February Flashcards
What kind of MI can cause bradycardia? Why?
Inferior MI - RCA - supplies SA node
Broad causes of bradycardia
Drugs Conductive (blood supply or structural) Structural (infection, infiltrates) Neural (vagal, increased ICP) Endocrine/homeostasis (hypothyroid, hypokalaemia, hypothermia)
Drugs that can cause bradycardia?
Antiarrythmics (amiodarone)
Beta blockers
CCB (verapamil)
Digoxin
Medical treatment options for profound bradycardia ?
Atropine up to 3g IV
Isoprenaline
Main important differential to identify in narrow complex tachycardia?
AF or not AF
Treatment options in acute tachy AF
Rate control - metoprolol or digoxin
If <48h - DC cardioversion, or amiodarone
Consider anticoagulation with heparin pr warfarom
3 rhythms described as broad complex tachys
Ventricular tachycardia
Torsade de pointe
SVT with BBB
What happens to QT interval in hypokalaemia?
Increased QTI
What electrolyte imbalance can cause VT?
Hypokalaemia and hypomagnesaemia
Causes of ventricular tachycardia
IM QVICK
infarction
Myocarditis
QT interval increase Valve disease - AS, MR Iatrogenic - digoxin, antiarrythmics, catheter Cardiomyopathy K low, Mg low, O2 low, acidosis
3 scenarios in AF
Acute <48 hrs
Paroxysmal
Persistent
Management of acute AF
Haemodynamically unstable = DC cardiovert
Otherwise - rate control with verapamil or diltiazem, or digoxin/amiodarone
Rhythm control with flecainide or amiodarone
Chadvasc score
Management of paroxysmal AF
Pill in pocket
Long term bb
Management of persistent AF
Anticoagulate for 3 weeks at least, then cardiovert DC or medical
Or rate control with BB or rate limiting CCB
What does a new onset LBBB also imply?
STEMI
Which coronary artery is implicated in STEMI seen in V2 3 4
Left anterior descending - anterioseptal
What should you consider if ST depression is seen in V 1 2 3?
Posterior STEMI
58 year old man presenting with chest pain. ECG shows sinus tachy with TWI.
Hx shows STEMI 1 week ago.
O/E mildy pyrexic, pain is relieved by sitting forward
What is the most likely diagnosis and what investigation needs to be done
Pericarditis
ECHO
In STEMI, if patient is not given PCI or thrombolysis, what should the patient be prescribed?
LMWH
Management of STEMI
ABCDE assessment O2, IV access Aspirin 300mg, clopidogrel 300mg PO Morphine 5-10mg IV, metoclopramide 10mg IV GTN, betablocker IV LMWH
Normal ejection fraction see on ECHO?
60%
Key investigation in heart failure
ECHO
Secondary causes of hypertension
PREDICTION P = primary 95% R = renal (renal artery stenosis, GNtis, APKD) Endocrine = cushings, phaeochromcytoma, conns, hyperthyroid, acromegaly Drugs = cocaine, NSAIDs, COCP ICP = increased ICP (cushings reflex) Coarctation of aorta Toxaemia of pregnancy Increased viscosity Overloaded with fluid Neurogenic causes
End organ damage due to hypertension
CANER
Cardiac - LVF, AR, MR, IHD Aortic - dissection, aneurysm Neuro - stroke, encephlopathy from malignant htn Eyes - hypertensive retinopathy Renal - proteinuria, CKD
Slow rising pule with narrow pulse pressure is a sign of whatr
Aortic stenosis
Ejection systolic murmur with no radiation and normal pulse is a sign of what?
Aortic sclerosis
Symptoms and signs of infective endocarditis
FROM JANE
Fever
Roth spots
Oslers nodes
Murmur
Janeway lesions
Anaemia
Nailbed haemorrhages
Embolus
Types of symptoms and signs in infective endocarditis
Systemic - septic picture, weight loss,
Vasculitic - janeway lesions, septic embolus, microvascular haemorrhages,
Immunologic - oslers nodes, roths spots, glomerulonephritis
What bloods can be seen increased in myocarditis?
Increased trop, increased CK
What is a cause for J waves and bradycardia?
Hypothermia
What drug is contraindicated in aortic stenosis?
Nitrates
What heart condition is associated with excessive alcohol intake?
Dilated cardiomyopathy
What condition is associated with electrical alternas
Cardiac tamponade
NICE guidelines for management of heart failure with reduced ejection fraction?
1) ACEi + BB (B1 specific e.g. bisoprolol)
2) Spironolactone or Hydralazine + Nitrate (afrocarribean)
3) Digoxin
Offer furosemide if fluid overload
Threshold for treating hypertension?
