CardioResp Flashcards
Describe the NYHA classification system.
- No limitation of physical activity
- Slight limitation on exertion
- Marked limitation but comfortable at rest
- Unable to carry out any physical activity without discomfort.
Give the symptoms that may be experienced during an acute myocardial infarction.
Crushing chest pain Pain the neck, jaw, and/or arm Sweating Nausea and vomiting Abdominal pain (especially if elderly) Anxiety
What is the acute treatment of an ST-elevated myocardial infarction?
Morphine 5mg Antiemetic Oxygen Nitrates Aspirin 300mg Prasugrel (or clopidogrel 300mg)
Admit to cath lab as soon as possible
What long-term medications should a patient be prescribed after an acute myocardial infarction?
Atorvastatin 80mg Bisoprolol Prasugrel (clopidogrel if over 80, high bleeding risk, under 60kg) Aspirin 75mg Ramipril
What are the potential complications of an acute myocardial infarction?
Heart failure
Arrhythmia
Cardiogenic shock
Cardiac arrest
What investigations might you use in a patient with angina?
Exercise ECG
Coronary angiogram
Thyroid function test if hyperthyroidism is suspected
FBC to check for anaemia
Give a short-acting nitrate that can be prescribed for the relief of angina pain.
Nitroglycerin
Glyceryl trinitrate
Explain how nitrates can relieve the pain in angina
They are metabolised to nitrous oxide in the blood, which can cause vasodilation in the coronary vessels. This is done by increasing the levels of cGMP which activates myosin light chain phosphatase, phosphorylating the myosin and causing it to dissociate, allowing relaxation of the muscle.
Give a long-acting nitrate that can be prescribed for the long-term control of angina.
Isosorbide mononitrate
Nicorandil
Aside from nitrates, what should be prescribed to patients with angina that reduces their morbidity and mortality?
Beta blockers such as atenolol and bisoprolol
Give two procedures which can help patients with angina.
Balloon angioplasty
Coronary artery bypass graft
How can angina be prevented?
Stop smoking
Lose weight
Improve diabetic and hypertensive control
Increase exercise
What symptoms would you expect in a patient with chronic aortic regurgitation?
Typically asymptomatic Progressive shortness of breath on exertion Orthopnoea Paroxysmal nocturnal dyspnoea Palpitations
How would you expect a patient with acute aortic regurgitation to present?
In heart failure with dyspnoea, fatigue, weakness, and oedema.
They may also have cardiogenic shock with hypotension combined with multisystem organ damage.
A patient in clinic is found to have a loud S2, mid-diastolic murmur, and a wide pulse pressure. What is the most likely cause?
Aortic regurgitation
What are the causes of an acute aortic regurgitation?
Infective endocarditis
Ascending aortic dissection
What are the causes of a chronic aortic regurgitation?
Rheumatic fever Infective endocarditis Trauma Thoracic aortic aneurysm Degeneration of the valve or root
What investigations would you use in a suspected aortic regurgitation and why?
Echocardiogram with doppler: assess flow across the valve, level of impairment, pulmonary hypertension, vegetations, pericardial effusions
ECG: left ventricular hypertrophy, left atrial enlargement, ST depression, T wave inversion
CXR: cardiomegaly, prominent aortic root
What can be used for symptom control in patients with aortic regurgitation who are not eligible for surgery?
Vasodilators
Nitrates
Diuretics
What is the typical triad of symptoms which may occur in aortic stenosis?
Syncope
Angina
Breathlessness
A patient in the clinic is found to have a quiet S2, systolic ejection murmur, and a slow rising carotid pulse. What is the most likely cause?
Aortic stenosis
What are the most common causes of aortic stenosis?
Aortic sclerosis (over 70)
Congenital bicuspid aortic valve (under 70)
Rheumatic heart disease
What investigations would you want for a patient with suspected aortic stenosis, and what would you expect to find?
Echocardiogram: assess structural damage or deformity, atrial thrombi
ECG: left ventricular hypertrophy with/without ST/T changes
CXR: check for cardiomegaly and calcification of the valves
Exercise ECG: can show severe LV dysfunction if the patient is asymptomatic.
What is the management for aortic stenosis?
Valve replacement via open heart surgery or TAVI
Balloon valvotomy, usually in congenital cases
Diuretics if there is fluid overload
Anti-arrhythmics if necessary
What are the changes seen in the lungs of asthmatics?
Bronchoconstriction, airway oedema and inflammation, airway hyper-reactivity, airway remodelling
What can trigger asthma exacerbations?
