KCP Flashcards
Where and what is pain from myocardial ischaemia felt?
Centre on the chest.
It may radiate to the neck, jaw, upper or lower arms
Occasionally, in the back
Dull, constricting, choking and is described as burning, aching or squeezing
takes several minutes to develop.
Accompanied by sweating, nausea, breathlessness or vomiting
Where and what is the pain of myocarditis or pericarditis felt?
To the left of the sternum, or in the left or right shoulder
Felt as sharp, and may ‘catch’ during coughing
Where is the pain of aortic dissection felt?
central, with radiation to the back.
severe, and ‘tearing, usually sudden onset
What is pleurisy?
a condition in which the pleura — two large, thin layers of tissue that separate your lungs from your chest wall — becomes inflamed
a sharp or catching chest pain aggravated by deep breathing,
What is angina caused by?
Occurs during exercise and is relieved by rest. Can be exacerbated by emotion, a large meal or cold wind.
What is pain caused by gastro-oesophageal reflux like?
central, dull and burning
can elicit a history relating chest pain to eating drinking or oesophageal reflex.
How can you tell the difference between ischaemic cardiac and non-cardiac chest pain?
What should clinicains investiagte if a patient presents with chest pain?
- 12 lead electrocardiogram (ECG)
-
What does chest pain accompanied by clinical evidence of increased intracardiac pressure indiacte?
Myocarial ischaemia or massive pulmonary embolism.
Legs should be examined for clinical evidence of deep vein thrombosis.
What is coronary heart disease usually caused by?
atherosclerosis (buildup of fats, cholesterol and other substances in and on your artery walls)
rarely, aortitis (inflammation of the aortia)
What are the risk factors for coronary heart disease?
Age
Genetics
Smoking
Hypertension
type 2 diabtetes
physical activity levels
obesity
Alcohol
social deprivation
What are risk factors for myocardial infarct?
Age, gender, obesity, lack of exercise, bad diet, smoking, blood pressure, family history, diabetes,
What is myocardial ischemia?
Myocardial ischemia occurs when blood flow to the heart muscle is obstructed by a partial or complete blockage of a coronary artery. A sudden, severe blockage of one of the heart’s artery can lead to a heart attack. Myocardial ischemia may also lead to abnormal heart rhythms (atrial fibrillation).
Why is troponin released into the blood during a myocardial infarction?
When the cell does not get enough oxygen, aerobic pathways cannot continue and ATP cannot be made. Anaerobic respiration takes place and lactic acid is produced. This leads to components of the cell being released, called troponins.
What are the steps of an ECG?
What happens when a trauma patient arrives at the hospital?
- hospital get a warning call- includes vital signs, injury, age and time of injury
- role allocation occurs, organise equipement and a room for the patient
- Once patient arrives, check for life threatening injuries
- May need to remove head blocks, stretcher, pelvic scoop and clothes.
- Aim to get a CT scan 20 mins after arriving in the hospital.
What initiative should emergency doctors follow?
ATLS (advanced trauma life support) which involves a primary and secondary check and the ABCDE checklist
What is the airway section of managing trauma patients?
If uncounscious, patients airway should be checked and cleared.
If the patient is vomiting, either log roll them or if chance of a spinal injury, head tipped bacl and vomit sucked away
Once airway checked, very patient should receive 100% oxygen at a flow rate of 15 L/min, and neck and cervical spine must be checked for injuries.
What does the breathing section of trauma patient managment include?
Check for tension pneumothorax, cardiac tamponade, open chest wound, massive haemoxthroax or flail chest
Respiratory rate must be measured
Chest x-ray crucial
Chest should be visually examined and listened to as well
What does the circulation and haemorrhage control section of managing trauma patients involve?
Look for clinical signs of shock, such as fast HR and poor capillary refill
Control any external haemorrage by pressure- torniquets only used when limb is unsalvagable
Blood should be taken to determine blood type, electrolyte concentrations, pH and blood gas analysis
The type of fluid given to patients differs in each region. To reduce the chance of hyperthermia, fluids must be warmed before use. If the vital signs do not improve at all, the patient has lost >40% of blood.
Whata are the D and E sections of managing a trauma patient?
D= disability, spinal cord and brain function tested by reflexes. The glasgow coma scale should be used
E=exposure and environment control- keep patient warm, continue to measure vital signs. Only after the main problems have been solved can move onto secondary survery.
What is hypovolaemic shock?
