Peer teachings Flashcards
What type of hypersensitivity is SLE
3 and 2
Triad of lupus
Fever, joint pain, rash in woman of child bearing age
What is needed for SLE diagnosis
4/11 Malar rash Discoid rash Photosensitivity Mouth/nose ulcers Serositis (pleuritis/pericarditis) Polyarthritis Renal Neurological (siezures) Haematologic Antinuclear antibodies Other antibody (anti-smith, anti dsDNA, antiphospholipid)
What can pANCA differentiate
Crohns and UC. UC has it. Crohns doesnt.
Parkinsons genes
Normally not genetic but: PINK1, Parkin, alpha synuclein
What is present in the substantia nigra of those with parkinsons
Lewy bodies (eosinophilic with alpha synuclein)
Clinical features of parkinsons
Pill roll resting tremor, Cog wheel rigidity, Bradykinesia, Hypokinesia, Akinesia (from difficulty initiation movements), postural instability
What doesnt parkinsons cause
Weakness
How does the tremor differ between parkinsons and cerebellar disease
Parkinsons is resting, cerebellar is intention
Other dopaminergic dysfunction leads to
Depression, dementia, sleep disturbances, difficulty smelling.
Parkinsons treatment
Levodopa, Ropinirole (dopamine agonist). Selegiline (MAO-B inhibitor, early on), Entacapone (COMT inhibitor, later on). Deep brain stimulation.
What is the role of Th1
Helps macrophages produce an immune response. IL2, IFN gamma
What is the role of Th2
Helps B cells produce immunoglobulins. IL4,5,10
Requirements for Obstructive spirometry
Reduced FEV1 (<80% normal), Reduced FEV1:FVC ratio (<0.7), reduced peak flow
Requirements for restrictive spirometry
Reduced FVC and FEV1. Normal ratio and peak flow
Interstitial lung disease examples
Sarcoidosis, IPF, Asbestosis, Goodpastures, GPA (Wegeners granulomatosis)
Define asthma
Chronic respiratory condition associated with airway inflammation and hyperresponsiveness
3 pathophysiological changes in asthma
Airway inflammation, airway obstruction and bronchial hyperresponsiveness
Which drugs can make asthma worse
NSAIDs, Aspirin and beta blockers
What causes the second wave of inflammation in asthma
Leukotriene release from mast cells
Symptoms of asthma
Tachypnoea, wheeze, cough
Signs of asthma
Expiratory polyphonic wheeze, hyperinflation, cyanosis, use of accessory muscles, hyperresonant, reduced air entry
Investigations for asthma
FeNO (>40ppb), Spirometry (FEV1/FVC <0.7), bronchodilator reversibility (>12%/200ml), peak flow meter (diurnal variation)
1st line asthma
Short acting B2 agonist (salbutamol) as needed
2nd line asthma
Low dose inhaled corticosteroid (beclametasone)
3rd line asthma
Low dose ICS + LABA (salmeterol)
4th line asthma
+Leukotriene receptor antagonist (Montelukast) then pred
What is used for asthma monitoring
Peak flow and asthma control test
What is the asthma control test
Past 4 weeks How often has it affected your work How often were you SOB How often nocturnal waking How often use rescue inhaler
What does unable to complete sentences suggest
Acute asthma. Give high flow O2, salbutamol nebs and prednisolone. Do ABG and CXR. Can add MgSO4
Causes of acute asthma
Infections esp viral, pneumothorax, triggers
PEF for severity of acute asthma
Moderate = 50-75
Severe= 33-50/ cant complete sentence
Life threatening= below 33 or altered conscious
Define COPD
A common preventable and treatable disease characterised by persistent airflow limitation that is usually progressive and associated with an enhance chronic inflammatory response
What is CREST
Limited cutaneous systemic sclerosis. Calcinosis cutis Raynauds phenomenon oEsophageal dysmotility Sclerodactyly Telangiectasis
What causes wheeze
Air thorugh mucus
What cuases crackles
Alveoli opening
COPD signs
Exertional breathlessness, chornic cough, regular sputum production, wheeze, frequent winter bronchitis
What are signs of COPD
Use of accessory muscles, pursed lip breathing, barrel chest, tar staining on fingers, cyanosis, weight loss form prolonged hypoxaemia, wheeze and reduced breath sounds
COPD v Asthma histologically: cells
COPD neutrophils, CD8 T cells and many macrophages. Asthma mast cells, eosinophils, CD4 T cells and macrophages
COPD v Asthma histologically: mediators
Asthma: Histamine, IL-4, IL5, some ROS. COPD: IL8 TNFa, many ROS
COPD v Asthma histologically: effects
Asthma: all airways, little fibrosis, epithelial shedding. COPD: Peripheral airways, lung destruction, fibrosis and squamous metaplasia.
COPD v Asthma response to steroids
Asthma is very responsive, COPD isnt
What is the classification for airflow limitation
GOLD. FEV1% Predicted 1, mild= >80% 2, moderate= 50-79% 3, severe= 30-49% 4, very severe= <30%
COPD investigations
Spirometry and CXR to rule out pathology
What tool is used for COPD prognosis
BODE index. BMI, airflow Obstruction, Dyspnoea, Exercise capacity index
Non inhaler management of COPD
Smoking cessation and pulmonary rehabilitation. Physiotherapy and dornase alfa for sputum clearance. Influenza and pneumococcal vaccinations
Step one COPD
LAMA (Tiotropium bromide) with rescue SABA
Step two COPD FEV1 >50%
+ LABA (Salmeterol)
Step two COPD FEV1<50%
+LABA (Salmeterol) and ICS (hydrocortisone)
What PaO2 is needed to get oxygen therapy
PaO2<7.3kPa
What is the gene in alpha 1 antitrypsin deficiency
SERPINA 1
Management of acute asthma
Salbutmaol Nebs, Oxygen then prednisolone and IV hydrocortisone
Causes of COPD exacerbations
Community: Haemophilus influeza B, Strep Pneuominae Hospital: Psuedomonas Aeurginosa
Define pneuomothorax
Air in the pleural cavity resulting in collapse of the lung on the affected side.
What increases your risk of smoking
Marfans, tall young man smoker
Secondary causes of pneumothoarx
CF, COPD, Sarcoidosis
Catamenial pneumothorax
During menstruation
What is tension pneumothorax
1 way valve of air entering
Presentation of pneumothorax
Dyspnoea, pleuritic chest pain, hyperresonant on percussion + decreased breath sounds on affected side, reduced chest expansion
What are the additional signs of tension pneumothorax
Deviated trachea, mediastinal shift, hyperexpanded chest, tachypnoea and hypotension
Investigations of pneumothorax
CXR unless tension which is an emergency
Management of tension pneumothorax
100% O2, Large bore IV cannula 2nd intercostal space in mid clavicular line, chest drain
Management of non tension pneumothorax
observation if small, needle aspiration if bigger, chest drain tube if more severe
Define pleural effusion
Abnormal collection of fluid in the pleural space
Transudate pleural effusion
Changes in osmotic pressure, CCF Cirrhosis Nephrotic syndrome, low protein levels
Exudate pleural effusion
Inflammation/malignacy leads to increased vascular permeability. Sepsis, malignancy, TB, infections. high protein levels.
Pleural effusion signs and symptoms
Pleuritic chest pain, SOB, cough, reduced chest expansion and breath sounds, stony dull percussion.
