptomatic tx in MS?
Fatigue: amantadine
Depression: SSRI
Pain: amitriptyline
Spasticity: baclofen, gabapentin and physio
Urgency/frequency: intermittent self catheterisation or anticholinergics
ED: sildenafil
Tremor: clonazepam
Poor prognostic signs in MS?
Older female
Motor signs at onset
Many relapses early on
Many MRI lesions
LMN signs?
Wasting
Fasciculations
Hypotonia
Hyporeflexia
Bilateral, symmetrical, distal LMN?
HMSN
Paraneoplastic
Lead poisoning
Acute: GBS, botulism
Bilateral, symmetrical, proximal LMN?
Inherited: musc dystrophy
Inflammation: poly/dermatomyositis
Endocrine: cushing’s, acrobatics, thyrotoxicosis, diabetic amyotrophy
Drugs: alcohol, statins, steroids
Malignancy: paraneoplastic
Unilateral LMN ddx?
Single limb with no sensory signs = polio
Group of muscles with same supply:
- segmental: nerve roots, plexus
- peripheral: mononeuropathy
Hand wasting ddx?
Anterior horn: syringiomyelia, MND, polio
Roots (C8 T1): spondylosis
Brachial plexus: compression/avulsion
Neuropathy: HSMN, mononeuritis multiplex (DM)
Muscle: disuse (RA), myotonic dystrophy
Investigations in prox myopathy?
Bloods: DM, muscle damage, endocrine, abs CXR EMG Genetic analysis Muscle bx
Causes of mainly sensory neuropathy?
DM Alcohol B12 def CRF and cancer Vasculitis Drugs e.g. isoniazid, vincristine
Causes of mainly motor neuropathy?
HMSN
Paraneoplastic: lung ca, RCC
Lead poisoning
Acute: GBS and botulism
Investigations for peripheral polyneuropathy?
Dipstick (glucose)
Bloods: glucose, LFT, b12/folate, U+E, TFTs, ESR/CRP etc
Imaging: CXR to exclude paraneoplasms
Other: nerve conduction, EMG, genetic (PMP22 gene in CMT), nerve bx
What do nerve conduction studies show?
Reduced conduction speed = demyelination
Reduced conduction amplitude = axonal degeneration
General mx of peripheral polyneuropathy?
MDT
Foot care and shoe advice
Splinting to prevent contractures
Specific mx of peripheral polyneuropathy?
Optimise glycemic control
Replace nutritional deficiencies
Avoid alcohol etc
Treat vasculitis with steroids and other immunosuppressants
Neuropathic pain: amitriptyline
GBS: IVIG
Causes of facial nerve palsy?
Bell’s
Ramsay Hunt
Cholesteatoma
Lyme disease
