Final Flashcards
Phase 2a Revision
1
Q
Presentation of angina.
A
Chest tightness / heaviness.
Central pain that radiates to the arms, jaw and neck.
Pain is provoked by exertion and relieved by GTN spray.
2
Q
Diagnosis of angina.
A
ECG may be normal or show ST depression and flat/inverted T waves.
Exercise tolerance test.
Coronary angiography.
3
Q
Treatment of angina.
A
Modify risk factors: smoking cessation, inc. exercise, weight loss. Aspirin. Simvastatin (statin). Atenolol (beta-blocker). GTN spray. Verapamil (ccb). PCI or CABG (intervention).
4
Q
Presentation of acute myocardial infarction.
A
Severe central chest pain lasting longer than 20 minutes.
Pain radiates to the left arm, jaw and neck.
Pain is not relieved by GTN spray.
Pain is associated w/ sweating, dyspnoea and fatigue.
5
Q
Diagnosis of acute myocardial infarction.
A
ECG (STEMI shows ST elevation, hyperacute T waves, LBBB, pathological Q waves - NSTEMI shows ST depression).
Troponin raised.
6
Q
Treatment of acute myocardial infarction.
A
Aspirin, sublingual GTN, morphine - pre-hospital.
IV morphine, oxygen, atenolol, clopidogrel - hospital.
PCI or alteplase (fibrinolysis).
7
Q
Presentation of cardiac failure.
A
Triad: shortness of breath, fatigue, ankle swelling. Dyspnoea. JVP raised. Cyanosis. Hypotension. Tachycardia. Pulmonary oedema. S3 and S4 heart sounds.
8
Q
Diagnosis of cardiac failure.
A
Brain natriuretic peptide (BNP) raised.
CXR may show alveolar oedema, cardiomegaly, dilated pulmonary vessels, pulmonary effusions.
ECG may show left ventricular hypertrophy, arrhythmia,
Echocardiogram may show dilated chambers, cardiomyopathies.
9
Q
Treatment of cardiac failure.
A
Lifestyle changes. Diuretics: furosemide (loop), bendroflumethiazide (thiazide), spironolactone (aldosterone antagonist). Ramipril (ACE-i) or candesartan (ARB). Bisoprolol (beta-blocker). Digoxin (positive inotrope).
10
Q
Presentation of mitral stenosis.
A
Generally asymptomatic until valve orifice < 2cm2.
Progressive dyspnoea. Haemoptysis.
Abdominal and lower limb swelling.
Diastolic murmur (at apex) and loud opening S1 snap.
11
Q
Diagnosis of mitral stenosis.
A
Echocardiogram can assess valve mobility and valve area.
CXR may show left atrial enlargement and pulmonary oedema.
ECG may show atrial fibrillation and left atrial enlargement.
12
Q
Treatment of mitral stenosis.
A
Atenolol (beta-blocker) and digoxin.
Furosemide (loop diuretic).
Percutaneous mitral balloon valvotomy or mitral valve replacement.
13
Q
Presentation of mitral regurgitation.
A
Exertional dyspnoea.
Fatigue and lethargy.
Soft S1 and pansystolic murmur (from apex to axilla).
14
Q
Diagnosis of mitral regurgitation.
A
Echocardiography can assess left atrial and left ventricle size and function, and valve function.
CXR may show left atrial enlargement.
ECG may show left atrial enlargement.
15
Q
Treatment of mitral regurgitation.
A
Ramipril (ACE-i).
Atenolol, verapamil, digoxin.
Furosemide (loop diuretic).
Mitral valve surgery.
16
Q
Presentation of aortic stenosis.
A
Chest pain (angina) and exertional dyspnoea/syncope in an elderly patient.
Soft or absent S2.
Prominent S4.
Ejection systolic murmur (crescendo-decrescendo pattern).
17
Q
Diagnosis of aortic stenosis.
A
Echocardiogram to assess LVH, dilation and pressure gradient across the valve.
CXR may show LVH and a calcified aortic valve.
ECG may show LVH and LA delay.
18
Q
Treatment of aortic stenosis.
A
In severe cases: surgical aortic valve replacement or transcutaneous aortic valve implantation (less invasive).
19
Q
Presentation of aortic regurgitation.
A
Exertional dyspnoea, angina and syncope.
Diastolic blowing murmur at the left sternal border.
Systolic ejection murmur.
Waterhammer pulse (bounding then collapsing).
Quincke’s sign - capillary pulsation in nail beds.
de Musset’s sign - head nodding w/ pulse.
20
Q
Diagnosis of aortic regurgitation.
A
Echocardiogram to assess the aortic valve and aortic root, measure left ventricle.
CXR may show LVH.
ECG may show signs of LVH.
21
Q
Treatment of aortic regurgitation.
A
Ramipril (ACE-i) for symptoms.
Aortic valve replacement surgery.
22
Q
Presentation of infective endocarditis.
A
Suspect in individuals w/ new murmur and fever.
Headache, malaise, confusion, night sweats.
Digital clubbing.
Embolic phenomena - splinter haemorrhages, Janeway lesions.
23
Q
Diagnosis of infective endocarditis.
A
Duke’s criteria for blood cultures - three sets at different sites taken over 24 hours.
Bloods = CRP and ESR raised, normochromic, normocytic anaemia and neutrophilia.
Urinalysis = haematuria.
CXR may show cardiomegaly.
Transoesophageal echocardiogram (better than TTE).
24
Q
Treatment of infective endocarditis.
A
Antibiotics: treat staph. aureus w/ vancomycin, if not staph. aureus then w/ benzylpenillin and gentamycin.
Good oral health is important for prevention.
