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PACES Station 1 Flashcards

1
Q

Causes of Cirrhosis

A

Alcohol
Viral: HepB/C
Autoimmune: PBC, PSC, Autoimmune hepatitis
Metabolic: NASH, Haemochromatosis, alpha1antitrypsin, wilsons, CF
Drugs: methotrexate, isoniazid, amiodarone, phenytoin

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2
Q

Features of alcohol misuse

A

Cachexia, tremor, parotid enlargement, dupuytrens, cerebellar syndrome, peripheral neuropathy, myopathy

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3
Q

Classification of Hepatic Encephalopathy

A

Grade 1: Insomnia, reversal of sleep
Grade 2: Lethargy, disorientation
Grade 3: Confusion, somnolence
Grade 4: Coma

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4
Q

Childs-Pugh Cirrhosis Severity and Prognosis

A

Bilirubin, ascites, encephalopathy, PT, albumin

Grade A 5-6: 90% 5 yr survival
Grade B 7-9: 80% 5 yr survival
Grade C >10: 33% 1 yr mortality

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5
Q

Strategy of Management of Cirrhosis

A

Treat underlying cause to stop or slow disease
Prevent superimposed liver damage
Prevent complications: surveillance, 6 monthly US and alphafetoprotein, endoscopy,
Transplant

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6
Q

Causes of Ascites

A 
Cirrhosis
Malignancy
Heart Failure
TB
Pancreatitis
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7
Q

SAAG

A

Serum albumin-ascites gradient
>11g/L suggests transudate
<11g/L suggests exudate

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8
Q

Pathophysiology of ascites and oedema in cirrhosis

A
  1. Disruption of portal flow in liver causing fluid to accumulate in peritoneum
  2. Vasodilation of splanchnic circulation
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9
Q

Hepatorenal Syndrome

A

Systemic vasodilation causes progressive decrease in effective circulation volume leads to RAS activation which reduces renal blood flow

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10
Q

Causes of Hepatomegaly

A 
Malignancy
RHF
Infection: viral hepatitis, toxoplasma, hydatid cyst
Infiltration: amyloid, sarcoid
Vascular: budd-chiari, sickle cell
Polycystic liver
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11
Q

Benign Liver Tumours

A

Cavernous haemangiomas (women of child bearing age)
Hepatic adenoma
Focal nodular hyperplasia

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12
Q

Causes of Splenomegaly

A 
Portal HTN
Myelofibrosis
Haematological malignancy - CML, lymphoma
Infection
Congestion
Splenic vein thrombosis
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13
Q

Cytogenetics of CML

A

Philadelphia translocation chr 9:22
bcr-abl oncogene
tyrosine kinase activity

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14
Q

Causes of hyposplenism

A 
Splenic infarction - vasculitic, sickle
Splenic artery thrombosis
Infiltrative condition - amyloid, sarcoid
Coeliac
Autoimmune disease
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15
Q

Haemochromatosis - genetics

A

Autosomal recessive
HFE gene on chr 6
Leads to raised transferrin saturations >50%

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16
Q

Complications of haemochromatosis

A 
Liver failure 
HCC
Diabetes
Skin pigmentation
Arthropathy
Dilated or restrictive cardiomyopathy
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17
Q

PBC management

A 
ADEK supplements
Treat bone disease
Treat high cholesterol
Treat liver disease with urso
Manage pruritus with cholesytramine but this inhibits absorption of urso
Manage fatigue - naltrexone
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18
Q

How to present renal abdomen

A
  1. Current mode of RRT
  2. Previous modes of RRT
  3. Adequacy of RRT - uraemia and volume
  4. Complications of renal failure e.g. anaemia/bone disease
  5. Complications of immunosuppressive drugs
  6. Aetiology if possible
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19
Q

Problems with haemodialysis

A 
Time
Washout - removal of too much fluid, feel fatigued, cramps, low BP
Bacteraemia - staph
Bleeding - heparin
Amyloidosis
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20
Q

Problems with peritoneal dialysis

A

Peritonitis
Diabetes - glucose in dialysate
Ultrafiltration failure - peritoneal sclerosis
Local hernia, infection, fluid leak

