Module A Flashcards
What cancer results in a secondary brain cancer?
Lung cancer Breast cancer Kidney cancer Melanoma skin cancer Colorectal cancer
What cancer results in a secondary bone cancer?
Prostate cancer Breast cancer Lung cancer Kidney cancer Thyroid cancer Myeloma
Typically involves spine, pelvis, ribs, skull, long bones
Px: pathological fracture, raised ALP, hypercalcaemia
Thrombophlebitis
Treatment with anti-inflammatory
Causes of metabolic acidosis with normal anion gap
AKA hyperchloraemic metabolic acidosis
gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula renal tubular acidosis drugs: e.g. acetazolamide ammonium chloride injection Addison's disease
Causes of metabolic acidosis with raised anion gap
lactate: shock, hypoxia
ketones: diabetic ketoacidosis, alcohol
urate: renal failure
acid poisoning: salicylates (due to lactic acid accumulation), methanol
Causes of metabolic alkalosis
vomiting/aspiration (e.g. peptic ulcer leading to pyloric stenos, nasogastric suction) diuretics liquorice, carbenoxolone hypokalaemia primary hyperaldosteronism Cushing's syndrome Bartter's syndrome congenital adrenal hyperplasia
Causes of respiratory alkalosis
anxiety leading to hyperventilation,
pulmonary embolism,
salicylate poisoning (due to hyperventilation)
CNS disorders: stroke, subarachnoid haemorrhage, encephalitis, altitude, pregnancy
Causes of respiratory acidosis
COPD
decompensation in other respiratory conditions e.g. life-threatening asthma / pulmonary oedema
sedative drugs: benzodiazepines, opiate overdose
CURB-65
Used to assess severity of pneumonia C - Confusion U - blood urea nitrogen > 7mmol/L R - RR ≥ 30 B - sBP < 90mmHg or dBP < 60mmHg 65 - age ≥ 65
Low severity = 0-1 (home)
Moderate severity = 2 (hospital admission)
High severity = 3-5 (possible ITU admission)
Aneurysm
Dilation of an artery which is greater than 50% of the normal diameter
NEWS2 score
National Early Warning Score - assesses degree of illness in pt
Uses RR, SpO2, BP, HR, Temp, Consciousness
0-4 low risk (vital signs monitored by ward team every 4-6hrs)
5-6 medium risk (urgent review by team for poss ICU review, vital signs monitored hourly)
Greater than or equal to 7 = high risk (ICU review and transfer for continuous vital signs monitoring)
GCS
Glasgow Coma Score - used to assess consciousness (E4 V5 M6)
Max = 15, min = 3
Eyes = 4 - spontaneous, verbal, pain, nil
Verbal = 5 - oriented, confused, inappropriate, incomprehensible, nil
Movement = 6 - obeys commands, localises pain, withdrawal from pain, flexion to pain, extension to pain, nil
P pulmonale
Tall peaked P waves seen on ECG
Associated with pulmonary hypertension, tricuspid valve disease, diffuse lung disease, enlarged right atrium due to coronary heart disease
Biphasic P wave
P wave has positive and negative deflections on ECG
Associated with left atrium enlargement
P mitrale
Bifid P wave (resembles an m) on ECG
Associated with mitral stenosis or left atrium enlargement
ECG findings with left axis deviation
Lead I = positive
Lead II = negative
Lead III = negative
Lead I & II repel each other
Causes: conduction heart defects
ECG findings with right axis deviation
Lead I = negative
Lead II = positive
Lead III = more positive
Lead I & II attract each other
Causes: right ventricular hypertrophy seen with pulmonary conditions and congenital heart defects
Abnormal T waves on ECG
Tall tented T waves = hyperkalaemia
T wave inversion = MI, cardiomyopathy, ischaemia, bundle branch block, raised ICP, intracranial haemorrhage, PE
ECG findings for raised ICP
T wave inversion
Prolonged QT interval
Causes of prolonged QT interval on ECG
Medication e.g. antipsychotics Low electrolytes e.g. Ca2+, K+, Mg2+ Hypothermia MI Raised ICP Congenital long QT syndrome
Causes of short QT interval on ECG
Digoxin effect (may cause large U wave) Congenital short QT syndrome Hypercalcaemia
1st degree heart block
Consistently prolonged PR interval (>200ms)
Causes: non-significant, coronary heart disease, acute rheumatic carditis, digoxin toxicity, electrolyte disturbances,