25
Presentation of hypertrophic cardiomyopathy.
Chest pain, dyspnoea, dizziness and syncope.
Ejection systolic murmur.
Jerky carotid pulse.
First presentation may be sudden death.
26
Diagnosis of hypertrophic cardiomyopathy.
ECG is abnormal and shows signs of LVH - progressive T wave inversion and deep Q waves.
Echo shows LVH and a small ventricle cavity.
27
Treatment of hypertrophic cardiomyopathy.
Amiodarone (anti-arrhythmic).
Verapamil (calcium channel blocker).
Atenolol (beta-blocker).
28
Presentation of dilated cardiomyopathy.
Shortness of breath, fatigue, dyspnoea, arrhythmia.
JVP raised.
Heart failure.
29
Diagnosis of dilated cardiomyopathy.
CXR shows cardiac enlargement.
ECG shows tachycardia, arrhythmia and T wave changes.
Echo shows dilated ventricles.
30
Treatment of dilated cardiomyopathy.
Treat heart failure w/ diuretics, ACE inhibitors, beta blockers and digoxin.
Treat arrhythmia w/ amiodarone.
31
Presentation of restrictive cardiomyopathy.
Dyspnoea, fatigue.
JVP raised.
Hepatic enlargement, ascites and dependent oedema.
S3 and S4 heart sounds.
32
Diagnosis of restrictive cardiomyopathy.
CXR, Echo and ECG are abnormal but non-specific.
| Cardiac catheterisation.
33
Treatment of restrictive cardiomyopathy.
No specific treatment - poor prognosis.
| Consider cardiac transplant.
34
Presentation of arrhythmogenic right ventricular cardiomyopathy.
Arrhythmia.
Syncope.
Right heart failure (late stage).
35
Diagnosis of arrhythmogenic right ventricular cardiomyopathy.
Genetic testing is gold standard.
ECG may be normal or show T wave inversion.
Echo may be normal or show right ventricular dilation.
36
Treatment of arrhythmogenic right ventricular cardiomyopathy.
Atenolol (beta-blocker) for non-life-threatening arrhythmia.
Amiodarone (anti-arrhythmic) for symptomatic arrhythmia.
Consider cardiac transplantation.
37
Presentation of atrial septal defect.
Dyspnoea.
Exercise intolerance.
Arrhythmia.
38
Diagnosis of atrial septal defect.
CXR shows an enlarged heart and large pulmonary arteries.
ECG shows right bundle branch block (due to RV dilation).
Echo shows hypertrophy and dilation of the right side of the heart.
39
Treatment of atrial septal defect.
Transcutaneous surgical closure.
40
Presentation of ventricular septal defect.
Small defects present w/ a large systolic murmur and thrill, but of a well grown baby w/ a normal sized heart.
Large defects present as a small, breathless baby w/ tachycardia and raised respiratory rate.
Babys w/ large defects may develop pulmonary hypertension and then cyanosis (via Eisenmenger).
41
Diagnosis of ventricular septal defect.
Large defects show as large heart on CXR.
42
Treatment of ventricular septal defect.
Difficult to repair.
| Pulmonary artery banding can reduce blood flow to the lungs and reduce pulmonary hypertension.
43
Presentation of atria-ventricular septal defect.
Complete defects result in breathlessness as a neonate w/ poor feeding and weight gain.
44
Treatment of atria-ventricular septal defect.
Difficult to repair.
| Pulmonary artery banding can reduce blood flow to the lungs and reduce pulmonary hypertension.
45
Presentation of patent ductus arteriosus.
Continuous 'machinery' murmur.
Bounding pulse.
Toe clubbing and turn blue.
46
Diagnosis of patent ductus arteriosus.
CXR shows prominent aorta and pulmonary arteries.
ECG shows signs of LA abnormality and LVH.
Echo shows dilation of the LA and LV.
47
Treatment of patent ductus arteriosus.
Repair surgically or percutaneously.
| Indometacin (prostaglandin inhibitor) can stimulate closure.
48
Presentation of coarction of the aorta.
```
Right arm hypertension.
Bruits over scapulae.
Murmurs.
Headaches and nose bleeds.
Radial pulse before femoral.
Long term: CAD, strokes, SAH.
```
49
Diagnosis of coarction of the aorta.
CT shows coarction and can quantify flow.
| ECG shows signs of LVH.
50
Treatment of coarction of the aorta.
Surgery.
| Balloon dilation and stenting.
51
Presentation of tetralogy of Fallot.
```
Cyanotic (blue).
Exertional dyspnoea.
Low birth weight.
Delayed puberty.
Systolic ejection murmur.
```
52
Diagnosis of tetralogy of Fallot.
CXR shows boot-shaped heart.
53
Treatment of tetralogy of Fallot.
Require surgery before the age of two.
| Will probably require surgery for pulmonary valve regurgitation (which is likely to develop in adulthood).
54
Presentation of pulmonary stenosis.
Severe stenosis presents w/ right ventricular failure as a neonate, poor pulmonary flow, RVH and tricuspid valve regurgitation.
55
Treatment of pulmonary stenosis.
Balloon valvoplasty - can result in pulmonary regurgitation.
Shunt.
56
Presentation of acute pericarditis.
```
Chest pain of sudden onset (worse when lying flat).
Pain is sharp and pleuritic.
Pain radiates to the trapezium.
Dyspnoea, cough, hiccups.
Pericardial friction rub.
```
57
Diagnosis of acute pericarditis.
```
ECG shows characteristic saddle-shaped ST elevation and PR depression.
White cell count raised.
CRP/ESR raised.
Troponin raised.
Presence of autoantibodies.
