Respiratory + Cardiac Flashcards
1
Q
COPD:
- mild, moderate, severe and very severe % FEV1? (4)
A
> 80%
50-79%
30-49%
<30%
1
Q
Pneumothorax:
- when to follow up after drain/ aspiration? (1)
- flying? (1)
- deep sea diving (1)
- follow-up if conservative management for primary (1) and secondary (1)
A
- follow-up after 2-4 weeks
- can’t fly 2 weeks
- NEVER
- patients with a primary spontaneous pneumothorax that is managed conservatively should be reviewed every 2-4 days as an outpatient
- secondary spontaneous pneumothorax that is managed conservatively should be monitored as an inpatient
2
Q
COD:
- when to give NIV? (1)
- what type is used? (1)
A
Respiratory acidosis: pH 7.25-7.35
if pH < 7.25 –> HDU
BIPAP
3
Q
CAP:
- discharge criteria (5)
A
NICE recommend that patients are not routinely discharged if in the past 24 hours they have had 2 or more of the following findings:
- temperature higher than 37.5°C
- respiratory rate 24 breaths per minute or more
- heart rate over 100 beats per minute
- systolic blood pressure 90 mmHg or less
- oxygen saturation under 90% on room air
- abnormal mental status
- inability to eat without assistance.
4
Q
Asthma
- step-down steroids? (1)
A
In the step-down treatment of asthma, aim for a reduction of 25-50% in the dose of inhaled corticosteroids
5
Q
Asthma:
- gold standard diagnosis adults (1)
- test for 6-16 years (1)
A
- FeNO test and spirometry with a bronchodilator reversibility test
(should do once child 5 years)
5-16 years
- spirometry with bronchodilator reversibility (BDR) test and a FeNO test if normal spirometry or obstructive spirometry with negative bronchodilator reversibility test
<5 years
clinical judgement
6
Q
COPD:
- oxygen management (1)
A
still give HFNO if septic/ unwell
if not:
a 28% Venturi mask at 4 l/min and aim for an oxygen saturation of 88-92% for patients with risk factors for hypercapnia but no prior history of respiratory acidosis
7
Q
COPD
- management (3)
A
- SAMA or SABA
- asthmatic= LABA+ICS (+SABA)
- non-asthmatic= LABA+LAMA (+SABA)
- LABA+LAMA+ICS (+SABA)
8
Q
COPD
- what oral Abx prophlatic (1)
- pre-requisites to giving it (6)
A
azithromycin
- don’t smoke
- optimised standard therapy
- continue to have exacerbations
- CT throax (to exclude bronchiectasis)
- sputum culture (to exclude atypical infections and tuberculosis)
- LFTs and an ECG to exclude QT prolongation should also be done as azithromycin can prolong the QT interval
9
Q
COPD infective exacerbation organism
A
haemophilus influenzae
10
Q
asthma management
A
SABA
SABA + ICS
SABA + low-dose ICS + leukotriene receptor antagonist (LTRA)
SABA + low-dose ICS + long-acting beta agonist (LABA)
Continue LTRA depending on patient’s response to LTRA
SABA +/- LTRA
Switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a low-dose ICS
11
Q
prednsiolone and breastfeeding
A
safe
‘inhaled drugs, theophylline and prednisolone can be taken as normal during pregnancy and breast-feeding’.
12
Q
Chest x-ray shows numerous parallel line shadows
A
bronchiectasis
(tram lines - indicate dilated bronchi due to peribronchial inflammation and fibrosis)
13
Q
Aspergilloma:
(a fungal growth)
- management (2)
- who does it impact (2)
- symptoms (3)
A
- itraconazole and steroids
- immunocompromised or people with underlying cavitationg disease e.g. TB/ emphysema
Symptoms of include fever, cough and haemoptysis.
14
Q
Aspergilloma XRAY
A
rounded opacity
15
Q
Granulomatosis with polyangiitis
A
A rare VASCULITIS in your nose, sinuses, throat, lungs and kidneys.
