General Medicine Flashcards
1
Q
What effect does metronidazole have on INR in patient’s on Warfarin?
A
Increases INR (increased haemorrage risk)
2
Q
What drugs decrease INR (clotting) in patients on warfarin? (3)
A
Carbamazepine (epilepsy)
Phenytoin (epilepsy)
Rifampicin (TB)
3
Q
What is the 1st line treatment for pulmonary oedema?
A
Furosemide
4
Q
Give 2 adverse effects of gentamicin use
A
Ototoxicity (due to auditory or vestibular nerve damage)
Nephrotoxicity (accumulates in renal failure. Toxicity is secondary to acute tubular necrosis)
5
Q
What condition is gentamicin contraindicated?
A
Myasthenia gravis
6
Q
At what level does the aorta terminate?
A
The aorta passes from T12 - L4
7
Q
Give 4 functions of somatostatin
A
Inhibits growth hormone secretion
Inhibits insulin and glucagon secretion
Decreases pancreatic enzyme secretion
Stimulates gastric mucous production
8
Q
Where is somatostatin produced?
A
Delta cells of the pancreas, pylorus and duodenum
9
Q
Name a somatostatin analogue and 2 conditions it is used to treat
A
Octreotide
Acromegaly and Oesophageal variceal bleeds
10
Q
Name 2 antibiotics that inhibit folate synthesis
A
Sulfadiazine (sulphonamide) and Trimethoprim
11
Q
What class of antibiotic is Doxycycline and what is it’s MOA?
A
Tetracycline
Inhibits protein synthesis
12
Q
What class of antibiotic is Flucloxacillin and what is it’s MOA?
A
Penicillin
Inhibits peptidoglycan crosslinking (involved in formation of bacterial cell wall)
13
Q
What class of antibiotic is Gentamycin and what is it’s MOA?
A
Aminoglycoside
Inhibits protein synthesis
14
Q
What class of antibiotic is Ciprofloxacin and what is it’s MOA?
A
Quinolone
Inhibits DNA synthesis
15
Q
What class of antibiotic is Sulfadiazine and what is it’s MOA?
A
Sulphonamide
Inhibits folic acid formation
16
Q
Define Community Acquired Pneumonia (CAP)
A
Describes an acute infection of lung tissue from the community or within 48 hours of hospital admission
17
Q
What are the most common pathogens causing CAP? (3)
A
Streptococcus pneumoniae (most common)
Haemophilus influenzae (most common in COPD)
Mycoplasma pneumoniae
18
Q
Define Hospital acquired pneumonia
A
Describes an acute infection of the lung that occurs in a patient >48 hours after hospital admission
19
Q
What is the most common pathogens causing early onset and late onset HAP?
A
Early onset (<5 days after hospital admission) - Streptococcus pneumoniae
Late onset (>5 days after hospital admission) - Aerobic gram negagive enterobacteria bacilli/rods (pseudomonas aeruginosa, E.coli or Kelbsiella pneumoniae) or Staphylococcus aureus
20
Q
What pathogen is associated with aspiration pneumonia and what name a characteristic feature.
A
Klebsiella pneumoniae
Red-Currant Jelly sputum
21
Q
What condition may cause someone to develop aspiration pneumonia
A
Gastro-oesophageal reflux
22
Q
What is the CURB-65 score?
A
C- Confusion
U- Urea (>7mmol/L)
R- Respiratory Rate >30
B - Blood pressure <90mmHg systolic and/or 60mmHg diastolic
65 - Age >65
23
Q
How does the CURB-65 score measure severity?
A
0-1 Mild
2 - Moderate
> 3 severe
24
Q
How is Mild CAP treated? (1st and 2nd line)
A
1st line - Amoxicillin
2nd Line Clarithromycin (if amoxicillin contraindicated)
25
How is Moderate CAP treated? 1st and 2nd line
1st line Dual - Amoxicillin + Clarithromycin
2nd line - Doxycycline if penicillin allergy
26
What should be offered instead of clarithromycin to pregnant patients with CAP?
Erythromycin
27
What are the 1st and 2nd line treatments for severe CAP?
1st line - IV co-amoxiclav and clarithromycin
(Or erythromycin if pregnant)
2nd line - Levofloxacin
28
How is aspiration pneumonia treated?
Co-amoxiclav
29
Name 2 organisms that cause atypical pneumonia (and name the agar they grow on)
Legionella pneumoniae (grows on charcoal agar)
Mycoplasma pneumoniae (eaton agar)
30
What type of pneumonia is common in patients following influenza infection?
Staphylococcus aureus
31
What type of pneumonia is common in HIV patients?
Pneumocystis jirovecii
32
What bacterium most predominantly causes TB?
Mycobacterium tuberculosis
33
Describe the epidemiology of TB (2)
Majority of cases are seen in Sub-saharan Africa and Asia
Common co-infection seen in HIV patients
34
What pathogen commonly causes pneumonia in patients with undiagnosed HIV?
Pneumocystis jiroveci (fungal)
35
Which white cell type is raised in viral infections?
Lymphocytes
36
Which white cell type is raised in bacterial infections?
Neutrophils
37
Where in the lungs does TB commonly localize?
Upper-middle portion (apex) of the lungs
38
What type of hypersensitivity reaction is seen in TB infection? What cells mediate this?
Type 4 hypersensitivity reaction
Mediated by T cells
39
In TB, the mycobacterium promotes recruitment of macrophages, what 2 changes do macrophages cause?
Formation of multinucleated giant cells (granulomas)
Formation of epithelioid cells
40
Describe the consistency of granulomas (TB) (2)
Caseous or cheese-like on examination.
Rich in mycolic acid, inducing granulomatous necrosis which may lead to cavitation.
41
Give 7 clinical features of TB
Low grade fever
Weight loss
Night sweats
Cough +/- sputum
Haemoptysis
Malaise
Clubbing (bronchiectasis)
42
Give 4 extrapulmonary features of TB
Lymphadenopathy
Ileocecal perforation/obstruction
Addison's disease
Lupus vulgaris (jelly like nodules)
43
Give 2 diagnostic tests for TB
Ziehl-Neelsen stain (Acid fast bacilli smear)
Lowenstein-Jensen media (gold standard for mycobacterium culture)
44
What is the treatment regimen for TB? (4)
RIPE
Rifampicin (6 months)
Isoniazid (6 months)
Pyrazinamide (first 2 months)
Ethambutol (first 2 months)
45
Give 2 side effects of Rifampicin
Hepatitis
Red-orange body secretions
46
Give 2 side effects of isoniazid
Hepatitis
Neuropathy (tingling hands/feet)
47
What should be given in conjunction with isoniazid to prevent neuropathy?
