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Cardiorespiratory Flashcards

1
Q

Give an example of a class 1a and 1b anti arrhythmic and what it might be used for.

A

A Quinidine
B lidocaine

Both for vt and vf

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2
Q

Give an example of a class 1c anti arrhythmic and what it might be used for.

A

Flecainide

Paroxysmal AF
Rentrant rhythms e.g. WPW

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3
Q

Give an example of a class 2 anti arrhythmic and what they might be used for.

A

Beta blockers
Bisoprolol or atenolol

Post MI
Angina
AF

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4
Q

Give an example of a class 3 anti arrhythmic and what they might be used for.

A

K channel blockers e.g. Amiodarone. Or sotalol at high dose has class 3 effects

VT or VF
Chemical cardioversion
SVT

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5
Q

Give an example of a class 4 anti arrhythmic and what they might be used for.

A

Calcium channel blocker eg Verapamil, diltiazem, amlodipine

Fast AF
SVT
Hypertension

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5
Q

What are the main 5 side effects of beta blockers?

A

Vagal GI disturbance - vomiting, diarrhoea, abdo pain, anorexia.
Bradycardia
Exacerbation of Reynauds and Claudication
Bronchospasm
Dizziness/ postural hypotension

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6
Q

What are the contra indications to beta blockers?

A

Asthma
Bradycardia/ hypotension
Heart block

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7
Q

Which ca channel blocker works more on the blood vessels than the myocardium?

A

Amlodipine

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8
Q

What are the indications for GTN spray?

A

Stable angina

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9
Q

What are the contra indications for ca channel blockers?

A

Heart failure - verapamil contraindicated. Can give amlodipine
Beta blockers - verapamil contraindicated
Heart block

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10
Q

What are the indications for IV gtn?

A

Unstable angina

Acute heart failure

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11
Q

What are the side effects of gtn?

A

Tolerance
Postural hypotension
Headache
Dizziness

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12
Q

What are the 4 effects of ACE inhibitors?

A

Inhibits angiotensin 2 therefore

  1. Decreases sympathetic
  2. Direct vasodilation
  3. Decrease aldosterone - decrease in Na (and fluid) retention via ENac
  4. Decrease ADH - decrease in fluid (and Na) retention via removal of Aquaporin2 channels from the apical membrane of collecting ducts.
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14
Q

What are the effects of ACE in CKD and AKI?

A

Protective in CKD by reducing the workload

Toxic in AKI by causing renal artery constriction

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15
Q

What are the indications for ACE inhibitors?

A

Hypertension (unless old, black, diabetes)
Heart failure
Post MI
CKD - especially diabetic

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16
Q

What are the side effects of ACE inhibitors?

A 
Dry cough
Angio oedema
Hyperkalaemia
Pancreatitis 
Renal impairment
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17
Q

What are the contra indications for ACE inhibitors?

A

Renal artery stenosis
Aortic stenosis
Pregnancy

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18
Q

What is furosemide and where does it act?

A

Loop diuretic.

Na k cl transporter in the thick ascending loop of henle

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19
Q

What are the indications for furosemide?

A

Symptomatic relief of pulmonary oedema
Refractive hypertension
CKD
Nephrotic syndrome

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20
Q

What are the common side effects of furosemide?

A 
Hypokalaemia
Hyponatraemia 
Low ca and mg
Metabolic alkalosis 
Hypovolaemia
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21
Q

What monitoring is required for furosemide?

A

Regular u and e for k and Na levels

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22
Q

What is bendroflumethiazide and where does it act?

A

Thiazides diuretic

Na cl channel on the distal convoluted tubule

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23
Q

What indications for bendroflumethiazide?

A

pulmonary oedema in heart failure

Second/third line in hypertension

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24
Q

What are the side effects of bendroflumethiazide?

