Core Conditions Continued Flashcards
What are the 5 most common causes of AF?
mrs SMITH:
Sepsis
Mitral valve stenosis or regurgitation
Ichaemic heart disease
Thyrotoxicosis
Hypertension
Rate control is the first line treatment for AF, unless….(4)
In which case, you can offer…?
- There is a reversible underlying cause
- New onset (within 48 hours)
- Heart failure caused by AF
- Symptomatic despite effective rate control
In which case you offer rhythm control (pharmacological or electrical cardioversion)
What metabolic abnormalities arise in refeeding syndrome? (4)
What does this increase your risk of? (3)
- Hypophosphataemia
- Hypokalaemia
- Hypomagnesaemia (→toursades de pointes)
- Abnormal fluid balance
// - Cardiac arrhythmias
- Heart failure
- Fluid overload
What medications can you give for rate control in AF?
Why does rate control help treat AF?
1st line = betablocker e.g. atenolol 50-100 mg OD
CCB e.g. diltiazem (avoid in heart failure)
Digoxin (only used in sedentary people, risk of toxcitiy, needs monitoring)
Aim is to get HR to <100 bpm to allow better ventricular filling during diastole
What medication is used for pharmacological cardioversion in AF?
Flecainide
Amiodarone (preferred if there is evidence of structural heart disease)
What medication might be given as long term rhythm control for AF?
1st line = beta-blocker
2nd line = dronadrone after successful cardioversion
What is polycythaemia vera?
A myeloproliferative disorder caused by clonal proliferation of a marrow stem cell.
Results in increased numbers of red blood cells.
Associated with JAK2 mutation.
Px of polycythaemia vera:
- Pruitus, typically after a hot bath
- Splenomegaly
- HTN
- Hyperviscosity leading to arterial and venous thrombosis
In a patient with AF who has just had a stroke, should you offer anticoagulation?
TIA:
1. Exclude haemorrhagic stroke
2. Start anticoagulation immediately (warfarin/apixaban)
Stroke:
1. Exclude haemorrhagic stroke
2. Treat with aspirin for 2 weeks before starting anticoagulation (warfarin/apixaban)
How do you treat an ischaemic stroke?
R/o haemorrhagic stroke
Symptom onset <4.5 hours ago? → thrombolysis with alteplase
Unsuitable for thrombolysis? → thrombectomy
+ Aspirin 300 mg OD for two weeks
+ Then start secondary prevention: clopidogrel 75mg OD and atorvastatin
Also found to have AF? Start an anticoagulant after two weeks e.g. warfarin or apixaban
How long should you not drive for following a TIA?
4 weeks
How do you treat a TIA?
300mg aspirin daily
Start secondary stroke prevention within 24 hours: clopidogrel + atorvastatin
Consider carotid artery endartectomy if >70% (ECST) or >50% (NASCET) stenosed)
Don’t forget to also anticoagulate if in AF!
Other than heart failure, what can cause a raised BNP?
MI
Valvular disease
CKD
How does acute mesenteric ischaemia present?
Give one key risk factor:
- Central abdominal pain
- Diarrhoea ± rectal bleeding
- Metabolic acidosis (due to dying tissue)
AF! Thrombus forms in LA and travels to superior mesenteric artery
How does chronic mesenteric ischaemia present?
- Central colicky pain afer eating
- Weight loss
- Abdominal bruit
Diagnosed with CT angiography
Right sided heart murmurs are heard loudest on..?
Inspiration
E.g. tricuspid regurg, pulmonary stenosis
Left sided heart murmurs are heard loudest on..?
Expiration
e.g. mitral stenosis, mitral regurg, aortic stenosis, aortic regurg
A patient with CKD needs a CT with contrast - what can you do to reduce the risk of contrast nephropathy?
Give IV 0.9% saline - some trusts also recommend oral actylcysteine but never IV as this can cause anaphylaxis
How high is CK in rhabdomyolysis?
> 10,000
What is primary sclerosing cholangitis?
A condition where intrahepatic or extrahepatic ducts become strictured and fibrotic.
This causes an obstruction to the outflow of bile out of the liver and into the intestines.
The cause is mostly unclear but there is an established association with ulcerative colitis.
What would a ‘cholestatic pattern’ on LFTs be?
ALP is the most deranged/only deranged LFT
What is the diagnostic investigation for primary sclerosing cholangitis?
Magnetic resonance cholagiopancreatography - involves an MRI of the liver/bile ducts/pancreas
A biopsy of a carcinoma will show these 3 features, regardless of location in the body:
Nuclei hyperchromasia (excessive pigmentation with staining)
Nuclei pleomorphism (multiple varying shapes and sizes)
Nuclei enlargement (
What is non-invasive ventilation?