Pyridoxine (vitamin B6)
48
Give 3 side effects of pyrazinamide
Hepatitis
Arthralgia/gout
Rash
49
Give 2 side effects of ethambutol
Optic neuritis
Visual impairment
50
What is the 1st line investigation for TB? What would it show?
Chest X-ray
Shows fibronodular opacities in the upper lobes (apices)
51
How does acute bronchitis typically present? And when?
Presents in autumn or winter
Presents with acute onset of;
Cough (may or may not be productive)
Sore throat
Runny nose
Wheeze
52
How is acute bronchitis managed?
Typically resolves in 3 weeks
53
When and which antibiotics (1st and 2nd line) are considered in acute bronchitis? (3)
1st line - Doxycycline (not in children/pregnant women)
2nd line - Amoxicillin
Consider if;
Patient is systemically unwell
Has pre-existing co-morbidities
Has CRP >100mg/L
54
What pathogen typically causes rheumatic fever?
Group A Streptococcus (Streptococcus pyogenes)
55
Describe the pathophysiology of rheumatic fever
Occurs due to molecular mimicry between streptococcal M protein and human cardiac myosin proteins
Similarities between the two results in antibody and T-cell activation, resulting in an immune response against both streptococcal and human proteins, resulting in tissue injury.
56
How is rheumatic fever diagnosed?
Requires either;
2 major criteria
or
1 major and 2 minor criteris
57
Give 5 major criteria for rheumatic fever
Erythema Marginatum (painless, nonpruritic pink/light red rash on trunk and limbs - face is spared)
Sydenham's chorea (involuntary, irregular, non-repetitive movements of limbs, neck, head and/or face)
Polyarthritis
Carditis and valvitis
Subcutaneous nodules (firm and painless)
58
Give 4 minor criteria for rheumatic fever
Raised ESR/CRP
Pyrexia
Arthralgia
Prolonged PR interval
59
How is Rheumatic Fever managed? (2)
Antibiotics - Oral Penicillin V
NSAIDs
60
What cardiac condition is seen in rheumatic fever? What would be heard on auscultation?
Mitral stenosis (mid-late diastolic murmur)
61
How is asymptomatic mitral stenosis managed?
Monitor with regular echocardiography
62
What laboratory findings would confirm group A streptococcal infection in rheumatic fever (2)
Elevated Antistreptolysin O
Elevated Antistreptococcal DNAase B
63
What would an ECG likely show in Rheumatic Fever?
PR prolongation
64
How is symptomatic mitral stenosis managed? (2)
Percutaneous mitral balloon valvotomy
Mitral valve surgery (commissurotomy or valve replacement)
65
What medical management should be offered to patients who develop atrial fibrillation from mitral stenosis?
Warfarin (Moderate/Severe) or DOAC (mild)
66
Describe the location of each heart valve on auscultation
Aortic valve - Right 2nd intercostal space
Pulmonary valve - Left 2nd/3rd intercostal space
Tricuspid valve - Left 4th/5th intercostal space
Mitral Valve - Left 5th intercostal space
67
Is the mitral valve best heard on inspiration or expiration?
Expiration
68
What are the 3 main branches of the aorta?
Brachiocephalic artery (splits into right common and right subclavian)
Left common carotid
Left subclavian artery
69
Give 4 clinical symptoms of aortic stenosis
Triad of; Angina, Syncope and Heart Failure (elderly patient)
Chest pain
Exertional dyspnoea
70
What clinical signs are likely seen in aortic stenosis? (3)
Ejection systolic murmur
Slow rising pulse (pulsus tardus) with narrow pulse pressure
Soft/absent S2 sound
71
What may be seen on echocardiogram in aortic stenosis
Left ventricular hyperetrophy
72
How is aortic stenosis managed? (2)
TAVI - Transcatheter aortic valve implementation
Infective endocardtits prophylaxis
73
Give 1 acute and 2 chronic cause of aortic regurgitation
Acute - Infective endocarditis
Chronic - Bicuspid aortic valve (most common) and rheumatic fever
74
Give 3 risk factors for aortic regurgitation
SLE/RA
Marfan's syndrome/Ehler's Danlos Syndrome
Infective endocarditis
75
Marfan's syndrome occurs due to a mutation in what protein?
Fibrillin 1
76
Ehler's Danlos syndrome occurs due to a mutation in what protein?
COL1A2 (Type I collagen)
77
What clinical signs are seen in Aortic regurgitation? (3)
High pitched End Diastolic Murmur
Collapsing Pulse (waterhammer)
Wide Pulse Pressure
78
What 2 features may be seen on echocardiogram in a patient with mitral regurgitation?
Left atrial dilation (due to pulmonary hypertension)
Left ventricular hypertrophy
79
Give 3 clinical signs of mitral regurgitation
Pansystolic murmur (heard at apex, radiating to axilla)
Quiet S1
3rd heart sound
80
What is the most common cause of Mitral Stenosis?
Rheumatic Fever (Streptococcus pyogenes infection)
81
How may mitral stenosis present? (3)
Symptoms of pulmonary hypertension (dyspnoea, oedema, haemoptysis, chronic bronchitis)
Malmar flush
Atrial fibrillation
82
Give 3 clinical signs of mitral stenosis
Rumbling mid-diastolic murmur
Loud S1
Prominent A wave on JVP
83
What pathogen most commonly causes infective endocarditis?
Staphylococcus aureus
84
What pathogen commonly causes infective endocarditis in patients with poor dental hygeine?
Streptococcus viridans
85
What pathogen most commonly causes infective endocarditis in patients following prosthetic valve surgery?
Coagulase negative Staphylococci - Staphylococcus epidermidis
86
What pathogen most commonly causes infective endocarditis in patients following prosthetic valve surgery?
