February Flashcards
Key signs you want to look for in someone undergoing chemotherapy
Neutropenic sepsis - count less than 1 and features of sepsis (hypotension, tachycardia) with or without fever
Neutropenia less than 1
Less than 0.5
Febrile neutropenia
Who are at risk of neutropenic sepsis?
Patients with haematological cancers Chemotherapy patients Transplant Medications - sulfasalazine, carbimazole, cotrimoxazole Myelofibrosis Myelodysplasia
Key time frame in developing neutropenic sepsis when undergoing chemotherapy
Days 7 to 21
Which antibiotic to give in sepsis?
Tazocin
Which antibiotics will you administer with higher news score?
Tazocin and Gentamicin
Which antibiotic would you give in septic shock?
Meropenam
What indicates severe sepsis?
Multi organ failure - renal and liver function alongside neutrophils and CRP
What would you consider in escalating a patient in severe sepsis?
Gentamicin IV fluids HDU/ITU Senior help DNA CPR
Most common site of spinal cord compression
Thoracic spine
Cancers associated with spinal cord compression
Breast, prostate, lung
Any cancer spreading to bone
MRI is classic investigation for spinal cord compression. Why are patients placed on bed rest when investigating malignant spinal cord compression?
Instability of the spine is a concern
What is the biggest indicator of prognosis when diagnosed with malignant spinal cord compression?
If ambulatory at diagnosis
90% will stay ambulatory
If not, only 10% will return to mobile
Superior Vena cava obstruction
Main causes malignant Shortness of breath Facial and arm swelling Headaches Dizziness Fatigue Weight loss
Fixed elevated JVP
Oedema
Peripheral cyanosis
Patient with cancer presents with confusion - possible causes
Hypercalcaemia
Brain mets
Treating hypercalcaemia
Check PTH if cause unclear Rehydration Bisphosphonates Calcitonin Steroids if needed
Treating hypercalcaemia
Check PTH if cause unclear Rehydration Bisphosphonates Calcitonin Steroids if needed
4 oncological emergencies
Neutropenic sepsis
Malignant spinal cord compression
Hypercalcaemia
Superior Vena Cava Obstruction
What are Aschoff bodies?
Granulomas with giant cells
In what condition would aschoff bodies be found?
Rheumatic heart disease
Which valve is most commonly affect in Rheumatic heart disease?
Mitral
What type of murmur is heard in rheumatic heart disease?
High pitched ,Holosystolic, loudest in apex, radiates to axilla
Indicates mitral
What is indicated by an Antistrepsylin O titres and what condition might you associate with it?
Exposure to streptococcus group A
Rheumatic heart disease - streptococcus pyogenes
How is Rheumatic heart disease diagnosed?
Need 2 major criteria
Or one major and 2 minor
Major criteria for rheumatic heart disease
erythema marginatum
Sydenham’s chorea: this is often a late feature
polyarthritis
carditis and valvulitis (eg, pancarditis)
The latest iteration of the Jones criteria (published in 2015) state that rheumatic carditis cannot be based on pericarditis or myocarditis alone and that there must be evidence of endocarditis (the clinical correlate of which is valvulitis which manifests as a regurgitant murmur)
subcutaneous nodules
Minor criteria for rheumatic heart disease
Pyrexia
Raised ESR or CRP
Arthralgia
Prolonged PR interval
Management of rheumatic heart failure
Oral penicillin V
Anti-inflammatories - NSAIDs
Manage any complications - heart failure
What condition is associated with Councilman bodies?
hepatitis C, yellow fever
What condition is associated with Mallory bodies?
Alcoholism
What condition is associated with Call-Exner bodies?
Granulosa cell tumour
What is associated with Schiller Duval bodies?
Yolk sac tumour
Management of Eisenmenger’s syndrome?
Heart-lung transplant
Features of Eisenmenger’s syndrome
original murmur may disappear cyanosis clubbing right ventricular failure haemoptysis, embolism CONGENITAL CONDITION - reversal of left to right shunt
Associations with Eisenmenger’s
ASD
VSD
PDA
Why is a loading dose of amiodarone required when attempting chemical cardioversion?