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21
Q

Manifestations of renal oseteodystrophy

A

Osteitis fibrosa - increase bone turnover due to secondary hyperparathyroidism, can cause bone pain and cysts (brown tumours)
Osteomalacia - decreased mineralisation of bone due to aluminium deposition

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22
Q

Definition of nephrotic syndrome

A

Proteinuria > 3g/24hr
Hypoalbumaemia <30g/L
Oedema

(thrombosis and hyperlipidaemia often seen)

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23
Q

Complications of nephrotic syndrome

A 
Oedema - diuretics and salt restrict
HTN - ACEi
High cholesterol 
Thrombosis
Infection - pneumovax and meningoccal vaccination
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24
Q

PCKD genetics

A

Autosomal dominant, most cases chr 16, some chr 4

Screen in over 20s with relative

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25
Extra renal manifestations of PCKD
Cerebral aneurysms Liver cysts Splenic and pancreatic cysts Mitral valve prolapse and aortic regurgitation
26
von-Hippel Lindau syndrome
Autosomal dominant condition on chr 3 Cerebellar, retinal and spinal haemangioblastomas Cysts on liver, kidney, spleen Increased risk of RCC (bilateral) and phaeochromocytoma
27
Clinical Features of Interstitial Lung Disease
``` Clubbing Features of rheumatoid disease Reduced expansion and TVF End inspiratory crackles Pulmonary HTN: raised JVP, parasternal heave, peripheral oedema ```
28
Causes of Interstitial Lung Disease
``` IPF/CFA Rheumatological: RA, SS, SLE, AS, Sj Eosinophilic: ABPA Inhaled: EAA, silicosis, asbestosis Drugs: amiodarone, nitrofurantoin, methotrexate, bleomycin Vasculitis: wegeners, C-S, Goodpastures Sarcoid Radiation ```
29
Respiratory Causes of Clubbing
``` Interstitial Lung Disease Ca Lung Mesothelioma Cystic fibrosis Bronchiectasis Lung abscess/empyema TB ```
30
Investigations for ILD
Bloods: FBC, ESR, Ig, ANA, ENA, ANCA, antiGBM, CK, RhF, Serum ACE ABG - T1RF CXR - bilateral reticulonodular infiltrates PFTs - restrictive pattern + reduced gas transfer HRCT MRI BAL/Biopsy
31
Apical Pulmonary Fibrosis
``` Inhaled agents: EAA, berylliosis, silicosis Radiation Sarcoidosis ABPA Ank SPond ```
32
Basal Pulmonary Fibrosis
IPF/CFA Most rheum disease/CTD Drugs
33
Complications of Pulmonary Fibrosis
``` Rest Failure Chest infection Pulmonary HTN Cor pulmonale Carcinoma of lung ```
34
Management of ILD
General measures: stop smoking, remove exposures, treat infection promptly, education Immunosuppressive therapy - trial of steroids Surgery - single or double lung transplant option
35
Clinical Features of COPD
``` Audible wheeze Nicotine staining Prolonged expiratory phase Tracheal tug Accessory muscles of Rs Hyper resonant Quiet breath sounds NOT clubbing ```
36
Definition of COPD
Umbrella term for obstructive airway disease including - Chronic Bronchitis - cough for 3 months during 2 consecutive years leading to inflammation - Emphysema - histological diagnosis of abnormal and permanently enlarged small airspaces leading to loss of elastic recoil
37
Spirometry in COPD
``` FEV1<80% predicted + FEV1/FVC: < 70% mild 30-50 moderate <30 severe Plus do reversibility testing ```
38
MRC Dyspnoea scale
1. Only breathless during strenuous exercise 2. SOB when hurrying or up slight incline 3. Walks slower than contemporaries on flat 4. Stops every 100m 5. Too breathless to leave house
39
Management of Acute IECOPD
``` Controlled O2 Nebuliser bronchodilators Antibiotics Steroids Consider IV aminophyline NIV in T2RF with pH<7.35 ```
40
Most common pathogens in IECOPD
Streptococcus pneumonia Haemophilus influenzae Moraxella catarrhalis
41
LTOT Criteria for COPD