Mobitz type 1
AKA wenkebach
Progressive lengthening of PR interval then non-conducting P wave followed by short PR interval
Causes: drugs (CCB, BB, digoxin, amiodarone), inferior MI, myocarditis, increased vagal tone (e.g. athletes), following surgery (e.g. mitral valve repair, tetralogy of Fallot repair)
Mobitz type 2
AKA hay
Intermittent non-conducting P wave
Constant PR interval then spontaneous drop of QRS complex
Causes: anterior MI, inflammatory conditions (rheumatic fever, lyme disease), autoimmune disease (SLE, systemic sclerosis), infiltrative disease (sarcoidosis, haemochromatosis, amyloidosis), hyperkalaemia, drugs (CCB, BB, digoxin, amiodarone), cardiac surgery, Lenegre-Lev disease
2:1, 3:1, or 4:1 conduction
Alternate conducting and non-conducting P waves resulting in 2/3/4 P waves per QRS complex respectively
3rd degree heart block
AKA complete heart block
no association between P wave and QRS complex
P wave regular but no conduction to ventricles hence slow escape mechanism results in slower QRS complexes
Causes: acute inferior MI (transient), bundle of His fibrosis (chronic), block of both bundle branches, AV nodal blocking drugs e.g. CCB, BB, digoxin
AV nodal blocking drugs
CCB
BB
Digoxin
Erythema nodosum
Form of panniculitis (inflammation of fat under skin)
Pt presents with tender red/purple nodules under skin, typically on shins
Triggers include Streptococcal infection (especially in children), Sarcoidosis, Inflammatory bowel disease, TB, Behcet’s disease, viral infection (HepB), sulfa antibiotics, pregnancy, oral contraceptive, malignancy
Sarcoidosis
More common in pts of Afro-Caribbean origin
Multi-system disorder, cause unknown
Presentation: cough, low-grade fever, erythema nodosum, polyarthralgia
Ix: bilateral hilar lymphadenopathy on CXR
Mx:
- no symptoms/low stage = no tx
- symptomatic/higher stage = prednisolone (1st line)
- 2nd/3rd line = methotrexate, rituximab, anti-TNF monoclonal antibodies
Dressler syndrome
Autoimmune response after injury to myocardium or pericardium e.g. MI typically 2-3 weeks after injury but, can be a few months later
PC: fever, pericarditis (pain better leaning forward), pleuritic pain +/- pericardial effusion
Smoking cessation advice
Get pt to choose a date, throw away accessories, consider motivations for stopping smoking
Nicotine replacement options: Nicotine gum Transdermal nicotine patches Dose increase at 1 week post cessation Varenicline Bupropion
ECMO
Extracorporeal membrane oxygenation = an artificial lung membrane outside the body that oxygenates blood and continuously pumps this blood into and around the body
Resembles a heart-lung bypass machine used in surgery
Used in patients who fail to respond to tx efforts in asthma attacks (or COVID-19), used for cardiac/respiratory failure
Offered in ITU/HDU setting
SEs: bleeding, failure to recover, renal failure, infection
Actions of alpha 1 and 2 adrenergic receptor
Vasoconstriction of blood vessels to increase SVR
Actions of beta 1 adrenergic receptor
Increase HR and contractility of cardiac muscle
Actions of beta 2 adrenergic receptor
Bronchodilation
Vasodilation to reduce SVR
Actions of beta 3 adrenergic receptor
Lipolysis and thermogenesis in brown adipose tissue
Bladder relaxation and prevents urination
Found in gallbladder, function unknown
Atrial natriuretic peptide
Released by cardiac myocytes in response to exercise, increased Na+, atrial wall stretch (due to atrial volume increase), sympathetic innervation
Causes a decrease in BP by reducing renin release, reducing Na+ resorption, increasing Na+ and water excretion via kidney
Hypovolaemia
May be due to dehydration or haemorrhage
Reduced venous return seen (hence reduced CO & BP), body compensates by increasing water retention via RAAS, and increases sympathetic drive to increase HR and contractility
Tx: IV fluid bolus, blood transfusion, inotrope infusion (to maintain BP)
What attachments retain the heart in its position in the thoracic cavity?