Environmental or occupational allergens Infections Exercise Inhaled irritants Emotion Aspirin Gastro-oesophageal reflux disease
What are asthmatics at increased risk of during pregnancy?
Prematurity Pre-eclampsia Growth restriction Maternal morbidity/mortality Caesarian delivery
What is status asthmaticus?
Severe persistent asthma with prolonged bronchospasm
What timing of symptoms in asthma is a red flag?
At night
How is asthma diagnosed?
Spirometry before and after the use of salbutamol to confirm airway reversibility. More than 20% reduction of symptoms is required.
Methacholine or histamine can be used to trigger symptoms.
Induced sputum with >1% eosinophils can confirm a diagnosis of eosinophilic asthma.
What are the stages in the pharmacological management of asthma?
Salbutamol inhaler PRN with low-dose corticosteroid inhaler
ADD salmeterol inhaler BD
ADD moderate-dose corticosteroid inhaler
What are the features of a moderate asthma exacerbation, and how would you manage it?
PEF 50-75% of predicted
No features of a severe exacerbation
Manage with nebulised salbutamol and oral steroids
Maintain O2 sats of 94-98%
What are the features of a severe asthma exacerbation, and how would you manage it?
PEF 33-50% of predicted
RR >25/min, hr 110/min
Can’t complete sentences in one breath
Manage with nebulised ipratropium bromide and back to back salbutamol. Oxygen to maintain saturations 94-98%.
Take and ABG and inform a senior.
What are the features of a life threatening asthma exacerbation, and how would you manage it?
PEF <33% of predicted.
Sat <92%, pO2 <8kPa
Cyanosis, poor respiratory effort, fully silent chest
Exhaustion, confusion, arrhythmia
Manage with nebulised salbutamol and tiotropium bromide, IV aminophylline, and O2 if needed.
ITU and anaesthetics assessment
ICU or anaesthetic assessment
Urgent portable CXR
What is the defining feature of near fatal asthma?
CO2 levels normal or high
What symptoms may a patient with atrial fibrillation present with?
Palpitations
Heart failure: dizziness, dyspnoea, peripheral oedema
Stroke
Renal failure due to systemic emboli
What signs would you expect to find in a patient with atrial fibrillation?
Pulse deficit
Irregularly irregular pulse
Loss of the A wave in the JVP
What are the common causes of atrial fibrillation?
Hypertension Cardiomyopathy Mitral or tricuspid valve disorders Hyperthyroidism Binge drinking
What investigations would you want in a patient with suspected atrial fibrillation?
ECG: irregularly irregular narrow complex tachycardia with no P waves
Echocardiogram: check for structural heart defects and thrombi in the atria
Thyroid function tests
Describe the CHADS VASC scoring system.
Congestive heart failure Hypertension Age >75 (2) Diabetes Stroke/TIA (2) Vascular disease Age >65 Sex Female
A score of 2 or more should have anticoagulation therapy
Describe the HAS BLED scoring system.
Hypertension Abnormal renal or hepatic function Stroke Bleeding Labile INR Elderly (>65) Drugs/alcohol
What is the mechanism of action for rivaroxaban and apixaban?
Selective factor Xa inhibitor
What is the mechanism of action of warfarin?
Vitamin K antagonist
Why should you be cautious using atenolol in patients with diabetes?
It augments the function of metformin and insulin, as well as other anti-hyperglycaemic medications
What is the mechanism of action of diltiazem?
Calcium channel blocker
What are the side effects of diltiazem and verapamil?
Heart block
Constipation
Symptoms related to bradycardia
What is the mechanism of action of digoxin?
Cardiac glycoside which inhibits the sodium/potassium exchange to reduce the rate of contraction but increase the force.
What drug monitoring is required when using digoxin?
Serum electrolytes
Renal function
What rate control medications are commonly used in atrial fibrillation?
Atenolol/bisoprolol
Diltiazem/verapamil
Digoxin
What rate control medications used in atrial fibrillation should not be used together?
Beta blockers and calcium channel blockers
What medications can be used for rhythm control in atrial fibrillation?
Amiodarone
Flecainide
In a patient with atrial fibrillation and haemodynamic instability, what should be the first management?
Electrical cardioversion
How can patients with atrial fibrillation for less than 24 hours be managed differently than those where it has been present for more than 24 hours?
Less: cardiovert immediately
More: anticoagulate for three weeks before cardioversion irrespective of CHADS VASC score
What is the mechanism of action of amiodarone?
Class III anti-arrhythmic
Slows the conduction rate and increases the refractory period in the SAN and AVN
What drug monitoring is important with amiodarone?
