Medicine 2 Flashcards
What do the three letters in naming pacemakers mean?
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
What are biventricular pacemakers used for?
Leads to both ventricles
Used for cardiac resynchronisation therapy in heart failure
NOTE: this aims to maximise the pumping action of the heart
List some complications of pacemakers.
Insertion: - Bleeding - Arrhythmia Post-Insertion: - Erosion - Lead migration - Pocket infection - Malfunction
List some causes of heart failure.
LEFT: ischaemic heart disease, dilated cardiomyopathy, hypertension, mitral and aortic valve disease
RIGHT: LVF, cor pulmonale, tricuspid and pulmonary valve disease
Which main investigations are used in heart failure?
Blood test - BNP, FBC, U&E, glucose, urine CXR - heart size, lung fields ECG - rhythm, ischaemia, LVH Echo - valves, ventricular function Lipid and BP
Outline the management of chronic heart failure.
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
What cardiovascular signs should you check for in a patient with COPD?
Cor pulmonale Raised JVP Left parasternal heavy (RVH) Tricuspid regurgitation Ascites and pulsatile hepatomegaly Peripheral oedema
What spirometry results would you expect to see in COPD?
Reduced FEV1
Low FEV1/FVC ratio (< 0.7)
Increased total lung capacity and residual volume
NOTE: bronchiectasis also gives an obstructive pattern
Which treatments can be offered to help people with COPD to stop smoking?
Specialist nurse and support programme
Nicotine replacement programme
Varenicline (partial nicotinic acetylcholine receptor agonist) and bupropion (noradrenaline-doparmine reuptake inhibitor)
List some causes of interstitial lung disease.
UPPER - aspergillosis - pneumoconiosis - extrinsic allergic alveolitis - TB LOWER - sarcoidosis - toxins (amiodarone, nitrofurantoin, methotrexate, sulfasalazine, bleomycine) - asbestosis - idiopathic - rheumatological (RA, SLE, systemic sclerosis)
What is the imaging modality of choice for interstitial lung disease?
High resolution CT
What spirometry results would you expect to see in a patient with pulmonary fibrosis?
FEV1: FVC ratio > 0.8
Low TLC
Low RV
Low FEV1 and FVC
What would you expect to hear on auscultation of the chest in a patient with bronchiectasis?
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)
List some causes of bronchiectasis.
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)
What are some causes of a transudative pleural effusion?
Congestive cardiac failure Renal failure Liver failure (hypoalbuminaemia) Hypothyroidism Meig syndrome
What are some causes of an exudative pleural effusion?
Infection (e.g. pneumonia) Cancer Inflammation (RA, SLE) Infarction (e.g. PE) Trauma
What are Light’s criteria for an exudative pleural effusion?
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
What are some complications of Pancoast tumours?
Horner’s syndrome
Recurrent laryngeal nerve palsy
Clawing of the hand and wasting of interossei (due to brachial plexus injury (T1))
List some indications for lobectomy or pneumonectomy.
Non-disseminated bronchial carcinoma (90%)
Bronchiectasis
COPD
TB
NOTE: they both have a relatively high mortality
What are the main types of lung cancer and which is most common?
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
Which dermatological conditions are associated with lung cancer?
Acanthosis nigricans Trousseau syndrome (migratory thrombophlebitis)
Aside from imaging, what other important test needs to be done before a patient is surgically treated for lung cancer?
Pulmonary function tests to assess fitness for surgery
Pneumonectomy is contraindicated if FEV1 < 1.2 L
Which organisms most commonly cause community-acquired, hospital-acquired and aspiration pneumonia?
CAP: pneumococcus, mycoplasma, haemophilus (COPD), chlamydia pneumophila, viruses
HAP: pseudomonas, staph aureus, Gram negative enterobacteriaceae (Klebsiella)
Aspiration: anaerobes
What is a thoracoplasty?
Old treatment for TB which involved surgically removing a rib in order to collapse the part of the lung affected by TB
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)
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
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)
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)
What should patients with chronic liver failure be screened for?
Hepatocellular carcinoma: US + AFP
Varices: OGD
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
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
How might hepatic encephalopathy manifest?
Asterixis Ataxia Confusion Dysarthria Constructional apraxia Seizures
NOTE: plasma ammonia will be high
How should hepatic encephalopathy be treated?
Lactulose (reduces nitrogen-forming bowel bacteria)
Rifaximin (kills intestinal microflora)
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
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
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
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)
What are the main indications for a liver transplant?
Cirrhosis
Acute liver failure (e.g. hepatitis A/B, paracetamol overdose)
Malignancy
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
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
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)
List some complications of splenectomy.
Redistributive thrombocytosis (leads to VTE)
Gastric dilatation (transient ileus)
Left lower lobe atelectasis
Pancreatitis
Increased susceptibility to infection (encapsulated)
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
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)
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
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
Which paraneoplastic phenomenon can result from RCC?
EPO --> polycythaemia PTHrP --> hypercalcaemia Renin --> hypertension ACTH --> Cushing's syndrome Amyloidosis
What are the most common indications for renal transplant?
Diabetic nephropathy
Glomerulonephritis
Polycystic kidney disease
Hypertensive nephropathy
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
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