- Hypovolaemic shock is a clinical state in which loss of blood, extracellular fluid, or plasma causes inadequate tissue perfusion.*
- Hemorrhagic shock is hypovolemic shock from blood loss*
How much blood needs to be lost until a healthy adult’s systolic blood pressure decreases?
30-40% of blood volume
What happens in haemorrhagic shock?
Haemorrhagic shock causes a significant lactic acidosis; pyruvate is unable to enter the Krebs cycle. Instead, pyruvate undergoes anaerobic metabolism in the cytoplasm, a process that is relatively inefficient for adenosine triphosphate (ATP) generation. ATP depletion causes cell membrane pump failure and cell death. The aim of resuscitation is to deliver oxygen rapidly to stop death.
What are signs of hypovolaemic shock?
- Skin pallor
- hypotension
- confusion, agression, drowsiness
- weakness
- thirst
What are the 3 different classes of hypovolaemic shock?
Why should no fluid be given prehospital if theres a pulse/ little fluid given if theres no pulse?
if the wounds are still open as extra fluid could dislodge clots and further cause bleeding
What fluid ratios should be given to patients?
Platelets : Fresh frozen plasma : blood
1:1:1
Where are the most common places patients bleed?
chest, abdomen, pelvis and femur
What are the 5 shapes of bone?
Long- cyndrical shape such as femur
Short- cube or box shaped such as carpals
Flat- broad and thin, such as scapulae
Irregular bones- clustered in groups, facial bones
Sesamoid bones- irregular bones that appear by themsleves such as patella
What is the medullary cavity?
Marrow cavity- filled with connective tissue rich in fat (yellow marrow). Lined by the endosteum
What is articular cartilage and periosteum?
Articular cartilage is the thin layer of hyaline cartilage that covers the articular or joint surfaces of epiphyses. The resiliency of this material cushions jolts and blows. Periosteum is dense, white fibrous membrane that covers bone except at joint surfaces. Many of the periosteum fibres penetrate the underlying bone and weld these two structures to each other. In addition, muscle tendon fibres interlace with periosteal fibres, thereby anchoring muscles firmly to bone.
What are the layers of flat bones?
Outer and inner walls of compact bone- called external and internal table.
Between them is a region called diploe, made of cancellous bone. Red marrow fills the spaces of the cancellous bone inside many flat bones.
Why is bone hard?
Results from the deposition of rocklike crystals of calcium and phosphate. Known as hydroxyapatite- make up 85% of organic mix
What structure does compact bone have?
Osteons or haversian systems, surrounding central canal. Made up of individual lamellae cyclinders.
What is cancellous or spongey bone made of?
No osteons, instead crisscross branches known as trabeculae. Nutrients are delivered to the cells and waste products are removed by diffusion through tiny canaliculi that extend to the surface of the very thin bony branches
What are the different bone cells?
- Osteoblasts mall cells that synthesize and secrete an organic matrix called osteoid. Collagen strands in the osteoid serve as a framework for the formation of hydroxyapatite crystals, which mineralizes the bone tissue.
- Osteogenic stem cells, found in the endosteum and lining the central canals, undergo cell division to form osteoblasts
- Osteoclasts are giant multinucleate cells that are responsible for the active erosion of bone minerals.Osteoclasts erode bone by releasing hydrochloric acid (HCl) that dissolves the hard mineral crystals and collagenase , which is an enzyme that breaks the peptide bonds in collagen proteins.
- Osteocytes are mature, nondividing osteoblasts that have become surrounded by matrix and now lie within lacunae. Maintain bone tissue
What is osteoporosis?
The defining feature of osteoporosis is reduced bone density, which causes micro-architectural deterioration of bone tissue and leads to an increased risk of fracture, in response to minor trauma.
What are the risk factors for Osteoporosis?
Exercise and Calcium intake during growth effect peak bone mass
Smoking
Alcohol
Age
Drugs such as glucocorticoid
Post-menopause
Ethnicity
What are the two types of osteoporosis?
Idiopathic OP- no specific underlying cause, usually old age
Secondary- caused by diseases and drug treatments such as glucocorticoid-induced OP
What is a DEXA scan?
Dual-energy X-ray absorptiometry is a means of measuring bone mineral density using spectral imaging. Two X-ray beams, with different energy levels, are aimed at the patient’s bones. When soft tissue absorption is subtracted out, the bone mineral density can be determined from the absorption of each beam by bone.
What main treatment is given for OP?
Bisphosphonates, target bone surfaces and are ingested by osteoclasts during the process of bone resorption. Impairs bone resorption. Increases bone density.
