Cardio and resp - from pass medicine Flashcards
Possible ECG features in WPW include: (4)
short PR interval
wide QRS complexes with a slurred upstroke - ‘delta wave’
left axis deviation if right-sided accessory pathway*
right axis deviation if left-sided accessory pathway*
Associations of WPW
HOCM (hypertrophic obstructive cardiomyopathy) mitral valve prolapse Ebstein's anomaly thyrotoxicosis secundum ASD
Management of WPW
definitive treatment: radiofrequency ablation of the accessory pathway
medical therapy: sotalol**, amiodarone, flecainide
in the majority of cases, or in a question without qualification, Wolff-Parkinson-White syndrome is associated with … axis deviation
left
A 51-year-old female presents to the Emergency Department following an episode of transient right sided weakness lasting 10-15 minutes. Examination reveals the patient to be in atrial fibrillation. If the patient remains in chronic atrial fibrillation what is the most suitable form of anticoagulation?
CHADS-VASc score = 3, so warfarin, target INR 2-3
If low risk (age <65 and no risk factors), what anticoagulation?
Aspirin 75mg-300mg/day
What does CHA2DS2-VASc stand for?
C Congestive heart failure 1 H Hypertension (or treated hypertension) 1 A2 Age >= 75 years 2 D Diabetes 1 S2 Prior Stroke or TIA 2 V Vascular disease (including ischaemic heart disease and peripheral arterial disease) 1 A Age 65-74 years 1 S Sex (female) 1
Restrictive lung diseases
Pulmonary fibrosis Asbestosis Sarcoidosis Acute respiratory distress syndrome Infant respiratory distress syndrome Kyphoscoliosis Neuromuscular disorders
Obstructive lung diseases
Asthma
COPD
Bronchiectasis
Bronchiolitis obliterans
2 level PE Wells Score
Clinical feature Points
Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) 3
An alternative diagnosis is less likely than PE 3
Heart rate > 100 beats per minute 1.5
Immobilisation for more than 3 days or surgery in the previous 4 weeks 1.5
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy (on treatment, treated in the last 6 months, or palliative) 1
common bendroflumethiazide SE?
hypokalaemia
Hypokalaemia causes on ECG
U waves
small or absent T waves (occasionally inversion)
prolong PR and QT interval
ST depression
‘In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT’
Two main types of VT:
monomorphic VT: most commonly caused by myocardial infarction
polymorphic VT: A subtype of polymorphic VT is torsades de pointes which is precipitated by prolongation of the QT interval. The causes of a long QT interval are listed below
Management of VT?
Management
If the patient has adverse signs (systolic BP < 90 mmHg, chest pain, heart failure or rate > 150 beats/min) then immediate cardioversion is indicated. In the absence of such signs antiarrhythmics may be used. If these fail, then electrical cardioversion may be needed with synchronised DC shocks
Drug therapy
amiodarone: ideally administered through a central line
lidocaine: use with caution in severe left ventricular impairment
procainamide
A 72-year-old man presents with lethargy and palpitations for the past four or five days. On examination his pulse is 123 bpm irregularly irregular, blood pressure is 128/78 mmHg and his chest is clear. An ECG confirms atrial fibrillation. What is the appropriate drug to control his heart rate?
B-blocker. A number of factors including age and symptoms would favour a rate control strategy. The NICE guidelines suggest either a beta-blocker or a rate limiting calcium channel blocker (i.e. Not amlodipine) in this situation. Some clinicians would prefer to use a more cardio-selective beta-blocker such as bisoprolol, although this is not stipulated in current guidelines
Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation
sotalol
amiodarone
flecainide
others (less commonly used in UK): disopyramide, dofetilide, procainamide, propafenone, quinidine
Management of a PRIMARY Pneumothorax
if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered
otherwise aspiration should be attempted
if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
Secondary pneumothorax
Recommendations include:
If the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.
otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours
Iatrogenic pneumothorax -
recommendations include:
less likelihood of recurrence than spontaneous pneumothorax
majority will resolve with observation, if treatment is required then aspiration should be used
ventilated patients need chest drains, as may some patients with COPD
Left ventricular aneurysm
a patient is noted to have persistent ST elevation 4 weeks after sustaining a myocardial infarction. Examination reveals bibasal crackles and the presence of a third and fourth heart sound
Ischaemia of the papillary muscle
a patient is noted to have a new early-to-mid systolic murmur 10 days after being admitted for a myocardial infarction
Causes of respiratory alkalosis
pulmonary embolism anxiety leading to hyperventilation pregnancy salicylate poisoning (initial stages) CNS disorders e.g. stroke, subarachnoid haemorrhage, encephalitis altitude
Causes of respiratory acidosis
COPD opiate overdose obesity hypoventilation syndrome neuromuscular disease life-threatening asthma (decompensated) benzodiazepines overdose
Drugs CId in asthma?
beta-blockers
adenosine
Drugs CId in recent myocardial infarction?
metformin
sildenafil
sumatriptan
hydralazine
What soes pulsus paradoxus imply?
severe asthma
a 60-year-old man with a history of tuberculosis presents with dyspnoea and fatigue. On examination the JVP is elevated, there is a loud S3 and Kussmaul’s sign is positive. Hepatomegaly is also noted
- stereotypical Hx of?
constrictive pericarditis
Stereotypical Hx of left ventricular free wall rupture
a patient develops acute heart failure 10 days following a myocardial infarction. On examination he has a raised JVP, pulsus paradoxus and diminished heart sounds
What SE do all these drugs have in common?
levodopa verapamil diltiazem isosorbide mononitrate bromocriptine amlodipine most diuretics (ACE inhibitors, thiazides and loop diuretics) atracurium
hypotension
2 drugs causing bronchospasm?
Bronchospasm
beta-blockers
adenosine
Side-effects of b-blockers?
bronchospasm
cold peripheries
fatigue
sleep disturbances, including nightmares
Contraindications to b-blockers
uncontrolled heart failure
asthma
sick sinus syndrome
concurrent verapamil use: may precipitate severe bradycardia
Indications for b-blockers?
angina post-myocardial infarction heart failure arrhythmias hypertension thyrotoxicosis migraine prophylaxis anxiety
pulse in mixed aortic valve disease?
pulsus bisferiens
pulse in PDA?
collapsing
Drugs predisposing to gluacoma?
corticosteroids
risk of thiazide diuretics for men?
impotence
Early diastolic murmur, high-pitched and ‘blowing’ in character (2)?
aortic regurgitation
Graham-Steel murmur (pulmonary regurgitation)
Mid-late diastolic murmur, ‘rumbling’ in character (2)?
mitral stenosis
Austin-Flint murmur (severe aortic regurgitation)
Lyme disease (Borrelia) effect on ECGs?
a prolonged PR interval
Left ventricular anuerysm effect on ECGs?
ST elevation
SEs of ACEis?
cough: occurs in around 15% of patients and may occur up to a year after starting treatment.
angioedema: may occur up to a year after starting treatment
hyperkalaemia
first-dose hypotension: more common in patients taking diuretics
CIs for ACEis?
pregnancy and breastfeeding - avoid
renovascular disease - undiagnosed bilateral renal artery stenosis
aortic stenosis - may result in hypotension
patients receiving high-dose diuretic therapy (more than 80 mg of furosemide a day) - significantly increases the risk of hypotension
Monitoring on ACEis?
urea and electrolytes should be checked before treatment is initiated and after increasing the dose
a rise in the creatinine and potassium may be expected after starting ACE inhibitors. Acceptable changes are an increase in serum creatinine, up to 30%* from baseline and an increase in potassium up to 5.5 mmol/l*.
6 nephrotoxic drugs?
ciclosporin aminoglycosides amphotericin B foscarnet vancomycin loop diuretics
Sounds heart in aortic stenosis?
fourth heart sound
soft S2
reversed split S2
4 causes of a loud S1?
mitral stenosis
left to right shunts
short PR interval, atrial premature beats
hyperdynamic states
Main organism causing IE in patients with no past medical history / prosthetic valves after two months?
