QM/BM Flashcards
Give the triad in multiple endocrine neoplasia.
Phaeochromocytoma is a rare cause of secondary hypertension in young patients, which causes a classic “triad” of symptoms - headache, sweating and tachycardia.
How do we treat bradycardia with adverse effects?
First line atropine up to 3mg, then temporary pacing
What are the two types of aortic dissection?
Stanford type A and type B.
How do we manage aortic dissection?
If B: intravenous beta blockers (to prevent propagation of the dissection) and opioid analgesia.
If A: ^ + open surgery
IE: how do perivavlular or aortic root abscesses present on ECG?
They manifest through prolongation of the PR interval on the ECG, which can be followed by higher degrees of heart block. Patients with infective endocarditis are monitored for this complication through daily ECGs.
What is the GRACE score?
GRACE risk score to estimate in-hospital mortality and another score to estimate mortality up to 6 months post-discharge in STEMI.
What is the pathophysiology of NSTEMI?
The underlying pathology of an NSTEMI is caused by an incomplete blockade of the coronary arteries.
Where do you see the pacing spikes in a) atrial and b) ventricular pacing?
a) preceding p waves
b) preceding QRS complex
How do we treat atrial flutter?
Beta-blockers are usually 1st line in management of atrial flutter
Give a common observation which can be serious in Brugada pts
Fever - can be life-threatening, treat with paracetamol
Define PR interval
The start of the P wave to the start of the QRS complex
How do we treat Brugada?
Implantable cardiac defibrillator
How do we treat stable ventricular tachycardia?
Amiodarone (anti-dysrhytmic), initially with a loading dose of 300mg IV over 20-60 minutes, followed by 900mg of amiodarone over 24hrs.
How do we treat beta blocker overdose?
Resus council guidelines state in such cases where beta-blocker (or calcium channel blocker) overdose is suspected, glucagon should be trialled before opting for transcutaneous pacing.
How do we treat AF within 48h of presentation?
With either pharmacological or electrical cardioversion along with low molecular weight heparin.
What is Behçet’s syndrome?
A systemic inflammatory disorder associated with oral and genital ulceration, anterior uveitis, arthritis, vasculitis, skin lesions (such as erythema nodosum) and is a known cause of acute pericarditis
What is Kussmaul’s sign?
Physiologically, the jugular venous pulsation should reduce and not rise when the intrapulmonary pressure reduces in inspiration. This is due to an inability of the right ventricle to fill with blood and instead the blood backs up into the venous system and causes a raised jugular venous pulsation.
What is the dose of atorvastatin post MI?
80mg
ST elevation in V1-3 and I, aVL and V5/6 shows occlusion of which artery?
This ECG shows ST-segment elevation in the anterior chest leads (V1-V3) and the lateral chest leads I, aVL, and V5/V6. This is, therefore, an anterolateral STEMI. In this infarction, it is usually the left anterior descending artery (or the left circumflex artery) that is involved.
When is PPCI indicated?
PPCI is indicated as first-line in patients with acute ST-segment elevation myocardial infarct if: a) presentation is within 12 hours of onset of symptoms, and b) PPCI can be delivered within 120 minutes of the time when fibrinolysis could have been given.
When do we commence rate control in AF?
If resting HR is >80
What is the murmur heard in aortic regurgitation?
Early diastolic murmur, exacerbated by leaning forward
What is the maximum dose of bisoprolol?
10mg
How does AF present on ECG?
The ECG showed no discernible p waves and irregularly irregular rhythm.
How does acute decompensated HF present?
His impaired left ventricle secondary to ischaemic heart disease is unable to meet the demands of his body, this has resulted in lack of forward flow to the kidneys causing an AKI and back pressure through the pulmonary veins into the lung parenchyma which is causing the alveolar oedema on his chest and driving the tachypnoea.
How do we treat AF in pts with HF?
Electrical cardioversion, and if the patient has permanent atrial fibrillation (rhythm control has failed to restore sinus rhythm). Patients with heart failure benefit from the combination of carvedilol (for rate control) with digoxin (which may improve ejection fraction). A warfarin is important for stroke prophylaxis in those with valvular AF and is required in this patient as the CHA2DS2-VASc score is 2.
