Med 1 LO's Flashcards

Question

clinical features of right sided heart failure signs and symptoms

Answer 1

RSHF causes venous congestion (pressure builds up behind the right heart) and pulmonary hypoperfusion (reduced r heart output) ***_symptoms_*** * ankle swelling * weight gain * abdominal distension and discomfort ***_Signs_*** raised JVP pitting oedema/ sacral oedema tender smooth hepatomegaly ascites transudative pleural effusion

Answer 2

* _**ECG**-_ underlying cause * **_NT-proBNP_**- released in response to myocardial stretch. has a high negative predictive value, so if BNP is low then theres a low chance that cardiac failure has occured. If raised over 400 refer for trans-thoracic echocardiogram. if \>2,000 then 2 week referral for specialist and echo. * **_echocardiogram_**- helps measure the ejection fraction. \<40%= heart failure with reduced ejection fraction. \>40% but raised BNP =HF with REF * **_blood tests_**- U+E for renal function, LFTs for hepatic congestion, TFTs for hyperthyroidism, glucose and lipids for assessing CV rfs * ***_CXR_***- ABCDEF (go into more detail in future)

Answer 3

1. ACEi and Bblocker (ARB if intolerant to ACEi) 2. Loop diuretics (furosemide or bumetanide) for symptoms ***_if symptoms persist consider:_*** * aldosterone antagonists like spironolactone or eplerenone * hydralazine or nitrate in afro-caribbeans * ivabradine if sinus rhythm but impaired EF * ARB * Digoxin- in those with AF, worsens mortality but improves morbidity

Answer 4

***_surgical/ device management options for HF_*** cardiac resynchromisation therpy ICDs are indicated if the following criteria are fulfilled QRS interval \<120ms, high risk sudden cardiac death, NYHA class I-III QRS interval 120-149ms without LBBB, NYHA class I-III QRS interval 120-149ms with LBBB, NYHA class I

Answer 5

1. Sit the patient up 2. Oxygen therapy (aiming saturations \>94% in normal circumstances) 3. IV furosemide 40mg or more (with further doses as necessary) and close fluid balance (aiming for a negative balance) 4. SC morphine - this is contentious with some studies suggesting that it might increase mortality by suppressing respiration

Answer 6

1. ***_CPAP_*** - reduces hypoxia and may help push fluid out of alveoli 2. ***_Intubation and ventilation_*** 3. ***_Furosemide infusion_*** - continuous IV furosemide given over 24 hours to maximise diuresis 4. ***_Dopamine infusion_*** - Continuous IV dopamine given over 24 hours. It works by inhibiting sympathetic drive and thereby increasing myocardial contractility. 5. ***_Intra-aortic balloon pump_*** - if the patient is in cardiogenic shock 6. ***_Ultrafiltration_*** - If resistant to or contraindicated diuretics

Answer 7

***_beta blockers-_*** bradycardia, hypotension, fatigue, dizziness ***_ACE inhibitors-_*** hyperkalaemia, renal impairment, dry cough, light headedness, fatigue, GI disturbances, angioedema ***_spironolactone-_*** hyperkalaemia, renal impairment, gynaecomastia, breast tenderness/ hair growth in women, hyponatraemia ***_furosemide-_*** hypotensio, hyponatraemia/kalaemia ***_hydralazine/ nitrate-_*** headaceh, palpitation, flushing ***_digoxin-_*** dizziness, blurred vision, GI disturbances

Answer 8

* most commonly sustained rhythm * no p waves * absence of isoelectric baseline * cariable ventricular rate * QRS complexes \> 120ms * fibrillatory waves may mimic P waves causes of a fib * [Ischaemic heart disease](https://litfl.com/myocardial-ischaemia-ecg-library/) * Hypertension * Valvular heart disease (esp. mitral stenosis / regurgitation) * Acute infections * Electrolyte disturbance ([hypokalaemia](https://litfl.com/hypokalaemia-ecg-library/), [hypomagnesaemia](https://litfl.com/hypomagnesaemia-ecg-library/)) * [Thyrotoxicosis](https://litfl.com/hyperthyroidism-ecg-library/) * Drugs (e.g. sympathomimetics) * Alcohol * [Pulmonary embolus](https://litfl.com/ecg-changes-in-pulmonary-embolism/) * [Pericardial disease](https://litfl.com/pericarditis-ecg-library/) * Acid-base disturbance * [Pre-excitation syndromes](https://litfl.com/pre-excitation-syndromes-ecg-library/) * Cardiomyopathies: [dilated](https://litfl.com/dilated-cardiomyopathy-dcm-ecg-library/), [hypertrophic](https://litfl.com/hypertrophic-cardiomyopathy-hcm-ecg-library/). * Phaeochromocytoma

Answer 9

* wheeze is a relatively high-pitched shound produced by movement of air through a narrowed or compressed **SMALL LOWER** airway (stridor = higher) * **expiratory** noise ***_Causes:_*** * Asthma * COPD * Heart failure * Anaphylaxis * Taxic inhalation * Acute bronchitis * Bronchiolitis * Foreign body aspiration

Answer 10

Lower respiratory tract infection in which the alveoli and terminal bronchioles are infected

Answer 11

***_Typicals_***- called so because of their rapid onset of symptoms, inc. high fever and productive cough; * **Strep pneumoniae-** 80% of acases (gram +ve coci) * **Staph aureus** * Haemophilius influenzae (gram -ve rod) ***_Atypicals-_*** more gradual onset of symptoms, may be non-specific initially (fever, myalgia, dry cough) * **Mycoplasma pneumoniae** * Chlamydia pneumoniae * Legionella pneumophila * Coxiella burnetti

Answer 12

viral much less common influenza A

Answer 13

***_Symptoms_*** * Cough * Sputum * Dyspnoea * Chest pain; may be pleuritic on inspiration * Fever * Rigors * Confusion (elderly) ***_Signs_*** * systemic inflammatory response (fever, tachycardia, CRP) * reduced oxygen saturations * reduced chest expansion * dull percussion * ausculatation (reduced breathing sounds, bronchial breathing, inreased vocal resonance)

Answer 14

antibiotics if bacterial ***_non-severe: (CURB-65= 2)_*** * 1st line- amoxicillin * alternative e.g., COPD use doxycycline ***_Severe; (CURB-65\> 3)_*** co-amoxiclav+ consider clarithromycin in addition

Answer 15

***_CURB-65_*** * Confusion * Urea\> 7mmol/L * Respiratpry rate \> 30/min * Blood pressure (systolic \<90mmHg or diastolic \<60 mmHg) * Age \>65 years score 1 point for each feature present * 0-1 low mortality 1.5% treat at home * 2 mortality intermediate 9.2% short stay inpatient * 3+ 22% mortality risk manage in hospital * 4/5 ICU

Answer 16

COPD is an umbrella term encompassing the older terms: * Chronic bronchitis * Emphysema Vast majority of cases is caused by smoking

Answer 17

***_Mutlisystem effects of COPD_*** * **_Cardiovascular_**; heart failure, ischaemic heart disease, pulmonary hypertension, arrhythmias * **_Brain;_** depression, anxiety * **_Bone abnormalities:_** osteopenia and osteoporosis present in 89% of COPD cases * **_Skeletal muscle_** atrophy * **_Sleep:_** obstructive sleep apnoea

