CRD Flashcards

Question

Management of angina

Answer 1

Modify CV risk factors Treatment should start before results Advice - during attack - rest, use GTN (wait 5 mins), use up to 3 times, call 999 Beta blocker or calcium channel blocker Add long acting nitrate e.g. nicorandil Start aspirin If diabetes + angina - ACEi If symptomatic on 2 anti-angina meds then PCI or CABG

Answer 2

``` MI - NSTEMI or STEMI Angina - stable or unstable Prinzmetal angina Acute pericarditis (constant pain, worse on inspiration, lying flat and movement) PE Pneumonia MSK e.g. costochondritis Aortic dissection Gallstones GORD ```

Answer 3

1 in 10 will have MI within 1 year | Benign

Answer 4

Canadian CV society functional classification 1. No angina with ordinary activity, only strenuous 2. angina during ordinary activity e.g. walking up hill with mild limitations 3. angina with low level activity e.g. walking on flat, marked limitation 4. angina at rest or with any exercise

Answer 5

QRISK2 - Age, BP, smoking, diabetes, cholesterol, BMI, ethnicity, deprivation, FHx, CKD, RA, AF, diabetes, HTN - If >10 start statin - Number = % who will have CV event in 10 years GRACE score Estimates 6 month mortality for those with ACE TIMI score Likelihood of ischaemic event or mortality in UA or NSTEMI

Answer 6

Education, psychological support, exercise training and behavioural change - Decreases morbidity and mortality - NICE recommended - Offer to all MI patients - Only 40% uptake 1. assess. reassure. educate. mobilise. discharge 2. screen for anxiety/depression 3. structured exercise and rehabilitation. graded exercise. aerobic low intensity. 4. regular review of patients in primary care long term

Answer 7

Hyperdynamic circulation - Anaemia - pregnancy - hyperthyroidism - mitral stenosis

Answer 8

Early or mid-systole aortic stenosis pulmonary stenosis prosthetic heart valve

Answer 9

Aortic stenosis Pulmonary stenosis Crescendo - decrescendo pattern

Answer 10

Mitral regurgitation | Tricuspid regurgitation

Answer 11

Aortic regurgitation Pulmonary regurgitation Soft blowing decrescendo pattern Best hear when sitting forward in expiration

Answer 12

Mitral stenosis Tricuspid stenosis Associated with opening snap

Answer 13

Ejection systolic Crescendo-descrescendo Radiates into neck Best heart at left sternal edge

Answer 14

``` Pansystolic Blowing Best heard at the apex Radiates to axilla best heard in left lateral position ```

Answer 15

``` Rheumatic fever Degenerative calcification in elderly Congenital SLE RA Infective endocarditits ```

Answer 16

Flow from LA to LV is restricted Left atrial pressure rises Pulmonary venous congestion (breathlessness) leading to pulmonary hypertension Dilation and hypertrophy of LA Can develop AF Exercise and pregnancy poorly tolerated as increase HR, shortens diastolic period with mitral valve open

Answer 17

``` Progressive breathlessness Orthopnoea, PND, pulmonary oedema Cough (pulmonary congestion) Chest pain (pulmonary hypertension) Oedema (right heart failure) Fatigue (low cardiac output) AF / Palpitations ```

Answer 18

``` Malar flush Raised JVP Right ventricular heave Laterally displaced apex beat Mid-late diastolic murmur best heard in left lateral position AF Signs of R heart failure - ascites, peripheral oedema Pulmonary oedema ```

Answer 19

CXR - LA enlarged, Kerley B lines (interstitial oedema) ECG - AF, tall R waves in V1-3, may have bifid p waves Echo - thickens immobile cusps Doppler - increases pressure gradient across valve

Answer 20

If asymptomatic - no intervention - yearly echos Diuretics or long acting nitrates (for dyspnoea) Beta blocker or calcium channel blocker Anticoagulation if AF If tachy, consider heart rate control PMC - percutaneous mitral commissurotomy (valvotomy)

Answer 21

1-2% of adults Increased in men Increases with age Increasing prevalence with increasing survival post MI and secondary prevention ``` RFs HTN IHD Valvular disease Cardiomyopathy Diabetes FHx Smoking Endocarditis Glitazones Sleep apnoea Alcohol Congenital defects Arrrhythmia ```

Answer 22

``` Dyspnoea Fatigue Peripheral oedema Orthopnoea Paroxysmal nocturnal dyspnoea (PND) Noctural cough Pink frothy sputum Wheeze Nocturia Cold peripheries Weight loss Muscle wasing Nausea Anorexia ```

Answer 23

``` Peripheral oedema Dyspnoea Raised JVP Cardiomegaly Murmur Crackles on lung auscultation Displaced apex R ventricular heave Hypotension Narrow pulse pressure Tachycardia Tachypnoea ```

Answer 24

HYPERTENSION Valvular disease (10%) 2y to myocardial disease - CHD, HTN, cardiomyopathy Drugs - beta blockers, calcium channel blockers, anti-arrhythmics, cytotoxic drugs Toxins: alcohol, cocaine Endocrine: diabetes, hypothyroid, hyperthyroid, Cushings, adrenal insufficiency Nutritional deficiency - thalamine, selenium Infiltrative: amyloidosis, sarcoidosis High output failure - anaemia, pregnancy, hyperthyroid, Paget's AF

Answer 25

Heart failure with reduced ejection fraction - Heart unable to pump blood which prevents filling with new blood - SYSTOLIC FAILURE - Long term cardiac remodelling leads to ventricular dilation - Increases preload and end diastolic volume - Dilation is a compensatory mechanism to decrease preload - Severe dilation is maladaptive Heart Failure with Normal Ejection Fraction - heart unable to relax fully preventing blood from entering or exiting the heart - DIASTOLIC FAILURE - Increased afterload, usually due to increased BP - Ventricular wall hypertrophy to try to decrease adterload - decrease ventricular size, decrease compliance, decrease cardiac output

Answer 26

If no MI - Measure serum BNP and pro-BNP (they are released when myocardium stressed) - NT-proBNP commonly used - If over 400 then refer to specialist and Doppler echo If previous MI - Refer to specialist and Doppler echo - CXR for cardiomegaly, prominent upper lobe vessels, bat winging, kerley B lines, pleural effusions - Blood tests: FBC, U&Es, creatinine, LFTs, glucose, fasting lipids, troponin - ECG: for heart block, AF, IHD - ABGs: acidosis or hypoxia

Answer 27

``` Cardiomegaly Prominent upper lobe vessels Bat winging (alveolar oedema) Kerley B lines (interstitial oedema) Pleural effusions ```

Answer 28

Lifestyle changes: smoking cessation, dietary changes, regular exercise, reduce alcohol First line: diuretic + ACEi + beta blocker Second line: ADD aldosterone antagonist OR ARB or hydralazine + nitrate 3rd line: digoxin or cardiac resynchronisation therapy

Answer 29

New York Heart Association Class 1: no symptoms on ordinary physical activity Class 2: slight limitation of physical by symptoms Class 3: less than ordinary activity leads to symptoms Class 4: inability to carry out any activity without symptoms

Answer 30

- Bloods, ECG, CXR - BNP or NT-proBNP, if raised Doppler echo with 48 hours - IV diuretics bolus or infusion - IV nitrates of myocardial ischaemia - Start beta blockers - Offer ACEi - Monitor renal function and electrolytes - ionatropes for short term acute decompensation

Answer 31

``` Very common 1 in 11 children, 1 in 12 adults Commonly starts at 3-5 years More common in boys, but more common in women FHx of atopy Increased in developed countries ``` ``` RFs Personal history of atopy Inner city environment Obesity Prematurity and low birth weight Viral infections in early childhood Smoking Maternal smoking Early exposure to broad spec antibiotics ``` PROTECTIVE factors: breast feeding, vaginal birth, farming environment

Answer 32

Breathlessness Wheeze Chest tightness Cough Symptoms worse at night or early morning Symptoms in response to exercise, allergen exposure or cold air Symptoms present after taking aspirin or beta blockers.

Answer 33

Widespread wheeze on auscultation Low FEV1 or PEFR Peripheral blood eosinophilia

Answer 34

Airflow limitations, airway hyper-responsiveness and bronchial inflammation Type 1 hypersensitivity reaction Triggers cause inflammatory cascade. 2 phase Broncho constrictor response Early: type 1. Preformed mediator release 0-90 minutes Late: types 2. Inflammatory cell recruitment and activation. Mast cells, eosinophils, oedema, smooth muscle hypertrophy, mucus plugging and epithelial damage. Raised IgE - Antigen detected by dendritic cell which presents it to TH1 and TH2 cells via IL12 - TH2 cells recruit mast cells, basophils and eosinophils - Release of inflammation mediators e.g. histamine, prostaglandins, leukotrienes - bronchial hyper responsiveness and airway obstruction

Answer 35

``` Allergens: grass pollen, dander Occupational sensitizers Viral infections Cold air Emotion Irritants: dust, vapour, fumes, smoker Genetic factors Drugs: NSAIDs, beta blockers Atmospheric pollution ```

Answer 36

Symptoms triggered by aspiring These inhibit cyclo-oxygenase which leads to shunting or arachidonic acid metabolism through lipo oxygenase pathway producing cysteinyl leukotrienes

Answer 37

Extrinsic - atopic individuals. Often starts in childhood | Intrinsic - middle age, non-atopic. More severe

Answer 38

``` Isocyanates - paint sprayers Flour - bakers Colophony and fluxes - soldering and printers latex - medical Animal - vets Aldehydes Wood dust - carpentry ```

Answer 39

SPIROMETRY for diagnosis FEV1>15% increase following bronchodilator or steroid trial or >20% diurnal variation on 3+ days/week for 2 weeks Peak flow - unreliable in under 5s Nocturnal dips or work related Should be measured every 15-30 minutes in acute attack Histamine or methacholine provocation or exercise or inhaled mannitol challenge Measure allergic status using skin prick test for attopy FBC: may have eosinophilia

Answer 40

Exacerbations occur with little or no warning

Answer 41

Mild: PEFR 75-100% Moderate: PEFR 50-75% Acute Severe: PEFR 33-50%, RR>25, HR >110, inability to complete sentence ``` Life threatening: PEFR <33%, Sats <92% Normal or raised PaCo2 Silent chest Cyanosis Bradycardia/arrhythmias Hypotension. Exhaustion. Confusion ``` Near fatal. Raised pCO2 requiring mechanical ventilation with raised inflation pressure

Answer 42

Mild - use inhaler, wait 60 minutes, home Moderate - ABG, nebulise 5mg salbutamol. high flow o2. Prednisolone 40mg PO. Wait 30 minutes, if PEFR<60% see below, if higher home Acute severe: ABG, nebulise 5mg salbutamol 2-4 hourly High flow o2 prednisolone 40mg PO or 200mg IV IV access, K+ levels, ADMIT Consider continuous nebuliser Consider IV mag sulphate Correct fluids and electrolytes - watch K+, often hypokalaemic ``` On discharge (for all): oral prednisolone 40mg PO for 5/7 Start or double inhaled corticosteroids ```

Answer 43

1. Salbutamol inhaler 2. Inhaled corticosteroid - If need to use >3 per week or waking due to asthma then start 3. Long acting B2 agonist. Should never be used without steroid 4. Increased inhaled steroid to 2000mcg/day - Leukotriene receptor antagonist - Theophylline - Oral B2 agonist 5. Oral steroid while maintaining inhaled steroids Once controlled, steroids should be lowered to the lowest possible dose to maintain symptom control.

Answer 44

1/3 worsen 1/3 stable 1/3 improve Uncontrolled asthma is biggest risk to foetus

Answer 45

Respiratory alkalosis Hypoxaemia or hypercapnia secondary to hyperventilation

Answer 46