Chest x-ray
Liver function tests
Urea and electrolytes
Thyroid function tests
Every 6 months
What are the major side effects of amiodarone?
Pulmonary fibrosis Photosensitivity Renal impairment Liver impairment Thyroid dysfunction Pneumonitis Optic neuritis
Why must amiodarone be administered via a central line?
It causes severe thrombophlebitis if administered through a peripheral vein
What is the mechanism of action of flecainide?
Sodium channel blocker
What are the side effects of flecainide?
Constipation Faintness Headache Nausea Chest pain Tachycardia
When should you avoid using flecainide?
Heart block
History of severe heart problems
When should you avoid using amiodarone?
Thyroid dysfunction
Conduction disturbance
What are the typical symptoms of bronchiectasis?
Chronic productive cough
Dyspnoea
Wheezing
Pleuritic chest pain
May cause massive haemoptysis
What would you expect to see on a chest x-ray for someone with bronchiectasis?
Thick airway walls
Tram lines
Tubular opacity (mucus plugs)
Ill-defined linear hilar density
What would you expect to see on CT for someone with bronchiectasis?
Airway dilation
Signet ring sign
Tram lines
May also have atelectasis, consolidation, and mucus plugs
What would you expect to find on pulmonary function tests in bronchiectasis? Why are they important?
Reduced FEV1, FVC, and FEV1:FVC ratio
May have a decreased DLCO
Used to document the baseline and monitor progression of the disease.
Describe the management of chronic bronchiectasis.
Respiratory therapy to ensure proper clearing of airway secretions
Salbutamol
Corticosteroids
How should bronchiectasis be managed during an acute exacerbation?
Antibiotics
Nebulised saline
Inhaled bronchodilators
What are the predisposing factors for bronchiectasis?
Persistent or recurrent infections
Alpha-1 antitrypsin deficiency
Cystic fibrosis
Primary ciliary disorders (Kartageners syndrome)
Primary or secondary immunodeficiency
Connective tissue disorder
Airway obstruction (tumour or foreign body)
What can cause radial-radial delay?
Coarctation of the aorta
What can cause a collapsing pulse?
Aortic regurgitation Fever Pregnancy Patent ductus arteriosus Anaemia AV fistula Thyrotoxicosis
What can cause a slow rising carotid pulse?
Aortic stenosis
What can cause a narrow pulse pressure?
Aortic stenosis
What can cause a wide pulse pressure?
Aortic regurgitation
What can cause a raised JVP?
Fluid overload
Right ventricular failure
Tricuspid regurgitation
What murmur is heard in mitral regurgitation?
Pansystolic murmur
What murmur is heard in aortic stenosis?
Mid-systolic ejection murmur
What murmur is heard in mitral stenosis?
Early diastolic decrescendo murmur with an opening snap
What murmur is heard in aortic regurgitation?
Early diastolic decrescendo murmur
What can cause pathological splitting of the S2 heart sound?
Aortic stenosis
Left bundle branch block
Hypertrophic cardiomyopathy
What can cause fixed splitting of the S2 heart sound?
Atrial septal defect
Bundle branch block
What can cause a loud S2?
Pulmonary hypertension
What changes will be seen on spirometry in a patient with COPD?
Low FEV1 and FEV1:FVC ratio
Describe the MRC dyspnoea score.
- Not troubled by breathlessness except on strenuous exercise
- Shortness of breath when hurrying on a level or walking up a slight hill
- Walks slower than most people on a level, stop after a mile or so, or stops after 15 minutes of walking at own pace.
- Stops for breath walking 100 yards or a few minutes on level ground.
- Too breathless to leave the house or breathless when dressing/undressing
Describe the management of COPD.
Smoking cessation, pulmonary rehabilitation, and dietetics
Tiotropium bromide inhaler
Combined steroid and bronchodilator inhaler if tiotropium is not sufficient.
Which patients with COPD should be offered long-term oxygen therapy?
Persistently low oxygen saturations <7.3kPa if no cor pulmonale, <8kPa with cor pulmonale
Non-smoker
Able to use for at least 16 hours per day
No high CO2 retention
Which patients with COPD can be eligible for lung volume reduction surgery?
Localised areas of emphysema
The rest of their lung is healthy
What interventions reduce mortality in COPD?
Smoking cessation
Long term oxygen therapy
Lung volume reduction surgery
How can COPD cause right heart failure?
It causes chronic hypoxic vasoconstriction which increases the afterload of the right ventricle.
What can be prescribed for COPD patients with right heart failure?
Furosemide
What are some of the side effects for patients using long-term steroids?
