Prof Meerans Lectures Flashcards
1
Q
Infective Endocarditis causative organism?
A
Strep Viridians
S. Aureus after IVDU
2
Q
Infective Endocarditis signs?
Hand, eyes, chest, abdomen
A
Hand = Clubbing, petichiae, splinter haemorrhages, Jane ways lesions and Olsen nodes
Eyes = Roth spots
Chest = changing murmur
Abdomen = microscopic haematuria and splenomegaly.
3
Q
What is acute rheumatic fever?
A
An immunological response to to strep pyogenes.
4
Q
Major criteria for acute rheumatic fever?
A
Carditis Arthritis Sydenham chorea Erythema marginatum Subcutaneous nodules
5
Q
Minor criteria for acute rheumatic fever?
A
Fever Arthralgia Raised ESR Leuocytosis Prolonged PR on ECG Hx of rheumatic fever
6
Q
Mitral stenosis murmur?
A
Blowing mid diastolic murmur with presystolic accentuation
7
Q
Clinical features of mitral stenosis?
A
Middle aged female Malar flush AF Tapping, non-displaced apex Right ventricular heave
8
Q
What murmur is mitral regurgitation?
A
Pansystolic murmur, radiating to the axilla
9
Q
Examination findings of mitral regurgitation?
A
Displaced apex
Apical thrill
Quiet S1, but S3 present
10
Q
Why is S1 loud in mitral stenosis?
A
Mitral valve can’t close properly, so force of the ventricles closes it loudly.
11
Q
What murmur is aortic regurgitation?
A
Early diastolic murmur at left sternal edge
12
Q
What are the clinical features of aortic regurgitation?
A
Collapsing pulse Corrigans sign = visible neck pulses De Mussets = head bobbing Dynamic apex Quinckes = capillary pulsation in the nail bed
13
Q
Causes of AF?
A
IHD
Thyrotoxicosis
Rheumatic Heart Disease
Also alcohol, PE, cardiomyopathy or lone AF.
14
Q
What are the different MI leads, and the artery supplying them?
A
II, III, aVF - inferior MI = right coronary
V1-V4 - anterior MI = LAD
I, V5 and V6 - lateral = circumflex artery
15
Q
Management of an acute MI?
A
Sit up and give oxygen if <94% GTN Aspirin 300mg and Clopidogrel Diamorphine IV 2.5-5mg If no PCI = Streptokinase 1.5MU over 1 hour (tPA has clear mortality benefits) If PCI = LMWH
16
Q
Complications if MI?
A
Arrhythmia
Cardiac failure
Embolism
Rupture / aneurysmal dilation
Pericarditis: early = full thickness anterior MI
Late = Dressler’s at 6 weeks
17
Q
What would left ventricular aneurysm look like on CXR and ECG?
A
Like a bubble, vs the uniform enlargement of cardiomegaly
ST elevation
18
Q
Pulmonary embolism ECG?
A
Most common is normal or sinus tachycardia
S1Q3T3 = deep S and Q, with t wave inversion (in V1-V4).
19
Q
Signs of heart failure?
A
Tachycardia and tachypnoea
Wheeze and bilateral crepitations
3rd heart sound
Raised JVP and peripheral oedema
20
Q
Causes of S3?
A
Rapid ventricular filling
Can be normal in <35
Heart failure, MR and constrictive pericarditis
21
Q
Causes of S4?
A
Atrial contraction against a stiff ventricle
Hypertension and aortic stenosis
22
Q
Heart failure vs cardiogenic shock ?
A
Heart failure is where CO is insufficient to meet tissue demands.
Cardiogenic shock is where heart failure is so severe that there is not enough pressure to perfume even the heart/brain
23
Q
Management of cardiogenic shock?
A
Dobutamine or dopamine
24
Q
Is apex beat displaced by dilatation or hypertrophy?
A
Dilatation
Caused by volume overload;
Aortic regurgitation
Mitral regurgitation
ASD/VSD
25
What causes hypertrophy?
Pressure overload:
Aortic stenosis
HTN
Coarctation of the aorta.
26
What to look for an an exercise ECG?
Enlarged V4/V5 = angina
27
Management of SVT?
Vasovagal manoeuvres
| Then IV adenosine 6mg then 12 then 12.
28
What are the clinical examination findings in consolidation?
Decreased expansion ipsilaterally
Dull to percuss
Increased tactile vocal fremitus
Bronchial breathing
29
Management of pneumonia?
Amoxicillin and clarithromycin
30
Are hand warm or cold in septic shock?
Warm
| Due to severe endotoxins release = vasodilation
31
Treatment of septic shock?
Fluids
| Noradrenaline to cause vasoconstriction.
32
Causes of respiratory clubbing?
```
Bronchogenic carcinoma
Cystic fibrosis
Bronchiectasis
Empyema
Fibrosis alveolitis
```
33
Signs of hypercapnoea?
