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MANCHESTER YEAR 3 > CardioRespiratory Prep > Flashcards

CardioRespiratory Prep Flashcards

1
Q

What are the 7 red flags associated with chest pain?

A
  1. exertional
  2. sudden onset
  3. breathlessness
  4. haemoptysis
  5. unintentional weight loss
  6. new onset dyspepsia (>55years)
  7. History of leg swelling, long haul flights, or immobility (PE)
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2
Q

What are some common differentials in someone presenting with chest pain?

A
  • stable angina
  • GORD
  • myocardial infarction (ACS)
  • pulmonary embolism
  • pneumothorax
  • aortic dissection
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3
Q

What are the 8 red flags associated with breathlessness?

A
  1. associated chest pain
  2. sudden onset
  3. visible physical signs = cyanosis or confusion
  4. stridor/audible wheeze
  5. worsening orthopnoea
  6. history of immobility
  7. unintentional weight loss
  8. hoarseness of voice
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4
Q

What are some common differentials in someone presenting with breathlessness?

A
  • asthma
  • pneumonia
  • COPD
  • interstitial lung disease
  • congestive cardiac failure
  • lung malignancy
    less common include ACS, tension pneumothorax, PE, acute pulmonary oedema
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5
Q

What are the 4 red flags associated with palpitations?

A
  1. associated exertion
  2. chest pain
  3. collapse
  4. family history of sudden unexpected death
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6
Q

What are some common differentials in someone presenting with palpitations?

A
  • ventricular tachycardia (most serious)
  • atrial fibrillation
  • supraventricular tachycardia
  • ectopic beats
  • anxiety
  • hyperthyroidism
  • phaeochromocytoma
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7
Q

What are the 8 red flags associated with a cough?

A
  1. unintentional weight loss
  2. hoarse voice
  3. more than 3 weeks onset
  4. recurrent infection
  5. haemoptysis
  6. pleuritic chest pain
  7. breathlessness
  8. persistent nocturnal cough
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8
Q

What are some common differentials in someone presenting with a cough?

A
  • URTI (most common)
  • pneumonia
  • ACEi - switch to ARB
  • lung malignancy
  • GORD
  • asthma
  • COPD
  • bronchiectasis
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9
Q

What are the 7 red flags associated with haemoptysis?

A
  1. weight loss
  2. heavy smoking history
  3. drenching night sweats
  4. foreign travel
  5. chest pain
  6. sudden onset dyspnoea
  7. risk factors for PE
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10
Q

What are some common differentials in someone presenting with haemoptysis?

A
  • acute bronchitis (most common)
  • lung malignancy
  • pulmonary embolism
  • pneumonia
  • tuberculosis
  • lung abscess
  • bronchiectasis
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11
Q

What are the (i) investigations and (ii) management for someone with suspected stable angina?

A

(i) ECG - usually normal but may show past MI
Exclude precipitating factors = anaemia, DM, thyrotoxicosis, hyperlipidaemia, temporal arteritis
(ii) 1. Modify risk factors = smoking, exercise, weight loss. If cholesterol greater than 4 prescribe statin
2. GTN spray
3. Aspirin 75-150mg/day
4. b-blockers (ivabradine if cannot tolerate)

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12
Q

What are the investigations for someone with suspected ACS?

A

1) ECG: within hours = tall T waves, ST elevation or new LBBB. Within days = T wave inversion, pathological Q waves
2) CXR = cardiomegaly, pulmonary oedema, widened mediastinum
3) Troponin T+I = rise within 3-12hrs and peaks at 24-48hrs

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13
Q

How do you treat a STEMI?

A 
FIRST = MONAC
- morphine + metclopramide
- if sats less than 90% give oxygen
- IV nitrates
- Aspirin
- clopidogrel 
Then 1) Primary angioplasty OR thrombolysis with alteplase
2) IV b-blocker (atenolol)
3) ACEi (lisinopril)
4) clopidogrel 300mg loading dose followed by 75mg/day for 30 days
Review at 5 wks and 3 months post MI
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14
Q

How do you treat an NSTEMI?

A

1) if sats less than 90% give oxygen
2) IV morphine + metclopramide
3) Nitrates (IV/PO)
4) Aspirin lifelong (lose if low GRACE score) + clopidogrel (12 months)
5) Antithombotic fondaparinux if low bleeding + no angioplasty planned
6) b-blocker
7) ACEi
8) statin + address modifiable risk factors e.g. smoking, exercise, DM, HTN, hyperlipidaemia
Review at 5 wks and 3 months post MI

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15
Q

What are the investigations for someone with suspected Heart Failure?