Upper respiratory tract: epistaxis, sinusitis, nasal crusting
Lower respiratory tract: dyspnoea, haemoptysis
Glomerulonephritis
Saddle-shape nose deformity
16
Q
which murmur causes haemoptysis
A
MITRAL STENOSIS:
Dyspnoea
Atrial fibrillation
Malar flush on cheeks
Mid-diastolic murmur
17
Q
COPD vaccinations (2)
A
annual influenza vaccination
one-off pneumococcal vaccination
18
Q
CURB-65
A
C Confusion (abbreviated mental test score <= 8/10)
R Respiration rate >= 30/min
B Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60 mmHg
65 Aged >= 65 years
19
Q
when to repeat CXR post pneumonia
A
6 weeks
20
Q
cut off for HTN age
A
55
21
Q
Stage 2 HTN (when to start antihypertensives straight away)
A
Clinic = 160/100 +
Home= 150/95 mmHg +
22
Q
what drug is contraindicated in VT
A
verapamil
23
Q
VT management
A
Shock if HISS
otherwise:
amiodarone: ideally administered through a central line
lidocaine: use with caution in severe left ventricular impairment
procainamide
24
aortic stenosis in a fit person- what is the management?
Prosthetic heart valves - mechanical valves last longer and tend to be given to younger patients
older = bioprosthetic aortic valve replacement
25
IVDU + IE = which valve?
tricuspid
26
previous normal values + IE = which valuve
mitral valve
27
IE: which organism most common?
Staph aureus
28
angina: appropriate prophylactic medication?
B blocker of CCB
if CCB alone= rate limiting (verapamil/ diltiazem)
29
what to add if stilll Sx after monotherapy for angina
a long-acting nitrate
ivabradine
nicorandil
ranolazine
30
isosorbide mononitrate: tolerance
patients who take standard-release isosorbide mononitrate should use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimise the development of nitrate tolerance
this effect is not seen in patients who take once-daily modified-release isosorbide mononitrate
31
when to check U&E post ACEi
should be checked at baseline, 2 weeks after starting treatment and 2 weeks after each dose change. Once a maintenance dose has been established urea and electrolytes should be checked at 1, 3 and 6 months.
32
early diastolic murmur
aortic regurgitation
33
pansystolic murmur
mitral regurgitation
34
acute cause of aortic regurgitation
aortic dissection OR IE
35
Pharmacological cardioversion
flecainide or amiodarone if there is no evidence of structural or ischaemic heart disease orc
amiodarone if there is evidence of structural heart disease.'
36
valve problem associated with polycystic kidney disease
mitral valve prolapse and mitral regurgitation being the most common
37
ECG normal variants in athlete
sinus bradycardia
junctional rhythm
first degree heart block
Mobitz type 1 (Wenckebach phenomenon)
38
NSTEMI
After an ECG and troponin testing, he is diagnosed with non-ST segment elevation myocardial infarction (NSTEMI). You assess him using the GRACE score and his predicted 6-month mortality is 2%. He does not have a high risk of bleeding. The nearest primary percutaneous intervention unit is more than one hour away.
GRACE <3
aspirin + ticegralor
GRACE >3
aspirin + prasugrel + unfractionated heparin
+ PCI
+ drug eluting stent
ticagrelor, if not high bleeding risk
clopidogrel, if high bleeding risk
GRACE<3%
give ticegrelor
GRACE >3%
PCI if unstable. give prasugrel/ ticegrelor = unfractionated heparin + drug eluting stents
39
AF + an acute stroke: when to start DOAC?
after 2 weeks
(anti platelet therapy intervening period)
40
when to start DOAC after TIA for AF?
straight away
41
clopidogrel common drug ineraction
omeprazole
42
statin blood tests
LFTs baseline, 3 and 12 months
43
GTN side effects
Hypotension + tachycardia + headache
44
Heart failure: what to do if unresponsive to IV loop diuretics and O2
CPAP
45
Amioderone:
monitoring?
TFT, LFT, U&E, CXR prior to treatment
TFT, LFT every 6 months
A baseline chest x-ray is required due to the risk of pulmonary fibrosis / pneumonitis in patients treated with amiodarone. Urea and electrolytes are suggested by the BNF to detect hypokalaemia which may increase the risk of arrhythmias developing.