Coagulase negative Staphylococci - Staphylococcus epidermidis
87
What antibiotics are given to patients with a native valve infective endocarditis caused by staphylococci? (1st and 2nd line)
1st line - Flucloxacillin
2nd line - Vancomycin + Rifampicin (if penicillin allergy or MRSA)
88
What antibiotic treatment is given to patients with prosthetic valve infective endocarditis caused by staphylococci? (1st and 2nd line)
1st line - Flucloxacillin + Rifampicin + Low dose Gentamicin
2nd line - Vancomycin + Rifampicin + Low dose gentamicin (if penicillin allergy or MRSA)
89
What antibiotic treatment is given to patients with infective endocarditis caused by a fully sensitive streptococci (e.g viridans)? (1st and 2nd line)
1st line - Benzylpenicillin
2nd line - Vancomycin + low dose gentamicin
90
What is the function of the parathyroid glands? (2)
Regulate calcium through production of parathyroid hormone.
Secreted in response to low ionized calcium levels
91
Give 4 actions of parathyroid hormone
Increases osteoclast activity (releasing calcium and phosphate from bone)
Enhances distal tubular resorption of calcium
Decreases renal tubular resorption of phosphate
Increases production of 1,25 dihydroxy-vitamin D3
Net effect is to increase calcium and decrease phosphate
92
Define primary hyperparathyroidism
Describes overactivation of the parathyroid glands, resulting in excess release of PTH, leading to symptoms of hypercalcaemia
93
What is the most common cause of primary hyperparathyroidism?
Solitary adenoma
94
Give 5 clinical features of hyperparathyroidism (hypercalcemia)
Polydispia/Polyuria (nephrogenic Diabetes insipidus)
Bone pain
Abdominal pain
Weak, Tired, Depressed
95
What blood test results suggest primary hyperparathyroidism? (4)
High PTH
High Calcium
High Alkaline Phosphatase
Low Phosphate
96
How is primary hyperparathyroidism managed? (2)
1st line - Parathyroidectomy
2nd line - Cinacalcet (used in patients too frail for surgery)
97
What is the MOA of Cinacalcet
Increases sensitivity of calcium receptors on parathyroid cells, reducing PTH levels and ultimately reducing calcium levels.
98
What are the most common causes of secondary hyperparathyroidism? (2)
Chronic Kidney Disease
Vitamin D deficiency
99
What blood results would be seen in secondary hyperparathyroidism? (5)
High PTH
Low Calcium
High Alkaline phosphatase
Low Phosphate
Low Vitamin D
100
What is the MOA of dabigatran?
Direct thrombin inhibitor
101
What is the MOA of Rivaroxaban and Apixaban?
Direct factor Xa inhibitors
102
What is the MOA of heparin?
Activates antithrombin III
103
What is the MOA of Warfarin?
Inhibits Factors II, VII, IX, X (1972)
104
Define hereditary spherocytosis
Describes an autosomal dominant haemolytic anaemia caused by a defect in the red blood cell cytoskeleton
105
What shape red blood cells are seen in spherocytosis?
Sphere shaped
106
Give 4 clinical features of hereditary spherocytosis
Failure to thrive
Jaundice/gall stones
Splenomegaly
Aplastic crisis precipitated by parvovirus infection
107
What laboratory results would be seen in hereditary spherocytosis? (3)
Spherocytes (spherical red blood cells)
Raised MCHC - Mean corpuscular haemoglobin Concentration
Increase in reticulocytes
108
What test is used to diagnose hereditary spherocytosis?
EMA binding test
109
Give 5 common symptoms of hypercalcaemia
'stones, bones, groans and psychic overtones'
Abdominal pain
Constipation
Increased confusion/lethargy
Gout
Postural hypotension
110
Hypercalcaemia is a common side effect of what drug?
Bendroflumethiazide
111
How is hypercalcaemia managed?
IV 0.9% sodium chloride
112
Give 3 common biochemical side effects of bendroflumethiazide
Hypercalcaemia
Hypokalaemia
Hyponatraemia
113
What is the MOA of thiazide diuretics? (bendroflumethiazide)
Inhibit sodium reabsorption at the distal convoluted tubule by blocking the Na/Cl symporter
114
What is the 1st and 2nd line investigations for acromegaly?
1st line - Serum IGF-1 levels
2nd line (if above positive) - OGTT and serial Growth hormone levels (confirms diagnosis)
115
Give 6 features of hypokalaemia in adults
Weakness
Constipation
Leg cramps
Cardiac arrhythmias (U waves, T wave flattening)
Rhabdomyolysis (severe)
Ascending paralysis (severe)
116
Give 4 causes of hypokalaemia
Drugs - (thiazides, loop diuretics), laxatives, glucocorticoids, penicillins
GI loss - Diarrhoea, vomiting, ileostomy
Salbutamol/Beta agonists
Magnesium depletion
117
How is severe (<2.5mmol/l) or symptomatic hypokalaemia managed?
IV KCL in 1L 0.9 saline
118
How is hypomagnesmia managed in a hypokalemia patient?
Initially give MgSO4 diluted with NaCL over 20 mins, then start KCL infusion
119
What ECG findings are present in hyperkalaemia? (4)
Tall Tented T waves
Prolonged PR interval
Absent/flat P wave
Widening QRS complex
120
What is the normal range for potassium in the blood?
3.5-5.0mmol/L
121
Give 4 clinical features of hyperkalaemia
Muscle weakness
Muscle stiffness
Fatigue
Arrhythmia (cardiac arrest)
122
What drugs can increase risk of hyperkalaemia?
ACEi
ARBs
Potassium sparing diuretics (spironolactone)
123
Define mild, moderate and severe hyperkalaemia
Mild - 5.5-5.9 mmol/L
Moderate - 6.0 -6.4 mmol/L
Severe - >6.5 mmol/L
124
How is hyperkalaemia managed (severe)? (4)
Stabilise cardiac membrane - IV calcium gluconate
Shift K from ECF to ICF - Insulin/dextrose infusion +/- nebulised salbutamol
Stop exacerbating drugs
IV bicarbonate if acidotic
125
What else can be used to facilitate the removal of potassium from the body in hyperkalaemia? (3)
Calcium resonium
Loop diuretics
Dialysis (consider in patients with AKI and persistent hyperkalaemia)
126
How may hypokalaemia present on ECG? (4)
Flattening T wave
Prolonged PR
QT prolongation
Prominent U waves
127
Define angina
Describes chest pain caused by insufficient blood supply to the heart muscle.
