QUESMED Flashcards
Recurrent ulcers in the mouth and groin aswell as erythema nodosum on the shins and painful eyes (uveitis) =>
Bechets disease
A 42 year old woman presents with a 9 week history of pain, swelling and morning stiffness in her hands and feet. She denies any recent diarrhoea or illness. She had a recent sexually transmitted infection (STI) screen which was normal. She is concerned about her nails which she describes as ‘peeling’. On examination, her fingers and toes are swollen. Which condition is this?
Psoriatic arthritis
Pseudogout joint aspiration features
Positively bifringent rhomboid shaped crystals
RF for pseudogout
Hypothyroidism
Joint damage
Diabetes
Management of acute pseudogout
Colchicine
First line treatment of newly diagnosed rheumatoid arthritis
DMARD (methotrexate) and steroids
When would you consider hydroxychlorquine in RA?
In mild disease
First line treatment of polymyositis?
Steroids
Symptoms of polymyositis
Central weakness
No rash
No pain
Which part of the spine does RA usually affect?
The cervical portion
Usually spares thoracic and lumbar regions
Which imaging might an anaesthetist want for a RA patient before surgery?
Cervical spine x-ray
This is because of risk of current damage and subluxation
During airway manipulation, the anaesthetist may cause minor neck trauma that can dislocate the cervical vertebrae and cause damage, even death if the vertebrae migrates upwards!
Young patient with septic arthritis, most likely cuase
STI (gonorrhoea or chlamydia)
Triad of disseminated gonorrhoea infection
Skin lesions
Polyarthralgias
Tenosynovitis
Treatment of gonorrhoea
Ceftriaxone
Sjogren’s increased your likelihood of contracting which malignancy?
MALT
mucosa-associated lymphoid tissue
How might MALT present?
Bilateral parotid swelling
Cervical lymphadenopathy
Young male patient with painful right testicle with intact reflexes, malaise and fever, ulcerating rash on the shins, potential Dx and which Ix to confirm?
Polyarteritis nodosa
Need a skin biopsy
Which virus is linked with polyarteritis nodosa?
Hepatitis B
Parietal lobe damage (e.g. from brain metastases) can present with what feature?
Visual inattention
Damage to which area of the brain can result in Wernickes aphasia?
Left posteriori superior temporal gyrus
Which area of the brain is damaged in Gerstmann’s syndrome?
Inferior parietal lobe
Symptoms of Gerstmann’s syndrome
agraphia (difficulty in writing)
acalculia (difficulty with math)
aphasia (language disorders)
agnosia (difficulty to perceive objects)
Symptoms of hypocalcaemia
Parasthesia
Tingling of hands and face
Iatrogenic cause of hypocalcaemia
Thyroidectomy
Symptoms of multiple myeloma
Constipation
Depression
Back pain
Anaemia
Symptoms of measles
Development of a fever above 40 degrees
Coryzal symptoms
Conjunctivitis followed by a rash about 2-5 days after onset of symptoms (often starts behind the ears and spreads)
Koplik spots are small grey discolourations of the mucosal membranes in the mouth and appear 1-3 days after symptoms begin during the prodrome phase of infection. They are pathognomonic for measles infection.
Complications of measles
Acute otitis media
Bronchopneumonia
Encephalitis
What antibody test can you do for measles?
ELISA
Management of measles
Supportive
Notifiable disease
Off school as infective for up to 10 days
What is the potential pathophysiology of motor neuron disease?
Glutamate signals for calcium to enter motor neurones
Excessive calcium kills the neurones
Symptoms of motor neuron disease
Mix up UMN and LMN signs
No sensory involvement
Fasting growing, most aggressive thyroid cancer and how might it present?
Anaplastic
Invades local structures (may be breathless or difficulty swallowing)
Lump in the neck that raises on swallowing but NOT tongue protrusion
The most common type of thyroid cancer
Papillary
Periosteal onion skinning suggests
Ewing’s sarcoma
Only real chest x-ray finding in asthma
Hyperinflation
Chest sign of asthma
Widespread wheeze
What is the doctrine of double effect?