46
Angina: when to refer to cardiology for PCI/ CABG? (1)
If on 3rd antianginal
47
pregnancy and statin
AVOID
48
Janeway lesions vs Oslers nodes
Janeway lesions are painless, erythematous haemorhagic lesions seen on the palms and soles. They are associated with infective endocarditis
Oslers nodes = OUCH
49
Warfarin management: major bleeding
Stop warfarin
Give intravenous vitamin K 5mg
Prothrombin complex concentrate - if not available then FFP*
50
Warfarin management: INR >8 and minor bleeding
Stop warfarin
Give intravenous vitamin K 1-3mg
Repeat dose of vitamin K if INR still too high after 24 hours
Restart warfarin when INR < 5.0
51
warfarin management: INR >8 and no bleeding
Stop warfarin
Give vitamin K 1-5mg by mouth, using the intravenous preparation orally
Repeat dose of vitamin K if INR still too high after 24 hours
Restart when INR < 5.0
52
warfarin management: INR 5-8 minor bleeding
Stop warfarin
Give intravenous vitamin K 1-3mg
Restart when INR < 5.0
53
warfarin management: no bleeding, INR 5-8
Withhold 1 or 2 doses of warfarin
Reduce subsequent maintenance dose
54
nicorandil (vasodilatory drum but NOT GTN)) side effects
headache
flushing
ANAL ulceration
55
Left ventricular hypertrophy and deep ST depression and T-wave inversions consistent with what cardiac condition
HOCM
56
HOCM:
inheritance? (1)
features? (5)
autosomal dominant
asymptomatic
exertion dypnoea
angina
syncope
sudden death (ventricular arrhythmias)
jerky pulse
systolic murmurs
57
murmur with HOCM
mitral regurgitation
58
most common cause of sudden death In HOCM
ventricular arrhythmia
59
Coarctation of the aorta
congenital narrowing or aorta
more common in men yet associated with Turners Sx
infancy: heart failure
adult: hypertension
radio-femoral delay
mid systolic murmur, maximal over the back
apical click from the aortic valve
notching of the inferior border of the ribs (due to collateral vessels) is not seen in young children
60
Off driving after CABG?
4 weeks
61
off driving after ACS
4 weeks - down to 1 week if successful angioplasty
62
U waves
Hypokalaemia
hypocalcaemia
hypothermia
63
when is third heart sounds normal?
<30 years
64
HOCM what medication to avoid
nitrates
ACE-inhibitors
inotropes
65
management HOCM
Amiodarone
Beta-blockers or verapamil for symptoms
Cardioverter defibrillator
Dual chamber pacemaker
Endocarditis prophylaxis*
Hypertrophic obstructive cardiomyopathy (HOCM) is an autosomal dominant disorder of muscle tissue caused by defects in the genes encoding contractile proteins. The estimated prevalence is 1 in 500
66
management WPW syndrome
definitive treatment: radiofrequency ablation of the accessory pathway
medical therapy: sotalol***, amiodarone, flecainide
sotalol should be avoided if there is coexistent atrial fibrillation as prolonging the refractory period at the AV node may increase the rate of transmission through the accessory pathway, increasing the ventricular rate and potentially deteriorating into ventricular fibrillation
67
what is WPW associated with
HOCM
mitral valve prolape
Abstains anomaly
thyrotoxicosis
68
short PR, palpitations post exercise
WPW
69
regular, low-volume pulse and a mid-diastolic murmur loudest with the patient leaning to his left-hand side.
mitral stenosis (P mitrale)
70
heart failure:
CXR signs
Alveolar oedema (bat's wings),
Kerley B lines (interstitial oedema),
Cardiomegaly, Dilated prominent upper lobe vessels,
Effusion (pleural) are features of heart failure on a chest x-ray
71
Surgery for bronchiectasis
only is localised disease
72
most common organism infection bronchiectasis
Haemophilus influenzae (most common)
73
Azithromycin:
before starting what should patient have? (4)
CT thorax, ECG, liver function testing, and sputum cultures.