``` Stopped smoking paO2 <7.3 when well OR 7.3-8 plus - secondary polycythaemia - pulmonary HTN - peripheral oedema - nocturnal hypoxaemia (sats <90% for >30% of time ) ``` ABG taken when well on 2 occasions at least 3 weeks apart
42
Alpha 1 antitrypsin deficiency
Autosomal dominant chr 14 encodes alpha 1 antitrypsin which is enzyme that inhibits neutrophil elastase Multiple phenotypes M (medium), S (slow), Z (very slow)
43
Management of COPD
General measures: stop smoking, immunise Stepwise bronchodilators/antiinflammatory Mucolytics LTOT Diuretics for cor pulmonale Pulmonary rehab - MDT programme - education, nutrition, psychological support, physical training
44
Role of surgery in COPD
Bullectomy, lung volume reduction surgery, transplantation
45
Stepwise therapies in COPD
1. SABA 2. FEV1>50% add LAMA or LABA, FEV1<50% add LABA+ICS or LAMA 3. Add in the other one Always educate and use spacer
46
Clinical Features of Pleural Effusion
Reduced chest expansion, Stony dull percussion note Reduced TVF Diminished breath sounds
47
Causes of Pleural Effusion
Exudate >30g/L: Neoplasm: Ca lung, mesothelioma, lymphoma CTD: Ra, SLE Infection: pneumonia, TB Sub-diaphragmatic: pancreatitis, abscess Drugs: methotrexate, nitrofurantoin, bromocriptine Other: asbestosis, sarcoid, dresslers, trauma, yellow nail syndrome ``` Transudate <30g/L CCF Constrictive pericarditis Low albumin Nephrotic syndrome Cirrhosis Dialysis Uraemia Hypothyroidism ```
48
What volume of pleural fluid can be detected on CXR?
180ml would show was loss of costophrenic angle
49
Pathophysiology of a Pleural Effusion
Inflammatory causes lead to altered permeability of membrane Reduced oncotic pressure in low albumin Increased hydrostatic pressure in CCF Reduced lymphatic drainage in malignancy
50
Causes of low glucose in pleural fluid | NB also causes of low pH (assuming patient has normal ABG)
``` Malignancy Empyema TB RA Oesophageal rupture SLE ```
51
What is the significant of low pH in context of malignant pleural effusion (<7.3)?
More extensive pleural involvement Higher yield on cytology Decreased success of pleurodesis Shorter life expectancy
52
Complications of pleural fluid drainage
Pneumothorax Haemothorax Hypovolaemia Unilateral pulmonary oedema (reexpansion)
53
Indications for pleurodesis
Recurrent malignant effusion | Recurrent pneumothoraces
54
Clinical Features of Bronchiectasis
``` Productive cough (sputum pot) Inspiratory coarse creps which alter after coughing Clubbing Sometimes wheeze Often no features of pulmonary HTN ```
55
Causes of Bronchiectasis
Childhood resp infection: pertussis, measles, TB Bronchial obstruction: foreign body, chronic aspiration, endobronchial tumour Long standing fibrosis Mucociliary clearance problem: CF, kartageners Immunodeficiency: hypogammaglobulinaemia, AIDS ABPA Autoimmune disease: RA, IBD, Sjogrens Congenital abnormality Idiopathic
56
Pathophysiology of Bronchiectasis
Abnormal bronchial wall dilatation, destruction and transmural inflammation caused by destruction of muscular and elastic components of bronchial wall leading to inflammation, oedema and scarring Impaired clearance of secretions leads to colonisation and infection causing further damage
57
Complications of Bronchiectasis
``` Pneumonia Pneumothorax Empyema Collapse Metastatic cerebral abscess Respiration failure Pulmonary HTN Amyloidosis ```
58
Anatomical distribution of Bronchiectasis and aetiology
Infection - lower lobes ABPA & TB - upper lobes Obstruction - right middle lobe
59
Diagnosis of Bronchiectasis
HRCT - signet ring sign - bronchial diameter greater than adjacent vessel Spirometry - may be normal, may have obstructive pattern, may be restrictive in advanced disease
60
