OSCE medical Flashcards
What are the types of AF?
There are three types of AF: paroxysmal, persistent and long-term persistent.
• Paroxysmal AF - symptoms start suddenly and resolves by itself within 7 days of no treatment. (episode may last even a few seconds only). Anticoags may still be prescribed to prevent stroke.
• Persistent AF - episodes are continuous and last more than 7 days. Beta blockers and calcium channel blockers are usually prescribed to slow down the heart rate (rate control). Cardioversion and ablation may also be offered.
Long term persistent AF (permanent AF) - This is the term given when medication, catheter ablation and cardioversion do not work. It is resistant to treatment. This is called long-term persistent AF and doctor and pt usually agree to still receive rate control and anticoag meds.
What medications are used for AF?
The aims of treatment for those with AF are to
1. Reduce the risk of stroke
2. Control any symptoms of AF
The need for coagulation is calculated using CHA2DS2-VAS score:
HASBLED score is used to identify the risk of a major bleed. Use this tool to also identify if the risks of anticoags outweigh the benefits.
Management of stroke risk is same no matter what AF you have since research suggests that stroke risk is the same even if you have paroxysmal AF vs permanent AF. If the cause of paroxysmal AF is not due to modifiable factors such as excessive alcohol or energy drink use (caffeine) then consider treatment.
Warfarin and Dabigatran are anticoags that are commonly used in NZ.
Rate and rhythm control is also used, where we lean more towards rate control due to simpler medicine regimens. (they both equally prevent strokes). However rhythm control can be used when AF causes HF or symptomatic paroxysmal attacks.
First line is a beta blocker (OTHER THAN SOTALOL (this can cause arrythmias)). E.g. metropolol,
A calcium channel blocker that one can use (say if they have asthma) are diltiazem or verapamil (BUT NOT IN PTS WITH less than 40% left ejection fraction (HF) due to negative inotropic effects (less strong contractions))
What is the CHADSVAS score?
Congestive heart failure HTN Age over 75 (2) Diabetes Stroke/TIA (2) Vascular disease Age over 65 Sex (female)
What are the investigations you need to order to diagnose AF?
- ECG - can show any causes for the AF such as MI or left ventricular hypertrophy. The QT interval may also need to be assessed before starting some medications
- Bloods - TSH to exclude hyperthyroidism, LFTs to exclude excessive alcohol use and prior to starting anticoags, FBC to exclude anaemia and infection as a contributor to AF, electrolytes to exclude any metabolic abnormalities, HbA1c to exclude diabetes as cause
- Echo - this is used to assess thrombolytic risk in those with poor LV function and which calcium channel blocker to use.
Sometimes with paroxysmal AF can use a holter monitor.
What are the differentials for palpitations?
- AF
- Anxiety/panic attack
- Hyperthyroidism related hypermetabolic state
- VT
Excessive alcohol or caffeine use
How to differentiate between types of cyanosis?
Peripheral cyanosis causes cold blue hands
Central cyanosis causes blue lips and tongue and when sever can cause blue hands but this is usually warm.
What are some causes of central cyanosis?
• Hypoxic lung disease
• Cyanotic congenital heart disease such as a right to left cardiac shunt.
Methaemalbuminaemia - caused by intravascular hemolysis.
What are some causes of peripheral cyanosis?
- Raynaud’s syndrome
- Peripheral vascular disease
- Heart failure
- Shock
What are the differentials for an irregularly irregular pulse and how to identify which?
• AF
• Ventricular ectopic beats (VEB’s)
• Complete HB with ventricular escape beats
To differentiate between AF and VEB’s you can do an ECG and look for sinus rhythm. And for vebs there will be random qrs complexes not necessarily followed after a p wave. If there is no ECG available, you can exercise the pt and if the irregularly irregular pulse dissapears it is VEB, if it doesn’t it is AF.
What are causes of AF?
• Excessive alcohol
• Previous mi
• Rheumatic heart disease
PE/pneumonia
Causes of absent radial pulse?