What heart condition can cocaine use predispose you to?
Coronary artery vasospasm
How does mitral stenosis present on examination?
Rumbling mid-diastolic murmur best heard at the apex
How do we medically manage angina?
Immediate symptomatic relief: GTN spray
Long term symptomatic relief: beta blocker or calcium channel blocker
Secondary prevention: aspirin, atorvastatin, ACEi
How do we treat htn in pts with T2DM?
in patients with a new diagnosis of hypertension who also have type 2 diabetes, first line management for controlling blood pressure is an angiotensin converting enzyme inhibitor.
What ECG changes can digoxin cause?
The patient’s ECG findings are consistent with digoxin toxicity of which frequent premature ventricular complexes are the most common.
How do NSAIDs increase BP?
NSAID use can increase blood pressure by inhibiting COX-2 in the kidneys and reducing sodium excretion. Through this mechanism it can inhibit the effectiveness of the diuretic based antihypertensive therapies – notably it has less effect on calcium channel blockers which act via a vasodilatory action.
What is apixaban an example of?
A NOAC (novel oral anticoagulant)
In which pts do we offer transcatheter aortic valve implantation (TAVI)?
Over 75’s who are haemodynamically stable. If younger, surgical aortic valve replacement
Will troponin be elevated in NSTEMI?
Yes, but not in unstable angina
What is Wellen’s syndrome?
Wellens syndrome describes an abnormal electrocardiographic (ECG) pattern, deeply inverted T waves in leads V2 and V3, that are secondary to proximal LAD stenosis. Treated like secondary angina.
How would RCA infarct present on ECG?
The RCA is the artery that supplies the inferior and posterior aspects of the left ventricle which corresponds to the leads II, III and aVF on the ECG.
Weber’s vs Rinne’s
Weber’s = middle of forehead: with unilateral conductive loss, sound lateralizes toward affected ear. With unilateral sensorineural loss, sound lateralizes to the normal or better-hearing side.
Rinne’s = mastoid bone: air conduction is better than bone conduction. The patient should be able to hear the sound of the tuning fork adjacent to their ear, persist for approximately twice as long as the sound they heard over their mastoid process. This is considered a “positive test.”
Key differential to Bell’s Palsy?
Ramsay-Hunt syndrome - presents with lesions in ear and vestibulocochlear nerve symptoms (tinnitus, unilateral hearing impairment) compared with Bell’s Palsy
How does empty nose syndrome present?
Rare, late complication of turbinate surgery
The most common clinical symptoms are paradoxical nasal obstruction, nasal dryness and crusting, and a persistent feeling of dyspnea.
What is presbycusis?
Presbycusis is one of the commonest causes of symmetrical bilateral hearing loss. It occurs gradually and most noticeable at higher frequencies. It is due to natural ageing of the auditory system: cochlear hair cells and auditory nerve fibres damaged symmetrically over time.
How does acute mastoiditis present?
Typical presentation of acute mastoiditis is severe otalgia, classically centred behind the ear and with a history of acute otitis media and fever. The patient is very unwell with swelling, erythema and tenderness over the mastoid process. The external ear may protrude forwards.
What is the most common source of epistaxis?
Blood vessels in Little’s area, hence why pinching the soft part of the nostrils is usually successful
How do we treat ongoing posterior epistaxis?
Nasal tampon
How does vitamin C deficiency present?
Loose teeth and poor gingival health
What is the most common type of mouth cancer, and how does it present?
Squamous cell carcinoma
A non-healing mouth ulcer, that is both painful and bleeding
What is an acoustic neuroma?
To do
How does Meniere’s disease present?
The three cardinal features of Meniere’s disease are tinnitus, deafness and vertigo. The majority of people with Meniere’s also experience aural fullness, which is frequently described as a feeling of fullness or pressure within the ear.
What causes Meniere’s disease?
Meniere’s disease is thought to be due to a build-up of lymphatic fluid in the inner ear, although the mechanism is incompletely understood.
What is the most common cause of progressive deafness in young adults?
Otosclerosis, an autosomal dominant condition. Ear examination is normal.
How does vestibular neuronitis present?