Given orally for upto 10 years. Have to be taken on an empty stomach.
What treatments other than Bisphosphates are given for OP?
Denosumab= a monoclonal antibody that inhibits bone resorption by neutralising the effects of RANKL. One potential adverse effect is hypocalcaemia but this can be mitigated by calcium and vitamin D supplements.
Calcium and vitamin D= Combined calcium and vitamin D supplements have limited efficacy in the prevention of osteoporotic fractures when given alone but are widely used as an adjunct to other treatments.
Surgery= Orthopaedic surgery with internal fixation is frequently required to reduce and stabilise osteoporotic fractures. Patients with intracapsular fracture of the femoral neck generally need hemi-arthroplasty or total hip replacement.
What are the 4 stages of bone remodelling?
What is defined as Osteoporosis?
Individuaos with a bone mineral density > -2.5 SD below the young normal mean
Who gets a DEXA scan?
DEXA scans are given to anyone who has had a fracture >50 years old, if there is a suspected vertebral fracture, taking oral glucocorticoids and if there 10-year fracture risk >10%
What are the adverse effects of taking OP treatment drugs?
Indigestion sometimes occurs with oral bisphosphonates, and some patients do not like fasting before taking it. Intravenous bisphosphonates may cause flu-like illnesses for a few days after treatment. Rare side effects- osteonecrosis of the jaw and if taken over long course- atypical femoral fractures. Romosozumab may increase the risk of CV events
What two drugs build new bone?
Teriparatide and romosozumab
What is breathlessness?
Uncomfortable need to breathe- often called dyspoea
What are the 4 main reasons someone is breathless?
Problem with lungs
Problems with the heart or circulation
Problems with oxygen transport
Problems with acid-base balance
What are acute causes of breathlessness?
Anaphylaxis
Asthma
Anaemia
Myocardial infarct
Pulmonary embolus
Pneumothorax
Heart failure- pulmonary oedema
Pneumonia
What are the causes of chronic breathlessness?
Asthma
Anaemia
Heart failure
Lung cancer
COPD
What is COPD
- Breathless on exertion
- Cough
- Recurrent chest infections
- progressive
What are the risk factors for COPD?
- SMOKING
- environmental dust, particles, fumes
- women more susceptible
- asthma
What are common multimorbitys associated with COPD?
Peripheral vascular disease
Hypertension
Ischaemic heart disease
Heart failure
How is COPD diagnosed?
Based on history, then backed up with chest x-ray and spirometry
What is a spirometry test?
Spirometry is a common test used to assess how well your lungs work by measuring how much air you inhale, how much you exhale and how quickly you exhale.
It’s carried out using a device called a spirometer, which is a small machine attached by a cable to a mouthpiece.
What is the difference in spirometry levels of a COPD patient?
•COPD diagnosed with an FEV1/FVC ratio <0.7
What is the treatment for COPD?
- stop smoking
- vaccinate against influenze, pneumococcus and COVID-19
- pulmonary rehabilitation
- lose weight
- inhalers
What is pneumothorax/risk factors for it?
It is presence of air in the pleural space, which can occur spontaneously or can be caused by injury or trauma to the lung/chest wall.
Smoking, tall stature and the presence of apical subpleural blebs ( small subpleural thin-walled air-containing spaces) are risk factors.
What are the 3 causes of pneumothorax?
Primary- no evidence of overt lung disease, air escapes into the lung through the rupture of a small pleural bleb.
Secondary- underlying lung disease, seen in asthma, TB, lung cancer and chronic obstructive pulmonary disease.
Traumatic- caused by surgery, a biopsy or chest wall injury
What are the 3 types of pneumothorax?
Closed- hole closes up after air escapes, infection uncommon
Open- hole fails to close up, and air continues to freely pass between bronchi and space.
Tension- when the air can enter the space, but not exit, causing large amounts of air to escape and cardiovascular compromise.
What are the clinical features of pneumothorax?
Chest pain, breathlessness, a larger pneumothorax results in decreased or absent breath sounds.
What is the treatment for pneumothorax?
Primary usually resolves itself, 20-40% percutaneous needle aspiration needed. For secondary, needle aspiration does not work and intercostal tube drainage and inpatient observation needed. For tension, insertion of a blunt cannula into the space immediately may be beneficial, allowing time to prepare for chest drain insertion.
Surgery may be needed if treatment does not work.
What could sudden breathlessness be a sign of?
Pneumothorax, or acute allergy
What could breathlessness that was onset over hours be?
Asthma, pulmonary oedema or infection
When does breathlessness from asthma occur?