A

Hypokalaemia
Hyponatraemia
Low ca and mg
Hyperglycaemia metabolic alkalosis

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25
What is spironolactone and where does it Act?
K sparing diuretic | Aldosterone antagonist
26
What are the indications for spironolactone?
Heart failure Liver failure Offset loop or thiazides
27
What are the side effects of spironolactone?
``` Gynaecomastia Impotence Menstrual problems Lethargy GI Hyperkalaemia ```
28
What is the mechanism of action of statins?
HMG co a reductase inhibitors Inhibit liver synthesis of Cholesterol. Upregulates ldl receptors so that more is absorbed out of the circulation
29
Give some side effects of statins
``` Hepatitis Myositis Rhabdomyelisis Parasthesia Headache ```
30
What are the contra indications for statins?
Cirrhosis/ liver disease | Pregnancy
31
What should be monitored when on a statin?
LFTs - hepatotoxic
32
Why should statins be taken in the evening?
Most cholesterol synthesis occurs when dietary intake is low.
33
What is gemfibrozil? Why might it be given? When should it not be given?
Fibrate Lowers triglycerides more than ldl. Can't be given with a statin because it increases the risk of rhabdomyelisis
34
What are the contraindications to adenosine?
Haemodynamically unstable - go straight to cardioversion of presumed VT Asthma
35
What is the effect of adenosine in a narrow complex tachycardia?
Returns to normal if AVNRT / SVT | Or will reveal atrial tachy/ AF / atrial flutter
36
What is the effect of adenosine in a broad complex tachycardia?
Testing a Broad complex tachy to see if it is vt or SVT with aberrancy If the rhythm goes back to normal it is SVT with aberrancy.
37
Which drugs can be cardio toxic?
Digoxin Na blockers -Tricyclics, lidocaine, carbamazepine, class 1 anti arrhythmic K blockers - citalopram, erythromycin, antihistamines, amiodarone, antipsychotics
39
How is atherosclerosis formed?
``` Endothelial damage LDL oxidation and accumulation in intima Taken up by macrophages- foam cells Cytokines released - platelet aggregation, fat and smooth muscle proliferation Lipid core and fibrous cap. ```
40
What happens to an atherosclerotic plaque to cause an acute coronary syndrome?
Rupture Platelet aggregation and adhesion Localised thrombus concludes the vessel
41
Which group of patients commonly present with silent MI? How does it present?
Diabetics and elderly No chest pain. Week long history of breathlessness. Can progress into pulmonary oedema due to acute heart failure.
42
What causes a raised troponin? (5 things)
``` MI PE Pericarditis Sepsis Tachyarrhythmias ```
43
How long after an MI does the troponin increase? How long before it comes down?
6-14 hrs after onset. | Remain high for 14 days
44
How long after an MI does the creatinine kinase rise? Hoe long does it stay high?
4 hours | Falls within 72 hours
45
What are the criteria for an acute MI?
Raised biochemical marker plus one of - Ischaemic symptoms Pathological q waves St elevation/depression
46
How do the ecg changes develop in a STEMI?
ST depression and T wave inversion ST elevation and pathological Q Q waves persist
47
List the investigations you would order for a suspected MI and give a reason for each.
1. Fbc - anaemia can precipitate MI in angina 2. U and e - Possible AKI due to poor perfusion in MI. Also MI is a proarrhythmic state and hyperkalaemia is a big risk. 3. Troponin and creatinine kinase 4. LFTs 5. Glucose and lipids - need to keep tight control of risk factors. 6. CXR - widened mediastinum of aortic dissection - do not thrombolyse!!! Hypertrophy- HF. Pulmonary oedema can form after a few hours of MI as it causes acute HF 7. ECG - to identify MI
48
Where is the MI located if ST elevation is seen in leads v1-4?
Anterior | LAD
49
Where is the MI located if ST elevation is seen in leads II, III and AVF?
Inferior | RCA or circumflex
50
Where is the MI located if ST elevation is seen in leads v4-6, aVL and I?
Lateral | Circumflex
51
Where is the MI located if ST elevation is seen in leads v1-6?
Anterolateral | Proximal LAD/ left main stem
52
What are the pathological differences between STEMI, nstemi, unstable angina, angina?