Criteria for exudative pleural effusion
Lights criteria 2/3
Pleural effusion investigations
chest xray and diagnostic aspiration
Management of pleural effusion
Treat underlying cause, drain if symptomatic, pleuroectomy if mesothelioma
Define bronchiectasis
Thickening and permanent dilatation of the airways
Causes of bronchiectasis
HIV TB
SLE
CF, foreign body
Presentation of bronchiectasis
cough with purulent sputum, wheeze, recurrent infections, clubbing, bilateral coarse crackles
Investigations of bronchiectasis
Gold standard= CT chest. CXR= tram track sign, spirometry= obstruction defect, sputum culture
Management of bronchiectasis
Smoking cessation exercise, chest physiotherapy, mucoltics (dornase alfa), prophylactiic abx, pneumococcal and flu vaccination
CF inheritance pattern and gene and chromosome
Autosomal recessive, mutation in cystic fibrosis transmembrane conductance regulator chromosome 7
Pulmonary CF presentation
cough with purulent sputum, wheeze, recurrent infections, clubbing, bilateral coarse crackles
Extra pulmonary CF manifestations
Pancreas= steatorrhea, diabetes, pancreatitis
GI: Distal intestinal obstruction syndrome, cirrhosis
GU: Lack of vas deferens and amenorrhea
Respiratory complications of CF
Pneumothorax and respiratory failure
Diagnosis of CF
In the presence of symptoms, sweat test for children, CF gene test for adults and IRT test for babies
What is the heel prick test for CF in babies
immunoreactive tripsinogen
CF complications from malabsorption
Underweight, fat soluble vitamin deficiency, reduced bone mineral density, distal intestinal obstruction syndrome
Chronic complications of CF
Cirrhosis, infertility diabetes
Respiratory management of CF
Exercise, stop smoking, physio, mucolytics (dornase alfa), prophylactic abx (azithromycin), pneumococcal and flu vacinations
GI management of CF
ADEK supplementaion, pancreatic enzyme replacement therapy, ursodeoxycholic acid for liver disease
CF screening
All babies in UK, immunreactive trypsinogen and sweat test and genetic testing to confirm
Describe ARDS
Acute onset, bilateral infiltrates on XRay, small pulmonary wedge pressure. Caused by release of acute phase proteins and inflammatory mediators. Causing pulmonary oedema
Causes of ARDS
Pneumonia, gastric aspiration, smoke inhilation, trauma, DIC, Pancreatitis
Pulonary signs/symptoms of interstitial lung diseases
Dry cough, SOB, progressive dyspnoea on exertion, infective exacerbations, inspiratory crackles
Systemic signs/symptoms of interstitial lung diseases
Lasting tiredness, weight loss, clubbing
Sarcoid treatment
Prednisolone and methotrexate can try infliximab. SERUM ACE IS HIGH
Sarcoid signs penumonic
Skin - erythema nodosum
Arthritis- feet and hands
Resp- bilateral hilar lymphadenopathy and pulmonary infiltrates
Cardio- Heart block, VT, HF
Occular- uveitis
Intracranial- chronic meningitis, neuropathy, seizures
Derangement of liver and renal function
IPF treatment
Best supportive care, transplant, exacerbations (antibiotics, steroids, oxygen, ventilation)
Consequences of occupational lung disorders
Risk of unemployment, loss of earnings, chronic ill health
What type of hypersensitivity is extrinsic allergic alveolitis
3
Treatment for EAA
Avoid allergens, steroids, best supportive care
Ix for EAA
FBC (inflammatory markers and WBC), Antibody titre, CXR, Spirometry
Asbestosis
Blue is worse. Pleural plaques lead to pleural thickening and mesothelioma
Rheumatoid antibodies
antiCCP, antidsDNA, ANA
Bradford hill criteria of causality
Temporarlity, reversibility, exposure-response, strength of association, specificity, consistency, analogy, biological plausability
Granulomatosis with polyangitis (Wegeners) signs
Saddle nose deformtiy, rash, malaise, diarrhoea, weight loss, joint pain/swelling, nose bleeds
wegeners diagnosis
CXR= cavitating lung lesions FBC= anaemia U&E= ESR and CRP high Urine= blood and protein cANCA Biopsy
Treatment of wegeners
Severe= steroids, cyclophosamide, biologics
No organ damage= prednisolone, methotrexate
Microscopic polyangitis
Small vessel vasculitis like wegeners but pANCA. Fatigue, fever, breathlessness, wheeze, cough, haemoptysis
ANCA associated vasculitis treatment
Prednisolone, rituximab, cyclophosamide
Rheumatoid arthritis risk factors
Women, caucasian, rheumatiod factor, HLA DR4, Other autoimmune conditions, stress, smoking
Symptoms and signs of RA
Symmetrical inflamed joint, nodules, episcleritis, carpal tunnel, lymphadenopathy, anaemia, RA nodules and pleural effusions, pericarditis, amyloidosis
RA diagnosis
Aspirate joint, FBC (Anaemia), ESR/CRP (high), RF, antiCCP (cyclic citrullinated peptic), XRay
RA on Xray
Soft tissue swelling
joint space narrowing
periarticular erosions
RA treatment
Methotrexate and sulfasalazine. Pred injections an option
Methotrexate pharmacology
Inhibits dihydrofolate reductase which is needed for replication and DNA synthesis, coprescribe folic acid
Methotrexate side effects
Mucosal damage, GI upset, nausea, teratogenic
Goodpastures syndrome features
Pulmonary haemorrhage and rapidly progressive glomerulonephritis
What type of hypersensitivity reaction is goodpastures
Type two
What is the cause of goodpastures
antiglomerular basement membrane (anti-GBM) IgM form to T4 collagen
Symptoms of goodpastures
Cough, dyspnoea, crackles, increased JVP and haematuria
Investigations in goodpastures
Abnormal U&Es, urinalysis (high protein and haemturia), renal biopsy (crescentric GN), CXR (Patchy bilateral symmetrical consolidation)
Goodpastures treatment
Plasma exchange and steroids
Define PE
Embolic blockage of pulmonary artery, usually from DVT. Means lung tissue is ventilated but not perfused
Clinical presentation of PE
Sudden onset unexplained dyspnoea, pleuritic chest pain, cough, haemoptysis with previous leg pain/swelling
Diagnosis of PE
Gold= CT pulmonary angiogram. Risk assessment using Well’s Score. Bloods, baseline clotting, D-Dimer, ECG, ABG
Immediate management of PE
100% O2 and IV analgesia and enoxaparin
Define pneumonia
Inflammation of the lung parenchyma usually secondary to infection of the alveoli and surrounding tissue
Bacterial causes of penumonia
Strep Pneumonia (80%) H. Influenzae (COPD exacerbations) Klebsiella pneumoniae (alcoholics hobo)
Atypical causes of pneumonia
Mycoplasma pneumonia, legionella pneumophilia, chlamydophila pneumoniae, chlamydophila psittaci
Viral causes of pneumonia
Influenza virus A/B
Fungal causes of pneumonia
Pneumocystis jiroveci (HIV)
Signs and symptoms of pneumonia
Cough, SOB, fever, rigors, chest pain, tachycardia, low sats, crackles, reduced breath sounds
Diagnosis of pneumonia
Clinical examination, Bloods (high WCC, neutrophils and CRP), XRay (areas of opacification) Microbiology
How do you do microbiology for pneumonia
Sputum gram stain, culture and snesitivity
Urine serology: legionella antigen
Bronchoscopy/ bronchoalveolar lavange
Consequence of CURB 0-1 score
Outpatient amoxicillin
Consequences of CURB 2 score
Hospital admission. Amoxicillin and clarithromycin PO
Consequences fo CURB score over 3
Urgent admission, consider ITU, IV coamoxiclav and clarithromycin
Define TB
Chronic granulomatous infectious disease caused by mycobacterium tuberculosis
Risk factors for TB
Poverty/cramped conditions, poor hygiene, Immunosuppression, smokers, foreign travel
Clinical presentation of TB
Weight loss, night sweats, malaise, cough, haemoptysis, SOB, chest pain.
What is the test for latent TB
Mantoux test, injection of PPD
Diagnosis of TB
Sputum tst x3, . CXR opacities.
