cardio/ resp

Question 1

What signs are associated with mitral stenosis?

Answer 1

malar flush on cheeks.
regular, low-volume pulse
mid-diastolic murmur loudest with the patient leaning to left, at apex, opening snap
Can cause AF due to atrial enlargement

Thinks ARMS - atrial regurg early murmur, followed by MS with mid murmur

Question 2

What signs are associated with aortic regurgitation?

Answer 2

early diastolic murmur over aortic area: intensity of the murmur is increased by the handgrip manoeuvre
collapsing/ waterhammer/ corrigans pulse
wide pulse pressure
Quincke’s sign (nailbed pulsation)
De Musset’s sign (head bobbing)

Question 3

What are all MI patients discharged on?

Answer 3

beta blocker
aspirin
ticagrelor / second line anti-platelet (DAPT - this is stopped at 12 months post MI
ACE inhibitor
statin

Question 4

1st, 2nd line and 3rd line mx of HF?

Answer 4

1st - BB (carvedilol or bisoprolol) + ACE-i (or ARB)
2nd - spironolactone (also think of SGLT-2 inhib if diabetic) then consider SGLT-2 inhib - in hfref
3rd- initiated by a specialist. Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy

Question 5

It cardiac arrest is witnessed on a monitor how should ALS be done

Answer 5

Witnessed cardiac arrest while on a monitor - up to three successive shocks before CPR

Question 6

When do patients get fibrinolysis for a STEMI?

Answer 6

should be offered within 12 hours of the onset of symptoms if primary PCI cannot be delivered within 120 minutesof the time when fibrinolysis could have been given. Should be given wtih an antithrombin drug eg fondaparinux. drug used in fibrinolysis is alteplase

Question 7

dresslers syndrome - what is it?

Answer 7

dresslers syndrome is pericarditis secondary to MI, occurs 3-6 weeks after MI

Question 8

What is Beck’s triad?
What can cause it? what do you see on ecg?

Answer 8

Muffled heart sounds + JVP raised + hypotension indicate Beck’s Triad -> cardiac tamponade
LV free wall rupturet MI
on ecg get tachy + electrical alternans

Question 9

Treatment for angina (initial)? 2nd line add in if uncontrolled? 3rd line?

Answer 9

Initial: bisoprolol, GTN, aspirin and statin OR if BB CI then start rate limiting CCB eg verapamil

2nd: longer-acting dihydropyridine calcium channel blocker should be added eg Nifedipine, amlodipine

3rd: a long-acting nitrate (Isosorbide mononitrate)/ ivabradine/ nicorandil/ ranolazine/ hydrolazine + refer to cardiology for PCI assessment

Question 10

What can be found on CXRs for bronchiectasis?

Answer 10

Parallel line shadows (often called tram-lines) are common in bronchiectasis and indicate dilated bronchi due to peribronchial inflammation and fibrosis.

Question 11

What is the 4th line management for BP?

Answer 11

if potassium < 4.5 mmol/l add low-dose spironolactone
if potassium > 4.5 mmol/l add an alpha- or beta-blocker

Question 12

When are prophylactic abx used in COPD? Which abx are used?

Answer 12

250mg azithromycin three times per week if:
Non-smoking
On maximum medical mx
Had pulmonary rehab
4 acute exacerbations in the last year (producing sputum), requiring hospital admission at least once.

Question 13

Howdo you interpret lung function tests?(restrictive vs obstructive) When should it be done?

Answer 13

Done Post bronchodilator in COPD for diagnosis, pre and post in asthma

FVC - reduced, FEV1 - reduced FEV1/FVC - normal.

Restrictive lung disease - scarring of lung means reduced compliance and capacity.
Reduced forced vital capacity (FVC) as decreased compliance. FEV1 decreases at same rate so means when devided is normal.

FEV1 - reduced, FEV1/FVC - reduced

obstructive diseases eg COPD, asthma, or bronchiectasis
Obstruction to airflow which means it is hard to exhale. FEV1 is reduced. FVC is normal/ slightly low. So ratio is low.

