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YEAR 6: PACES > Medicine 2 > Flashcards

Medicine 2 Flashcards

1
Q

What do the three letters in naming pacemakers mean?

A

1st: chamber paced (A, V, D)
2nd: chamber sensed (A, V, D)
3rd: response (inhibited, triggered, dual)

E.g. VVI: paces the ventricle but also senses intrinsic ventricular activity which would inhibit a pacing output

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2
Q

What are biventricular pacemakers used for?

A

Leads to both ventricles
Used for cardiac resynchronisation therapy in heart failure

NOTE: this aims to maximise the pumping action of the heart

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3
Q

List some complications of pacemakers.

A 
Insertion:
- Bleeding 
- Arrhythmia
Post-Insertion:
- Erosion
- Lead migration 
- Pocket infection 
- Malfunction
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4
Q

List some causes of heart failure.

A

LEFT: ischaemic heart disease, dilated cardiomyopathy, hypertension, mitral and aortic valve disease
RIGHT: LVF, cor pulmonale, tricuspid and pulmonary valve disease

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5
Q

Which main investigations are used in heart failure?

A 
Blood test - BNP, FBC, U&E, glucose, urine 
CXR - heart size, lung fields 
ECG - rhythm, ischaemia, LVH
Echo - valves, ventricular function 
Lipid  and BP
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6
Q

Outline the management of chronic heart failure.

A 
Risk factor modification 
1st line: Beta-blocker + ACE inhibitor + loop diuretics (e.g. frusemide) 
2nd line: add spironolactone 
3rd line: consider digoxin
4th line: consider CRT

Final line: heart transplant

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7
Q

What cardiovascular signs should you check for in a patient with COPD?

A 
Cor pulmonale 
Raised JVP 
Left parasternal heavy (RVH)
Tricuspid regurgitation 
Ascites and pulsatile hepatomegaly 
Peripheral oedema
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8
Q

What spirometry results would you expect to see in COPD?

A

Reduced FEV1
Low FEV1/FVC ratio (< 0.7)
Increased total lung capacity and residual volume

NOTE: bronchiectasis also gives an obstructive pattern

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9
Q

Which treatments can be offered to help people with COPD to stop smoking?

A

Specialist nurse and support programme
Nicotine replacement programme
Varenicline (partial nicotinic acetylcholine receptor agonist) and bupropion (noradrenaline-doparmine reuptake inhibitor)

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10
Q

List some causes of interstitial lung disease.

A 
UPPER
- aspergillosis
- pneumoconiosis
- extrinsic allergic alveolitis
- TB
LOWER
- sarcoidosis
- toxins (amiodarone, nitrofurantoin, methotrexate, sulfasalazine, bleomycine)
- asbestosis 
- idiopathic 
- rheumatological (RA, SLE, systemic sclerosis)
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11
Q

What is the imaging modality of choice for interstitial lung disease?

A

High resolution CT

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12
Q

What spirometry results would you expect to see in a patient with pulmonary fibrosis?

A

FEV1: FVC ratio > 0.8
Low TLC
Low RV
Low FEV1 and FVC

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13
Q

What would you expect to hear on auscultation of the chest in a patient with bronchiectasis?

A

Coarse, wet crackles which may change once the patient coughs
May also hear a wheeze
Coughing may clear the wheeze if it is due to a mucus plug

ALSO: clubbing, copious sputum, features of cor pulmonale (raised JVP, loud P2)

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14
Q

List some causes of bronchiectasis.

A 
ACQUIRED
Idiopathic (50%)
Post-infectious (pertussis, TB, measles)
Obstruction (tumour, foreign body) 
Associated (RA, IBD, ABPA) 
CONGENITAL
Cystic fibrosis 
Kartagener's syndrome 
Young's syndrome 
Hypogammaglobulinaemia (CVIS, Bruton's X-linked)
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15
Q

What are some causes of a transudative pleural effusion?

A 
Congestive cardiac failure 
Renal failure 
Liver failure (hypoalbuminaemia)
Hypothyroidism 
Meig syndrome
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16
Q

What are some causes of an exudative pleural effusion?

A 
Infection (e.g. pneumonia)
Cancer 
Inflammation (RA, SLE)
Infarction (e.g. PE) 
Trauma
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17
Q

What are Light’s criteria for an exudative pleural effusion?