How long do you give TB drugs for
RIPE for 2 months, continue with R and I for 4 more
Pyrazinamide side effects
Arthralgia and hepatitis
Describe small cell tumours
15%. Highly associated with smoking. Neuroendocrine tumours. Rapid growth, highly malignant, poor prognosis
Which hormones are secreted by small cell lung cancers
5-HT, ACTH, ADH
Name three non small cel lung cancers in order of prevalence
Squamous cell, large cell, adenocarcinoma
Common sites of metastasis for bronchial carcinoma
Lymph, brain, bone
Symptoms of bronchial carcinoma
Cough with haemoptysis, weight loss, SOB, chest pain, Sx of mets (bone pain, seizures)
Do you get osteoporosis from inhaled corticosteroids
No
Diagnosis of bronchial carcinoma
CXR/ Chest CT and biopsy
Treatment of bronchial carcinoma
Surgery, chemo, radiotherapy
Define mesothelioma
Aggressive tumour of mesothelial cells which usually occurs in the pleura
Symptoms of mesothelioma
SOB, chest pain, weight loss, fatigue, signs of pleural effusion
Diagnosis of mesothelioma
CXR/ Chest CT and pleural biopsy
Treatment for mesothelioma
Surgery, chemo, radio
AIDS defining infections
Candidiasis oesophageal, mycobacterium TB, persistent herpes simplex, pneumocystis jirovecci penumonia, recurrant bacterial pneumonia
AIDS defining neoplasms
Kaposis carcinoma, NonHodkins lymphoma
Direct HIV effect conditions
HIV dementia
HIV associated wasting
Causes of acute breathlessness
Asthma, pneumonia, PE, pneumothorax, hyperventilation
CV causes of clubbing
Cyanotic congenital heart disease
Right to left defect
IE
GI causes of clubbing
IBD, PBC, Cirrhosis
Endo causes of clubbing
Acromegaly and graves acropachy
What do leads I, aVL, V5 and V6 represent
Lateral region, circumflex
What do leads II, III and aVF represent
Inferior, right coronary artery
What do leads V1-4 represent
Septal and anterior. LAD
Define ischaemic heart disease
Myocardial demand for oxygen/nutrients greater than delivery via coronary arteries
Causes of IHD from occlusion
Atherosclerosis, thrombosis, spasm, embolus, arteritis
Causes of IHD from reduced oxygen delivery
Anaemia and hypotension
Causes of IHD from increased oxygen requirements
Thyrotoxicosis, aortic stenosis
Non modifiable IHD risk factors
Age, male gender, family history
Modifiable IHD risk factors
Smoking, alcohol, poor diet, obesity, lack of exercise
Clinical IHD risk factors
Hyperlipidaemia, diabetes, hypertension
Psychosocial IHD risk factors
Work stress, lack of social support, depression
Define angina
Chest pain arising from the heart due to myocardial ischaemia
Describe the pain of angina
Heavy central (+retrosternal, radiates to arms and jaw), exertional with no clinical signs usually
Angina investigations
Exercise ECG showing ST depression, angiogram if uncertain or intervention likely
Acute management of angina
GTN spray, regular nitrates, beta blockers, CCB, revascularisation
Secondary prevention of angina
Lifestyle change, control risk factors, aspirin and a statin
How do you differentiate NSTEMI and unstable angina
Measure the serum troponin level at 12 hours. Will be positive in MI but not in unstable angina
Describe the pain in ACS
Severe central crushing, radiates to arms and jaw. Not relieved by nitrates or rest. Breathless, nausea, sweating, pale, sense of impending doom
Investigations for ACS
ECG, troponin, FBC
ECG changes in STEMI
Q waves, >1mm broad and 2mm deep, negative deflection at start of QRS, Normal in AVR and V1, ST elevation, T wave inversion
ECG changes in NSTEMI
No Q waves, deep ST depression, T wave inversion
Acute management of STEMI
ABCDE, MONA (Morphine, oxygen, nitrates, aspirin), Emergency PCI or thrombolysis
Which drugs are used for thrombolysis
Streptokinase or alteplase
Name two nitrates
Isosorbide mononitrate and glyceryl trinitrate
Long term management of ACS
Aspirin, beta blocker, statin, ACE inhibitor, optimise risk factors, no driving for 1 month
Early complications of MI
Arrythmias, sudden death, pericarditis, heart failure, cardiogenic shock, mitral regurgitation, VSD, cardiac dilatation
Late complications of MI
DVT, PE, Mural thrombus, cardiac aneurysm, Dressler syndrome
What is dressler syndroms
Post MI. Fever, chest pain, pericarditis
Causes of primary HTN
Idiopathic, genetic factors, fetal factors, obesity, alcohol,, salt intake, stress
Secondary causes of HTN
Renal, Endocrine (Conns, adrenal hyperplasia, phaeochromocytoma, cushings, acromegaly), coarctation, OCP, Steroids, NSAIDs, pregnancy
Stage 1 hypertension
Clinic 140/90, ambulatory 135/85
Stage 2 hypertension
clinic 160/100, ambulatory 150/95
Severe HTN
Clinic 180/110, Ambulatory 180/110
Diabetes HTN target
130/80
Investigations in HTN
Looking for end organ damage Urine dipstick for protein + blood Serum creatinine, electrolytes and eGFR 12 lead ECG (LVH or CHD signs) Echocardiography Fasting glucose, fasting serum total and HDL
Who do you treat in HTN
Over 80, stage1 +target organ damage or disease
Everyone with stage 2
Target BP under 80
140/90
Target BP over 80
150/90
Examples of ACE inhibitors
Rampiril, lisinopril, enalapril
Examples of Angiotensin II receptor antagonists
Losartan, candesartan
Examples of betablockers
Atenolol, bisoprolol
Examples of calcium channel blockers
Amlodipine, nifedipine
Examples of thiazide diuretics
Bendoflumethiazide
First line <55
Ramipril
First line Black or >55
Amlodipine
What to give instead of CCB if intolerant or high risk of heart failure
Bendroflumethiazide
Resistant hypertension
Consider adding low dose spironolactone or higher dose thiazide and refer
Define heart failure
The heart is unable to maintain sufficient cardiac output to provide a physiologically normal circulation
What two systems are involved in heart failure
RAAS and sympathetic
What is the sympathetic heart failure physiology
Reduced cardiac output, baroreceptor activation, tachycardia, cardiotoxicity, heart failure
What is the RAAS heart failure physiology
Reduced cardiac output, activated RAAS, vasoconstriction and sodium retention, increased peripheral resistance and increased venous pressure, heart failure
Left heart failure causes
IHD, cardiomyopathy, hypertension, aortic/mitral valve disease, arrythmias, congenital heart disease
Clinical features of left heart failure
Fatigue, SOBOE, Orthopnoea, Paroxysmal nocturnal dyspnoea, tachycardia, fine crackles at lung base
What is orthopnea
Shortness of breath which occurs when lying down
Right heart failure causes
Cor pulmonale, PE, pulmonary HTN, left to right shunts, tricuspid regurgitation
Clinical features of right heart failure
Fatigue, anorexia/nausea, GI upset, raised JVP, pitting oedema, ascites, pleural effusion, hepatomegaly
Investigations of heart failure
Chest XRay (ABCDE), ECG (for underlying cause), FBC, LFTs, U&Es, glucose, TFTs, Serum BNP (always high), Echocardiogram (ejection fraction below 0.45)
Signs of heart failure on XRay
Alveolar oedema Kerly B lines (interstitial oedema) Cardiomegaly Dilated upper lobe vessels pleural Effusion
Non drug treatment of heart failure
Education, lifestyle measures, optimise risk factors, correct aggravating features like anaemia, pneumococcal and influenza vaccines, driving unrestricted
Drugs for heart failure
ACE-i Bisoprolol Candesartan Digoxin Diuretics Spironolactone
Surgical treatment of heart failure
CABG, Valve replacement, pacemaker, heart transplant
Causes of congenital heart disease
Maternal factors -maternal rubella -foetal alcohol syndrome -maternal SLE Genetic -trisomy 21 -turners syndrome
Acyanotic congenital heart diseases with shunts
ASD, VSD, PDA
Acyanotic congenital heart diseases without shunts
Coarctation of the aorta, congenital aortic stenosis
Cyanotic congenital heart disease with shunts
Tetralogy of fallot, transposition of the great arteries
Cyanotic congenital heart disease without shunts
Severe pulmonary cyanosis
common consequences of congenital heart disease
Central cyanosis, congestive heart failure, pulmonary hypertension, polycythaemia, eisenmengers syndrome
Signs of ASD
Mid systolic ejection murmur in pulmonary area, fixed splitting of S2.
Symptoms of right heart overload
Dyspnoea, fatigue, exercise intolerance
Investigations for ASD
CXR- dilated pulmonary artery
ECG- right axis deviation
Echo- hypertrophy and dilation of right heart
Management for ASD
Conservative or surgery
Signs of VSD
Pansystolic murmur at left lower sternal edge, systolic thrill left parasternal heave
Consequence of small VSD
Loud murmur, asymptomatic
Consequences of a large VSD
Pulmonary hypertension, breathless, poor feeding
Investigations for VSD
CXR, ECG, Echo
Management of VSD
Conservative or surgery
What is patent ductus arteriosus
Bypass from the pulmonary artery to the aorta
Causes of PDA
90% isolated, 10% from maternal rubella
What is QRISK2
Used to calculate the risk of CVD event in the next ten years. Age, Sex, Ethnicity, Smoking, RA, Diabetes, CKD, AF, angina
Signs of PDA
Usually asymptomatic, continuous machinery murmur, pulmonary HTN
PDA management
Percutaneous devices, endocarditis prophylaxis
4 features of tetralogy of fallot
RV outflow obstruction
Large VSD
R ventricular hypertrophy
Overriding aorta
Tetralogy of fallot symptoms
Cyanosis, feeding difficulty, failure to thrive
Tetralogy of fallot signs
Clubbing, loud harsh ejection sysolic murmur at lower left sternal edge. Hyper cyanotic spells.