Most common pathogens in bronchiectasis
``` Staphylococcus aureus Haemophilus influenzae Pseudomonas Streptococcus pneumoniae Klebsiella Aspergillus ```
61
Cystic Fibrosis
Autosomal recessive, defect on chr7 CFTR Chloride channel abnormality leads to thick mucus and impaired ciliary clearance. Also causes meconium ileum, gallstones, bile salt malabsorption, arthropathy and fertility problems in men
62
ABPA
Allergic bronchopulmonary aspergillosis Hypersensitivity to aspergillus in patients with asthma or CF. Excess mucus production and ciliary clearance. Immune complex deposition incites type III reaction to damage bronchial wall leading to bronchiectasis
63
General management of bronchiectasis
General measures: smoking cessation, immunisations, nutrition, MDT, LTOT if needed Antibiotics including nebuliser tobramycin in CF Postural drainage and chest physio - flutter devices Bronchodilators Steroids Surgical resection if localised, transplant in CF
64
Clinical Features of Ca Lung
``` Cachectic Productive cough Clubbing Palpable LNs Dull percussion, reduced TVF (may have effusion) Bronchial breathing above dullness Pan coast tumour - reduced sensation C8-T1, wasting of muscles, ipsilateral horners (ptosis, miosis, anhydrosis) Deviated trachea Radiation burns ```
65
Classification of bronchial Ca
``` Small cell - 20%, smokers Non small cell including: - adenocarcinoma: non-smokers, peripheral - bronchoalveolar: develops at multisite - squamous: cavitation, smokers - large cell: undifferentiated ```
66
Risk factors for Lung Ca
``` Smoking ILD Radon Asbestos Arsenic Coal tar Radiation ```
67
TNM classification of Lung Ca
``` Tis - in situ T1 <3cm T2 >3cm, invasion of pleura/main bronchus T3 extra pulmonary extension T4 Extensive extra pulmonary extension ``` N1 ipsilateral intrapulmonary nodule N2 ipsilateral mediastinal LN N3 contralateral nodule or scalene/supraclavicular nodule M0 - none, M1 mets
68
Paraneoplastic Lung Ca in SCLC
Endocrine: -SIADH ,Cushings, Hypercalcaemia, hypoglycaemia Neurological: - Lambert-Eaton myasthenia - presynaptic Ca channel Abs - Cerebellar degeneration - antiYo - Sensory neuropathy - anti Hu MSK - dermatomyositis - clubbing - osteoarthropathy Skin - acanthuses nigricans - ichthyosis
69
Pancoast Tumour
Apical lung tumour erodes into lower part of brachial plexus (C8-T1) and cervical sympathetics Ipsilateral wasting of small muscles of hand with dermatomal sensory loss Ipsilateral horners
70
General Management of Lung Ca
``` MDT!!! surgery, chemotherapy, radiotherapy Analgesia Anxiolytics Stents in palliative Pleurodesis Psychological support ```
71
Clinical Features Lobectomy/Pneumonectomy
``` Deviated trachea Thoracotomy scar Reduced chest expansion Dull percussion Absent breath sounds/bronchial breathing above Clubbing - indicates bronchiectasis or malignancy or ILD Palpable LNs - malignancy Deformity of chest wall ```
72
Indications for Lung Lobectomy
``` Bronchiectasis with uncontrolled symptoms Malignancy Solitary pulmonary nodule CF TB ```
73
Indications for Pneumonectomy
Bronchiectasis Malignancy TB
74
Clinical Features of Old TB
Apical fibrosis Scars from thoracoplasty/pneumonectomy/lobectomy Phrenic nerve crush - left supraclavicular scar and raised hemidiaphragm
75
Patients at risk of TB
``` Immigrant population Immunocompromised Elderly Alcoholics Malnutrition Homeless ```
76
Complications of TB
``` Pneumothorax Pleural effusion Empyema Collapse Tubulointerstitial nephritis ARDS TB meningitis Miliary TB Fibrosis Bronchiectasis ```
77
Interferon Gamma Testing in TB
Allows to distinguish between active TB and someone who has previously had BCG and thus positive tuberculin skin test
78
Indications for chemoprophylaxis in TB