• Congential (usually bilaterally)
• Artherosclerotic disease in subclavian artery
Previous artery line
coarctation of the aorta
What are some causes of a non-palpable apex beat?
• Something in between your hand and the heart - fat (obese pt), air (pneumothorax), fluid (pleural effusion, hemothorax, pericardial effusion)
The apex is not in its normal position - displaced usually in LHF, or dextrocardia
What are the 5 causes of cardiac failure?
- Pump failure - ischemaic heart disease, cardiomyopathy, constrictive pericarditis, arrythmia, negative inotropes/chronotropes.
- Excessive preload - regurgitant valvular disease (MR/AR), volume overload (IV fluids, renal failure)
- Excessive afterload - AS, HTN
- Isolated RHF - cor pulmonale which is secondary to chronic lung disease, pulmonary HTN (primarye.g. COPD/due to MS)
- High output cardiac failure (which is rare) - due to pregnancy, anemia or hyperthyroidism.
What are things you may see on CXR for a person with LHF?
A. Alveolar edema B. Kerley B lines C. Cardiomegaly D. Upper lobe venous Diversion E.Pleural Effusion
What are some causes of pericarditis?
• Viral (coxsackie) • Bacterial/fungal infection • Post MI • Dressler's syndrome (2-10 weeks post MI) • Malignancy SLE/RA/scelroderma
How to describe a heart murmur?
TIP PQRS Timing Intensity Position hear loudest Position that you put patient in that you heard it loudest Quality Radiation to carotids? Systemic features - other stuff like water-hammer pulse etc.
Example of describing AS
• Ejection systolic murmur
• Heard loudest over aortic area
• Radiates to carotid arteries
• Loudest on expiration and sitting forward
• Slow rising pulse with narrow pulse pressure
Non-displaced, heaving apex beat (if present indicates left ventricular hypertrophy)
Example of describing AR
Decrescendo early diastolic murmur
Heard loudest at left sternal edge (the direction that turbulent blood flows) – sometimes heard loudest over the aortic area
Collapsing pulse (i.e. water hammer pulse with wide pulse pressure)
Displaced, hyperdynamic apex beat
Example of describing MR
Pansystolic murmur
Heard loudest over mitral area
Radiates to axilla
Heard loudest using the bell of the stethoscope
Loudest on expiration in the left lateral decubitus position
Displaced, hyperdynamic apex beat
Example of describing MS
Low-pitched, rumbling mid-diastolic murmur with an opening click (click heard in mid-diastole when the mitral valve opens)
Heard loudest over the apex
Loudest in left lateral decubitus position on expiration
Low-volume pulse which may be irregularly, irregular (atrial fibrillation is common in mitral stenosis)
Malar flush
Right sternal heave
What are some causes of cranial nerve palsy?
• Diabetes bc of microangiopathy of the vasa nevorum • Stroke • SLE • Sarcoidosis • Tumour • MS Vasculitis
What are some differentials for CN I palsy?
• Trauma (base of skull fracture)
• Front lobe tumour
Meningitis
What are some differentials for CN II palsy?
Monocular blindness - MS, giant cell arteritis
Bitemporal hemianopia - pituitary tumour, internal carotid artery aneurysm
Homonymous hemianopia - anything after the optic chiasm, tumour, stroke, abscess
What are some differentials for CN III palsy?
• Partial loss of movement (means with pupils spared) - diabetes because microangiopathy does not affect the parasympathetic nerves.
Complete loss of the CN III - raised intracranial pressure with tentorial herniation and posterioir cerebral artery aneurysm.
What are some differentials for CN IV palsy?
Single palsy is rare. Get pt to look down and see the blood vessel move medially. Likely due to orbit trauma.
What are some causes for CN V palsy?d
• Trigeminal neuralgia
• Acoustic neuroma
Herpes zoster
What are some differentials for CN VI palsy?
Lateral rectus muscle affected.
• Skull fracture involving petrous temporal bone
• Nasopharyngeal carcinoma
Raised intracranial pressure
What are some differentials for CN VII palsy?