A

BNP - raised
CXR - alveolar oedema, kerley B lines, cardiomegaly, dilated prominent upper lobe vessels, pleural effusion
ECG - determine cause and degree of LV function
Diagnose using Framingham criteria and classify based on NYHA classification

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16
Q

What is the management for someone with heart failure?

A

Stop smoking, eat less salt, optimise weight and nutrition
Then treat cause. Treat exacerbating factors (anaemia, thyroid, infection, HTN) and avoid drugs that can exacerbate (NSAIDs, verapimil)
1. Loop diuretics e.g. furosemide
2. ACEi/ARB
3. B blocker
4. Spironolactone
5. Digoxin (if in AF and have HF)
6. Vasodilators (hydralazine and isosorbide dinitrate) if intolerant to ACEi/ARB or used in standard therapy for patients of black ethnic origin

17
Q

What are the (i) investigations and (ii) management for someone with suspected atrial fibrillation?

A

(i) ECG = irregular QRS, absent P waves
Bloods = U+E, cardiac enzymes (trops), TFTs
(ii)
ACUTE AF (less than 48h)
- O2, U+E, emergency DC cardioversion (if unavailable then amiodarone IV)
- treat associated illness
- control rate (1st line = verapimil or bisoprolol
- anticoagulate with LMWH
CHRONIC AF (prioritise rate control + anticoag)
- anticoagulation = warfarin, aspirin, dabigatran
- rate control = b-block or verapimil or diltiazem
PAROXYSMAL AF = flecainide ‘pill in pocket’

18
Q

What are the (i) investigations and (ii) management for someone with suspected infective endocarditis?

A

(i) blood cultures - 3 separate occasions
bloods - normocytic normochromic anaemia
urinalysis - microscopic haematuria
ECG - prolonged PR interval/complete AV block
Echo = vegetations
Use DUKE’s criteria for diagnosis
(ii) Antibiotics (amoxicillin +- vancomycin/gentamicin)
Consider surgery.
Dental and oral hygiene is important

19
Q

What are the 3 stages of hypertension?

A
  1. clinic BP over 140/90 or ABPM over 135/85
  2. clinic BP over 160/100 or ABPM over 150/95
  3. clinic: diastolic over 110 or systolic over 180
20
Q

What is the management for hypertension?

A

UNDER 55:
ACEi - ACEi+CCB or ACEi+diuretic, then ACEi+CCB+diuretic
- add further diuretic/alpha blocker/beta blocker

OVER 55 or black ethnicity:
CCB/diuretic - ACEi+CCB or ACEi+diuretic - ACEi+CCB+diuretic
- add further diuretic therapy/alpha blocker/beta blocker

21
Q

What are the investigations involved in severe pulmonary oedema?

A

CXR = cardiomegaly, ‘bat wings’, effusion and kerley B lines
ECG = signs of MI, dysarrhythmias
U+E, troponins, ABG, plasma BNP
Consider ECHO

22
Q

What is the management in severe pulmonary oedema?

A
  1. sit patient UPRIGHT
  2. oxygen 100% if no pre-existing lung disease
  3. IV access and ECG
  4. Diamorphine IV
  5. Furosemide IV
  6. GTN spray
  7. If SBP over 100mmHg start a nitrate infusion (isosorbide nitrate). If sys is under 100mmHg, treat as cardiogenic shock
23
Q

What are the investigations involved in suspected pneumonia?

A

CXR
Oxygen sats + BP plus maybe ABGs
Bloods = U+E, FBC (leucocytosis), LFT, CRP
Blood culture
Sputum culture
Urine anitgen testing for legionella and pneumococcus

24
Q

What is the criteria of the CURB-65 score? How is it used to base treatment of pneumonia?

A

Confusion
Urea over 7mmol
Resp rate over 30 breaths/min
BP sys under 90mmHg or diastolic under 60mmHg
Aged over 65
0-1 = home treatment (mild) with amoxicillin or clarithromycin
2 = amoxicillin and clarithromycin
3-5 = severe, co-amoxyclav and clarithromycin
- consider oxygen and fluids, plus VTE prophylaxis
- analgesia if in pleuritic pain

25
Q

What are the (i) investigations and (ii) management for someone with suspected bronchiectasis?