```
58
Treatment of acute pericarditis.
Restrict physical activity.
Ibuprofen and aspirin (NSAIDs).
Colchicine.
59
Presentation of pericardial effusion.
Soft and distant heart sounds.
JVP raised.
Dyspnoea.
60
Diagnosis of pericardial effusion.
CXR shows an enlarged, globular heart.
ECG shows low voltage QRS complexes.
Echo shows an echo-free zone surrounding the heart.
61
Treatment of pericardial effusion.
Treat underlying cause.
| Repeated effusions may require pericardial fenestration.
62
Presentation of cardiac tamponade.
```
Pulse raised, BP low.
JVP raised.
Kusmmaul's sign.
Pulsus paradoxus.
Muffled S1 and S2.
```
63
Diagnosis of cardiac tamponade.
CXR shows enlarged, globular heart.
ECG shows low voltage QRS complex.
Echo shows echo-free area surrounding heart.
64
Treatment of cardiac tamponade.
Urgent drainage via pericardiocentesis. Fluids sent for culture, Ziehl-Nielsen stain and cytology.
65
Presentation of hypertension.
Asymptomatic but found through screening.
Stage 1: ≥ 140/90 mmHg
Stage 2: ≥160/100 mmHg
Severe: systolic ≥180 mmHg / diastolic ≥ 110 mmHg
66
Diagnosis of hypertension.
Look for end-organ damage:
Urinalysis shows proteinuria, haematuria, albumin:creatinine ratio.
ECG and Echo shows signs of LVH.
Fundoscopy shows retinal haemorrhage or papilloedema.
67
Treatment of hypertension.
Focus on lifestyle factors: smoking cessation, weight loss, reducing alcohol intake, improving diet, reducing salt intake, getting more exercise.
A - ACE-i / ARB (ramipril / candesartan).
C - calcium channel blocker (amlodipine or nifedipine).
D - diuretic (bendroflumethiazide or furosemide).
68
Presentation of atrial fibrillation.
```
Palpitations.
Dyspnoea.
Chest pain.
Fatigue.
Apical pulse greater than radial pulse.
```
69
Diagnosis of atrial fibrillation.
ECG shows absent P waves.
| ECG shows irregular, rapid QRS complex.
70
Treatment of atrial fibrillation.
Acute management w/ cardioversion: defibrillator w/ enoxaparin (LMWH) OR amiodarone/flecainide.
Long term management rate control w/ beta-blockers, calcium channel blockers and oral anticoagulants.
Long term management rhythm control w/ cardioversion, beta-blockers, anticoagulants.
CHA2DS2-VASc is used to assess stroke risk.
71
Presentation of atrial flutter.
```
Palpitations.
Breathlessness.
Chest pain.
Dyspnoea.
Syncope.
```
72
Diagnosis of atrial flutter.
ECG shows characteristic sawtooth-like (F) waves.
73
Treatment of atrial flutter.
Give enoxaparin (LMWH) then electrical cardioversion.
Catheter ablation.
IV amiodarone and bisoprolol (beta-blocker).
74
Presentation of first-degree AV heart block.
Asymptomatic.
75
Diagnosis of first-degree AV heart block.
Prolongation of PR interval to > 0.22 seconds.
76
Treatment of first-degree AV heart block.
No treatment.
77
Presentation of second-degree AV heart block.
Mobitz 1: Light headed, dizzy, syncope.
| Mobitz 2: Chest pain, postural hypotension, shortness of breath.
78
Diagnosis of second-degree AV heart block.
Mobitz 1: ECG shows progressive PR interval prolongation then QRS complex drops.
Mobitz 2: ECG shows constant PR interval then QRS complex drops.
79
Treatment of second-degree AV heart block.
Pacemaker.
| IV atropine.
80
Presentation of third-degree AV heart block.
Dizziness.
| Blackouts.
81
Diagnosis of third-degree AV heart block.
ECG shows a QRS complex < 0.12s = narrow-complex escape rhythm.
ECG shows a QRS complex > 0.12s = broad-complex escape rhythm.
82
Treatment of third-degree AV heart block.
Treat acute NCER w/ IV atropine.
Treat chronic NCER w/ pacemaker.
Treat BCER w/ pacemaker.
83
Presentation of bundle branch block.
Asymptomatic.
84
Diagnosis of bundle branch block.
Wide QRS complex (> 0.12s) on ECG.
RBBB: QRS = 'M' in V1, QRS = 'W' in V5 and V6.
RBBB: splitting of S2 sound.
LBBB: QRS = 'W' in V1 and V2, QRS = 'M' in V4-V6.
LBBB: reverse splitting of S2 sound.
85
Presentation of atrioventricular nodal re-entrant tachycardia.
Rapid, regular palpitations.
Chest pain and breathlessness.
Neck pulsations.
Polyuria.
86
Diagnosis of atrioventricular nodal re-entrant tachycardia.
Pulse ≥ 100 bpm.
87
Treatment of atrioventricular nodal re-entrant tachycardia.
Bisoprolol (beta-blocker).
88
Presentation of atrioventricular re-entrant tachycardia.
Palpitations.
Severe dizziness.
Dyspnoea.
Syncope.
89
Diagnosis of atrioventricular re-entrant tachycardia.
ECG shows short PR interval and wide QRS complex with delta waves (slurred start to the QRS complex).
90
Treatment of atrioventricular re-entrant tachycardia.
Emergency cardioversion if haemodynamically unstable.
If stable try vagal manoeuvres: breath-holding, carotid massage, valsalva manoeuvre.
IV adenosine stops conduction to reset.
Surgery - catheter ablation of the accessory pathway in AVRT.
91
Presentation of abdominal aortic aneurysm.