Clinic BP > 140 offer APBM/HBPM
If home <135 average, monitor
If ≥135 AND <80 y/o treat IF end organ damage, renal disease, diabetes, established cardiovascular disease, qrisk score≥10%
If ≥ 150 treat
If clinic BP ≥ 180 treat
What is BNP a marker of?
Ventricular heart strain
What non-cardiac cause can raise a BNP
CKD
Why is patent ostium secundum more likely to cause a stroke than a ventricular septal defect
Cos higher pressure in right atrium causing right to left shunting. Compared to ventricles where left ventricle is higher pressure causing left to right shunting
causes of respiratory alkalosis
initial asthma attack anxiety salicilate poisoning CNS disorders pulmonary embolism pregnancy
what is the pattern of fibrosis in idiopathic pulmonary fibrosis?
usually bilateral lower lobes
what conditions predominantly affect lower zones?
IPF
SLE
drug induced e.g. methotrexate
asbestosis
what zones does coal workers pneumoconiosis predominatly affect?
upper zones
how to tell difference between ARDS and pulmonary edema with pulmonary capillary wedge pressure?
pulmonary edema will show increased pulmonary capillary wedge pressure vs ARDS which shows normal
what spirometry picture would be seen in extrinsic allergic alveolitis?
restrictive picture
eosinophils are raised in hypersensitivity pneumonitis, true or false?
false - EEA or HP does not show raised eosinophils
what in a patient’s history can point to a diagnosis of rheumatic fever
recent sore throat/streptococcal infection 2-6 weeks prior
what pH should a NG tube aspirate be?
<5.5
which lobes would Alpha-1 antitrypsin deficiency manifest with emphysema?
lower lobes mostly
how to diagnose asthma in >17 year old?
FeNO + spirometry reversibility test
what type of chorea is found associated with rheumatic fever?
sydenham chorea
what is meig’s syndrome?
ovarian mass + ascites + pleural effusion
management for pneumothorax
pri pmtx - if >2cm aspirate then consider chest drain
sec pmtx - if over 50 and >2cm = chest drain, if not aspirate
what drug is the most common cause of drug induced angioedema?
ACEi
what is Beck’s triad?
cardiac tamponande
hypotensive
raised jvp
muffled heart sounds
which type of lung cancer is most associated with gynaecomastia?
adenocarcinoma
what kind of neuropathy can diabetes cause?
autonomic and sensory
what does bendroflumethiazide do to serum calcium levels?
hypercalcaemia
common cancers causing lung mets
before computer people read books
breast colorectal prostate renal bladder
Which diuretic can cause osteoporosis ?
Loop diuretics - furosemide
In t1dm, what to do with insulin when ill?
Increase
when to stop insulin iv infusion during DKA episode?
After patient eating normally, long acting insulin night before, then short acting insulin morning during breakfast, stop IVI 30 mins after short acting insulin
Why antibodies are present in autoimmune thyroiditis?
Hypo - anti TPO
Hyper - TRab
What thyroid condition presents with a painful goitre?
De Quervains thyroiditis
what is secondary hyperparathyroidism?
Vit D deficiency
What do Ca, PTH, ALP, phos look like in secondary hypeparathyroidism ?
Low ca, high pth, high alp, high phosphate
What do Ca, PTH, ALP, Phos look like in primary hypeparathyroidism ?
High ca, high or inappropriately normal PTH, low ALP, low phos
How to investigate cushings syndrome?
24 hr urinary cortisol
Serum/salivary cortisol at midnight and morning
Dexamethasone suppresion
Imaging
Explain dexethasone supp tests
If not supressed after low dose = cushings syndrome
After high dose look at ACTH and cortisol
If ACTH low, cortisol low = ACTH producing pituitary adenoma
If ACTH high, cortisol high = ACTH producing exogenous tumour
If ACTH low, cortisol high = cortisol producing tumor
2 causes of primary hyperaldosteronism
Adrenal hyperplasia
Conns syndrome = adrenocortical adenoma
Symptoms of hyperaldosteronism
Low K+, high Na, high BP,
How to interprete aldosterone:renin ratios?
If high aldos:renin ratio = primary hyperaldosteronism
If normal aldos:renin = secondary hyperaldosteronism
What causes secondary hyperaldosteronism
Reduced renal perfusion causing high renin secretion
How to treat hyperplasia hyperaldosteronism
Spironolactone
what diabetes and treatment is associated with HNF1-alpha mutation?
MODY1 - use sulphonylurea
what diuretic can cause gynaecomastia?
spironolactone