Weight gain Osteoporosis Mood changes and psychosis Bruising GI symptoms
How should COPD exacerbations be managed?
Controlled oxygen therapy (Venturi masks)
Nebulised tiotropium bromide
Oral steroids
IV aminophylline
Antibiotics if there is a raised CRP or WCC
If a patient with a COPD exacerbation has been treated but their ABG does not improve, how should they be managed?
BIPAP (non-invasive ventilation)
Who is BIPAP (non-invasive ventilation) contraindicated in?
Untreated pneumothorax GCS <8 Facial injury Life-threatening hypoxia Vomiting Agitation
Why is therapeutic drug monitoring required for aminophylline?
It has a narrow therapeutic index
What are the side effects of aminophylline?
Palpitations
Gastric irritation
Hypotension
Convulsions
Describe the main presentation of cystic fibrosis.
Newborn screening
Meconium ileus
Chest infections
Intestinal malabsorption
What are the typical respiratory effects of cystic fibrosis?
Recurrent or chronic infections
Pneumothorax
Haemoptysis
Cor pulmonale
What are the typical gastrointestinal effects of cystic fibrosis?
Meconium ileus (abdominal distention, vomiting, failure to pass meconium)
GORD
Malnourised
Constipation or bowel obstruction
Bulky and offensive stools (pancreatic insufficiency)
Features of vitamin ADEK deficiency
Why do cystic fibrosis patients often have reduced fertility?
In men, the failure of the vas deferens to develop is the most common cause. There may also be obstruction of the ducts that semen passes through.
In women, there are often viscous cervical secretions which reduce the passage of sperm through the cervix.
What investigations are required to diagnose cystic fibrosis?
Chloride sweat testing
Genetic testing for CFTR mutations
What would you expect to find on pulmonary function tests in a patient with cystic fibrosis?
Reduced FVC and FEV1
Increased residual volume
What lifestyle advice should be given to patients with cystic fibrosis?
Diet therapy
No smoking
Avoid contact with other cystic fibrosis patients and people ill with respiratory infections
Regular exercise and airway clearance
Clean and dry nebulisers properly
NaCl tablets in hot weather, be careful of dehydration
What are common complications of cystic fibrosis?
Diabetes
Malabsorption
Distal intestinal obstruction syndrome
Right heart failure
What are some genetic conditions which cause dyslipidaemia?
Familial hypercholesterolaemia: LDL receptor defect reducing clearance
Familial defective ApoB: reduces LDL clearance
PCSK9 GoF mutation: increased degradation of LDL receptors
Lipoprotein lipase deficiency: reduced chylomicron clearance from blood vessels
ApoC-II deficiency: functional LPL deficiency
What are the causes of secondary dyslipidaemia?
Sedentary lifestyle with an excessive intake of saturated fats, cholesterol, and trans fats
Diabetes mellitus
Alcohol overuse
Chronic kidney disease
Hypothyroidism
Cholestatic liver disease
Drugs: thiazides, beta blockers, oestrogen, progestins, glucocorticoids, antiretrovirals
What investigations are important when diagnosing dyslipidaemia
Serum lipid profile Fasting glucose Liver enzymes Creatinine TSH Urinary protein
What is the non-pharmacological management of dyslipidaemia?
Dietary modification and regular exercise
What is the pharmacological management of dyslipidaemia?
Atorvastatin/simvastatin (first line)
Benzafibrate
Ezetimibe
What is the mechanism of action of atorvastatin and simvastatin?
HMG-CoA reductase inhibitor, reducing cholesterol synthesis in the liver
What are the common side effects of atorvastatin and simvastatin?
Myalgia
Abdominal pain
Raised LFTs
What is the mechanism of action of benzafibrate?
Stimulates endothelial lipoprotein lipase to increase fatty acid oxidation in the liver and muscle, as well as decreasing LDL synthesis in the liver.
Why should statins and fibrates not be used together?
It increases the risk of rhabdomyolysis
What are the common side effects of benzafibrate?
Dyspepsia
Abdominal pain
Raised LFTs
What is the mechanism of action of ezetimibe?
Reduces cholesterol absorption in the small intestine
What are the common causes of acute heart failure?
Infection Allergic reactions Pulmonary emboli Cardiopulmonary bypass surgery Severe arrhythmias Heart attack
What are the common causes of chronic heart failure?
Coronary artery disease Hypertension Myocardial infarction Arrhythmia Diabetes medication Heart defect Alcohol overuse Kidney problems Sleep apnoea
What are the symptoms of heart failure?