This is otherwise known as acute vestibular failure or labyrinthitis. This most frequently follows a recent upper respiratory tract infection
Notitis media vs otitis externa
to do
Hodkin’s vs non=hidkins
To do
Which manoeuvre is used to diagnose benign paroxysmal positional vertigo?
Dix-Hallpike
Which manoeuvre is a treatment option for BPPV?
Epley manoeuvre
How do we treat severe hayfever short term?
Short course oral prednisolone - not to be prescribed long term
Useful when improvement is needed for a short time
When do we use rigid bronchoscopy vs Magill forceps?
A circular radio-opaque foreign body with a halo seen on the chest radiograph is very suggestive of a button battery. This must be removed immediately. Since the patient is wheezy, this suggests a lower airway obstruction. Therefore, rigid bronchoscopy is the most appropriate intervention. Magill forceps is only used if the foreign body is located in the oropharynx and laryngeal inlet.
How does peritonsillar abscess present?
Similar to tonsillitis, on examination, the patient is having some difficulty fully opening her mouth, but you can see an erythematous swollen soft palate on the right side, and the uvula is deviated towards the left.
What is a Stokes-Adams attack?
Cardiogenic syncope due to bradycardia. Treated with IV atropine initially, and then transcutaneous pacing.
When would we treat with apixaban instead of thrombolysis in massive PE?
If there is a high risk of haemorrhage, such as due to recent stroke
How does ascending cholangitis present?
Charcot’s triad: RUQ pain, fever/raised WCC, jaundice
Acute cholecystitis presents with both but w/o jaundice
Biliary colic is just pain
In which patients can we not use 6mg IV adenosine to treat narrow complex tachycardia?
Those with asthma, so verapamil is used instead
What would you do with a COPD patient who has become drowsy after being started on 60% oxygen?
This patient has started to become drowsier, confused and developed a headache about half an hour after being started on 60% oxygen. In the context of a COPD patient, this must be treated as hypercapnia, and thus reduce oxygen to 20%
When do we investigate leads V7-9?
The ECG changes are typical of those which appear in a posterior myocardial infarction. If a STEMI occurs then in the posterior area of the heart then reciprocal changes are seen in the anterior and septal leads of V1-3. In order to investigate the posterior aspect of the heart directly leads must be placed on the back - these are leads V7-9.
How do we treat pneumothorax?
Chest drain insertion
How do we treat tension pneumothorax?
Immediate needle decompression with a large-bore needle in the 2nd intercostal space mid-clavicular line
What is IV phenytoin given for?
To do
A pt with anorexia nervosa presents with paracetamol overdose. How does this affect management?
There is increased risk of paracetamol toxicity in patients that are in glutathione deplete states. This includes eating disorders, HIV and malnutrition. A history of anorexia nervosa would warrant immediate administration of NAC.
How much glucose do we give to patients with severe hypoglycaemia?
15-20g of rapid-acting carbohydrate
Which antibiotics can cause torsades de pointes?
Macrolide antibiotics can cause QT prolongation, which increases the risk of developing torsades de pointes. She has likely been started on this for the treatment of pneumonia.
How does Budd-Chiari syndrome present?
Budd-Chiari syndrome describes a syndrome where there is hepatic vein obstruction. It is considered primary if there is hepatic vein thrombosis, often seen in patients with underlying haematological conditions or in pro-coagulable state
In this case, the patient has polycythaemia rubra vera. It is considered secondary if it there is external compression of the hepatic vein, secondary to a liver, renal or adrenal tumour. Budd-Chiari presents with the classic triad of severe abdominal pain, ascites and tender hepatomegaly.
How do we diagnose Budd-Chiari syndrome?
Gold standard for diagnosis is an abdominal ultrasound with Doppler studies.
How do we treat MALT lymphoma?
MALT lymphoma is a low-grade form of non Hodgkin’s lymphoma. The initial treatment for a patient with H. Pylori-positive gastric MALT lymphoma is H. Pylori eradication therapy. Most patients can be fully treated using these antibiotics.
What is Barrett’s oesophagus, and what can it lead to?