Investigations for tetralogy of fallot
CXR, ECG, Echo
Management of tetralogy of fallot
Initially medical, surgery at 6 months
Descibe coarctation of the aorta
Narrowing of the aorta at the ductus arteriosus.
Sever: collapse and heart failure
Mild: raised BP and mid-late systolic murmur
Symptoms of coarctation of the aorta
headaches, nose bleeds and claudication
Signs of coarctation of the aorta
Radio-femoral delay, BP higher in arm than leg. Poor peripheral pulses
Management of coarctation of the aorta
Surgery
Causes of aortic stenosis
Calcification
Congenital (bicuspid)
Rheumatic fever
Outflow obstruction- hypertrophic obstructive cardiomyopathy
Symptoms of aortic stenosis
exercise induced angina, syncope, breathlessness. Sudden death
Signs of aortic stenosis
Slow rising pulse, sustained apex beat, systolic thrill in aortic region
Aortic stenosis heart sounds
Ejection systolic murmur in aortic area, radiated to the carotid, soft second heart sound, fourth heart sound
Investigations for aortic stenosis
ECG - LV Hypertrophy (depressed ST, T wave invert)
Echo is diagnostic
Management of aortic stenosis
Conservative, valve replacement if severe/symptomatic
Acute causes of aortic regurgitation
Acute rheumatic fever, IE, aortic dissection
Chronic causes of aortic regurgitation
Rheumatic fever Marfans Syphilis Autoimmune Bicuspid aortic valve Severe hypertension
Symptoms of aortic regurg
Asymptomatic until LV fails
Palpitations
Angina/ dyspnoea
Signs of aortic regurgitation
Left ventricular failure
Quinckes sign (pulsating nailbeds)
de mussets sign (head nodding with heart beat)
waterhammer pulse
Pistol shot femoral (sharp bang on ausculation)
Aortic regurgitation heart sounds
Displaced hyperdynamic apex beat
Soft early diastolic murmur at left sternal edge
Accentuated when patient sits forward
Severe= austin flint murmur
Aortic regurgitation investigations
Chest XRay
ECG- LV hypertrophy
Echo
Management of aortic regurgitation
Mild= vasodilators and diuretics
Valve replacement
Causes of mitral stenosis
Rheumatic fever
Symptoms of mitral stenosis
Only in severe, breathlessness, paroxysmal nocturnal dyspnoea, haemoptysis, recurrant chest infections
Signs of mitral stenosis
Malar rash Small-volume pulse Atrial fibrillation Tapping apex beat Signs of RV failure
Mitral stenosis heart sounds
Loud first heart sound, opening snap, rumbling mid diastolic murmur at apex with patient on their left
Mitral stenosis investigations
Chest XR
ECG= bifid P WAVE
RV hypertrophy
Echo
Mitral stenosis management
Diuretics, digoxin, anticoagulation, valvotomy, replacement
Mitral regurgitation causes
Mitral valve prolapse Rheumatic fever Infective endocarditis IHD Cardiomyopathy SLE/Marfans/ Ehlers-Danlos
Symptoms of mitral regurg
Palpitations, dyspnoea, orthopnoea, fatigue, right heart failure
Signs of mitral regurg
Cardiac failure, laterally displaced apex, hyperdynamic, systolic thrill
Mitral regurg heart sounds
Soft first heart sound, loud pansystolic murmur at apex radiating to axilla, third heart sound
Mitral regurg investigations
Chest XR- left atrial and ventricular enlargement
Echo
Management of mitral regurg
Echo monitoring, endocarditis prophylaxis, valve replacement
Define pericarditis
Inflammation of the pericardium
Viral causes of pericarditis
Coxsackie B, echovirus (EBV, HIV)
Bacterial causes of pericarditis
Pneumococcal, staphylococci, gram-ve organisms, TB
Non infective causes of pericarditis
Dresslers syndrome, autoimmune (Rheumatic fever, SLE, RA)
Symptoms of pericarditis
Chest pain (worse on breathing and lying flat, relieved by sitting forward, may radiate to neck and shoulders) malaise
Signs of pericarditis
Fever, tachycardia, pericardial friction rub, dyspnoea
Investigations of pericarditis
Bloods, ECG, CXR, Echo
Bloods of pericarditis
Raised WCC, CRP/ESR, Blood cultures, cardiac enzymes
ECG of pericarditis
Widespread shaddle shaped ST elevation
Treatment of pericarditis
Treat cause, analgesia, NSAIDs, rest, manage complications ie pericardial effusion
Define cardiomyopathy
Disease of the myocardium that effects the mechanical or electrical function of the heart
Types of cardiomyopathy
Hypertrophic, dilated, restrictive, arrythmogenic
Define hypertrophic cardiomyopathy
Marked ventricular hypertrophy in the absence of abnormal loading conditions
What is teh effect of hypertrophic cardiomyopathy
Impaired diastolic filling, reduces stroke volume, most common cause of sudden death in young people. Most causes are familial and autosomal dominant
Symptoms of hypertrophic cardiomyopathy
Asymptomatic, breathless, angina syncope, sudden death
Signs of hypertrophic cardiomyopathy
Atrial and ventricular arrythmias, jerky carotid pulse, ejection systolic murmur, pansystolic murmur
Investigations of hypertrophic cardiomyopathy
ECG always abnormal
Echo shows ventricular hypertrophy
Genetic analysis
Management of hypertrophic cardiomyopathy
Amiodarone (reduces arrythmias and sudden death), if high risk then implantable cardioverter defibrillator. Beta blocker for symptoms
Define dilated cardiomyopathy
Dilated left ventricle which contracts poorly
Causes of dilated cardiomyopathy
Autosomal dominant familial disease Alcohol Post pregnancy Hypertension Valvular heart disease
Clinical features of dilated cardiomyopathy
SOB mainly, can present with embolism, arrythmia or proggressive heart failure
Dilated cardiomyopathy investigations
CXR (cardiac enlargement)
ECG
Echo
Management of dilated cardiomyopathy
Treat HF and AF, Implantable cardiac defibrilator, cardiac transplant
Define peripheral vascular disease
Disease which occurs when there is significant narrowing of the arteries distal to the arch of the aorta, most commonly due to atherosclerosis
Fontane classification for PVD
I asymptomatic
II intermittent claudication
III rest pain
IV necrosis/gangrene
Why is there fixed splitting of S2 in atrial septal defects
Because the pulmonary valve closes after the aortic
What has a boot shaped heart on XRay
Tetralogy of fallot
When is PCI contraindicated
When it is too late or they have already had it
Define intermittent claudication
Exertional discomfort mainly in the calf, relieved by rest
Define rest pain
Unremitting pain in the foot, stops patient from sleeping, relieved by dangling foot over the bed
Signs of PVD
Cold dry skin, diminshed pulses, ulceration
Investigations in PVD
Pulse, Ankle-Brachial pressure index, duplex ultrasound
ABPI results
1 or more= symptom free
0.9-0.5= intermittent claudication
<0.5= critical limb ischaemia
Management fo PVD
Aggressive risk factor management, statin, aspirin
The 6Ps of acute limb ischaemia
Pain Pallor Pulselss Paraesthesia Paralysis Perishingly cold
Causes of acute limb ischaemia
Can by embolic or thrombotic
Management of acute limb ischaemia
Heparin, if embolic long term warfarin, bypass graft
Define arrythmia
Abnormality of cardiac rhythm
Symptoms of. arrythmias
Asymptomatic, palpitations, dizziness, syncope, sudden death
What causes sinus arrythmia
Fluctuations in the autonomic tone results in changes in the sinus discharge rate
Extrinsic to heart causes of bradycardia
Drugs, hypothyroid, hypothermia, cholestatic jaundice, raised ICP
Intrinsic to heart causes of bradycardia
Ischaemia, infarction, fibrosis of atrium and sinus node
Treatment of bradycardia
Pacemaker if symptomatic
Causes of sinus bradycardia
Normal during sleep and athletes
Causes of neurally mediated bradycardia
Carotid sinus syndrome, vasovagal attacks
Common causes of heart block
Coronary artery disease, cardiomyopathy, fibrosis in conducting tissue
Causes of AV block
Block in the AV node or bundle of his
First degree AV block ECG
Delayed AV conduction, prolonged PR interval. No change in HR and no treatment needed
Second degree AV block cause
Some atrial impulses fail to reach the ventricle
Mobitz type 1 ECG
Progressive PR prolongation until fails to conduct
Mobitz type 2 ECG
Intermittent non conducted P waves without progressive prolongation of the PR interval
Third degree AV block
All atrial activity fails to conduct to the ventricles, atria and ventricles contact independently. No association between P waves and QRS on ECG
What is bundle branch block
Complete block of a bundle branch leads to abnormal conduction and widening of QRS >120ms
Right bundle branch block ECG
RBB no longer conducts impulse, spread of impulse from left to right. Secondary R wave in V1, slurred S wave in V6
Left bundle branch block ECG
Deep, wide S in V1, Secondary R wave in V6
What is sinus tachycardia
Physiological response to exercise or excitement. Occurs with fever, anaemia, HF, thyroid, PE, hypovolaeia and drugs
What is AV node reentrant tachycardia
The most common SVT, P waves arent visible or are seen directly before or after QRS. Narrow QRS complexes