Exertional dyspnoea Orthopnoea Fatigue and weakness Tachycardia/arrhythmia Reduced exercise tolerance
What investigations are important in patients with heart failure?
Chest x-ray Blood tests Electrocardiogram Serum BNP Transthoracic doppler echocardiogram
TFT, LFT, eGFR, fasting lipids/glucose, urinalysis, and peak flow/spirometry may also be useful in chronic heart failure to assess the impact on other organs systems and rule out other disorders.
What would you expect to see on a chest x-ray of a patient with heart failure?
Cardiomegaly Kerley B-lines Upper zone vessel enlargement Batwing alveolar oedema Blunt costophrenic angles
What drugs improve prognosis in heart failure?
Angiotensin receptor blockers ACE inhibitors Beta blockers Spironolactone Aldosterone inhibitors
Describe the management of heart failure.
Beta blockers (ACEi or ARB if reduced LVEF)
Diuretics to relieve congestive symptoms
Amlodipine for comorbid treatment of hypertension
How can heart failure cause renal dysfunction?
Reduced cardiac output causes reduced perfusion of the kidney, which is exacerbated by the activation of RAAS. This causes vasoconstriction of the renal arterioles as well as increasing ADH production.
What drugs commonly used in heart failure can contribute to renal dysfunction?
Diuretics
ACE inhibitors
ARBs
What blood pressure indicates mild hypertension?
> 140/90
What blood pressure indicates moderate hypertension?
> 160/100
What blood pressure indicates severe hypertension?
> 180/110
What are some of the causes of secondary hypertension?
Primary aldosteronism Phaeochromocytoma Cushing syndrome Renal parenchymal disease Renovascular disease Congenital adrenal hyperplasia Hyperthyroidism Myxoedema Coarctation of the aorta
Describe the non-pharmacological management of hypertension.
Weight loss
Reduced salt intake
Stop smoking
Reduced alcohol intake
What is the first-line therapy for a 45 year old patient with hypertension?
Ramipril
What is the first-line therapy for a 76 year old patient with hypertension?
Amlodipine
What investigations should be conducted in a patient with hypertension?
Multiple blood pressure measurements
Urinalysis and urea:creatinine to measure renal function
Fasting lipids
TSH measurement if thyroid abnormalities
What are the overarching features of interstitial lung disease?
Chronic inflammation
Progressive interstitial fibrosis
What are the risk factors for interstitial lung disease?
Age and gender
Past medical history (radiotherapy-induced)
Drug history (amiodarone, methotrexate, bleomycin)
What is the typical presentation of interstitial lung disease?
Dyspnoea on exertion
Non-productive paroxysmal cough
What are the typical changes on CT in interstitial lung disease?
Honeycombing
Traction bronchiectasis
Mosaicism
Hilar lymphadenopathy
What are the typical examination findings in a patient with interstitial lung disease?
Clubbing
Reduced chest expansion
Fine end-inspiratory crepitations
Cor pulmonale
What investigations are important in patients with interstitial lung disease?
FBC, CRP, ESR LFT for drug monitoring Calcium levels anti-GBM if haemoptysis is present ACE if sarcoid IgG for specific precipitation RhF in rheumatoid arthritis HIV if relevant Oxygen levels Urinalysis ECG Imaging Pulmonary function tests
What are the typical changes in pulmonary function tests in interstitial lung disease?
Reduced: TLCO DLCO FVC TLC Restrictive pattern
Describe the management of interstitial lung disease.
Remove the cause if there is one Prednisolone/methotrexate Transplantation if young and fit Treat infections early (may be atypical) Oxygen therapy Stop smoking
Give some of the more common interstitial lung diseases.
Idiopathic pulmonary fibrosis SLE Rheumatoid arthritis Sarcoidosis Asbestosis
What are the most common causative organisms in community acquired pneumonia?
Streptococcus pneumoniae
Haemophilus influenzae
Mycoplasma pneumonia
What are the most common causative organisms in hospital acquired pneumonia?
Enterobacteria
Staphylococcus aureus
Pseudomonas
Who is at increased risk of aspiration pneumonia?
Stroke Dementia Myasthenia gravis Reduced conciousness GERD Achalasia Poor dental hygeine
What are the most common causative organisms in patients who are immunocompromised?
Streptococcus pneumoniae Haemophilus influenzae Staphylococcus aureus Moraxella catarrhalis Mycobacteria pneumoniae Gram negative bacilli
What are the most common causes of viral pneumonia?
Influenza
Measles
CMV
Varicella zoster
What are the symptoms of pneumonia?