Myocardial oxygen demand transiently exceeds the supply, resulting in reversible myocardial ischemia
128
Name 4 types of angina
Stable angina
Unstable angina
Prinzmetal angina
Syndrome X
129
Describe stable angina
Describes chest discomfort that is worsened by exertion and relieved by rest or nitroglycein (GTN spray)
130
Describe unstable angina
Describes chest discomfort occurring on minimal exertion or at rest.
131
Describe prinzmetal angina. Give 4 causes
Describes angina that occurs at rest due to coronary vasospasm
Causes;
Cocaine
Marijuana
Amphetamine
Low magnesium
132
Describe syndrome X
Describes angina pain + ST elevation on exercise test but with NO evidence of atherosclerosis
133
How does typical angina present? (3)
Presents with all 3 of the following
Chest pain precipitated by physical exertion (or emotion, cold weather and heavy meals)
Constricting discomfort in the chest, neck, shoulders, jaw or arms
Relieved by rest or GTN spray
134
Describe atypical angina
Presents with 2 features of typical angina and atypical symptoms, such as;
Gastrointestinal discomfort
Breathlessness
Nausea
135
What diagnostic test is used to confirm angina?
CT coronary angiography
136
What ECG signs may indicate previous MI or ischemia in a patient presenting with angina? (4)
Pathological Q waves
LBBB
ST elevation
Flat/inverted T waves
137
What is the 1st and 2nd line treatment for angina?
1st line - GTN spray + Beta blocker/Calcium channel blocker
2nd line - Isosorbide mononitrate
138
What CCB should be used in angina monotherapy?
Rate-limiting CCB - Verapamil/Diltiazem
139
What CCB should be used in conjunction with a Beta Blocker in angina treatment?
Slow release dihydropyridine - Nifedipine
140
What medication should not be taken with isosorbide mononitrate? and why?
Phosphodiesterase inhibitors (sildenafil)
Can cause excessive hypotension
141
How do Beta Blockers reduce symptoms of angina?
Act as negative inotropes (reduce force of contraction)
142
How do CCBs reduce symptoms of angina?
Act as primary arteriodilators
Dilate systemic arteries so reduces afterload (reducing blood pressure)
143
Name 2 surgical interventions used in patients with advanced IHD (who have failed to restore coronary artery flow)
Percutaneous coronary intervention (PCI - Stenting)
Coronary Artery Bypass Graft (CABG)
144
What artery is used in CABG?
Left internal mammary artery.
Used to bypass proximal stenosis in the Left Anterior Descending Artery
145
How is essential hypertension defined?
Blood pressure >140/90mmHg
146
Define malignant hypertension. Give 3 symptoms
Describes an acute, rapid rise in blood pressure, leading to severe vascular damage.
Presents with severe hypertension >180/120mmHg
Symptoms include;
Bilateral retinal haemorrhage +/- papilloedema
Headache
Visual disturbance
147
Define Masked Hypertension
Describes when clinical blood pressure readings are <140/90 but ABPM/HBPM is much higher
148
Describe how blood pressure is measured in a clinical setting
Measured using a Sphygmomanometer
Measure blood pressure in both arms
If difference between arms is >15mmHg then repeat
If difference remains >15mmHg then measure subsequent pressures form arm with higher reading
149
What investigations should be offered to all patients with hypertension? (4)
Test for proteinuria (albumin:creatinine ratio and haematuria)
Measure HbA1c, electrolytes, creatinine, eGFR, total cholesterol and HDL cholesterol
Examine fundi (hypertensive retinopathy)
Arrange ECG
150
Describe the treatment regimen for patients with hypertension who either have type 2 diabetes, are <55 or are NOT afro-carribbean (1st, 2nd and 3rd line)
1st line - ACEi (ramipril) or ARB (losartan)
2nd line - ACEi/ARB + Calcium Channel Blocker (nifedipine/amlodipine)
3rd line - ACEi/ARB + CCB + Thiazide like diuretic (indapamide)
151
Describe the treatment regimen for patients withy hypertension who; do NOT have type 2 diabetes, are >55 or are Afro-Carribbean.
1st line - Calcium channel blocker (nifedipine/amlodipine)
2nd line - CCB + ACEi/ARB (ramipril/losartan)
(Consider ARB >ACEi in afrocarribbean)
3rd line - CCB + ACEi/ARB + Thiazide like diuretic (indapamide)
152
Describe the 4th line treatment for hypertension. What does it depend on?
Depends on blood potassium levels
If blood potassium <4.5mmol/L - Spironolactone
If blood potassium >4.5mmol/L - Alpha blocker (doxasin/tamulosin) or Beta blocker
153
What type of diuretic is spironolactone?
Aldosrterone antagonist (potassium sparing diuretic)
154
Give 2 common side effects of spironolactone
Hyperkalaemia
Gynaecomastia
155
Give 3 common side effects of ACE inhibitors
Dry Cough
Hyperkalaemia
May lower blood glucose in diabetics
156
Give 1 common side effect of calcium channel blockers
Oedema
157
Give 4 contraindications for calcium channel blocker use
Angina (stable/unstable)
Cardiogenic shock
Aortic stenosis
MI in last month
158
What pulse is seen in atrial fibrillation?
Irregularly irregular pulse
159
What pulse is seen in atrial fibrillation?
Irregularly irregular pulse
160
Name 3 types of atrial fibrillation
Paroxysmal AF (self-terminating)
Persistent AF
Permanent AF
161
Define paroxysmal AF (self-teminating)
Describes episodes lasting >30 seconds for <7 days that are self-terminating and recurrent.
162
Define persistent AF
Describes episodes of AF lasting >30 seconds or <7 days BUT require pharmacological or electrical cardioversion
163
Describe permanent AF
Describes AF that;
Fails to terminate following cardioversion
AF that is terminated but relapses in 24 hours
Longstanding AF (usually >1 year) in which cardioversion has not been indicated or attempted
164
What are the most common complications of AF?
Thromboembolism > Stroke
165
Give 3 common causes of AF
Heart Failure
Ischemic Heart Disease
Hypertension
166
Give 5 symptoms of AF
Dyspnoea
Palpitations (irregularly irregular pulse)
Chest pain
Syncope/dizziness
Stroke/TIA
167
What is used to confirm diagnosis of AF? What would it show?
ECG
Shows;
Absent P waves
Irregularly irregular pulse
168
What risk score is used to assess stroke risk in AF?