74
Berylliosis
condition is caused by exposure to beryllium dust. This is almost always an occupational exposure and is seen in workers of the electronics and metal extraction industries.
75
Mantoux test is for..
TB
76
Lung volume reduction surgery
removes the worst affected part of the lungs in order to improve airflow and alveolar gas exchange in the remaining portion of the lung.
77
Alpha-1 antitrypsin deficiency
no smoking
supportive: bronchodilators, physiotherapy
intravenous alpha1-antitrypsin protein concentrates
surgery: lung volume reduction surgery, lung transplantation
78
Nicotine replacement:
what other medications can you try? (2)
how long to prescribe for? (1)
when to offer repeat? (1)
- varenicline or bupropion
- until 2 weeks after the target stop date.
- if unsuccessful, don't offer another until 6 months unless they're demonstrated they are going to stop
79
Bupropion:
- how does it work? (1)
- what is it used for? (1)
- contraindications (3)
norepinephrine-dopamine reuptake inhibitor and nicotinic antagonist
an antidepressant used for smoking cessation
SEIZURES, pregnancy/ breast feeding
start 2 weeks before quitting
80
Varenicline:
how does it work? (1)
side effects? (2)
- nicotine receptor agonist
- varenicline should be used with caution in patients with a history of depression or self-harm. There are ongoing studies looking at the risk of suicidal behaviour in patients taking varenicline
- SE: nausea is the most common adverse effect. Other common problems include headache, insomnia, abnormal dreams
81
Pregnany and smoking
all pregnant women should be tested for smoking using carbon monoxide detectors, partly because 'some women find it difficult to say that they smoke because the pressure not to smoke during pregnancy is so intense.
82
Mining occupation, upper zone fibrosis, egg-shell calcification of hilar nodes
Silicosis
83
pneumoconiosis
a class of lung disease characterised by inhalation of (usually occupational) dust.
84
swinging fevers, night sweats, pleuritic chest pain, dyspnoea, and cough
lung abscess
85
Most common cause lung abscess
secondary to aspiration pneumonia
86
Treatment abscess if Abx failed?
Percutaneous drainage should be considered if a lung abscess is not improving with intravenous antibiotics
87
Difference presentation abscess vs pneumonia
Sx develop subacute (over weeks)
88
Pneumonia + upper lobe+ diabetic/alcoholic
Klebsiella pneumonia
Klebsiella most commonly causes a cavitating pneumonia in the upper lobes, mainly in diabetics and alcoholics
red currant jelly sputum
89
an atypical pneumonia that commonly spreads via a contaminated water supply (e.g. air conditioner vents). Common symptoms include fever, cough and myalgia. Bilateral chest symptoms are more common and other extra-pulmonary symptoms (e.g. hyponatraemia and hepatitis) are seen.
legionella
90
an atypical pneumonia with symptoms including coryza and a dry cough. This form of pneumonia is associated with extra-pulmonary symptoms such as haemolytic anaemia and erythema multiforme that are not seen here.
Mycoplasma pneumonia
91
most common cause of community-acquired pneumonia with symptoms including a classical history of fever, productive cough and shortness of breath.
Strep pneumoniae
92
Asthma:
cannot complete sentences
severe asthma
93
Asthma:
RR>25
HR >110
severe asthma
94
Asthma: PEFR 33-50%
severe
95
ASthma: PEFR <33%
life threatening
96
Asthma: Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
life threatening
97
What is a near Fatal asthma attack?
raised pC02 and/or requiring mechanical ventilation with raised inflation pressures.