Fever, rigors, malaise, anorexia Dyspnoea Cough Sputum Haemoptysis Pleuritic chest pain Confusion (may be only sign in elderly)
What are the common signs found on examination of. someone with pneumonia?
Diminished expansion Dull percussion Increased vocal fremitus Bronchial breathing Tachycardia, tachypnoea, hypotension, pyrexia May have cyanosis
What investigations should be done in pneumonia?
Oxygen saturation
FBC, U+E, LFT, CRP
Blood/sputum culture and microscopy
Sample and culture pleural fluid if present
Bronchoscopy and/or bronchoalveolar lavage if immunocompromised or ITU
Describe the CURB-65 scoring system.
Confusion Urea >7mmol/L Respiratory rate >30/min BP <90/60 Age >65
Describe the management of pneumonia.
Oral antibiotics (amoxicillin/doxycycline/..)
Oxygen to maintain O2 sats >94%
IV fluids to combat anorexia, dehydration, shock
Analgesia if they have pleurisy
What is the mechanism of action of doxycycline?
Inhibits protein synthesis
What are the side effects of doxycycline?
Blood disorders
GI disturbance
Tinnitus
What is the mechanism of action of gentamicin?
Inhibits the 30S ribosome to reduce protein synthesis
What are the serious side effects of gentamicin?
Ototoxic
Nephrotoxic
Peripheral neuropathy
What is the mechanism of action of ceftriaxone?
Inhibits bacterial wall synthesis
What are the side effects of ceftriaxone?
Dizziness Diarrhoea Superinfection Anaemia Increased bleeding with anticoagulants
What is the mechanism of action of metronidazole?
Inhibits nucleic acid synthesis by disrupting DNA
What are the serious side effects of metronidazole?
Hepatotoxic
Peripheral neuropathy
What is the most likely type of respiratory failure in pneumonia?
Type 1 respiratory failure
What are the common complications in pneumonia?
Hypotension Respiratory failure Atrial fibrillation Pleural effusion Empyema Lung abscess Sepsis
In pneumonia patients, what are the potential reasons for a chest x-ray that isn’t clear 6 weeks after discharge?
Complications (empyema/abscess)
Host (immunocompromised)
Antibiotics (inadequate or inappropriate)
Organism (resistant or unexpected)
Second diagnosis (pulmonary embolism, cancer, organising pneumonia)
When might a tuberculin skin test give a false negative?
Immunosuppression
Miliary TB
Sarcoidosis
Lymphoma
What are the common chest x-ray changes in tuberculosis?
Upper lobe consolidation
May have cavitation
Areas of fibrosis and calcification
How is tuberculosis diagnosed?
Sputum ZN staining
Why is tuberculosis culture important even though it can take up to 12 weeks?
Identification of rifampicin or multidrug resistance
What is seen on histology in a tuberculosis infection?
Caseating granuloma
Epithelioid cells
Langhans giant cells
What is the typical antibiotic regime in tuberculosis?
Rifampicin and isoniazid for 6 months
Pyrazinamide and ethambutol for 2 months
What are the side effects of rifampicin?
Hepatoxic
Thrombocytopaenia
Orange secretion
What are the side effects of isoniazid?
Hepatotoxic
Leukopaenia
Neuropathy
What are the side effects of pyrazinamide?
Hepatitis
Arthralgia
Precipitate acute gout
What are the side effects of ethambutol?
Optic neuritis
What should be tested during drug therapy for tuberculosis?
Colour vision
FBC
U+E
LFT
What is the most common presentation of tuberculosis?
Cough Sputum Malaise Weight loss Night sweats Pleurisy Haemoptysis Pleural effusion
What are the risk factors for peripheral vascular disease?
Age Hypertension Diabetes Dyslipidaemia Smoking Obesity Male
What is the most common presentation for peripheral vascular disease?
Intermittent claudication - pain, aching, cramping in the legs during walking which is relieved at rest
What is commonly found on examination in peripheral vascular disease?
Peripheral pulses diminished or absent Atrophic skin Non-healing wounds Gangrene Ulceration
What is LeRiche syndrome?
Buttock, thigh, calf claudication with erectile dysfunction due to aortoiliac peripheral arterial disease
What investigations can be useful in peripheral vascular disease?
Doppler ultrasound MRI angiography (if surgery considered)
Describe the management of peripheral vascular disease
Reduce modifiable risk factors Supervised exercise programmes Angioplasty Bypass surgery Major amputation
What investigations are useful in a patient with a pleural effusion?
Chest x-ray
Thoracentesis (colour, biochemistry, cytology, microbiology)
What are some causes of a transudate pleural effusion?