CHA2DS2 VASc
169
What risk score is used to assess bleeding risk in AF? When should it be used?
HAS-BLED/ORBIT
Used to assess bleeding risk when considering starting anti-coagulation in AF AND when reviewing patients already on anticoagulants
170
How is acute atrial fibrillation managed?
Antiarrhythmic + Anticoagulant
Amiodarone/Flecanide + Heparin/DOAC
171
Describe the moa of amiodarone. Give 1 side effect
Blocks potassium currents (in 3rd phase of cardiac action potential)
Contains iodine so can cause hyperthyroidism
172
Describe the moa of flecainide. Who should it not be given to?
Prolongs depolarization by binding to fast-inward sodium channels. Also blocks potassium currents (similar to amiodarone)
Should be avoided in patients with structural heart defects, heart failure or IHD
173
How is chronic AF managed? (2)
Rate or rhythm control
174
Describe Rate Control of AF. 1st and 2nd line.
Involves accepting the fact that the patients pulse will be irregular but slow the rate down to avoid negative effects.
1st line - Beta blocker or RL calcium channel blocker (diltiazem/nifedipine)
Avoid CCB if patient has AF with HF
2nd line - Add digoxin
Long term anticoagulation (warfarin/DOAC)
175
What is the MOA of digoxin?
Positive inotrope (increases contractility) + Negative chromotrope (decreases rate)
Inhibits Na/K ATPase
176
When should Rhythm Control (cardioversion) be offered to patients with AF?
Offered to patients who continue to have symptoms after heart rate control or for whom rate control has not been successful.
177
Describe 2 types of rhythm control (cardioversion) in AF.
Electrical cardioversion - Offered to patients whom AF has persisted for >48 hours
Pharmaceutical cardioversion - Flecainide
178
Describe CHA2DS2-VASc score
Congestive Heart Failure
Hypertension
Age >75
Age 65-74
Diabetes
Stroke/TIA
Vascular disease
Sex (female)
179
What ECG finding is present in atrial flutter?
Sawtooth patten of inverted flutter waves (in leads II, III and AvF)
180
Define UTI. How is it characterised?
UTI describes an inflammatory response of the urothelium to bacterial invasion.
Characterised by;
Bacteriuria (bacteria in urine)
and
Pyuria (pus/leukocytes in urine)
181
How are UTIs classified?
Upper - Pyelonephritis (infection of kidney/renal pelvis)
Lower - Cystitis (bladder), Prostatitis (prostate), Urethritis (ureter)
182
Describe uncomplicated and complicated UTIs
Uncomplicated - Normal renal tract function and structure
Complicated - Structural/functional abnormality of GU tract
183
Complicated UTIs include (7)
Pregnant women
Male
Children
Recurrent UTIs
Elderly
Abnormality in urinary tract (stones, obstruction)
Catheterisation
184
What pathogen most commonly causes uncomplicated UTI
E.coli
185
What are the 5 most common pathogens causing UTIs? (KEEPS)
Klebsiella (catheterisation/hospital associated)
E.coli (most common)
Enterococci
Proteus (renal stones)
Staphylococcus aureus (deep seated infection)
186
Give 5 risk factors for UTIs
Female (due to short urethra and proximity to anus)
Sexual intercourse
Decreased urinary flow (dehydration/obstruction)
Pregnancy
Post menopause
187
Give 5 classic signs of UTI
Bacteriuria
Pyuria (pus/leukocytes)
Dysuria (painful urination)
Cloudy urine
New nocturia
188
Give 5 classic signs of UTI
Bacteriuria
Pyuria (pus/leukocytes)
Dysuria (painful urination)
Cloudy urine
New nocturia
189
Give 6 symptoms of cystitis (bladder inflammation)
Dysuria (burning pain when urinating)
Frequency/urgency
Polyuria
Haematuria
Suprapubic tenderness
Foul smelling urine (streptococcus pyogenes infection)
190
Give 3 symptoms of acute pyelonephritis (inflammation of kidney/renal pelvis)
Fever/rigors
Loin pain/tenderness
Vomiting
191
Give 4 symptoms of prostatitis (prostate inflammation)
Dysuria
Pain (lower back, perineum, rectum, scrotum)
Fever, malaise, nausea
Swollen/tender prostate on PR
192
What is the 1st line investigation for UTI in non-pregnant women?
Urine dipstick
193
What is the 1st line investigation for UTI in pregnant women, men, children <16?
Urine culture and antibiotic sensitivity
194
What are the 1st and 2nd line treatments for lower UTI in non-pregnant women >16?
1st line - Nitrofurantoin
2nd line - Pivmecillinam (penicillin) or Fosfomycin
195
What are the 1st and 2nd line treatments for UTI in pregnant women >12?
1st line - Nitrofurantoin (don't use in 3rd trimester)
2nd line - Amoxicllin or Cefalexin
196
What is the 1st line treatment for UTI in men aged >16?
Trimethoprim or Nitrofurantoin (if eGFR <25ml/min)
197
What is the 1st line treatment for acute pyelonephritis in non pregnant women and men >16?
1st line oral antibiotic - Cefalexin
1st line IV antibiotic (if vomiting or unable to take oral) - Co-amoxiclav
198
What is the 1st line antibiotic treatment for acute pyelonephritis in pregnant women >12?
1st line oral antibiotic - Cefalexin
1st line IV antibiotic - Cefuroxime
199
How is cardiac output calculated?
CO = Heart rate x Stroke volume
200
Define stroke volume
Volume of blood ejected from the left ventricle during systole
201
Define end diastolic volume
Volume of blood in the ventricles at the end of diastole
202
Define heart failure
Describes an inefficiency of the heart as a pump. Cardiac output is inadequate for the body's requirements.
203
Name 2 types of Heart Failure
Heart failure with Reduced Ejection Fraction (HF-REF)
Heart failure with Preserved Ejection Fraction (HF-PEF)
204
Define HF-REF. Give 3 causes
Describes an inability of the ventricles to contract resulting in decreased cardiac output
Causes;
IHD
MI
Cardiomyopathy
205
Define HF-PEF. Give 3 causes
Describes an inability of the ventricles to relax and fill normally (due to abnormal thickening/stiffening of cardiac muscle) resulting in creased filling pressures
Causes;
Ventricular hypertrophy
Constrictive pericarditis
Tamponade
206
Give 5 symptoms of chronic heart failure
Dyspnoea (on exertion, at rest or when lying flat) - May get paroxysmal nocturnal dyspnoea)
Fatigue
Peripheral oedema
Cold peripheries
Increased weight (oedema) + Cachexia (muscle wasting)
207
What is used to classify heart failure?