Central tendon of the diaphragm
Sternopericardial ligaments
Pericardium
Formed of fibrous and serous (parietal + visceral) layers
Fibrous layer innervated by phrenic nerves hence pain may be referred to supraclavicular shoulder or neck region associated with C3/4/5
Pericarditis
Cause: viral, bacterial, systemic, post-MI
PC: central crushing chest pain radiating to arms, relieved on leaning forward
Ix: ECG
Tx:
Pericardial effusion
Excess fluid in pericardial cavity
Can lead to cardiac tamponade
Tx: pericardiocentesis
Cardiac tamponade
Leads to biventricular failure
Constrictive pericarditis
Abnormal thickening of pericardial sac to cause compression of heart leading to heart failure
Dx: kussmaul’s sign (raised jugular venous pulse on inspiration)
Tx: surgical opening of pericardial sac
Ciliary dyskinetic syndromes
Kartagener’s syndrome
Young’s syndrome
Associated with bronchiectasis
S1 heart sound
Closure of the atrioventricular valves
S2 heart sound
Closure of the bicuspid valves (pulmonary & aortic) heard at the end of systole (beginning of diastole)
On inspiration, S2 is composed of:
A2 = aortic valve closure (typically heard loudest over all chest zones)
P2 = pulmonary valve closure (if more pronounced, heard best at the left parasternal 2nd intercostal space)
If P2 > S2, this is associated with pulmonary hypertension commonly (or atrial septal defects)
Carcinoid syndrome
paraneoplastic syndrome caused by excessive serotonin secretion
Results in flushing, diarrhoea, abdominal pain, tricuspid valve disease (serotonin causes fibrosis of TV)
Roth’s/Litten spots
Non-specific red spots with pale centre on retina due to endothelial damage of retinal capillaries
Typically seen with infective endocarditis
May be seen with HTN, T2DM, leukaemia, HIV
STEMI Mx
Primary percutaneous coronary intervention with: Aspirin Ticagrelor Unfractionated or LMW heparin Oxygen PRN
If PCI is unavailable, thrombolysis offered (tissue plasminogen activator, or tenecteplase) with ECG 90mins after procedure to confirm >50% resolution of ST elevation
Hyperglycaemia management = dose-adjusted insulin infusion to maintain BM < 11mmol/L
Salicylate overdose
Px: tinnitus, anxiety, diaphoresis (sweating), N&V, hyper/hypoglycaemia, seizures, coma
Results in respiratory alkalosis due to hyperventilation then metabolic acidosis due to lactic acid accumulation
Tx: ABC approach, charcoal, IV sodium bicarbonate (increased aspirin elimination in urine), haemodialysis (if acidosis resistant to tx, serum conc >700mg/L, acute renal failure, pulmonary oedema, seizures, or coma)
PESI
Pulmonary embolism severity index Determines 30d outcome of PE Parameters include: - age - gender - hx of cancer, chronic lung disease, heart failure - HR ≥ 110bpm - sBP < 100mmHg - RR ≥ 30 breaths - Temp. < 36°C - SpO2 < 90% - altered mental state
Score determines class (I-V) with mortality varying from 0% to 24.5%
Obstructive lung diseases
Asthma
COPD
Bronchiectasis
Cystic fibrosis
FEV1/FVC < 0.7 Flow volume loop shows shorter curve (lower PEFR) and kink in expiration curve due to obstruction Spirometry curve (volume/time) shows flatter curve with v. low FEV1 and low FVC
Restrictive lung disease
Interstitial pneumonia Pneumoconiosis ILD e.g., pulmonary fibrosis Sarcoidosis Connective tissue disorders Fibrosis Obesity Pleural effusion Kyphoscoliosis Neuromuscular problems e.g., MND, myotonic dystrophy
FEV1/FVC > 0.7 & FVC < 80% predicted
Flow volume loops shows normal curve with lower PEFR