Barrett’s oesophagus refers to metaplasia of the lower oesophageal mucosa, whereby the usual squamous epithelium is replaced by gastric columnar epithelium. The strongest risk factor is gastro-oesophageal reflux disease (GORD). Other risk factors include obesity, male gender and smoking. There is an increased risk oesophageal adenocarcinoma (almost 50 fold). This is now the most common type of oesophageal cancer.
Define excoriations
Skin-picking
How does Coeliac disease present dermatologically?
Dermatitis herpetiformis is a dermatological manifestation of coeliac disease, characterised by pruritic papulovesicular lesions over the extensor surfaces of the arms, legs, buttocks, and trunk.
What is the Rockall risk score used for?
The Rockall risk score can be used to assess patients who are at high risk of further upper GI bleeds and deterioration.
How do we treat sudden onset hepatic encephalopathy?
This patient’s confusion is likely secondary to hepatic encephalopathy and first line treatment for this is lactulose. Lactulose is a laxative which also helps by eliminating ammonia. Patients with hepatic encephalopathy should be prescribed regular lactulose and aim for 2-3 loose stools per day.
How does pharyngeal pouch present, and how is it diagnosed?
To do, but barium swallow
What do we advise to pts using symptomatic relief of angina?
Take GTN, then repeat after 5 minutes. If there is still pain 5 minutes after the repeat dose – call an ambulance.
How does Munchausen’s syndrome present?
The patient in this question is intentionally faking signs and symptoms (i.e. adding blood to urine and complaining of pain) in order to gain attention and play “the patient role”. This is consistent with Munchausen’s syndrome.
How does Normal Pressure Hydrocephalus present on CT brain scan?
This man is is presenting with the triad of “Wet, Wobbly & Weird”. This is typical of Normal Pressure Hydrocephalus, which is caused by an abnormal increase in cerebrospinal fluid (CSF) in the ventricles. The sulci are absent because they are compressed by the ventricles which allows for the pressure to be normal despite the CSF increase. The fact that he has not had headaches, nausea nor vomiting helps to point away from any causes of raised intracranial pressure.
What is the most common cause of haemolytic uraemic syndrome?
E Coli 0157
How does haemolytic uraemic syndrome present?
Bloody diarrhoea, fever and abdominal pain
Low platelets, an AKI and a haemolytic anaemia
How does isoniazid affect warfarin metabolism?
Isoniazid is a hepatic enzyme inhibitor, which leads to a decrease in the metabolism of Warfarin and therefore an increase in the International Normalised Ratio.
In what condition is anti-mitochondrial antibody M2 subtype (AMA M2) positive?
Primary biliary cholangitis
Where do you find cherry red skin? How do we treat the condition?
CO poisoning
Hyperbaric oxygen
How does hyposplenism present on blood film?
Howell-Jolly bodies, monocytosis, lymphocytosis, and increased platelet counts
Think coeliac diseasE?
What do we advise to patients taking doxycycline?
Doxycycline is an antibiotic used in the treatment of pneumonia that is also associated with the development of oesophagitis due to its direct chemical irritant effect on the mucosa. Patients should be advised to take Doxycycline with a large glass of water whilst in an upright position.
How do we treat antifreeze overdose?
Fomepizole inhibits alcohol dehydrogenase. At a sufficiently high concentration, ethanol saturates alcohol dehydrogenase, preventing it from acting on ethylene glycol, thus allowing the latter to be excreted unchanged by the kidneys. Historically, this has been done with intoxicating doses of ethanol. However, ethanol therapy is complicated by its own toxicity. Fomepizole inhibits alcohol dehydrogenase without producing serious adverse effects.
Large amounts of ethylene glycol in antifreeze
Which antibodies are raised in autoimmune hepatitis?
This patient is presenting with signs and symptoms that may be consistent with autoimmune hepatitis, which tends to present in pre-menstrual females with jaundice, fatigue and anorexia. Anti-smooth muscle antibodies and Anti-nuclear antibodies are likely to be positive in this individual.
How do we treat C. difficile infection?
Vancomycin
Do we give vancomycin IV or orally in C difficile infection?
Vancomycin does not cross the blood-gut barrier so is most effective when administered orally.
How does Addisonian crisis present?
To do
How do we treat Addisonian crisis?
IV hydrocortisone
How do we manage torsades de pointes?