New York Classification
208
Describe the New York Classification of Heart Failure (4)
Class I - No limitation to physical activity
Class II - Slight limitation - comfortable at rest but ordinary physical exercise causes symptoms (mild HF)
Class III - Marked limitation - comfortable at rest but less than ordinary physical exercise causes symptoms
Class IV - inability to carry out physical activity without discomfort
209
Describe the MRC breathlessness criteria for assessing dyspnoea (5)
0 - No breathlessness except with strenuous exercise
1 - SoB when hurrying on level or walking up slight hill
2 - Walks slower than people of same age due to SoB or has to stop for breath when walking at own pace
3 - Stops for breath after walking 100m or after a few minutes of walking
4- too breathless to leave the house or breathless when dressing
210
What blood test result is likely raised in heart failure?
NT-proBNP (indicates increased wall tension)
211
What would a chest X-ray likely show in heart failure? (ABCDE)
A- Alveolar oedema
B- Kerley B lines
C- Cardiomegaly
D- Dilated prominent upper lobe veins
E- Pleural effusions
212
What is the 1st line treatment for HF-PEF?
Low dose loop diuretic - Furosemide
213
What is the 1st and 2nd line treatment for HF-REF?
1st line - ACEi (ramipril) + Beta blocker (bisoprolol)
2nd line - Aldosterone antagonist (spironolactone)
214
What should be offered to patients with HF-REF whom cannot tolerate ACEi/ARBs?
Hydralazine (vasodilator) with nitrate
215
What medication should be avoided in HF-REF?
Calcium channel blockers
216
Give 5 symptoms of acute heart failure
Dyspnoea, Orthopneoa, Pink frothy sputum
Cyanosis/pale
Sweaty
Tachypnoea
Pulsus alterans (alternating strong and weak pulses - indicates LV dysfunction)
217
Give 1 side effect of furosemide (loop diuretic)
hypocalcemia
218
Describe the initial management of acute heart failure (3)
Diamorphine
Diuretics (furosemide)
Ventilation (if resp failure or cardiogenic pulmonary oedema)
219
What treatment is given once a patient with acute heart failure is stable?
Beta blocker + ACEi (or ARB)
220
Give 5 symptoms of STEMI
Acute central chest pain lasting >20 minutes (may radiate to jaw, arm or back)
Nausea
Sweatiness
Palpitations
Dyspnoea
221
What may be seen on an ECG in STEMI? (2) What blood test should also be performed?
ST elevation
Pathological Q waves
Blood test - Troponin (raised)
222
Describe the immediate management of STEMI (MONA)
M- Morphine
O - O2 (if sats <94%)
N - Nitrates
A - Aspirin (offer ASAP) with ticagrelor
223
What should be offered with aspirin in the immediate management of STEMI if the patient has a high bleeding risk?
Clopidogrel (P2Y12 receptor antagonist)
224
Name 2 forms of reperfusion therapy used in STEMI management. When is each performed?
Angiography with Primary PCI - Offered if presenting within 12 hours of symptoms and PCI can be delivered in 2 hours
Fibrinolysis (streptokinase/alteplase) - Offered if presenting in 12 hours of symptoms and PCI cannot be delivered in 120 minutes
225
In a patient having PCI, what medication should they be given (prior to the PCI)? (1st and 2nd line)
1st line - Aspirin + Prasugrel
2nd line - Aspirin + Clopidogrel (if patient is on anticoagulant)
226
What is the MOA of streptokinase/alteplase
Thrombolytics - Activate plasminogen to form plasmin which degrades fibrin, leading to breakdown of thrombi
227
Describe the secondary prevention for STEMI (prevent future MIs - ADBSA)
A - ACEi (ramipril) or ARB (candesartan)
D - Dual antiplatelet therapy - Clopidogrel and Aspirin
B - Beta blocker - Propranolol
S - Statin (atorvastatin)
A - Aldosterone antagonist (spironolactone)
228
What would an ECG show in NSTEMI and Unstable angina? What blood test should be performed?
ST depression
Deep T wave inversion
No pathological Q waves
Blood test - troponin (raised)
229
Describe the immediate management of NSTEMI (3)
Aspirin (ASAP)
Fondaparinux (antithrombin)
- Give Dalteparin or IV dose adjusted heparin where therapeutic range of anticoagulation is required (prosthetic valves, AF with thromboembolism ect)
MONA
230
What can occur 2-6 weeks following MI? Describe it. How may it present? (4)
Dressler's syndrome
Describes autoimmune reaction to antigenic proteins formed as myocardium recovers.
Characterised by;
Fever
Plueritic pain
Pericardial effusion
Raised ESR
231
Describe the pain in pericarditis
Pain worse when lying down
232
Define addisonian crisis
Describes an acute severe glucocorticoid deficiency requiring immediate emergency treatment
233
Gave 3 precipitating factors for addisonian crisis
Stress in patients witn underlying adrenal insufficiency
Sudden discontinuation of glucocorticoids after prolonged glucocorticoid therapy
Bilateral adrenal haemorrhage or infarction (watrerhous-Friderichsen syndrome)
234
Give 4 symptoms of addisonian crisis
Hypotension/shock
Impaired consciousness
Fever
Vomiting/diarrhoea/severe abdominal pain
235
What investigation results would likely be seen in addisonian crisis? (4)
Hyponatremia
Hyperkalemia
Hypoglycemia
Metabolic acidosis
236
How is addisonian crisis managed? (2)
IV hydrocortisone (1st line)
Saline + dextrose (if hypoglycemia)
237
Name 2 types of gout
Monosodium Urate Crystals (gout)
Calcium pyrophosphate crystals (pseudogout)
238
How does monosodium urate crystal gout appear histologically?
Needle shaped, negatively bifringent crystals under polarized light
239
How does calcium pyrophosphate crystals (pseudogout) appear histologically?
Small rhomboid brick shaped, positively bifringent under polarised light.
Pyrophosphate crystals
240
Name 4 drugs that increase the risk of gout, and why?