Long half-life is correct. Drugs with a long half-life are eliminated from the body slowly and only need a low maintenance dose to maintain appropriate therapeutic concentrations. However, this means that in the absence of a higher initial dose, it would take a long time for these drugs to reach a steady-state concentration.
Adverse effects of amiodarone
thyroid dysfunction: both hypothyroidism and hyper-thyroidism corneal deposits pulmonary fibrosis/pneumonitis liver fibrosis/hepatitis peripheral neuropathy, myopathy photosensitivity 'slate-grey' appearance thrombophlebitis and injection site reactions bradycardia lengths QT interval
Key feature of left-sided heart failure
Paroxysmal nocturl dyspnoea
What is paroxysmal nocturnal dyspnoea?
Sudden waking at night SOB
Signs of right-sided heart failure
Raised JVP
Ankle oedema
Hepatomegaly
Systemic vascular resistance =
Cardiac output divided by Mean Areterial Pressure
Which drugs reduce the antihypetensive effects of ACEi?
NSAIDs
What is Brugada syndrome?
Autosomal dominant cause of sudden cardiac death in the young
What is Chaga’s disease?
Paraasytic disease occurs in South America causing ventricular damage
What signs are associated with Hypertrophic Obstructive Cardiomyopathy? HOCM
Exertional dyspnoea
Syncope
Chest pain
What is the leading cause of sudden cardiac death in young patients?
HOCM
ECG taken on admission reveals sinus rhythm, with generalised deep Q waves and widespread T waves. There is evidence of left ventricular hypertrophy. What does this ECG indicate when young patient presents with exertional dyspnoea, syncope and chest pain?
HOCM
Name an adverse effect of thiazide diuretics
Hyponatraemia
Features of heart block
syncope heart failure regular bradycardia (30-50 bpm) wide pulse pressure JVP: cannon waves in neck variable intensity of S1
Contraindications of nicorandil
Left ventricular heart failure (pulmonary oedema)
Why does nicorandil complicate the management of acute pulmonary oedema?
Causes hypotension
Adverse effects of nicorandil
headache
flushing
anal ulceration
Mechanism of action of nicorandil
Potassium channel activaton
vasodilation is through activation of guanylyl cyclase which results in increase cGMP.
In which condition is nicorandil used to medicate?
Angina
Mainstay therapy for acute pulmonary oedema?
Oxygen
Nitrates
Morphine
Furosemide
Most common cause of secondary hypertension?
Renal disease
What is indicated by a continuous machine like murmur in a newborn?
Patent ductus arteriosus
Symptoms of peripheral arterial disease
Asymptomatic Claudication (leg cramping relieved at rest) Leg pain at rest Ulceration Gangrene
Signs of peripheral arterial disease
Absent leg and foot pulses Cold white legs Atrophic skin Arterial ulcers Long capillary filling time
First line investigation of peripheral arterial disease
Ankle Brachial Pressure Index ABPI
Investigations for peripheral arterial disease
ABPI
Imaging - Colour duplex ultrasound
MR/CT angiography if considering intervention
Management of peripheral arterial disease
Risk factor modification e.g. smoking cessation, treat hypertension and high cholesterol, prescribe clopidogrel
Supervised exercise programs to increase blood flow
Percutaneous transluminal angioplasty
Surgical reconstruction i.e. bypass graft using the saphenous vein
Amputation
Signs of transposition of the great arteries
cyanosis tachypnoea loud single S2 prominent right ventricular impulse 'egg-on-side' appearance on chest x-ray
Management of transposition of great arteries
Maintain ductus arteriosus with prostaglandin
Surgical correction
Equation to calculate pack years
Number of cigarettes per day / 20 x Years of smoking
In pleural effusion to determine whether fluid is transudate or exudate the aspiration must be compared to serum levels. What conditions could cause a low glucose in the pleural fluid?
Infection
Empyema
Rheumatoid arthritis
Malignancy
Causes of transudates
Cirrhosis
Cardiac failure
Nephrotic syndrome
Constrictive pericarditis
Causes of exudates
Pneumonia
Malignancy
Mesothelioma
Rheumatoid arthritis
A CT chest was performed and reported as showing, “Enhancing, circumferential, nodular left pleural thickening involving the mediastinal pleura associated with reduced left lung volume”. What is the likely diagnosis and what question in the history would indicate its likelihood?
