Cases with Kariiiiim

Question 1

Cause of S3

Answer 1

As you get lub then dub, the mitral valve opens during systole, but you get a sound because of rapid ventricular filling due to VENTRICULAR DILATION

NOTE: Might be normal in athletes

Question 2

Cause of S4

Answer 2

Atrial contraction against ventricular hypertrophy (due to htn) as the ventricle is stiff so you hear the last push of the atria

Question 3

Ventricular hypertrophy on ECG

Answer 3

Tall R waves in lead 5
deep s wave in lead 2

If you add the s wave and r wave together above, and it’s more than 45 mm = lvh

Question 4

What is ventricular gallop

Answer 4

All four heart sounds

Question 5

After what BMI does death rate increase in Asians?

Answer 5

23

Question 6

What do you do if the BP diastolic is above 140?

Answer 6

Repeat again

Question 7

What SIGNS would you look for in hypertension

Answer 7

S4
Heave
Bruits
Fundoscopy - papilledema
NOTE: you can't detect LVH on clinical examination, only dilatation presents with axis deviation

Question 8

Grade 1 htn on fundus

Answer 8

Silver wiring in the middle of retinal arteries comnig from

Question 9

Grade 2 htn on fundus

Answer 9

AV nipping - when an artery crosses a vein and narrows

Question 10

Grade 3 htn on fundus

Answer 10

Flame shaped haemmorhages

Maybe cotton wool spots (ischemia in the area around it)

Question 11

Grade 4

Answer 11

Flame shaped haemorrhage
Cotton wool spot
PLUS Papilloedema - no visual edge of optic disc

Question 12

Name another cause of papillodema

Answer 12

Obstructive hydrocephalus blocking third or fourth ventricle

Question 13

When do you get hard exudates?

Answer 13

Diabetes due to cholesterol deposition

Question 14

What does hypertensive retinopathy mean?

Answer 14

Pt has had retinopathy for a long time

Question 15

Six causes of secondary hypertension

Answer 15

Phaeo
Cushings
Conns
Acromegaly
Renal artery stenosis
Coarctation of aorta

Question 16

Which comes first, hypertension or atherosclerosis?

Answer 16

Atherosclerosis results from hypertension

Question 17

What basic investigations do you do for hypertension and why? OSCE MATERIAL

Answer 17

FBC for polycythemia
U and E as potassium might be low, and affect renal function
ECG for LVH
Urinalysis for nephritis or renal disease

Question 18

Which part of the kidney makes renin?

Answer 18

JGA makes renin

Question 19

What controls release of aldosterone

Answer 19

Angiotensin 2 controls release for aldosterone

Question 20

If someone DOESN’T have cushings or acromegaly like clinical features, what hypertension investigations would you do?

Answer 20

Renin
Aldosterone
24hr urine for catecholamines

Question 21

High renin
High aldosterone
Everything else is normal

Answer 21

Renal artery stenosis - low pressure causes more renin production, but the high BP doesn’t get through to the kidneys because of the stenosis, so it remains high

Question 22

What imaging is done to investigate renal artery stenosis

Answer 22

Digital subtraction angiogram

Question 23

Features of phaeo

Answer 23

nervousness
sweat down face
palpitations
episodic severe htn
severe vasoconsriction causing necrotic bowel

Question 24

First therapeutic step for phaeo

Answer 24

Alpha blockade plus saline so bp doesn’t drop too much

Question 25

Differentiate between conns and phaeo

Answer 25

conns tumour - continuous raised htn whereas phaeo big on imaging conns small tumour

Question 26

Why do you give beta blockers after alpha blockers for phaeo

Answer 26

b2r causes peripheral dilatation so blocking it might cause more hypertension

Question 27

Treatment for phaeo

Answer 27

Alpha blockade Beta blockade Localise the lesion Surgery

Question 28

Scan for phaeo

Answer 28

MIBG scan - metaiodobenzylguanidine | precursor for something that allows phaeos to be seen

Question 29

IF someone has HTN plus BPH, treatment?

Answer 29

Alpha blockers

Question 30

HF/MI/Diabetes + HTN

Answer 30

ACEi

Question 31

ACE intolerance (cough) MI in past Chronic stable angina + HTN

Answer 31

ARBs

Question 32

Angina/elderly/isolated systolic hypertension + htn

Answer 32

CCB

Question 33

stroke prevention + htn

Answer 33

thiazide diuretics

Question 34

HTN treatment strategy

Answer 34

under 55 - A over 55 - C second step - A and C third step - A C D fourth step - add alpha blocker/beta blocker

Question 35

Treatment for renal artery stenosis?

Answer 35

ACEi/ARB Angiography Surgery

Question 36

Optimum treating for preventing second

Answer 36

``` Intensive lifestyle modification Aspirin to prevent second MI Statin 40-80mg OD to prevent second MI BP control Assessment for T2DM ```

Question 37

Statin intolerant patients

Answer 37

Ezetimibe

Question 38

Name an LDL receptor destroyer

Answer 38

PCSK9 Proprotein convertase subtilisin kexin 9 - involved in destruction of LDL receptor

Question 39

Name a drug that inhibits PCSK9

Answer 39

Evolocumab

Question 40

Who benefits from PCSK9?

Answer 40

Only really patients with Familial hypercholemia Statin intolerant Unctrolled lipids

Question 41

What do you use in patients with microalbuminuria and diabetes?

Answer 41

ACEi (apparently see DPD1 for explanation)