Spirometry (volume/time) curve shows normal curve with lower FEV1 and FVC
Hashimoto’s thyroiditis
chronic autoimmune thyroiditis, common in women
hypothyroidism + goitre (firm, non-tender) + anti-TPO
may be seen with transient thyrotoxicosis in the acute phase
Other Ix: anti-thyroglobulin antibodies
Associated with other autoimmune conditions e.g. coeliac disease, type 1 diabetes mellitus, vitiligo; and MALT lymphoma
Tx: levothyroxine
Candle breath
AKA pursed lip breathing
Used to control breathing when pt feels breathless with chronic lung conditions by allowing better flow of breath to reduced the feeling of restricted breathing
Pt takes a deep breath in through the nose, purses lips, and breaths out slowly as if trying to flicker the flame of a candle
Expiration should be longer than inspiration
Respiratory physiotherapist responsible for…
airway clearance
dysfunctional breathing
non-invasive ventilation
rehabilitation
Stages of cough
Natural defence mechanism
Irritation
Inspiration
Compression (glottis closes allowing intrathoracic pressure to increase)
Expulsion (explosive glottis opening with abdominal contraction)
Cough strength >270L/min required to clear secretions
Equal pressure point
Point at which pressured in the airways is equal to the pressure outside
Can be utilised to assist secretion clearance
Airway clearance techniques
- Active cycle of breathing (breathing exercises helps to loosen secretions for acute setting & at home)
- Postural drainage (gravity assisted positioning with head at a lower level than feet, used in out pt setting)
- PEP devices (positive expiratory pressure = mucus clearance by preventing airway closure and increasing collateral ventilation for acute setting e.g. acapella)
- Cough augmentation (manual assist cough, frog breathing, lung volume recruitment bag for acute setting or at home)
Causes of dysfunctional breathing
Organic disorders e.g., asthma, ILD, heart failure, PE, and pain (fibromyalgia, chronic fatigue)
Physiological e.g., increased progesterone
Psychological disturbances e.g., triggers (bereavement, emotional event, personality), heightened emotional state (fear, anger, depression), mental health issues (panic attacks, anxiety states, agoraphobia)
Nijmegen questionnaire
Confirms breathing dysfunction/hyperventilation syndrome diagnosis
Score >23 (out of 64) indicates hyperventilation
Other diagnostic tools for hyperventilation syndrome
Breath hold tests
ABG
ETCO2
(Nijmegen questionnaire)
Papworth method
Diaphragmatic breathing involves controlled slow nasal breathing for symptom relief and to increase CO2
Used for hyperventilation syndrome and to reduce the frequency of asthma attacks
Buteyko nasal breathing
Nasal breathing exercises aimed at reducing hyperventilation
Improves asthma symptoms and reduces bronchodilator requirement in adults with asthma
Non-invasive ventilation
Ventilatory support though the upper airway using a mask or similar device
BiPAP or CPAP
Ward NIV indications: COPD, Neuromuscular disease, and Obesity hypoventilation
BiPAP
Bilevel positive airway pressure (IPAP & EPAP)
Used in acute or home setting for acute/acute on chronic/chronic T2RF e.g., COPD, Guillain-Barre syndrome, severe ARDS
CPAP
Continuous positive airway pressure = keeps airways continuously open for pts who can breathe spontaneously
Used in OSA, asthma, pneumonia
Can be used to facilitate extubation
Aims of respiratory rehabilitation
Promote functional independence
Augments tidal volume
Aids collateral ventilation (alveolar ventilation via non-conventional route) with secretion clearance