Answer 18

* dyspnoea * cough; often productive * wheeze * in severe cases: weight loss, fatigue, right sided heart failure possible to have an infective exacerbation

Answer 19

Smoking history- are they still smoking Occupational and industrial exposures History of exacerbations Presence of comorbidities Impact on patient’s life Typically \>20 pack years

Answer 20

(how many packs smoked per day) x (how many years smoked)

Answer 21

* Raised Resp rate * **Hyperextended/ barrel ches**t * Prolonged expiratory time \>5s with pursed lip breathing * Use of accessory muscles on respiration * Quiet breath sounds (especially in apices) +/- wheezing * Quiet heart sounds (due to overlapping hyperinflated lung) * Basal crepitations * Signs of cor pulmonale (Raised JVP, ankle odema, warm peripheries, bounding pulse) * CO2 retention flap

Answer 22

***_post-bronchodilator spirometry_*** to demonstrate airflow obstruction--\> FEV/FCV ratio \<70% is diagnostic ***_CXR:_*** hyperinflated, bullae, flat hemidiaphragm

Answer 23

looking at post-bronchodilator FEV1

Answer 24

scale to measure severity of pneumonia * **Grade 0**= not troubled by breathlessness except on strenuous exercise * **Grade 1**= short of breath when hurrying or walking up a slight incline * **Grade 2**= Walks slower than contemporaries on ground level * **Grade 3**= Stops for breath every 100m * **Grade 4**= Too breathless to leave the house

Answer 25

* **Airflow limitation and gas trapping-** chronic inflame and fibrosis of airways leads to air trapping in the small airways * **Destruction of alveoli-** permanent enlargement of airspaces * **Mucous gland hyperplasia** * **Thickened pulmonary arteriolar wall** and **remodelling** occur with hypoxia, leading to increased pulmonary vascular resistance, pulmonary hypertension and impaired gas exchange * **Increased pul resistance--\>**more force needed for RV contraction--\> dilation and hypertrophy --\> loss of RV function --\> backing up of blood into RA and subsequently systemic venous circulation

Answer 26

* Smoking cessation * Education * Pulmonary rehabilitation * Diet * Self-management therapy * Psychosocial support

Answer 27

Stepwise approach (one is carried onto the next, higher step) 1. Short acting beta2 antagonist (salbutamol) or short acting muscarinic antagonist (ipratropium) 2. LABA (salmeterol) and LAMA (glycopyrronium)/ inasthmatics ICS 3. LABA+LAMA+ICS

Answer 28

Bronchiectasis is permanent dilation of the bronchi and bronchioles due to chronic infection. ***_The main organisms include_***: Haemophilius Influenzae, Pseudomonas aeruginosa, Streptococcus Pneumoniae, Staphylococcus aureus

Answer 29

Post-Infection: Tuberculosis; HIV; Measles; Pertussis; Pneumonia * Bronchial Pathology: Obstruction by foreign body or tumour * Allergic Bronchopulmonary aspergillosis (ABPA) * Congenital: Cystic fibrosis; Kartagener's syndrome; Primary ciliary dyskinesia; Young syndrome * Hypogammaglobulinaemia * Idiopathic

Answer 30

Begin insidiously and gradually get worse with periods of exacerbation * (Most common) **Chronic cough** that produces **thick, tenacious**, often **purulent sputum** * **Dyspnoea** * **Wheezing** * Hypoxia * **Haemoptysis** (can be massive) * Fever and constitutional symptoms * Exacerbations are common and often triggered by new infection

Answer 31

Abnormal breath sounds (crackles, rhonchi, wheezing) Digital clubbing Pulmonary hypertension Nasal polyps

Answer 32

* Previous childhood respiratory infections due to viruses * Previous infections by TB or severe bacteria pneumonia * Immunodeficiency * CF * Alpha-1-antitrypsin deficiency- also causes COPD and emphysema * Aspiration or inhalation injury * CT disorders- rheumatoid arthritis * IBD

Answer 33

***_conservative_*** * Patient Education * Support Group * Chest Physiotherapy – Postural drainage at least twice daily to aid mucous drainage * Smoking Cessation ***_Medical_*** * Antibiotics – recurrent exacerbations may require long term antibiotic treatment * Bronchodilators – Including salbutamol can be given to patients with symptoms of dyspneoa and wheeze such as COPD, ABPA, asthma * Corticosteroid - Prednisolone is used in ABPA treatment * Carbocysteine - Mucolytic which reduces the viscosity of sputum ***_surgical_*** * Surgical excision of localized area of disease or cessation of haemoptysis. * Lung transplant may be indicated in certain patients

Answer 34

* Blood splits the arotic media with **sudden tearing chest pain** (with or without **radiation to back**) . Surging of blood through a tear I the intima. Forms a false lumen (channel) through which blood can flow. * Hypertension is an important contributor. * Most common site is the **proximal ascending aorta**- within 5cm of the aortic valve

Answer 35

***_deBakey_***- * **type 1-** 50%- ascending aorta through to aortic arch and below * **type 2**- start in and are confined to ascending aorta * **type 3**- dissections start in the descending aorta ***_Stanford_*** **Type A:** Involves the ascending aorta, arch of the aorta **Type B:** Involves the descending aorta.

Answer 36

* Hypertension * Connective tissue disease e.g. Marfan's syndrome * Valvular heart disease * Cocaine/amphetamine use

Answer 37

Usually presents in men over the age of 50 * **Sudden onset 'tearing' chest pain** or **interscapular pain radiating to the back.** * It can also present with (depending on how far the dissection extends): * Bowel/limb ischaemia * Renal failure * Syncope

Answer 38

* Unequal arm pulses * Acute limb iscahemia * Paraplegia if spinal arteries affected * Anuria if renal arteries affected

Answer 39

* Transoesophageal echocardiography * CT angiography * MRA (Magnetic Resonance Angiography) * ECG and CXR * Bloods- troponin, D-dimer

Answer 40

* reuscitation * Cardiac monitoring * Strict blood pressure control (e.g. IV metoprolol infusion) ***_definitive treatment_*** * Type A: Usually requires surgical management (e.g. aortic graft) * Type B: Normally managed conservatively with blood pressure control. If there is evidence of end organ damage then endovascular/open repair may be performed.

Answer 41

**heterogenous group** of diseases of the **myocardium,** characterised by mechanical and/ or electrical dysfunction that typically results in **inappropriate ventricular hypertrophy or dilatation** due to multiple causes (usually genetic). ***_classifications_*** * Primary cardiomyopathies- predominantly confined to the heart * Secondary cardiomyopathies- typically part of generalised multisystem diseases

Answer 42

1. dilated 2. hypertrophic 3. restrictive

Answer 43

Myocardial dysfunction causing heart failure in which dilation causes **systolic dysfunctio**n predominate. Most common form ***_causes_*** * **Ischaemic** changes can over time particularly post-myocardial infarction * **Hypertensive** * **Genetic and congenital** * **Toxin-related** - excessive alcohol consumption Cocaine is also associated with ischaemia and DCM.Clozapine * **Infiltrative** - haemochromatosis, amyloidosis and sarcoidosis are known to cause DCM * **Peripartum** - * **Thyrotoxicosis** * I**nfectious** - DCM can occur secondary to myocarditis, or as a direct result of infection from HIV, Lyme disease and Chagas disease * **Stress induced cardiomyopathy** (Takotsubo cardiomyopathy) refers to transient left ventricular ballooning precipitated by intense psychologic stress. Almost all patients recover completely * **Idiopathic** - when other potential causes have been ruled out ***_presentation_*** * Mostly gradual onset * Fatigue * Acute pulmonary oedema * Progressive symptoms of heart failure: * Nocturnal dyspnoea * Orthopnea * Paroxysmal nocturnal dyspnoea * Swelling ***_management_***

Answer 44

***_symptoms_*** * Exertional dyspnoea * Orthopnoea * Proxysmal nocturnal dyspnoea * Peripheral oedema ***_Signs_*** * displaced apex beat * S3 gallop rhythm (rapid ventricular filling) * Murmur of mitral regurgitation (due to displacement of the valve leaflets) * Signs of heart failure (such as oedema, hepatomegaly, ascites, raised JVP).