All children under 5 in close contact | Patients with previous hx of TB or radiological evidence and starting on immunosuppressive therapy
79
Clinical Features of Lung Consolidation
Productive cough trachea pulled to affected side Increased vocal resonance, coarse creps Underlying cause: features of malignancy, pneumonia, infarction (PE)
80
Typical Pathogens in CAP
Streptococcus pneumoniae Haemophilus influenzae Staphylococcus aureus
81
Atypical Pathogens in CAP
Mycoplasma Legionella Chlaymdia Coxiella
82
Pathogens in HAP
Gram negs: klebsiella, pseudomonas, e.coli Staph Anaerobes Fungi
83
Mycoplasma pneumonia
``` occurs in epidemics every 3-4 years children and young adults prolonged prodromal phase Neurological manifestations: meningitis, encephalitis, GBS, transverse myelitis Cardiac: myocarditis, pericarditis Rheum: arthralgia, myalgia, myositis Haem: thrombocytopenia, DIC GI: D&V, hepatitis, pancreatitis Derm: erythema nodosum, S-JS Renal: glomerulonephritis ```
84
ECG features of PE
``` sinus tachycardia Tall R in V1 Right ventricular strain RBBB TWI V1-V3 S1Q3T3 ```
85
Secondary Causes of Pneumothorax
Resp: COPD, CF, Asthma, ILD, TB, Malignancy, Sarcoid CTD: Marfans, Ehlers-Danlos Lung cysts: Neurofibromas, tuberous sclerosis Iatrogenic: pleural aspiration, biopsy, pacemaker insertion, CPR Trauma
86
Clinical Signs of Tension Pneumothorax
Tracheal deviation, away Mediastinal shift - displaced apex Raised JVP
87
Management of Spontaneous Primary Pneumothorax
If <2cm on CXR repeat in 7-10days, return if develop breathlessness More than >2cm aspirate and if unsuccessful consider chest drain
88
Role of chest drain suction
Added after 48 hrs if persistent air leak or failure of pneumothorax to re-expand
89
Management of Secondary Pneumothoraces
Admit all If <1cm and asymptomatic can observe If <50, <2cm and asymptomatic can aspirate All others require drain
90
Main predictor of re-expansion pulmonary oedema
greater time the lung has been collapsed the greater the risk
91
Clinical Features of Rheumatoid Lung
Inspiratory clicks Symmetrical deforming arthropathy of hands Clubbing Steroid purpura Fine end inspiratory crackles at bases extending to mid zone, do not alter with coughing May be some bronchiectatic changes also
92
Respiratory Manifestations of Rheumatoid Arthritis
``` Pleural effusions Basal fibrosis: RA, gold, methotrexate Pneumonitis Pulmonary nodules Bronchiectasis Caplans syndrome ```
93
Pulmonary nodules in RA
histologically similar to subcutaneous nodules In pleura or lung parenchyma often do not compromise function but can lead to bronchopulmonary fistula or infection
94
Features of RA pleural effusion
Exudate High protein and LDH Low glucose and complement High rheumatoid factor
95
Caplans syndrome
pneumoconiosis in patient with RA associated with coal miners
96
Causes of Lung Collapse
Obstructive -malignancy, extrinsic compression, TB, mucus plus, foreign body Non-obstructive - adhesive atelectasis: PE, radiation, ARDS, pneumonia - Relaxation atelectasis: pleural effusion, pneumothorax - Rounded atelectasis: asbestos
97
Clinical Features of SVC obstruction
Upper limb and face oedema Plethoric Cyanosed Conjunctival suffusion Venous angiomata on undersurface of tongue Prominent and dilated veins over upper limbs, neck and anterior chest Firm raised venous pressure Look for signs of radiation marks/effusions to suggest underlying malignancy
98
Causes of stridor
``` Inspiratory (mostly): Acute epiglottis Croup Vocal chord dysfunction Foreign body Trauma Neck surgery ``` ``` Expiratory: Foreign body Bronchial Ca Stricture secondary to TB, sarcoid Lymphadenopathy ```

PACES (3 decks)

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