What is Atrioventricular reciprocating tachycardia
Wolff-Parkinson-White syndrome, short PR interval, narrow QRS complexes
Supraventricular tachycardia symptoms
Rapid, regular palpitations, abrupt onset, sudeen termination. Dizziness, dyspnoea, central chest pain, syncope, aggravated by exercise, caffeine and alcohol
Treatment of unstable patient SVT
Emergency cardioversion, O2, electrolyte abnormalities corrected
Treatment of stable patient SVT
Vagal stimulation, adenosine, long term= ablation
Causes of atrial arrythmias
IHD, rheumatic disease, thyrotoxicosis, cardiomyopathy, pneumonia, ASD, pericarditis, alcohol use, cardiac surgery
Define atrial fibrillation
Uncoordinated rapid continous activation of the atria, leading to mechanically innefective contraction
What is the pulse like in atrial fibrillation
Irregularly irregular pulse
Presentation of atrial fibrillation
Asymptomatic, palpitations, reduced exercise tolerance, heart fialure, embolic events, irregularly irregular pulse
Investigations for AF
ECG: No P waves, irregular rapid QRS rhythm
Management of AF
Rate control -beta blockers or CCBs Rhythm control -if young, symptomatic or HF -electrical DC cardioversion then beta blockers -or with amiodarone
What score is used to determie the coagulation for AF
CHADS2VASc determines the risk of stroke
What does a score of 1 need
Aspirin
What does a score of 2 need
Warfarin
How do you calculate CHADS2VASc
Congestive heart failure Hypertension Age -65-74 -75=2 Diabetes mellitus Stroke of TIA=2 Vacular disease Sex female
Atrial flutter
Atrial rate of 300bpm and ventricular rate of 150bpm
Investigations of atrial flutter
Sawtooth F waves on ECG
Define aortic aneurysm
A permanent and irreversible dilation of a blood vessel by atleast 50% of normal
Risk factors for aortic aneurysm
Severe atherosclerotic damage, family history, smoking, male, increasing age, hypertension, COPD, hyperlipidaemia
Presentation of aortic aneurysm
Pain in back, abdomen, loin to groin. Pulsatile abdominal swelling. If ruptures then sever and sudden pain. Syncope, shock or collapse
Aortic aneurysm on examination
Pulsatile, expansible mass
Aortic anurysm investigations
Ultrasound, ct, mri angiography
Management of aortic aneurysm
Anti HTN, Statin, smoking cessation.
How does the size of aneurysm alter the treatment
Ultrasound and. surgery if big >5cm
Describe aortic dissection
Results from a tear in the intima, blood under high pressure seperates the aortic wall layers creating a false lumen. False lumen can obstruct the true lumen.
Risk factors for aortic dissection
Hypertension, smoking, hyperlipidaemia, aortic disease, bicuspid aortic valve, history of cardiac surgery
Inherited risks of aortic dissection
Marfans, Ehlers Danlos. Familial thoracic aneurysm type 1 and 2.
Aortic dissection presentation
Sudden tearing central pain which radiated to the back and moves as dissection progresses.
Investigation for aortic dissection
ECG, CXR, Imaging= CT, TOE, MRI
Management of aortic dissection
IV access, intensive care, aggressively control BP (<120sys with BB), blood, surgery
What do you call it when someone can speak but is making no sense
Expressive aphasia
Define transient ischaemic attack
Brief episode of neurological dysfunction due to temporary focal cerebral or retinal sichaemia without infarction, usually lasting seconds or minutes with complete recovery
Differential diagnosis of TIA
Hypoglycaemia Migraine aura Focal epilepsy Cerebral amyloid angiopathy Hyperventilation Retinal bleeds
Causes of tia
Atherothromboembolism (from carotid)
Cardioembolism- mural thrombus post MI or in AF, valve disease or prosthetic valve
Hyperviscosity- polycythaemia, sickle cell, myeloma
Vaculitis- SLE, syphilis, GCA
TIA anterior circulation
Amaurosis fugax, aphasia (brocas), hemiparesis or hemisensory loss
TIA posterior circulation
Diplopia, vertigo, vomiting, choking, dysarthria, ataxia, hemianopic visual loss, tetraparesis
What score is used for the risk of stroke within two days of TIA
ABCD2
How do you work out ABCD2 score
Age >60=1 BP >140/90=1 Clinical features, -unilateral weakness=2 -speech disturbance without weakness=1 Duration of symptoms ->60mins =2 - 10-59mins=1 Diabetes=1
Which ABCD2 score requires urgent investigation and. secondary prevention
> 4 or two recent TIAs
Investigations for TIA
Bloods, CXR, ECG and Echo, Carotid doppler and angiography, CT
Management of TIA
Control cardiovascular risk factors, antiplatelets, warfarin and carotid endarterectomy
How does clopidogrel work
It is a ADP receptor blocker
How does dipyridamole work
Increases cAMP and reduces thromboxane A2
Which antiplatelets would you use in TIA
Aspirin then Clopidogrel and dipyridamole together
Define stroke
A syndrome of rapid onset neurological defecit caused by focal, cerebral, spinal or retinal infaction. Tissue injury is confirmed by neuroimaging
Modifiable stroke risk factors
Hypertension, smoking, hyperlipidaemia, Diabetes mellitus, heart disease, increased alcohol, pill and hrt
Non modifiable stroke risk factors
Age, male, afrocarribean, previous vascular event, family history
Causes of ischaemic stroke
Thrombotic, large artery stenosis, small vessel disease, cardioembolic, hypoperfusion
Causes of haemorrhagic stroke
Intracerebral haemorrhage, subarachnoid haemorrhage. Other (arterial dissection, venous sinus thrombosis, vasculitis)
What classification is used for ischaemic stroke presentation
Bamford classification
What is the presentation of. an ischaemic stroke
Acute onset of negative symptoms indicating focal deficits in brain function such as weakness, sensory loss, dysphasia and visual loss
Anterior cerebral artery stroke symptoms
Leg weakness, sensory disturbance in legs, gait apraxia, incontinence, drowsiness, akinetic mutism
Middle cerebral artery stroke symptoms
Contralateral arm and leg weakness, contralateral sensory loss, hemianopia, aphasia or dysphasia, facial droop, neglect syndromes
Which ABCD2 score strongly predicts a stroke
> 6
Posterior cerebral artery symptoms
Contralateral homonymous hemianopia, cortical blindness, visual agnosia, prosopagnosia, anomic aphasia (colour naming and discrimination problems), unilateral headaches
Primary causes of intracerebral haemorrhage
Hypertensive- rupture of charcot bouchard aneurysms
Cerebral amyloid angiopathy
-lobar, recurrant, associated with alzheimers
Secondary causes of intracerebral haemorrhage
Tumour
Arterovenous malformations
Anticoagulants
Venous infarctions
Clinical features of intracerebral haemorrhage
Similar to ischaemic but more associated with severe headache and coma from raised intercranial pressure
Investigations in intracerebral haemorrhage
CT imaging
MRI and MR angiography for AVM or aneurysms
Management of ischaemic stroke
Frequent monitoring of GCS and signs
Reverse anticoagulation (vitamin K)
BP control
Where are berry aneurysms common
Between posterior communicating and ICA
Between anterior communicating and anterior cerebral
Consequence of posterior communicating aneurysm pressing on neighbouring structure
3rd nerve palsy
Causes of subarrachnoid haemorrhage
Berry aneurysm rupture, arteriovenous malformation
Clinical features of subarachnoid haemorrhage
Sudden severe thunderlap headache with lasts for housrs. Often associated with vomitting, HTN, neck stiffness or pain. Kernigs sign and budzinskis sign
What is kernigs sign and when is it present
Patient cant extend leg when hip flexed. SAH and meningitis
What is brudzinskis sign and when is it present
Neck pulled forward causes knee flexion. SAH and meningitis
Investigations of SAH
CT
If CT negative then 12 hours later do a LP if no CI and it will be Xanthochromic
Management of SAH
Urgent neurosurgery referral, regular CNS examination, hydration and antihypertensives, nimodipine for 3 weeks
Why is Nimodipine given in SAH
It is a CCB and reduces vasospasm
Cause of subdural haemorrhage
Rupture of bridging veins, caused by head injury and in the elderly, alcoholics and babies
Cause of extradural haemorrhage
Skull fracture tearing a branch of the middle meningeal artery
Time frame for subdural haematoma
Days weeks or months after
Time from for extradural haematoma
Lucid interval of hours or days
Presentation of subdural haematoma
Fluctuating conciousness, headache, personality change, unsteadiness, hemiparesis, focal sensory loss, seizures, unequal pupils
Extradural haematoma presentation
Low GCS as severe headache, vomitting, confusin, seizures, hemiparesis. Brisk reflexes, upgoing planter reflex. Coma, ipsilateral pupil dilation and irregular breathing
Subdural haematoma on CT
Crescent shaped with midline shift
Extradural haematoma on CT
Biconvex shape and midline shift
Treatment of subdural haematoma
Close attention, neurosurgery burr hole drill of craniotomy. Can resolve itself.