Answer 45

(Standard treatment for heart failure with reduced ejection fraction) * Diuretics * ACE inhibitors * Angiotensin II receptor inhibitors * B-blockers * Spironolactone * Digoxin * Nitrates * Aldosterone antagonists * Antiarrhythmic agents * Device therapy * Cardiac resynchronisation +anticoagulants when AF present

Answer 46

Hypertrophic cardiomyopathy (HCM) is a **genetic condition** characterised by left ventricular hypertrophy of varying degrees. a mutation in one of several myocyte sarcomere genes such as myosin and troponin. ratio of vessels to tissue is low so widespread low grade ischaemia, leads to fibrosis

Answer 47

* Found alongside acromegaly, pheochromocytoma, neurofibromatosis * Symptoms appear between 20 and 40 and are exertional but symptoms may be highly variable * Dyspnoea * Chest pain (resembling typical angina) * Palpitations * Syncope * (ejection fraction is preserved so fatigue isn’t often felt- abnormal diastolic function responsible for symptoms) * Mitral regurgitation sound heard at the apex * Bifid carotid pulse

Answer 48

Symptoms B-blockers- mainstay for angina, dyspnoea, giddiness and syncope treatment Calcium channel antagonists- verapamil and diltiazem Arrythmias B blockers Amiodarone (both for SVTs) Radiofrequency ablation

Answer 49

* Characterised by non-compliant ventricular walls that resist diastolic filling * One (most commonly the left) ventricle is usually involved * Least prevalent form of cardiomyopathy * Genetic abnormality * Fabry disease * Gaucher disease * Haemachromatosis * CT disorders * Amyloidosis * Other * Carcinoid tumours * Radiation * Sarcoidosis

Answer 50

* Exertional dyspnoea * Orthopnea * Peripheral oedema * AF and ventricular arrhythmia * Fatigue * LV +/- RV failure * Functional AV valve regurgitation

Answer 51

"stress induced cardiomyopathy" * Weakening of the left ventricle because of severe emotional or physical stress such as sudden illness or the loss of a loved one. * Left ventricle changes shape, having a narrow neck and a round bottom. * Typically affects more women than men, **Symptoms:** mimics MI- sudden intense angina and SOB **Diagnosis;** ECG, echocardiogram, MRI, angiogram **Treatment**; diuretics, B blockers and ACEi, anti-coagulation

Answer 52

Infection of endovascular structures causes infective endocarditis- think valves ***_rfx:_*** * Age \> 60 years * Male sex * Intravenous drug use - predisposition to Staph. aureus infection and right-sided valve disease e.g. tricuspid endocarditis * Poor dentition and dental infections ***_co-morbid conditions:_*** * Valvular disease * Congenital heart diseases * Prosthetic valves * Intravascular devices * Haemodialysis * HIV infection

Answer 53

* ***Staph. aureus*** * ***Strep. viridans\*\*\*\* (most common)*** * Enterococci * Coagulase negative *staphylococci* e.g. *Staph. epidermidis* * *Strep. bovis* - often in patients with colonic lesions, e.g. IBD or carcinoma * Fungi * HACEK organisms - Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella ***_Symptoms_*** * **Fever** (most common) * Anorexia * **Weight loss** * Headache * Myalgia * **Night sweats** * Cough * Pain made worse by leaning forwardss??

Answer 54

***_signs of infective endocarditis_*** * Murmurs are common * Janeway lesions- nontender macules on plasms and soles * Osler nodes- tender subcutaneous nodules on finger pads and toes * Roth spots- exudative haemorrhagic retinal lesions with pale centres * Microscopic haematuria and glomerulonephritis * Splinter haemorrhages * PR prolongation or complete av block ***_complications_*** * May often be the presenting complaint * Valvular insuffiency causing heart failure * Neurological complications * Embolic complications causing infarction of kidneys, spleen or lung * Infection e.g., osteomyelitis

Answer 55

* ECG * CXR * Blood tests: FBC, UE, LFT, CRP * 3 sets of cultures * Transthoracic echocardiogram * Transoesophageal echocardiogram **_duke's criteria_** * Blood positive for IE * Imaging positive for IE * + 1 minor point (predisposing condition, fever, vascular phenomena, immunological phenomena, microbiological evidence)

Answer 56

Well's score

Answer 57

* Caused by diseases of the heart, lungs, or abnormal haemoglobin * Seen in the tongue, lips and is due to desaturation of central arterial blood resulting from cardiac and respiratory disorders associated w shunting of deoxy venous blood into systemic circulation * Often peripherally cyanosed also ***_common causes: neonates_*** * Transposition of great arteries * Fallots tetralogy * Stenosis of pulmonary valve * Tricuspid valve * Truncus arteriosus ***_In adults_*** * Birth injury * Haemorrhage * Pulmonary oedema * Pleural effusion * Pulmonary oedema * PE * Severe pneumonia * COPD

Answer 58

* Caused by decreased local circulation and increased extraction of oxygen in peripheral tissues * Isolated peripheral cyanosis occurs in conditions with peripheral vasoconstriction and stasis of blood in the extremities- e.g., congestive heart failure, circulatory shock, exposure to cold temperatures and abnormalities of the peripheral circulation * Bluish tinge to affected area all the same causes as central + * Peripheral arterial disease- e.g., thrombosis, atheroma or embolism * Vasoconstriction * Cold exposure * Raynauds * Beta blocker drugs * Venous obstruction

Answer 59

* **Blood pH** (normal range **7.35 - 7.45**) - high indicates alkalosis; low indicates acidosis. * **Blood carbon dioxide** level (PaCO₂ level; normal range **4.7 - 6.5** KPa) - this may indicate a breathing problem. * **Bicarbonate** level (represents levels of alkali; normal range 22-26 mEq/L). * **Blood oxygen** levels (PO₂ level; normal range **10.5 - 13.5** KPa) - if the PO₂ level is low, it indicates an abnormally low concentration of blood oxygen (hypoxaemia).