An alternative to full intubation and ventilation to support the lungs in respiratory failure to due obstructive lung disease.
Can either be BiPAP or CPAP.
BiPAP: bilevel positive airway pressure
CPAP: continuous positive airway pressure
Give 3 indications for CPAP:
Used as an alternative to full intubation/ventilation to support the lungs and maintain the airway in conditions where they are prone to collapse. Such as:
- Obstructive sleep apnoea
- Congestive heart failure
- Acute pulmonary oedema
What are the criteria for initiating BiPAP?
Used in type 2 respiratory failure, criteria for initiation is: respiratory acidosis despite adequate medical tx.
Decision must be made by a reg or above. CI in untreated pneumothorax, or any structural abnormality affecting the face/airway/gi tract.
What is the most common organism that causes infective endocarditis?
Name one other organism that can cause IE
Staph. aureus - associated with IVDU and prosthetic valves
Strep. viridans - associated with sub-acute IE
6 signs/symptoms of infective endocarditis:
- Fever + new murmur = IE until proven otherwise
- Signs of sepsis
- Janeway lesions - non-painful erythematous macules on palms
- osler nodes - painful nodules on finger tips/toes
- roth spots - retinal haemorrhages with pale centres
- splinter haemorrhages
3 important investigations in infective endocarditis:
- Transoesophageal echo - vegetations >3mm
- Blood cultures - repeated at least 3 times from different sites
- ECG - might show heart block
Which criteria are used to diagnose infective endocariditis?
Duke’s criteria
What are the three big causes of bowel obstruction?
- Adhesions (small bowel)
- Hernia (small bowel)
- Malignancy (large bowel)
Signs/symptoms of bowel obstruction:
How might paralytic ileus present differently?
Bowel obstruction: bilious green vomiting, abdo distention, diffuse abdominal pain, absolute constipation and lack of flactulence, ‘tinkling’ bowel sounds early on
Paralytic ileus presents basically exactly the same, except you’re more likely to get completely absent bowel sounds (no tinkling). The hx will be helpful to differentiate e.g. most commonly a complication of handling the bowel during surgery.
How do you manage a bowel obstruction?
“Drip and suck”: IV fluids and TPN, NG tube with free drainage, +/- surgery
Where is Wernicke’s area? What does it do?
Wernicke’s area is in the temporal lobe (left/dominant hemisphere), it is involved in language comprehension.
Where is Broca’s area? What does it do?
Broca’s area is in the frontal lobe (left/dominant hemisphere), it is involved in producing fluent speech.
What is a case-control study?
Compares people with a disease to those without a disease. Retrospective.
A researcher is seeking to examine whether long-term mobile phone use is linked to acoustic neuroma risk. The information on mobile phone usage is collected from participants with acoustic neuroma and a comparable group of participants without acoustic neuroma, selected from the general practice register.
What kind of study design is this?
Case-control study
What are the cut-offs for stage 1, 2 and severe hypertension?
1 = clinic BP≥140/90, ABPM ≥135/85
2 = clinic BP ≥160/100, ABPM≥150/90
Severe = clinic systolic ≥180, or clinic diastolic ≥110
When should you treat stage 1 hypertension?
If <80 years old and has any one of:
- end organ damage
- established CVS disease
- renal disease
- diabetes
- 10 year CVS risk equivalent to 10% or more
Lifestyle advice for hypertension:
Reduce salt intake
Reduce caffiene intake
Stop smoking
Increase exercise (60 mins/day moderate, 3 days/week vigorous)
Draw out the NICE HTN flowchart:
Give an example of an ACEi, ARB, CCB and thiazide-like diuretic:
ACEi = ramipril
ARB = candesartan, valsartan, losartan
CCB = amlodipine, verapimil, nifedipine
Thiazide like diuretic = indapamide
Give 3 drugs that can cause pulmonary fibrosis:
Amiodarone
Cyclophosamide
Methotrexate
Nitrofurantoin
Give 4 psychiatric and 4 physical symptoms of delirium tremens:
When does delirium tremens normally occur?
Psych:
1. Visual hallucinations
2. Confusion
3. Agitation
4. Delusions
Physical:
1. Seizures
2. tachycardia
3. Tremor
4. Excessive sweating
24 to 72 hours after alcohol consumption is stopped/reduced
(6-12 hours: tremor, sweating, headache, craving and anxiety
12-24 hours: hallucinations
24-48 hours: seizures
24-72 hours: “delirium tremens”)
How do you treat delirium tremens?