If someone is on max morphine on end of life care but still has pain, you can prescribe more morphine to treat that pain in the knowledge that it may hasten their death
Symptoms of prolactinoma
In women = lack of libido, galactorrhiea and infertility
In men = gynaecomastia, lack of lidido, less body hair
Also mass-producing effects such as headache and bitemporal hemianopia
Mx of symptomatic aortic aneurysm (back pain and epigastric tenderness)
Elective surgery
What is Mirrizzi’s syndrome?
Stone in the cystic duct compresses the bile duct and causes obstructive jaundice
Features of Mirrizzi’s syndrome
Recurrent abdominal pains
Jaundice
Dark urine
Pale stools
Signs of COPD on respiratory examination
Prolonged expiratory phase, reduced chest expansion and widespread wheeze on auscultation.
Management of life-threatening asthma
Oxygen
Salbutamol and ipratropium nebulisers
Steroids
Urgent senior support
What is a myoclonic seizure?
Sudden jerking of a limb (say the neck)
Treatment of myoclonic seizures
Sodium valproate
What do you need to screen for before initiating biological therapies in rheumatoid arthritis?
TB (may get reactivated)
What does rituximab target?
CD20 on B cells
Management of alcohol dependence
CBT
Oral acamprosate or naltrexon
Consider admission if the dependence is severe (young pt, 30 units a day, vulnerable patients)
Medication for BPH with a PMH of postural hypotension?
Finasteride
First-line treatment of BPH
Tamsulosin
Most common ECG abnormality in anorexia nervosa
Prolonged QT interval
Due to electrolye disturbance
Symptoms of Reye’s syndrome
Reduced GCS
Mild anaemia
A transaminitis (high liver enzymes because its basically liver failure)
Raised bilirubin
A prolonged international normalised ratio
Raised lactate
Raised C-reactive protein
The typical history of Reye’s syndrome
Child under 12yo
Had viral illness
Given aspirin
Most common causes of HF in the Western world
Coronary artery disease
Hypertension
Valvular disease
Symptoms of pulmonary oedema
Shortness of breath on exertion
Orthopnoea
Paroxysmal nocturnal dyspnoea
Nocturnal cough (± pink frothy sputum)
Which classification system to grade heart failure?
New York Hear Association
A good measure to do that can help to rule out heart failure
BNP
Blurry vision that gets worse over the course of the day
Patient appears tired at the end of each day
Myasthenia Gravis
Absent p waves
Widened QRS complexes
Peaked t waves
Hyperkalaemia
Treatment for pseudogout in one joint in patient with CKD
Intra-articular steroid injection
Renal impairment and high HBA1c, symptoms of diabetes, whats the first line treatment?
Basal insulin therapy because of their renal impairment
Humeral fracture can damage which nerve, leading to inability to extend wrist and loss of sensation on the back of the hand
Radial
Mx of acute angle glaucoma
Topical pilocarpine
IV acetozolamide
Peripheral laser iridotomy = definitive
Features of acute closed angle glaucoma
Fixed dilated pupil
Hard orbit when pressed
Red and watery
Blurred vision
How quickly does baby blues present?
First 2 weeks after birth
Resolves spontaneously
When does post partum depression typically present?
Typically start 1 month post partum and peak at 3 months
Mx of post-partum depression
CBT
Risk assessment
Consider inpatient admission with baby is severe
Symptoms of anterior uveitis
Painful red eye
Irregularly shaped pupil
Blurry vision
History of back pain or IBD etc. (HLA related)
Conditions that can predispose to anterior uvietis (HLA-B27 conditions)
Ankylosing spondylitis Idiopathic juvenile arthritis Multiple sclerosis SLE Inflammatory bowel disease Granulomatosis with polyangiitis Reactive arthritis Infections: herpes, tuberculosis, syphilis, HIV
Symptomatic patient, diabetes cut off for diagnosis
Random blood glucose =11.1mmol/l
Fasting plasma glucose =7mmol/l
2 hour glucose tolerance =11.1mmol/l
HbA1C =48mmol/mol (6.5%)
Smoking is a risk factor for which oesophageal cancers?
