Clinical Skills Flashcards
What would you follow up on after a cardiovascular examination?
Complete peripherel vascular examination, ECG and blood pressure
When does physiological splitting of second heart sound occur?
During inspiration, physiological splitting of the 2nd heart sound may occur due to the pulmonary component of 2nd heart sound delayed a fraction of a second behind the aortic component
Is a low frequency 3rd heart sound pathological in 16 year old boy?
No, it can be a normal finding caused by low frequency (bell, less pressure) filling sound. However, it can be a sign of heart failure in a patient with evidence of heart disease
Is a 4th heart sound in a 16 year old boy pathological?
Yes, the 4th heart sound indicated ventricular stiffness (eg: left ventricular hypertrophy) and is due to active filling of a stiff non-compliant ventricle by atrial contraction. It is always pathological.
Patients with isolated systolic hypertension should be offered the same treatment as both raised?
True, Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure.
ACE inhibitor and ARB drugs are recommended to be given together
False, do not combine an ACE inhibitor with an ARB to treat hypertension
Aspects of lifestyle change for hypertensives
Diet, alcohol, smoking, exercise, reduce caffeine, low Sodium diet
What is stage 1 and stage 2 hypertension?
Stage 1 - Clinic blood pressure 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring daytime average or home blood pressure monitoring average blood pressure 135/85 mmHg or higher
Stage 2 - Clinic blood pressure 160/100 mmHg or higher and subsequent ambulatory blood pressure monitoring daytime average or home blood pressure monitoring average blood pressure 150/95 mmHg or higher
When should antihypertensive drugs be started?
For patients aged 80 years and below with Stage 1 hypertension or any age with Stage 2 hypertension
What is the white coat effect?
A discrepancy of more than 20/10 mmHg between clinic and average daytime ambulatory blood pressure monitoring
Beta blockers should be avoided in ladies of child bearing age
True, beta-blockers are not a preferred initial therapy for hypertension in this case. Look into using ACE inhibitors or ARB
First line treatment for persons aged 55 and over and to black people of African or Caribbean family origin of any age.
Calcium Channel blocker. If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic.
What Thiazide-like Diuretic should be offered in preference to conventional Thiazide like Diuretic
Offer a thiazide like diuretic, such as chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide.
If blood pressure is not controlled by step 1 treatment, what is 2nd line of treatment
Calcium channel blocker combination with ACE inhibitor or ARB. Offer a thiazide like diuretic if CCA is not suitable
For black people of African or Caribbean family origin, what is preferred, ARB or ACE inhibitor as 2nd line treatment along with Calcium channel blocker?
ARB - Angiotensin 2 Blocker
If therapy for hypertension is initiated with a beta blocker, what second drug is preferred?
CCB rather than a thiazide-like diuretic to reduce the person’s risk of developing diabetes.
What combination is given as 3rd line treatment for hypertension?
ACE inhibitor/ARB + Calcium Channel blockers + Thiazide-like Diuretic such as chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) should be used.
What is resistance hypertension?
Regard clinic blood pressure that remains higher than 140/90 mmHg after treatment with the optimal or best tolerated doses of an ACE inhibitor or an ARB plus a CCB plus a diuretic as resistant hypertension, and consider adding a fourth antihypertensive drug and/or seeking expert advice
What can be used to help patients choose a healthy, balanced diet?
The EatWell plate
Why should pulse be manually checked before using a blood pressure machine?
Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation
Results of ABPM or HBPM should be waited for before starting anti-hypertensive treatment
If the person has severe hypertension, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.
Recommended drugs for the following - Angina Congestive Heart Failure Diabetic Nephropathy Prostatism Elderly
B Blockers (Ca Blockers) in Angina ACEI & B Blockers in CCF ACEI / ARBs in Diabetic nephropathy Alpha Blockers in prostatism (caution) Thiazides in elderly
Most effective treatment for resistance hypertension
Spironolactone - Aldosterone antagonist Start low; go slow! Caution: diabetes & low GFR 12.5mg /day (25mg every second day) Liquid available Tolerate 25% rise in K+ & Creat
What constitutes resistant hypertension?
Resistant hypertension occurs when 1) use of at least three antihypertensive drugs at full daily dosage - of which a diuretic- are unsuccessful in controlling blood pressure, and, having excluded pseudoresistance (white coat phenomenon), 2) contributing factors such as certain exogenous substances, or secondary causes of hypertension including hyperaldosteronism, obstructive sleep apnea, parenchymal and vascular kidney disease, pheochromocytoma, are possibly at work.
What can Carotid baroreceptor stimulation be used for?
It is used to decrease sympathetic nervous system predominance in conditions such as obesity, obstructive sleep apnoea and isolated systolic hypertension
Which murmurs are heard better on expiration
Left sided murmurs
Which murmurs are heard better on inspiration
Right sided murmurs
Which murmurs are heard better on position change
Diastolic murmurs
Which murmurs tend to radiate
Systolic mumurs
Common cause infective endocarditis in developing countries
Streptococcus viridans, also when there’s absence of specific risk factors
Infective endocarditis organism that can be found in patients who have colorectal cancer
Streptococcus bovis
Infective endocarditis cause in immunocompromised individuals
Candida albicans
Infective endocarditis cause in IV users/developed
Staphylococcus aureus
Infective endocarditis cause if prosthetic valve
Staphylococcus epidermis
This lady with a history of diabetes, hypertension, and diabetes who presented with palpitations most likely has?
Atrial fibrillation
A higher INR indicates a higher risk of bleeding and the target for patients on warfarin for atrial fibrillation is?
2 to 3
What clotting factors does Warfarin affect
Factors II, VII, IX, X, protein C and S
Which one of the following structures separates the subclavian artery from the subclavian vein?
Scalenus anterior
Where does the Superior Mesenteric Artery leave the aorta
The SMA leaves the aorta at L1. It passes under the neck of the pancreas prior to giving its first branch the inferior pancreatico-duodenal artery.
What is the most common cause of hypertension in children?
Renal hypertension
A 72-year-old man has been unwell for may years and following his death a post mortem is performed. Tissue is submitted for microscopic evaluation. Evaluation of sections of the myocardium demonstrates evidence of apple green birefringence with polarised light. What is the most likely diagnosis?
Amyloidosis
A 25-year-old man presented to the emergency department after suffering from a syncope whilst playing football. He is usually fit and well with no previous medical history. He also reports intermittent palpitations, however, he attributes it to possibly being caused by alcohol or caffeine. On further questioning, his father has suddenly passed away at the age of 35-years-old with a ‘heart condition’. What is the underlying pathophysiological change for the patient?
Brugada Syndome - Abnormal electrical activity in the heart increasing risk of sudden cardiac death. Patient has episodes of passing out. Inherited from first degree relative.
Hypertrophic cardiomyopathy - Such as asymmetrical septal hypertrophy; it is genetic, chest pain and syncope
Which lies more medial, internal or external carotid?
External but supplies outer part of brain
Most feared complication of Group A streptococcus
Rheumatic fever, not Septicaemia generally. Mitral regurgitation occurs early on followed by Mitral stenosis
