Renal, Cardio, Endo Flashcards
What to prescribe when ACR >30 + htn (or just >70mg/mmol) in CKD
ACEi
When to refer to nephrologist for proteinuria
when ACR>70 and no diabetes
When ACR>3 + hematuria/rapidly declining egfr
How to treat anaemia in CKD
Iron studies + iron treatment first before EPO (this will be normocytic + egfr <35)
Bc of inc Herceptin impairs iron absorption
ECG changes of hyperkalaemia
Tall tented T
Loss p waves
Broad QRS
sinusoidal wave pattern
Name some nephrotoxic drugs
NSAIDs
Aminoglycosides
ACEi
ARBs
Diuretics
ECG changes for hypokalaemia
U waves
Small T waves
Prolonged PR interval
ST depression
Mx if inc risk of contrast induced nephropathy
IV 0.9% nacl 1ml/kg/hr for 12 hours pre and post
withhold metformin 48 hours post normal renal function
Mx of CKD BMD
Correct hyperphosphataemia first - low pi diet, then pi binders sevelamer
What to monitor for HSP
urinalysis and bp
Symptoms of HSP
Palpable purpuric rash on bum/legs/arms
abdo pain
polyarthralgia
hematuria/renal failure
When to refer for 2ww cystoscopy
> 45 + unexplained visible haematuria
60 + unexplained invisible hematuria + dysuria/inc acc
Peritoneal dialysis causative organism
staph epidermidis
add vancomycin + ceftazidime to fluid
or vanc to fluid + oral ciprofloxacin
Complications of peritoneal dialysis
hernia
peritoneal sclerosis
hydrothorax
drainage problems
peritonitis
Biopsy findings for nephritic syndrome
- buegers
- post strep
- goodpastures
- alports
- vasculitis
- Buergers: mesangial iga deposits in glomeruli
- post strep: igg + Igm + c3 deposits of sub epithelial humps + starry sky immunofluorescence
- Goodpastures: linear igg deposits along bm
- alports: basket weave
- vasculitis: segmental necrotising
Wegeners (Granulomatosis with polyangitis) vs churg-strauss syndrome (eosinophilic granulomatosis with polyangitis)
GPA: cANCA, binds to pr3 - renal failure (glomerulonephritis), epistaxis, hemoptysis
EGA: pANCA, binds to mpo, eosinophilia, late onset asthma
Both have sinusitis and SOB
CVS abnormality in PCKD
mitral regurgitation
Triad for HUS
AKI
Micoangiopathic hemolytic anaemia
Thrombocytopenia
Gold standard ix for HUS
Blood film - schistocytes
Can also do fbc, u+es, stool culture, Coombs test
Features of acute tubular necrosis
AKI
Muddy brown casts
Poor response to fluids
Causes of acute tubular necrosis
ischaemic (sepsis/shock)
nephrotoxins (contrast, aminoglycosides, myoglobin (creatine kinase inc >5x)
Features of acute interstitial nephritis
Fever
Rash
Arthralgia
Eosinophilia
HTN
Mild AKI
White cell casts
Sterile pyuria
Causes of acute interstitial nephritis
Drugs (penicillamine, rifampicin, nsaids)
SLE/sjogrens
Staph infection
How long do you treat provoked PEs for
3 months (6 months if cancer)
6 months if unprovoked
Wells score for PE
likely - more than 4
unlikely - 4 or less
Features of HOMC
Mutation in myosin heavy cain
hAsymptomatic
Exertional dyspnoea, fatigue, syncope, angina
Sudden death (ventricular arrythmias, HF)
Bisferians pulse
Ejection systolic murmur, pan systolic murmur (mitral regurgitation)
S4
Ix for HOMC
ECG: LVH (tall R, T inversion, deep Q, AF)
ECHO: MR SAM ASH - mitral regurg, sys anterior motion, asymmetric hypertrophy
Mx HOMC
A - amiodarone
B - b blocker
C - cardio defibrillator
D - dual chamber pacemaker
E - endocarditis prophylaxis
What to avoid in HOMC