Unruptured AAAs are generally asymptomatic, thought there may be some pain in the abdomen, back or groin.
Ruptured AAAs present w/ pain in the abdomen that radiates to the back and groin. Hypotension. Tachycardia. Profound anaemia. Sudden death.
92
Diagnosis of abdominal aortic aneurysm.
Abdominal ultrasound - aortic dilation > 3cm = AAA.
| CT angiography.
93
Treatment of abdominal aortic aneurysm.
Monitor AAA < 5.5cm and modify risk factors (smoking cessation, weight loss, diet improvement, alcohol reduction).
Surgery - has better outcomes on larger, symptomatic aneurysms.
94
Diagnosis of abdominal aortic aneurysm.
Abdominal ultrasound - aortic diameter > 3cm = AAA.
| CT angiography.
95
Treatment of abdominal aortic aneurysm.
Monitor AAA < 5.5cm and modify risk factors (smoking cessation, weight loss, diet improvement, alcohol reduction).
Surgery - has better outcomes on larger, symptomatic aneurysms.
96
Presentation of thoracic aortic aneurysm.
```
Normally asymptomatic.
Pain in chest, neck, upper back, mid-back and epigastrium.
Aortic regurgitation.
Haemoptysis.
Collapse.
```
97
Diagnosis of thoracic aortic aneurysm.
CXR - aortic diameter > 3cm = TAA.
CT angiography.
Transoesophageal echo.
98
Treatment of thoracic aortic aneurysm.
Treat symptomatic TAA w/ surgery.
Control BP w/ bisoprolol (beta-blocker).
Modify risk factors.
99
Treatment of thoracic aortic aneurysm.
Treat symptomatic TAA w/ surgery.
Control BP w/ bisoprolol (beta-blocker).
Modify risk factors.
100
Presentation of type 1 diabetes mellitus.
Typically young and lean patients.
Polydipsia, polyuria, weight loss.
Tired and lethargic.
Diabetic ketoacidosis (fruity breath).
101
Diagnosis of type 1 diabetes mellitus.
Random blood glucose > 11.1mmol/L.
Fasting blood glucose > 7mmol/L.
^ in symptomatic patients 1 abnormal result confirms diagnosis, in asymptomatic patients 2 abnormal results confirm diagnosis.
OR oral glucose tolerance test (OGTT): fasting blood glucose < 7mmol/L, 2 hours after glucose given > 11.1mmol/L.
OR haemoglobin A1c > 6.5% normal (48mmol/mol).
102
Treatment of type 1 diabetes mellitus.
Educate the patient on how to regulate blood glucose in light of exercise, fingerprick glucose and calorie intake.
SC insulin injections. Regimes: twice a day OR ultra-fast before each meal and long-acting before bed OR once daily long-lasting before bed.
103
Presentation of type 1 diabetes mellitus.
Typically young and lean patients.
Polydipsia, polyuria, weight loss.
Tired and lethargic.
Diabetic ketoacidosis (fruity breath) and ketonuria.
104
Diagnosis of type 1 diabetes mellitus.
Random plasma glucose >11.1mmol/L.
Fasting plasma glucose >7mmol/L.
^ in symptomatic patients 1 abnormal result confirms diagnosis, in asymptomatic patients 2 abnormal results confirm diagnosis.
OR oral glucose tolerance test (OGTT): fasting blood glucose <7mmol/L, 2 hours after glucose given > 11.1mmol/L.
OR haemoglobin A1c >6.5% normal (48mmol/L).
105
Treatment of type 1 diabetes mellitus.
Educate the patient on how to regulate blood glucose in light of exercise, fingerprick glucose and calorie intake.
SC insulin injections. Regimes: twice a day OR ultra-fast before each meal and long-acting before bed OR once daily long-lasting before bed.
106
Presentation of type 2 diabetes mellitus.
Typically older, overweight patients.
Polyuria, polydipsia, weight loss.
Acanthosis nigricans (in severe cases).
107
Diagnosis of type 2 diabetes mellitus.
Random plasma glucose >11.1mmol/L.
Fasting plasma glucose >7mmol/L.
^ in symptomatic patients 1 abnormal result confirms diagnosis, in asymptomatic patients 2 abnormal results confirm diagnosis.
Oral glucose tolerance test for borderline cases: fasting blood glucose <7mmol/L, 2 hours after glucose >11.1mmol/L.
OR Haemoglobin A1c >6.5% (48mmol/L).
108
Treatment of type 2 diabetes mellitus.
1st line - lifestyle changes: exercise, smoking cessation, good diet (low in sugar and fat, high in fibre and carbohydrates), can give w/ statins, ramipril and orlistat.
2nd line - oral metformin, if Hb1Ac >53mmol/L 16 weeks later give gliclazide, if Hb1Ac >57mmol/L 6 months later give isophane insulin.
109
Presentation of diabetic ketoacidosis.
Typically in patients w/ type 1 diabetes mellitus.
Breath smells like pear-drops.
Profound dehydration, vomiting, drowsiness.
Kussmaul's respiration - heavy, laboured breathing.
110
Diagnosis of diabetic ketoacidosis.
Hyperglycaemia (blood glucose > 11mmol/L).
Raised blood ketones > 3mmol/L.
Blood pH < 7.3.
Urinalysis: glycosuria and ketonuria.
Total body potassium is low (serum raised).
111
Treatment of diabetic ketoacidosis.
Give 0.9% saline and replace K+.
| Give insulin w/ glucose (to prevent hypoglycaemia).
112
Presentation of hyperosmolar hyperglycaemic state.
Severe dehydration.
Reduced level of consciousness.