Streptococcus viridans
SEs of amiodarone
thyroid problems Slate-grey appearance Interstitial lung disease Corneal deposits Gynaecomastia Epididymitis Peripheral neuropathy Raised LFT results, rarely jaundice/hepatitis
What type of met. change does a PE cause?
resp alkalosis
What type of met. change does salicylate poisoning cause?
salicylate overdose leads to a mixed respiratory alkalosis and metabolic acidosis. Early stimulation of the respiratory centre leads to a respiratory alkalosis whilst later the direct acid effects of salicylates (combined with acute renal failure) may lead to an acidosis
Step 3 of chronic asthma Mx?
- Add inhaled long-acting B2 agonist (LABA)
- Assess control of asthma:
good response to LABA - continue LABA
benefit from LABA but control still inadequate: continue LABA and increase inhaled steroid dose to 800 mcg/day* (if not already on this dose)
no response to LABA: stop LABA and increase inhaled steroid to 800 mcg/ day.* If control still inadequate, institute trial of other therapies, leukotriene receptor antagonist or SR theophylline
Step 5 of asthma Rx?
Use daily steroid tablet in lowest dose providing adequate control. Consider other treatments to minimise the use of steroid tablets
Maintain high dose inhaled steroid at 2000 mcg/day*
4 features of sarcoid?
acute: erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, polyarthralgia
insidious: dyspnoea, non-productive cough, malaise, weight loss
skin: lupus pernio
hypercalcaemia: macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol)
What is Lofgren’s syndrome?
an acute form of sarcoidosis characterised by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia. It usually carries an excellent prognosis
What is Heerfordt’s syndrome (uveoparotid fever)?
parotid enlargement, fever and uveitis secondary to sarcoidosis
What does Carboxyhaemoglobin do to the oxygen dissociation curve?
Shifts it to the left
Asbestosis typically causes?
lower lobe fibrosis. As with other forms of lung fibrosis the most common symptoms are shortness-of-breath and reduced exercise tolerance.
Possible features of mesothelioma
progressive shortness-of-breath
chest pain
pleural effusion
Asbestosis and lung Ca?
Asbestos exposure is a risk factor for lung cancer and also has a synergistic effect with cigarette smoke.
6 antimuscarinics
ipratropium oxybutynin benzhexol procyclidine benzotropine tolterodine
Wha are methylxanthines?
One example. Problem with their use?
eg. theophylline
Non-specific inhibitor of phosphodiesterase resulting in an increase in cAMP
• Given orally or IV
• Has a narrow therapeutic index
Causes of lower zone fibrosis? Which conn. tissue disorder is upper zone?
cryptogenic fibrosing alveolitis
most connective tissue disorders (except ankylosing spondylitis)
drug-induced: amiodarone, bleomycin, methotrexate
asbestosis
7 causes of upper zone fibrosis
extrinsic allergic alveolitis coal worker's pneumoconiosis/progressive massive fibrosis silicosis sarcoidosis ankylosing spondylitis (rare) histiocytosis tuberculosis
3 drugs causing pulmonary fibrosis
amiodarone, bleomycin, methotrexate
3 paraneoplastic features of small cell lung Ca?
ADH
ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc
Lambert-Eaton syndrome
3 paraneoplastic features of squamous cell lung Ca?
parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia
clubbing
hypertrophic pulmonary osteoarthropathy (HPOA)
hyperthyroidism due to ectopic TSH
paraneoplastic feature of adenocarcinoma?
gynaecomastia
Features of silicosis?
risk factor for developing TB (silica is toxic to macrophages)
fibrosing lung disease
‘egg-shell’ calcification of the hilar lymph nodes
Best Ix for Idiopathic pulmonary fibrosis?
high-resolution CT scan
Extrinsic allergic alveolitis
(EAA, also known as hypersensitivity pneumonitis) is a condition caused by hypersensitivity induced lung damage due to a variety of inhaled organic particles. It is thought to be largely caused by immune-complex mediated tissue damage (type III hypersensitivity) although delayed hypersensitivity (type IV) is also thought to play a role in EAA, especially in the chronic phase.
