Common Presentations Flashcards
aortic stenosis
- signs/symptoms; slow rising pulse, narrow pulse pressure, heaving and undisplaced apex bear, harsh ejection systolic murmur with radiation to the carotids, signs of decompensation
- causes; bicuspid valve, rheumatic heart disease, senile calcification
- treatment; valve replacement if lv dysfunction or valve gradient >50mmhg at angiography or 60mmhg on echo
aortic regurgitation
- signs/symptoms; collapsing pulse, wide pulse pressure, thrusting displaced apex beat, high-pitched early diastolic murmur
- causes; rheumatic heart disease, bicuspid valve, infective endocarditis, aortic root dilation, inflammatoru causes including syphilis
- treatment; valve replacement based on symptoms and response to medical therapy
mitral stenosis
think af
- signs/symptoms; af, tapping undisplaced apex beat, loud s1, mid-diastolic rumbling murmur at apex in left lateral position, accentuated by exercise, malar flush, opening snap
- causes; rheumatic heart disease, congenital heart disease, carcinoid syndrome, sle
- treatment; antigcoagulation for af, percutaneous balloon valvuloplasty, valvotomy, valve replacement
mitral regurgitation
think af
- signs/symptoms; thrusting displaced apex beat, soft s1, loud pansystolic murmur radiates to axilla, best in left lateral position, signs of decompensation
- causes; rheumatic heart disease, ihd lv impairment and annular dilation, endocarditis, connective tissue disease, collagen disorders
- treatment; valve replacement surgery considered if nyha 2 and medical management failed
cabg
- internal mammary artery or long saphenous vein used as graft vessel
- midline sternotomy scar
prosthetic valves
- listen for metallic click and where it appears in each cycle
- assess if midline sternotomy scar and whether cabg was also performed
- may have been replaced percutaneously
- tissue vs mechanical
- look for signs of anticoagulation
mechanical
- starr-edwards, ball and cage
- bjork-shiley, pivoted single tilting disc
- st judes, double tilting discs
pacemaker/icd
-always assess upper chest and axilla for pacemaker/icd
tricuspid regurgitation
- look for tender pulsatile hepatomegaly
- af
- elevated jvp
- pansystolic murmur
causes
- congenital
- rheumatic heart disease, rare
- endocarditis
- carcinoid syndrome
- blunt trauma
- secondary to left heart failure
hocm
autosomal dominant myosin defect with family history of sudden cardiac death
manage with beta blockers, calcium channel blockers and icd insertion
- jerky peripheral pulse
- forceful apex beat
- ejection systolic murmur
coarctation
radial-radial or radial-femoral delay
- bp discrepancies
- systolic murmur
- weak femoral pulses
congenital or iatrogenic
associated with a bicuspid aortic valve in 50%
asd/vsd
- murmur
- maladie de roger
- vsd can progress to eisenmengers syndrome
dextrocardia
consider primary cilliary dyskinesia
eisenmengers
increased right sided pressure eventually leads to right-left shunt through vsd which is cyanotic
blalock-taussig shunt
used to partially correct tetralogy of fallot
- usually connects pulmonary arteries with right subclavian artery
pulmonary fibrosis
b - berylliosis r - radiation e - extrinsic allergic alveolitis a - ankylosing spondylitis/allergic bronchopulmonary aspergillosis s - silicosis/sarcoidosis t - tuberculosis
r - rheumatoid arthritis
a - asbestosis
i - idiopathic pulmonary fibrosis
d - drugs; belomycin, methotrexate, amiodarone, nitrofurantoin, hydralazine, busulphan
copd
- not fully reversible airway obstruction
- look for cor pulmonale, lung cancer, ihd and alpha 1 antitrypsin deficiency; neutrophil elastase
- mild >80% fev1, moderate 50-79% fev1, severe 30-49% fev1, very severe <30% fev1
bronchiectasis