Stupor or coma.
113
Diagnosis of hyperosmolar hyperglycaemic state.
Hyperglycaemia (blood glucose > 11mmol/L).
Hyperosmolality.
Urinalysis: glycosuria and no ketonuria.
Total body K+ low (serum raised).
114
Treatment of hyperosmolar hyperglycaemic state.
Give 0.9% saline and replace K+.
Low rate insulin infusion.
SC enoxaparin (LMWH).
115
Presentation of macrovascular complications of diabetes mellitus.
Stroke.
Ischaemic heart disease.
Peripheral vascular disease - intermittent claudication and rest pain, cool feet and toes, hair absent on legs and feet.
116
Diagnosis of macrovascular complications of diabetes mellitus.
PVD - doppler ultrasound.
117
Treatment of macrovascular complications of diabetes mellitus.
Modify risk factors.
General management: simvastatin, ramipril.
PVD - advise to walk through claudication pain (to produce new collaterals).
118
Presentation of diabetic retinopathy.
Microaneurysms.
Haemorrhages.
Cotton wool spots.
119
Diagnosis of diabetic retinopathy.
Fundoscopy.
120
Treatment of diabetic retinopathy.
Laser therapy slows disease progression but has risks (loss of night vision and peripheral vision).
121
Presentation of diabetic nephropathy.
Nocturia, polyuria.
| Tiredness, nausea and vomiting.
122
Diagnosis of diabetic nephropathy.
Albumin:creatinine ration > 3.
Albuminuria.
Normochromic, normocytic anaemia.
123
Treatment of diabetic nephropathy.
Aggressive treatment of blood pressure: ramipril (ACE-i) or candesartan (ARB).
RRT - dialysis or renal transplant.
124
Presentation of diabetic neuropathy.
Pain - allodynia, paraesthesia, pain and burning.
Autonomic - postural hypotension, constipation, diarrhoea, erectile dysfunction, incontinence.
Insensitivity - 'glove and stocking' sensory loss.
Diabetic amyotrophy - wasting of the quadriceps.
125
Treatment of diabetic neuropathy.
```
Good glycaemic control.
Paracetamol.
Amitriptyline (tricyclic antidepressant).
Gabapentin (anti-convulsant).
Tramadol (opiod).
Transcutaneous nerve stimulation.
```
126
Presentation of diabetic foot ulceration.
Painless, punched-out ulcer of foot in an area of thick callus.
127
Treatment of diabetic foot ulceration.
Management: foot screening and patient education (check feet daily, seek advice early, check shoes for sharps, check bath temperature before stepping in).
128
Presentation of hypoglycaemia.
Sweating, anxiety, hunger, tremor.
Confusion and visual trouble.
Coma.
129
Diagnosis of hypoglycaemia.
Plasma glucose <3mmol/L.
Drug history.
Exclude liver failure.
Bloods: insulin, c-peptide, ketones.
130
Treatment of hypoglycaemia.
Oral glucose and long-acting starch (toast).
If unable to swallow give IV 50% glucose.
If no IV access give IM glucagon.
131
Presentation of Graves' disease.
Goitre and associated symptoms of hyperthyroidism.
Graves' opthalmopathy - inflammation and swelling of the extra-ocular muscles, exophthalmos, photophobia, diplopia, corneal ulceration.
Graves' dermopathy - pretibial myxoedema (purplish skin lesions), thyroid acropachy (clubbing, swollen fingers).
132
Diagnosis of Graves' disease.
Thyroid function tests: suppressed TSH and raised T3 and T4.
Raised TSH receptor stimulating antibodies.
133
Treatment of Graves' disease.
Propranolol (beta-blocker) for symptom relief.
Propylthiouracil (PTU) - stops conversion of T4 to T3.
Carbimazole.
Radioactive iodine (131).
Total thyroidectomy.
134
Presentation of hyperthyroidism.
```
Diffuse goitre.
Palpitations.
Lig lag.
Weight loss.
Diarrhoea.
Warm (vasodilation).
Sweating.
```
135
Diagnosis of hyperthyroidism.
Suppression of TSH.
T3 and T4 raised.
Thyroid ultrasound.
136
Treatment of hyperthyroidism.
Propranolol (beta-blocker) for symptoms.
Propylthiouracil - stops conversion of T4 to T3.
Carbimazole.
Radioactive iodine (131).
Surgery.
137
Presentation of thyroid storm.
Hyperpyrexia, tachycardia, extreme restlessness.
| Delirium, coma, death.
138
Treatment of thyroid storm.
Large doses of: carbimazole, propranolol, hydrocortisone, potassium iodide.
139
Presentation of hypothyroidism.
```
Goitre.
Constipation, weight gain.
Bradycardia.
Ataxia.
Dry, thin skin/hair.
Yawning/drowsy.
Cold hands.
Ascites.
Round puffy face.
Immobile.
Congestive heart failure.
```
140
Diagnosis of hypothyroidism.
TSH raised.
T4 low.
Thyroid antibodies.
Anaemia.
141
Treatment of hypothyroidism.
Levothyroxine.
142
Presentation of Cushing's syndrome.
```
Central obesity.
Moon facies.
Muscle atrophy.
Increased blood pressure.
Fractures.
Infection.
```
143
Diagnosis of Cushing's syndrome.
Carefully check drug history (for steroids).
Random plasma cortisol levels are high.
Overnight dexamethasone suppression test (<50nmol/L) - no suppression in Cushing's.
48 hour dexamethasone suppression test (<50nmol/L) - no suppression in Cushing's.
ACTH plasma levels - high in Cushing's disease or ectopic production, undetectable in adrenal tumour.
CRH test.