Answer 60

***_metabolic acidosis_*** * Build-up of lactic acid; seen in shock, infection, hypoxia * Acute or chronic kidney injury * Build up of ketones; diabetes mellitus, alcohol poisoning * Severe diarrhoea ***_metabolic alkalosis_*** * Vomiting * Hypokalaemia * Excessive amounts of alkali-containing medication * Burns ***_respiratory acidosis_*** * depression of central resp centre by stroke * inability to ventilate properly- myasthenia gravis, muscular dystrophy * acute asthma exacerbation of COPD ***_resp alkalosis_*** * hyperventailtion- anxiety, stroke, meningitis, altitude, pregnancy

Answer 61

**_afferent pathway-_** * cough receptors activated, receptor potential to afferent nerves, info reaches vagus nerve and is passed to medulla oblangata **_central pathway-_** * sensory info to nucleus tractus solitarius of the medulla * vagus nerve passes info to effector muscles **_motor efferent pathway-_** * diapragm, laryngeal muscles, rectus abdominus

Answer 62

* smoking * heartburn (acid reflux) * allergies – for example, hay fever * infections like bronchitis * mucus dripping down the throat from the back of the nose * cancer * ACEi

Answer 63

This is a generic term used to describe a number of conditions that primarily affect the lung parenchyma in a diffuse manner. Characterised by chronic inflammation and/ or progressive interstitial fibrosis. ***_symptoms_*** * paroxysmal (sudden attack of) dry hacking cough * SOB at rest or aggravated by exertion * reduced exercise tolerance ***_Signs_*** * Alveolar septal thickening * Fibroblast hyperproliferation * Collagen deposition * Pulmonary fibrosis * Abnormal breath sounds

Answer 64

* **CT disorders**: ankylosing spondylitis, SLE * **Drug**s: carbamazapine, nitrofurantoin, dexamethasone * **Occupational**/ **environmental**: aluminium, asbestos, bird fanciers lung, charcoal * **Infections**: pneumonia, TB * **Vasculitis**: eosinophilic granulomatosis * **Sarcoidosi**s * pulmonary lymphoma

Answer 65

restrictive ventilatory effect due to decreased distensibility of lung parenchyma * FEV1 normal or decreased * Decreased FVC * Normal or decreased FEV1/FVC reduced total lung capacity reduced diffusing capacity

Answer 66

***_Pulmonary hypertension_***- type of high blood pressure that affects the arteries in the lungs and the right side of the heart

Answer 67

1. pulmonary arterial hypertension- mutations, CHD, HIV 2. due to left sided heart disease- valvular disease 3. hypoxia+/- COPD- pul fibrosis, obstructive sleep apnoea 4. chronic thromboembolic pulmonary hypertension - PE, clotting disorder 5. unclear or multifactorail aetiologies- sarcoidosis, kidney disease

Answer 68

* Calcium channel blockers- amlodipine * Anticoagulants- apixaban, dabigatran, rivaroxaban, warfarin * Diuretics * Oxygen treatment

Answer 69

***_Antiplatelets_*** **Cox inhibitors**- aspirin, NSAIDs (nurofen) **P2Y12 inhibitors**- clopidogrel, ticagrelor ***_Anticoagulants_*** **Direct thrombin inhibitors**- dabigatran **Indirect thrombin inhibitors**- dalteparin, fondaparinux **Direct factor X inhibitors**- apixaban, rivaroxaban **Thrombolytics**- plasminogen activators, alteplase, streptokinase

Answer 70

A pneumothorax is defined as air within the pleural space. ***_Rfxs_*** * Previous PTX * COPD * Alpha-1 antitrypsin deficiency * Underlying lung disease * Smoker * Valvular heart disease * Tall and thin * Marfan’s syndrome

Answer 71

***_spontaneous_*** 1. **_primary-_** (no underlying lung pathology - typically tall thin young men) 2. **_secondary_**- (underlying lung pathology) CT disorders (Marfan's syndrome), obstructive lung disease (such as asthma and COPD), infective lung disease (such as TB and pneumonia), fibrotic lung disease (such as cystic fibrosis and idiopathic pulmonary fibrosis), and neoplastic disease (such as bronchial carcinoma ***_Traumatic_*** causes 1. ***_iatrogenic causes (_***such as insertion of a central line or positive pressure ventilation) 2. **Non-iatrogenic causes** (either a penetrating trauma or blunt trauma with rib fracture).

Answer 72

* sudden-onset SOB * Pleuritic chest pain * Important to note in the history whether there are any risk factors for a spontaneous primary pneumothorax (tall and thin young male, smoker), spontaneous secondary pneumothorax (COPD, asthma, Marfan's syndrome), or traumatic pneumothorax (recent chest trauma, recent invasive medical procedure). ***_signs:_*** * tachypnoeac * respiratory distress * reduced chest expansion * hyper resonant percussion note * reduced or absent breath sounds * Additional signs in a tension pneumothorax include: signs of haemodynamic compromise (tachycardia and hypotension) and tracheal deviation to the contralateral side.

Answer 73

* History and exam * Bloods * U+E, LFT, FC, CRP * ESR, autoantibodies * Amylase * CXR- should not be ordered in tension pneumothorax as it will delay immediate treatment , otherwise look for area devoid of lung markings at the periphery of lungs * Pleural ultrasound * Consider CT chest * Pleural aspiration ***_pleural aspiration_*** * Ultrasound guided * Pass needle into pleural fluid * Aspirate sample * Investigations * Colour, viscosity, smell * Biochemistry: protein, LDH, glucose * Fluid pH * Microbiology * Cytology

Answer 74

* Observation- if rim of air \>2cm on CXR then… * Aspiration if not successful then… * Chest drain * Pleural vent ***_Chronic management_*** * reoccurance at 3 years is 50% * main treatment is surgical where blebs are stapled

Answer 75

***_what is a tension pneumothorax_*** * Air drawn into the pleural space w every inspiration and has no route of escape. Mediastinum gets pushed over to the contralateral hemithorax, kinking and compressing the great veins. Unless air is removed, cardiorespiratory distress will occur. ***_signs_*** * resp distress, tachycardia, hypotension, distended neck veins, deviated trachea ***_treatment_*** * To remove air, large bore caneedle with syringe, partially filled with 0.9% saline intp 2^nd intercostal space in the midclavivular line on the side of the suspected pneumothorax * Remove plunger to allow air to bubble through the syringe until a chets tube can be placed

Answer 76

**pleural space**- potential space between the visceral and parietal pleura which naturally contains 10-20ml of fluid. the aim is the lubrication of the pleura to maintain apposition of the membranes ***_pleural effusion_*** increased accumulation of pleural fluid in the pleural space

Answer 77

done via ***_Light's criteria_*** **_transudative effusions_**- caused by increase in hydrostatic pressure and decreased plasma oncotic. Can be treated without extensive investigations. 1. Plural fluid protein/serum protein \>0.5 2. Pleural fluid LDH/serum LDH \> 0.6 3. Pleural fluid LDH \> 2/3 upper limit of lab normal value for serum LDH ***_exudative effusion_***s- caused by local changes to capillary wall permeability. * High fluid protein- fluid: serum \>0.5 * High LDH- fluid: serum LDH \>0.6 * Haemothorax- blood in pleural space

Answer 78

tr***_ansudate causes_*** * Fluid leaks in to pleural space from elsewhere * Too much fluid in the body * Heart failure or pericarditis * Renal failure * Liver cirrhosis * Fluid leaking from elsewhere * Hypoalbuminaemia * Ascites/ peritoneal dialysis * Other stuff * Infections e.g., pneumonia * TB * PE * Swelling of the pancreas ***_exudate causes_*** * Too much fluid produced/ failure of reabsorption due to damage to pleural surface * Pleural malignancy * Pneumonia * Empyema- infection in pleural space * Connective tissue disease * Benign asbestos pleuritis * Pancreatitis * Drug induced