LMN (forehead affected) • Bells palsy • Malignant parotid tumour • Herpes zoster UMN (forehead spared) Stroke/tumour
What are some differentials for CN VIII palsy?
• Excessive noise exposure levels
• Meniere’s
• Frusemide
Gentamicin
What are some differentials for CN IX, X, XII palsy?
LMN (bulbar palsy) • Motor neuron disease • Diptheria • Polio • Gullian-barre syndrome • Syringobulbia UMN (psuedobulbar palsy) • Motor neuron disease • Bilateral strokes MS
What will an acoustic neuroma or meningioma usually cause?
• Loss of corneal reflex (trigeminal)
• And facial nerve - movements of face and loss of sense of taste
• Vestibulocochlear nerve - loss of hearing
• Glossopharyngeal nerve - movement of tongue
CN 5, 7, 8, 9 and 10
How will Paget’s disease of bone present?
Narrowing of the bony foramina of the skull, which causes impingement of nerves.
5, 7 and 8. Trigeminal, Facial and Vestibulocochlear.
What is Gardenigo syndrome and what CNs does it affect?
A complication of otitis media where the petrous temporal bone is affected.
CN 5 and 6 are affected.
What is syringobulbia and what CNs does it affect?
Syringobulbiais a neurological disorder characterized by a fluid-filled cavity (syrinx) within the spinal cord that extends to involve the brainstem (medulla). • Causes bulbar palsy - CN 9, 10, 12 • CN 8 - vertigo and nystagmus • CN 5 - facial pain and sensory loss May also have Horner's syndrome
UMN cranial nerve signs?
• Facial nerve palsy with forehead sparing because there is bilateral cortical representation of the forehead
• Brisk jaw jerk reflex
Pseudobulbar palsy
What are some differentials for ophthalmoplegia?
• Myasthenia gravis
• Cranial nerve palsy
• Grave’s disease
Wernicke’s encephalopathy
What does it mean if Rinne’s test in left ear shows bone conduction to be louder than air and Weber’s test to show that it lateralizes to the left ear?
Conducting hearing loss in the left ear
What does it mean if Rinne’s test in left ear shows bone conduction to be louder than air and Weber’s test to show that it lateralizes to the right ear?
Complete sensorineural loss in the left ear
What does it mean if Rinne’s test in both ears shows air conduction to be louder than bone and Weber’s test to show that it lateralizes to the left ear?
louder than bone and Weber’s test to show that it lateralizes to the left ear?
Sensorineural hearing loss in the right ear
Causes of interstitial lung disease? Aka pulmonary fibrosis?
• Idiopathic
• Inhaling antigens - bird owners, farmers
• Inhaled irritant - asbestos, coal workers
• Associated with systemic disease - SLE, RA, systemic sclerosis,
Drug induced - methotrexate, amiodarone
What are some differentials for horner’s syndrome?
• Central lesion/stroke/syringobulbia
• T1 root - neurofibroma tumour
• Brachial plexus - pancoast tumour, trauma
• Neck - tumour, carotid artery aneurysm
Can be associated with cluster headaches
Causes of a raised hemidiaphragm?
- Phrenic nerve palsy
* Thoracic surgery/trauma/malignancy
Reasons for having pneumonectomy/lobectomy?
○ Lung cancer
○ Bronchiectasis
Trauma
What are some signs of hyperinflation?
• Reduced circosternal distance • Increased AP diameter • Intercostal indrawing • Apex beat not palpable Hyper resonant percussion note.
What does bronchial breathing sound like?
• Loud and blowing
Audible gap between inspiration and expiration
Differential for bibasal crepitations?
• Pulmonary edema
• Interstitial lung disease
• Bronchiectasis
Cystic fibrosis
Differences between transudate and exudate causes in pleural effusions:
Transudate is less than 30g protein per litre. Causes: • Hypoalbuinemia • Volume overload • Heart failure Exudate is more than 30g protein per litre. Causes: • Infection (TB, pneumonia) • PE (infarction) • Inflammation (SLE, RA) Malignancy
What signs will be shown for consolidation on examination?