Mesothelioma
Asbestos - occupational exposure
Complication of lung biopsy?
Pneumothorax
What investigation is reuqired prior to ultrasound guided biopsy of lung?
Spirometry
Full blood count - platelets
Factors increasing fluid overload
Heart failure Cirrhosis Chronic Kidney disease (CKD) Perpheral Vascular Disease Diabetes Pregnancy Elderly Malnourished
Mediastinal widening on chest X-ray, ST elevation in leads II, III, and aVF - diagnosis?
Aortic dissection
Patient presents with hypertension, tearing chest pain and aortic regurgitation - what is the diagnosis?
Aortic dissection
Key finding of aortic dissection on CT
False lumen of descending aorta
Broca’s area is supplied by which artery?
Middle cerebral
Mechanism of action in calcium channel blockers eg amlodipine
Blocks opening of voltage depending calcium channels in smooth muscle decreasing peripheral vascular resistance
Hydralazine mechanism of action
Elevates cGMP leading to relaxation of arterioles more so than veins
Which substance reduces absorption of ACE inhibitors
Antacids
Mechanism of action of dipyridamole
Non specific phosphodiesterase inhibitor. Inhibits uptake of adenosine
Indication of dipyridamole
Anti platelet
Taken with aspirin in ischaemic stroke and TIA
Drugs that interact with warfarin
Cytochrome p450 inhibitors
Eg NSAIDS, SSRIs, amiodarone and antibiotics
Name a cause of pulsatile hepatomegaly
Tricuspid regurgitation
What is Antiphospholipid syndrome and what does it provoke?
Autoimmune, hypercoagulable condition - promotes arterial and venous blood clots
Pregnancy related complications of antiphospholipid syndrome?
Still birth
Miscarriage
Preterm delivery
Severe pre-eclampsia
Diagnostic criteria for Antiphospholipid syndrome
One event
2 positive blood tests spaced 3 months apart
Which anitbodies are positive for antiphospholipid syndrome?
Lupus anticoagulant
Anti-cardiolipin
anti-B2-glycoprotein
What other autoimmune disease can antiphospholipid syndrome occur secondary to?
Systemic Lupus Erythematosus
Rapid organ failure and generalised thrombosis due to antiphospholipid syndrome is known as
Catastrophic Antiphospholipid Syndrome
How is antiphospholipid syndrome treated?
Using anticoagulants eg heparin (warfarin teratogenic)
Aflatoxin is a carcinogen associated with which cancer?
Hepatocellular carcinoma
Analine dyes are a carcinogen associated with which cancer?
Bladder cancer
Vinyl chloride is a carcinogen associated with which cancer?
Hepatic angiosarcoma
Asbestos is a carcinogen associated with which cancer?
Mesothelioma
Bronchial carcinoma
Nitrosamines are carcinogens associated with which cancer?
Oesophageal
Gastric
Crisis management for sickle cell disease
Analgesia Rehydrate Oxygen Antibiotics Blood transfusion Exchange transfusion - if neurological complications
Long-term management for sickle cell disease
Hydroxyurea- increase HbF levels - prevent painful crises
Pneumococcal polysaccharide vaccine every 5 years- according to NICE CKs
Causes of iron-deficiency anaemia
Menorrhagia Gastro-intestinal bleed (e.g. cancer) Malabsorption (e.g. coeliac disease) Physiological change (e.g. pregnancy) Diets (vegetarian/vegan) Hookworm
Management of iron deficiency anaemia
Oral Ferrous sulphate
Take 3 months after corrected to replenish stores
Diet
Side effects of iron supplements
Nausea
Abdo pain
Diarrhoea
Constipation
A man presents with abdominal pain and is found to have splenic atrophy. Which condition is he likely to have?
Coeliac disease
Treatment for Non-Hodgkin’s lymphoma
R-CHOP chemotherapy regime Rituximab Cyclophosphamide doxorubicin Vincristine Prednisolone