Answer 79

***_rfx pleural effusion_*** * Chest injury * Radiation therapy * Surgery (especially to the: heart, lungs, belly, organ transplants) ***_symptoms_*** * Dyspnoea * Tachypnoea * Pleuritic chest pain * Stomach pain * Cough * Haemoptysis * Weight loss * Fever or chills ***_signs_*** * Absent tactile fremitus * Dullness on percussion * Reduced chest wall movements * Decreased breath sounds on the affected side * Rapid and shallow breaths in big effusions * Pericardial rub

Answer 80

***_tests_*** * CXR * LFTs, U&Es, FBC, CRP, LDH * Thoracentesis (procedure to remove fluid or air from around the lungs) looking at: LDH and protein, cytology, pH, ADA, AFB and TB culture, amylase, haematocrit and glucose ***_management_*** * Pleural aspiration (thoracentesis)- Treat underlying cause e.g., pneumonia or heart failure * Consider contrast enhanced CT thorax * Pleural biopsy (radiologically guided VATS) * NSAID’s for pain ***_chronic management_*** * Pleurodesis- artificially obliterating pleural space * Intermittent drainage with indwelling catheter

Answer 81

***_Cystic fibrosis-_*** inherited disease of the exocrine glands affecting primarily the GI and respiratory systems. Leads to chronic lung disease, exocrine pancreatic insufficiency, hepatobiliary disease and abnormally high sweat electroytes. All babies screened at birth

Answer 82

* autosomal recessive inheritance * responsible gene found on the long arm of chromosome 7 * this genes ecnodes for thr DF transmembrane conductance regulator (CFTR) * **CFTR** is a c**AMP-regulated chloride channel**, **regulating chloride and sodium transport across epithelial membranes** multisystem disease as the CFTR gene is found within multiple organ systems

Answer 83

Nearly all exocrine glands are affected in varying distribution and severity. Increased sodium absorption and abnormal chloride secretion. This leads to thicker mucous that impairs the function of cilia. Glands may be: * Obstructed by viscid or solid eosinophilic material in the lumen (pancreas, gall bladder etc.) * Produce excessive secretions (tracheobronchial and Brunner glands) * Secrete excessive sodium and chloride (sweat, parotid and salivary glands)

Answer 84

***_Lungs-_*** comes on as child * Mucous plugging * Chronic lower resp bacterial infection * Damage to airways- eventual bronchiectasis * Nasal Polyps * Symptoms including cough, wheeze, haemoptysis * Pneumothorax * Cor pulmonale ***_GI-_*** * Pancreatic insufficiency resulting in diabetes mellitus and steatorrhea * Cirrhosis * Portal hypertension * Gallstones Male infertility * Duodenal- viscous and lacks bicarbonate

Answer 85

* Failure to thrive * Meconium Ileus * Rectal prolapse

Answer 86

* Neonatal heel prick day between day 5 and day 9 * Sweat test: sweat sodium and chloride \>60mmol/L * Faecal elastase: this can provide evidence for abnormal pancreatic exocrine function. * Genetic screening: This can identify CF mutations ***_Conservative management_*** * Education about the condition * Fertility and genetic counselling * Dietician * Psychosocial counselling * Chest physiotherapy: postural drainage and active cycle breathing techniques * Screening for complications of Cystic Fibrosis such as osteoporosis

Answer 87

***_infective exacerbations_***: antibiotics, nebulised mucolytics, bronchodilators ***_pancreatic insufficiency_***: insulin replacement regime, exocrine enzymatic replacement, vitmains A,D,E,K ***_Liver_***: ursodeoxycholic acid ***_Worsening progressive lung disease:_*** oxygen, non-invasive ventilation, diuretics if signs of cor pulmonale ***_Surgical treatment of CF_*** cirrhosis eventual liver tranplant, lung transplant

Answer 88

* Anxiety * Haemorrhage * Drug overdose (aspirin for example) * Severe pain * Pregnancy * Lung infection * Lung diseases- COPD, asthma * Diabetic ketoacidosis

Answer 89

non-small cell carcinoma

Answer 90

* Cough * Haemoptysis * Chest pain * Weight loss * SOB * Hoarse voice and other features of direct intrathoracic invasion * Hoarseness (left recurrent laryngeal) * SVC obstruction from tumour or thrombosis * Dysphagia from oesophageal compression * Elevated diaphragm * Pericardial involvement * Recurrent or slowly resolving pneumonia

Answer 91

* Fixed monophasic wheeze * Cachexia * Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy * Finger clubbing * Pleural effusion * Tracheal deviation (lobar collapse/ whole lung collapse) * Osetoarthropy * Confusion * Fits falls

Answer 92

small cell lung cancer (SCLC)- about 15% non-small cell lung cancer (NSCLC)- 85%

Answer 93

* **highly aggressive** * almost always occurs in smokers * **starts from** **endocrine cells** (Klutchisky cells) so often secrete polypeptide hormones resulting in **paraneoplastic syndromes** * rapidly growing and disseminating * 80% have evidence of metastasis at diagnosis * **not amenable to surgery** * often very chemosensitive/ radiotherapy

Answer 94

* squamous 30% * adenocarcinoma 27% * large cell 10% * adenocarcinoma in situ (rare) 1% ***_Shared features:_*** * early stage is curable by surgery * radiotherapy and cehmotherapy can help symptoms * immunotherapy pr biological egnts possible

Answer 95

based on the secretion of; * antidiuretic hormone (**ADH**) resulting in hyponatremia * secretion of adrenocorticotropic hormone (**ACTH**) or rarely corticotropin-releasing hormone (**CRH**) resulting in Cushing syndrome * secretion of growth hormone-releasing hormone

Answer 96

* Smoking (tobacco and cannabis) * Passive smoking * Occupation exposure (asbestos, silica, welding fumes, coal) * HIV * Organ transplantation * Radiation exposure (X-ray, gamma rays). * Beta-carotene supplements in smokers.

Answer 97

brain, breast, adrenals and bone.

Answer 98

squamous cell carcinoma tends to cause early symptoms **usually begins in the bronchial tubes** * 2nd most common type of lung cancer in the UK * presents as obstructive lesions of the bronchus leading to an infection * most likely lung cancer to cavitate * hypercalcaemia- bone degradation or PTH

Answer 99

***_imprtant features of adenocarcinoma_*** most common type in the UK Usually starts in the outer border of the lungs * arises from the mucous cells in the bronchial epithelium * commonly invades mediastinal lymph nodes and the pleura, and soreads to the brain and bones * does not cavitate * most likely to cause pleural effusion

Answer 100

***_important features of large cell carcinoma_*** * tends to grow rapdily and cause late symptoms * usually begins in the outer edges of the lungs

Answer 101

* CXR * Urgent referral to clinic * CT or combined PET-CT- also used to guide biopsy * Pleural tap-cytopathology examination of pleural fluid or sputum * Usually bronchoscopy-guided biopsy and core biopsy * Sometimes open lung biopsy * PET scan if curative treatment feasible

Answer 102

* Pancoast syndrome * Recurrent laryngeal nerve palsy * Phrenic nerve palsy * Rib erosion * Pericarditis * AF

Answer 103

Occurs when apical tumours, usually NSCLC invade the branchial plexus, pleura or ribs causing shoulder and upper-extremity pain and weakness or atrophy of the ipsilateral hand. May also include Horner’s syndrome.