``` Smoking Increasing age Family history (1st degree male under 55, or female under 65) Obesity Hypertension High cholesterol Ethnicity - South Asian or African T2DM Alcohol Low socioeconomic background Male Stress ```

Answer 47

1 - Clinic BP >140/90 and ambulatory blood pressure (ABPM) >135/90 2 - Clinic BP > 160/110 |AND ABPM >150/95 3 - Clinic BP > 180 systolic or >110 diastolic

Answer 48

1st degree male under 55, | or female under 65

Answer 49

BP in both arms, if difference >20mmHg then repeat If BP >140/90 measure twice, if different then take 3rd. Record LOWEST of last 2 BPs If over 140/90 offer ABPM If stage 3 - >180 or >110 then treat without ABPM Test for organ damage - LV hypertrophy, CKD, hypertensive retinopathy and CV risk

Answer 50

``` Labile or severe hypertension headache Palpitations Pallor Diaphoresis ```

Answer 51

Under 40s Low potassium and high sodium (adrenal disease) Raised creatinine or low GFR (renal disease) Proteinuria or haematuria With labile or worsening HTN

Answer 52

``` LV hypertrophy CCF CAD Arrhythmias - AF Microvascular disease ``` Increased risk of stroke and dementia Hypertensive retinopathy Hypertensive nephropathy End stage renal disease Glomerular injury

Answer 53

RENAL - chronic pyelonephritis - diabetic nephropathy - glomerulonephritis - PKD - Obstructive nephropathy - Renal cell carcinoma VASCULAR - Renal artery stenosis - Coarctation of aorta ENDOCRINE * Primary hyperaldosteronism (low potassium, high bicarbonate, high sodium) - Phaeochromocytoma - Cushing's syndrome - Acromegaly - Hypothyroidism - Hyperthyroidism DRUGS - Alcohol misuse - Cocaine - ciclosporin, COCP, corticosteroids, EPO, leflunomide, NSAIDs, liquorice, sympathomimetics (cough and cold meds), venlafaxine

Answer 54

``` Upper limb hypertension Large difference between arms Absent or weak femoral Radio-femoral delay Suprasternal murmur, radiating to back ```

Answer 55

Aim for under 140/90 in under 80s, or 150/90 in over 80s Lifestyle: smoking cessation, weight loss, low salt diet, reduce alcohol. 1. ACE inhibitor, unless over 55 or Black then calcium channel blocker 2. ACEi or ARB + CCB 3. Add thiazide like diuretic (Monitor U&Es) 4. Add spironolactone No ACEi in pregnancy or renovascular disease ACEi best for heart failure and Type 1 diabetes

Answer 56

QRISK2 Used up to 84 year olds Age, sex, ethnicity, postcode, smoking, diabetes, FHx, CKD, AF, RA, cholesterol, BMI, BP

Answer 57

Clustering of CV risk factors relating to insulin resistance 1 in 5 adults Any 3 or more of the following: - Increased weight, BMI or waist circumference - Raised triglycerides - Low HDL - Hypertension - Raised fasting plasma glucose

Answer 58

Chronic obstructive pulmonary disease Airflow obstruction, not reversible. Airflow limitation if progressive and encompasses bronchitis and emphysema FEV1

Answer 59

Affects men and women equally Increases with age ``` RF Smoking Occupational exposure to dust/chemicals Air pollution alpha 1 antitrypsin deficiency Low birth weight Childhood infections Maternal smoking Recurrent infections Low socioeconomic status ```

Answer 60

``` Exertional breathlessness Chronic cough Regular sputum production Frequent winter bronchitis Wheeze Weight loss Ankle swelling ```

Answer 61

``` Tachypnoea Dyspnoea Increased use of accessory muscles Asterixis Confusion Pursed lip breathing Peripheral oedema Cyanosis Wheeze Hyperinflation of chest Quiet vesicular breath sounds ```

Answer 62

Loss of elastic recoil and collapse of small airways on expiration Abnormal enlargement of air spaces distal to terminal wall Enlargement of goblet cells and increased numbers Pulmonary vascular remodelling Unopposed action of proteases and oxidants leading to destruction of alveoli Infiltration of walls with inflammatory cells - CD8+ Expiratory airlflow limitation and decreased recoil = VQ mismatch Patients rely on hypoxic drive due to persistent raised pCO2 If rely on hypoxic drive = renal hypoxia = fluid retension & polycythaemia Alpha1 antitrypsin is an antiprotease deactivated by smoking

Answer 63

Spirometry - FEV1/FVC <70% - FEV1 <80% Chest x-ray can be normal - low flattened diaphragms - large bullae - vessels may be large proximally Bloods - Hb may be raised with raised PCV (polycythaemia) ABGs - Hypoxia and hypercapnia if severe Sputum culture if ? infection - Can test alpha 1 antitrypsin - CT

Answer 64

- Pneumococcal and influenza vaccinations - Smoking cessation - Regular assessment of lung function 1. Short acting B2 (salbutamol) 2. Long acting B2 (salmetrol) 3. Antimuscarinic (ipratropium) 4. Add theophylline/phosphodiesterase inhibitor (moneleukast) 5. Inhaled corticosteroid (never without long acting B2) 6. Pulmonary rehab 7. Home oxygen Can add carbocysteine (antimucolytic) If acute - O2 where tolerated - Removal of secretions - Respiratory support - Corticosteroids - Antibiotics

Answer 65

``` Chronic hypoxia Cor pulmonale from pulmonary hypertension Pneumothorax Respiratory failure Arrhythmias - AF Infection Secondary polycythaemia ```

Answer 66

0 - only breathless on regular exercise 1 - SOB on slight incline or hurried on flat 2 - walks slower than others or has to stop 3 - stops after 100m or few minutes on level 4 - too breathless to leave the house of on dressing

Answer 67

GOLD or BODE index BODE uses FEV1, GOLD FEV1/FVC ``` GOLD 1 - mild FEV1/FVC <70% but FEV1>80% 2 - moderate FEV1/FVC 50-79% 3 - severe FEV1/FVC 30-50% 4 - very severe FEV1<30% or respiratory failure ``` ``` BODE 1 - mild FEV1>80% but symptomatic 2 - moderate FEV1 50-79% 3 - severe 30-49% 4 - <30% or respiratory failure ```

Answer 68

``` Ischaemia Hypertension Rapid AF Medication initiation Alcohol abuse Non-adherence Active infection PE Anaemia Hyperthyroidism ```

Answer 69

``` Urinalysis FBC (Hb and Hct) U&Es Fasting glucose Cholestrol work up ECG CXR ```

Answer 70

``` Hypotension Soft S1 S3 gallop Decreased volume carotid pulse LV apical enlargement Pulmonary congestion (rales) Mitral regurg ```

Answer 71

``` Older age Diabetes Renal disease LV hypertrophy Vascular disease CHD Cerebrovascular disease ``` Aim for 130/80 vs 140/90

Answer 72

Permanent dilation and thickening of airways characterised by chronic cough, excessive sputum production, bacterial colonisation and recurrent acute infections.

Answer 73

More than 1 type can be present in the same patient. - Cylindrical: bronchi are enlarged and cylindrical (signet appearance of bronchi) - Varicose: bronchi are irregular with areas of dilation and constriction. - Saccular or cystic: dilated bronchi form clusters of cysts. Most severe form (often in CF patients). Degree of bronchial dilation increased from proximal to distal.

Answer 74

More common in women Increases in age 3 per 1000 Increase in pacific nationality ``` RFs Cystic fibrosis Immunodeficiency PHx of infections Alpha 1 antitrypsin deficiency Connective tissue disorder Primary ciliary dyskinesia IBD Aspiration or inhalation injury Congenital disorder of bronchial airways ```

Answer 75

Caused by chronic inflammation 42% develop post-infection No identifiable cause in up to 50% Post infection - childhood viral infection (measles, pertussis, influenza), TB, bacterial pneumonia Immunodeficiency e.g. HIV Connective tissue disease - RA, Sjorgen's, systemic sclerosis, SLE, Ehler's Danlos syndrome, Marfan's Congenital defects - CF, primary ciliary dyskinesia, alpha 1 antitrypsin deficiency ``` Asthma Allergic bronchopulmonary aspergillosis Gastric aspirations Bronchial obstruction by lymphadenopathy, tumour or inhaled foreign body IBD ```

Answer 76

1. Persistent airway inflammation 2. Development of bronchial wall oedema and increased mucus production 3. Recruitment of inflammatory cells 4. Release of inflammatory cytokines, proteases and reactive oxygen mediators 5. progressive destruction of airways Vicious cycle - insult by primary infection, increased inflammation, bronchial damage, increase capacity for colonisation of airways

Answer 77

``` Vary from intermittent episodes of expectoration to persistent daily expectoration of large volumes of purulent sputum. Dyspnoea Chest pain Haemoptysis Wheezing Cough Rhinosinusitis ```

Answer 78

``` Coarse crackles - early in inspiration and in lower zones Areas of crackles corresponds poorly with radiological findings Large airway rhonchi Wheeze High pitched inspiratory squeak Dyspnoea Haemoptysis Fever Clubbing ```

Answer 79

Persistent productive cough AND ONE OF: - young age at presentation - Hx of symptoms spanning years - absence of smoking history - daily expectoration of large volumes of sputum - Haemoptysis - Colonisation of P. aeuroginosa - Unexplained haemoptysis

Answer 80

CXR - baseline in all patients, 90% are abnormal. Ring or tubular opacities, tramlines, fluid levels HRCT - high resolution CT is GOLD STANDARD - Bronchial wall dilation - Bronchial wall thickening Sputum microbiology FBC - raised WCC or polycythaemia Immune function testing CF in all under 40 - CFTR genetic mutation analysis or sweat chloride Lung function tests - FEV1, FVC, peak flow (annual repeat)

Answer 81

CFTR genetic mutation analysis | Sweat chloride

Answer 82

Smoking cessation Immunisation against influenza and pneumococcus Healthy diet and physical exercise Physiotherapy - airway clearing techniques with or without sterile water Antibiotics (in acute exacerbations) - amoxicillin or clarithromycin - send of sputum and culture If more than 3 exacerbations per year requiring antibiotics then long term antibiotics (azithromycin) Beta 1 agonists and anticholinergic bronchodilators (theophylline and aminophylline) No steroids. No mucolytics. Oxygen Surgery - lung resection if not controlled by medical treatment.