Both adenocarcinoma and squamous cell carcinoma
Difference between superficial dermal and superficial epidermal burn
Dermal may see blistering, more seen in scalds from liquids
Epidermal = more from flash burns
Both typically heal in 10-14 days (painful) but with minimal scarring
What are ecchymoses?
Areas of bleeding under the skin (bruising)
First line management of ?hip fracture?
ABCDE
Anterior and lateral hip x-rays
What is the management of grade 1/2 intracapsular hip fractures?
Garden 1/2 fractures can be treated with ORIF and cancellous screws
2.5yo with waddling gait and big thigh muscles, what is the inheritance pattern?
X-linked recessive
Duchenne’s muscular dystrophy
Pt with Hickmann line, pyrexial and tachycardic but haemodynamically stable. New onset heart murmur in tricuspid area, which antibiotic would you start?
IV vancomycin
Immediate management of Quinsy in the community?
Immediate referral to hospital
Infection can easily spread or cause airway compromise
Signs of Quinsy
Deviated uvula
Swelling
Very painful sore throat
Inability to open the mouth easily
Common causes of heart failure
Coronary artery disease
Hypertension
Valvular disease
What is high output heart failure?
The insufficiency of the heart to supply the metabolic demands of the body is due to the needs being increased = ANAEMIA
What is low output heart failure?
The body is normal but the heart can’t give enough = dilated cardiomyopathy, restrictive
Causes of high output heart failure?
PAT
Pregnancy
Anaemia
Thyrotoxicosis!
Causes of low output heart failure
Pump failure, ARRYTHMIAS, excess after-load or excess pre-load
What is diastolic low output heart failure?
Impaired ventricular FILLING during diastole
Because its all crusty, restricted or big and unable to be filled easily
What is systolic low output heart failure?
Impaired ventricular contraction during systole
When it’s weak or really dilated
Causes of systolic heart failure?
Ischaemic heart disease
Dilated cardiomyopathy
Myocarditis
Infiltration (e.g. in haemochromatosis or sarcoidosis)
Causes of diastolic heart failure?
Hypertrophic obstructive cardiomyopathy
Restrictive cardiomyopathy
Cardiac tamponade
Constrictive pericarditis
BNP>2000ng/L Mx
2w referral for specialist assessment and an echo
Cut off for ejection fraction
40%
40%< ejection fraction but heart failure =
Preserved ejection fraction heart failure
Which Ix to test ejection fraction?
Echo
HIV pt with generalised weakness, head CT shows a single, lobulated lesion, most likely cause and treatment?
HIV related primary CNS lymphoma
Treatment = commence cART and whole brain irradiation
Which part of the nephron do thiazide diuretics work on?
DCT on the sodium, potassium channels
What can taking bendroflumethiazide do when also taking metformin?
Can increase glucose levels because it interacts with K+ channels, reducing insulin release
What type of drug is baclofen?
Its a muscle relaxant
What is baclofen used for in MND?
Reduce spasticity
In AKI, what can happen to baclofen levels?
Rise, because excreted by kidneys
Can result in drowsiness/LOC
In renal tubular acidosis, why do you get an acidosis?
Impaired acid excretion leads to hyperchloraemic metabolic acidosis.
This leads to activation of the Renin Angiotensin system leading to potassium wasting and hypokalaemia
What is type 1 renal tubular acidosis
DISTAL RTA
The inability of the kidneys to excrete H+ ions
What is type 2 renal tubular acidosis?