Answer 104

Horner's syndrome is characterised by ptosis, meiosis with or without anhydrosis. It is due to an interruption of the sympathetic nerve supply to the eye * *Ptosis**- drooping of the upper eyelid (due to oculomotor palsy levator palpebri superioris * *Miosis**- pupil constriction **Anhidrosis**

Answer 105

pupil dilates mydriosis radial muscles contract pupil constricts miosis sphincter muscle innervated by parasympathtic fibres constricts

Answer 106

Only known pleural cancer Caused by asbestos exposure- asbestos was heavily used historically in the shipbuilding and construction industries due to its fire resistant qualities.

Answer 107

***_Signs and symptoms_*** * Dyspnoea * Non-pleuritic chest pain * Constitutional symptoms are uncommon * Pain * Hoarseness * Dysphagia * Horner syndrome * Brachial plexopathy * Ascites ***_Diagnosis_*** * CXR * Pleural fluid cytology// pleural biopsy * Staging via- CT chest, mediastinoscopy, MRI ***_Treatment_*** * Supportive care * Pleurectomy * Analgesia with opioid’s * Chemotherapy

Answer 108

***_SIRS_*** ≥ 2 of: * \> 38°C or \< 36°C * Heart rate \> 90 * Respiratory rate \> 20 * WBC \> 12,000/mm³ or \< 4,000/mm³ ***_Sepsis-_*** SIRS+ suspected or confirmed infection ***_Severe sepsis_***- Sepsis plus evidence of organ dysfunction: confusion, hypoxia, oliguria, metabolic acidosis ***_Septic shock_***- severe sepsis with hypotension, despite adequate fluid resuscitation, or lactic acidosis (lactate \> 4mmol/L)

Answer 109

lactate \>2 bicarb \<18 CRP raised LFTs off coag deranged (PT\>20) platelets low

Answer 110

* responds to voice/ pain/ unresponsive * mental state- acute confusional state * systolic bp- 90mmHg or drop of \>40% of normal * HR- \>130 * RR- \>25/min * Sp02- oxygen needed to maintain above 92% * rash- non-blanching, cyanotic, mottled * urine- not passed urine in the last 18 hrs * lactate- \>2 mmol.L * recent chemotherapy

Answer 111

***_3 in_*** * administer **oxygen**, aim to keep sats \>94% * administer **broad spectrum antibiotics** * give **IV fluid** ***_3 out_*** * take **blood cultures** * measure **serum lactate** (via ABG) * measure accurate **hourly urine output**

Answer 112

Imaging e.g chest xray, echocardiogram, abdominal ultrasound Viral PCR for e.g. influenza Urinalysis +/- culture Lumbar puncture

Answer 113

***_symptoms_*** * Fever, sweats or chills * Breathlessness * Headache * Nausea and vomiting * Diarrhoea ***_signs_*** * Tachycardia * Hypotension * Pyrexia * Peripherally vasodilated * Hypoxia * Tachypnoea

Answer 114

qSOFA and SOFA * O2 * platelets * bilirubin * cardiovascular * GCS * creatinine * urine output Score of more than 3 in any parameter then think sepsis

Answer 115

* **pH** 7.35-7.45 * **paCO2** 35-45 * **HCO3-** 21-28 * **PaO2** 80-110

Answer 116

* Antigen pro-inflammatory stimulus is found in the intravascular compartment. * Innate immune system is activated--- pro-inflammatory response and coagulative cascade produces microemboli * Initial hypotension in response to arteriole dilation, cardiac output increases for a time “warm shock” * Eventually hypotension increases further due to dilatation and increased permeability of vessels * Distributive shock as oxygenated blood is shunted away from capillary beds and tissues become hypoxic * Micro-emboli also block capillary beds

Answer 117

* Mouth and throat * Skin * Lungs * Kidneys and bladder, especially if you have a catheter to drain urine * Cannula sites * Wounds or where wound

Answer 118

* Person to person contact * Person to animal contact (e.g., bites) * Contaminated surfaces * Contaminated food * Environment into open wounds * Hospital setting

Answer 119

***_targeted-_*** when you know the exact causative organism ***_empirical_***- when you don't the precise organism but you have a good idea of what it will be and its sensitivities ***_Prophylactic_***- use before the fact in anticipation of infection

Answer 120

***_infection prevention and control_*** * prevent spread- vaccines, antiseptic technique ***_antimicrobial stewardship_*** * reduce broad spectrum use * reduce treatment regime * reduce antibiotic use when no infection present

Answer 121

* Efflux pumps- remove the active substance * Limiting uptake of drug- * Modification of target- make it so antibiotic cant bind * Inactivation of a drug * Bypassing the targeted process- e.g., metabolism routes

Answer 122

HIV is a **retrovirus** which infects and **replicates within human lymphocytes** (**CD4+ T cells**) and macrophages. This leads to **progressive immune system dysfunction**, **opportunistic infections** and **malignancy** --\> AIDS (acquired immunodeficiency syndrome). Transmission is via? --\> blood, sexual fluids and breast milk * Sexual * Perinatal * Blood transfusion * Sharing needles

Answer 123

* HIV-1 (global epidemic) * HIV-2: less common, mostly in West Africa, less transmissible ***_Pathophysiology_*** HIV binds, via its GP120 envelope glycoprotein, to CD4 receptors on helper T cells, monocytes and macrophages. These infected cells migrate to lymphoid tissue where the virus replicates producing millions of virions. They are released as they burst out of the cell, in turn infecting more CD4+ cells, leading to ↓ immune function. key enzyme? **reverse transcriptase**

Answer 124

early/ primary infection- asymptomatic in 80% coryzal symptoms: fever, rash, myalgia, pharyngitis, lymphadenopathy, headache most infectious in primary infection

Answer 125

* Acute HIV infection- 0-12 weeks * Chronic HIV infection- clinical latency * Acquired immunodeficiency (AIDS)- constitutional symptoms and opportunistic infections each stage gets worse

Answer 126

* Generally, develops **within 2-4 weeks after infection** with HIV. * Flu-like symptoms: headache, rash, fever, sore throat * As infection slowly weakens the immune system, * Swollen lymph nodes * Weight loss * Diarrhoea * cough * HIV multiplies rapidly and spreads throughout body * Virus invades, replicated within and destroys CD4+ cells * **HIV levels in blood** (viral load) **very high**- **very infectious** * **Start RT here** to experience health benefits

Answer 127

* HIV continues to divide but at a much lower rate * May not have any HIV symptoms it will present with deranged lab results- e.g., anaemia, neutropenia, lymphopenia, thrombocytopaenia, diffuse hypergammaglobulinaemia * Possible to stay in this stage for 10+years if on ARTs * If well medicated- very small chance of passing on disease via sex

Answer 128

* Cannot fight off opportunistic infections- PCP, CMV, MAI, non-Hodgkins lymphoma * High viral load and very infectious * 3 year survival rate if unmedicated * Constitutional symptoms may present like: night sweats, malaise, fatigue, diarrhoea, weight loss of more than 10kg

Answer 129

* **Karposi's sarcoma**- herpes virus 8 * **Oral hairy leukolakia**- caused by EBV * **Oesophageal candiasis**- white plaques on the buccal and pharyngeal mucosa

Answer 130

***_UTI-_*** infection of the urinary tract (anywhere from the kidney to the urethra) ***_Cystitis-_*** infection from UTI that affects urinary bladder ***_Symptoms_*** * dysuria- pain on urination * frequency- increased fequency of urination * urgency- abrupt, strong overwhleming need to urinate * haematuria in older patients