Question 14

Mx of spontaneous pnuemothorax? High risk features?

Answer 14

High risk features:
haemodynamically unstable
hypoxia
bilateral
underlying lung disease
>50 with sig smoking history
haemopneumothorax

If patient asx/ pneumothorax not big enough to drain - conservative mx

If patient sx + high risk + >2cm on CXR —> chest drain

If patient sx + low risk + >2cm on CXR —> needle aspiration/ ambulatory device

Question 15

What are electrolyte causes of prolonged QT and potential VT?

Answer 15

hypocalcaemia, hypokalaemia, hypomagnesaemia

Question 16

osler nodes vs janeway lesions?

Answer 16

Janeway lesions - erythematous macular or nodular lesions caused by septic emboli

osler nodes - painful erythematous lesions caused by immune complex deposition

Question 17

what venturi mask should you use on CO2 retainers if NOT critically ill

Answer 17

28% Venturi mask at 4 litres/min is used prior to the results of blood gases in patients with risk factors for hypercapnia aiming for oxygen saturation of 88-92%.

If critically ill just whack on 15L

Question 18

What are the rate limiting CCB? What are the dihydropyrodine CCB?

Answer 18

rate-limiting one such as verapamil or diltiazem

onger-acting dihydropyridine calcium channel blocker e.g. amlodipine, modified-release nifedipine

Question 19

What is the mx of COPD?

Answer 19

1st line: SABA/ SAMA
2nd line:
If asthma features (diagnosis prev of asthma/ atopy/ raised eosinophils/ diurnal variation in peak flows) - add ICS + LABA
If no asthma features add LAMA + LABA
3rd line: all three - ICS +LABA +LAMA

Question 20

What do the different leads on the ecg correspond to in terms of coronary arteries and what complications post MI can they lead to?

Answer 20

RCA - inferior leads - supplies AV node - so get AV block
LAD - anterior leads - left ventricle thrombus / ventricle free wall rupture/ VSD
Circumflex - lateral leads

Question 21

ECG changes in pericarditis?

Answer 21

the changes in pericarditis are often global/widespread, as opposed to the ‘territories’ seen in ischaemic events
‘saddle-shaped’ ST elevation
PR depression: most specific ECG marker for pericarditis

Question 22

How does miliary TB look on CXR?

Answer 22

scattered, fine nodules throughout lungs

Question 23

What is moderate vs severe vs very severe copd?

Answer 23

The severity of COPD is based upon FEV1 readings. mildis >80% Moderate is FEV1 50-79%, severe is 30-49%, and very severe is <30%.

Question 24

What ECG findings would you see in cardiac tamponade?

Answer 24

electrical alternans - alternation of QRS complex

Question 25

Mx of asthma in <12? vs >12?

Answer 25

<12 SABA ---> add ICS ---> add LTRA ---> refer >12 Low dose ICS/ fometerol --> low dose MART --> moderate dose MART ---> check FeNO and eosinophil count, if raised refer if not ---> trial LTRA/ LAMA for 8-12 w --> refer

Question 26

What medications are given for pharmacological cardioversion?

Answer 26

flecainide or amiodarone if there is no evidence of structural or ischaemic heart disease or amiodarone if there is evidence of structural heart disease.

Question 27

What coronary artery is affected in new LBBB?

Answer 27

anterior/ anteroseptal

Question 28

What lung cancer type has the highest incidence after asbestosis exposure?

Answer 28

Bronchogenic carcinoma

Question 29

What are two causes of treatment resistant HTN?

Answer 29

coarctation of the aorta (aorta narrowed distal to ductus arteropsusto upper limb BP higher than lower branches) renal artery stenosis

Question 30

After DC cardioversion for AF how long should anti-coagulation be continued?

Answer 30

forever even once sinus rhythm maintained

Question 31

HOCM ECG findings?