Proximal RTA
Issue with the proximal tubule (usually caused by Fanconi syndrome)
Can reabsorb a bit of HCO3-
Urine will be acidic
What is type 4 renal tubular acidosis?
Mineralocorticoid deficiency
Normal urine pH
Hyperkalaemia (because switch less K+ for Na+)
Low blood pressure
What might the heart rate be in inferior MI?
Bradycardia
Because AV block (can’t message between them so just go at basal ventricular rate)
Cut off INR for absolute contraindication for surgery?
INR 1.5
Absolute contraindications for laparoscopic surgery
Obvious indication for open therapeutic intervention – Perforation, peritonitis, known intra-abdominal injury, complications of previous surgery, shock, evisceration or abdominal wall dehiscence
Acute intestinal obstruction associated with a massive (>4 cm) bowel dilatation – Can obscure the view making intervention harder.
Uncorrected coagulopathy – INR should be corrected to at least < 1.5, although some surgeons prefer INR to be even lower than this.
Tense or distended abdomen – Suspected intra-abdominal compartment syndrome
Trauma with hemodynamic instability
Clear indication of bowel injuries (e.g. presence of bile or evisceration)
Severe chest pain when swallowing, especially cold drinks, what does this suggest?
Oesophageal spasm
Diagnosis of oesophageal spasm
Barium swallow showing corkscrew oesophagus
Birth defects associated with folic acid antagonists
Anencephaly, cleft lip/palate, skull defects
One attempt at endoscopy with band ligation for variaces, still bleeding the next day, what do you do?
If haemodynamically stable -> repeat endoscopy with therapeutic intention
If unstable, consider balloon tamponade
If refractory, consider transjugular intrahepatic portosystemic shunt (TIPS)
Scoring system for upper GI bleed?
Glasgow-Blatchford score
Viral cause of roseola
HHV6
High fever for 5 days, single seizure, as the fever subsides a maculopapular rash appears, Dx?
Febrile convulsion (most likely caused by roseola)
Redman syndrome is also known as…
Erythoderma
Definition of erythroderma
> 90% body surface red and potentially scaling
Most common site of occlusion in acute mesenteric ischaemia
Superior mesenteric artery
Triad of acute mesenteric ischaemia
Shock
Diffuse abdominal pain
Insignificant abdominal examination
Management of transient synovitis
Supportive
Features of transient synovitis
Recent infection
Both septic arthritis and transient synovitis cause acute onset limp where the child avoids bearing weight and presents with fever.
Generally, the features of transient synovitis are milder than septic arthritis (mild/absent fever versus high fever, mild vs severe pain).
How long do symptoms have to last to consider juvenile idiopathic arthritis?
6w<
Morning stiffness, starting at the hands and feet and progressing to the spine
Features of Klinefelter’s syndrome
Small, firm testis
Gynaecomastia
Delayed puberty
Tall (because delayed puberty, keep growing at child rate)
Causes of delayed puberty
Androgen insensitivity
Klinefelter’s syndrome
Chronic illness (e.g. CF or coeliac)
Most common cause of delayed puberty
Late bloomers
Parent’s probably had later puberty
Microcytic anaemia in a patient taking isoniazid but with normal iron levels, cause =?
Sideroblastic anaemia
Caused by isoniazid treatment
Hypochromic, microcytic but with normal iron!
What is sideroblastic anaemia?
Inability to produce RBC very well
Get a hypochromic, microcytic anaemia
What is herpes labialis?
Cold sores
Which type of pneumonia is linked to cold sores?
Streptococcus pneumoniae
Most common causative organism for lobar pneumonia?
Streptococcus pneumoniae
What might you find on examination for pneumonia?
Bronchial breathing over one lobe Increased vocal resonance Reduced chest expansion Increased RR Pleuritic chest pain
Risk factors for anorexia nervosa
Dieting Maternal encouragement of weight loss Family history of eating disorders Adolescent period Personal history of anxiety disorders Depressive disorders or obsessive-compulsive disorders Perfectionist traits At-risk professions such as sportspeople, dancers or models
Chronic ketamine use is associated with which bladder condition?