Aspirin, Indapamide, Tacrolimus (severe eczema), Pyrazinamide
Reduce urate excretion
241
What diagnostic test is required to diagnose gout?
Joint aspiration with synovial fluid analysis
242
How is gout treated? (3)
Stop diuretics (like indapamide) and switch to ARB (losartan promotes uric acid excretion)
Acute - NSAIDs
Recurrent;
-Allopurinol (xanthine oxidase inhibitor)
- Probenexid (uricosuric agent)
- Rasburicase (recombinant urate oxidase)
243
Give 1 side effect of Probenecid
Kidney stones (so use is contraindicated in a patient with kidney stones)
244
When should allopurinol be discontinued?
If patient develops a rash
245
What diet can help reduce risk of developing gout?
High dairy diet
246
How do CCBs work?
Act to as smooth muscle dilators, allowing for vasodilation of arteries.
Act as a negative inotrope (reduces hearts force of contractility)
247
What effect does digoxin have on the heart?
Positive inotrope (increases force of contractility)
Negative chronotrope (decreases rate)
248
Describe the typical 'exam' presentation of a patient with Rhabdomyolysis
A patient who has had a fall or prolonged epileptic seizure and is found to have an acute kidney injury on admission
249
Define rhabdomyolysis
Describes the breakdown of skeletal muscle
250
Describe the pathophysiology of rhabdomyolysis
Creatinine phosphokinase and serum myoglobin are released into blood > Pigment nephropathy > acute tubular necrosis > AKI
251
what triad of symptoms is typically seen in rhabdomyolysis
Triad;
Myalgia
Generalised weakness
Darkened urine (tea coloured)
252
What biochemical changes are likely seen in rhabdomyolysis (5)
Elevated creatinine kinase
Myoglobinuria
Hypocalcemia (myoglobin binds calcium)
Hyperphosphatemia (released from myocytes)
Metabolic acidosis
253
What is Crush syndrome?
Rhabdomyolysis + Hypovolemia and Shock
(systemic manifestation of crush injury)
254
What combination of drugs can cause rhabdomyolysis
Statins + Clarithromycin
255
How is rhabdomyolysis managed? (1)
IV fluid resuscitation
Urine alkalization - Sodium bicarbonate IV promotes renal excretion
(may be required but not recommended)
256
Define AKI. How is it typically characterised?
Describes an acute decline in kidney function resulting in a failure to maintain fluid, electrolyte and acid-base homeostasis
Typically characterised by;
- Increase in serum creatinine
- Decrease in Urine Output
257
Name 3 types of AKI
Pre-renal (most common)
Renal (intrinsic)
Post renal (obstruction to urine outflow)
258
How is Pre-renal AKI characterised? What may cause it? (3)
Characterised by reduced kidney perfusion (blood flow), resulting in ischemia and a reduced eGFR.
Causes;
-Hypovolemia (haemorrhage, burns, pancreatitis)
- Reduced cardiac output
- Renal vasoconstriction (ACEi, ARBs, NSAIDs, loop diuretics)
259
How is renal AKI characterised? What may cause it? (4)
Characterised by structural damage to the kidneys.
Causes;
Toxins and drugs (antibiotics, contrast, chemo)
Vascular pathology (vasculitis, thrombosis,haemolytic uraemic syndrome)
Glomerulonephritis
Acute tubular necrosis
260
How is post-renal AKI characterised? What can cause it?
Characterised by an acute obstruction of the outflow of urine, resulting in increased intratubular pressure and decreased GFR
Causes include;
Obstruction (renal stones, malignancy, enlarged prostate, blocked catheter)
261
Give 4 complications of AKI
Hyperkalaemia
Metabolic acidosis
Peripheral/Pulmonary oedema
Uraemia
262
Give 2 clinical features of AKI?
Nausea, vomiting, diarrhoea or evidence of dehydration
Confusion, fatigue or drowsiness
263
Describe the stages of AKI
(Units - mL/Min/1.73m2)
Stage 1: >90
Stage 2 : 60-89
Stage 3A: 45-59
Stage 3B: 30-44
Stage 4: 15-29
Stage 5/ESRF: <15
264
Give 4 clinical signs of AKI
Reduced urine output (oliguria) or changes in urine colour
Pulmonary/peripheral oedema + basal crepitations
Arrhythmias (due to hyperkalaemia)
Features of uraemia (pericarditis, encephalopathy)
265
What tests should be performed in a patient with AKI? (4)
U and E
Urine output
Urine dipstick (ASAP)
Ultrasound (assess kidney size - Small = CKD)
266
How is AKI managed? (3)
Pre-renal - Correct volume depletion and/or increase renal perfusion
Renal - Refer for biopsy and specialist treatment
Post-renal - Refer for catheter, nephrostomy or stenting
267
What drugs should be stopped in AKI? (5)
ACEi
ARBs
NSAIDs
Gentamicin
Amphotericin (antifungal)
268
Describe the pathology of prostate cancer
Majority are multifocal adenocarcinomas sarising in the peripheral zone of the prostate gland
269
Where in the prostate gland does prostate cancer typically arise?
Peripheral zone
270
What is the most common cancer that metastasizes to bone?
Prostate cancer
271
Give 5 clinical features of prostate cancer
Lower back, or bone paion
Nocturia, dysuria or heritancy
Poor stream, dribbling
Weight loss
Haematuria
272
How might prostate cancer feel on PR exam?
Hard nodular prostate
273
What score is used to assess the likelihood that a patient has prostate cancer?
Likert Score
1- Very unlikely
2 - Unlikely
3- Difficult to tell
4- likely
5- Very likely
274
What score is used to grade prostate cancer?
Gleason Score
275
How is localised prostate cancer managed?
Low/intermediate risk;
Active surveillance
Radical prostatectomy
Radical radiotherapy
High risk;
Prostatectomy or radical radiotherapy
276
How is metastatic prostate cancer managed? (2)
External beam radiotherapy
Androgen deprivation therapy (groserelin and leuprorelin)
277
Give 3 adversed effects of hormone therapy in the management of prostate cancer and state how they are managed.
Hot flushes - Medroxyprogesterone
Sexual dysfunction - Sildenafil (phosphodiesterase inhibitors)
Osteoporosis - Bisphosphonates
278
Define benign prostatic hyperplasia
Describes enlargement of the inner (transitional zones) of the prostate
279
How may BPH be different to prostate cancer on PR examination?