98
When to do CXR in asthma?
if:
- suspected penumonothorax
- failed to respond to treatment
- life-threatening asthma
99
Asthma:
when to discharge? (3)
been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12-24 hours
inhaler technique checked and recorded
PEF >75% of best or predicted
100
COPD:
thresholds for severity of Stage 1-4? (4)
>80% (mild - Stage 1)
50-79% (moderate)
30-49% (sever)
<30% (very severe - Stage 4)
101
COPD + peripheral oedema, raised jugular venous pressure, systolic parasternal heave, loud P2 - what is it? (1)
treatment (2)
cor pulmonale
can consider loop diuretic or LTOT
102
Factors improving COPD survival? (3)
smoking cessation - the single most important intervention in patients who are still smoking
long term oxygen therapy in patients who fit criteria
lung volume reduction surgery in selected patients
103
Anterior mediastinal mass (4)
4 T's: teratoma, terrible lymphadenopathy, thymic mass and thyroid mass
104
Pneumothorax:
when safe to fly?
2 weeks after if no residual air
105
Pneumothorax treatment if asymptomatic?
conservative care regardless of side
106
Pneumothorax:
if symptomatic, what is the next step in assessment? (1)
feature (6)
what to do? (1)
1. Symptomatic VS not
if SYMMPOTOMATIC --> process to step 2
if NOT --> no treatment
2. HIGH RISK?
haemodynamic compromise (suggesting a tension pneumothorax)
significant hypoxia
bilateral pneumothorax
underlying lung disease
≥ 50 years of age with significant smoking history
haemothorax
if HIGH RISK --> CHEST DRAIN
if NOT HIGH RISK --> choice
107
if no high risk features but symptomatic pneumothorax?
if no high-risk characteristics are present, and it is safe to intervene, then there is a choice of intervention:
conservative care
ambulatory device
needle aspiration
108
How to know a chest drain or aspiration is safe?
2cm laterally or apically on CXR
OR
any size on CT scan
109
Pneumothorax follow-up:
Conservative management spontaneous pneumothorax- when to review? (1)
needle aspiration (1)
chest drain (1)
every 2-4 days for conservative
aspiration: after 2-4 weeks (if failed then do chest drain)
drain: daily r/v as IP then 2-4weeks post discharge
110
pleural plaques follow-up
Pleural plaques are the most common form of asbestos-related lung disease and are benign. They are not associated with an increased risk of lung cancer or mesothelioma. This patient should be reassured and advised that no follow-up of these specific plaques is necessary, although an ongoing review of his lung disease is encouraged.
111
Most common cause of asbestos in the lung
pleural plaque
112
Asbestos:
lung problems
plural plaques
pleural thickening
asbestosis
mesothelioma
113
management mesothelioma (1)
palliative chemotherapy
terrible prognosis
limited role of surgery or radiotherapy
114
most common cancer in asbestos exposure
LUNG cancer (not mesothelioma!)
115
BiPAP: what type of respiratory failure due it help? (1)
Type 2 resp failure
116
Lung cancer:
small cell
arise from APUD* cells
associated with ectopic ADH, ACTH secretion
ADH → hyponatraemia
ACTH → Cushing's syndrome
ACTH secretion can cause bilateral adrenal hyperplasia, the high levels of cortisol can lead to hypokalaemic alkalosis
Lambert-Eaton syndrome: antibodies to voltage gated calcium channels causing myasthenic like syndrome
117
The combination of pulmonary haemorrhage (haemoptysis), renal impairment (rapidly progressive glomerulonephritis) and flat or saddle nose (due to a collapse of the nasal septum)
is characteristic of granulomatosis with polyangiitis.
118
Chest tube placement critiera
Patients with frankly purulent or turbid/cloudy pleural fluid on sampling should receive prompt pleural space chest tube drainage.
The presence of organisms identified by Gram stain and/or culture from a non-purulent pleural fluid sample indicates that pleural infection is established and should lead to prompt chest tube drainage.
Pleural fluid pH < 7.2 in patients with suspected pleural infection indicates a need for chest tube drainage.