```
Retention flap
Bounding pulse
Vasodilation = warm hands
Papilloedema
Mental changes
Drowsiness
```
34
Types of obstructive airway disease?
Asthma = reversible
Emphysema = irreversible, destruction of lung distal to terminal bronchiole
Chronic bronchitis
35
Signs of acute severe asthma?
```
Not talking
Peak flow <150
Cyanosis
Tachycardia
Silent chest
Normal carbon dioxide
Pulsus paradoxus = inspiratory systolic pressure fall >20mmHg.
```
36
Management of acute severe asthma?
High flow oxygen
Nebulised salbutamol 5mg driven by oxygen
Ipratropium bromide 0.5mg
Steroids 100mg IV hydrocortisone and 40mg prednisolone
If bad ITU and aminophylline 100-200mg IV bolus
37
Blood gases in asthma?
Oxygen and carbon stay normal until it hits severe
Severe = low Oxygen and high carbon
38
Features of pancoasts tumour?
Horners syndrome = ptosis, mitosis and anhydrosis
Thenar wasting
39
Endocrine manifestations of lung cancer?
Cushings = cortisol from oat cell carcinoma
SIADH = ADH from oat cell carcinoma
- high urine osmolality, low serum osmolality
- low sodium
PTH from squamous cell carcinoma = hypercalcaemic
40
Signs of obstructive airway disease?
```
Hyperexpansion
Barrel chest = reduced cricosternal distance
Tracheal tug
Decreased expansion
Resonant
Expiration you wheeze
```
41
Signs of pleural effusion?
Decreases expansion
Normal trachea
Reduced air entry and vocal fremitus
Stony dull to percuss
42
Signs of stable chronic liver disease?
Spider naevi >5, in distribution of SVC
Palmar erythema
Gyanecomastia
Dupuytren’s
43
Signs of liver cell failure?
```
Jaundice
Leuconychia = low protein
Brushing = clotting deranged
Ascites and oedema = hypoalbuminaemia
Encephalopathy
```
44
Signs of portal HTN?
```
SAVE
Splenomegaly
Ascites
Varices- oesophageal or caput medusa
- blood goes away from the umbillicus
Encephalopathy
```
45
Causes of ascites?
```
Portal HTN
IVC / hepatic vein obstruction
Constrictive pericarditis
Malignancy / TB
Meigs syndrome = ascites, pleural effusion and benign ovarian tumour
```
46
How do you clinically distinguish obstructive jaundice from hepatic?
```
Pale stool, dark urine and pruritic
Urine negative for urobilinogen
LFT’s cholestatic = ALP very high
PBC = AMA+ve, with high IgM
CAH = ANF+ve, high IgG
```
47
Distinguishing kidney mass vs spleen in LUQ?
Spleen:
- moves across not just down like kidney
- find a notch
- dull to percuss
- can’t get above the spleen
- not ballotable
48
Cardiogenic vs Septic vs Hypovolaemic shock?
Blood pressure low in all of them
JVP will be raised in cardiogenic, low in other two.
Peripheries warm in septic shock, cold in other two
Management:
Cardiogenic = dobutamine
Septic = noradrenaline
Hypovolaemic = Blood
49
Erythema nodusum - what is it and causes?
Painful red lesions on shins
```
Sarcoid
Sulphonamides
Salicylates
Streptococcal infection
IBD
```
50
Erythema multiforme - what is it and what causes it?
Typical target lesion
Usually in children or young adults, 7-14 days after herpes simplex virus
Mycoplasma
Drugs e.g. sulphonamides and sulphonylureas
If severe = Stevens Johnson’s syndrome
- associated mucosal ulceration
- liver failure
51
Erythema ab igne - what is it and causes?
Brown pigment art discolouration caused by chronic heat over skin
Often seen in cases with chronic pain.
52
Erythema marginatum - what is it and causes?
Annular eruption with well defined erythematous borders and central clearing
Rheumatic fever
53
Diabetic ketoacidosis features?
No insulin = glucose cannot enter cells
Blood glucose high as cannot enter cells
Body makes ketones to fuel brain = high blood ketones
Severe dehydration and air hunger
54
Diabetes glucose definitions?
Fasting > 7.0
- impaired 6.0 - 7.0
OGTT > 11.1
55
Is HONKC more likely to occur in type 1 or type 2?
Type 2
Significant hyperglycaemia in the absence of ketosis, as insulin is sufficient to suppress ketogenesis but not hyperglycaemia.
Management: rehydrate slowly with normal saline
56
DKA management?
Rehydrate with normal saline and IV insulin infusion
Replace total body potassium
If pH falls below 7.0 May try small amount of bicarbonate 1.26%
57
Stages of diabetic retinopathy?
What you see in each stage....
Background = venodilation, microaneurysms and hard exudates
Pre-proliferative = soft exudates (cotton wool spots)
Proliferative = new vessels
58
Hypertensive retinopathy stages ?