Ketamine cystitis
Features of dysuria and blood
Cystoscopy shows thickened bladder walls and inflammation
Screening for AAA 3.3cm
Once yearly USS
Screening for AAA 4.7cm
Repeat USS every 3mo
Mx of AAA size 5.7cm
2w surgery
Procedure for malrotation in children
Ladd’s procedure, twisting and fixing
Removing Ladd’s bands of adhesion and also removing the appendix while you are in there
Symptoms of malrotation
Bilious vomiting
Constipation
Distended abdomen
Causes of obstructive shock
Cardiac tamponade
Pulmonary embolism
These STOP the flow from the heart
pathophysiology of neurogenic shock
Mass peripheral vasodilation due to loss of neurogenic tone
Diagnosis of aplastic anaemia
Anaemia: haemoglobin <10 g/dL
Thrombocytopenia: paltelets <50 x 10^9/L
Neutropenia: absolute neutrophil count <1.5 x 10^8/L
Management of twin to twin transfusion syndrome
Specialist centre -> in utero laser of problem vessels
What type of drug is acetazolamide?
Carbonic anhydrase inhibitor
Used in glaucoma to reduce acqeous humour production
Recurrent episodes of self-limiting high fever and painful serositis associated with a typical lower limb erysupelas-like rash Dx?
Familial Mediterranean fever
Gene in Mediterranean Fever
MEFV on chromosome 16
What long-term therapy should patients with familial Meditarranean fever be put on?
Colchicine to reduce long standing inflammation and reduce chance of amyloidosis
Electrolyte measurements in tumour lysis syndrome
Hyperkalaemia, hyperuricaemia, hyperphosphataemia -> drives HYPOcalcaemia
Normal calcium levels
2.2 - 2.6
Causes of HYPOcalcaemia
Vit D deficiency (e.g. ostomalacia or malabsorption => coeliac/chronic pancreatitis)
hypoparathyroidism
Hyperphosphateaemia
Causes of malabsorption
Gastrectomy
Short bowel syndrome
Coeliac disease
Chronic pancreatitis
Signs of hypocalcaemia =?
SPASM Spasms Parathesia Anxiety Seizures Muscle tone increase
Ix for hypocalcaemia
ECG (looking for arrhythmia)
Bone profile (calcium, phosphate, albumin, total protein, ALP)
PTH
Vitamin D
Amylase (if suspected pancreatitis)
X-rays (if suspected osteomalacia)
Long standing hearing loss and painless otorrhoea, foul smelling discharge, that is not improving with repeated courses of antibiotics
Cholesteatoma
benign growth of keratinising squamous epithelium trapped in the middle ear cavity
Can be acquired (repeated chronic otitis media) or congenital
Features of cor pulmonale
Hx of COPD or other chronic lung disease
RHF = pitting oedema, ascites, tender smooth hepatomegaly, raised JVP
Ulnar deviation, Z thumb deformity, smooth mass in LUQ that moves with ventilation =>
Felty’s syndrome!
DDx of splenomegaly
Haematological: CML, myelofibrosis, haemolysis
Infective: tropical (malaria, leishmaniasis) and non-tropical (Epstein barr virus)
Other: portal hypertension, infiltration (e.g. sarcoidosis, amyloidosis), Felty’s syndrome
H.pylori positive with an associated MALT lymphoma found on endoscopy, what is the management?
Amoxicillin, clarithromycin and omeprazole to try to eliminate the H.pylori
If H.pylori eradication fails when treating a MALT lymphoma, which drug can you use?
Rituximab
Skin change seen in chronic venous insufficency, dark pigmentation caused by chronic haemosiderin deposition.
Dry skin and often have venous ulcers
Dx?
