Myocardial Infection (M.I) Flashcards
Fesicular breath sounds are?
Normal breath sounds.
The presenting complaint should be written in the ____ _____
Patients words
Acute coronary syndromes include?
ST-Elevation myocaridal infarction (STEMI) Non ST- Elevation myocardial infarction (NSTEMI) Unstable Angina (UA)
What is the difference between NSTEMI and UA?
In NSTEMI there is occluding thrombus, which leads to myocardial necrosis and a rise in serum troponins or CK-MB.
When does Myocardial infarction occur?
When cardiac myocytes die due to myocardial ischaemia.
What is a Type 1 Myocardial infarction?
Spontaneous MI with Ischaemia due to a primary coronary event, e.g. plaque erosion/rupture, fissuring or dissection.
What is a type 2 MI?
MI secondary to Ischaemia due to increased oxygen demand or decreased supply, such as coronary spasm, coronary embolism, anaemia, arrhythmias, hypertension or hypotension.
What are type 3 MI’s?
Diagnosis of MI in sudden cardiac death.
What are type 4a MI’s?
Diagnosis of MI after percutaneous coronary intervention (PCI). Trop x5 >99th centile)
What is a type 5 MI?
Diagnosis of MI after Coronary artery bypass graft (CABG). Trop x 10 >99th centile
What is the common mechanism to acute coronary syndrome?
Rupture or erosion of the fibrous cap of a coronary artery plaque. This leads to platelet aggregation and adhesion, localised thrombosis, vasoconstriction and distal thrombus embolisation. Thrombus formation, and the vasoconstriction produced by platelet release of serotonin and thromboxane A2 results in myocardial ischaemia due to reduction of coronary blood flow.
In pleural effusion, tracheal deviation is ___. Expansion is ___, the percussion note is ____Tactile vocal phremetis and breath sounds are _____.
Away from the effusion. Reduced Stony Dull Decreased
In pneumothorax tracheal deviation is ___. Expansion is ___, the percussion note is ____Tactile vocal phremetis and breath sounds are _____.
Central in normal - Away in Tension Decreased Hyperresonant Decreased
In Lung collapse tracheal deviation is ___. Expansion is ___, the percussion note is ____Tactile vocal phremetis is _____and breath sounds are _____.
Towards the collapsed lung Decreased or equal Dull Reduced Reduced or absent
In Pneumonia tracheal deviation is ___. Expansion is ___, the percussion note is ____Tactile vocal phremetis and breath sounds are _____. Added sounds are ____ and/or ____
Central Equal or decreased Dull Increased (bronchial breathing) Crackles - Coarse Pleural Rub
In COPD tracheal deviation is ___. Expansion is ___, the percussion note is ____Tactile vocal phremetis and breath sounds are _____. Added sounds are ____.
Central Hyper-inflated, equal, but expands less Hyperresonant Decreased Expiratory polyphonic wheeze
In ABG, you must perform which test, and why?
Allen’s test - to check that hand perfusion is suitable from ulnar artery alone.
What does JACCOL stand for in note taking?
Jaundice, anaemia, clubbing, cyanosis, oedema or lymphadenopathy.
Anosmia is an abnormality of which cranial nerve?
1 - Olfactory
Partial sight/blindness, scotoma, aniscoria and optic disk changes are all signs of a problem with which cranial nerve?
II - Optic
Impaired or lost accommodation reflex, strabismus, diplopia and nystagmus indicate a problem with which cranial nerves?
III - Oculomotor IV - Trochlear VI - Abducens
Impaired or distorted facial sensation, corneal reflex, and weakness of chewing movement indicate a problem with which cranial nerve?
V - Trigeminal
Facial weakness, and loss of or change in taste at the front of the tongue indicate a problem with which cranial nerve?
VII - Facial
A Lower motor neuron lesion does not spare the forehead - true or false?
True. an UMN spares it.
Impaired hearing or deafness, and vertigo indicate a problem with which cranial nerve?
VIII - Vestibulocochlear
A loss of pharyngeal sensation would show a problem with which cranial nerve?
IX Glossopharyngeal
Impaired palate movements indicate a problem with which cranial nerve?
X - Vagus
Weakness of neck movement is suggestive of a problem with which cranial nerve?
XI - Accessory
Dysarthria and chewing/swallowing problems indicate a problem with which cranial nerve?
XII - Hypoglossal
What three signs would you see in the face of a px with bells palsy?
smooth forehead eyebrow droop Droop of the corner of the mouth
What is the maximum length for a normal PR interval?
200 ms
What is the maximum length of time for a normal QRS segment?
120 ms
What is the maximum length of time for a normal QT segment?
450ms
Two signs of Atrial fibrillation on ECG?
No P-waves Rhythm-irregularly irregular
What is paroxysmal atrial fibrillation?
Atrial fibrillation present for less than seven days
What is persistent AF?