A

(i) CXR = cystic shadows, thickened bronchial walls
High res CT to show extent of disease
Sputum culture and sensitivity
Spirometry (obsructive), FBC, bronchoscopy
serum immunoglobulins, CF, sweat test, aspergillus skin prick test
(ii) healthy diet and exercise (pulmonary rehab)
- airway clearance therapy = postural drainage
- inhaled bronchodilators
- Abx (amoxicillin/clarithromycin)
- surgery may be indicated in recurrent infections, severe haemoptysis or focal disease

26
Q

What are the (i) investigations and (ii) management for someone with suspected bronchial carcinoma?

A

(i) CXR = nodules, consolidation, collapse, effusion, bony mets
CT to stage tumour
cytology = sputum and pleural fluid
Bronchoscopy + biopsy
LFTs (for lobectomy). Bone scan if mets
(ii) SMOKING CESSATION
NSCLC = surgery (lobectomy or pneumonectomy) for peripheral tumours with no metastatic spread. Chemoradiotherapy for more advanced disease
SCLC = chemo and radiotherapy but relapse often occurs. Prophylactic cranial irridation for those at high risk of bony mets

27
Q

What are the investigations performed in a patient with suspected asthma?

A 
FEV1, FVC
Peak flow rate
CXR = hyperinflated
FBC = increased eosinophils/neutrophils
Skin prick allergen testing
Bronchial challenge test
Immunoassay for allergen specific IgE
28
Q

What is the treatment plan for asthma patients?

A

1st line = SABA as reliever therapy
2nd line = add ICS (beclometasone) if using SABA more than 3x/week
3rd line = add leukotriene receptor antagonist (montelukast)
4th line = ass LABA to ICS + review LTRA use
5th line = MART
6th line = consider increasing ICS dose and/or trial of additional drug e.g. theophylline or LAMA

  • ensure patient has an personalised asthma action plan
  • if control is good for more than 3 months, consider downgrading treatment
29
Q

What are the (i) investigations and (ii) management for someone with suspected COPD?

A 
(i) Spirometry + CXR (hyperinflation)
FBC (increased haematocrit and WBC)
ECG = RA and RV hypertrophy
(ii) SMOKING CESSATION
SABA or LABA first line
- LABA + ICS/LAMA depending on features suggesting steroid responsiveness
- then use all 3 if still SoB
- pulmonary rehab, oral corticosteroids, oral theophylline, oral mucolytic (carbocisteine), oral prophylactic Abx (azithromycin) or long term O2 therapy are additional treatments that can be offered
30
Q

What are the risk factors for a pulmonary embolism?

A
  • recent surgery
  • thrombophilia
  • leg fracture
  • prolonged bed rest/immobility
  • malignancy
  • pregnancy/post-partum/pill/HRT
  • previous PE
31
Q

What are the investigations involved in diagnosing a PE?

A

FBC, U+E, baseline clotting, D-dimers
CTPA
V/Q scan, ECG
Wells score - if greater than 4 PE is likely and do CTPA, no d-dimer. If 4 or less do d-dimer - if positive do CTPA and if negative stop workup

32
Q

What is the treatment for a pulmonary embolism?

A
  1. Give O2 if sats are low
  2. Thrombolysis (alteplase) if massive PE (haemodynamic instability)
  3. Give LMWH for 5 days or until INR is over 2 (whichever is longer)
  4. Give VitK antagonist (warfarin, rivaroxaban) within 24h and continue for min of 3 months (6m if unprovoked)
33
Q

What are the (i) investigations and (ii) management of a suspected pneumothorax?

A

(i) CXR
(ii) TENSION = immediate needle decompression in 2nd ICS MCL. Give O2 therapy and insert chest drain to reduce risk of immediate recurrence
SPONTANEOUS = O2 and percutaneous aspiration plus chest drain insertion

34
Q

What are the investigations used for a suspected pleural effusion?

A

CXR = blunting of costophrenic angles
Pleural USS = pleural space contains fluid
Diagnostic aspiration = send to lab for clinical chemistry (protein, glucose, pH, LDH, amylase), bacteriology (M+C, auramine stain, TB culture) cytology + if indicated immunology
Pleural biopsy = only if prev tests are INCONCLUSIVE

35
Q

What is the management of a pleural effusion?

A
  1. Drainage = if large/symptomatic via therapeutic thoracentesis
  2. Pleurodesis with talc, bleomycin or tetracycline for recurrent infections
  3. Surgery = if persistent collections and increasing pleural thickness (on USS) via surgical thorascopy

MANCHESTER YEAR 3 (11 decks)

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