Asthma commonly wakes patients in the night, and comes on during exercise. some days however you cannot feel it.
What is a wheeze?
Wheeze describes the high pitched ‘whistling’ sound, most commonly heard during expiration. It is typical of small airways diseases. Most commonly associated with asthma or COPD. Could mean acute respiratory tract infection.
What is a stridor?
A harsh grating respiratory sound created when the airway is critically narrowed by compression, tumour or inhaled foreign material. Rapid investigation and treatment are vital when this sign is present.
what is Haemoptosis?
Means coughing up blood, associated with acute or chronic respiratory tract infections. It may also indicate pulmonary embolism and, if recurrent, lung cancer.
Why is back pain so common?
sitting down all day, heavy lifting, awkward movement, people living older, poor posture, lack of exercise, central obesity, pregnancy, trauma and the fact humans are bipedal.
How does sitting contribute to back pain?
Sitting shortens the psoas muscle, which pulls slightly on the spine
(Lumbar lordosis is the inward curve of the lumbar, or lower, spine in the lower back)
What is the radiculopathy of L2- L5?
Radicular pain is often secondary to compression or inflammation of a spinal nerve. ALSO KNOWN AS SCIATICA
L2-L4 radiculopathy- weakness of the hip flexion, knee extension and leg adduction. Reduced sensation over the anterior thigh down the medial aspect of the skin. Absent knee jerk.
L5 radiculopathy- weakness of foot dorsiflexion, toe extension, foot inversion and eversion. Numbness in lateral shin and dorsum of the foot. Reflexes normal.
What is ankylosing spondylitis?
Ankylosing spondylitis (AS) is a long-term condition in which the spine and other areas of the body become inflamed.
Symptoms- most common is back pain. Insidious onset, improves by exercise and worsens with rest. There is pain at night, pain in buttocks and hips.
Treatments- basics are patient education- exercise and posture. Patient support groups, stop smoking, physiotherapy, NSAIDs.
What causes lumbar radiculopathy?
Most commonly due to:
Disc herniation (slipped disk)
Spondylosis (pain in the spine) due to degenerative osteoarthritis
What are myotomes?
MYOTOMES-> the response that occurs due to certain nerves. Eg L5= sensory loss in big toe and pain down back of thigh.
What are clinical red flags in back pain?
Progressive or severe motor deficit
Suspected or known cancer (could be due to metastases)
Suspected infection (could be an abscess)
Urinary retention
Urinary or faecal incontinence
Numbness round the anus (saddle anesthesia), loss of anal sphincter tone
Bilateral symptoms
What is radiculopathy of S1?
Loss of achilles reflex
Effects Ankle plantar flexsion
Sensory loss of lateral foot and pain down back of calf
How to diagnose and treat lumbar radiculopathy?
Clinical diagnosis
Treatment- exercise regime, physio therapy, cognitive behavioural therapy, NSAIDs. avoid opiates
What are osteoporotic vertebral fractures?
Can happen acutely or slowly overtime. Most likely thoracic or lumbar spine. Acute episode associated with sudden onset of back pain. Pain normally resolves within 4-6 weeks. Leads to loss of height.
Treatment= analgesia, paracetamol, NSAIDS. Check and then treat for osteoporosis.
Use a DEXA scan
What is cauda equina?
Central disc protrusion
Malignancy= Cancer spread to vertebra and compress lumbosacral nerve roots, Prostate, breast and lung are most common but any malignancy could cause it
Back pain is usually first followed by progressive neurological signs, Lower limb weakness, Bowel and bladder dysfunction including urinary retention,Sensory loss (often less prominent)
Is a medical emergency- MR scan spine, Neurosurgical intervention may be required
What is the homunculus?
The sensory homunculus is a map along the cerebral cortex of where each part of the body is processed.
What is the pyramidal tract?
pathways and junctions from the central cortex to the peripheries.
What are the clincial features of Parkinsons disease?
- Tremor
- Rigidity
- Bradykinesia
- Postural instability
Whilst walking, legs shuffle along the ground and hands do not swing
What causes Parkinson’s disease?
- Loss of dopaminergic neurons in the substantia nigra
- Dopamine exerts inhibitory effects in the basal ganglia
- Overactivity of basal ganglia neurons lead to tremor and rigidity
What causes strokes and TIAs?
Interrpution of blood supply to the brain
In strokes- usually caused by blood clots (85%) or brain bleeds (15%)
What are modifable risk factors for a stroke?