Grade 1 = arteriolar narrowing and silver wiring
Grade 2 = AV nipping
Grade 3 = Flame shaped haemorrhages and cotton wool spots
Grade 4 = papilloedema
59
What is Graves ?
Systemic autoimmune disease involving several autoantibodies:
- TSH
- growth factor receptors in extra ocular muscles
- one that stimulates growth in the pretibial region
60
Features of Graves?
Hyperthyroidism
Exophthalmos
Pretibial myxoedema
Smooth goitre
61
Features of thyrotoxicosis
```
Weight loss with increased appetite
SOB, palpitations
Sweating
Heat intolerance
Diarrhoea
Lid lag
```
62
Why does lid lag occur?
Sympathetic innervation to the eyelid is over activated by thyroxine = open eye lid
63
Management of hyperthyroidism?
Medical = beta blockers, carbimazole and propyluracil
Radioiodine
Surgical
64
Acromegaly instant things on walking in?
Good acromegaly question for growth?
Shake hand = sweaty and doughy, large person
Any change in hat size, ring size , shoe size.
65
Complications of acromegaly?
Bitemporal hemianopia
Pituitary macroadenoma secreting GH
- perform OGTT and measure GH, it should be suppressed.
66
Acromegaly management?
Transphenoidal hypophysectomy
Pituitary irradiation
Medical = octreotide 100-200mcg every 8 Hours, cabergoline
67
Cushing’s syndrome causes?
Pituitary dependant Disease = 85%
Ectopic ACTH = 5%
Adrenal adenoma secreting cortisol = 10%
68
Complications of cushings?
Proximal myopathy and centripetal obesity
HTN
Diabetes
Osteoporosis
69
What is pagets?
Overactive osteoclasts.
70
Pagets clinical features?
Warmth and tenderness over bones
Hearing loss
- pagets of ossicles = conductive deafness
- pagets of 8th nerve canal = neurosensory deafness
Bowed legs
Frontal bossing
71
Management of pagets?
None may be needed
Simple analgesia
Calcitonin injections can suppress osteoclasts
IV pamindronate every 3 months
Regular bisphosphonates .
72
Meningitis causative organisms?
Neonate = e.coli, GBS
Adults = streptococcal
Old = pneumococcal
73
What does blood in the CSF indicate?
Subarachnoid
Can manage with nimodipine to maintain brain perfusion.
74
Someone hit on the head by cricket ball?
Extradural
Has to have a skull fracture, which will tear middle meningeal vessels
Clinically = lucid interval for an hour, then deteriorates.
Lens shape on CT
75
Features of Parkinson’s disease?
Bradykinesia
Cogwheel rigidity
Pill rolling tremor
76
What is synkinesis?
In parkinsons, tone will increase on distraction
77
Features of carpal tunnel syndrome?
Thenar wasting
Sensory loss over median distribution
Pain at night, relieve by hanging hand out of bed
Tinels tap test
78
Clinical signs of a cerebellar lesion?
```
Dysdiadokinesia
Ataxia
Nystagmus
Intention tremor
Staccato speech
Hypotonia
```
79
Neurofibromatosis 1 features?
Autosomal dominant inheritance
Axillary and inguinal freckling
Optic glioma and brain tumours
Iris hamartoma
Small risk of phaeochromocytoma
80
INO: where is the pathology?
Lesion to the medial longitudinal fasiculus, a collection of neuronal fibres which co-ordinates occulomotor, trochlear and abducens.
81
INO: what are the clinical features?
Dissociated eye movements
Impaired adduction ipsilaterally
And nystagmus in the contralateral eye on abduction.
I ADore NYC DUCks
82
INO: causes ?
MS
Vascular brainstem lesions
Encephalitis
83
Argyll Robertson clinical features?
Like a prostitute = accommodates but doesn’t react.
So small irregular pupils that do not constrict to bright light
84
Where’s the lesion of Argyll Robertson pupil.
Lesion in the pretectal region
85
What is Argyll Robertson a classic sign of?
Neurosyphilis
Also diabetes and MS.
86
What are the clinical features of Holmes Adie pupil?
Sudden onset blurred vision in a female.
Pupils are large
React very slowly to light and accommodation
Dilation also slow
Slow deep tendon reflexes
87
Is MS UMN or LMN?
Always UMN!!!
88
What are the clinical features of Marcus Gunn pupil?
RAPD
Pupil will constrict consensually when light shone on good eye
Pupil will dilate when light removes from other eye and moved to the blind eye.
89
Cause of Marcus Gunn pupil?
Multiple sclerosis
90
APTT, PT and bleeding time in:
Haemophilia
Vitamin K deficiency
Von Willebrands
Haemophilia:
APTT raised. Normal rest.
Vit K = APTT, PT raised. Normal bleeding
VWD = Prolonged bleeding, APTT raised. Normal PT