Answer 83

``` Repeated infection Decreased lung function Empyema Lung abscess Pneuomothorax Life threatening haemoptysis Respiratory failure Cor Pulmonale Decreased quality of life ```

Answer 84

-2 to +2 Positive numbers = alkalotic Negative number - acidosis

Answer 85

Low pH < 7.35 Raised pCO2 Normal bicarbonate (if no compensation) Raised bicarbonate (if compensated) Lung disease - COPD, late asthma Respiratory depression Sleep disordered breathing Neuromuscular disorders causing decreased muscle ability Increased CO2 production - seizures, hyperthermia, seizures, Breath holding

Answer 86

High pH > 7.45 Low CO2 Low bicarbonate (if compensating) Breathing off too much CO2 - Fever - Sepsis - Anxiety - Aspirin poisoning - Pulmonary oedema - Pneumonia - Profound anaemia - Pleural effusion - PE - Hyperthyroidism

Answer 87

Low pH < 7.35 Low bicarbonate Low CO2 (if compensating) ``` DKA Sepsis Renal failure Tissue ischaemia GI loss of bicarbonate (diarrhoea) Renal tubular disease Uraemia ```

Answer 88

High pH Raised bicarbonate High CO2 if compensating GI loss of H+ (vomiting) Renal loss of H+ (loop/thiazide diuretics) Hypovolaemia

Answer 89

Hypoxaemic respiratory failure Low O2 with normal or low CO2 ``` COPD Pneumonia Pulmonary oedema Asthma Pulmonary fibrosis Pneumothorax Pulmonary hypertension PE Bronchiectasis ARDS Obesity Cyanotic congenital heart disease ```

Answer 90

Hypercapnic respiratory failure High pCO2 and low O2 ``` COPD Severe asthma Drug OD Myasthenia gravis Polyneuropathy Polio Muscle disorders Head and neck injury Pulmonary oedema ARDS Hypothyroidism ```

Answer 91

``` Hypovolaemia Shock (septic or cardiogenic) Severe anaemia Drug OD Neuromuscular disease Spinal/head injury ```

Answer 92

``` Dyspnoea Confusion Tachypnoea Cyanosis Stridor Accessory muscle use Anxiety Headache Retraction of intercostal spaces Hypoventilation Polycythaemia (chronic) Cor pulmonale Cardiac arrhythmia ```

Answer 93

``` Pulse Oximetry ABGs ECG D-dimer for PE CXR Pulmonary function tests LFTs and U&Es TFTs Echo ```

Answer 94

ABCDE Supplemental o2 to sats >90% Treat underlying cause BiPap Intubation and mechanical ventilation - RSI Bronchidialtors, corticosteroids, antibiotics, opiods

Answer 95

94-98% | For COPD 88-92%

Answer 96

``` Flow rate > 4l/min for several days Tracheostomy CF Bronchiectasis Chest infection training secretions ```

Answer 97

``` Extremes of age Smoking Alcohol Previous recent viral illness (predisposes to strep pneumonia) Asthma COPD (increased H. influenza or morexella) Malignancy Bronchiectasis CF Immunosuppression - AIDS, chemo etc. (increased gram negatives, S.aureus or P.jiroveccii) IV drug use (S. aureus) Diabetes CV disease Nursing home (H. influenza) ``` Hospitalisation - hospital acquired Decreased consciousness, neurological disease = aspiration

Answer 98

``` Productive cough Purulent sputum Breathlessness Fever Malaise ``` ``` Focal chest signs Increased temperature Tachypnoea. Tachycardia. Bronchial breathing + crepitations Dullness on percussion pleural rub Pleuritic chest pain ``` Confusion, myalgia, anorexia, fatigue (in elderly) Non-specific symptoms + abdo pain (children)

Answer 99

- Streptococcus pneumonia (66%) - Haemophilus influenzae - Klebsiella pneumonia - Staphylococcus aureus

Answer 100

Gram positive Diplococci Common in winter Common in creasing age, co-morbidities, CV disease, a

Answer 101

Gram positive | Coccobaccilus

Answer 102

Gram negative bacillus More common in men - can cause decreased platelets and leuopaenia

Answer 103

Gram positive Coccus More common after influenza like illness

Answer 104

Mycoplasma pneumonia - More common in young patients or prior antibiotics - Slower onset, neurological complications, dry cough Chlamydia pneumoniae - Initial upper RTI leading to bronchitic or pneumonitic features - Cough with scanty sputum - Hoarseness, headache Legionella pneumoniae - Sever infection - Water sources in Mediterranean - Abnormal LFTs, raised CK - Mild headache, myalgia, chills, rigors, haemoptysis, GI upset Pneumocysitic jirovecci - only in immunocompromised

Answer 105

FBC - Raised WCC Raised CRP LFTs (decreased albumin) U&Es - if high urea then poor prognosis Blood cultures Urinary antigen tests - legionella or pneumococcus (c-polysaccharide) CXR - Consolidation. May have effusions or collapse Sputum examination and culture Pulse oximetry or ABGs Aspiration of pleural fluid for culture

Answer 106

``` CURB65 Confusion Urea >7 Respiratory rate >30 BP < 90 (systolic) Age over 65 All worth one point ``` 0 or 1 - LOW 2 = moderate 3 = severe

Answer 107

Smoking cessation Oxygen for hypoxia Fluids for dehydration Analgesics - care with opiates RE respiratory depression LOW (CURB 0 or 1) - Treat at home - 5 day course oral amoxicillin - If penicillin allergic = clarithromycin or doxycycline MODERATE (CURB 2) - Hospital - Amoxicillin and clarithromycin Severe (CURB 3+) - Co-amoxiclav and clarithromycin IV - Add levofloxacin if ? legionella - ? ITU admission

Answer 108

``` Pleural effusion Empyema Lung abscess pneumothorax DVT Bronchiectasis AKI Sepsis - pericarditis, endocarditis, osteomyelitis, meningitis ```

Answer 109

New radiographic infiltrate in presence of infection with onset 48 hours after admission

Answer 110

``` Over 70 Chronic lung disease Co-morbidities Decreased consciousness Chest or abdominal surgery Mechanical ventilation NG feeding PHx of antibiotic exposure Poor dental hygiene Steroids Chemotherapy ```

Answer 111

Gram negative enteric bacilli and pseudomonas - Pseudomoas aerginosa - intubation - E. Coli - Klebsiella Strep pneumonia and H. influenza Staph aureus - neurosurgery patients and trauma Anaerobes e.g. enterobacter after abdo surgery

Answer 112

``` Co-amoxiclav Ceftriaxome Tazocin Carbopenam Gentamicin ```

Answer 113

Increase in fluid volume between visceral and parietal pleura

Answer 114

Benign (more common) or malignant Transudate - disruption of hydrostatic and oncotic forces operating across pleural membranes LOW PROTEIN <30 Exudate - increased permeability of pleural surface - usually due to inflammation HIGH PROTEIN >30

Answer 115

``` Heart failure Cirrhosis Hypoalbuminaemia Peritoneal dialysis Atelectasis Hypothyroidism Nephrotic syndrome Mitral stenosis PE SVC obstruction Constrictive pericarditis Ovarian Hyperstimulation Meig's syndrome - benign ovarian tumour, ascites, pleural effusion ```

Answer 116

TRIAD Pleural effusion Ascites Benign ovarian tumour

Answer 117

``` Pneumonia Malignancy Pulmonary infarction PE Autoimmune - RA Asbestos exposure Pancreatitis TB Complication of acute MI (Dressler's syndrome) Drugs - methotrexate, Amiodarone, nitrofurantoin ```

Answer 118

``` SOB Cough Dyspnoea Pleuritic pain Dullness on percurssion Decreased breath sounds Decreased chest expansion Decreased tactile and vocal fremitus ```

Answer 119

CXR - Blunting of costophrenic angles - 200ml needed to see PA, 50ml on lateral Thoracocentesis/pleural aspiration - Only if exudate - Cytology, protein, LDH, pH, gram stain, culture and sensitivity, lipids, amylase (pancreatitis) - Not if bilateral ``` ESR CRP Albumin Amylase TFTs Blood cultures D-Dimer CT ``` CT of thorax +/- abdomen Pleural biopsy Thoracoscopy/Bronchoscopy

Answer 120

``` Malignancy PE Infraction Trauma benign asbestos Post cardiac injury syndrome ```

Answer 121

``` Infection and empyema RA SLE TB Malignancy Oesophageal rupture ```

Answer 122

Aimed at treating underlying cause If small then observe If large the tapping fluid can give symptomatic relief and is useful for diagnosis but recurrence common DO NOT DRAIN MORE THAN 1.5L in one go ``` Chest drain (Can use long term indwelling pleural draining in malignant effusions) ``` Pleurodesis - injection of sclerosing agent to cause pleural adhesion and prevent recurrence - sterile talc, tetracycline, bleomycin Pleurectomy if all other options failed

Answer 123

``` Pneumothorax Traumatic pneumothorax Pleural effusion Haemopneumothorax Peri-operative - oesophageal or cardiothoracic surgery ```

Answer 124

Between - Lateral edge of pec major - Base of axilla - Lateral edge of lat dorsi - Above 5th IC space If apical pneumothorax - 2nd intercostal space

Answer 125

Patient lying at 45 degrees. arms raised. Local anaesthetic Thoracostomy or seldinger technique used to insert tube Insert into safe triangle Aspirate fluid and/or air Open incision with blunt dissection of deep tissue Connect drainage system DO NOT REMOVE MORE THAN 1.5L Suture to skin CXR to confirm placement

Answer 126

Incorrect placement Injury to intercostal muscles Perforation of other vessels Pain

Answer 127

Collection of air in the pleural cavity resulting in the collapse of the lung on the affected side Extent of collapse depends on amount of air

Answer 128

``` Primary spontaneous Secondary spontaneous Tramatic Iatrogenic Catamenial Tension ```

Answer 129

``` Occurs in healthy people Increased in: Tall, thin and healthy Male Marfan's Prengnacy Smokers ``` Occurs from ruptures of blebs and bullae

Answer 130

Associated with underlying lung disease Consequences are greater and management more difficult ``` Associated with: Smoking COPD Asthma HIV TB Sarcoidosis CF Cancer Idiopathic pulmonary fibrosis Ehler's Danlos syndrome RA Marfan's FHX Ankylosing spondylitis ```

Answer 131

Follows penetrating chest trauma Stabbing/gun shot/fractured rib High risk occupations - diving or flying

Answer 132

Following certain medical procedures ``` Lung biopsy Transthoracic needle aspiration Throacocentesis Central line insertion Intercostal nerve block Tracheostomy APR NG tube placement ```

Answer 133

At time of menstruation 30-40 years old with pelvic endometriosis 90% in R lung and within 72 hours of onset of menstruation

Answer 134

MEDICAL EMERGENCY | Occurs in - ventilated patients, trauma, CPR, lung disease, blocked or clamped chest drain, hyperbaric oxygen treatment

Answer 135