Treatment of extra dural haematoma
Neurosurgery, clot evacuation and ligation of bleeding vessel
What does it need to be to have thrombolysis
Clinical ischaemic stroke diagnosis
Assessed by experienced team
Within 4.5hours
What is alteplase
Tissue plasminogen activator used in thrombolysis
What can a space occupying lesion lead to
brain herniation and death
What is used to combat anticoagulants
Beriplex and Vitamin K
Beriplex is quicker
What are lacunar infarcts
Subcortical infarcts
What is a watershed infarct
Infarct at the border of arterial supplies caused by severe cerebral hypoperfusion
Why is extradural haemorrhage biconvex
As ararchnoid granulations restrict spread
Very painful eye movements. Bilateral internuclear opthalmoplegia
Multiple sclerosis
Define multiple sclerosis
Chronic autoimmune T cell mediated inflammation of the CNS. Plaques of demyleination occur thorughout the brain and spinal cord sporadically over years
Who gets MS
Women, 20-40, genetics, further from equator (VitD), can be triggered by viruses like EBV
Types of MS
Relapsing remitting
Secondary progressive
Primary progressive
Progressive relapsing
Describe relapsing remitting MS
Clearly defined disease relapses with full or partial recovery. Periods between disease relapses characterised by a lack of disease progression
Describe secondary progressive MS
Initial relapsing remitting pattern is followed by progressive disability allowing for occasional remission and relapses
Describe primary progressive MS
Disease progression from onset with occasional plateaus and temporary improvement allowed
Clinical presentation of MS
Optic neuritis, brainstem demyelination, spinal cord lesions
What are the symptoms of brainstem legions in MS
diplopia, vertigo, facial numbness/weakness, dyarthria and dysphasia. Bilateral internuclear opthalmoplegia
What are the symptoms of spinal cord lesions in MS
Thoracic or cervical lesions can lead to assymetric walking difficulty or numbness in limbs. Paraparesis develops over days or weeks.
Common symptoms in MS
Visual change Sensory symptoms Clumsy hand or limb Ataxia or unsteadiness Bladder hyperreflexia Neuropathic pain Fatigue Spascitiy Temperature sensitivity
What is uhthoff’s pnenomenon
Temperature sensitivity in MS
What is Lhermittes sign
Neck flexion leads to electric shock sensation
Late stage MS
Severe disability Spastic tetraparesis Optic atrophy Brainstem signs Urinary incontinence Pseudobulbar palsy Cognitive Impairment (often frontal lobe) Usually 15 years to needing walking aids and 25 to a wheelchair.
Diagnosis of MS
2 or more attacks disseminated in time and space, McDonald criteria
Investigations of MS
MRI brain + spinal cord
CSF= oligoclonal IgG bands
Blood tests to exclude other inflammatory disorders
Who can diagnose MS
Only consultants
Long term management of MS
No cure, education, MDT (physio, OT, counsellor), prevent infections with nonlive vaccinations
How to treat acute relapses of MS
Methylprednisolone
Disease modifying drug for MS
Beta interferon
Treatment for very aggressive RRMS
Immunomodulatory drugs- Natalizumab
Drug for spasticity
Baclofen or gabapentin
Drug for emotional lability
Amitriptyline
Drug for pain in MS
Amitriptyline
Drug for tremor in MS
Beta blockers or botulinum toxin A type
Urinary urgency/ frequency in MS treatment
Intermittent self catheterisation
Signs of meningism
Headache, neck stiffness, photophobia, Kernigs and Brudzinskis
Immediate signs of Bacterial meningitis
Fevers, rigors, severe headache, photophobia and vomitting
Signs of bacterial menigitis that appear within hours
Neck stiffness and positive Kernig’s sign
Signs of viral meningitis
Self limiting, headache, high fever
Causes of viral meningtis
Coxsackie, HSV, EBV, HIV mumps
Causes of bacterial meningitis in neonates
Ecoli, Group B strep, Listeria
Causes of bacterial meningitis in infants
Neisseria meningitidis, haemophilus influenzae, strep pneumoniae
Causes of bacterial meningitis in adults
Neisseria meningitidis, strep pneumonia
Causes of bacterial meningitis in the elderly
Strep pneumoniae, neisseria meningitidis, listeria
Investigations in meningtisi
Lunbar puncture, blood culture, nose and throat swabs, stool sample
What does non blanching petechial rash suggest
meningococcal septicaemia
Treatment for N.meningitidis in the community
IM Benzyl penicillin
Meningitis with no signs of sepsis or raised ICP treatment
Blood culture, lumbar puncture, IV dexamethasone. Then Ceftriaxone, fluids bloods
Meningitis with riased ICP management
Oxygen, blood culture, IV dexamethasone, delay LP. Give IV cefriaxone. CT imaging. Then bloods
Meningitis with severe sepsis or evolving rash managament
Oxygen, blood cultures, fluids. Delay LP. IV ceftriaxone, bloods
When wouldnt you lumbar puncture
Severe sepsis or rapidly evolving
Severe respiratory or cardiac compromise
Significant bleeding risk
Signs of raised ICP (need CT)
Migraines with aura diagnostic criteria
1 aura symtopm -visual, zigzags, spots -unilateral sensory, tingling, numbness -speech -motor weakness 2 out of -aura spreads gradually over >5mins or theres 2 aura symptoms -aura symptom lasts 5-60mins - an aura symptom is unilateral -headache follows aura within an hour
Migraine without aura criteria
>5 attacks lasting 4 to 72 hours 2 of -unilateral, pulsating, moderate/severe pain, aggravated by exercise 1 of -nausea/vomitting -photophobia and phonophobia
Triggers for Migraine
Sleep- too much or too little
Stress
Oestrogen for women
Eating- skipping meals and big meals, alcohol
Bright lights, loud noises, physical exercise
Mild migraine management
Aspirin + metoclopramide
Name an antiemetic
metoclopramide
Severe migraine management
Triptan + Paracetamol
Migraine preventative measures
Propanolol, acupuncture, amitriptyline
Describe tension headache
30mins to 7 days. Bilateral pressing mild/moderate pain. No associated symptoms. Take paracetamol
Describe cluster headache
15-180mins, unilateral retroorbital boring severe pain. With autonomic symptoms on the same side of the face. Take sumatriptan and 100% O2
Describe trigeminal neuralgia
Lasts seconds, unilateral electric severe pain with many triggers. No associated symptoms. Treat with carbamazepine
More than 50, jaw claudiaction, visual distrbance, tender and pulseless temporal arteries
Giant cell arteritis
Severe eye pain, red eyes, cloudy cornea, dilated and unresponsive pupil
Acute glaucoma
Headache worse on bending over
Sinusitis
Sudden onset thunderclap
Subarachnoid haemorrhage
Worse on lying down, exercise or valsalva
increased ICP
Fever fits and altered consciousness
Encephalitis
Define epilepsy
Paroxysmal event in which changes of behaviour, sensation or cognitive processes are caused by excessive hypersynchronous neural discharges in the brain
Are ischaemic or haemorrhagic strokes painful
Haemorrhagic
Temporal lobe seizure with awareness (simple partial)
Deja vu,, fear, olfactory, gustatory or auditory hallucinations
Ocipital lobe seizure with awareness (simple partial)
Visual phenomena such as zigzags
Frontal lobe seizure with awareness (simple partial)
Adversion seizures, jacksonian march
What is aura
A sensation percieved by a patient that preceds a condition affecting the brain
Temporal seizures with impaired awareness (complex partial)
Automatisms, auras, behaviour arrest, 1-2 minutes. Then post ictal confusion
Frontal seziures with impaired awareness (complex partial)