STEMI - complete occlusion of artery by thrombus and full thickness infarct. Troponin positive NSTEMI - partial occlusion of artery by thrombus - partial thickness infarct or infarct in small vessel. Troponin positive (mild) Unstable angina - partial occlusion of artery by thrombus. No infarct. Troponin negative. Angina - no thrombus. Partial occlusion by atheroma. Relieved by rest.
53
What are the complications associated with an MI?
Ischaemic - recurrence, angina Mechanical - aneurysm, heart failure, mitral regurgitation, ruptured papillary muscles, cardiogenic shock, embolism Arrhythmia Dresslers - pericarditis
54
Where is the MI located if ST depression is seen in leads v1-2?
Posterior Right coronary Do v7 8 and 9 to confirm
56
Describe the management of an acute MI
``` MONA 5-10mg morphine IV with 10mg metoclopramide Oxygen - 15L via non rebreather mask GTN - 2 puffs sublingual Aspirin 300mg ```
56
What is the difference between the type of clots found on a mechanical heart valve and in IHD? What is the significance?
Mechanical heart valve - fibrin rich IHD- platelet rich Antifibrin - warfarin Antiplatelet - prasugrel/ticagrelor/clopidogrel
57
What are the contra indications for thrombolysis in an acute MI?
``` Recent stroke or GI bleed Brain tumour Bleeding disorder Aortic dissection (Pregnancy, warfarin) ```
58
What are the complications of thrombolysis?
``` Bleeding Hypotension Intracranial haemorrhage Embolism Allergic reaction ```
59
Give 3 causes of AF
IHD Hyperthyroidism Valvular disease Plus previous cardiac surgery, sleep Apnoea, caffeine
60
Which scores would you use in tandem to decide whether to anticoagulate a patient with AF?
CHADSVAS | HASBLED
62
How would you initially treat an anaphylactic reaction?
``` Oxygen Fluid 100mg hydrocortisone IV Adrenaline 0.5mg every 5 mins 10mg chlorpheniramine IV Protect airway - consider intubating ```
63
What tests would you request in an anaphylactic reaction?
``` General observations BM Abg for lactate Chest x Ray CT head if loss of consciousness ```
64
What can cause a positive D Dimer?
``` PE Pregnancy Surgery Trauma Infection Hepatorenal disease Cancer ```
65
Which systems are affected by cystic fibrosis?
Respiratory - thickened mucus, recurrent infection, bronchectasis Pancreas - enzymes and insulin GI - malabsorption, steattorea and low body weight due to low pancreatic enzymes Reproductive - males due to cftr in vas deferens. Females have 70-80% fertility due to cftr in Fallopian tube.
66
What is creon?
Pancreatic enzyme replacement for cf patients
67
What are the radiological signs of left sided heart failure?
``` A - a large heart B - batwing oedema C - Kerley B lines D - dilated upper lobe vessels E - effusion F - fluid in the fissure ```
68
What are the emergency complications associated with cystic fibrosis?
Recurrent infection Pneumothorax Hypersensitive drug reactions Meconium ileus / DIOS distal intestinal obstruction syndrome
68
What is different about cf associated diabetes?
Transient insulin levels (go up and down) | Requires insulin treatment
68
What lifestyle advice would you give to a patient with cf?
``` Stay away from other cf patients Don't smoke Avoid people with colds Avoid jacuzzis- pseudomonas Avoid stables and compost aspergillus fumigatus Flu jab ```
68
Which drugs are given to a patient after an MI?
``` Bisoprolol Aspirin Ramipril Atorvastatin Prasugrel (STEMI) Ticagrelor (nstemi) ```
69
What is Dressler's syndrome?
Autoimmune pericarditis triggered by a recent MI. | Treat with steroids.
70
What causes acute left ventricular failure?
``` MI Hypertension Aortic stenosis Aortic regurgitation Mitral regurgitation ```
71
How does acute L ventricular failure present?
``` Breathless Cough Frothy pink sputum Orthopnoea and pnd Arrest ``` Tachy Fine bilateral crepitations 3rd heart sound - gallop rhythm
72
Which drugs actually improve morbidity in heart failure? Which are for symptomatic relief?
Morbidity- spironolactone, beta blocker. Symptoms - loop diuretic, ACE inhibitors, nitrates, ionotropes - dopamine, digoxin
73
What is a normal/abnormal ejection fraction?
Normal is above 50% | Borderline - 41-50
74
How does heart failure present on a chest x Ray?
``` Batwing oedema Pleural effusion Fluid in the fissure Kerley B lines Upper lobe blood vessel dilation ```
75
Give some differentials for palpitations