``` Sudden onset pain - stabbing, radiating to shoulder, increased on inspiration SOB - depends on size Cyanosis Distressed Sweating Decreased breath sounds or absent over affected area Hyper resonance Trachea deviates AWAY from pneumothorax Symptoms can be minimal in primary ``` Tension - Hypotension - Raised JVP - Tachycardia - Pulsus paradoxicus (pulse slows on inspiration)

Answer 136

In normal respiration, pleural space has negative pressure As chest wall expands, surface tension of pleura expands lung outwards If pleural space invaded by gas then llung collapses until equilibrium is achieved or rupture sealed Decreased vital capacity Decreases PaO2 Tension - Injured tissue forms one way valve - Air allowed in but not out - Increases pressure, lung collapses and hypoxia - Decreased venous return to heart - Respiratory insufficiency, CV collapse and death

Answer 137

CXR - Lung edge and absent lung markings peripherally - Blunting of ipsilateral costophrenic angle - Width of rim of air is used to classify size (Small <2cm, Large >2cm) 2cm= 50% of lung volume US Chest CT in complicated or uncertain cases ABGs - hypoxia more disturbed in secondary Occasionally hypercapnia

Answer 138

Is tension pneumothorax suspected? - YES then immediate needle decompression followed by chest drain insertion PRIMARY - Depth less than 2cm - discharge and follow up - >2cm aspirate. In then under 2cm with clinical improvement then discharge and follow up - If no improvement then Admit and fit chest drain SECONDARY - Over 2cm or SOB - admit and fit chest drain - Depth 1-2cm - aspirate, if <1cm then admit, high flow O2 and observe, if >1cm then admit and fit chest drain - If <1cm then admit, high flow O2 and observe Aspirate = thoracocentesis - 2nd or 3rd intercostal space, midclaviucular line - OR 4th or 5th intercostal space over superior rib margin in anterior axillary line - Enter just above a rib Pleurodesis if risk high Surgery - If persistent air leak or failure of lung to expand Open thoracotomy and pleurectomy OR VATS - video assisted throacoscopic surgery and pleurectomy is better tolerated but higher recurrence

Answer 139

Also known as subcutaneous emphysema - Occurs as air tracks below skin under pressure from pleural space - Results from large air leaks or blocked chest drain Harmless treat with high flow oxygen

Answer 140

- Major abdo/pelvic surgery - Post-op ITU - Late pregnancy - Malignancy - Fractures - C-section - Varicose vein surgery - Decreased mobility - Hospitalisation - Spinal cord injury - IV drug use - Major trauma - Central venous lines ``` MINOR - congenital heart disease - congestive heart failure = hypertension - COCP - Stroke - myeloproliferative disorders - thrombotic disorders - HRT - COPD - Sedentary travel - Obesity - IBD ```

Answer 141

Venous stasis Vessel wall damage Hypercoagulability

Answer 142

Virchow's triad - venous stasis, vessel wall damage, hypercoagulability - Endothelial damage prmotoed thrombus formation, usually at valves - Poor blood flow and stasis also promotes thrombus formation Thrombus forms and dislodges, becomes trapped in pulmonary vasculature Obstruction increased pulmonary resistance Increased work of right ventricle R ventricle over distension, increased end diastolic pressure and decreased output

Answer 143

``` Dyspnoea Pleuritic pain Cough Haemoptysis Dizziness Syncope Any chest symptoms with signs of DVT ```

Answer 144

``` Tachypnoea Tachycardia Hypoxia Pyrexia Raised JVP Pleural rub Hypotension Cardiogenic shock Gallop heart rhtyhm ```

Answer 145

Wells PE Score - If more than 4 points then likely then CTPA - If 4 or less points then unlikely - D-dimer, if positive then CTPA CTPA first line Baseline investigations - - O2 sats - FBC, U&Es, clotting, troponin ECG - S1Q3T3 deep s waves in I, Q waves in III, inverted T waves in III - Right axis deviation - RBBB - Right ventricular strain - Sinus tachycardia - AF CXR - usually normally, may have decreased vascular markings Late sign = Hampton's hump ABGs = low PaO2, low PaCO2 if hyperventilation D-dimer - raised in VTE, not specific Leg US - if suspected DVT If no cause found - need to investigate for an undiagnosed cancer

Answer 146

- S1Q3T3 deep s waves in I, Q waves in III, inverted T waves in III - Right axis deviation - RBBB - Right ventricular strain - Sinus tachycardia - AF

Answer 147

Suspected DVT - 3 Alternative diagnosis less likely than PE - 3 Tachycardia - 1.5 Immobilisation >3 days or surgery in last 4 weeks - 1.5 Hx of DVT or PE - 1 Haemoptysis - 1 Malignancy - 1 If 4 points or less UNLIKELY (D-dimer) If OVER 4 points LIKELY (CTPA)

Answer 148

Resuscitation - oxygen, IV access, analgesia Anticoagulation - LMWH, fondaparinux ASAP unless renal impairment, significant bleeding risk or haemodynamic instability - Continue for 5 days - Warfarin or rivaroxiban once confirmed within 24 hours and continue for 3 months - Only thrombolysis with alteplase if hypotensive If not suitable for anticoagulation - IVC filters Surgical embolectomy if high risk or failed or contraindicated thrombolysis

Answer 149

Limb pain and tenderness along line of deep veins Unilateral swelling of calf or thigh Pitting oedema Distension of superficial veins Increased skin temperature Skin discolouration (red) Palpable cord - hard thickened, palpable vein

Answer 150

Wells score for DVT Likely 2 or more Unlikely <2 Likely = Proximal leg vein US Positive = DVT Negative D-dimer Unlikely = D-dimer If positive then proximal leg vein US ``` CT/MRI venography Contrast venogram (old gold standard) ``` If no diagnosis of cancer and first DVT over 40 - CT abdo and chest + mammogram

Answer 151

Likely 2 or more Unlikely <2 ``` Active cancer - 1 Paralysis or immobilisation - 1 Recently bedridden - 1 Localised tenderness in leg veins - 1 Entire leg swelling - 1 Calf swelling >3cm - 1 Unilateral pitting oedema - 1 Previous DVT - 1 Collateral superficial vein - 1 ``` If alterative cause at least as likely - MINUS 2

Answer 152

As PE Anticoagulation - LMWH, fondaparinux ASAP unless renal impairment, significant bleeding risk or haemodynamic instability - Continue for 5 days - Warfarin or rivaroxiban once confirmed within 24 hours and continue for 3 months - Only thrombolysis with alteplase if hypotensive If not suitable for anticoagulation - IVC filters Consider extending anticoagulant >3m if high risk of recurrence and no increased bleeding risk Below knee compression stockings after swelling gone down or 1 week

Answer 153

``` Chronic venous hypertension Pain Swelling Hyperpigmentation Dermatitis Ulcers Gangrene ``` Post DVT in 20-40%

Answer 154

High risk patients -0 - GA with surgery > 90 minutes - Acute surgical admission - Decreased mobility - 1 or more risk factors for DVT/PE - Avoid dehydration - Early mobilisation - Graduated compression stockings - Intermittent pneumatic compression devices - LMWH/Fondaparinux/Unfractionated heparin (if CKD)

Answer 155

Complelely flat lesion | Smooth small area of colour change <1.5cm

Answer 156

Discrete raised palpable lesion <1cm

Answer 157

Discrete raised palpable lesion >1cm

Answer 158

Small raised lesion filled with purulent fluid

Answer 159

Raised area of skin with flat top and clear edge | Circumscribed, superficial, elevated plateau 1-2cm

Answer 160

Hard thickening of skin with accentuated skin markings | Results from inflammation or rubbing

Answer 161

Small superficial circumscribed containing serous fluid < 0.5cm

Answer 162

Large superficial circumscribed containing serous fluid > 0.5cm

Answer 163

Transient circumscribed elevated papules or plaques with erythematous borders and pale centres

Answer 164

Chronic T cell mediated autoimmune condition affecting extensor surfaces Involves hyperproliferation of the keratinocytes in the epidermis with increased cell turnover rate

Answer 165

Female 5-10 years Male 15-19 years Peak for both in 60-70 years Genetic influence in younger category Gender equal More common in Caucasians FHx - YES (30%) HLA Cw6 RF IBD Immunocompromised

Answer 166

``` Streptococcal infection (guttate psoriasis) Winter HIV infection Psychological stresses Post partum hormonal changes Smoking Alcohol Skin trauma Drugs - lithium, antimarials, steroid withdrawal, beta blockers, NSAIDs, ACEi, antibiotics ```

Answer 167

``` 90% extensor plaque psoriasis Flexural Guttate Pustular Unstable Erythrodermic Psoriatic arthritis Napkin Nail ```

Answer 168

Commonly extensor surfaces - elbows, knees, scalp, trunk, nails, genitals Erythematous plaques Well demarcated, non-coherent silver plaques Scaling - thickened with masses of adherent shedding white scales Scratching produces waxy appearance (tache de bougie = candle wax) Glassy homogeneous erythema Symmetrical Can be encircled by paler peripheral zone nail changes Kobners reaction - new lesions at site of trauma or injury Pustules in palmoplantar psoriasis Auspitz sign - when scales scraped off reveals dilated blood vessels beneath

Answer 169

Psoriasis | when scales scraped off reveals dilated blood vessels beneath

Answer 170

Oncholysis - nail lifting off bed Subungal hyperkeratosis - accumulation of chalky material under nail Pitting Beau's lines - transverse lines on nail bed Splinter haemorrhages

Answer 171

Keratinocytes grow from epidermal base to surface. In psoriasis there is increased turnover from 23 days to 3-5 days causing thickened skin Normally lose nuclei but quick progression leads to retained nuclei Genetic predisposition - HLA Cw6 Combined with precipitating factors Involvement of IL12, IL23, TNF and IFN gamma

Answer 172

Smooth inflamed regions Without scaling due to moist area Armpit, groin, under breast and skin folds Needs to be distinguished from fungal infection

Answer 173

Small salmon pink plaques 1-10cm in diameter Predominantly on trunk May be scaly Appears suddenly 2-3 weeks after URTI with group B strep Usually completely resolves in few weeks but can start chronic psoriasis

Answer 174

Sterile pustules on palms and soles Can be diffuse over the body It may cycle through: erythema-pustules-scaling If diffuse then often associated with fever and unwell Most are smokers Can be precipitated by oral steroids

Answer 175

``` Generalised erythema Pain Itching Fine scaling Covers nearly all body surface area Accompanied by fever, chills, hypothermia and dehydration Very serious Systemically unwell ```

Answer 176

Usually in small joints Occurs in 5-10% Stiffness, pain, progressive Causes permanent joint damage

Answer 177

Diagnosed clinically Can do biopsy Would show - basal cell hyperplasia, proliferation of subepidermal vasculature, absence of normal cell maturation and keratinisation