Answer 31

left ventricular hypertrophy non-specific ST segment and T-wave abnormalities, progressive T wave inversion may be seen deep Q waves

Question 32

Which HF medications reduce their mortality?

Answer 32

ACE-inhibitors/ ARBs Beta-blockers Aldosterone antagonists Hydralazine and nitrates

Question 33

What is seen on CXR for an aspergilloma?

Answer 33

The air crescent sign on chest x-ray is a characteristic finding of aspergilloma where a crescent of air that surrounds a radiopaque mass present in a lung cavity is visible. Ball shaped opacity in apices

Question 34

Presentation of digoxin toxicity?

Answer 34

generally unwell, lethargy, nausea & vomiting, anorexia, confusion, yellow-green vision arrhythmias (e.g. AV block, bradycardia) gynaecomastia

Question 35

When can you restart sildenafil post MI/ stroke?

Answer 35

6 months

Question 36

When do you recieve a bioprosthetic valve vs mechanical?

Answer 36

Bioprosthetic are used in >65s as no need for life-long anti-coagulation and have lower risk of VTE, however do not last as long as mechanical

Question 37

Mx of pleural paques?

Answer 37

Pleural plaques are the most common form of asbestos-related lung disease and are benign. They are not associated with an increased risk of lung cancer or mesothelioma. This patient should be reassured and advised that no follow-up of these specific plaques is necessary, although an ongoing review of his lung disease is encouraged.

Question 38

What medication is CI in HOCM?

Answer 38

ACE-i nitrates inotropes rs can reduce afterload which may worsen the LVOT gradient.

Question 39

What are some SE/ big CI to adenosine?

Answer 39

adenosine can cause a brief sensation of flushing and intense chest pain, but the side-effects should resolve fastly. This medication should not be administered to asthmatics as it can cause bronchospasm.

Question 40

Which cardiac med can patient develop tolerance to?

Answer 40

Patients may develop tolerance to this medication necessitating a change in dosing regime Isosorbide mononitrat

Question 41

When would you record a posterior ECG?

Answer 41

Posterior MI is suggested by the following changes in V1-3: Horizontal ST depression Tall, broad R waves (> 30ms) Upright T waves

Question 42

What is pancoasts syndrome?

Answer 42

apical lung ca leads to horner's syndrome + brachial plexus invasion Needs MRI chest

Question 43

How should you treat MI secondary to cocaine use?

Answer 43

IV benzodiazepines

Question 44

ECG features in hypokalaemia?

Answer 44

U waves small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT

Question 45

How is asthma diagnosed in adults?

Answer 45

Adults with suspected asthma should have both a FeNO test and spirometry with reversibility

Question 46

What is lights criteria?

Answer 46

Light’s criteria are used for establishing an exudative effusion using protein or lactate dehydrogenase (LDH): Pleural fluid protein / serum protein greater than 0.5 Pleural fluid LDH / serum LDH greater than 0.6 Pleural fluid LDH greater than 2/3 of the normal upper limit of the serum LDH pH not part of criteria

Question 47

Exudative vs transudative pleural effusions?

Answer 47

Exudative – a high protein content (more than 30g/L) eg cancer, RA, infection Transudative – a lower protein content (less than 30g/L) eg HF, Hypothyroidism, meigs syndrome, hypoalbuminaemia, liver + renal failure

Question 48

When do you use adrenaline in ALS and dose?

Answer 48

adrenaline 1 mg as soon as possible for non-shockable rhythms during a VF/VT cardiac arrest, adrenaline 1 mg is given once chest compressions have restarted after the third shock repeat adrenaline 1mg every 3-5 minutes whilst ALS continues

Question 49

When do you use amiodarone in ALS and doses?

Answer 49

amiodarone 300 mg should be given to patients who are in VF/pulseless VT after 3 shocks have been administered. a further dose of amiodarone 150 mg should be given to patients who are in VF/pulseless VT after 5 shocks have been administered

Question 50

mx of following if tachycardia with no life-threatening features: polymorphic VT eg torsades de pointes VT SVT If tachycardia with life threatening features?