- Hypertension
- smoking
- diabetes mellitus
- excessive alcohol intake
- atrial fibrillation
- hyperlipidaemia (high level of cholesterol or triglycerides in your blood)
How can you differentiate between a stroke and a TIA?
TIA (transient ischemic attack) begins just like an ischemic stroke; the difference is that in a TIA, the blockage is temporary and blood flow returns on its own. Since blood flow is interrupted only for a short time, the symptoms of a TIA don’t last long
What are the symptoms of a TIA or a stroke?
Facial weakness/ arm weakness/ speech problems
What is the arterial blood supply to brain like?
What is the circle of Willis and why is it important?
The Circle of Willis is the joining area of several arteries at the bottom (inferior) side of the brain.
Circle of Willis is important in circulation as there are connections so if one path gets slowly blocked, the blood can go the other way.
What is the standard treatment of a stroke?
Oral aspirin for 14 days - 300mg dose
Ischaemic strokes can often be treated using injections of a medicine called alteplase, which dissolves blood clots and restores blood flow to the brain.
This use of “clot-busting” medicine is known as thrombolysis.
What ia osteoarthritis?
Is a whole joint disease
Degeneration of the cartilage
Inflammation of the synovium
subchondral bone cysts and altered bone turnover
Ligament and tendon imflammatio
What is the most common symptomS of OA?
Pain
Morning stiffness < 30 mins
swelling
crepitus
What are risk factors for OA?
Age
Female
Genetics
BMI
Diet
Physical activity and muscle weakness
Repetitive joint movement
Joint trauma
What joints are most commonly affected by OA?
- Knees
- Hips
- First interphalangeal joint
- First carpometacarpal joint
- First tarsometaphalangeal joint
- Apophyseal joints of lower cervical and lumbar spine
What do each of the arrows point to and what is the diagnosis?
Diagnosis- OA
What do each of the arrows point to and what is the diagnosis?
Diagnosis- OA
What are the most important elements of managing OA?
Patient education
Weight control
Exercise
Social support
What is the treatment of OA?
Pain control- Oral Paracetamol, Topical non-steroidal anti-inflammatory drugs (NSAIDs) and Oral NSAIDs
Intra-articular injection of glucocorticoids for swollen acutely painful joint
There are no disease modifying agents for OA
Joint replacement may be needed for patients who have significant impairment on their quality of life
What is different from OA to other diseases?
Symptoms do not correlate with pathological changes
What is gout?
Gout is a type of arthritis that causes sudden, severe joint pain. Gout is caused by a condition known as hyperuricemia, where there is too much uric acid in the body.
Can become super saturated in the joints as crystals - known as gout
What are risk factors for gout?
Alcohol use
High fractose sweetened drinks
High meat and seafood consumption
Heart disease, hypertension, diabetes, hyperlipidaemia
Renal disease
Why has uric acid stayed insoluable in humans?
Uric acid is insoluable
In most mammels uricase breaks it down to 5-hydroxyisourate, which is more soluable
However this gene has been silenced in great apes as uric acid have enabled great apes to store fructose from fruit as fruit and it stimulates blood pressure in response to salt
What leads to hyperuicemia (high uric acid concentrations)?
What is septic arthritis?
Bacteria gets into a joint, the inflammatory immune response creates a whole body response including increased HR, temperature increases/decreases, low blood pressure, hypoxia, reduced urine output and confusion/drowsiness.
How do check for gout or septic arthritis?
Aspirate the joint and send blood cultures
If theres bacteria= sepsis, if there is monosodium urate crystals is gout
What is the treatment of gout and septic arthrits?
Gout= NSAIDs as well as lifestyle, alcohol, diet and weight
Septic arthritis= antibiotics
What are the symptoms of rhaeumatoid arthritis?
Early morning stiffness, tiredness, painful and swollen joints as well as functional loss
Multiple joints involved with pain tenderness and swelling
Symptoms for weeks to months
What is the diagnosis for rheumatoid arthritis?
It is a clinical diagnosis supported by other investigations
Blood tests-
Signs of inflammation e.g. raised C-reactive protein
Antibodies to cyclic citrinullated peptide (anti-CCP antibody) and/or rheumatoid factor
What treatment is there for rheumatoid arthritis?
•Suppress inflammation
Nonsteroidal anti-inflammatory drugs or Corticosteroids
•Suppress the immune system=Disease modifying anti-rheumatic drugs (DMARD)
Methotrexate- Start once diagnosis made
What is important to consider in a hot swollen joint?
May be sepsis- important to treat fast