Management of breathlessness
Proning
Lying patient on stomach
Used for COVID-19 and ARDS
Improves atelectasis, recruits posterior alveoli in ventilation, and improves secretion clearance
Overall, reduces V/Q mismatch and hypoxaemia
Spirometry
Assesses lung compliance and expulsion of air from the lungs
Measures FVC, FEV1, and FEV1:FVC ratio
Spirometry graph shows volume against time
Problems: poor effort or understanding, Mask leak, Failure to coordinate forced breath, Incomplete exhalation, coughing
Gas transfer
Lung function test
Assesses lungs ability to transfer oxygen from alveolar air to RBC in capillary bed
Measures transfer factor/TLco/DLco (diffusing capacity of the lung for carbon monoxide) in mmol/min/kPa
Test gas used = carbon monoxide because taken up in similar style to oxygen
Gas mixture given to pt: 0.3% CO, 14% He, 18% oxygen with nitrogen balance
Helium used to identify lung volume available for gas transfer = alveolar volume (Va) measured in L
Transfer coefficient (KCO) = uptake of CO per unit of
lung volume (DLco divided by Va)
Reduced DLco/TLco/transfer factor
Anaemia
V/Q mismatch
Interstitial lung disease (e.g. pulmonary fibrosis, pneumoconiosis, sarcoidosis, cryptogenic fibrosing alveolitis)
Reduced alveolar surface space e.g. pneumonectomy, emphysema
Increased DLco/TLco/transfer factor
pulmonary haemorrhage
polycythaemia
Epworth sleepiness scale
Used to diagnosis obstructive sleep apnoea
Score for each section ranging from 0-3, max 24 score
Questions:
- Sitting and reading
- Watching TV
- Sitting still in a public place (e.g., a theatre, a cinema or a meeting)
- As a passenger in a car for an hour without a break
- Lying down to rest in the afternoon when the circumstances allow
- Sitting and talking to someone
- Sitting quietly after lunch without having drunk alcohol
- In a car or bus while stopped for a few minutes in traffic
Interpretation: 0-5 lower normal daytime sleepiness 6-10 normal daytime sleepiness 11-12 mild excessive daytime symptoms 13-15 moderate excessive daytime symptoms 16-24 severe excessive daytime symptoms
Body plethysmography
Lung function test
Volume of lung determined by pressure changes
Used to measure total lung capacity and residual volume
Also determines TGV (thoracic gas volume = amount of air in thorax including non-ventilated areas)
Helium dilution
Lung function test
Volume of lung in ventilated parts determined by giving a known volume of helium to the unknown volume of lung
Under-estimates hyperinflation of lung due to trapped air not able to ventilate e.g. bullae
Peak expiratory flow rate
maximum flow achievable at the beginning of a forced expiration from full inspiration in litres/min
Used to monitor asthma control
T1RF
Type 1 respiratory failure
Associated with hypoxaemia
Ix: normal pH and PaCO2, reduced oxygen, SpO2 <92%
T2RF
Type 2 respiratory failure
Associated with respiratory acidosis
Ix: acidic pH, raised PaCO2, reduced PaO2, SpO2 <92%
If acute, hospital NIV used because reversible cause (weaned over 3d)
If chronic, home NIV used
Invasive ventilation
Endotracheal ventilation (infraglottic)
Supraglottic airways - laryngeal mask airway, OPA, NPA
Cricothyrotomy (emergency access)
Tracheostomy (long term access e.g. ventilator attachment)
FEV1 & FVC
FEV1: volume of air exhaled in 1 second from full
inspiration
FVC: total volume of air exhaled from full inspiration
Bronchodilator reversibility