Answer 178

1st line - topical therapies: corticosteroids, tar, vitamin D analogues 2nd line - phototherapy +/- systemic therapy 3rd line - biological therapy Topic therapy - Regular emollient - Topical steroids: short term or intermittent use of beclamethasone (potent) - if facial or flexural used moderate potency - clobetasone - Vitamin D analogues: used for longer term treatment, improvement in 2-8 weeks. CALCIPOTRIOL - Risk of hypercalcaemia, parathyroid hormone suppression - Coal Tar - Tazarotene gel (vitamin A analogue) Photochemotherapy - PUVA (photosensitive drug) + UVA light - 2-3 times per week Systemic agents - Methotrexate (ciclosporin if pustular) - Works in 4-12 weeks 2nd line - hydroxycarbamide, sulfasalazine, azathioprine, leflunomide Biological therapy - etanercept - efalizumab - adalimumab - infliximab

Answer 179

``` Psoriasis area and severity index (PASI) For each area calculate: - % involved - severity of erythema - thickness and scaling ```

Answer 180

Chronic, relapsing inflammatory skin condition | Characterised by itchy red rash that favours skin creases

Answer 181

``` Very common High prevalence 20% children, 2-18% of adults Most cases are in under 5s Equal in gender Mainly Caucasian High in developed countries FHx associated ```

Answer 182

Irritants - soaps and detergents Skin infections - S.aureus Contact allergens Extremes of temperature or humidity Abrasive factors or fabrics Dietary factors Inhaled allergens - dust mites, pollen, dander, moulds Genetic mutation in production of FILLAGRIN - converts keratinocytes to outmost layer of skin Stress Hormonal changes - pre-menstrual changes, flare ups

Answer 183

Combination of genetic susceptibility and environmental factors - Defects in skins barrier function (FILAGGRIN) - Immune dysregulation - Allergen exposure

Answer 184

Itchy skin condition plus 3 or more of the following: - History of itchiness in skin creases - History of asthma or hayfever (or in 1st degree relative if under 4) - General dry skin in preceding year - Visible flexural eczema - Onset in first 2 years of life Associated disease: asthma, hayfever, allergic rhinitis

Answer 185

``` Atopic Pityriasis alba Eczema herpeticum Lichen simplex Asteatotic Discoid Pompholyx Varicose ```

Answer 186

Type of eczema | Pale patches of hypopigmentation on face of children

Answer 187

Herpes simplex virus infection superimposed onto skin affected by eczema. History of contact with adult with cold sore - Areas of rapidly worsening painful eczema - Clustered blisters consistent with early stage cold sores - Punched out erosions - 1-3mm and uniform - Fever, lethargy or distress

Answer 188

Localised areas of lichenification from rubbing

Answer 189

Older people with dry skin on lower legs | Crazy paving

Answer 190

``` Intensely pruritic Coin shaped lesions Most commonly on limbs May be vesicular Frequently colonised by S. aureus More common in males ```

Answer 191

``` Itching vesicles Fingers, palms and soles Blisters are small, firm and intensely itchy Occasionally painful More common in nickel allergy ```

Answer 192

Occurs in lower legs with venous insufficiency | Haemosiderin pigmentation

Answer 193

Impairment in skin barrier function leading to increased sensitisation to cutaneous antigens Links to genes of EDC - epidermal differentiation complex Links to FILAGGRIN - mutation leads to poor barrier function Immune response is predominantly TH2 mediated - IL 4, 5, 13 These interleukins increase production of IgE and eosinophilia Persistent inflammation and scratching can lead to chronic atopic dermatitis with thick lichenified skin

Answer 194

Tendency for dry skin Flare ups may vary from vesicles to areas of poorly demarcated redness - crusting, scaling, cracking or swelling Repeated scratching causes thickening of chronic lesions Infancy - face, scalp, extensor surfaces Adults - generalised dryness and itching Can develop bacterial infection - crusting, weeping, postulation, cellulitis

Answer 195

Not usually required for diagnosis Mild atopic eczema do not need clinical testing for allergies Estimation of IgE and RASTs (radioallergosorbent tests) only confirm atopy RAST and prick testing assess type 1 hypersensitivity Swab if infection Assess severity - eczema area and severity index For each body area - %area, severity score, redness, thickness, scratching, lichenification

Answer 196

Avoid provoking factors Emollients - liberal and frequent Topical steroids - mild potency on face, potent in lichenified or discoid eczema if on limbs or trunk - Once of twice daily - Short periods only Tacrolimus and pimecrolimus - If not controlled by maximal topical steroid or s/e too great Treat infections with flucloxacillin Severe may require - Phototherapy - Systemic steroids - Systemic therapy (azathioprine, ciclosporin) - Wet wraps with emollient under

Answer 197

``` Diagnosis uncertain Uncontrolled (1-2 flare ups per month) On face and not responding Contact dermatitis Severe bio/psycho/social issues Severe and recurrent infections ```

Answer 198

Inflammatory skin reaction in response to an external stimulus acting as an allergen or irritant

Answer 199

More common in females Most commonly occupational ``` Working with wet hands, soap and cleaning materials Florists hairdressers Cooks beautician Nurses/doctors e,g, gloves ```

Answer 200

Allergic contact dermatitis - type 4 hypersensitivity reaction. Often occurs after sensitisation and subsequent re-exposure to an allergen - cosmetics - metal: nickel/cobalt - topical medications - rubber additives - textiles - acrylic - plants Irritant contact dermatitis - inflammatory response that occurs after damage to the skin, usually by chemicals. Not an allergy. Can occur in anyone exposed to the irritant. Can be acute or chronic - water - detergent/soap - solvents/abrasives - Acids and alkalis - Reducing agents - Plants - Powders, dust and soil

Answer 201

Allergic contact dermatitis - Requires prior sensitisation to occur - Most allergens are HAPTENS than must bind to proteins to become antigenic - Hapten protein complex enters the statum corneum and binds to epidermal antigen presenting cells in Langerhans cells - These cells process the antigen and present it to CD4 T cells - They proliferate into memory and effector T cells which illicit allergic contact dermatitis in 2-4 days

Answer 202

``` Burning Stinging Soreness Onset with 48 hours, can be immediate Rash only in exposed areas Quick resolution with removal Commonly associated with atopic eczema Exposure to soap, water ```

Answer 203

``` Redness, itching, scaling Delayed onset Rash not only in exposed areas Resolution longer Decreased associated ```

Answer 204

Made on clinical findings and history Patch testing is gold standard - should always be done if occupational Occasionally skin biopsy

Answer 205

Avoidance of irritant Notify HSE all occupational cases Liberal emollient Topical corticosteroids - potency depends on severity In acute severe - short course of oral steroids or if over 20% surface area 2nd line - PUVA + phototherapy, ciclosporin or azathioprine

Answer 206

Mediated by IgE Allergic reaction provoked by RE-EXPOSURE to a specific type of antigen referred to as an allergen - Asthma - Anaphylaxis - Penicillin allergy - Food allergy

Answer 207

Cytotoxic reactions which produce haemolysis and purpura Produced antibodies bind to antigens on patient's own cell surfaces B cell mediated - produce antibodies against foreign antigens. IgG and IgM bind and form complexes - classical pathway of complement activation - ABO blood incompatibility - Goodpasture's syndrome

Answer 208

Immune complex reactions which result in vasculitis, serum sickness and urticarial - Accumulation of immune complexes (antigen antibody complexes) that have not been adequately cleared - Giving rise to inflammatory response and attraction of leukocytes - SLE - RA - Post-streptococcal glomerulonephritis - Polyarteritis nodosa - Reactive arthritis - Serum sickness - Farmer's lung - Henoch-Schonlein purpura

Answer 209

Delayed type reaction with cell-mediated hypersensitivity CD4 T cells recognise antigen with MHC II complex on surface antigen cells Secretion of IL2 and interferon gamma, release of cytokines CD8 cells destroy target cells on contact - Allergic contact dermatitis - Autoimmune myocarditis - Type 1 DM - Granulomas - Hashimoto's thyroiditis - IBD - MS - RA

Answer 210

``` Drug induced skin reaction 7-14 days after first drug exposure Or 3 days after 2nd exposure Potentially fatal 50% mortality On spectrum with Steven-Johnson syndrome, SJS if <10% of body, TEN >30% ``` Burning painful macular or popular rash that spreads from the face Bullae form and coalesce. Epidermis slough in sheets Hyperpyrexia Causes: - Allopurinol - Anticonvulsants - NSAIDs - Penicillin - Sulfonamides

Answer 211

``` Drug induced skin reaction 10% mortality Severe mucosal infection Flu like symptoms lesions on palms, soles, dorsum of hands, trunk Macule -> papules, vesicles, bullae ``` Can be caused by malignancy in adults or viral infection - Amoxicillin - Allopurinol - Carbamazepine - Ciprofloxacin - Diclofenac/ibuprofen - Lamotrigine - Phenytoin - Penicillin's - Tetracycline's

Answer 212

Drug induced skin reaction Acute onset of fever with generalised erythema Small sterile non follicular pustules ``` Caused by antibiotics Paracetamol sertraline diltiazem furosemide ```

Answer 213

``` Acute nodular erythematous eruption Front of shins Flu like symptoms Drug reactions COCP Penicillin Sulfonamides ``` Also associated with: IBD, Streptococcal infection in children, TB, EBV, Sarcoidosis, bechet's disease, pregnancy, cancer

Answer 214

Recur in same area when the same drug is give - Plaques circular and oedematous - Resolve to macular hyperpigmentation - Hands, feet, genitals Caused by aspirin, antibiotics, NSAIDs, COCP, phenytoin and benzos

Answer 215

Remove drug FBC - if serious can have leukopaenia, thrombocytopaenia and eosinophilia Monitor LFTs and U&Es 2 blood samples for mast cell tryptase if ?anaphylaxis Prick testing is dangerous - only used for penicillin allergy Oral provocation tests are gold standard but require strict supervision

Answer 216

``` Child Usually face and limbs Highly contagious Background erythema with yellow crusting and exudates If bullae = staph aureus If lymphadenopathy = strep pyogenes ```

Answer 217

Usually legs, bearded area and scalp Precipitated by waxing and shaving Staph aureus or pseudomonas aeruginosa

Answer 218

``` Deep form of impetigo Mainly on legs Slow healing Small bullae with adherent crust overlying ulceration Group A strep or Staph aureus ``` Treat with oral penicillin

Answer 219

Face or lower leg Skin infection with strep pyogenes / group A strep Well demarcated, red, shiny, raised, spreading plaque

Answer 220

Antiseptic skin washes e.g. chlorhexidine hydrochloride Topical antibiotics - localised infections (fusidic acid) maximum of 2 weeks Oral antibioics - if extensive - Staph = flucloxacillin - Strep = penicillin

Answer 221

3 main types: - Broadband UVB - Narrow band UVB - PUVA = psoralen + UVA = photochemotherapy Uses UV light to decrease inflammation Given as hospital outpatient 2-5 times per week Average course = 15-20 treatments Starting dose calculated using test patch of skin First dose < 1 minute, up to several minutes

Answer 222

``` Redness Folliculitis Discomfort Dry itching skin Blisters Sunlight induced rash - polymorphic light eruption ```

