PACES Flashcards
What are the indications for a VATS
Vats is a video assisted thoracoscopic surgery and is used primarily for pulmonary, mediastinal, and pleural pathology.
Indications include biopsy, wedge reseciton, lobectomy, bullectomy, pneumonectomy as well as treatment for recurrent pneumothorax like pleuradehesis and recurrent effusions
VATS vs Thoracotomy
VATS has a typical 3 pronged scar - but can be 2 or 1.
Thoracotomy is usually lateral and transverse scar across the anterior/posterior chest wall.
Benefits of VATS =
Quicker recovery, less pain, shorter hospital stay, quicker return to chemo, older people may qualify vs thoracotomy.
Thoracotomy may be surgically necessary and VATS has a higher pneumothorax rate post operatively vs Thoracotomy. (5% vs 1%).
Respiratory Causes of Clubbing
Lung cancer (all except small cell)
Chronic suppurative lung disease (cystic fibrosis, bronchiectasis, lung abscess, empyema)
Pulmonary fibrosis
Classify Lung Cancer
Lung Cancer can be generally grouped into small cell or non small cell lung cancer.
Non small cell is much more common and has 3 histological groups.
- Squamous Cell (Most common) Associated with smoking. Decent prognosis. Central Tumour (PTH secretion- high Ca)
- Adenocarcinoma (20%, Non smokers, Asbestos) is a peripheral tumour
- Large Cell (Central and Bad Prognosis)
Then Small cell lung Ca has the worst prognosis:
- Small cell lung cancer (30%) has a poor prognosis due to the stage of disease at presentation being advanced. (SIADH and Cushings)
Biological vs Mechanical Heart Valves
Heart Valve Replacement is still an important therapy despite the decline in rheumatic heart valve disease. Most commonly replaced valves are the aortic and mitral and the options are broadly biological (bovine or porcine) and Mechanical.
The benefits of biological valves is that the patient won’t require life long anticoagulation. However, these are more prone to mechanical damage over time and so have a much reduced life span of 10-15 years.
Mechanical valves are much more durable but require life long anticoagulation.
(Bileflet valves most common and Ball and Cage rarely used due to need for higher INR and more clot formation).
What is a paraparesis?
Paraparesis is bilateral weakness in the lower limbs
Paraparesis suggests at least a meylopathy (spinal cord issue) of the thoracic level. However, if you’ve only done the legs, you’d need to do the arms to ascertain if this was cervical myelopathy. You would be able to then find a level and also have normal cranial nerves.
What would you expect to find in cervical meylopathy?
Cervical meylopathy is disease of the spinal cord at the level of the cervical spine. My examination findings would reflect this with likely upper motor neurone signs througout the arms and legs - notably, spasticity, hyperreflexia, motor loss +/- sensory loss.
I would be expecting to be able to find a sensory level.
What are the differentials for a meylopathy?
Compressive:
Disk Herniation, tumours - intra or extra medullary - primary or secondary. and spinal stenosis
Autoimmune: MS, Lupus and sarcoidosis
Infectious: HIV / Varicella
Nutritional: Vitamin B12 / Copper
Hereditary: Genetic causes of spastic paraperesis
What is paraplegia
Total loss of movement in the legs
Tetraparesis
Loss of motor and likely sensory in all 4 limbs - pointing to a cervical spine lesion
brown sequard syndrome findings and definition
Loss of motor on the same side of the lesion
Loss of vibration and fine touch on the same side of the lesion
Loss of temperature and pain on the contralateral side of the lesion
i know that the majority of fibres decussate in the medula - like in normal stroke. So I know that the lesion will be ipsilateral in spinal cord disease.
What is bss? It is hemisection of the cause causing a partial myelopathy with ipsilateral motor and fine touch loss and contra lateral pain and temperature loss
Peripheral stigmata of chronic liver disease?
Jaundice
Asterixis (Liver flap)
Palmar Erythema
Clubbing
Jupitons Contracture
Echymosis
Signs of decompensation
Encephalopathy
Jaundice
Ascites
Coagulopathy
Differentials of Chronic Liver Disease
Most common cause of liver disease is alcoholic liver disease.
Next I would like to think about Infective causes like Hepatitis B, and C and also consider sending an HIV test. Tattoos and risk taking behvaiour like IVDU may be relevant risk factors for this
The Next cause to consider is MASH metabolic associated steotohepatitis (Formally Non Alocholic). I’d be looking to take the BMI, look for other risk factors like evidence of hypercholesteromaemia, blood pressure and blood sugars.
Following this I’d be thinking about immune causes. These would notably be autoimmune hepatitis, primary biliary colangitis and primary sclerosis cholangitis which is associated especially with IBD.
Following on from this, I would think about Iron and copper storage disorders including Haemochromatosis and Wilsons and I’d also want to conisder Alpha 1 antitrypsin deficiency if there was evidence of Emphysema.
Malignancy would also be important to consider. This could be primary or secondary.
I’d also consider various drugs - notably amiodarone if cardiovascular patient and also methotrexate
Investigations of chronic liver disease
FBC - look at anaemia / acute hb drop and also platelets - increased sequestration in portal hypertension.
Next would be Renal function.
Notably I would want to check if the patient is heading to renal failure. Are they dehydrated. Is there evidence of hyponatraemia due to the RAAS activation and is there a high urea (we’d expect low in CLD) which would therefore perhaps be suggestive of a GI bleed.
Following this I would look at the LFTs
Notably, is the bilirubin raised
Is the hepatic enzymes raised and what kind of picture is it - cholestatic suggesting a biliary cause or hepatic. I could also look at the AST: ALT ratio at this point.