nitrates
acei
intense exercise
Poor prognostic indicators after ACS
cardiogenic shock
age
cardiac arrest on admission
elevated initial cardiac markers
high serum creatinine concentration
pulmonary oedema
Causes of long QT (which causes torsades)
tcas
antipsychotics
macrolides
amiodarone
SAH
hypothermia
hypocalcaemia
When to treat HTN
If stage 1 + <80 + organ damage/cvs disease/renal/diabetes/qrisk>10%
If >180/120 refer same day if papilledema/confusion/chest pain or other signs. If asymptomatic just immediate bloods/urine acr/ecg and if all ok then repeat bp in 7 days
Target BP <80 vs >80
<80 140/90
>80 150/90
Gold standard ix for aortic dissection
ct angiogram (false lumen)
if unstable transoesophageal echo
Which HF causes pulmonary oedema vs which HF causes peripheral oedema
Left: pulmonary oedema
Right: peripheral oedema
New York heart association HF classification
- no symptoms
- slight limitation on physical activities
- moderate
- severe, no physical activity without symptoms, symptoms at rest
Indications for surgery for endocarditis
severe valve failure
aortic abscess (inc PR)
resistant infection
HF
recurrent emboli
pregnant
Complications of MI
- cardiac arrest - VF
- cardiogenic shock
- chronic HF
- Tachyarrhythmia (VF), and bradyarrhythmia (AV block)
- pericarditis (dresslers if 2-6 weeks post)
- LV aneurysm: persistent ST elevation and LV failure so anticoagulant needed
- LV free wall rupture: 1-2 weeks post causes cardiac tamponade hence HF
- VSD: pansystolic murmur, if interventricular septum rupture
- Acute mitral regurg: if inferoposterior - hypotension + pulmonary oedema
Murmur for congenital pulmonary stenosis
Ejection systolic murmur
Loud on inspiration
Features of cardiac tamponade
becks triad - hypotension, muffled hs, raised jvp
pulsus paradoxus (large drop in bp when inspiration)
electrical alternans
Gold standard diagnostic ix for cardiac tamponade
Echo
Name 4 Hs and 4 Ts of cardiac arrest
Hypoxia
Hypothermia
Hypovol
Hyperkal
Thrombosis
Tension pneumothorax
Tamponade
Toxins
Paediatric cardiac arrest
Check femoral or brachial pulse
5 rescue breaths
15:2 if professional people and 30:2 if normal people
2nd line therapy for HFrEF
SGLT2 inhibitors
Signs of HTN emergencies
Encephalopathy
LVF (pulmonary oedema)
Aortic dissection
Renal failure (AKI)
Unstable angina (MI)
Caused by phaeochromocytoma, cushings, primary hyperaldosteronism
Following a TIA, If AF Is found when do you start anticoagulation
Immediately with a DOAC
(if its a stroke then 2 weeks post)
Indications for surgery for aortic stenosis
Symptoms
Severe LV dysfunction
Exercise intolerance
Having another cardiac surgery
Aortic valve gradient >40
TAVI if high risk patient
INR = 3
Periarrest bradycardia mx
atropine up to 3mg if life threatening (if dont monitor unless recent asystole, mobitz2, complete h block, ventricular pause over 3 seconds)
transcut pacing/ aderenaline / isoprenaline
transvenous pacing
ECG changes in bi fascicular block vs tri
bi: RBBB + LAD
tri: RBBB + LAD + 1st degree heart block
What is takotsubo cardiomyopathy
broken heart syndrome
transient apical ballooning of myocardium
ST elevation
Chest pain, HF symptoms
Self limiting
Causes of pericarditis
viral infection (coxsackie, tb)
autoimmune ra/sle
idiopathic
methotrexate
MI
malignancy - lung
hypothyroidism