A

Effusion: serum protein ratio > 0.5
Effusion: serum LDH ratio > 0.6
Effusion LDH is 0.6 x ULN

Effusion protein < 25 g/L = transudate
Effusion protein > 35 g/L = exudate
Between

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18
Q

What are some complications of Pancoast tumours?

A

Horner’s syndrome
Recurrent laryngeal nerve palsy
Clawing of the hand and wasting of interossei (due to brachial plexus injury (T1))

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19
Q

List some indications for lobectomy or pneumonectomy.

A

Non-disseminated bronchial carcinoma (90%)
Bronchiectasis
COPD
TB

NOTE: they both have a relatively high mortality

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20
Q

What are the main types of lung cancer and which is most common?

A

Non-Small Cell Lung Cancer (80%)
- SCC (35%) - smoking, central, PTHrP
- Adenocarcinoma (25%) - peripheral, less associated with smoking
- Large cell
Small Cell Lung Cancer (20%)
- highly related to smoking, central, ADH/ACTH

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21
Q

Which dermatological conditions are associated with lung cancer?

A 
Acanthosis nigricans 
Trousseau syndrome (migratory thrombophlebitis)
22
Q

Aside from imaging, what other important test needs to be done before a patient is surgically treated for lung cancer?

A

Pulmonary function tests to assess fitness for surgery

Pneumonectomy is contraindicated if FEV1 < 1.2 L

23
Q

Which organisms most commonly cause community-acquired, hospital-acquired and aspiration pneumonia?

A

CAP: pneumococcus, mycoplasma, haemophilus (COPD), chlamydia pneumophila, viruses
HAP: pseudomonas, staph aureus, Gram negative enterobacteriaceae (Klebsiella)
Aspiration: anaerobes

24
Q

What is a thoracoplasty?

A

Old treatment for TB which involved surgically removing a rib in order to collapse the part of the lung affected by TB

25
Q

List the main side-effects of medical TB treatment.

A

Rifampicin: orange urine, enzyme induction (reduced COCP efficacy), hepatitis
Isoniazid: peripheral neuropathy
Pyrazinamide: hepatitis, arthralgia
Ethambutol: optic neuritis (loss of colour vision)

26
Q

Describe the different X-ray features of primary TB.

A

Ghon Focus: primary subpleural lesion
Ghon Complex: hilar lymphadenopathy + lung lesion
Ranke Complex: fibrosis and calcification of Ghon complex

27
Q

Which investigations are used to diagnose TB?

A

Latent TB: IGRA assay, tuberculin skin test
CXR
3 x sputum samples (one in morning) - microscopy (Ziehl-Neelsen) and culture on Lowenstein-Jensen
PCR (identify rifampicin resistance)

28
Q

What are the components of a liver screen?

A

FBC and LFTs (alcohol, macrocytic anaemia)
Hepatitis serology
Lipids (NASH)
Autoantibodies (ASMA, AMA, pANCA, ANA)
Immunoglobulins (high IgG in autoimmune hepatitis; high IgM in PBC)
Caeruloplasmin, ferritin, A1AT
Cancer (AFP, CA19-9)

29
Q

What should patients with chronic liver failure be screened for?

A

Hepatocellular carcinoma: US + AFP

Varices: OGD

30
Q

What grading system is used for Cirrhosis and what factors does it take into account?

A 
Child-Pugh Grading System
Albumin
Bilirubin
Clotting 
Distension (ascites) 
Encephalopathy
31
Q

How can the complications of chronic liver disease be managed?

A

Ascites: daily wt, fluid and Na restrict, diuretics, tap
Coagulopathy: Vit K, FFP, platelets
Encephalopathy: avoid sedatives, lactulose, rifaximin
Sepsis / SBP: tazocin or cefotaxime
Hypoglycaemia: dextrose
Hepatorenal syndrome: IV albumin + terlipressin

32
Q

How might hepatic encephalopathy manifest?

A 
Asterixis 
Ataxia
Confusion 
Dysarthria 
Constructional apraxia 
Seizures

NOTE: plasma ammonia will be high

33
Q

How should hepatic encephalopathy be treated?

A

Lactulose (reduces nitrogen-forming bowel bacteria)

Rifaximin (kills intestinal microflora)

34
Q

Outline the treatment of spontaneous bacterial peritonitis.