2.5mg nebulised salbutamol given to assess degree of reversibility of airflow obstruction in spirometry
Positive reversibility if FEV1 increases by 200ml and 12%
Makes asthma more likely
Graves’ Disease
Hyperthyroidism, commonest cause of thyrotoxicosis
Seen in F>M 30-50yrs
Ix: anti-TSH antibodies (90%), anti-TPO(75%), raised T4, low TSH
Px: heat intolerance, sweating, palpitations, pretibial myxoedema (uncommon but specific), diffuse goitre, ophthalmoplegia, exophthalmos, thyroid acropachy (swelling of extremities causing digital clubbing, swelling of hands and feet, periosteal new bone formation), onycholysis
Thyroid scintigraphy shows diffuse, homogenous thyroid with increased radioactive iodine uptake
Tx: carbimazole or propylthiouracil (TPO inhibition), propranolol for symptomatic relief; ablation of thyroid gland surgically or using radioactive iodide then thyroxine to supplement T3/4
Hashimoto’s thyroiditis
Autoimmune cause of hypothyroidism
Associated with other autoimmune diseases e.g., coeliac disease, T1DM, RA, Sjorgen, SLE
Px: weight gain, cold intolerance, low mood, dry skin/hair, constipation, fatigue, menstrual disturbance
Ix: anti-TPO antibodies, low T4
Tx: levothyroxine 50-100mcg od (25mcg in elderly or IHD pts)
Monitor tx response via TSH; check 8-12 weeks after dose change
If pt becomes pregnant, increase dose by 25-50mcg to meet demands of pregnancy
Hyperosmolar hyperglycaemic state
50% mortality as typically newly diagnosed T2DM pt
Features: severe hyperglycaemia, dehydration and renal failure (electrolyte disturbance), and mild/absent ketonuria
hyperglycaemia (>30 mmol/L) causes osmotic diuresis leading to hyponatraemia and hypokalaemia which causes hyperosmolarity (>320 mosmol/kg) hence hyperviscous blood
Px: fatigue, lethargy, N&V, altered consciousness, headaches, papilloedema, weakness, dehydration, hypotension, tachycardia
Develops over days rather than rapidly like DKA
Complications: rhabdomyolysis, VTE, lactic acidosis, hypertriglyceridaemia, renal failure, stroke, cerebral oedema (due to rapid osmolar shifts with rapid fluid replacement)
Tx: fluid replacement 0.9% saline (NaCl) aiming to replace 50% of estimated fluid loss within the first 12 hours
Blood glucose target 10-15mmol/L
Monitoring: serum osmolarity, sodium and glucose levels hourly on graph
Insulin only given if ketonaemia observed (fixed rate IV insulin at 0.05 units/kg/hour)
All should resolve in 72hrs
Digoxin toxicity
Px: lethargy, N&V, yellow-green vision, anorexia, gynaecomastia, AV block, bradycardia
Typically seen with hypokalaemia but, other low electrolytes may precipitate toxicity
Tx: digibind, correct arrhythmia, monitor K+
Multiple endocrine neoplasia
Autosomal dominant inheritance
Functioning hormone-producing tumours
Type 1: MEN1 gene, common px = hypercalcaemia
Parathyroid hyperplasia/adenoma
Pituitary: prolactin or growth hormone
Pancreas: insulinoma, gastrinoma (recurrent peptic ulceration)
Type 2a: RET oncogene
Medullary thyroid cancer
Parathyroid hyperplasia/adenoma
Phaeochromocytoma
Type 2b: RET oncogene Phaeochromocytoma Medullary thyroid cancer Marfanoid body habitus Neuromas
Allergic bronchopulmonary aspergillosis
Allergy to Aspergillus spores
Px: bronchoconstriction (wheeze, cough, dyspnoea), bronchiectasis
Ix: peripheral blood eosinophilia, CXR shows hilar mass with tram lines, positive radioallergosorbent (RAST) test to Aspergillus, raised IgE, positive IgG precipitins, IgM to A.fumigatus
Tx: oral prednisolone, itraconazole (2nd line)
Asthma tx regimen