IV Magnesium Sulphate is the most appropriate treatment for TDPs, which is what this patient has on ECG. Antipsychotics can cause a prolonged QT interval, which can develop into TDP.
In which patients are ACEi contraindicated?
Those with AKI
Where do we use faecal occult blood testing?
is offered to (asymptomatic) people aged 55 and over to screen for bowel cancer, rather than used to investigate symptomatic people.
What is ischaemic hepatitis?
Ischaemic hepatitis describes diffuse hepatic injury secondary to acute hypoperfusion of the liver. This pattern is typically seen in patients who become acutely hypotensive or have a cardiac arrest.
Where do you find organophosphates, and what do they cause?
Organophosphates (found in pesticides) cause over-activity of the cholinergic system giving the symptoms described in this scenario.
Difficulty breathing, diarrhoea, urinary frequency and muscle spasms.
On examination his eyes are watering and he appears sweaty. He is also bradycardic.
Which organism can likely cause GBS?
C. jejuni
Which cancers are patients with coeliac’s disease more likely to suffer from?
atients are at increased risk of small bowel lymphoma and adenocarcinoma. The risk is thought to normalise within a few years of a gluten free diet.
Too much to do
An irregular broad complex tachycardia is assumed to be ventricular fibrillation. The patient should be managed according to the Advanced Life Support guidelines. If there are no signs of life, the resuscitation team should be called and CPR commenced. Shockable rhythms (VF or VT) are managed with unsynchronised DC cardioversion.
Synchronised DC cardioversion is used in the management of haemodynamically unstable patients with a tacchyarrhythmia, who show signs of life (i.e. have a pulse). Synchronised cardioversion delivers a low energy shock in time with a specific point in the QRS complex, to avoid inducing ventricular fibrillation. Unsychronised cardioversion (defibrillation) delivers a high energy shock at any point in the cardiac cycle when there is no coordinated intrinsic myocardial activity, with the aim to allow the heart’s intrinsic rhythm to regain control.
How does acute-on-chronic renal failure present?
These include hyperkalaemia (tented T-waves on ECG, best seen in precordial leads), acute pulmonary oedema (bi-basal crepitations and Type I respiratory failure on an ABG) and uraemia (confusion and uremic pericarditis).
How do we treat hyperkalaemia?
It would be most important to start an intravenous infusion of Calcium gluconate, which stabilises the myocardium and prevents the development of ventricular tachyarrhythmias.
Give two alternatives to clopidogrel.
Ticagrelor and prasugrel
What should all patients be offered following MI?
All patients following a myocardial infarction (MI) should be offered dual antiplatelet therapy, ACE inhibitor, beta-blocker and statin.
How does rheumatic fever present?
This woman presents with evidence of previous group A streptococcal infection (positive ASO titre, recent sore throat), along with core features of rheumatic fever: carditis (a new murmur), arthralgia, a characteristic rash (erythema marginatum), and raised inflammatory markers.
What ECG changes do you see in hypothermia?
A J-wave/Osborne wave is classically associated with hypothermia. This is when a positive deflection is seen occurring at the junction between the QRS complex and the ST-segment.
Do we give bisoprolol or propanolol as rate control in the management of fast AF
Bisoprolol is cardioselective, propanolol is non-cardioselective
Treating thyroid storm
To do
Symptom control:
IV propanolol
IV digoxin if propanolol fails or is contraindicated (e.g. asthma, low BP)
Reduce thyroid activity:
Propylthiouracil - preferred because it inhibits peripheral thyroxine conversion
Lugol’s iodine 4 hours later
Methimazole/carbimazole is considered second-line
IV hydrocortisone to reduce thyroid inflammation
Treat complications: (e.g. heart failure, hyperthermia)
Which fluid do we use for initial resuscitation, and why?
Crystalloid IV fluid not colloid due to risk of anaphylaxis
What is the commonest cause of sudden cardiac death in young people?
Hypertrophic cardiomyopathy
How does eosinophilic granulomatosis with polyangitis present?
adult-onset asthma, symptoms of nasal obstruction and bilateral nasal polyps classical features of this condition.
How does vestibular schwannoma present?