144
Treatment of Cushing's syndrome.
Iatrogenic - stop steroids.
Cushing's disease (pituitary disease) - surgery.
Adrenal adenoma - surgery.
Adrenal carcinoma - mitotane then surgery.
Ectopic ACTH production - metyrapone.
145
Presentation of Conn's syndrome.
Hypokalaemia - weakness, paraesthesia, tremor.
| Hypertension - associated w/ renal, cardiac and retinal damage.
146
Diagnosis of Conn's syndrome.
ECG shows flat T waves, ST depression and long QT.
| Bloods: low renin, high aldosterone.
147
Treatment of Conn's syndrome.
Laproscopic adrenalectomy.
| Spironolactone.
148
Presentation of Addison's disease.
Abdominal pain and vomiting.
Depression.
Diarrhoea/constipation.
Tired, teary and weak.
149
Diagnosis of Addison's disease.
Bloods: hyponatraemia, hyperkalaemia, hypoglycaemia, low cortisol, uraemia, anaemia.
ACTH stimulation test - test plasma cortisol, give tetracosactide, if plasma cortisol >550nmol/L after 30mins exclude Addison's.
150
Treatment of Addison's.
Replace glucocorticoids w/ hydrocortisone.
Replace mineralocorticoids w/ fludrocortisone.
Advise danger w/ abruptly stopping drugs.
151
Presentation of Addisonian crisis.
Shock - increased pulse, postural hypotension, confusion, weakness, oliguria.
Pain in lower back, abdomen or legs.
Vomiting and diarrhoea.
Low blood pressure.
152
Treatment of Addisonian crisis
IV hydrocortisone.
153
Presentation of acromegaly.
Headache, sweating, weight gain, loss of libido.
Malocclusion,
Increase in size of hands, jaw and feet.
Skin darkening.
Big supraorbital ridges.
Macroglossia.
Obstructive sleep apnoea.
154
Diagnosis of acromegaly.
```
Low glucose.
Low calcium.
Low phosphate.
Oral glucose tolerance test (OGTT) - no suppression of GH.
MRI.
Visual fields.
Old photos.
```
155
Treatment of acromegaly.
```
Trans-sphenoidal surgery to remove pituitary tumour.
IM octreotide (somatostatin analogue).
SC pegvisomant (GH receptor antagonist).
```
156
Presentation of hyperprolactinaemia.
Women: galactorrhea, amenorrhoea, oligomenorrhoea, loss of libido, dry vagina, weight gain.
Men: erectile dysfunction, galactorrhea, loss of facial hair, gynecomastia.
Prolactinoma: headache and vision impairment.
157
Diagnosis of hyperprolactinaemia.
High prolactin levels in the blood - taken by non-stressful venipuncture between 9am and 4pm.
158
Treatment of hyperprolactinaemia.
Cabergoline (dopamine agonist).
159
Presentation of syndrome of inappropriate antidiuretic hormone secretion.
Nausea, vomiting, tremors, muscle cramps.
| Headaches, confusion, hallucinations, seizure, coma, death.
160
Diagnosis of syndrome of inappropriate antidiuretic hormone secretion.
Hyponatraemia w/o hypovolaemia, oedema, diuretics - urine sodium high, plasma sodium low.
161
Treatment of syndrome of inappropriate antidiuretic hormone secretion.
Fluid restriction, increase dietary intake of sodium and protein.
Can give hypertonic saline.
Demeclocycline (inhibits ADH action).
162
Presentation of diabetes insipidus.
Polyuria and polydipsia.
Hypernatraemia: lethargy, thirst, weakness, irritated, fits, confusion, coma.
Dehydration.
163
Diagnosis of diabetes insidious.
Urine volume > 3L/day.
Exclude DM (w/ glucose absence of glycosuria).
Water deprivation test - begin 8am, empty bladder and no fluids, if >3% weight loss order serum osmolality, if serum osmolality >300mOsmol/kg give desmopressin and observe response:
- if urine osmolality >600mOsmol/kg = cranial DI.
- if urine osmolality <600mOsmol/kg = nephrogenic DI.
164
Treatment of diabetes insidious.
Treat the cause of DI.
Bendroflumethiazide (thiazide diuretic) can induce hypovolaemia and increase Na reabsorption in PCT.
Ibuprofen (NSAID) inhibits prostaglandins to increase effect of ADH.
165
Presentation of hypercalcaemia and hyperparathyroidism.
Bones: pain, fracture, osteomalacia/osteopenia/osteoporosis.
Stones: renal colic and biliary stones.
Groans: abdominal pain, malaise, nausea, polyuria and polydipsia.
Psychiatric moans: depression, anxiety, insomnia, coma.
166
Diagnosis of hypercalcaemia and hyperparathyroidism.
```
Raised serum parathyroid hormone.
Raised serum alkaline phosphatase.
Renal function test.
24hr urinary calcium.
MRI.
DEXA.
```
167
Treatment of hypercalcaemia and hyperparathyroidism.
Hypercalcaemia: 0.9% saline to rehydrate, IV pamidronate (bisphosphonate) - prevents osteoclastic bone breakdown.
Hyperparathyroidism: surgical removal, cinacalcet (calcimimetic) - increases sensitivity of parathyroid to calcium.
168
Presentation of hypocalcaemia and hypoparathyroidism
```
Spasm (Trousseau's sign).
Perioral paraesthesia.
Anxiety.
Seizures.
Muscle (smooth) tone increases - wheezing.
Orientation impaired.
Dermatitis.
Chvostek's sign.
```
169
Diagnosis of hypocalcaemia and hypoparathyroidism.