• No mediastinal shift
• Dull to percussion
• Bronchial breath sounds (since solid transmits sound better than air)
Increased vocal resonance
What signs will be shown for collapse on examination?
• mediastinal shift towards
• Dull to percussion
• Decreased breath sounds
Decreased vocal resonance
What signs will be shown for effusion on examination?
• mediastinal shift away if bug
• Stony dull to percussion
• Decreased breath sounds
Decreased vocal resonance
What signs will be shown for pneumothorax on examination?
• mediastinal shift away if tension
• resonant to percussion
• Decreased breath sounds
Decreased vocal resonance
What signs will be shown for pneumonectomy on examination?
• mediastinal shift towards
• dull to percussion
• Absent breath sounds
Absent vocal resonance
Differentials for a LIF mass
kidney transplant ovary loaded colon diverticular mass colorectal carcinoma
Differentials for a RIF mass
kidney transplant ovary appendix mass crohns disease (inflamed, matted small intestine) caecal carcinoma
differentials for bilateral enlarged kidneys
Polycystic kidney disease (autosomal dominant)
bilateral hydronephrosis
amyloidosis
differentials for unilateral enlarged kidneys
unilateral hydronephrosis
renal cancer
renal cyst
spleen vs kidney on examination
spleen has a notch spleen moves up and down with each breath kidney is ballotable percussion note is resonant over kidney your hand can get over the kidney
what are some indications for dialysis in those with chronic renal failure
progressive decline in renal function - egfr usually less than 15 ml/min
renal bone disease
pericarditis
ureamia despite conservative treatment
volume overload despite fluid restriction and diuretics
hyperkalemia despite treatement
what are some components of renal bone disease?
vitamin d deficiency - causes decreased calcium absorption in the gut - causes osteomalacia.
hyperparathyroidism due to the altered physiological response to parathyroid hormone - increased phosphate in blood due to increased bone resorption, seen especially on hand xray
osteoporosis - chronic disease
osteosclerosis - prolonged hyperparathyroidism
complications of hemodialysis
hypokalaemia
hypotension
hypovolemia
cerebral edema due to disequilibration syndrome
side effects of immunosuppressive drug therapy post kidney transplant
cushingoid features - moon face, acne, hirsutism, thin skin bruising purple abdominal striae central obesity muscle wasting
difference between RHF and LHF
sx of RHF: distended neck veins raised JVP hepatomegaly splenomegaly enlarged and congested kidneys pitting ankle edema ascites all of these are due to systemic circulatory congestion.
LHF sx: pulmonary edema coughing, frothy sputum SOB orthopnea cyanosis
WHat are some causes of RHF?
LHF
cor pulmonale (pulmonary HTN) often due to COPD
tricuspid regurgitation
What are some causes of LHF?
HTN MI mitral valve incompetence aortic valve incompetence coronary artery disease
warfarin vs dabigatran
warfarin requires INR mintoring but can be given in renal failure. It has lower risk of GI bleeding and in causing GI side effects than dabigatran. warfarin however interacts with a lot of drugs such as SSRI.
Dabigatran is more conveniant to take as less monitoring - except must monitor renal function every 12 months as cannot be given in renal failure. It has higher risk of GI bleeding and cannot be given for prosthetic heart valve pts.
examples of obstructive vs restrictive lung disease and the difference
obstructive is when the pt cannot exhale fully out due to damage and narrowing to airways, which is why at the end of an exhale an abnormal amount of air is left in lungs (hyperinflation) eg copd, asthma, bronchiectasis
restrictive is when pt cannot fully inhale air as lungs are restricted from fully expanding usually due to stiffness in lungs, stiff chest wall, weak muscles or damaged nerves e.g. idiopathic pulmonary fibrosis, obesity, scoliosis, neuromuscular disease
how to differenitate from obstructive to restrictive via spirometry?
FEV1/FVC will be decreased in obsturctive lung disease. FEV1/FVC will be normal or increased in restrictive lung disease 1
What is the surgical sieve?
VITAMIN D vascular inflammatory/infective trauma autoimmune metabolic iatrogenic/idiopathic neoplastic degenerative