A

Cefotaxime or tazocin (until sensitivities known)
Long-term ciprofloxacin and beta-blocker (propranolol)

NOTE: diagnosed if > 250 PMN/mm^3 in ascitic fluid. Usual organisms are E. coli, Klebsiella and Streptococci

35
Q

Outline how SAAG is used to differentiate causes of ascites.

A 
SAAG > 11 g/L 
- Cirrhosis
- congestive cardiac failure 
SAAG < 11 g/L
- neoplasia
- inflammation 
- infection (e.g. TB peritonitis)
- nephrotic syndrome

NOTE: portal hypertension = pressure > 10 mm Hg

36
Q

Outline the management of ascites.

A

GENERAL: alcohol abstinence, daily weight, fluid restrict (< 1.5 L), low sodium diet
DIURETICS: spironolactone, add frusemide if poor response
Therapeutic paracentesis with albumin infusion
Refractory ascites: TIPSS, transplant
Prophylactic ciprofloxacin for SBP prevention

37
Q

List some signs of immunosuppressant use.

A 
Cushingoid (steroids) 
Skin tumours (e.g. actinic keratosis, SCC, BCC)
Gingival hypertrophy (ciclosporin)
Hypertension (ciclosporin, tacrolimus) 
Fine tremor (tacrolimus)
38
Q

What are the main indications for a liver transplant?

A

Cirrhosis
Acute liver failure (e.g. hepatitis A/B, paracetamol overdose)
Malignancy

39
Q

Which stains should be used on a liver biopsy of a patient with cirrhosis?

A 
Pearl's stain (iron)
Rhodamine stain (copper)
PAS stain (A1AT)
Apple-green birefringence with Congo Red (amyloidosis)
Check for granulomata
40
Q

List some differentials for splenomegaly.

A

Infection: EBV
Haematological: CLL, lymphoma, CML, myelofibrosis, splenic sequestration crisis
Infiltrative: amyloidosis, Gaucher’s disease
Other: malaria, leishmaniasis, portal hypertension, RA, SLE

41
Q

List some causes of hyposplenism.

A

Splenectomy
Coeliac disease
Inflammatory bowel disease
Sickle cell disease

NOTE: hyposplenism is managed with immunisations (pneumovax, Hib, men C, annual flu) and daily antibiotics (Pan V or erythromycin)

42
Q

List some complications of splenectomy.

A

Redistributive thrombocytosis (leads to VTE)
Gastric dilatation (transient ileus)
Left lower lobe atelectasis
Pancreatitis
Increased susceptibility to infection (encapsulated)

43
Q

List some differentials for enlarged kidneys.

A 
BILATERAL
- ADPKD 
- bilateral RCC 
- bilateral cysts (von Hippel Lindau)
- amyloidosis 
UNILATERAL
- simple renal cyst 
- renal cell carcinoma 
- compensatory hypertrophy
44
Q

What blood test results would you expect to see in a patient with renal failure?

A

Anaemia
Deranged U&E
Hypocalcaemia, high phosphate, high PTH (secondary hyper PTH)

45
Q

Which gene most often causes polycystic kidney disease?

A

PKD1 gene on chromosome 16 (85%)
Remainder caused by PKD2 gene on chromosome 4

NOTE: patients with ADPKD should be screened for Berry Aneurysms with an MRA

46
Q

List some causes of renal cysts.

A

Simple renal cysts (present in 1/3 over 60 yrs)
Dialysis-associated renal cysts (increased risk of RCC)
Tuberous sclerosis

47
Q

Which paraneoplastic phenomenon can result from RCC?

A 
EPO --> polycythaemia 
PTHrP --> hypercalcaemia 
Renin --> hypertension 
ACTH --> Cushing's syndrome 
Amyloidosis
48
Q

What are the most common indications for renal transplant?

A

Diabetic nephropathy
Glomerulonephritis
Polycystic kidney disease
Hypertensive nephropathy

49
Q

Which assessments need to be carried out before renal transplantation?

A 
Virology
Co-morbidities (anaesthetic fitness) 
ABO 
Anti-HLA antibodies 
Haplotype (DR > B > A) 
Pre-implantation cross-match
50
Q

List some complications of renal transplantation.

A

Bleeding
Graft thrombosis or dysfunction
Infection secondary to immunosuppression (PCP, CMV)
Increased risk of other pathology (skin cancer, post-transplant lymphoproliferative disease, cardiovascular disease)
Recurrence of original disease
Urinary leaks

YEAR 6: PACES (22 decks)

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