Present for > 7 days - may be reverted back to sinus rhythm
What is permanent AF?
As name suggests, cannot be reverted back to sinus rhythm.
Which two drugs could you use to control rhythm in AF?
Flecanide Amiodarone
Which drugs could you use to control RATE in AF?
Beta blockers, calcium channel blockers (diltiazem, verapamil), digoxin
A saw toothed ECG baseline is indicative of what?
Atrial flutter P waves at rate of approx 300 Usually with 2:1 block, but other blocks can be seen. Carries a sim. stroke risk to AF.
What causes atrial flutter?
Re-entry circuit within the right atrium.
Bifid P waves indicate what?
Left atrial hypertrophy.
Name a cause of left atrial hypertrophy.
Mitral stenosis, aortic stenosis, mitral regurgitation
Short PR interval, sinus, Broad QRS with a slurred upstroke of the Q wave (this is otherwise known as a delta wave) on ECG is a sign of what?
Wolff-Parkinson- White Syndrome. Due to an accessory pathway.
An ECG showing increased R wave in V4-V6 and increased S wave in V1-V3 is indicative of what?
Left ventricular hypertrophy
What qualifies as ST elevation?
Elevation of the ST segment above the baseline. To qualify, should be more than 2 small squares above baseline in chest (precordial) leads, or more than 1 small square above baseline in limb leads.
What can ST depression indicate?
NSTEMI Unstable angina
Anterior STEMi results from occlusion of which artery?
Left anterior descending
The lateral wall of the left ventricle is supplied by which arteries?
Left anterior descending and circumflex arteries.
In lateral STEMI, what would you expect of the T waves?
Tall/hyperacute
In an inferior STEMI, which leads would you expect ST elevation in?
II, III, and AVF.
Which artery is occluded in an inferior STEMI?
Posterior interventricular artery
Inferior MI’s account for what percentage of all Myocardial infarctions?
40-50%
What may cause widespread ST elevation throughout the precordial and limb leads?
Pericarditis
Name some causes of pericarditis.
Dressler’s syndrome (4-6 post MI) Infection Immune or drug related
What is prolonged QT interval, and what risk does it pose?
Delayed Repolarisation of the heart following a heartbeat, increasing the risk of torsades de pointes.
What is the treatment for prolonged QT long-term?
implantable cardioverter-defibrillator
What does Hyperkalaemia cause?
Prolonged PR interval Broad and bizarre QRS complexes *PEAKED T WAVES - MAY LOSE P WAVE*
QRS positive in leads I and AVL, negative in leads II and AVF - what is this?
Left axis deviation
What causes left axis deviation?
Left ventricular hypertrophy Left bundle branch block
QRS positive in leads III and AVF, and negative in leads I and AVL. What is this?
Right axis deviation
Name some causes of Right axis deviation
Right ventricular hypertrophy Pulmonary embolism COPD
Pulseless electrical activity - will a shock help?
NO!
Asystole - “flat lining”. Besides making sure everyone is watching how cool you’re about to be, what do you do?
This is a non-shockable rhythm Give adrenaline (1mg) once IV access and then every 3-5 minutes following. After all, YOLO.
VF and VT are both what?
Shockable rhythms
With reagrds to the JVP, what is the A wave?
This is first peak. It is caused by back pressure in the Jugular vein during atrial contraction.
With regards to the JVP, what is the X wave?
The drop in pressure, caused during atrial relaxation.
With regards to the JVP, what is the C peak?
A small increase in pressure (small pressure wave), caused by closure of the tricuspid valve.
With regards to the JVP, what is the X prime wave?
This is a pressure drop, caused by the right Ventricular contraction.
With regards to the JVP, what is the V wave?
Venous filling with a closed tricuspid valve, causing an increase in pressure.
With regards to the JVP, what is the Y descent?
A drop in venous pressure, as a response to atrial emptying.
What is the JVP?
A measurement of the pressure in the internal jugular vein, as an extension of the R atrium
What would cause a decrease in JVP in a normal heart?
Atrial relaxation Tricuspid valve open
What does an a wave represent?
Atrial contraction
Just preceding the C wave (JVP), what happens?
Closure of tricuspid valve due to ventricular systole.
Specifically, what does the X wave represent?
Atrial relaxation
What is the y descent?
Blood from the atrium, going to the ventricle.
What is the V wave?
Specifically, filling of the right atrium. Think “Villing!”
What is the order of wave forms in the JVP?
A,C,X,V,Y
What change in the JVP would you expect to see in pulmonary hypertension (Tricuspid stenosis, pulmonic stenosis)
Increased/Higher a wave. May also see lessening of the Y wave
What changes in JVP might we see in AF?
There would not be an a wave There would be no x descent (no atrial relaxation)
What would you see in JVP with Complete heart block (3rd degree heart block/VT)?
A Cannon a wave - a huge increase in the a wave, very high on physical examination. This is due to atria contracting on a closed Tricuspid valve. It’s due to AV dysynchrony.