Answer 131

***_Rfxs_*** * Sexual intercourse * Diaphragm and spermicide use * Antibiotic use * New sex partner within the past year * History of UTIs within 1^st degree female relatives * History of recurrent UTIs * First UTI at early age * Catheter insertion ***_Likely pathogens_*** abx use can kill off native flora and allow commensal **E.coli** to overgrow staph saprophycitcus likely pathogens for cystis: enteric gram negative (enterobacteria, klebsiella, pseudomonas auruginosa)

Answer 132

***_NEWS monitoring_*** * Urine dip (check for presence of leukocytes or nitrate positive * Urine cultures (to confirm epirical treatment) * consider bloods if unwell ***_treatment options for UTI_***

Answer 133

advice on self care- paracetamol, intake of fluids to avoid dehydration, don't encourage cranberry products immediate abxs take into account local guidelines: * Nitrofurantoin 100mg modified-release twice a day for 3 days * Trimethoprim 200mg twice a day for 3 days

Answer 134

* discuss behavioural and personal hygiene advice * in post menopasual women consider prescribing vaginal oestrogen * abx prophylaxis: trimethoprim or amoxicillin

Answer 135

pain relief AVOID nitrofurantoin at term (39 weeks?) use amoxicillin or cefalexin

Answer 136

Protozoan infection Acquired through ingestion of contaminated water or food Self-limiting in immunocompetent people, but causes * chronic diarrhoea * abdominal cramps and weight loss in people with HIV * diagnosed on stool microscopy or PCR

Answer 137

Protozoan parasite, commonest cause of brain lesion in people with HIV Usually due to reactivation of previous infection, causes focal neurological symptoms, fever , seizures Can also cause chorioretinitis

Answer 138

caused by **herpes zoster** infection painful vesicular lesions that occur in a **dermatomal distribution** *_complications:_* post-herpetic neuralgia, blindness, meningitis

Answer 139

Commonest cause of infection in patients with HIV ***_Presents with_*** * Progressive dyspnoea * Fever * Malaise * Desaturation on exertion, CXR shows diffuse alveolar infiltrates * Diagnosis is by PCR of induced sputum or BAL or histology

Answer 140

Rare brain and spinal cord disease caused by JC virus, seen almost exclusively in people with HIV Symptoms include: * Loss of muscle control * Paralysis * Blindness * Speech problems * Altered mental state Progresses rapidly and can be fatal

Answer 141

Herpes virus Viral infection that can cause pneumonia, colitis, encephalitis and retinitis Can cause blindness if not treated promptly

Answer 142

Common cause of meningitis in HIV ***_Presents with insidious onset:_*** * Fever * Headache * Visual change * Neck stiffness * Seizures

Answer 143

* Singular acute, painful, swollen joint * Restricted movement in 80% of patients * Pain on active and passive movemnts * Examination findings: warm to touch/ fluctuant * Fever- present in the majority of patients * Unable to weight bear * Symptoms more obvious and florid in native joint infection ***_initial investigations for septic arthritis_*** * Synovial fluid sampling- look for white cells and bacteria -\> send for gram stain * Done prior to administration of antibiotics ideally * Blood cultures * FBC + CRP+ ESR+ urate levels * Plain radiograph- nothing in early disease, capsule and soft tissue swelling, fat pad shift or joint space widening in later disease * CT or MRI in specific joints- e.g., sternoclavicular joint

Answer 144

usually bacterial Due to either: * Hematogenous spread (most common) * Direct inoculation. **Staphylococcus aureus** (including MRSA) - 50% of cases **Streptococci** - (group A, B, C or G) 2nd **Neisseria gonorrhoeae** - particularly in young, sexually active patients **Pseudomonas aeurginosa** - usually healthcare associated **Salmonella** - those with sickle cell anaemia particularly at risk.

Answer 145

* IV drug users * Diabetes Mellitus * Older age * Underlying joint injury * Underlying joint disease (e.g. osteoarthritis, rheumatoid arthritis) * Prosthetic joint * Immunosuppression (due to medications or disease e.g. HIV) * Unprotected sex (gonococcal arthritis) * Peripheral vascular disease * Alcoholism

Answer 146

* ***_Synovial fluid sampling_***- look for white cells and bacteria  send for gram stain * Done prior to administration of antibiotics ideally * Blood cultures * FBC + CRP+ ESR+ urate levels * Plain radiograph- nothing in early disease, capsule and soft tissue swelling, fat pad shift or joint space widening in later disease * CT or MRI in specific joints- e.g., sternoclavicular joint

Answer 147

***_Primary immunodeficiencies-_*** genetically determined and may appear alone or as part of a syndrome. Usually present during childhood. Defined by which part of the immune system they interact with. ***_Secondary immunodeficiencies_***- occur in older or sick patients * Endocrine- diabetes mellitus * GI- hepatic insufficiency * Haematologic- aplastic anaemia, multiple myeloma * Iatrogenic- certain drugs such as chemotherapeutics, immunosuppressants * Infectious- HIV, EBV, measles * Nutritional- alcoholism, undernutrition * Physiologic- physiological immunodeficiency * Renal- nephrotic syndrome * Rheumatologic- SLE

Answer 148

mycobacteria- slow growing aeorbic bacilli ## Footnote Distinguished by a **complex, lipid rich cell envelope** responsible for characterisation as acid-fast (i.e. resistant to decolourisation by acid after staining) and their relative resistance to gram stain. **STAINS BRIGHT RED** **aerobic** so like to grow in the apices

Answer 149

Have to be in contact for a while cramped conditions and residents * **T**ight living quarters * **B**elow or at the poverty line * **R**efugees or immigrants * **I**mmune system issues (HIV, immunosuppressants) * **S**ubstance abusers * **K**ids\< age of 5 * via droplets that can survive in their environment for a long time

Answer 150

***_Primary and secondary infection:_*** * **Infection-** In 90% the immune system contains the infection, through macrophages that engulf bacteria and localize them to the hilar lymph nodes. Here, they are eliminated or may be encapsulated by a barrier of granulation tissue (considered to be in a dormant state). * A **small proportion progress to active TB**, with an increased risk in those who are immunosuppressed (e.g. HIV). This is known as Secondary TB and usually occurs in the apex of the lungs. From here it can spread locally or to distant sites. * Some patients are not able to contain the primary infection, and it disseminates widely via the bloodstream. This is known as **miliary TB** (due to the characteristic pattern on Chest X-ray like 'millet-seeds' when re-infection of lungs occurs after passing through circulation). * When immune system is weak you see **secondary infection of TB**

Answer 151

* Subacute to chronic in onset * Symptoms depend on the main site of infection, but are usually accompanied by; * night sweats * fever * weight loss * other systemic symptoms

Answer 152

* Most common * Chronic cough productive of purulent sputum +/- hemoptysis. * Can get bronchiectasis, pneumonia and pleural effusions. ***_CNS_*** * TB meningitis or tuberculoma * Headache * Meningism * Focal neurological signs * Decreased consciousness ***_Additional presentation_*** * May get palpable tender, firm superficial lymphadenopathy. * Causes 'sterile' pyuria, kidney pathology, abscesses, salpingitis and infertility, epididymo-orchitis.