``` Arrhythmia - AF, flutter, wpw, ectopics, avnrt, SVT, long qt Anxiety - sinus tachycardia Hyperthyroidism Caffeine Hypertrophic cardiomyopathy ```
76
Give some differentials for haemoptysis.
``` Lung cancer Pneumonia/ TB Bronchiectasis PE Lung abcess Vasculitis ```
77
Give some differentials for shortness of breath
Asthma/ COPD Pneumonia/ TB Pneumothorax/ pleural effusion PE Pulmonary oedema / heart failure Arrhythmia Valve disease
78
Give some differentials for pleuritic chest pain.
``` PE Pneumothorax Pleural effusion/ empyema Endocarditis Irritation of diaphragm Gastric reflux ```
79
Which antibiotic is used for a septic patient?
Meropenem
81
Which antibiotic is given to a curb 3-5 pneumonia?
Co amoxiclav and doxycycline Or Meropenem and doxycycline
82
What is CURB 65? What does it stand for?
``` Measure of severity of pneumonia C - confusion U - urea above 7 R - Resp rate above 30 B - bp below 90/60 65 years or older ``` Score 1 for each
83
What is the follow up for a patient with pneumonia following discharge?
Chest X-ray in 6 weeks.
84
What are the causes of copd?
Smoking Alpha 1 anti trypsin Industrial exposure - soot
85
What is the pathophysiology of emphysema?
Alveolar wall destruction - irreversible enlargement of airspaces distal to terminal bronchioles. Bulla formation. Loss of surface area for gas exchange.
86
What is the outpatient care bundle for copd?
Smoking cessation Pulmonary rehab to break the deconditioning cycle Bronchodilators - salbutamol or ipratropium Steroids - fluticasone Mucolytic - carbocysteine
87
How long must oxygen therapy be used per day to have a survival benefit?
16 hours
88
When is long term oxygen therapy offered for copd?
pO2 below 7.3 or below 8 with cor pulmonale
89
Why is it important to check the ankles in a respiratory examination?
Cor pulmonale - right heart failure caused by pulmonary hypertension from lung pathology
90
What is the care bundle for acute copd exacerbation?
Venturi mask for controlled oxygen therapy - 88-92 sats Salbutamol and ipratropium nebs Prednisolone 30mg stat and OD for 7 days Consider NIV if becomes acidotic 7.25-7.35 Below 7.25 call ITU
91
How are pack years calculated?
Packs of 20 each day x years of smoking So 10 a day for 5 years is 1/2 x 5 = 2.5 pack years
92
What is the pathophysiology of chronic bronchitis?
Mucous gland hyperplasia | Chronic inflammation of the bronchi
93
What is the pathophysiology of bronchectasis?
Chronic dilatation of the bronchi Mucous plugging Damage to ciliary escalator - recurrent infection Haemoptysis due to damage to the bronchial arteries
94
What is the pattern of spirometry in copd?
Obstructive pattern Scooped out edge Reduced fev1 /fvc (less than 70%) and reduced fev1 (less than 80%)
95
What is the role of pulmonary rehab in copd patients?
Break the cycle of deconditioning
96
Give 5 causes of non resolving pneumonia
``` Empyema Immunocompromise PE Cancer Wrong dose/wrong antibiotic Organising pneumonia ```
96
What organisms commonly cause hospital acquired pneumonia?
Staph aureus - MRSA | Pseudomonas aeruginosa
96
What organisms are commonly found in infections in CF patients?
Staph aureus - MRSA Pseudomonas aeruginosa Haemophillus influenza Burkholderia cepacia
96
Which copd treatments affect survival?
Long term oxygen therapy - 16 hours a day at least NIV if acidotic Smoking cessation
97
What organisms commonly cause community acquired pneumonia?
Strep pneumoniae Haemophillus influenza Group A strep - like strep throat - pyogenes
99
Why is uncontrolled oxygen therapy dangerous in copd patients?
The choroid plexus has reset to accept a hypercapnia so that it is no longer the main driver for respiratory effort. Instead hypoxia is the main driver so needs to be maintained. Also there is hypoxic vasoconstriction in copd to maximise the perfusion to well sventilated areas. So there is a compensatory v/q mismatch. Too much oxygen causes these areas to reperfuse even though they are inefficient at gas exchange so the compensation is overridden.
101
What questions would you ask a patient with asthma?
Diurnal variation? (Worse in morning and night) Atopy? (Hay fever, allergy, eczema) Ever been in ICU?
102
What are the definitions for mild moderate severe life threatening and near fatal asthma?
``` Mild - over 75% peak flow Moderate - 50-75% Severe - 33 - 50% Life threatening- less than 33% Near fatal - rise in co2 ```