What do you see in the JVP if a patient has tricuspid regurgitation?
A CV wave. This is a lack of the X descent, instead having a positive wave from C to V.
What happens to JVP in tamponade?
Reduced atrial relaxation, causing loss of y descent. This is because when blood leave R atrium to R ventricle, external fluid shifts and compresses R atrium, resulting in loss of Y descent.
What happens to JVP in constrictive pericarditis?
Constrictive paricarditis is a fibrous “wall” that prevents expansion of right ventricle. This means that the Y descent is a very sharp, and deep y descent, quickly returning to baseline. This is sometimes known as a square root descent.
Sphenoid sinus drainage and posterior ethmoid drainage meet where?
The Sphenoethmoidal recess
Where does the frontal sinus drain to?
Anterior Hiatus semilunaris
Where do the anterior ethmoid air cells drain into?
The Ethmoid bullae
Where does the maxillary sinus drain to?
Hiatus semilunaris
A 32 year old man presents to his GP with a 2 day history of dyspnoea and retrosternal chest pain which came on gradually. No history of trauma or abnormal exertion, and the patient has never been ill before. The pain is stabbing in quality, radiates to the neck and left shoulder, is relieved by sitting upright, and is made worse by lying flat and coughing.
Pericarditis. It may seem a bit like reflux, but it’s retrosternal, and stabbing in quality.
A 35 year old man has been brought to A&E by ambulance having collapsed at work. His chest pain began 40 minutes ago and has worsened gradually. It is now in a tight band across his chest and radiates to his neck but not his arms. On examination, he is grey, sweaty and short of breath with a pulse of 40 beats per minute. What do you suspect?
Myocardial Infarction
A 67 year old hypertensive obese man brought to A&E having collapsed whilst moving a cupboard. Chest pain began suddenly when lifting is central, severe, burning and tearing in quality, and radiates through to his back and up to his neck. BP 190/120 Right arm, and 160/90 left arm. What did you suspect?
Dissecting thoracic aortic aneurysm
A 68 year old female presents with heavy central chest pain radiating to her left arm which began an hour ago and woke her from sleep. The pain is similar to, but more severe than her usual angina, and her GTN spray has not relieved it. She is admitted to hospital where serial troponin T tests are negative. What is this?
Unstable angina.
A 38 year old female with SLE presents to A&E with a 24 hour history of sharp, right sided chest pain which is made worse by deep inspiration. She is not short of breath. She suffered a miscarriage five days ago, necessitating overnight admission to hospital for evacuation of retained products of conception. Since leaving hospital her left leg has become swollen, warm and tender to palpation. What is this?
This is pulmonary embolism. Loads of thrombotic risk factors.
Name the two branches of the Opthalmic division of the trigeminal cranial nerve (CNVI).
The frontal nerve Nasociliary nerve
Name the two branches of the frontal nerve
Supraorbital nerve Supratrochlear nerve
Name the two branches of the Nasociliary nerve
Anterior ethmoidal nerve Posterior ethmoidal nerve
Which muscle does the Frontal nerve sit on the superior aspect of when crossing the orbit?
IT crosses the superior aspect of levator palpebrae superioris muscle.
Which three nerves are parts of the maxillary division of the trigeminal cranial nerve (CN V2)?
The maxillary division gives off the zygomatic nerve, then two pterygopalatine nerves.
Sensory fibres from the pterygopalatine ganglion supply the nose, paranasal sinuses and palate as:?
Pterygopalantine nerves Nasopalatine nerves Greater and Lesser palantine nerves
When does the maxillary division become the infraorbital nerve?
As it enters the infraorbital canal. Just before this canal, it gives off the posterior superior alveolar nerve.
Which two divisions of infraorbital nerve exit the infraorbital canal along its route?
Middle superior alveolar nerve Anterior superior alveolar nerve
What is the Pterygopalantine ganglion?
It’s a knot of nerve fibres found in the pterygopalantine fossa. It allows parasympathetic from the greater petrosal nerve of the facial nerve and sympatheti fibres from the deep petrosal nerve of the internal carotid plexus to pass along fibres of the Maxillary branch of the trigeminal nerve (CN VII).
What do the sympathetic and parasympatheitc fibres of the pterygopalatine ganglion control?
Lacrimation Nasal secretions Nasal airflow
Lacrimation is controlled by?
Zygomatic nerve
Nasal secretions are controlled by which nerves?
Pterygopalantine, nasopalantine and greater palantine nerves.
What is nasal airflow controlled by (nerve)?
It is controlled via the pterygopalantine nerve to turbinates on the lateral nasal wall.
Which nerve supplies the frontal sinuses?
Branches of the supraorbital nerves (CN V1)
Which nerves supply the Ethmoid sinuses?
Branches of the nasociliary nerves (anterior and posterior ethmoidal nerves)