Medical emergency, 35% mortality if untreated!
- Chlordiazepoxide - a benzo to combat effects of alcohol withdrawal
- IV high-dose B vitamins (pabrinex) to prevent Wernicke’s encephalopathy
What is SIADH? How does it affect urine concentration?
Syndrome of inappropriate ADH secretion:
- Too much ADH is secreted
- ADH stimulates too much water to be absorbed in the collecting ducts
- Leads to very dilute plasma and very concentrated urine
-> dilutional hyponatraemia
5 causes of SIADH:
S = small cell lung cancer
I = infection (TB, pneumonia, meningitis)
A = abcess
D = drugs (especially carbamazepine and antipsychotics)
H = head injury
Diagnostic criteria for SIADH: (4)
- Concentrated urine
- Hyponatraemia
- Low plasma osmolarity
- Clinically and biochemically euvolemic
Tx of SIADH: (4)
- Tx underlying cause
- Restrict fluids (1L/day)
- Tolvaptan 15 mg OD to block the affect of ADH on the kidneys
- Demeclocycline to make kindeys resistant to ADH
Investigations for DVT:
Investigations are dependent on the well’s score!
- Suspected DVT + wells score≥2 → USS doppler
- USS doppler +ve → treat for DVT
- USS doppler -ve → check d-dimer (if raised, repeat USS in 6-8 days)
- USS not available within 4 hours → treat and scan later - Suspected DVT + wells score <2 → D-dimer
- D-dimer positive → USS doppler
- D-dimer negative → consider alternative diagnosis - Offer all patients with an unprovoked DVT or PE the following investigations for cancer: physical exam, CXR, blood tests, urinalysis. If over 40, also get an abdo-pelvis CT scan.
(NB: you may also want to check for antiphospholipid antibodies or hereditary thrombophilia)
What is a prospective cohort study?
A study where a group of individuals, who differ with respect to one or more factors, are followed to determine who these factors affect outcomes.
E.g. Pregnant mothers followed from the first prenatal visit until after delivery to investigate the association between maternal smoking and birth weight.
Symptoms of hyperprolactinaemia:
- Menstrual irregularity/amennohrea
- Reduced libido
- Erectile dysfunction
- Galactorhea
How do you treat a prolactinoma?
First line: dopamine agonist to block prolactin effects e.g. cabergoline
Second line: surgical resection via transphenoidal surgery
Which type of airway is best for protecting against aspiration?
Tracheal tube - seals off the tracheal and protects against aspiration
What is haemochromatosis?
An autosomal recessive genetic disease where iron accumulates in tissues, especially the liver, due to increased absorption in the gut.
Asymptomatic until late stage, signs/symptoms usually begin around 40-60 years in men, and after menopause in women.
What tests can confirm haemochromatosis?
serum ferritin (shows iron overload) and transferrin saturation
if transferrin saturation is increased -> HFE genetic testing
A 78 year old man has type 2 diabetes. His clinician does not invite him to join
an internet-based self-monitoring programme because she considers him to
be too old to engage with it effectively.
What is this clinician’s behaviour defined as?
Discrimination: the unjust or prejudicial treatment of different categories of people.
How does cocaine cause an MI?
Causes coronary artery spasm
What are the maintenence fluid requirements for someone with underlying cardiac disease?
20-25 ml/kg
Myasthenia gravis can cause acute respiratory failure - how should you monitor respiratory function in a patient with this condition?
Monitor FVC!
Also keep an eye on ABG (will show hypercapnia first, then hypoxia), a weak cough also indicates weakness of expiratory muscles. Have a low threshold for endotracheal intubation due to rapid deterioration of bulbar and resp muscles.
What is the first line treatment for sinus bradycardia?
Atropine sulfate
GO OVER RINNE’S AND WEBER’S
3 common causes of cellulitis:
Staph. aureus
Group A strep. pyogenes (common in leg cellulitis and post-op cellulitis)
Group C strep. dysgalactiae
What is superficial thrombophlebitis?
Inflammation and clotting in a superficial vein. May be spontaneous or assocaited with risk factors e.g. varicose veins, IVDU
Treat with a topical anti-inflammatory cream and oral NSAID for pain relief
Why should you consider stopping metformin before a surgery?
When is it ok to continue it?
When must it be stopped?
What are the consequences for stopping metformin for surgery?
It is renally excreted, renal impairment will lead to accumulation and lactic acidosis during surgery.