103
What is the significance of eosinophilia in a patient with asthma?
Aids diagnosis - Indicates atopical traits | Generally responsive to steroids
108
Give some differentials for a pleural effusion
``` Usually transudate - Heart failure - congestive Nephrotic syndrome Glomerulonephritis SVC obstruction Cirrhosis ```
109
Give some differentials for pulmonary oedema.
Exudative - pneumonia, PE, lung cancer Transudative - heart failure,cirrhosis, nephrotic syndrome Other - MI, valve disease, tamponade, dissection, fluid retention
110
What might cause a transudate effusion?
Heart failure Cirrhosis Nephrotic syndrome
111
How would you treat a new Left bundle branch block?
As a STEMI
112
Give some causes of ST elevation
``` STEMI Pericarditis- diffuse st elevation with saddle shape Coronary artery spasm PE Hyperkalaemia ```
113
Give 4 causes of coarse crepitations
Pneumonia Bronchiectasis TB Cystic fibrosis
114
Describe the classic ecg of PE
S1-Q3-T3 Large S in I Q inversion in III T inversion in III Although generally just a sinus tachycardia
115
Describe the classic ecg of hyperkalaemia
Tall tented T Flat p Broad qrs Slurring into a sine wave
116
Give 3 causes of fine crepitations
Pulmonary oedema ILD/fibrosis Chronic bronchitis
117
Give 5 respiratory causes of clubbing
``` Lung cancer Cystic fibrosis Bronchiectasis Lung abcess ILD ```
118
Give 5 non respiratory causes of clubbing
Congenital heart defects, Infective endocarditis Cirrhosis Celiacs Crohns Hyperthyroidism
119
Give 6 signs of infective endocarditis
``` Clubbing Splinter haemorrhage Osler nodes and janeway lesions Changing heat murmur Microscopic haematuria Roth spots ```
120
Give 5 ways that lung cancer can present
``` Asymptomatic/ incidental findings Haemoptysis Horners Superior vena cava obstruction Mets / paraneoplastic ```
121
Give 5 risk factors for lung cancer
``` Smoking Family history Copd ILD Exposure to asbestos ```
122
What is the WHO performance status scale?
``` 0 - normal 1 - able to do lîght work 2 - ambulatory and self caring 3 - some self care. confined to bed/chair for 50% waking hours 4 - cannot self care. Confined to bed. 5 - dead ```
123
What are the treatment options for stage 1-2 lung cancer?
Curative surgery | Curative CHART radiotherapy
124
What are the treatment options for stage 3-4 lung cancer?
Chemo | Palliative radiotherapy
125
What is the 5 year survival rate for lung cancer?
13%
126
Describe the ecg of pericarditis
Diffuse st elevation with no regional pattern | Saddle qrs
127
Describe the ecg of digoxin toxicity
Inverted reverse tick T | Plus or minus AF
128
What might cause an exudate effusion?
Infection Cancer PE
129
What is the difference between a transudate and an exudate?
Lights criteria - Exudate if effusion/serum protein ratio greater than 0.5 Or effusion/serum LDH ratio greater than 0.6
130
What hormone is commonly secreted by a bronchial squamous cell carcinoma? What about a small cell carcinoma?
Squamous - PTH | Small cell - ADH and acth - cortisol
131
What are the 2 main types of lung cancer?
Small cell | Non small cell - inc squamous and adenocarcinoma
132
How does ILD present?
Dry non productive cough Exertional progressive sob ?exposure to methotrexate, nitrofurantoin, amiodarone ?exposure to asbestos
133
What are the signs of ILD?
Late inspiratory fine crackles | Clubbing
134
What causes early inspiratory and expiratory fine crackles?
Alveoli pop open early because there is hyperinflation COPD - chronic bronchitis
135
What causes late inspiratory fine crackles?
Alveoli popping open late after being held shut by fibrosis/oedema/negative pressure ILD Pneumonia Pulmonary oedema Atelectasis - collapsed lung
136
What causes early inspiratory coarse crackles?
Excess fluid on the lung Pulmonary oedema Bronchiectasis CF Pneumonia
137
What causes a polyphonic vs a monophonic wheeze?
Mono- single obstruction | Poly - general bronchial obstruction
138
What causes an expiratory wheeze?
Asthma | COPD
139
What causes an inspiratory wheeze?
Stiff stenosis - cancer, scarring
140
What causes a pleural rub? What does it sound like?
Pleurisy Pneumothorax Pleural effusion Walking in snow
141
What do you normally hear in a pleural effusion?