Lipodermatosclerosis
Most likely cause of atraumatic vertebral collapse in an elderly man
Metastatic malignancy
Mx of verebral collapse causing cord compression
Oral steroids
Surgical decrompression
(aim within 48hr)
First line treatment of UC
Topical or oral ASA (mesalazine)
Extensive UC management
Mesalazine + prednisolone
Management of acute severe UC
IV corticosteroids
1st line treatment of GBS?
IV immunoglobulin
Low sodium to high, your pons will…
DIE
High sodium to low, your brain will…
Blow
Most common cause of blindness worldwide
Trachoma
Cause of trachomas (think Sudan eye disease)
Chlamydia trachomatis
Man works with livestock and drinks unpasteurised milk. Now has arthralgia and hepatosplenomegaly -cause?
Brucellosis
Treatment of brucellosis
Dual antibiotic therapy
Doxycyclin and gentamicin
Presentation of brucellosis
Fever Weight loss Night sweats Lymphadenopathy Joint pain Spinal tenderness PUO!
Feel unusually prominent foetal parts on abdomen, what does this suggest?
Oligohydramnios
Potentially due to fetal renal agensis, use of ACEi in pregnancy, malnutrition
Causes of polyhydramnios
Maternal diabetes Foetal renal disorders TTTS Foetal anaemia Diaphragmatic hernia of foetus, duodenal atresia (can't swallow amniotic fluid)
Causes of metabolic alkalosis
Loss of chloride = Vomiting NG suction Diuretics (thiazides, loop diuretics) Diarrhoea (e.g. chloride secreting villous adenoma) Cystic fibrosis
Loss of potassium =
Primary hyperaldosteronism
Cushing’s syndrome
Other causes =
Carbonate overuse
Massive transfusion
Genetics of Turner’s syndrome
XO
Signs and symptoms of ectopic pregnancy
Lower abdominal pain Vaginal bleeding Cervical motion tenderness Positive B-HCG test Shoulder tip pain Vaginal bleeding
DDx of painful vaginal bleed
Miscarriage
Ectopic pregnancy
Medical management of ectopic pregnancy
One off methotrexate
Treatment of measles
Supportive care
Signs and symptoms of measles
Grey spots on mucosa Blanching, maculopapular rash all over
Fever
Cough
Runny nose
Causes of high anion gap
MUD PILES Metformin Uraemia DKA Paracetamol Iron Lactic acidosis Ethylene Salicylates
Causes of metabolic acidosis with normal anion gap
ABCD Addisons (adrenal insufficiency) Bicarbonate loss (GI/renal) Chloride excess Diuretics
A TCA overdose can cause what ABG picture?
Metabolic acidosis with raised anion gap
Which drug should be co-prescribed with methotrexate?
Folic acid
Helps reduce toxicity and side effects
Management of anaphylaxis
Stop offending drug Administer IM adrenaline 1:1000 0.5ml IV hydrocortisone 200mg IV chlorphenamine 10mg IV NaCl1 500ml
Tachycardic, hypotensive, decreased consciousness, metabolic acidosis, normal anion gap =>
Severe diarrhoea
Herepes zoster on face in one dermatome (shingles), eye involvement if the rash is where?
Nose tip = Hutchinson’s sign
1st line Mx of lactic acidosis in metformin use
500ml 0.9% saline bolus
Causes of lactic acidosis
Tissue hypoxia (Type A) Shock (e.g. cardiogenic, hypovolaemic, haemorrhagic) Hypoxia Acute mesenteric ischaemia Limb ischaemia Severe anaemia Seizures Vigorous exercise
Abnormalities in metabolism of lactate (Type B) Diabetic ketoacidosis Cancer Liver disease Inborn errors in metabolism Drugs: Metformin - impairs liver metabolism of lactate Aspirin
Frontal headache, impotence, bitemporal hemianopia, Ix?
Head MRI for pituitary adenoma
Which AF patients get rate control
HR > 90
Which AF patients get cardioversion?