Examples of EAA?
bird fanciers’ lung: avian proteins
farmers lung: spores of Saccharopolyspora rectivirgula (formerly Micropolyspora faeni)
malt workers’ lung: Aspergillus clavatus
mushroom workers’ lung: thermophilic actinomycetes*
Presentation of EAA?
acute: occur 4-8 hrs after exposure, SOB, dry cough, fever
chronic: similar but more insidious
Investigation of EAA?
chest x-ray: upper/mid-zone fibrosis
bronchoalveolar lavage: lymphocytosis
blood: NO eosinophilia
Which drugs are non-specific inhibitors of phosphodiesterase resulting in an increase in cAMP
Methylxanthines
What is expiratory reserve volume?
maximum volume of air that can be expired at the end of a normal tidal expiration
What is physiological dead space (VD)?
VD = tidal volume * (PaCO2 - PeCO2) / PaCO2
where PeCO2 = expired air CO2
How does ipratropium work?
Blocks the muscarinic acetylcholine receptors
• Short-acting inhaled bronchodilator. Relaxes bronchial smooth muscle
• Used primarily in COPD
• Tiotropium has similar effects but is long-acting
Benzo overdoses -> what kind of pH abnormality?
resp acidosis
which lung cancer can cause hypercalcaemia 2’ to PTHrp?
squamous cell
An elderly patient presents with watery diarrhoea after being treated for pneumonia. Blood tests show a new, marked neutrophilia is a stereotypical history for gastroenteritis caused by
C. diff
clari for which type of pneumonia?
Caused by atypicals
Initial empirical therapy of meningitis (aged < 3 months)?
intravenous cefotaxime + amoxicillin
Miningitis pathogens in <3 month olds
Group B Streptococcus (most common cause in neonates)
E. coli
Listeria monocytogenes
What does HbeAg presence imply?
HbeAg results from breakdown of core antigen from infected liver cells as is therefore a marker of infectivity
What does HBsAg normally imply?
acute disease (present for 1-6 months). If >6mo, chronic/infectious disease.
Results if previous hepatitis B, now a carrier:
anti-HBc positive, HBsAg positive
Which organism can cause pneumonia in people aged > 60 years or 0 - 3 months
Listeria m.
Basics of bronchiolitis?
respiratory syncytial virus (RSV) is the pathogen in 75-80% of cases
other causes: mycoplasma, adenoviruses
may be secondary bacterial infection
more serious if bronchopulmonary dysplasia (e.g. Premature), congenital heart disease or cystic fibrosis
SIGN suggested the following criteria for referral to hospital in bronchiolitis?
poor feeding (< 50% normal) lethargy apnoea respiratory rate > 70/min nasal flaring or grunting severe chest wall recession cyanosis oxygen saturation < 94% uncertainty regarding diagnosis
Ix of bronchiolitis
immunofluorescence of nasopharyngeal secretions may show RSV
Abx for gonorrhea?
Intramuscular ceftriaxone + oral azithromycin
When is phenoxymethylpenicillin used?
erysipelas throat infections (requiring antibiotics)
What does H. influenzae cause?
infective exacerbation of COPD
exacerbation of bronchiectasis
acute epiglottitis
Basic facts about staphylococci
Gram-positive cocci
facultative anaerobes
produce catalase
What causes skin infections (e.g. cellulitis), abscesses, osteomyelitis, toxic shock syndrome?
S. aureus
What is coagulase-negative and causes central line infections and infective endocarditis
S. epidermidis
Abx for bacterial vaginosis
oral or topical metronidazole or topical clindamycin
An elderly patient presents with fever and a cough productive of ‘rusty’ coloured sputum. On examination there is dullness at the right base of the lung and bronchial breathing - pathogen?
Streptococcus pneumoniae
Rx of chlamydia?
doxycycline or azithromycin
A 20-year-old man presents in summer with gradually worsening flu-like symptoms and a dry cough. On examination he is noted to have erythema multiforme is a stereotypical history of:
mycoplasma
