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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
List the main side-effects of medical TB treatment.
Rifampicin: orange urine, enzyme induction (reduced COCP efficacy), hepatitis Isoniazid: peripheral neuropathy Pyrazinamide: hepatitis, arthralgia Ethambutol: optic neuritis (loss of colour vision)
26
Describe the different X-ray features of primary TB.
Ghon Focus: primary subpleural lesion Ghon Complex: hilar lymphadenopathy + lung lesion Ranke Complex: fibrosis and calcification of Ghon complex
27
Which investigations are used to diagnose TB?
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
What are the components of a liver screen?
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
What should patients with chronic liver failure be screened for?
Hepatocellular carcinoma: US + AFP | Varices: OGD
30
What grading system is used for Cirrhosis and what factors does it take into account?
``` Child-Pugh Grading System Albumin Bilirubin Clotting Distension (ascites) Encephalopathy ```
31
How can the complications of chronic liver disease be managed?
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
How might hepatic encephalopathy manifest?
``` Asterixis Ataxia Confusion Dysarthria Constructional apraxia Seizures ``` NOTE: plasma ammonia will be high
33
How should hepatic encephalopathy be treated?
Lactulose (reduces nitrogen-forming bowel bacteria) | Rifaximin (kills intestinal microflora)
34
Outline the treatment of spontaneous bacterial peritonitis.
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
Outline how SAAG is used to differentiate causes of ascites.
``` 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
Outline the management of ascites.
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
List some signs of immunosuppressant use.
``` Cushingoid (steroids) Skin tumours (e.g. actinic keratosis, SCC, BCC) Gingival hypertrophy (ciclosporin) Hypertension (ciclosporin, tacrolimus) Fine tremor (tacrolimus) ```
38
What are the main indications for a liver transplant?
Cirrhosis Acute liver failure (e.g. hepatitis A/B, paracetamol overdose) Malignancy
39
Which stains should be used on a liver biopsy of a patient with cirrhosis?
``` Pearl's stain (iron) Rhodamine stain (copper) PAS stain (A1AT) Apple-green birefringence with Congo Red (amyloidosis) Check for granulomata ```
40
List some differentials for splenomegaly.
Infection: EBV Haematological: CLL, lymphoma, CML, myelofibrosis, splenic sequestration crisis Infiltrative: amyloidosis, Gaucher's disease Other: malaria, leishmaniasis, portal hypertension, RA, SLE
41
List some causes of hyposplenism.
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
List some complications of splenectomy.
Redistributive thrombocytosis (leads to VTE) Gastric dilatation (transient ileus) Left lower lobe atelectasis Pancreatitis Increased susceptibility to infection (encapsulated)
43
List some differentials for enlarged kidneys.
``` BILATERAL - ADPKD - bilateral RCC - bilateral cysts (von Hippel Lindau) - amyloidosis UNILATERAL - simple renal cyst - renal cell carcinoma - compensatory hypertrophy ```
44
What blood test results would you expect to see in a patient with renal failure?
Anaemia Deranged U&E Hypocalcaemia, high phosphate, high PTH (secondary hyper PTH)
45
Which gene most often causes polycystic kidney disease?
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
List some causes of renal cysts.
Simple renal cysts (present in 1/3 over 60 yrs) Dialysis-associated renal cysts (increased risk of RCC) Tuberous sclerosis
47
Which paraneoplastic phenomenon can result from RCC?
``` EPO --> polycythaemia PTHrP --> hypercalcaemia Renin --> hypertension ACTH --> Cushing's syndrome Amyloidosis ```
48
What are the most common indications for renal transplant?
Diabetic nephropathy Glomerulonephritis Polycystic kidney disease Hypertensive nephropathy
49
Which assessments need to be carried out before renal transplantation?
``` Virology Co-morbidities (anaesthetic fitness) ABO Anti-HLA antibodies Haplotype (DR > B > A) Pre-implantation cross-match ```
50
List some complications of renal transplantation.
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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