Liver failure, nephrotic syndrome, malabsorption, chronic infection (hypoalbuminaemia)
Constructive pericarditis, heart failure, fluid overload
Meig’s syndrome
Hypothyroidism
What are some causes of an exudate pleural effusion?
Rheumatoid arthritis, granulomatous disorders, SLE, pulmonary infarction
Bronchial carcinoma, metastases
Empyema, TB
Describe the management options for a pleural effusion.
If a clear transudative cause, treat this then wait for the effusion to resolve itself.
With exudative causes, insert a chest drain to gradually remove the fluid.
Permanent chest drain or pleurodesis if malignant cause.
What is the problem with draining pleural effusions too quickly?
It causes pulmonary oedema
Who is most at risk of a primary spontaneous pneumothorax?
Tall
Male
Smoker (especially cannabis or heroin)
What are the causes of. a secondary spontaneous pneumothorax?
Cystic fibrosis COPD Pneumonia Diving Trauma Ehlers-Danlos Marfans
Describe the intervention in a primary pneumothorax.
If >2cm, aspirate and discharge
If <2cm, insert a chest drain
Describe the intervention in a secondary pneumothorax.
If >2cm, insert a chest drain and admit. Give oxygen therapy.
If a patient has a narrow-complex tachycardia and is haemodynamically unstable, what is the management?
Electrical cardioversion immediately
If a patient has narrow-comlex tachycardia and is haemodynamically stable, what is the management?
Valsava manoeuvre
Carotid sinus massage
Adenosine
What broad-complex tachycardias can be terminated with adenosine?
Supraventricular tachycardia with abberancy
Wolff-Parkinson-White syndrome (antidromic)
Supraventricular tachycardia with bundle branch block
What is the long term management of a narrow-complex tachycardia?
Bisoprolol
Flecainide (pill in pocket or regular)
Verapamil
Amiodarone (rarely)
Ablation if medical therapy is insufficient.
What should you treat any regular broad-complex tachycardia as?
Ventricular tachycardia
What are the risk factors for venous thromboembolism?
Immobility Recent surgery Flight more than 4 hours Pregnancy Combined oral contraceptive pill Cancer Obesity Fracture History of VTE
How can a deep vein thrombosis be confirmed?
Doppler ultrasound
D-dimer testing
What are the Well’s criteria for pulmonary embolism?
Clinical signs and symptoms of DVT PE is number 1 diagnosis or equal HR over 100bpm Immobilised >3 days or surgery within 4 weeks Previous DVT/PE Haemoptysis Malignancy <6 months or palliative
What are the symptoms of pulmonary embolism?
Acute onset shortness of. breath Pleuritic chest pain Haemoptysis Syncope Sense of impending doom, anxiety Tachypnoea Tachycardia Accentuated second heart sound Fever Cyanosis
What investigations are important with a suspected pulmonary embolism?
CT pulmonary angiogram D-dimer Acid-base status ECG to rule out MI Chest radiography (can be suggestive and rule out cause
What are some differential diagnoses for unilateral leg swelling?
Deep vein thrombosis Lymphoedema Varicosities Lymphoedema Cellulitis Baker's cyst
What is the acute management of a pulmonary embolism if there is haemodynamic stability?
Dalteparin
What is the long-term prevention of a pulmonary embolsim
Warfarin
Rivaroxaban
Apixaban
What is the acute management of a pulmonary embolism if there is haemodynamic instability?
Alteplase
Reteplase
Streptokinase
Urokinase
What are the options for the management of a pulmonary embolism where thrombolysis is contraindicated or treatment has failed?
Embolectomy
IVC filter
What can be used for thromboprophylaxis in pregnant women?
Heparin
warfarin crosses the placenta
What type of lung cancer typically causes obstruction and is detected before metastasis?
Squamous cell carcinoma
What type of lung cancer is most likely to cause excessive mucus secretion?
Adenocarcinoma
Where do adenocarcinomas arise from?
Mucus cells of the bronchial epithelium
Why are small cell carcinomas able to present in a wide variety of ways?
They arise from enterochromaffin cells which are able to produce a range of polypeptides
What is the most common presentation of lung cancer?
A persistent cough
How does a pancoast tumour typically present?
With severe pain and weakness in the shoulder, inner surface of the arm, and weakness in the hand due to compression of C8, T1, and T2
Explain how a lung cancer can cause Horner’s syndrome
A central posterior tumour can compress the sympathetic chain at or above the stellate ganglia
What is the presentation of Horner’s syndrome?