Answer 153

***_Latent TB_*** ***_Active TB_*** Not contagious Contagious No signs and symptoms Signs and symptoms Normal CXR Abnormal CXR Negative sputum Positive sputum for mycobacterium Mantoux + blood test positive Mantoux + blood test positive Still needs Tx to prevent active status Can spread via lymphatic system to other organs

Answer 154

* **CXR**- look for multinodular infiltrate behind the clavicle. Calcified hilar nodes. * **Acid**-fast stain and culture from sputum culture- use ZE stain. Drug susceptibility tests. * **Mantoux test**- indell will appear if you are positive for infection. This doesn’t specify whether active, latent or from inoculation. 6-15mm is a positive test * **Bronchoscopy** * **IGRA**- blood test. Interferon Gamma Release Assay- * **PCR**- quick and easy + helps detect sensitivity to rifampicin

Answer 155

RIPE * **R**ifampicin * **I**soniazid * **P**yrazinamide * **E**thambutol rifampicin makes your urine red

Answer 156

* inflammation and destruction of bone,caused by bacteria, mycobacteria and fungi ***_presentations_*** Peripheral bones * Weight loss * Fatigue * Fever * Localised warmth * Swelling * Erythema * Tenderness Vertebral osteomyelitis Localised back pain Tenderness with paravertebral muscle spasm

Answer 157

Staphylococcus bacteria in most cases **Staph. Aureus** Staph. Epidermidis ***_investigations_*** * Definitive diagnosis - need a **bone biopsy** for pathology and culture. ***_Supportive diagnostic tests:_*** * Blood inflammatory markers ***_Imaging:_*** * **X-ray** - may be negative early on as periosteal reaction cannot be seen until about 7 days and bone necrosis after 10 days. It is useful in the diagnosis of chronic osteomyelitis. * **MRI** - good for viewing bone and soft tissue. Imaging modality of choice. * **CT** - good for identifying necrotic bone and for guiding needle for biopsy. ***_Other tests;_*** * Blood cultures, and culture of any expressed pus (but note that samples from sinus tracts are unreliable)

Answer 158

* **Unvaccinated child** * **Fever \>40** * Cough * Coryza * **Conjunctivitis** * **White spots in the mouth** (koplik spots) * MEASLES- e**rythematous maculopapular rash** across **head, neck, torso** and **limbs**

Answer 159

3-5 day high fever Followed by a maculopapular rash Caused by human herpes virus 6

Answer 160

Child 2-10 years ***_Triad of:_*** 1. Purpura over extensor surfaces of the lower limb 2. Abdominal pain 3. Arthritis Urinalysis and blood pressure to check renal involvement

Answer 161

* An infection caused by a few Plasmodium species * Caused by single celled parasites that are spread by mosquito * Once plasmodium enters the blood stream it infects and destroys mainly liver and red blood cells. Particularly dangerous for: * Young children under 5 * Pregnant women * Patient with other conditions like HIV/ AIDS * Travellers with no prior exposure to malaria

Answer 162

tropical areas premunition- tolerance plasmodium vivax

Answer 163

1. Plasmodium infected **female anopheles mosquito** hunts for a blood meal in the evening- night. Mosquitos are drawn to CO2. 2. Plasmodium is in a stage of development called a **sporozoite** in the mosquito’s **salivary gland**. 3. When mosquito pierces skin, worm like sporozoites enter our bloodstream. 4. Reach **liver** and go **dormant for months**/ years before engaging in **asexual reproduction** (reason for gap in infection  symptoms) 5. **Merozoites** are released into blood where each one **enters a RBC** (young RBCs) 6. Undergoes **asexual reproduction** and **changes form**. 7. **Gametocytes** released within RBC. 8. Infected RBC collected by a **different mosquito** taking a blood meal. 9. Gametocytes reach the **mosquitos gu**t where they fuse into a mature **zygote**. 10. Zygote matures into **oocyst** and ruptures **releasing sporozoites into the mosquito gut** 11. Migration into salivary gland to repeat cycle.

Answer 164

incubation period for months asymptomatic then * haemolytic anaemia- extreme fatigue, headaches, jaundice, splenomegaly * tertian fever every 48 hours * rigors * muscle pains * chills * ischaemic damage from RBC clumping together *

Answer 165

* **Thick blood smear**- locates parasites sitting in RBCs * **Thin blood smear-** directly identifies plasmodium species * **FBC** * Important to know percentage of RBCs affected * Thrombocytopaenia * Normochromic + normocytic anaemia (few RBC but normal in size and colour)

Answer 166

1) **_Suppressive treatment or chemoprophylaxis_** Kills sporozoites before they infect hepatocytes Given to travellers before they go 2) ***_Therapeutic treatment_*** Aimed at eliminating merozoites in the erythrocytic phase (while replicating in RBCs) Given during active infection ***_3) Gametocidal treatment_*** Aimed at killing gametocytes Prevents spread of disease and creation of resistant forms of the parasite ***_4) Radical treatments_*** Aimed at killing hypnozoites in the liver for non-severe--\> ***_Chloroquinone, doxycycline, quinine_***

Answer 167

**Valvular heart disease**- one or more of the valves in your heart doesn’t work properly stenosis- narrowing or constriction of valve regurgitation- when blood travels back through a valve when it shouldn't insufficiency - when a valve doesn't close properly

Answer 168

**_Tricuspid valve-_** located between the right atrium and right ventricle. **_Pulmonary valve-_** located between the right ventricle and the pulmonary artery **_Mitral valve_**- located between the left atrium and the left ventricle **_Aortic valve_**- located between the left ventricle and aorta

Answer 169

***_options:_*** **_Valvuloplasty-_** balloon valvuloplasty is a procedure done to open a stenosed heart valve. **_Valve replacemen_**t- annuloplasty or valvuloplasty. Important procedure as it can preserve heart function. ***_valve replacement_*** ***_treatment of secondary heart failure to manage symptoms_***

Answer 170

* Changes in heart valve structure due to aging * Coronary heart disease and heart attack * Heart valve infection * Birth defect * Rheumatic disease- happens after infections from bacteria that cause strep throat. Causes valvular scarring * **Endocarditis**- disease in the blood leads to endocarditis. Therefore IV use can cause it. * Heart failure * Hypertension * MI * Autoimmune diseases- lupus * Marfan syndrome- disease of connective tissue * Syphilis (a sexually transmitted infection)

Answer 171

* Angina * Palpitations caused by irregular heartbeats (atrial flutter or fib) * Fatigue * Exertional syncope * Dizziness * Low or high blood pressure * SOB * Abdo pain (hepatomegaly if tricuspid failure) * Leg swelling * Orthopnea * Heart murmur * Heart failure symptoms essentially

Answer 172

* Carcinoma in the bronchus * Pneumothorax- pleuritic chest pain * Pericardial disease * Respiratory tract infection (pneumonia, influenza, TB) * PE * Ischaemic heart disease * Pleurisy (sharp pain when breathing- inflamed pleural membranes) * Aortic dissection

Answer 173

* Lymphoproliferative disease- lymphadenopathy * Malaria * Myeloproliferative disorders- problems with bone marrow e.g., polycythemia vera * Thromboembolic disease * TB * Endocarditis

Answer 174

* **ramipril**- ACE inhinitor * **Nefedipine-** DHP-Calcium Channel Blocker * Combine CCB and ACE-I/ARB * Add a thiazide like diuretic (Indapamide)

Answer 175

slurred upstroke of the QRS complex Wolff parkinson syndrome

Answer 176

it is an AVN blocking drug used in SVTs