Reduced/absent breath sounds | Can have a pleural rub
142
What are the causes of ILD?
Idiopathic- ipf Drugs - methotrexate, amiodarone, nitrofurantoin Rheumatoid- sarcoidosis, SLE, arthritis, sjrojens. Occupational - asbestos, soot
143
What are the radiological findings in ILD?
CXR- Reticular nodular opacities | CT - honeycombing or ground glass
144
What is the spirometry pattern in ILD?
``` Restrictive Reduced FVC (less than 80) but normal fev1 ```
145
What might cause central cyanosis?
Desaturation of central arterial blood. Colour is caused by desaturated haemoglobin. Severe lung disease - COPD, acute severe asthma, PE, severe pneumonia, high altitude Right to left cardiac shunt (some blood avoids the lungs) - fallots, pda Abnormal haemoglobin (doesn't uptake o2) - genetic or drug induced - quinones, sulfonamides.
146
What might cause peripheral cyanosis?
``` Central cyanosis Vasoconstriction- reynaud, beta blockers Reduced cardiac output - heart failure, shock Peripheral arterial disease Peripheral venous disease ```
147
Why might sats be normal but pa02 down?
Anaemia All the existing haemoglobin is saturated, there is just not enough of it to maintain o2 levels so they are hypoxic. They may not be cyanotic.
148
Which patient groups should have especially tight control of hypertension?
Those with existing cardiovascular risk factors ``` Hyper cholesterol Smoking CKD Diabetes Previous IHD Rheumatoid arthritis ```
149
Why might the sats be down but the pa02 normal?
Polycythaemia - Increased rbcs measured by an increase in haematocrit Not all haemoglobin may be saturated and therefore some deoxygenated haem causes cyanosis. But there is so much in total that the pa02 is normal and they are not hypoxic.
150
Is cyanosis related to sats or pa02? Which is more important?
Cyanosis is a sign of low sats because the colour comes from deoxygenated haemoglobin. Pa02 is more important because it is a marker of o2 that reaches the tissue.
151
What is the definition of hypertension?
140/90
152
What mechanisms might cause secondary hypertension?
Raised sympathetic drive - increases renin - increases raas activation Decreased perfusion to nephron - increases renin - increase raas activation Decreased egfr - decreases Na cl in Dct - increases renin - increases rasa activation Increased aldosterone - increased Na uptake at enac channels
153
Give a lost of causes of secondary hypertension.
Horners Phaeochromocytoma Carcinoid syndrome Renal artery occlusion CKD Polycystic kidney disease Conn's - aldosterone secreting tumour Cushing's - high concentration cortisol acts on mineralocorticoid receptor
154
What complications are associated with hypertension?
LVH - HF Atherosclerosis- IHD, stroke Intracranial haemorrhage Peripheral vascular disease Aneurysm Nephropathy Retinopathy - aneurosis fugax
155
What investigations would you ask for to investigate secondary hypertension?
U and e and Renal ultrasound - renal function Then CT renal - renal artery stenosis Urinary catecholamines - phaeochromocytoma Urine cortisol and dexamethasone suppression- cushings
156
What signs and symptoms would make you suspect a secondary cause of hypertension?
Young - under 35 Greater than 180/110, retinopathy, HF at a young age Sweating, dizziness, tachycardia - high sympathetic Different bp in each arm - renal artery stenosis Cushingoid appearance
157
Describe the management of primary hypertension
Weight loss and exercise Reduce salt Reduce alcohol Address cardiac risk factors - smoking, cholesterol ACE - ramipril for under 55, not pregnant, not diabetic, not black. Otherwise ca channel blocker - amlodipine.
158
What is the difference between the ca channel blockers? What are they each used for?
All act on L type ca channels. Amlodipine - greater affinity when channels inactive - more often in blood vessels - used in hypertension Verapamil- greater affinity when channels open - more often in sa node - used in arrhythmia . Don't use in hf because decrease contractility in any open channels!! Diltiazem - more often in cardiac myocytes - used in angina
159
How is losartan different from ramipril?
Arb - angiotensin receptor blocker . Same effect except no effect on bradykinin Therefore decreased side effects - no dry cough or angio oedema
160