characterised by;
- infection and bronchial oedema
- inflammation and remodelling, hypertrophy and tortuosity of airways and vessels, and neovascularisation
- difficulty clearing secretions and increased propensity to acute and chronic infection, and to haemoptysis
causes;
- genetic; cf, marfans, kartagener
- chronic lung disease eg copd
- connective tissue disease; third of ra patients
- chronic inflammatory disease eg ibd
- chemical damage; recurrent acid reflux aspiration
- focal bronchial obstruction
- infection
- hypogammaglobulinaemia
- allergic bronchopulmonary aspergillosis
pneumonectomy/lobectomy
indications for lobectomy
- lung cancer; clubbing may suggest
- bronchiectasis; clubbing may suggest
- chronic lung abscess
- tb; peripheral calcified lymph nodes may suggest
- benign tumours
- fungal infections; life threatening haemoptysis due to aspergillus infection
- congenital abnormalities
other cause of thoracotomy scars
- oesophageal surgery
- heart valve replacement
- diaphragmatic repair
- thoracic aortic aneurysm repair
- anterior spinal tumour excision
- latissimus dorsi flaps
consider vats; video assisted thorascopic surgery, if small scars consistent with port entry
pneumonia
Streptococcus pneumoniae (pneumococcus)
- Accounts for 80% of cases
- Particularly associated with high fever, rapid onset and herpes labialis
- A vaccine to pneumococcus is available
Haemophilus influenzae
- Particularly common in patients with COPD
Staphylococcus aureus
- Often occurs in patient following influenza infection
Mycoplasma pneumoniae
- One of the atypical pneumonias, which often present a dry cough and atypical chest signs/x-ray findings
- Autoimmune haemolytic anaemia and erythema multiforme may be seen
Legionella pneumophilia
- Another one of the atypical pneumonias
- Hyponatraemia and lymphopenia common
Klebsiella pneumoniae
- Classically seen in alcoholics
Pneumocystis jiroveci
- Typically seen in patients with HIV
- Presents with a dry cough, exercise-induced desaturations and the absence of chest signs
assess using curb-65
pleural effusion
exudates
- infection; bacterial, pneumonia, mycobacterial
- malignancy; commonest cause in over 60s
- pulmonary embolism
- autoimmune; rheumatoid, lupus
- pancreatitis; may be haemorrhagic
- drugs
- post cabg
transudates
- cardiac failure; commonest cause overall and usually bilateral
- cirrhotic liver disease
- peritoneal dialysis
- nephrotic syndrome
- hypothyroidism
assess
- microscopy and culture
- cytology
- ph; <7.2 indicates the need for a chest drain in a parapneumonic effusion
- ldh and protein to characterise using lights criteria
lung cancer; especially pancoast
- squamous cell carcinoma 35%; PTHrp, clubbing, HPOA
- adenocarcinoma 30%; commonest in non-smokers
- small cell carcinoma 15%; ADH, ACTH, lambert-eaton myasthenic syndrome
- large cell carcinoma 10%
- other 5%
pulmonary oedema
- fluid in the alveolar spaces
- kerley b lines
- increased vascular shadowing in a bats wing distribution
- upper lobe diversion
- pleural effusions
sarcoidosis
systemic inflammatory granulomatous disease of unknown origin
respiratory
- Stage I: bilateral hilar lymphadenopathy (BHL) alone
- Stage II: BHL with pulmonary infiltrates
- Stage III: pulmonary infiltrates without BHL
- Stage IV: fibrosis
- skin
- heart
- eye
- nervous system
- blood
- bones, joints and muscles
- endocrine/exocrine
- gi/gu
hepatomegaly; painful/non-painful
- cirrhosis
- congestive cardiac failure
- neoplastic; secondary and primary eg heptatoma
- infective; acute viral hepatitis, liver abscess, hydatid cyst
- polycystic disease
- tricuspid regurgitation; pulsatile hepatomegaly
- budd-chiari syndrome
- haemochromatosis
- infiltrative; amyloidosis, sarcoidosis