Answer 223

``` Eczema Psoriasis Dermatitis Generalised itching Cutaneous T cell lymphoma Vitiligo ``` These conditions not controlled by topical therapy

Answer 224

``` Can't attend regularly Made worse by sunlight Can't stand for 10 minutes Xeroderma pigmentosum Hx of skin cancer Lupus erythematous Taking methotrexate or ciclosporin Immunosuppressed Not PUVA in renal or liver disease Maximum number of treatments reached ```

Answer 225

Wet bandages wrapped over emollients +/- topical steroids Useful in erythroderma or hot weeping eczema Cooling as water evaporates Moisturisers are deeply absorbed Decreases itching, scratching, redness, inflammation Increases rehydration and skin healing Reduces steroid requirement

Answer 226

Dermatologists provide - information for patient - pre-treatment assessment - Initiate treatment - Issue clinic letter to GP - Assess response to treatment and make dose adjustments GP - Issues prescription - Carry out monitoring stated by dermatologists - Contact dermatology for any abnormal results - monthly blood checks

Answer 227

Abnormal controlled lesions that arise from basal cells which line the deepest layer of epidermis. Slow growing, locally invasive malignancy

Answer 228

``` Most common skin cancer 80% of non-melanoma skin cancers More common in men Increases in age More common in Caucasians higher in equatorial areas ```

Answer 229

``` Genetic predisposition Exposure to UV radiation Sun exposure as a child Skin type 1-2 (always burns/rarely tans) PMHx of BCC Basal cell naevus (Gorlin's syndrome) Xeroderma pigmentosa Immuosuppression ```

Answer 230

rare, autosomal recessive disorder. There is an impairment of the skin's ability to repair damage from ultraviolet (UV) light, leading to early skin changes, early sunburn, dry skin and a vastly increased tendency to develop skin tumours and eye damage from UV light.

Answer 231

Nodular - solitary, shiny, red nodule with large telangiectasia vessels Superficial - Face, trunk and limbs. Equally distributed - Erythematous, well demarcated, scaly plaques - Rolled edge Morphoeic - sclerosing or infiltrative BCC - More aggressive, prone to recurrence - Poorly defined borders, thickened yellow plaques Pigmented - Nodular or superficial histology + brown/blue/grey - More common in darker skinned people

Answer 232

``` Multiple BCCs Autosomal dominant Jaw cysts Spine and rib abnormalities Pitting of palms and soles Cataracts Calcification of falx cerebri ```

Answer 233

Arises from hair follicles Tumour infiltrates local tissues through slow irregular growth of subclinical finger like projections Mutations in p53 Activation of sonic hedgehog signally cascade

Answer 234

``` Sun exposed areas of head or neck Small, translucent or pearly Raised areas of telangiectasia RODENT ULCER - indurated edge Ulcerated centre Slow growing ```

Answer 235

``` Visual inspection Removal for histology All specimens must go to histology All must be biopsied No format staging beyond examination for lymphadenopathy ```

Answer 236

Surgery - excision with closure. Excise margin of at least 4mm - Moh's micrographic surgery - best for high risk - Curettage and cautery - Cryotherapy if small and low risk (need to biopsy first for histology) Non-surgical - Topic imiquimod 5% (can use 5-FU) - Photodynamic therapy - minimal side effects with good cosmetic result - Radiotherapy if recurrent, incomplete excision or bone/cartilage involvement = 90% cure, poor cosmetic outcome

Answer 237

Mets rare Mortality low Increased risk of SCC and MM

Answer 238

Malignant tumour arising from keratinising cells of epidermis or its appendages Locally invasive Has potential to metastasise

Answer 239

``` Increases with age Increased in men Increased in Caucasians Increased in equatorial regions 2nd most common (behind BCC) ```

Answer 240

``` Chronic UV exposure - holidays, outdoor occupation, sunbeds Fair Skin Blond/red hair Chemical carcinogens HPV infection Ionising radiation Immunodeficiency Chronic inflammation Xeroderma pigmentosum Albinism Bowen's disease Actinic keratosis Ciclosporin ```

Answer 241

Arises in keratinocytes that have undergone uncontrolled proliferation Accumulation of genetic mutations Decrease levels of PTEN (tumour suppressor) Can be caused by immunosuppression Precursor: actinic keratosis

Answer 242

Indurated (hardened) nodular keratinising or crusting tumour Non healing ulcer in exposed area Head and neck Very variable presentation Sharply defined red scaling plaques Bleeding and crusting As it enlarges the centre becomes necrotic Can give rise to local mets or spread to local lymoh nodes

Answer 243

``` Incisional biopsy Full excision under local if possible - take dull depth and wide margins FNA/Biopsy for any enlarged lymph nodes CT/MRI if ? spread Refer for dermatological biopsy ```

Answer 244

Refer to dermatology and skin cancer MDT - Complete surgical excision and histopathology - Curettage and cautery if small <1cm - Cryotherapy if small - Topical imiquimod 5% - Photodynamic therapy has limited efficacy - Radiotherapy if it cannot be treated with surgery

Answer 245

Met rate <5% but only 30% survival at 5 years if mets occur Large size, depth increases risk As does Bowen;'s disease, radiation area or non-exposed sites Increased if on ear or lip

Answer 246

4% of skin tumours More common in women Women tend to get on arms and legs, men = head and neck Increases with age Superfiical spreading is most common subtype More common in Caucasians

Answer 247

``` Previous history of melanoma Naevi = more than 100 common or 2 atypical Atypical mole syndromes Naevi on unusual suites Sun exposure - Acte in childhood and severe sunburn - Occupation and leisure - airline, gardener, cricketer - Host response to UV is more important than dose - Past sun bed use in under 30s Skin type 1 or 2 Fhx of melanoma Solar keratosis Past pesticide exposure Higher socioeconomic group ```

Answer 248

Superficial spreading (50%) - Large, flat, pigmented lesion which grows laterally before vertical invasion develops - More common in females on lower leg Nodular melanoma (25%) - Most aggressive - Rapidly growing pigmented nodule which bleeds or ulcerated - More common in males - Commonest on trunk ``` Lentigo melanoma (15%) - patch of lentigo maligna develops a papule or nodule ``` Acral lentiginous malignant melanoma - Pigmented lesions on palms, soles or under nail - presents late, poor prognosis

Answer 249

Most common sites to spread: Lymph, liver, lung, bone, brain BRAF is an activator of MAP kinase 50% of those with melanoma have BRAF mutations BRAFV600 therapy is a target

Answer 250

``` NICE 7 point check lists Major features - 2 points each - Change in size - Irregular colour - Irregular shape ``` Minor features - 1 point each - Size over 7mm - Inflammation - Oozing - Change in sensation 2 week referral if 3 or more points ABCDE Asymmetry, Border irregular, Colour irregular, Diameter >7mm, Evolving Spontaneous bleeding or ulceration Altered pigmented lesion

Answer 251

- Full thickness excisional biopsy - Dermoscopy: examine lesion - Genetic testing: CDKN2A - All excised lesions to histology - Sentinel lymph node biopsy and removal for staging - Scan for mets: CXR/CT chest, CT TAP - FBCs, LFTs, LDH

Answer 252

Measurement in mm of distance between granular cell layer to deepest identifiable melanoma cell

Answer 253

- Refer to dermatology - Skin cancer MDT - DO NOT REMOVE IN PRIMARY CARE - Stage 0 = excise with 0.5cm margin. Consider imiquimod - Stage 1 = Excise with 1cm margin - Stage 2 = Excise with 2cm margin - Stage 3 = lymph node dissection. Palliative care - Stage 4 - surgery to control symptoms Targeted treatment - Dabrefenib if BRAF V600 + Chemotherapy: dacarbazine

Answer 254

Very poor if mets - survival 6-9 months 5 year survival 80%

Answer 255

Squamous cell carcinoma in situ of the skin Arises in outer layers of epidermis Risk of progression to invasive SCC is low 3-5%

Answer 256

More common in women (75%) Common in 60-70 years ] Higher in Caucasians ``` RFs - Sun damage - Irradiation damage - Carcinogens - HPV infection (usually HPV16) Immunosuppression (AIDs, organ transplant) Chronic skin injury ```

Answer 257

Slowly growing erythematous patch or plaque Sharply demarcated, scaling or hyperketatoic with red/pink surface May be a small erosion Generally asymptomatic but can bleed Most on limbs, head and neck (sun exposed areas)

Answer 258

Cryotherapy - often first line Topical 5FU Curettage Surgical excision

Answer 259

Also known as solar keratoses | UV light induced lesions on the skin and are the most common lesions with malignant potential into SCC

Answer 260

Increase with age More common in men More common in Caucasians Increased in equatorial areas ``` RFs Outdoor lifestyle Sun beds Working outside Immunosuppressed Skin type 1 or 2 ```

Answer 261

Sun exposed areas Telangiectasis, elastosiss Small rough spots, more easily felt than seen Enlarge over time becoming red and scaly Can be pigmented, have horn like projection or be thickened Flare and erythematous when immunosuppressed 10% undergo malignant change

Answer 262

``` None unless malignancy suspected Biopsy if: - pronounced hyperkeratosis or erythema - recurring lesions - unresponsive to treatment - confluent lesions - transplant recipient - past history of SCC ```

Answer 263

Mild = emollient or no therapy Topical 5FU Phototherapy if superifical Curettage or excisional surgery for histological information Refer if multiple confluent AKs, organ transplant patient or unclear diagnosis

Answer 264

Flat topped warty looking lesions that appear stuck on Usually pigmented Well circumscribed Surface pitted and irregular with visible keratin dots giving a rough and glandular appearance Most common on trunk Usually asymptomatic

Answer 265

``` 1 - always burns, never tans 2 - always burns, sometimes tans 3 - somestimes burns, always tans 4 - never burns, always tans 5- brown skin (Asian) 6 - Black skin ```

Answer 266

Volume of air the patient is able to exhale in the first second of forced expiration

Answer 267

Forced vital capacity | Total volume of air a patient can forcibly exhale in 1 breath

Answer 268

FEV1<80% | FEV1/FVC <70%%

Answer 269

FEV1<80% FVC<80% FEV1/FVC>70%

Answer 270

Notifiable disease Chronic granulomatous disease caused by Mycobacterium tuberculosis It is spread via inhalation of infected droplets

Answer 271

14 per 100,000 Increased in ethnic minorities Increased in elderly Increased in Non UK born population RDs - Healthcare worker - Alcoholic - Close contact of TB patient - Homeless / poor housing / over crowding - Poverty - Drug use - Malnutrition - Prison - Immunocompromised - HIV (60% have TB) - Haematological cancers - Diabetes - long term steroids - Silicosis

Answer 272

Causes by mycobacterium tuberculosis Can be Multi-drug resistant - resistant to more than 1 drug Extensively drug resistant = resistant to more than 3 drugs

Answer 273

- Primary infection host macrophages in lung engulf organisms and carry to hilar lymph nodes which forms GHON FOCUS - Some organisms disseminate via lymph nodes to distant sites - Small granulomas are formed around the body to contain the bacteria - 80% heal spontaneously and bacteria are eliminated - OR bacterial remain encapsulated in defensive barrier but persist - DORMANT DISEASE Secondary TB - activation of dormant disease usually preceded by immunosuppression, malnutrition, aids. Reactivation usually occurs in APEX of lungs and can spread