Answer 50

No life threatening features and polymorphic VT eg torsades de pointes: magnesium 2g VT: amiodarone 300mg IV ---> synchornised DC shock up to x3 SVT: vagal manouveres --> adenosine 6mg --> adenosine 12mg --> adenosine 18mg --> verapamil/ BB If tachycardia with life threatening features: synchornised DC shock up to x 3 --> amiodarone 300mg IV ---> repeat shock

Question 51

When do you give atropine for bradycardia? Dose? next steps if doesn't work?

Answer 51

If at risk of haemodynamic compromise: clinical shock, syncope, MI, HF or complete heart block with broad complex QRS, recent asystole, Mobitz type II AV block, ventricular pause > 3 seconds need to treat Atropine (500mcg IV) 1st line tp to maximum of 3mg --> transcutaneous pacing or isoprenaline/adrenaline infusion titrated to response

Question 52

Most common cause of arrest post MI?

Answer 52

VF

Question 53

What are the different complications of a MI?

Answer 53

Immediate: Cardiogenic shock (low ejection fraction and poor output); tachyarrthymias; bradyarrthymias (most common is AV block in inferior MI) Short-term: pericarditis (48 hrs, has pericardial rub and typical sx); LV aneurysm (weakness in myocardium causes peristent ST elevation and LV filure -need anti-coag due to thrombus risk) intermediate term: dresslers syndrome (2-6 weeks, fever, effusion, raised ESR, pleuritic pain, mx with NSAIDs); LV free wall rupture (1-2 weeks post MI, acute HF due to tamponade so need urgent pericardiocentesis); VSD (in first week, rupture of septum, causes HF and pansystolic murmur, need echo and sugrery, anteior MI); Acute mitral regurgitation (?pansystolic murmur, most commonly infero-posterior MI, can be due to rupture papillary muscle, hypotension, early-to-mid systolic rupture, give vasodilator therapy, often need surgery) Long term: Chronic heart failure

Question 54

Bacterial causes of IE and their associations?

Answer 54

Staphylococcus aureus - most common cause overall, associated with IVDU step viridans - associated with dental procedures Staphylococcus epidermidis - associated with prosphetic valves and lines Streptococcus bovi- associated with colorectal cancer

Question 55

What pulls trachea away vs towards white out on CXR?

Answer 55

towards: Pneumonectomy Complete lung collapse e.g. endobronchial intubation Pulmonary hypoplasia away: Pleural effusion Diaphragmatic hernia Large thoracic mass pneumothorax also pushes away

Question 56

CI to thrombolysis in STEMI (ie alteplase)?

Answer 56

Contraindications to thrombolysis active internal bleeding recent haemorrhage, trauma or surgery (including dental extraction) coagulation and bleeding disorders intracranial neoplasm stroke < 3 months aortic dissection recent head injury severe hypertension

Question 57

presentation and mx of lung abscess

Answer 57

Lung abscess, often occur due to aspiration pneumonia, cause fever, foul smelling productive cough, gen unwell, air fluid level on CXR treat with clindamycin 4-6w if doesn't work percutaneous drainge

Question 58

how long does someone need anti-coag for in considering carioversion for AF (in those who are stable and has AF >48 hrs)?

Answer 58

Acute onset of atrial fibrillation: if ≥ 48 hours - rate control initially, then if considered for long-term rhythm control, delay cardioversion until they have been maintained on therapeutic anticoagulation for a minimum of 3 weeks

Question 59

How can sarcoidosis present?

Answer 59

acute: erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, polyarthralgia insidious: dyspnoea, non-productive cough, malaise, weight loss ocular: uveitis skin: lupus pernio - puple/ blue lesions on extremities eg nose hypercalcaemia: macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol) can get Heerfordt's syndrome (uveoparotid fever) there is parotid enlargement, fever and uveitis secondary to sarcoidosis

Question 60

features of aortic stenosis?