New onset AF
Triggered AF
What Ix might you consider after a diagnosis of myasthenia gravis?
CT chest
Because myasthenia gravis is strongly associated with abnormalities of the thymus
Who performs the booking appointment for pregnancy?
Midwife who will support throughout the pregnancy
What blood tests are offered for expectant mothers?
HIV
Hepatitis B
Syphilis
What dose of ICS may you add first line in chronic asthma management in adults?
400 MICROGRAMS
Mx of mild Parkinsons disease
Ropinerole
Mx of Parkinson’s disease
Levodopa and carbidopa
Treatment of severe aortic stenosis
Surgical (if young)
Transcatheter aortic valve implantation (TAVI) if older
What Ix must you do to determine severity of a heart murmur, e.g. aortic stenosis?
Echocardiogram
What is TAVI?
Transcather aortic valve implantation
Triad of symptoms of aortic stenosis
Syncope
Heart failure
Angina
Symptoms of aortic stenosis
Syncope Angina Heart failure Exertional dyspnoea Decreased exercise tolerance
Buttocks and back pain, vascular cause
Ilioaortic disease (claudication)
Mx of claudication
Doppler ABPI RF modification Statins Aspirin Clopidogrel
Potential further options = bypass
Standard treatment for chronic HF
ACEi (improve heart remodelling) Beta blockers (improve heart efficiency) Diuretics (symptomatic)
QRISK 15% means…
15% chance of heart attack in the next 10 years
What should you consider prescribing for a patient with QRISK 11%?
A statin
Atorvastatin 20mg once nightly (because the cholesterol enzyme is more active at night!)
Mx of patient with high QRISK score
Life modifications
Regular testing of lipids
Statin (e.g. atorvastatin)
Secondary causes of hyperlipidaemia
Diabetes mellitus
Hypothyroidism (poor clearance of LDL)
Nephrotic syndrome (hypoalbuminaemia leads to hyperlipidaemia)
Blood pressure cut offs in ascending order of severity
- Single reading >140/90 mmHg and average ambulatory readings >135/85 mmHg
- Single reading >160/100 mmHg and average ambulatory readings >150/95 mmHg
- Single reading with systolic >180 mmHg or diastolic >110 mmHg.
Single reading high blood pressure cut off
140/90
Average ambulatory cut off for high blood pressure
135/85
What type of drug is carvedilol?
Beta blocker
Medical management of heart failure
Lisinopril (ACEi)
Carvedilol (B blocker)
Furosemide (diuretic)
Sx of heart failure, what do you need to do first to screen?
Measure BNP
If elevated, refer for trans-thoracic echocardiogram
When is BNP released?
When the ventricles stretch
It has a high negative predictive
When is BNP released?
When the ventricles stretch
It has a high negative predictive value, if it isn’t raised, it probably isn’t heart failure
Features of HOCM
Ejection systolic murmur louder when squatting
Palpitations and feeling faint when exercising
What is HOCM?
Genetic mutations in sarcomere lead to cardiac hypertrophy
What is holiday heart syndrome?
Big night out, triggers AF
Causes of AF
Ischaemic heart disease (most common)
Rheumatic heart disease
Hypertension
Non-cardiac Dehydration Infective Alcohol Electrolyte disturbance
Classification of AF
Acute (lasts <48 hours)
Paroxysmal (lasts <7 days and is intermittent)
Persistent (lasts >7 days but is amenable to cardioversion)
Permanent (lasts >7 days and is not amenable to cardioversion)
Cause of mid-systolic click
Mitral valve prolapse
Complications of HTN
Coronary artery disease Heart failure Renal failure Stroke Peripheral vascular disease
Gene for haemochromatosis
HFE
What is the pathophysiology of haemochromatosis?