Answer 274

When primary infection is not adequately contained it enters the blood stream and causes severe disease

Answer 275

Most cases occur from latent infection from previous exposure Onset is insidious 1y infection - asymptomatic 2y infection is variable and non-specific TB can affect all organs and body systems - General symptoms: fatigue, weight loss, anorexia, pyrexia - Pulmonary symptoms: chronic productive cough +/- haemoptysis, lobar collapse, bronchiectasis, pleural effusion, pneumonia, pneumothorax - GU: most common site outside of lung. infertility, pyuria, swelling of epididymis - MSK: pain, arthritis, osteomyelitis, nerve compression - CNS: meningitis - GI: ileocecal regions: abdo pain, bloating, obstruction - Lymph nodes: tender, firm, discrete - Skin - pericardial effusion

Answer 276

CXR (even if no pulmonary symptoms) - Primary: central apical portion + lower lobe infiltrate or effusion - Severe = millet seeds - patchy nodular shadows - upper zones - Loss of volume - fibrosis +/- cavitation Microbiology - 3 sputum samples for culture - Analysed using Ziehl-Neelson stain to test for acid/alcohol fast bacteria - 4-8 weeks for culture as slow growth lab tests for HIV, Hep B and C FBC, U&Es, CRP, ESR, U&Es

Answer 277

Mantoux test or IGRA (interferon gamma release assay) If had vaccine: Mantoux +, IGRA - If have TB - Mantoux +, IGRA + If no vaccine, no TB - Mantoux -, IGRA - Mantoux measures response to tuberculin - <5mm is negative, 5-10mm is positive, 10-15mm is strongly positive For contact screening use Mantoux

Answer 278

Notify public health Most managed as outpatients but some need admitting to monitor drug adherence. Well ventilated single room, away from immunocompromised - 6 months, 4 drugs - Isoniazide, rifampicin - Ethambutol and pyrazinamide (only for first 2 months) - If meningeal then 12 months with 2-3 weeks of steroids - Regularly check LFTs due to drug toxicity - Avoid ethambutol in renal failure - Compliance is a large problem

Answer 279

Skin tags/acrochordons - small pedunculated skin coloured papules occur most frequently with skin folds 0.2-0.5mm

Answer 280

``` TB Extrinsic allergic alveolitis Coal workers pneumoconiosis Silicosis Sarcoidosis Ankylosing spondylitis Histocytosis ```

Answer 281

bleomycin idiopathic pulmonary fibrosis Connective tissue disorder Drug induced - methotrexate, Amiodarone, asbestosis

Answer 282

Most common valve disease 2-7% of population over 65, 10% over 80s Can be congenital Aged 30-60 in rheumatic disease, 50-60 with bicuspid valves, 70-90 with calcific changes

Answer 283

Congenital aortic stenosis Congenitally biscuspid valve Rheumatic disease Degenerative - calcified

Answer 284

Cardiac output is maintained at the expense of steadily increasing gradient LV becomes hypertrophied and coronary blood flow may then become inadequate Fixed outflow obstruction limits and increase in cardiac output with exercise Eventually LV cannot overcome obstruction and pulmonary oedema occurs

Answer 285

Tend to be asymptomatic for years and deteriorate rapidly SOB on exertion Angina Dizziness Syncope (on exertion) Predisposition to angina - 50% have coronary artery disease Risk of sudden death so avoid exertion TRIAD - chest pain, heart failure and syncope Episodes of acute pulmonary oedema

Answer 286

``` Ejection systolic murmur Radiates to carotids Most commonly heard in aortic area Slow rising pulse - pulsus parvus et tardus Narrow pulse pressure Thrills 4th heart sound if severe Thrusting apex beat from LV pressure overload Crepitations from pulmonary oedema ```

Answer 287

ECG: LVH and LBBB Left ventricular strain pattern, down slowing ST segments, ST depression, T wave inversion CXR - may be normal Cardiomegaly, enlarged LV and dilated ascending aorta Echo: calcified valve with restricted opening, hypertrophied LV Doppler to measure degree of stenosis Cardiac catheterisation - identify coronary artery disease and measure gradient across the valve No exercise testing unless they are asymptomatic CT and cardiac resonance imaging for quantifying calcification and used in prognosis

Answer 288

Avoid heavy exertion Early surgical intervention as no medical management can improve outcome - Statins - Modify atherosclerotic risk factors - Digoxin, diuretics and ACEi if awaiting or not suitable for surgery - Manage hypertension and maintain sinus rhythm - If severe, monitor every 6 months and echo, mild-moderate review yearly Aortic valve replacement - Definitive therapy, mortality 1-3%, Balloon valvuplasty - NICE recommended but restenosis and deterioration occurs within 6-12 months for most paitnets, only used if unsuitable for replacement Transcatheter aortic valve implantation - Under general or local - Balloon valvuoplasty followed by insertion of specialised valve device - Fluoroscopy guided

Answer 289

``` LV dysfunction Heart failure Infective endocarditis Small systemic emboli Sudden death ```

Answer 290

Most commonly caused by rheumatic disease Peak age 40-60 2% ``` RFs Marfan's SLE Ehler's Danlos syndrome Turners Ankylosing spondylitis Reactive arthritis Takayasu's disease Behcet's disease Acute severe follows infective endocarditis or aortic dissection ```

Answer 291

``` Rheumatic disease Bicuspid aortic valve Infective endocarditis Collagen vascular disease Degenerative aortic valve disease Aortic dilatation - Marfan's, aneurysm, dissection, ankylosing spondylitis ```

Answer 292

LV dilated and hypertrophies to compensate for regurg Stroke volume can be doubled/tripled As disease progresses, LV diastolic pressure rises and causes breathlessness

Answer 293

``` Often asymptomatic Palpitations breathlessness Angina PND Peripheral oedema ```

Answer 294

Early diastolic murmur best heard in aortic area Sitting forward in expiration Austin Flint murmur Wide pulse pressure with sudden collapse of pulse at the end Water hammer/Corrigan pulse head bobbing with each pulse - Musset's sign Pulsus bisferienes (double peak of pulse) Bounding peripheral pulses Femoral bruit (Duroziez's sign) Capillary pulsation in nail beds - Quincke's sign Displaced apex beat Creps

Answer 295

Head bobbing with each pulse | Seen in aortic regurgitation

Answer 296

Capillary pulsation in nail beds | Seen in aortic regurgitation

Answer 297

ECG - initially normal, then LV hypertrophy and T wave inversion CXR - cardiac dilatation, features of left heart failure Echo - dilated LV, hyperdynamic LV, fluttering anterior mitral leaflet Cardiac resonance imaging/ CT if enlarged aorta on echo e.g. Marfan's Can do cardiac catheterisation - dilated LV, aortic regurg, dilated aortic root

Answer 298

If acute - urgent surgical intervention Mild-moderate - monitor annually, echo every 2 years Severe every 6 months, echo every year Vasodilators and inotropic agents - short term ACEi in chronic severe Surgery if symptomatic - Aortic valve replacement - Valve sparing aortic replacement is becoming more common - Operative mortality 1-4%

Answer 299

Primary Intrinsic lesions affect one or several components of the valve Degenerative mitral regurgitation is the most common cause Acute can be caused by papillary muscle rupture, infective endocarditis or trauma Secondary (functional) Valve leaflets normal but MR results from distortion of subvalvular apparatus due to LV enlargement May be due to cardiomyopathy

Answer 300

2nd most prevalent valve disease after aortic stenosis Increased in females increases with age RFs - Lower BMI - Renal dysfunction - Prior MI - Prior mitral stenosis or mitral valve prolapse

Answer 301

``` Coronary artery disease (papillary muscle dysfunction) Infective endocarditis Following mitral valve surgery Myxomatous degeneration - Ehler's Danlos, Marfan's, SLE, scleroderma Cardiac tumours - atrial myxoma Rheumatic fever Acute LV dysfunction Congenital heart disease Drug related ```

Answer 302

Chronic mitral regurg causes gradual dilation of LA with little increase in pressure causing few symptoms LV dilates slowly and LV diastolic and LA pressures increase gradually as a result of chronic volume overload

Answer 303

If acute, rapid pulmonary oedema which can be fatal and requires emergency valve repair Chronic - Heart failure - breathlessness - Pansystolic murmur best heard at the apex - Radiates into axilla - Dyspnoea (pulmonary venous congestion) - Fatigue (low cardiac output) - Palpitations - Oedema, ascites (R sided HF)

Answer 304

Pansystolic murmur best heard at apex, radiates to axilla Cardiomegaly AF or atrial flutter Signs of pulmonary venous congestion - creps, effusions

Answer 305

CXR Enlarged LA, enlarged LV, pulmonary venous congestion, pulmonary oedema if acute ECG Left atrial hypertrophy, broad P wave, LV hypertrophy Echo: dilated LA, LV. structural abnormalities of mitral valve Cardiac catheterisation - dilated LA, LV, mitral regurg, pulmonary hypertension, co-existing coronary artery disease Angiography for CAD

Answer 306

Surgery if signs of LV dysfunction, new onset AD or pulmonary hypertension Follow up yearly with echo every 2 years, severe every 6 months with echo annually Medical - Nitrates, diuretics, positive ionotropic agents (Digoxin)- Anticoagulation if AF present Surgery - urgent if acute severe - valve replacement, repair where possible - Percutaneous not recommended

Answer 307

Pulmonary hypertension LV dysfunction AF Thromboembolism due to AF

Answer 308

Permanent and irreversible dilation of the aorta by at least 50% its normal diameter Normal diameter of the aorta is 2cm, but increases with age AAA is >3cm Most arise from above the renal arteries

Answer 309

1-12% of the population More common in men Symptomatic in 25/100,000 ``` RFs Hypertension Fhx (minimal) Severe atherosclerotic changes to vessel wall Smoking COPD Hyperlipidaemia ```

Answer 310

Most have no specific cause - Trauma - Infection - HIV, TB, Brucellosis, salmonellosis - Inflammatory disease - behcet's and takaysau's - Connective tissue disorders - Marfan's, Ehler's Danlos syndrome

Answer 311

Degradation of elastic lamellae Leukocytic infiltrate Enhanced proteolysis Smooth muscle cell loss Dilation affects all 3 layers of the cell wall The larger the AAA the larger the growth rate and the greater the risk of rupture

Answer 312

Most have no symptoms Incidental finding on examination Can have pain in back, abdomen or groin (? due to pressure on nearby structures) Pulsatile abdominal swelling Distal embolization can produce features of limb ischaemia Hydronephrosis Abdominal bruits

Answer 313

Hypotension Atypical abdominal symptoms Sudden and severe abdominal pain (or back or loin) Syncope Shock or collapse Cold, sweaty, faint Vomiting Degree of shock depends on site of rupture and whether it is contained Retroperitoneal bleeding may cause Grey Turner's sign - flank bruising TRIAD - pain in flank or back, hypotension, abdominal pulsatile mass If thoracic - then chest pain, cardiac tamponade and haemoptysis