Answer 60

murmur of aortic stenosis is a crescendo-decrescendo, high-pitched ejection systolic murmur, heard loudest in the second right intercostal space, which radiates to the carotids. If severe stenosis is present other examination findings may include: narrow pulse pressure slow rising pulse a thrill palpable over the cardiac apex a fourth heart sound (S4) indicative of left ventricular hypertrophy a soft/absent S2

Question 61

What is included in the GRACE score?

Answer 61

age heart rate, blood pressure cardiac (Killip class) and renal function (serum creatinine) cardiac arrest on presentation ECG findings troponin levels

Question 62

Type A vs type B aortic dissection?

Answer 62

Stanford classification type A - ascending aorta, 2/3 of cases - sugrical mx - can affect aorta and cause murmur on presentation type B - descending aorta, distal to left subclavian origin, 1/3 of cases - conservative mx will have widened mediastium on XR and CT angio shows false lumen

Question 63

features of klebsiella pneumonia?

Answer 63

more common in alcoholic and diabetics may occur following aspiration 'red-currant jelly' sputum often affects upper lobes

Question 64

What is an atrial myxoma?

Answer 64

myxoma = tumour Causes HF type sx Abnormal HS Familial inheritance assciated with CARNEY syndrome

Question 65

What signs are heard in mitral regurgitation?

Answer 65

pansystolic murmur at apex raidtaes to axilla louder on expiration

Question 66

Absolute CI to thrombolysis for MI?

Answer 66

Prev IC haemorrhage ischemic stroke <6m cerebral neoplasm or AVM major trauma/ surgery/ head injury in last 3 weeks Aortic dissection Active bleed GI bleed non-compressionnable punctures in last 24 hrs eg liver biopsy, LP

Question 67

Differentiating obesity hypoventilation from OSA?

Answer 67

Both cause daytime sleepiness, hypoventilation at night and are linked to obesity Obesity hypoventilation causes daytime hypercapnia OSA will have epworth score over 10

Question 68

Presentation of mesothelioma vs bronchial carcinoma vs asbestosis

Answer 68

bronchial carcinoma causes 95% of lung ca - causes haemopysis, consolidation and clubbing mesothelioma - causes pleural effusion, pleural thickening, asbestosis exposure long time ago normally, usually palliate asbestosis - type of ILD causing pulmonary fibrosis, will be honeycombing on CT

Question 69

Mx of tension pneumothorax?

Answer 69

needle decompression - 2nd intercostal space, mid clavicular line, above the 3rd rib

Question 70

What is Goodpasteurs?

Answer 70

Autoantibodies form against the basement membrane of the lungs and kidney Get cough, SOB, haemoptysis, kidney injury Anti-GBM antibodies found Wegeners is similar BUT you get also nosebless and c-ANCA

Question 71

NICE criteria for two week CXR?

Answer 71

Clubbing Lymphadenopathy (supraclavicular or persistent abnormal cervical nodes) Recurrent or persistent chest infections Raised platelet count (thrombocytosis) Chest signs of lung cancer Two or more unexplained symptoms in patients that have never smoked One or more unexplained symptoms in patients that have ever smoked or had asbestos exposure The unexplained symptoms that the NICE guidelines list are: Cough Shortness of breath Chest pain Fatigue Weight loss Loss of appetite

Question 72

STEMI management? in context of reperfusion therapy (PCI or fibrolysis) or medical mx?

Answer 72

PCI - Prasagrul + aspirin, offer clopidogrel + aspirin if on a DOAC or had previous stroke/ TIA fibrinolysis - offer ticagrelor + apirin, offer aspirin alone of with clopidogrel if high bleed risk medical - offer ticagrelor + apirin, offer aspirin alone of with clopidogrel if high bleed risk

Question 73

Which respiratory conditions do NOT cause clubbing?

Answer 73

pneumonia COPD asthma

Question 74

ms of PE causing haemodynamic instability?