SABA SABA + ICS SABA + ICS + LABA (MART) SABA + medium ICS + LABA SABA + high ICS + LABA +/- PO LTRA/theophylline PO Prednisolone + above
COPD tx regimen
SABA/SAMA
SABA + LAMA + LABA OR SABA + LABA + ICS (if asthmatic features)
SABA + LAMA + LABA + ICS
Consider addition of PO steroids/theophylline/mucolytic agent/roflumilast
Acute Asthma mx
Nebulised salbutamol 5mg/4h driven by oxygen
IV hydrocortisone OR PO prednisolone
Nebulised ipratropium added if severe or life-threatening
Reassess and repeat salbutamol after 15mins if PEF <75%
IV MgSO4 1.2-2g single dose
ICU admission - IV aminophylline, IV salbutamol, intubation
PO 40-50mg prednisolone for 5-7d once stable
Asthma exacerbation severity assessment
Moderate 50% < PEF < 70% of predicted, normal speech, RR < 25, HR < 110bpm
Severe 33% < PEF < 50% of predicted, incomplete sentences, RR >25, HR > 110bpm
Life threatening PEF < 33% of predicted, normal PaCO2, SpO2 <92%, PaO2 < 8kPa, exhaustion, silent chest, reduced resp. effort, cyanosed, hypotension, bradycardia, arrhythmias, confusion, coma
Near fatal: raised PaCO2 or mechanical ventilation
COPD exacerbation severity assessment
FEV1:FVC < 0.7 (all stages) Mild FEV1 > 80% Moderate 50% < FEV1 < 79% Severe 30% < FEV1 < 49% Very severe FEV1 < 30%
Acute COPD mx
Nebulised salbutamol + ipratropium bromide
Oxygen via venturi mask 28% 4l/min if SpO2 < 88%
IV hydrocortisone 200mg & 30mg PO prednisolone
If no improvement, IV aminophylline, NIV (BiPAP), Doxapram (resp. stimulant), intubation
PO amoxicillin 500mg TDS for 5-7d if infective cause
Bronchiectasis
Permanent dilation of bronchi due to irreversible damage to bronchial wall
Aetiology: post LRTIs, primary ciliary dyskinesia, Marfan’s, cystic fibrosis, ABPA, RA, IBD, hypogammaglobulinaemia, asthma, COPD, Kartagener’s syndrome
Px: persistent cough with sputum, coarse crackles, wheeze
Ix: CXR (tramlining/parallel line shadows due to peribronchial inflammation/fibrosis, signet rings, thick bronchial airways, cystic shadows), sputum sample, bloods (FBC + WBC differential, cultures), spirometry (FEV1:FVC <0.7)
Exacerbation: H. influenzae, S. pneumoniae, S. aureus, P. aeruginosa causing SOB, fever, change in cough/sputum
Long term mx: airway clearance techniques, mucolytic (carbocisteine), nebuliser, long term abx, bronchodilator, prednisolone + itraconazole, surgery
Exacerbation mx: amoxicillin 500mg PO TDS 7-14d if H. influenzae or S. pneumoniae
NYHA classification
New York Heart Association classification of heart failure
Class I: no symptoms or limitations
Class II: slight limitation of physical activity (SOB, palpitations, or fatigue) e.g. when walking to bus stop
Class III: marked limitation of physical activity e.g. moving around house
Class IV: symptoms at rest
Lung cancer features
Persistent cough Haemoptysis Dyspnoea Chest pain Hoarse voice Fixed monophonic wheeze Lymphadenopathy (supraclavicular or cervical) Clubbing Thrombocytosis
Pancoast tumour
Upper lung tumour
Px: cough, hoarse voice (compression of recurrent laryngeal nerve)
Superior vena cava syndrome
Partial obstruction or compression of SVC
Commonly associated with lung cancer
Can also occur with lymphoma, sarcoidosis and aortic aneurysms but less common
Px: SOB, progressive facial or arm swelling, visibly distended veins on neck and chest, headache/migraine
Ix: CXR, CT
Tx: usually resolved once chemotherapy started, prednisolone to decrease inflammatory response to tumour, diuretics to reduce venous return to heart
Small cell lung cancer