119
Lights criteria: What signifies an exudate? (1)
PROTEIN:
This can sometimes be ascertained quite easily by looking at the protein content of the pleural fluid (transudate protein content < 25g/L and exudate protein content > 35g/L)
LDH: (if uncertain)
Effusion LDH level greater than 2/3rds the upper limit of serum LDH points to exudate
120
Pleural aspiration:
what needle used? (1)
what is examined in the fluid (4)
what imaging used? (1)
a 21G needle and 50ml syringe should be used
fluid should be sent for pH, protein, lactate dehydrogenase (LDH), cytology and microbiology
US recomended to reduce complication rate
121
what signfies pleural infection in fluid sampling?
pH < 7.2
122
Effusion fluids
low glucose (2)
raised amylase? (2)
blood staining (3)
low glucose: rheumatoid arthritis, tuberculosis
raised amylase: pancreatitis, oesophageal perforation
heavy blood staining: mesothelioma, pulmonary embolism, tuberculosis
123
reducing steroid inhaler of 200BD
reduce to 200OD
(Not 100 BD)
124
bupropion contraindication
epilepsy
125
fungal growth affecting immunocompromised patients or those with underlying cavitating lung disease such as tuberculosis or emphysema. Symptoms of include fever, cough and haemoptysis. Treatment is with anti fungal medications such as itraconazole.
aspergilloma
126
statin bloods monitoring
LFT at baseline, 3 months and 12 months
126
cut off for Type 2 HTN (when to start treatment at diagnosis )
Stage 1 hypertension is defined by an ABPM reading of >= 135/85 mmHg, with stage 2 hypertension having a cut-off of >= 150/95 mmHg.
126
PESI score
used to help identify patients with a pulmonary embolism that can be managed as outpatients
127
alternative mineralcorticoid receptor antagonist to spirolactone in heart failure
eplerenone
(1st line= ACEi+BB,
2nd= aldosterone antagonist / mineralocorticoid receptor antagonist *monitor K+)
consider SGLT2 if reduced EF
127
Concurrent use of which drug may make clopidogrel less effective?
omeprazole
127
post STEMI meds
A
B
C
Dual anti platelets (one of which aspirin)
aspirin
128
when to check U&E in ACEi
, 2 weeks after starting treatment and 2 weeks after each dose change. Once a maintenance dose has been established urea and electrolytes should be checked at 1, 3 and 6 months.
129
Statins + erythromycin/clarithromycin
an important and common interaction --> myopathy
130
management HOCM
Hypertrophic obstructive cardiomyopathy (HOCM) is an autosomal dominant disorder of muscle tissue caused by defects in the genes encoding contractile proteins. The estimated prevalence is 1 in 500.
Management
Amiodarone
Beta-blockers or verapamil for symptoms
Cardioverter defibrillator
Dual chamber pacemaker
Endocarditis prophylaxis*
131
what drug to avoid HOCM
ACEi
132
27 yo. On examination, he had a midsystolic murmur heard best at the left lower sternal border. It was louder with the Valsalva manoeuvre. An echocardiogram reported mitral regurgitation, systolic anterior motion of the anterior mitral valve leaflet, asymmetric hypertrophy and left ventricular outflow tract obstruction.
HOCM
133
When to treat stage 1 HTN
treat if <80yo and any of:
Target organ damage
Established cardiovascular disease
Renal disease
Diabetes
10yr CVD risk >=10% (QRISK)
134
how long to wait to take sildenafil post STEMI
6 months
135
'notching of the inferior border of the ribs' and HTN in young person
coarctation of the aorta. The aortic obstruction gives rise to the development of dilated intercostal collateral vessels to allow sufficient blood flow to reach the descending aorta. The pressure of these vessels erodes the inferior margin of the ribs. Coarctation also explains this patient's refractory hypertension.
136
shortened PR interval and wide QRS complexes associated with a slurred upstroke seen in lead II
Wolff-Parkinson White
caused by a congenital accessory conducting pathway between the atria and ventricles leading to atrioventricular re-entry tachycardia (AVRT). As the accessory pathway does not slow conduction AF can degenerate rapidly to VF.