Complex movements like bicylce movement of legs, repeated words or phrases. Post ictal confusion
Gneralised absense seizure
loss of awareness and vacant expression for less than 10 seconds. Children
Myoclonic generalised seizure
Sudden, breif jerking of a limb face or trunk
Tonic generalised seizure
Body becomes stiff, can fall to the ground
Tonic clonic generalised seizure
Tonic phase (LOC increased tone) Clonic hase (synchronous jerking). Eyes open tongue biting. Postical confusion
Atonic generalised seizure
Sudden collapse with loss of muscle tone and consciousness
Epilepsy triggers
Sleep deprivation, missed doses, alcohol and recreational drug (withdrawal), exhaustion, intercurrent illness or metabolic disturbance
Which children and teenagers get epilepsy
Genetic, perinatal and congenital disorders
Which young adults get epilepsy
Trauma, drugs and alcohol
Which older adults get epilepsy
Vascular disease and neoplasms causing mass legions
Epilepsy investigations
Bloods, ECG, MRI, EEG, VIDEO telemetry DIAGNOSTIC
Management of focal seizures
Carbamazepine (lowers effectiveness of pill)
Management of general seizures
Sodium valproate (teratogenic)
How do you treat status epilepticus (seizure >5mins)
Airway, O2, IV access. Diazepam. Rectal in community, IV in hospital
Describe epilepsy
Aura, common from sleep, less than 2mins, rhythmical jerking, eyes open, tongue biting, incontinence, breathing stops, recovery slow
Describe non epileptic attack disorder
Aura, common in medical situations, more than 2 mins, thrashing movements, hip thrusting, respiration fast, eyes closed no tongue biting or incontince
Describe syncopy
Nausea, sweating, visual grey out, prolonged standing or on stnading. Less than 2 mins, occasional limb jerks, eyes closed no tonuge biting. Normal breathing, fast recovery
Ascending weakness, fasciculations, no sensory sphincter or eye loss, 50-70
MND
Define MND
Neurodegenerative condition caused by progressive loss of upper and lower motor neurones in the spinal cord, cranial nerve nuclei and motor cortex
Familial cause of MND
SOD1 gene mutation
Describe upper motor neurone legion
Weakness, increased reflexs, plantar and tone. No fasciculations or atrophy
Describe lower motor neurone lesions
Weakness atrophy fasciculation. Reduced reflexes, plantars, tone
What are the four clinical patterns of MND
Amyotrophic lateral sclerosis
Progressive muscular atrophy
Progressive bulbar palsy
Primary lateral sclerosis
Amyotrophic lateral sclerosis
UMN and LMN
Progressive muscular atrophy
LMN
Progressive bulbar palsy
CN 9-12
Primary lateral sclerosis
UMN
Over 40, stumbling spastic gait, footdrop, weak grip, weak shoulder abduction, aspiration pneumonia
MND
Diangosis of MND
Clinical
Electromyography confirms LMN
Brain/cord MRI for excluding other things
Diagnosis confirmed by steady progression over time
MND management
Specialist MDT. Non invasive ventilatory support and feeding (gastronomy. Riluzole
What drug is used in MND and what does it do
Riluzole, sodium channel blocker, inhibites glutatmate rlease
Define parkinsonism
Clinical syndrome characterised primarily by bradkinesia, rigidity, resting tremor and loss of postural reflexes
Describe the pathophysiology of parkinsons
Loss of dopaminergic neurones in the substantia nigra pars compacta and Lewy bodies leads to breakdown of the striatum pathway and decreased output tothe cortex
Describe spasticity
There is increased tone at the start of motion but this tops through the range of motion
3 cardinal features of parkinsons
Bradykinesia (button problems, micrographia, expressinoless face, dysphonia, dysdiadochokinesia) Resting tremor (unilateral pill rolling) Rigidity (paian, cog weel, stooped posture)
Characteristic gait of parkinsons
Slow to start walking, rapid short stride length, festination, reduced arm swing, impaired balance on turning
Not movement features of PD
Depression, phobias, anxiety, dementia, autonomic (constipation, increased urinary frequency. Not incontinence)
Parkinsons drugs to increase dopamine availability
Cocarledopa, levodopa and carbidopa(reduces SE from increased dopamine). These treat bradkyinesia and rigidity
Dopamine agonists used in parkinsons treatment
Ropinirole
Drugs which inhibit the enzymatic breakdown of dopamine in the treatment of parkinsons
Entacapone (COMT) Selegilene (MAO-B)
How do you treat the tremor in parkinsons
Anticholinergics- amantadine
Motor complications of late stage PD
Wearing off, on dyskinesias, off dyskinesias, freezing
Hyperkinetic movements, deranged liver function tests, kayser fleischer rings
Wilsons disease
Magnetic gait, incontience, dementia
Normal pressure hydrocephalus
Signs of cauda equina syndrome
Bilateral sciatica, bilateral flaccid leg weakness, saddle anaesthesia, bladder/bowel dysfunction, erectile dysfunction, areflexia
Causes of cauda equina syndrome
Herniated lumbar disc, lumbar spinal stenosis, inflammatory conditions, osteomyelitis, tumours/neoplasms, trauma
Diagnosis of cauda equina syndrome
MRI spine
Treatment of cauda equina syndrome
Surgical decompression by lumbar laminectomy
Describe the pathology of huntigntons
Autosomal dominant conditions. more than 39 repeats of the CAG triplet of the huntingtin gene. Striatum atrophy and depletion of GABA. Increased dopamine and increased movement
Clinical features of huntingtons
Irritability, depression, self neglect,behavioural problems
Chorea and rigidity
Dementia
How do you treat huntingtons
Chorea= sulpride Depression= SSRI Aggression= risperidone
What does anticipation in huntigntons mean
The symptoms get more severe and onset is earlier as the condition is passed from one generation to the next
Define myasthenia gravis
Autoimmune disease against nicotinic acetylcholine receptors in the neuromuscular junction
Presentation of myasthenia gravis
Painless, fatiguable muscle weakness particularly
-proximal limbs
-extra occular muscles
-bulbar and facial muscles
Worse at night, respiratory symptoms= cirsis
Stairs, chairs, hair
What is lambert eaton myasthenic syndrome
Paraneoplastic from small cell lung cancer. Defective Ach release but improves with exercise
Investigations for myasthenia gravis
Look for antiAChR and if negative look for antiMusk
Treatment for myasthenia gravis
Pyridostigmine (anticholinesterase), oral prednisolone
Define guillain barre syndrome
Acute inflammatory demyelinating ascending polyneuropathy affecting the peripheral nervous system following URT or GI infection
How do you treat guillain barre
IV immunoglobulin and enoxaparin
How does guillain barre present
Symmetrical ascending muscle weakness 1-3 weeks post infection
Carpal tunnel
Median nerve compression at the wrist. Tinnels or Phalens signs may be positive. Splinting and corticosteroid injections treatment
Clinical features of encephalitis
LOC, Confusion, seizures, headache and fever
Investigations of encephalitis
MRI, EEG, LP
Viral causes of Encephalitis
mumps, rabies, EBV
Define herpes zoster
Reactivation of varciella zoster virus in the dorsal root ganglia due to decreased immunity
Treatment of herpes zoster
Oral acyclovir. Post herpetic neuralgia=amitryptilline
Where do secondary brain tumours come from
Lungs, breast, melanoma, renal, GI
Glial cell tumours can be
Atrocytic or oligodendroliomas
Classification of astrocytomas
I Pilocytic
II premalginant
III anaplastic
IV diffuse glioblastoma multiforme
What causes the conversion to malginant