Rinne’s and Weber’s tests reveal sensorineural deafness of the left ear. This and the tinnitus reveal palsy of cranial nerve (CN) VIII. Loss of corneal reflex points to CN V palsy. These are in keeping with vestibular schwannoma (previously termed acoustic neuroma), which is a tumour of Schwann cells of CN VIII that is located in the cerebellopontine angle (CPA). As the tumour enlarges, it can compress local nerves including CN V (leading to loss of corneal reflex) and/or the brainstem. Late in the disease course, it can rarely affect CN VII (which may cause unilateral lower motor neuron palsy manifesting in inability to bear teeth on one side and change in taste). The enlarging tumour can also cause a headache due to mass effect, which is most frequently occipital in location.
What can epistaxis be the result of in middle-older aged men?
Liver disease
Describe the signs you would see in tension pneumothorax
Tracheal deviation to the left, reduced chest expansion, hyperresonant percussion on the right, decreased vocal resonance on the right
A tension pneumothorax may be large enough to shift the trachea to the opposite side. Due to the collection of air in the pleural space, percussion will appear hyperresonant and vocal resonance will be decreased on the same side as the pneumothorax. Other findings may include signs of haemodynamic instability and crepitus over the skin from surgical emphysema.
How does Meniere’s disease present?
Ménière’s disease presents with sudden, unpredictable attacks of vertigo lasting between 20 minutes and 12 hours, often with fatigue and dysequilibrium afterwards. According to the AAO-HNS criteria, it is associated with low- to mid-frequency sensorineural hearing loss and fluctuant aural symptoms (hearing, tinnitus, or fullness) in the affected ear.
Describe the signs seen in aortic regurgitation
early diastolic murmur, widened pulse pressure, soft S1 and a history of previous rheumatic fever, which are all associated with aortic regurgitation
How does cardiac tamponade present?
This lady also displays Beck’s triad - the combination of raised JVP, hypotension and muffled heart sounds
She has Kussmaul’s sign (rise in JVP with inspiration) and pulsus paradoxus (drop in systolic blood pressure of about 15 mmHg with inspiration), which are also features of cardiac tamponade.
How do we treat cardiac tamponade?
Pericardiocentesis involves the insertion of a needle into the pericardial sac to relieve over-accumulation of fluid. A needle is usually inserted just left to the xiphoid process, aiming towards her left shoulder.
Give common complications of myocardial infarct
Common complications resulting from a myocardial infarct that can result in a murmur include mitral regurgitation secondary to rupture of the papillary muscle/chordae tendineae as well as ventricular septal defect due to rupture of the inter-ventricular wall. In both cases, they result in a pan-systolic murmur.
What investigation should patients with strep bovis endocarditis have?
Screening colonoscopy
How does digoxin toxicity present?
This patient most likely takes Digoxin for congestive heart failure. The abdominal pain, nausea and vomiting may be explained by gastroenteritis, or due to the effects of Digoxin toxicity itself. Hypokalaemia (which can result from vomiting and diarrhoea) worsens Digoxin toxicity - allowing it to occur in therapeutic concentrations. The downsloping ST segment is the characteristic ‘Salvador Dali’s moustache’ or reverse tick sign - this does not necessarily indicate toxicity, but is seen with Digoxin use. Note, yellow discolouration of vision (xanthopsia) is a classic but rare sign of Digoxin toxicity.
What is the ORBIT score used for?
To do
What is a cholesteatoma?
This is a rare but important condition. Cholesteatoma is a misnomer; it is not a tumour and is not related to cholesterol. Instead, it is a destructive, expansive mass of keratinised squamous epithelium that requires surgical removal, because it has the potential to invade medially into the ear ossicles and beyond.
How does amyloidosis present in cardiology?
esults in amyloid protein deposition in various tissues in the body, such as kidneys and the heart. It can lead to a restrictive cardiomyopathy that appears “sparkling” on an echocardiogram. This man has presented with symptoms of heart failure with a preserved ejection fraction (HFpEF). Amyloid deposition also causes arrhythmias and conduction disturbances.
What is suxamethonium apnoea?
It occurs when a patient does not possess the enzymes (plasma cholinesterase) to metabolise suxamethonium leading to sustained action of the drug on the post-synaptic membrane of the neuromuscular junction.