Prostate cancer is nodular and asymmetrical
280
How is BPH managed? (3)
Alpha blockers - Tamsulosin
5a reductase inhibitor - Dutasteride
Surgery - Transurethral resection of prostate (TURP)
281
Name 1 common side effect of Tamsulosin (alpha blocker)
Postural hypotension (as alphablockers induce dilation of venous capacitance vessels)
282
Give 1 side effect of TURP
Impotence
283
Name 2 types of ventricular tachycardia
Monomorphic VT - Most commonly caused by MI
Polymorphic VT - Subtype is torsades de pointes (precipitated by prolongation of QT interval)
284
What is torsades de pointes associated with?
Prolonged QT interval
285
What can torsades de pointes degenerate into?
Ventricular fibrillaiton
286
Give 2 congenital causes of prolonged QT interval
Jervell-Lange-Nielsen syndrome (inc deafness due to abnormal potassium channel)
Romano-ward syndrome (no deafness)
287
Name 4 drugs that can cause QT prolongation
Amiodarone
Tricyclic antidepressants (fluoxetine)
Chloroquine
Erythromycin
288
Name 3 electrolyte imbalances that can cause QT prolongation
Hypocalcaemia
Hypokalaemia
Hypomagnesaemia
289
Describe the acute management of SVT (3)
Valsalva manoeuvre
IV adenosine (contraindicated in asthmatics, give verapamil instead)
Electrical cardioversion
290
SVT management - In what patients is adenosine contraindicated? What should be given instead?
Asthmatics
Give Verapamil instead
291
What impact can haemodynamic instability have on heart rate?
Can cause symptomatic bradycardia
292
How may symptomatic bradycardia present? (3)
Recurrent episodes of syncope
Dizziness/Disorientation
Hypotension
293
How is symptomatic bradycardia managed? (2)
1st line - Atropine/Transcutaneous pacing
2nd line - Adrenaline/Isoprenaline
294
What medication is used in the management of cardiovascular failure 2nd to beta-blocker overdose?
Glucagon
295
Give 4 indications of haemodynamic compromise
Shock; hypotension (systolic <90), pallor, sweating, cold
Syncope
Myocardial ischemia
Heart failure
296
What 3 ECG features are present in Wolf-Parkinson-White syndrome?
Short PR interval
Delta waves
Prolonged QRS complex
297
What congenital accessory pathway is present in WPW?
Bundle of Kent
298
Define 1st degree heart block
Patients experience a slower condution velocity, resulting in prolonged PR interval
299
What ECG finding may be present in a patient with a 1st degree heart block?
Prolonged PR interval
300
Give 4 causes of 1st degree heart block
Inferior MI
Hyperkalaemia
AV node blocking drugs (beta blockers, calcium channel blockers, Digoxin, Amiodarone)
301
Name 2 types of 2nd degree heart block
Type I - (Wenckebach or Mobitz I)
Type II - (Mobitz II)
302
How is Wenckebach/Mobitz 1 heart block characterised on ECG?
Progressive prolongation of PR interval followed by blocked P wave.
(PR interval is longest before non-conducted P wave, and shortest immediately after)
303
Do Mobitz I heart blocks require a pacemaker?
No
304
Describe Mobitz II heart block
Describes a failure of conduction through the His-Purkinje system. May be due to structural changes/damage (fibrosis/necrosis/infarction)
305
How is Mobitz II heart block characterised on ECG? (2)
Constant (unchanged) PR interval
Dropped (disappearing QRS complexes)
(QRS complex disappears but P wave remains)
306
Do Mobitz II heart blocks require pacemaker treatment? Why?
Yes
Carry high risk of sudden complete AV block
307
How is 3rd degree heart block characterised?
Characterised by complete absence of AV conduction to the ventricles. Resulting in no association between P waves and QRS complexes on ECG.
308
How may a 3rd degree heart block present on ECG? (2)
Independent atrial (p waves) and ventricular (QRS complexes) rates. (likely more P waves than QRS complexes)
Bradycardia (as ventricular escape rhythm is slower than sinus)
309
How may a left bundle branch block present on ECG?
WiLLiaM
Deep S waves in V1 (W)
Tall/Broad 'Notched' R waves (M) in V6
310
How may Right Bundle Branch Block present on ECG?
MaRRoW
RSR pattern (M shaped) in V1
Wide Slurred S waves in V6
311
Give 3 causes of RBBB
Pulmonary hypertension
Pulmonary embolism
Right ventircular hypertrophy/cor pulmonale
312
Name 2 types of frailty scoring
Phenotype (Fried criteria)
Cumulative deficit model (e-FI, CFS, Rockwood criteria)
313
Describe how Fried Criteria describes frailty and what criteria it uses. (5)
Frailty is defined as 3 or more of the following;
Unintentional weight loss
Self reported exhaustion
Weakness (grip strength)
Slow walking speed (timed up ant to go test)
Low physical activity
314
What is the cut off for the Timed Up and Go Test?
10 seconds
315
Define pre-frail (according to Fried Criteria)
Patients who meet only 2 of the criteria
316
Describe end of life care
Term used to describe the last 12 months of life.
317
In whom should antibiotics be offered for patients presenting with pressure ulcers? (3)
Clinical evidence of systemic sepsis
Spreading cellulitis
Underlying osteomyelitis
318
Give 4 causes of acute liver failure
Paracetamol overdose
Hepatitis A
Pre-eclampsia developing into HELLP syndrome
Fructose intolerance
319
What enzyme does Aspirin target?
COX1
320
Describe the Mx of steroid responsive COPD
1st - SABA or SAMA
2nd - SABA + LABA + ICS (if originally on SAMA, discontinue and start SABA)
3rd - SABA + LABA + ICS + LAMA (tiotropium)
321
Describe the Mx for non-steroid responsive COPD
1st - SABA or SAMA
2nd - SABA + LABA + LAMA (If originally on SAMA discontinue and start SABA)
322
Name 1 SABA
Salbutamol (Beta agonist)
323
Name 1 LABA
Salmeterol
324
Name 1 SAMA (short acting muscarinic antagonist)
Ipratropium bromide
325
Name one LAMA (long acting muscarinic antagonist)
Tiotropium
326
Name 1 ICS (inhaled corticosteroids) used in COPD
Beclometasone or Fluticasone