Most common ECG finding for pericarditis
PR depression
When to give oxygen in ACS
When sats <92%
Most common organisms for endocarditis
staph aures (esp IVDU + <1yr valve)
strep viridians (>1 yr valve)
staph epidermis (following <2 months prosthetic valve surgery)
Enterococcus (GI)
HACEK if - culture - haemophilus, actinobacillus, cardiobacterium, eikenella, kingella
biopsy for GPA
necrotising granulomatosis (caseating granulomas)
Metabolic abnormality in renal tubular acidosis
Hyperchloraemic metabolic acidosis
Normal anion gap
Normal ECG variants in athletes
sinus bradycardia
1st degree AV block
Mobitz type 1
Junctional rhythm
ECG signs for MI
hyperacute t waves
st elevation
T waves inverted in 1st 24 hours and can last months
Pathological Q waves after several days indefinitely
ECG finding of hypocalcaemia vs hypercalcaemia
Hypo: prolonged QT
Hyper: shortened QT
Last line for HTN and K+>4.5
then alpha blocker (carvedilol) or b blocker instead of spironolactone
Features of brugada syndrome
cause of sudden cardiac death so need implantable cardio defibrillator
st segment elevation + partial rbbb - more prominent after flecainide so ix of choice
Types of RTA
- in distal: can’t secrete H+ therefore hypokal - RA, SLE - leads to renal stones
- in proximal: less hco3 reabsorption therefore hypokal + osteomalacia - Wilsons + multiple myeloma - leads to osteomalacia
- hyperkalaemic: less aldosterone means less ammonium secretion so hyperkal - in hypoald, diabetes
mx via oral bicarb to neutralise the acid
Hypovolaemic hyponatraemia urine Na <20 vs >20
<20 = non renal problem = d+v + pancreatitis
>20 = renal loss = thiazides, diuretics
Mx for hyponatraemia
- if hypovolaemic: normal nacl
- if hypervolaemic or euvolaemic: fluid restrict 500-1000ml/day +/- tolvaptan + furosemide
- if severe <120 or symptomatic then hypertonic saline 3%
Correction of hypernatraemia too fast vs hyponatraemia
Hyponatraemia: central pontine myelinolysis
Hypernatraemia: cerebral oedema
Causes of SIADH
Post operative
Pneumonia/tb
Head haemorrhage
SSRIs/carbamazepine
SCLC
Meningitis
SAH
Mx SIADH
Fluid restrict
Tolvaptan
Demeclocycline
Indications for primary prevention statin
QRISK >10%
T1DM >40yrs/>10yrs diagnosis/nephropathy/CVS risk f
CKD
Causes for diabetes insipidus
Cranial:
- trauma
- tumour
- tb
- meningitis
- sarcoidosis
- haemochromatosis
Nephrogenic:
- congenital
- lithium
- hypokal/hypercalc
- PCKD
Xray findings for primary hyperparathyroidism
osteopenia
erosion of terminal pharyngeal tufts
subperiosteal resorption of bone
Metabolic abnormality in addisonian crisis
hyperkalaemic metabolic acidosis
Mx for addisonian crisis
hydrocortisone 100mg every 6 hours
Oral replacement may begin after 24 hours and reduced to maintenance over 3-4 days
If hypoglycaemia 0.9% nacl over 1 hour
Diagnostic ix for Addisons disease
Short synacthen test
Metabolic abnormality for cushings syndrome
hypokalaemic metabolic alkalosis
Triad for prolactinoma
Amenorrhoea
Headaches
Bitemporal hemianopia
Somatostatin analogue medicine
GH receptor antagonist medicine
S: octreotide
GH: pegvisomant
Most common cause of primary hyperaldosteronism
Bilateral idiopathic adrenal hyperplasia
What is a pituitary apoplexy
Sudden enlargement of a NFPA due to haemorrhage or infection
Leads to sudden onset vomit, headache, stiffness, visual defects