What is the appropriate follow up for a patient with hypertension?
Yearly checkup ``` End organ damage - fundoscopy, pulses Urine dip ECG U and e Cholesterol and lipid profile BM Echo if LVH ```
161
What is the significance of differentiation between small cell and non small cell lung cancer?
Small cell = Short history, aggressive, likely to metastasise quickly But chemo sensitive
162
What are the causes of angina symptoms?
``` Atherosclerosis Arteriospasm Aortic stenosis Anaemia Hyperthyroidism ```
163
What are the side effects of salbutamol?
Sympathetic agonist Tachycardia Palpitations Tremor Hypokalaemia
164
What type of drug is theophylline and how does it act?
Xanthine Antagonises sleepy adenosine just like caffeine
165
What side effects of theophylline?
Same as salbutamol.. Tachycardia Arrhythmia Tremor Hypokalaemia
166
How does tiotropium / ipratropium bromide work? What is the difference?
Both anticholinergics. Non specific but inhaled acts on M3 Tiotropium - spireva inhalerfor copd control Ipratropium - nebs for acute exacerbation
167
What are the side effects of ipratropium or tiotropium?
Anticholinergic... Urinary retention Constipation Tachycardia Palpitations
168
Give some differentials for syncope?
Cardiac - Tacchyarrthmia Bradyarrhthmia Stoke-Adams attack - transient asystole Outflow obstruction- aortic or pulmonary stenosis, pulmonary hypertension, hypertrophic cardiomyopathy Non cardiac ``` Epilepsy Hypo Postural hypotension Vasovagal - hyper stimulated vagus - av node block - Brady PE Sepsis ```
169
Give 3 causes of aortic stenosis
Bicuspid aortic valve - under 65 Age related calcification- over 65 (Rheumatic fever)
170
Give the main causes of aortic regurgitation
Rheumatic fever Infective Endocarditis Marfans Syphilis
171
Give the main causes of mitral stenosis
Rheumatic fever | Calcification from old age
172
Give the main causes of mitral regurgitation
Cardiomyopathy (any kind) Post MI papillary muscle rupture Rheumatic fever Connective tissue disorders - marfans, ehlers Danlos, osteogenesis imperfecta
173
What are the main types of cardiomyopathy?
Ischaemic - post MI heart failure Hypertrophic - genetic Dilated - genetic/viral/autoimmune/thyroid
174
What kind of history would make you suspect aortic stenosis?
Exercise induced syncope Then later (Angina, Dyspnoea)
175
What are the signs of aortic stenosis?
Slow rising pulse Narrow pulse pressure (difference between systolic and diastolic) Left sided heave
176
Describe the murmur of aortic stenosis
Ejection systolic Crescendo decrescendo Radiates to carotid Variable volume of first heart sound Lub whoosh. Dub
177
What indicates a severe aortic stenosis?
Absent 2nd heart sound Left sided heave Narrow pulse pressure
178
What is the mechanism of action of digoxin?
Blocks Na k atpase therefore blocking the av node
179
What is digoxin used for?
Not much. Potent av node blocker so useful in AF when there is a big difference between the apex and radial pulse.
180
What causes radioradial delay?
Coarctation of the aorta | Subclavian stenosis
181
Why must you measure an irregular pulse at the apex with the Stethoscope?
Some impulses are not transmitted fully as the refractory period is so quick, so the radial pulse is an underestimate.
182
What are the most common organisms associated with infective endocarditis?
Natural valve - Streptococcus viridans (from upper Resp tract) Prosthetic valve - Staph aureus
183
What makes up vegetation found in Endocarditis?
Fibrin rich Some platelets Adherence and colonisation of bacteria
184
Why is infective endocarditis so life threatening?
Host defences struggle to reach the vegetation because- No blood supply to valves Fibrin blocks them
185
What are the most common murmurs associated with endocarditis?
Aortic regurgitation | Mitral regurgitation
186
What are dukes major criteria for endocarditis?
Typical Organism found in 2 cultures or any Organism in 3 Plus Endocardial involvement- on echo or new regurgitation
187
What are dukes minor criteria for endocarditis?
Predisposition Fever over 38 Vascular signs Positive culture or echo that don't meet major criteria
188
Define infective endocarditis according to dukes criteria
2 major criteria 1 major 3 minor 5 minor
189
What causes a split second heart sound?