Low serum calcium.
| Low parathyroid hormone or vitamin D deficiency (low 25-hydroxy vitamin D).
170
Treatment of hypocalcaemia and hypoparathyroidism.
Acute hypocalcaemia: IV calcium gluconate.
Vitamin D deficiency: cholecalciferol.
Hypoparathyroidism: calcium supplements and calcitriol.
171
Presentation of hyperkalaemia.
Fast, irregular pulse.
Chest pain.
Weakness.
Light headedness.
172
Diagnosis of hyperkalaemia.
Serum potassium >5.5mmol/L.
| ECG shows tall T waves, small P waves, wide QRS complex.
173
Treatment of hyperkalaemia.
Review medications: NSAIDs, potassium-sparing diuretics, ACE inhibitors. Polystyrene sulfonate resin.
Severe/emergency: calcium gluconate, actrapid and glucose, salbutamol.
174
Presentation of hypokalaemia.
```
Usually asymptomatic.
Muscle weakness.
Cramps.
Constipation.
Hypotonia.
Palpitations.
Light headedness.
```
175
Diagnosis of hypokalaemia.
Serum K+ <3.5mmol/L.
| ECG shows small T waves, prominent U waves and ST depression.
176
Treatment of hypokalaemia.
Treat the cause and review meds (loop and thiazide diuretics).
Moderate cases may need oral sando-k and replace loop/thiazide diuretics w/ spironolactone.
Severe cases: IV K+.
177
Presentation of chronic bronchitis.
Productive cough.
Wheeze, crackles, hypoxaemia, hypercapnia (cyanosis).
Blue bloaters.
178
Diagnosis of chronic bronchitis.
Lung function tests: spirometry - forced expiratory volume.
| CXR may shows hyperinflated lungs or diaphragm compression.
179
Treatment of chronic bronchitis.
Lifestyle modification - stop smoking.
Bronchodilators.
Steroids.
Antibiotics.
180
Presentation of emphysema.
```
Dyspnoea.
Pink puffers - exhale slowly through pursed lips to prevent airway collapse.
Weight loss.
Hypoxaemia.
Barrel chest.
```
181
Diagnosis of emphysema.
Lung function tests: spirometry to measure forced expiratory volume.
High resolution CT can show emphysematous bullae.
182
Treatment of emphysema.
Lifestyle modification - stop smoking.
Bronchodilators.
Steroids.
Antibiotics.
183
Presentation of alpha-1 antitrypsin deficiency.
```
Shortness of breath.
Wheeze.
Mucus production.
Chronic cough.
Hepatic encephalopathy.
Impaired coagulation.
Jaundice.
Portal hypertension.
```
184
Diagnosis of alpha-1 antitrypsin deficiency.
Check serum A1AT levels.
185
Treatment of alpha-1 antitrypsin deficiency.
Give IV infusion A1AT.
186
Presentation of chronic obstructive pulmonary disease.
Productive cough w/ white/clear mucus.
| Wheeze and breathlessness.
187
Diagnosis of chronic obstructive pulmonary disease.
Lung function tests: FEV1.
CXR shows hyper inflated lungs, flattened diaphragm.
High resolution CT scan shows ephysematous bullae.
188
Treatment of chronic obstructive pulmonary disease.
Stop smoking.
Bronchodilators: tiotropium (anti-muscarinic), salbutamol (beta-2-agonist).
Corticosteroids: prednisolone then inhaler beclometasone.
189
Presentation of bronchiectasis.
Productive cough w/ copious amounts of foul-smelling mucus (may have blood).
Dyspnoea and wheeze.
Clubbing (in chronic hypoxia).
190
Diagnosis of bronchiectasis.
Pulmonary function tests: total lung capacity and peak expiratory flow.
CT scan shows dilated bronchi and bronchioles.
Sputum culture.
191
Treatment of bronchiectasis.
Antibiotics - amoxicillin for Haemophilus influenzae.
Postural drainage.
Surgery to localised area.
192
Presentation of cystic fibrosis.
```
Meconium ileus.
Pancreatic insufficiency: poor weight gain, failure to thrive, steatorrhoea.
Pancreatitis.
Endocrine dysfunction.
Cough, fever, wheeze.
Infertility in men.
Digital clubbing.
```
193
Diagnosis of cystic fibrosis.
Screening for neonates.
Immunoreactive trypsinogen present in blood.
Sweat test - high chloride.
194
Treatment of cystic fibrosis.
Antibiotics.
Nutrition: fat soluble vitamins, pancreatic enzymes, extra calories.
Pulmonary physiotherapy.
N-acetylcysteine and dorna alfa (thin mucus).
195
Presentation of asthma.
Intermittent dyspnoea, wheeze, cough (especially nocturnal), sputum production.
196
Diagnosis of asthma.
Lung function test w/ peak expiratory flow meter.
If PEFR improves by 15% w/ bronchodilator = asthma.
Trial corticosteroids.
Exercise tolerance test.
Blood and sputum culture (look for eosinophils).
197
Treatment of asthma.
Stop smoking, avoid triggers, show correct inhaler technique.
SABA - salbutamol.
ICS - beclometasone.
LABA - salmeterol.
4th - theophylline or leukotriene receptor antagonist.
Oral prednisolone.
198
Presentation of pulmonary embolism.
```
Sudden onset dyspnoea and chest pain.
Fatigue.
Cyanosis.
Hyperventilation.
Tachycardia.
```
199
Diagnosis of pulmonary embolism.
CT pulmonary angiography.
| Ventilation/perfusion scan.
200
Treatment of pulmonary embolism.
```
High flow oxygen.
Enoxaparin (LMWH).
Alteplase (fibrinolytic).
IV morphine and anti-emetic.