Then I’d want to check the synthetic funciton of the liver. Notably looking at the ablumin and the clotting screen for the patient.
Following this my investigaitons would be more focused on cause. For this I’d want to send things like Auto antibody screens, immunoglobulins, amylase or lipase, iron studies including tranferrin saturations and ferritin. Copper and caerulosplasmin as well as viral hepatitis screens. Tumour markers may also be appropriate and I’d send the majority of these tests off in a NILS - non invasive liver screen.
Following this, we can consider imaging. The primary test I’d go with is an US due to the low radiation and good views we can achieve of the liver. Notably, we’d be able to assess for hepatosplenomegaly and the presence of ascites. Following this, we could also try to view the gall bladder.
Other radiology to consider would be a fibroscan in the context of cirrhosis as a differential as well as CT if our initial radiology didn’t find anything.
At this point in the patients work up I’d expect the gastroenterology team to be involved and we’d consult them with regards to further investigations, notably a biopsy and if this was appropriate. Dependent on the aeitiology and presence of complicaitons of Chronic liver disease, there may be a scope for endoscopic investigations like OGD, MRCP as well as colonoscopy.
Causes of a sensory peripheral neuropathy?
Metabolic causes
Commonest is diabetes
Hypothyroidism
Vitamin deficiencies. B12, B6 and B1
Toxic Causes
In this I could put alcohol at the top of my list. Then i’d think about chemotherapy agents including platinum based drugs and vincristine. Other drugs like antibiotics (Ethanbutol, antivirals)
Nitrous oxide would be an increasingly common cause from illicit drug use.
Other causes i’d think of would be immune mediated causes, in systemic disease like GPA or rheumatoid arthritis.
Or Neurological diseases like CIDP and Gillan bare.
Infection like HIV
Sensory Neuropathy Acronym
DAM IT BICH
DIABETES
Drugs/Toxins:
Heavy Metals, Vincristine, Nitrofurantoin
Alcohol
Metabolic
Diabetes, hypothyroidism, uraemia
Infection/post infection: HIV/Lymes/GBS (usually predominantly motor)
Tumor: Paraneoplastic like Lung or Myeloma / MGUS (Think of grandad)
B - B1, B6, B12
Idiopathic
Connective tissue diseases and vasculitis
Hereditary Causes
Purely motor peripheral neuropathy
GBS
Diabetes
Hereditary motor and sensory neuropathy
Rare causes like acute intermittent porphyria, lead poisoning and diptheria
Deformity and condition?
Rheumatoid arthritis
Boutonniere Deformity
Deformity and condition?
Rheumatoid Arthritis
swan neck deformity
Deformity and condition?
Heberden node of Osteoarthritis
Heberden is distal IP
Boucharrds is proximal
Deformity and condition?
Boucharrds node is proximal
Probably some heberden nodes distally here too of OA.
Mitral Regurgitation signs other than murmur
Signs of severity?
REMEMBER - MITRAL VALVE IS IN THE LA - AF, LV dilatation / failure.
Murmur
Pan systolic Murmur Apex/ going to the axilla. louder on Exhaled.
Other signs:
AF
Displaced Apex Beat
Signs of severity
Displaced Apex Beat
LV Failure
Wide Split S2
Left venticular dilatation indicated by a displaced apex beat
signs of left ventricular failure
Wide split S2 - this is because Aortic (A2) is premature due to half the blood going into the LA through regurgitant valve
Signs of Aortic stenosis other than murmur
Signs of severe Aortic Stenosis
Aortic Stenosis is a ejection systolic murmur heard loudest in the aortic region which radiates to the carotids
Signs other than the murmur are
Slow rising pulse
Narrow pulse pressure
Heave (undisplaced) due to hypertrophy of the left ventricle
Signs of Severity include
timing of the ejection systolic murmur is more delayed in increasing severity
soft s2
Narrow or reverse split S2 - A2 is increasingly delayed
Apex beat Displaced due to dilatation of the ventricle
Gallavardin phenomenon
radiation to apex of AS to mimic MR
Differentials of an ejection systolic murmur
Aortic Stenois
Pulmonary Stenosis
Aortic sclerosis - calvified valve without restricition on function - no radiation to carotids and normal pulse pressure.
Subvalular (HOCM with LV outflow tract obstruction)
Supravalvular like Williams syndrome lesions
Flow Murmur.
Causes of Aortic Stenosis
Most common is Degenerative disease
Other acquired causes include calcification accelerated by CKD or Severe Pagets.
Rheumatic Fever - normally mitral involvement
Infective endocarditis
Congential casues: Valvular - bicsupid aortic valve.
Fixed Split S2
Think ASD - there is communication between R and L side of the heart allowing for pressures to normalise on inspiration and expiration
What is reverse splitting of S2
S2 if split should increase with inspiration
This is because Aortic valve shuts before Pulmonary. Then as you inspire, the R sided volume increases and so P takes longer to shut. This increases the splitting.
However, reverse splitting is where the S2 splitting increases on expiration.
This would mean that the Aortic Valve is delaying to the point where it is shutting last. This is seen with LV outlet obstruction like Aortic Stenosis or LBBB.
Causes of Hepatomegaly
CCF
TR
Malignancy
Lymphoma
Malaria / Leishmaniasis and hepatitis
Scoring system for acute alcoholic hepatitis
Maddrey’s discriminant function test. PT and Bilirubin. if > 32 for Steroids as high mortality rate.
Treatment of Alcoholic hepatitis = supportive. Nutrition, BO, fluids, infection treatment, abstinence from alcohol and steroids if Maddrey’s > 32
AScites in the absence of stimata of Chronic liver disease?
Think Malignancy. Palpate for the spleen and for lymphadenopathy - cervical / axillary and offer others…