Isocitrate dehydrogenase 1
Presentation of brain tumours
Headache, papilloedema, seizures, progressive neurologicla deficit
Investigations of brain tumours
MRI/CT
Treatment of brain tumours
Debulking surgery, radiotherapy, chemo and dexamethasone
Define dementia
A syndrome caused by a number of brain disorders which causes memory loss, difficulty thhinking, problem solving or language and difficulties with activites of dailly living
Types of dementia
Alzheimers, vascular, lewy body, frontotemporal
What causes alzheimers
Accumulation of beta amyloid peptide causes progressive neuronal damage, neurofibrillary tangles, amyloid plaques and loss of ACH
5 Key features of alzheimers
Short term memory loss. Disintegration of personality and intellect Decline in language Decline in visuosptail skills Agnosia
Medication for alzheimers
Acetylcholinesterase inhibitors- donepezil
Antibiotics which cause C.dificle
Clindamycin, ciprofloxacin, coamoxiclav, cephalosporins
What is a mallory weiss tear
Linear tear in mucosa were the oesophagus meants the stomach
What does painless cholestatic jaundice suggest
Pancreatic cancer
What are varices
Distended veins from portal hypertension
What are the U+Es like in upper GI bleed
Only urea is raised and this is because of breakdown of blood
How do you treat mallory weiss tear
Minor=fluids
Major= banding
How do you treat varices
Banging and propanolol
Prehepatic cause of portal hypertension
Portal vein thrombosis
Hepatic cause of portal hypertension
Primary biliary cirrhosis, cirrhosis, buddchiari
Post hepatic cause of portal hypertension
Constrictive pericarditis, IVC obstruction
Causes of upper GI bleed
Mallory weiss tear, grastic and duodenal ulcer, varices
Causes of upper GI motility probelms
Achalasia and systemic sclerosis
How do you detect upper Gi motility problems
barium swallow
What are teh signs of limited systemic sclerosis
Calcinosis Raynauds phenomenon Esophageal dysfunction Sclerodactyly Telangiectasis
How do you detect systemic sclerosis
Anit nuclear antibodies
How do you treat upper GI motility disorders
Omeprazole, antacids and surgery
Define GORD
Excessive entry of gastric contents into the oesophagus through the gastrooesophageal junction
Risk factors for GORD
NSAIDs, large meals, hiatus hernia, obesity, prengancy, alcohol, coffee
Symptoms of GORD
Reflux, indigestion, heart urn, acid tast, bloatin, belching, discomfort, odynophagia
Diangosis of GORD
History and improvement with PPI
Managemtn of GORD
Weight loss, reduced alcohol, smoking cessation, avoid large or bedtime meals. Omeprazole and ranitidine (H2 antagnoist)
Define barrets oesophagus
Change in the lower oesophagus from squamous to columnar epithelium - metaplasia
Peptic ulcer disease investigation
H pylori testing and endoscopy only if over 55 or red flags
Treatment for PUD
Stop smoking, treat cause
- omeprazole, clarithromycin and amoxicillin
- stop NSAIDs
Wchich artery do posterior duodenal ulcers go into
Gastroduodenal artery
Which artery do gastric ulcers go into
Left gastric artery
What relieves pain in gastric
Vomitting, antacids and milk
What relieves pain in duodenal
Intake of food and anatacids and milk
Describe gastric ulcers
Occur in the stomach, epigastric pain 1-2hours after eating, cause haematemesis or melena, heart burn, chest discomfort and early satiety are ofetn seen. Can cause gastric carcinoma
Describe duodenal ulcers
Occurs in the duodenum, epigastric pain 2-5 hours after eating, cases melena or blood in stools. Pain may awaken patient during the night
Name 3 things H pylori can cause
Peptic ulcers, atopic gastritis, cancer
Investigations for H pylori
Endoscopy and biopsy for ulcers, C13 breath test
Dyspepsia features
Postprandal fullness, early satiation, epigastric burning
Causes of dyspepsia
GORD, IBS, PUD, lactose intolerance, anxiety or depression
Red flags in upper GI
Unexplain weight loss, anaemia, GI blood loss, dysphagia, upper abdo mass, persistent vomitting
early post prandial pain
GORD or gastritis
late post prandial pain
duodenal
Risk factors for oesophageal metaplasia
Obestiy, reflux, age
Risk factors for oesophageal squamous cell carinoma
Alcohol, smoking, east asia
Treatmetn of oesophagel cancer
Resection if fit, stent, chemo radio, palliative
Diangostic testing in oesophagel
Endoscopy, CT, PET
2 week wait for endoscopy if
Dysphagia or over 55 and upper abdo pain or reflux or dyspepsia
Non urgent endoscopy if
Haematemsis, over 55 with upper abso pain and anaemia, raised platelets, symptoms of GI cancer
Define coeliac disease
Systemic autoimmune disease trigerred by dietary gliadin
Describe the pathophysiology of coeliac disease
Autoimmune reaction, antiendomysial antibodies attack tissue transglutaminase enzyme which breaks down gluten
Risk factors for coeliac
HLA DQ2/8. T1D, AI addisons and gravves
Histoloical findings in the small intestine in coeliac
Increased lymphocytes in the epithelium and lamina propria, crypt hyperplasia, villous atrophy
Symptoms of coeliac disease
Abdo pain, bloating, diarrhoea, steatorrhea, weight loss
Signs of coeliac
dermatitis hepetiformis, anaemia, osteoporosis, failure to thrive
Where is iron absorbed
First part of the duodnum
Where is folate absorbed
jejunum
Where is B12 absorbed
Terminal ileum
What is dermatitis hepatiformis
Rash on the extenosr surfaces of the arms
Coeliac diagnosis
Tissue transglutaminase antibodies (IgA) (and endomysial antibodies. Bloods for serology, FBC and ferritin. Endoscopy and diagnosis is by small bowel biopsy
What would you see on a coeliac endoscopy
Atrophy and scalloping of mucosal folds, nodularity and mosaic pattern of mucosa
General symptoms of IBD
abdo pain, chronic diarrhoea (+- blood and mucous), weight loss
Describe UC
Continous inflammation that begins at the rectum to the ileocaecal valve. Cardinal symptom bloody diarrhoea. HLAB27
Describe crohns
Transmural and granulomatous inflammation from mouth to anus. Has skip legions. Mouth ulcers and perianal disease are classic. Smoking worsens symptoms
Investigations of IBD
Bloods: anaemia, FBC, increased CRP B12/Folate deficency, Stool MC&S, TFTs. Sigmoidoscopy Colonoscopy Diagnosed with biopsy
How do you differentiate IBD and IBS
IBD has increased faecal calprotectin
UCR v crohns histology
UC: not beyond submucosa, neutrophils migrate to form crypt abscesses, reduced goblet cells and mucin
Crohns: Non caseating granuloma, transmural inflammation, lymphocytic infiltration
UC v Crohns endoscopically
UC: uniform inflammation and pseudopolyps
Crohns: Skip lesions and cobblestone appearnace, commonly affects terminal ileum
UC v crohns long term complications
UC: haemorrhage, toxic megacolon, marked increase in colon cancer risk
Crohns: Fistula, abscess, obstruction, slight increased colon cancer risk
IBD extra intestinal manifestations
Erythema nodosum, pyoderma gangrenosum, irritis, conjunctivits, episcleritis, large joint arthrits, ank spond
How do you treat relapses of IBD
Prednisolone then mesalazine maintenance
What is mesalazine
5-aminosalicylic acid
Prophylactic treatment for severe IBD first and second line
Azathiopine then metronidazole
Diarrhoea which is winter, hospital outbreaks, selflimiting
Rotavirus
Undercooked meat
Campylobacter jejuni
Poor food hygeine
Staph aureus
Watery travellers diarhoea
Enterotoxigenic E Coli
Bloody diarrhoea
Eneterohaemorrhagic Ecoli (0157)
Parasitic causes fo diarrhoea
Giardia lamblia and schistosomiasis