Young on inspiration - physiological Fixed - MI, cardiomyopathy, heart failure, hypertension
190
What is the empirical treatment for infective endocarditis?
Benzylpenecillin plus gentamicin Or Vancomycin plus gentamicin
191
What are the main risk factors for infective endocarditis?
``` IVDU Valve disease Congenital abnormality Prosthetic valve Previous endocarditis ```
192
What is a sign of LVH? What is a sign of cardiomegaly?
LVH - left sided heave | Cardiomegaly- displaced apex beat
193
What are the signs of mitral regurgitation?
Malar flush Displaced apex beat - Cardiomegaly Palpable thrill
193
Describe the murmur of mitral regurgitation
Pan systolic Radiates to axilla Rumbling
194
What are the signs of mitral stenosis?
AF Malar flush Loud 1 st heart sound
195
Describe the murmur of aortic regurgitation
High pitched early diastolic Like a cymbal Lub d tahhh Exaggerated left sternal edge on expiration
196
What are the signs of aortic regurgitation?
``` Collapsing pulse Wide pulse pressure Displaced apex beat - cardiomegaly Quincke's sign - capillary pulsation De Musset's sign - head bobbing ```
197
Describe the murmur of mitral stenosis
Rumbling low pitch mid diastolic murmur with an opening snap Exaggerate with the bell at apex leaning left Lub de derrrr
198
Describe the severity grading of COPD
FEV1 % predicted > 80% Stage 1 - Mild 50-79% Stage 2 - Moderate 30-49% Stage 3 - Severe < 30% Stage 4 - Very severe
199
What is Kartagener's syndrome?
dextrocardia or complete situs inversus bronchiectasis recurrent sinusitis subfertility
200
Give 4 causes of bronchiectasis
CF Post infective - TB, pertussis, pneumonia Ciliary dysmotility eg Kartagener's Allergic bronchopulmonary aspergillosis
201
What is the most common type of lung cancer in non-smokers?
Adenocarcinoma
202
What is your first differential for an ecg with a rate of 150?
Atrial flutter with 2:1 block
203
What are the differences between type 1 and type 2 respiratory failure?
Type 1 is low o2 Caused by Alveolar issues across the the membrane. Peripheral o2 chemoreceptors in the carotid and aortic arch trigger hyperventilation so co2 is blown off Eg, PE, pneumonia, ASD, VSD Type 2 is low o2 plus high CO2 Caused by pump failure as even though chemoreceptors are triggered, hyperventilation is not possible. Eg tiring in near fatal asthma, neuromuscular, opioids, obesity, COPD
204
How long is the window of opportunity to treat an MI with PCI?
2 hours | otherwise thrombolysis
205
How is torsades de pointes treated?
IV magnesium
206
Describe the ECG of hypokalaemia
In hypokalaemia U have no pot of T, but a long PR and a long QT U waves Absent T Long PR Long QT
207
What are the main causes of torsades de pointes?
Long QT Hypokalaemia Antipsychotics
208
How would you decide whether to use rate control or rhythm control for chronic AF?
Rate - elderly, hx of IHD | Rhythm - young, symptomatic, heart failure
209
What drugs are used to rate control AF?
``` Beta blockers (not sotalol) Ca channel blocker (verapamil or diltiazem) Digoxin ```
210
What drugs are used to rhythm control AF?
Sotalol Flecainide Amiodarone
211
What is the treatment for paroxysmal AF?
Flecainide | "Pill in pocket"
212
How would you treat acute fast AF?
Electrical cardioversion | or amiodarone if not available
213
What are the side effects of amiodarone?
Pulmonary fibrosis Hypo and hyperthyroid Heptatotoxic CYP inhibitor
214
What is amiodarone used for?
Chemical cardiovesion of: Acute fast AF (when electrical unavailable) VT VF
215
What are the causes of heart block?
Beta blockers Ca channel blockers Digoxin IHD Infiltrative - sarcoidosis, haemochromatosis Infective - endocarditis, Lyme disease
216
What are the contraindications to PCI for MI?
Onset of symptoms greater than 2 hours | Intolerance to antiplatelet
217
Which drugs are contraindicated in heart block?
Beta blockers Ca channel blockers Digoxin Amiodarone
218
How is heart block treated?
Pacemaker | Atropine if haemodynamcally unstable
219
What is the relevance of Starling's curve to heart failure?
Left ventricular dysfunction leads to decreased contractility of the heart (the gradient of the starling curve) This means that for any given end diastolic volume, there is a decreased cardiac output

Junior blocks (12 decks)

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