Ptosis, miosis, dilation lag
Also have anhydrosis in half of the face but this is hard to detect
What is the presentation of superior vena cava syndrome?
Early morning headache
Oedema of the upper limb
Distention of the veins in the neck and chest
Facial congestion
How do liver metastases typically present?
Painless jaundice
Pruritis
How do bone metastases typically present?
Severe bone pain
Pathological fractures
Compression of the spinal cord
If a patient with lung cancer had metastases to their spine, what symptoms would you expect them to develop?
Back pain
Urinary retention
Saddle-pattern sensory loss
What type of lung cancer is most likely to cause endocrine complications?
Small cell lung cancer
What are the ymptoms or signs of hyponatraemia?
Nausea Malaised Reduced conciousness Seizure Coma
Describe SIADH seen in lung cancer.
The ectopic production of ADH by the tumour increases water retention by the kidneys and can cause hyponatraemia. The fluid overload can be negated by limiting the water intake.
How can lung cancer cause Cushing’s syndrome?
The tumour can produce ACTH ectopically which increases the amount of corticosteroids produced by the adrenal glands.
Describe the typical presentation of a patient with lung cancer causing Cushing’s syndrome.
Weight gain
Acne
Thin skin
Increased pigmentation
How can lung cancer cause hypercalcaemia?
Ectopic production of PTHrP (parathyroid hormone related peptide) which stimulates the parathyroid glands, increasing the release of calcium from bones as well as calcium retention in the kidneys.
What type of lung cancer is most likely to cause hypercalcaemia?
Squamous cell carcinomas
What is the likely presentation of a lung cancer patient with PTHrP secretion?
Renal stones Constipation Depression Polyuria Psychosis
What are paraneoplastic syndromes?
Conditions which are non-neoplastic and non-endocrine that occur alongside malignancy
Give some examples of paraneoplastic syndromes seen in patients with lung cancer.
Polyneuritis Cerebellar degeneration Lambert-Eaton syndrome Hypertrophic pulmonary osteoarthropathy Clubbing Carcinoid syndrome
What is polyneuritis?
Inflammation of the myelin sheath which is caused by autoantibodies. It can present with any neurological symptom and is irreversible.
What is the presentation of cerebellar degeneration?
Cerebellar ataxia with a typical gait, clumsy movement of the arms and legs, slurred speech, nystagmus
What is Lambert-Eaton syndrome?
Myasthenia gravis-like symptoms caused by autoantibodies that are triggered by the lung cancer
What is hypertrophic pulmonary osteoarthropathy?
Joint stiffness with pain in the wrists and ankles which may be accompanied by gynaecomastia, caused by lung cancer. It is associated by clubbing of the fingers.
What is carcinoid syndrome?
Hepatomegaly, flushing, and diarrhoea caused by the secretion of serotonin and kallikreine.
What might be found on examination in a patient with lung cancer?
Nothing Pleural rub Stony dull percussion (pleural effusion) Axillary lymph node enlargement Absent breath sounds and dull percussion at the lung bases if there is phrenic involvement
What should be covered by a staging CT for lung cancer?
Liver
Adrenal glands
Brain
What is the most accurate scan for staging lung cancer?
PET scan
When should a bronchoscopy done in lung cancer?
Tumours which are 10cm around the hilum
Biopsy of mediastinal lymph nodes
What blood-related investigations would you want to do in lung cancer and why?
FBC - anaemia is common
LFT - check for liver involvement
Blood biochemistry - hyponatraemia indicates adrenal involvement, hypercalcaemia indicates bone involvement
What staging system is used for lung cancer?
TNM
Describe the WHO performance status.
- Fit and active
- Fit but unable to work
- Up for more than 50% of the day, able to self care
- Up for less than 50% of the day, able to self care
- Bed bound, unable to self care
- Dead
What are the treatment options for a patient with stage 1 lung cancer?
Surgical resection
What are the treatment options for a patient with stage 2 lung cancer?
Surgical resection (although likely to have metastases)
What are the treatment options for a patient with stage 2a lung cancer?
Surgical resection with adjuvant chemotherapy
What are the treatment options for a patient with stage 4 lung cancer
Chemotherapy
What are the categories of small cell lung cancer, and why are they different to non-small cell lung cancer?
Limited -. confined to one lung or hemithorax, may have spread to unilateral lymph nodes
Extensive -. distant metastases
It is very aggressive so metastasises early.
What is the mainstay of treatment for small cell carcinoma?
Chemotherapy
What limits patients having surgery for lung cancer?
Maximum T2N1M0
Must have a WHO performance status between 0 and 2