Needs urgent mri, steroids + surgery
Cancers associated with MEN
Phaeochromocytoma (2)
Medullary thyroid (2)
Insulinoma (1)
Mx for pheochromocytoma
a blocker phenoxybenzamine
then b blocker labetalol
then adrenalectomy
Complications of phaeochromocytoma
HTN crisis
Arrhythmias
Pulmonary oedema
Hyperglycemia
Encephalopathy
Features of CAH
Recessive where impairment of adrenal steroid synthesis so increase in ACTH which increases androgens
In f: ambiguous genitalia, precocious puberty, infertility, accelerated growth, salt wasting crisis
- ACTH stimulation test
What is a thyroid storm
- fever, tachycardia, confusion, n+v, htn
- need to treat underlying event, iv propranolol, antithyroid drugs, dexamethasone
What is myxoedema coma
Emergency hypothyroidism
Confusion and hypothermia
IV thyroid
IV fluids
IV steroids until adrenal insufficiency ruled out
Correct electrolyte imbalance
How to treat subclinical hypothyroidism
If TSH>10 on 2 separate occasions 3 months apart then levothyroxine
If <65yrs and 5.5-10 and symptoms then 6 month trial
If assymp retest in 6 months
Black man on amlodipine and needs additional
arb
Sick euthyroid syndrome features
asymptomatic
significant illness/trauma
dec t3/4
Metabolic abnormality in DKA
metabolic acidosis
increased anion gap
Acute vs chronic graft rejection
acute = <6 months
signs of infection
inc creatinine + proteinuria
Aldosterone: renin test
if >20 then low renin so primary hyperaldosteronism
if <20 then high renin so secondary hyperaldosteronism
Mx bilateral adrenal hyperplasia
spironolactone
Gastroparesis in diabetes features
erratic blood glucose control
bloating
vomiting
needs metoclopramide
Native endocarditis initial empirical treatment
iv amoxicillin
(vancomycin + rifampicin if prosthetic valve)
Causative organism for IVDU IE
staph aures
CXR findings for HF
Alveolar oedema (bat’s wings)
Kerley B lines (interstitial oedema - perihilar shadowing)
Cardiomegaly
Dilated prominent upper lobe vessels
Effusion (pleural)
Valvular af + mechanical valve - what medicine??
warfarin
(if bioprosthetic valve = aspirin)
Features of takayasus arteritis
large vasculitis of aorta
young asian females
unequal bp in both arms
claudication
aortic regurgitation
renal artery stenosis
MR angiogram
needs steroids
Features of posterior stemi
ST depression
tall, broad R waves
upright T waves
dominant R wave in V2
RCA
Causes of postural hypotension
hypovolaemia
diabetes
parkinsons
alcohol
diureitcs/antihtn/sedatives
Hypomagnesia mx
if <0.4 or seizures then iv mg
if >0.4 then oral mg salt (diarrhoea SE)
Mx post partum thyroiditis
propranolol
Features insulinoma
hypoglycaemia
rapid weight gain
high c peptide
ct
Pre-diabetes
hba1c 42-47 (6-6.4)
fasting 6.1-6.9
ogtt 7.8-11
Diagnosis of T2DM
OGTT >11
HbA1c >48 + symptoms (or repeated twice)
Diagnosis of T1DM
Fasting >7
Random >11.1
On 2 separate occasions if assymptomatic
ALS mx v fib/v tach
- check pulse
- if none then 3 synchronised shocks - with 2 mins cpr in between each one
- adrenaline 1 in 10000 repeat every 3-5 + amiodarone
ALS mx pea/asystole
- check pulse
- if none then adrenaline + repeat every 3-5 mins and then cpr
Acute HF mx
oxygen
250ml bolus
iv furosemide
if htn dobutamine (b agonist makes heart pump harder) or vasopressors like adrenaline to cause vasoconstriction
CPAP if resp failure