Gene mutation (HFE), increased iron absorption, leading to high iron levels This iron accumulates in organs such as the heart and skin and pancreas. Causing dilated cardiomyopathy, heart failure, tanned skin and diabetes
Most common cause of mitral stenosis
Rheumatic fever
Management of late stage heart failure after max medical treatment
Cardiac resynchronisation therapy (CRT)
What drug can be used as a pill in the pocket for AF in young people?
Flecainide
Rate control drugs for AF
Beta blockers
Verapamil or diltiazem (CCB)
Digoxin = second line
Chest pain and new onset bundle branch block on ECG, what are you concerned about?
ACS
Treat urgently with primary percutaneous coronary intervention if possible
First line investigation of angina
CT coronary angiography
Sinus bradycardia with no adverse signs, what do you need to do?
Observe and try to identify a cauase (e.g. hypothyroidism)
Cut off for bradycardia
HR < 60bpm
Drug that can induce bradycardia
Verapamil + B blocker!
Syncope, dizziness, tiredness, what Ix should you do?
ECG
HR 48 with symptoms of syncope, what should you give?
Atropine
Block parasympathetic activity, increasing heart rate
Most common heart murmur post MI
Mitral regurgitation (secondary to rupture of papillary muscle) Ventricular septal defect
These both give a PAN-SYSTOLIC murmur
Slow rising pulse is associated with which heart valve murmur?
Aortic stenosis
Collapsing pulse is associated with which murmur?
Aortic regurgitation
Causes of aortic regurgitation
Rheumatic heart disease
Infective endocarditis
Aortic dissection
IHD
Chronic causes of regurgitation murmurs (mitral and aortic)
Calcific aortic valve disease (age related)
Congenital disease e.g. bicuspid aortic valve
Rheumatic heart disease - most common cause in the developing world
Infective endocarditis
Rheumatic causes e.g. rheumatoid arthritis, antiphospholipid syndrome
Marfan’s syndrome
Electrolyte imbalance that causes prolonged QT interval
Hypocalcaemia
Hypokalaemia
What electrolyte imbalance is common after thyroidectomy?
Hypocalcaemia because loss of parathyroid glands
Clinical features of pericarditis
Chest pain (usually pleuritic and worse on lying flat) Fever Pericardial friction rub ECG changes Widespread saddle-shaped ST elevation PR depression Raised troponin
Management of stable angina
The management of stable angina includes optimising risk factors for cardiovascular disease:
Smoking cessation Glycaemic control Hypertension Hyperlipidaemia Weight loss Alcohol intake
First line medical
Aspirin
Statin
Sublingual GTN
Beta blocker or rate limiting calcium channel blocker
Can add a long acting nitrate
Medical treatment of chronic heart failure
ACEi
Beta blocker
Furosemide
Spironolactone
Causes of heart failure
Causes of systolic heart failure Ischaemic heart disease Dilated cardiomyopathy Myocarditis Infiltration (e.g. in haemochromatosis or sarcoidosis)
Causes of diastolic heart failure Hypertrophic obstructive cardiomyopathy Restrictive cardiomyopathy Cardiac tamponade Constrictive pericarditis
What is high output heart failure?
Increased metabolic demands so the heart can’t cope
E.g. anaemia or infection or thyrotoxicosis
Clinical features of Brugada syndrome
Coved ST elevation followed by inverted T waves = Brugada sign
Episodes of palpitations and dizziness
Syncope
Management of Brugada syndrome
Implantable cardiodefibrillator
ECG changes in posterior STEMI
ST elevation in leads 2, 3, aVF
ECG changes in NSTEMI
ST depression in whichever leads
T wave inversion!
The inheritance pattern of HOCM
Autosomal dominant
50% chance of son having it!
Features of insulinoma
Aggression
Raised C-peptide
Low glucose
Signs of hypoglycemia
What is a Whipple’s procedure?
Pancreaticoduodenectomy
COPD management
Conservative:
COPD nurse
Chest physio
Medical =
SABA
LABA + ICS if asthma Sx
LABA + LAMA if not
Then all of them