Answer 314

Flank bruising (due to retroperitoneal bleeding)

Answer 315

``` Bloods - FBC, clotting screen, renal function, LFTs, cross match units for surgery ESR or CRP if ? inflammatory cause ECG CXR Lung function tests ``` Scans US CT - crescent sign (blood within thrombus which may predict immanent rupture) MRI angiography

Answer 316

If UNCOMPLICATED: - Monitor if <5.5cm, consider surgery in over 5.5cm - US monitoring frequency depends on size, 3-4.5 every year, >4.5 every 3 months - Change RFs where possible Surgery - If over 5.5 - High risk of rupture - Rapid expansion - Symptomatic Open repair with aortic and iliac clamping, replacement of segment with prosthetic graft OR endovascular repair: stent-graft system through femoral arteries

Answer 317

Death AKI Multi-organ failure Respiratory failure Risk determined by diameter 2.4% mortality with elective repair 20% annual survival rate if over 5.5vm 80% mortality with ruptured AAA

Answer 318

Initiated by electrical discharge in SA note Atria and ventricles depolarise sequentially. SA node acts as pace maker, intrinsic rate determined by autonomic nervous system Passes through AV node, into bundles of His then pirkinje fibres

Answer 319

HR under 60bpm in sinus rhythm ``` MI Sinus node disease (sick sinus syndrome) Hypothermia Hypothyroidism Cholestatic jaundice Raised ICP Drugs - beta blockers, digoxin, verapamil ``` NORMAL in athletes

Answer 320

Often asymptomatic Fatigue Lightheadedness Syncope

Answer 321

Normally responds to IV atropine | If recurrent or persistent then cardiac pacing

Answer 322

Sinus >100bpm ``` Anxiety Fever/Sepsis Thyrotoxicosis Anaemia Phaeochromocytoma heart failure Drugs - beta agonists Pregnancy Exercise ```

Answer 323

Also referred to as Sinoatrial Disease - Most common in elderly - Underlying pathology can be fibrosis, degenerative changes or ischaemia - Characterised by a number of arrhythmias - May have palpitations, dizzy spells, syncope - Intermittent tachycardia, bradycardia or pauses with no atrial or ventricular activity Features: - Sinus bradycardia - Sinoatrial block - Paroxysmal AF - Paroxysmal atrial tachycardia - AV block Treat symptomatic patients with pacing

Answer 324

Extrasystoles, premature beats usually causes no symptoms ECG shows a premature but otherwise normal QRS If the visible p wave has a different morphology, from abnormal site No consequence, however, very frequent atopics can lead to onset of AF

Answer 325

Large re-entry circuit within the R atrium Atrial rate 300bpm, usually associated with 2:1, 3:1 or 4:1 block (producing HR 150, 100 or 75) - Saw tooth flutter waves - Should always be suspected if narrow complex with 150bpm - Management - Carotid sinus pressure or IV adenosine can slow rate to see sawtooth waves - Treat with digoxin/beta blockers/verapamil - Can try to restore rhythm through DC cardioversion or IV Amiodarone - Beta blocker or Amiodarone can help prevent recurrence - Catheter ablations can give chance of complete cure and is treatment of choice with persistent symptoms

Answer 326

Most common sustained cardiac arrhythmia 0.5% prevalence, increases to 9% in over 80s Abnormal automatic firing with presence of multiple atrial re-entry circuits Becomes sustained after re=entry conduction Atria beat rapidly, ineffectively and in-coordinated Ventricles activated irregularly determined by conduction through AV node Irregularly irregular pulse Normal but irregular QRS No p wave Can be paroxysmal or permanent Initial physical changes - electrical remodelling After a few months - structural remodelling with atrial fibrosis and dilation

Answer 327

``` Idiopathic MI Valvular heart disease (particularly mitral disease) Hypertension SA node disease Hyperthyroidism Alcohol Cardiomyopathy Congential heart disease Chest infection PE Pericardial disease ```

Answer 328

``` Palpitations Breathlessness Fatigue Lightheadedness Chest pain (if coronary artery disease) May have reduced BP ``` Often asymptomatic Stroke/TIA

Answer 329

12 lead ECG - Irregular QRS - No p waves - Fast ventricular rate 120-160, slows with chronic Bloods - FBC (anaemia may precipitate) - U&Es (potassium is a culprit) - LFTs and coag screen prior to anticoagulation - TFTs CXR - may show structure causes Echo - baseline needed for longer term management, if considering cardioversion or high risk of functional or structural heart disease

Answer 330

- Treat any underlying cause - Control of arrhythmia (rate and rhythm) - Thromboprophylaxis Rate control is first line unless: reversible cause of AF, heart failure caused by AF or new onset AG - beta blocker or rate limiting CCB - Consider digoxin if permanent AF and sedentary patient - If monotherapy fails, try combining - No Amiodarone Rhythm control - if AF continues post rate control or unsuccessful - Cardioversion (electrical, Amiodarone therapy for 4 weeks before and 12 months after to maintain sinus) - Drug treatment: - 1st line: beta blocker - Dronedarone or Amiodarone is LV impairment of HF - Left atrial ablation if drugs unsuccessful - Pacing and ablate strategy Anticoagulation - Apixaban, rivaroxaban or warfarin or dabigatran - Use CHA2DS2-Vasc score

Answer 331

``` CHA2DS2 Vasc score Congestive heart failure Hypertension Age>75 - 2 points Diabetes past Stroke or TIA - 2 points ``` Vascular disease Age 65-75 - 1 point Sex - female If males score 1 or more, or females 2 or more - start anticoagulation, proving consideration of bleeding risk HAS-BLED

Answer 332

Stroke Can precipitate acute heart failure or aggravate established heart failure Cardiomyopathy Premature death

Answer 333

If life threatening haemodynamic instability then emergency electrical cardioversion and resuscitation] Rhythm control if within 48 hours of start, rate control if unsure or longer

Answer 334

Paroxysmal - intermittent episodes that self-terminate in 7 days Persistent - prolonged episodes which can be terminated with chemical or electrical cardioversion Permanent

Answer 335

Re-entry circuit involving AV node and its 2 right atrial input pathwyas - Produces tachycardia at 120-140bpm - Occurs in absence of structural disease - Rapid, forceful regular heart beat - Chest discomfort - Breathlessness - Lightheadness - Tachycardia with normal QRS complexes - Adenosine or verapamil will restore sinus rhythm in most cases

Answer 336

Shortened PR interval Slurred initial deflection of QRS - DELTA WAVE Broad QRS complex

Answer 337

Abnormal band of conducting tissue connects atria and ventricles Accessory pathway - bundle of Kent contains rapidly conducting fibres rich in sodium channels As the AV node and accessory pathway have different conduction speeds and refractory periods - therefore a re-entry circuit can develop causing tachycardia - If AF occurs very dangerous as no rate limitation from AV node (emergency)

Answer 338

Broad, premature and bizarre QRS complexes Ventricles are activated sequentially and not simultaneously Unifocal or multifocal Pulse irregular with weak or missed beats Generally asymptomatic but can have irregular hearbeat, missed beats or unusually strong beats More prominent at rest and decreases with exercise No treatment unless symptomatic - use beta blockers or catheter ablations

Answer 339

Alternating between ventricular ectopics and sinus rhythm between on each beat S - E - S - E - S - E

Answer 340

At rest In patients with heart failure and cardiomyopathy Increases in age Digoxin toxicity

Answer 341

Tachycardia, rate over 120bpm Broad, abnormal QRS complexes Marked left axis deviation Can be difficult to distinguish between this and SVT with BBB

Answer 342

Ventricular tachycardia - Occurs most commonly in MIs and cardiomyotahty, where there is extensive ventricular disease - May cause haemodynamic compromise and progress to VF - It is caused by abnormal automaticity or triggered activity in ischaemic tissue

Answer 343

Symptoms: - Syncope - Palpitations - Lightheadedness - Dyspnoea Features - History of MI - AV dissociation - Capture or fusion beats - Extreme left axis deviation - Very broad QRS > 140ms - No response to carotid sinus massage or IV adenosine

Answer 344

Prompt action to restore sinus rhythm - DC cardioversion if BP<90 - IV Amiodarone if arrhythmia well tolerated - Correct: hypokalaemia, hypoxia, hypomagnesaemia, acidosis - Avoid class 1c anti-arrhythmic

Answer 345

Rapid irregular complexes the oscillate from upright to inverted position and twists around the baseline as mean QRS axis changes Non sustained, repetitive, but can degenerate into VF Prolonged QT interval

Answer 346

``` Bradycardia Hypokalaemia Hypomagnesaemia Hypocalcaemia Class 1a and class 1c anti-arrhythmic drugs Amitriptyline and other TCAs Chlorpromazine Congenital syndromes ```

Answer 347

Long QT1 - triggered by exercise Long QT2 - triggered by sudden noise Long QT3 - common during sleep

Answer 348

Treat underlying cause IV magnesium in all cases Atrial pacing If very long >500ms then implanted defibrillator

Answer 349

Genetic disorder which can present with polymorphic VT or sudden death Due to a defect in the sodium channel function RBBB and ST elevation in V1 and V2 with no prolongation of QT interval

Answer 350

AV conduction delayed | Prolonged PR interval > 200ms

Answer 351

2:1 Mobitz type 1 Wenckeback PR interval increases until QRS dropped 2:2 - mobitz type 2 PR interval remains constant but some QRS complexes are not conducted, Regular p waves

Answer 352

QRS and p waves do not correlate Occurs when AV conduction fails completely Slow regular pulse 25-50bpm Pulse does not vary with exercise

Answer 353

``` Congential Idiopathic fibrosis MI Inflammation - infective endocarditis, sarcoidosis, Chaga's disease Cardiac surgery Drugs - Digoxin, beta blockers ```

Answer 354

Episodes of ventricular asystole that can complicate 3rd degree or mobitz type 2 heart block Sudden loss of consciousness that occurs without warning and results in collapse Brief anoxic seizure if prolonged Pallor and death like appearance during attack followed by characteristic flushing Rapid recovery unlike epilepsy

Answer 355

``` Normal variant Right ventricular hypertrophy or strain PE Congenital heart disease e.g. atrial septal defect Coronary artery disease ```

Answer 356

Coronary artery disease Hypertension Aortic valve disease Cardiomyopathy

Answer 357

Depolarisation goes through a smaller myocardial route rather than fast Purkinje fibres Causes delayed conduction into one of the ventricles Broad QRS > 120ms WilliaM - LBBB has W in V1 and M in V6 MarroW - RBBB has M in V1 and W in V6

Answer 358

``` Hypovolaemia Hypoxia Hydrogen ions (acidosis) Hypothermia Hypokalaemia/ hyperkalaemia Hypoglycaemia ``` ``` Toxins Tamponade (cardiac) Tension (pneumothorax) Thrombosis (coronary or pulmonary) Trauma ```