Prevention: warfarin and heparin, inferior vena cava filter, compression stocks prevent formation of DVT).
```
201
Presentation of pulmonary oedema.
Severe shortness of breath and orthopnoea (worse when lying flat - in left sided heart failure).
202
Diagnosis of pulmonary oedema.
CXR or CT scan shows fluid accumulation in the interstitial space of the lungs.
203
Treatment of pulmonary oedema.
Supplemental oxygen.
Furosemide (diuretic).
Aspirin and ramipril (in cardiogenic causes of pulmonary oedema).
204
Presentation of pulmonary hypertension.
Severe shortness of breath and orthopnoea.
Ankle swelling.
Chest pain.
Syncope.
205
Diagnosis of pulmonary hypertension.
Right heart catheterisation - mPAP >25mmHg.
Echocardiogram - increased pressure in the pulmonary arteries and right ventricle.
CXR - enlarged heart and proximal pulmonary arteries.
206
Treatment of pulmonary hypertension.
Supplemental oxygen.
Amlodipine (calcium channel blocker).
Bosentan (endothelin receptor antagonist).
Phosphodiesterase-5 inhibitors.
Inhaled iloprost (prostanoid analogue for PAH).
207
Presentation of pneumonia.
Dyspnoea, chest pain, productive cough.
| Fever, fatigue, malaise, riggers, anorexia.
208
Diagnosis of pneumonia.
```
CXR shows patchy areas.
Dullness to percussion.
Tactile vocal fremitus.
Later inspiratory crackles.
WBC raised, ESR and CRP raised, urea raised.
```
209
Treatment of pneumonia.
Antibiotics - amoxicillin if mild, co-amoxiclav if severe.
Cough suppressants.
Pain medication - paracetamol or NSAIDs.
210
Presentation of tuberculosis.
Chronic illness w/ fever and weight loss.
Anorexia, night sweats, malaise.
Productive cough w/ haemoptysis.
Chest pain, breathlessness.
211
Diagnosis of tuberculosis.
Tuberculin skin test: inject tuberculin between layers of dermis, positive reaction develops over 48-72 hours - skin hard and red = previous exposure. Doesn't differentiate between active and latent disease and isn't sensitive to immunocompromised individuals.
Interferon gamma release assay - more specific.
CXR shows patchy areas and fibrosis.
Sputum or bronchoalveolar lavage cultures.
212
Treatment of tuberculosis.
Active disease, isolate patient and give: rifampicin (s/e hepatitis), isoniazid (s/e B6 deficiency, give w/ pyridoxine), pyrazinamide (s/e rash), ethambutol (s/e optic neuropathy).
Antibiotics given at DOTs clinic.
Latent disease: isoniazid for six months.
213
Presentation of pertussis.
Catarrhal phase: nasal congestion, low grade fever, cough.
Paroxysmal phase: violent coughing fits (machine gun bursts) and whooping noise.
Vomiting.
Broken rib.
Collapsed lung.
Petechiae (broken vessels in face).
214
Diagnosis of pertussis.
Nasopharynx swabbed: culture, PCR, fluorescent antibody, pertussis serology.
215
Treatment of pertussis.
Cattarhal phase can be treated w/ clarithromycin (macrolide antibiotic).
Prevention w/ pertussis vaccine (part of 6 in 1) at 8 weeks. Can also give vaccine to pregnant women.
216
Presentation of pleural effusion.
Sharp chest pain (particularly when breathing in). Shortness of breath. Worse when laying down.
217
Diagnosis of pleural effusion.
Decreased breath sounds.
Dullness to percussion.
Decreased tactile fremitus.
CXR shows fluid accumulation in costophrenic angle.
Thoracentesis: clear - transudative fluid, straw-coloured - exudative fluid, milky - lymphatic fluid, yellow - empyema.
Protein concentration of fluid: <25g/L - transudative.
>35g/L - exudative.
25-35g/L and [fluid protein]/[serum protein] > 0.5 - exudative.
218
Treatment of pleural effusion.
Diuretics and sodium restriction.
| For large pleural effusion drainage w/ tube may be necessary.
219
Presentation of pneumothorax.
Shortness of breath.
Chest pain.
Reduced breath sounds.
Hyperresonance.
220
Diagnosis of pneumothorax.
CXR or CT.
| Tension pneumothorax may cause displacement of chest structures - tracheal deviation.
221
Treatment of pneumothorax.
Small pneumothorax will resolve.
| Tension or large pneumothorax will need air removed (w/ chest tube).
222
Presentation of idiopathic pulmonary fibrosis.
```
Dry cough.
Shortness of breath.
Cyanosis.
Exertional dyspnoea.
Malaise.
Weight loss.
Clubbing.
```
223
Diagnosis of idiopathic pulmonary fibrosis.
CT shows honeycomb appearance of the lungs and thickening of interstitial walls.
Lung function tests - decrease in total lung capacity, forced vital capacity and forced expiratory volume in one second.
CRP raised.
Immunoglobulins raised.
224
Treatment of idiopathic pulmonary fibrosis.
Give supplemental oxygen.
Pirfenidone (antifibrotic).
Lung transplant.
225
Presentation of sarcoidosis.
```
Shortness of breath.
Cough.
Vision change.
Erythema nodosum.
Fever, weight loss, fatigue.
```
226
Diagnosis of sarcoidosis.
CXR/CT shows bilateral lymphadenopathy.
Bloods: ACE raised, calcium raised.
Bronchoalveolar lavage shows increased T cells.
Biopsy shows non-caseating granulomas.
227
Treatment of sarcoidosis.
Most resolve spontaneously.
| If severe give oral prednisolone.