If only one meal will be missed AND eGFR > 60, AND low risk of AKI you may be able to continue metformin.
If a patient will miss more than one meal OR there is significant risk of an AKI, you must stop metformin when the pre-operative fast begins.
If the patient has more than one dose/day OR CBG is >12 on two occasions - you will need to start a variable insulin infusion.
A patient has foot drop due to the loss of active dorsiflexion. What nerve is most likely to be affected?
common peroneal
Ovarian cancer most commonly spreads to which regional lymph nodes?
Para-aortic nodes - the main lymphatic drainage of the ovaries is to these nodes
CSF findings for bacterial meningitis:
Cloudy and turbid
High opening pressure
High WBCs (leukocytes)
Low glucose
High protein
CSF findings for viral meningitis:
Clear
Normal or high opening pressure
High WBCs (lymphocytes)
Normal glucose
High protein
CSF findings for SAH:
Blood stained initially, then xanthochromia
High opening pressure
High WBCs
High RBCs
Normal glucose
High protein
4 causes of an SAH:
- Berry aneurysm
- Clotting disorder
- Ateriovenous malformation
- Trauma
NB: Don’t forget PKD is strongly associated with blood vessel malformations leading to SAH
What is terson’s syndrome?
An intraoccular vitreous haemorrhage resulting from raised ICP due to a SAH or subdural haemorrhage.
Tx of an SAH:
Nimodipine to prevent vasospasm
Endovascular coiling or neurosurgical clipping
Which type of intracranial haemorrhage is associated with old age and alcoholism?
Subdural haemorrhage - bridging veins are stretched and vulnerable due to brain atrophy, trauma causes them to shear
How does a subdural haemorrhage present?
Fluctuating consciousness levels
Headaches
Drowsiness
Symptoms may be present for weeks as ICP rises
What does a subdural haemorrhage look like on a CT head?
Crescent shape
What does an extradural haemorrhage look like on a head ct?
lemon shape
How does an extradural haemorrhage present?
Deterioration in consciousness level
Associated with focal neurological signs
Can have a lucid interval
What is heliballismus?
A lesion in the subthalamic nucleus causing uncontrollable thrashing movements.
Which anti-emetic is safe to use in Parkinson’s disease?
Domperidone - does not cross the BBB
What is the classic triad of normal pressure hydrocephalus?
- urinary incontinence
- Dementia and bradyphenia (slow processing/thinking)
- Gait abnormality
Sx typically develop over a few months.
What is normal pressure hydrocephalus?
An abnormal build up of CSF in the brain’s ventricles, possibly due to reduced CSF absorption at the arachnoid villi.
It is a reversible cause of dementia in elderly patients.
It can also be secondary to head injury, SAH or meningitis.
What is Bell’s palsy?
Which demographic are most commonly affected?
Idiopathic acute unilateral paralysis of the facial nerve.
LMN lesion resulting in facial drooping, and in severe cases disturbance to taste sensation in the anterior 2/3rds of the tongue and intolerance of loud noises.
Pregnant women and adults aged 20-40.
Px of Bell’s palsy:
- Drooping eyelid
- Hyeracusis (sensitivity to loud noises)
- Loss of taste sensation on anterior 2/3rds of tongue
- Forehead is affected (LMN palsy)
What does right homonymous hemianopia mean?
Loss of vision on the right side of the visual field in both eyes.
What does the anterior cerebral artery supply? (2)
Anteromedial portions of the cerebrum
The leg, foot and trunk portion of the primary motor and somatosensory cortex (imagine the motor and sensory homonculuses with their leg dangling into the central sulcus)
JVP has its own waveform which consists of five parts, what does each part show?
A wave - contraction of the right atrium, blood forced upwards towards the IJV
X descent (1) - relaxation of the right atrium, blood fills the right atrium and leaves the IJV
C wave - contraction of the right ventricle, upwards force causes a temporary rise in the IJV
X descent (2) - final stage of right ventricular contraction, JVP falls again
V wave - relaxation of right atrium with tricuspid valve closed, temporary rise in JVP
Y descent - tricuspid valve opens, blood fills RA and RV, JVP decreases
What ECG changes are seen in acute pericarditis?
Throughout most leads:
Saddle-shaped ST elevation
PR depression (most specific marker for pericarditis)
(May see reciprocal ST depression and PR elevation in lead aVR)
What is secondary adrenal insufficiency?
Insufficient production of ACTH therefore leading to insufficient stimulation of the adrenal glands, and insufficient production of steroid hormones.
Usually due to damage to the pituitary gland.