Paraneoplastic syndrome causes ADH secretion resulting in hypertension, hyperglycaemia, hypokalaemia, alkalosis, muscle weakness, Lambert Eaton syndrome
Squamous lung cancer
Paraneoplastic syndrome causes parathyroid hormone-related protein secretion resulting in hypercalcaemia, hypertrophic pulmonary osteoarthropathy, hyperthyroidism (due to ectopic TSH), clubbing
Lung Adenocarcinoma
Paraneoplastic syndrome causes gynaecomastia and hypertrophic pulmonary osteoarthropathy
Thyroid cancer
Associated with radiotherapy in UK; radiation exposure leads to I-131 accumulation in thyroid stimulating DNA mutations (may produce an oncogene) causing uncontrolled proliferation of follicular cells
Px: hoarse voice or voice changes
Ix: TFTs (normal), iodine uptake scan (cold appearance)
Thyrotoxicosis causes
Graves disease Toxic multinodular goitre Toxic adenoma (benign) De Quervain's thyroiditis Ectopic thyroid tissue (metastatic follicular thyroid tumour) Iodine excess Amiodarone Levothyroxine excess (high T4, low T3, low thyroglobulin)
Hypothyroidism causes
Primary atrophic hypothyroidism Hashimoto's thyroiditis Iodine deficiency Amiodarone (iodine excess inhibits T4 release) Lithium Post-thyroidectomy or radioiodine tx
Diabetic neuropathy
Sensory neural loss resulting in neuropathic pain
May cause gastrointestinal autonomic neuropathy resulting in gastroparesis (erratic blood glucose control, vomiting, and bloating), chronic diarrhoea, GORD (due to reduced lower oesophageal sphincter pressure)
Mx of neuropathic pain:
1st line = amitriptyline, duloxetine, pregabalin, gabapentin (swap do not add together)
Tramadol for exacerbations
Pain management clinic for resistant pain
Mx for GI neuropathy: metoclopramide, domperidone or erythromycin for prokinetic effects
Neuropathic pain
Mx: 1st line = amitriptyline, duloxetine, pregabalin, gabapentin (swap do not add together)
Tramadol for exacerbations
Pain management clinic for resistant pain
Topical capsaicin for post-herpetic neuralgia
Aortic calcification vs aortic sclerosis vs aortic stenosis
Aortic calcification - calcium deposits on aortic valve
Aortic sclerosis - calcification and thickening of valve cusps without outflow obstruction
Aortic stenosis - impairment of outflow obstruction (narrowing)
Aortic stenosis
Crescendo-decrescendo ejection systolic murmur heard best over the aortic area (2nd intercostal space, R sternal edge) when pt leans forward during expiration
Radiation to carotid arteries
Px: SAD = exertional syncope, angina, dyspnoea
Other features: slow-rising pulse with narrow pulse pressure, non-displaced heaving apex beat, reversed splitting of S2 (P2 before A2), absent or reduced A2 (severe AS)
Aetiology: aortic calcification, bicuspid aortic valve, rheumatic heart disease (rare)
Aortic regurgitation
Decrescendo early diastolic murmur heard best at L sternal edge
Severe disease causes an Austin-Flint murmur (low, rumbling mid-diastolic murmur
Associated signs: Corrigan’s sign, De Musset’s sign, Quicke’s sign, waterhammer pulse, displaced hyperdynamic apex beat
Aetiology: rheumatic heart disease, bicuspid aortic valve, Marfan’s, Ehlers-Danlos, RA, SLE, aortic dissection, HTN, ankylosing spondylitis, infective endocarditis
Px: asymptomatic, HF signs, cardiogenic shock
Hypertensive encephalopathy
Raised blood pressure results in generalised brain dysfunction
Nausea, vomiting, confusion, headache, papilloedema (blurred vision), seizure
Tx: nicardipine, nitroprusside
Meds vasodilate vessels to reduce BP by 10-20% ASAP, action starts within 2mins