Answer 74

give continuous unfractionated heparin infusion consider thrombolytic therapy

Question 75

What is cor pulmonale? Causes?

Answer 75

cor pulmonary overload of R ventricle due to pulmonary HTN Causes = ARDS, PE, SCD, severe asthma acutely, chronic lung diseases, pulmonary vacular disorders, neuromuscular diseases, thoracic cage abnormalities eg kyphosis

Question 76

When do you refer to sleep clinic urgently for ?OSA?

Answer 76

Urgently if symptoms such as excessive sleepiness are impacting on their role as a professional driver or safety-critical worker; or if OSAS can worsen the prognosis of a comorbid cardiopulmonary condition, if the person is pregnant, or undergoing pre-operative assessment for major surgery.

Question 77

What is the best way to check lung function in chronic lung disease?

Answer 77

TLCO

Question 78

What is aortic sclerosis

Answer 78

ejection systolic murmur, incidental, in older ppl, no other sx

Question 79

How would you diagnose an empyema?

Answer 79

on pleural tap pH would be less than 7.2

Question 80

What are the features of brugada syndrome? what do you do with it?

Answer 80

features: ST elevation in V1-V3, AD inheritance, impaired sodium channels, more prevalent in SE asian Needs urgent cardio input for ICD

Question 81

What are other causes of a raised troponin other than ACS? How long does troponin remain risen for post MI?

Answer 81

Other causes of raise in trop: post PCI, post heart surgery, peri/ myocarditis, aortic dissection, cardiotoxic chemo, catheter ablation, defib/ cardioversion, amyloidosis, HF, PE, AKI, sepsis, rhabdomyolysis, mismatch of oxygen supply + demand eg COPD, acute HF, tachyarrhythmia Troponin can remain elevated for up to 2 weeks post MI, peak levels are at 18-24 hrs, start to rise at 2-4 hrs post MI

Question 82

mx of 1st degree heart block?

Answer 82

if asx no further management needed, relatively common → caution using BB, dig and diltiazem as could prolong AV block

Question 83

Which lung cancer is most associated with hypercalcaemia?

Answer 83

SCC

Question 84

What is 1st line for HTN in >55? If this is not tolerated what do you do next?

Answer 84

1st line for >55 without diabetes or if afro-caribbean is CCB If a CCB is not tolerated, for example, because of oedema, offer a thiazide-like diuretic, such as indapamide.

Question 85

What cancer is asbestosis most likely to cause?

Answer 85

Asbestosis is most likely to cause lung cancer NOT mesothelioma Can cause other cancers too

Question 86

70 yr old, confused, pyrexia, rust coloured sputum, RR=26, creps R lower base, CXR shows consolidation ?cause

Answer 86

s.pneumoniae

Question 87

What peak flows correspond to which classifications of astham attacks?

Answer 87

Pefr 50-75 = moderate, 50-33 = severe, <33 = life threatening

Question 88

What might you find on ecg in hypercalcaemia

Answer 88

J wave shortened QT

Question 89

What is the most important ix for diagnosing pericarditis?

Answer 89

ECG

Question 90

What are important points for checking a chest drain?

Answer 90

Chest drains should be kept below patients chest level to help with drainage, should rise and swing with respiration, are removed on expiration, should only be clamped when changing bottle as risk of pneumothorax, if air leak (continous bubbling) is noted - check chest tube, connecting tubage, drainage bottle + wound for loose connection/ tube dislodged. If disconnection occurs tube wont swing with inspiration, tube should be reconnected, ask patient to cough, air bubbles confirm is working and in right position

Question 91

What does hyperresonant chest percussion show?

Answer 91

COPD (hyperinflation) or pneumothorax

Question 92

caucasian young woman, painful red eye, 6 week dry cough ? cause

Answer 92

sarcoidosis

Question 93

What does GRACE score (used for NSTEMI) >3% indicate

Answer 93

need for PCI in 72 hrs