Management
definitive treatment: radiofrequency ablation of the accessory pathway
medical therapy: sotalol***, amiodarone, flecainide
sotalol should be avoided if there is coexistent atrial fibrillation as prolonging the refractory period at the AV node may increase the rate of transmission through the accessory pathway, increasing the ventricular rate and potentially deteriorating into ventricular fibrillation
137
Infective endocarditis most common causes
Gram positive cocci (Common causes:
Streptococcus viridans
Staphylococcus aureus (in intravenous drugs uses or prosthetic valves)
Staphylococcus epidermidis (in prosthetic valves)
138
Has only been demonstrated to improve mortality in patients with NYHA class III or IV heart failure who are already taking an ACE inhibitor
spirolactone
139
anti anginals
BB or Ca2+ CB (verapamil)
+ aspirin
+ simvastatin
140
nicorandil
Nicorandil is a vasodilatory drug used to treat angina. It is a potassium-channel activator with vasodilation is through activation of guanylyl cyclase which results in increase cGMP.
Adverse effects
headache
flushing
skin, mucosal and eye ulceration
gastrointestinal ulcers including anal ulceration
Contraindications
left ventricular failure
141
Verapamil should be avoided in patients with
HF
142
what is GRACE calculated on
The doctor is calculating the 6-month mortality using a GRACE score - this includes age, ECG, troponin, renal function.
143
ECG changes in mitral stenosis
P Mitrale represents left atrial hypertrophy/strain e.g. in mitral stenosis
144
best test for addisons
short synachten test
145
investigation for secondary hypoparathyroidsim
MRI brain - Secondary hypothyroidism is caused by pituitary failure and needs imaging
146
how to gliptins work
Gliptins (DPP-4 inhibitors) reduce the peripheral breakdown of incretins such as GLP-1
147
OGTT readings
fasting >7 and has polyuria, polydipsia, or other symptoms, we diagnose diabetes.
If BMs >6.1 but <6.9, we call them as having impaired fasting glucose and offer them OGTT.
6. On OGTT, if the fasting glucose is <7 and the OGTT 2-hour value is =/>7.8 but <11, we call them to have Impaired glucose tolerance and offer lifestyle advice and call them prediabetic.
148
viral thyroiditis
= subacute thyroiditis = de Quervain’s
149
Subacute thyroiditis vs haeimoaos thyoritisi
raised ESR in subacute
150
ADDisosn is Hypo or hyperaldosteronism
HYPO
151
digoxin vs cardiac resynchronisation therapy in HF
In symptomatic heart failure patients who are on optimal medical therapy, there are several treatment options to improve mortality. Cardiac resynchronisation therapy is indicated in patients with left ventricular dysfunction, ejection fracture <35% and QRS duration >120ms. An Implantable cardiac defibrillator (ICD) is indicated in patients with previous sustained ventricular tachycardia, ejection fraction <35% and symptoms no worse than class III of of the New York Heart Association functional classification.
Digoxin reduces hospitalisation but not mortality in heart failure. Increasing the furosemide dose may help with symptomatic relief from fluid overload but has no effect on mortality. Heart transplantation and ventricular assist devices would not be an option in a patient of this age.
152
A 39-year-old man presents with headaches and excessive sweating. He also reports some visual loss. Visual fields testing reveals bitemporal hemianopia.
Acromegaly 50%
Features of acromegaly include:
coarse facial appearance, spade-like hands, increase in shoe size
large tongue, prognathism, interdental spaces
excessive sweating and oily skin
features of pituitary tumour: hypopituitarism, headaches, bitemporal hemianopia
153
3rd antihypertensive cut off (1)
what else to consider?
K+ 4.5
<4.5 --> SPIROLACTONE
> 4.5mmol/l - add an alpha- or beta-blocker
NICE also suggests seeking specialist advice and discussing adherence with patients in these cases. Patients should also be assessed for postural hypotension (this can be done by measuring lying to standing blood pressure).
154
When should you NOT use DOAC for VTE?
eGFR <15 (renal impairment)
antiphospholipid synrome
LMWH followed by warfarin
155
Hypokalaemia ECG
U waves
small or absent T waves (occasionally inversion)
prolong PR interval
ST depression
long QT
156
SVT management if vagal manoeuvres failed (1)
when to NOT give (1)
rapid IV bolus of 6mg → if unsuccessful give 12 mg → if unsuccessful give further 18 mg
contraindicated in asthmatics - verapamil is a preferable option
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Third heart sound casues
<30 = physiological
>30 = heart failure (heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation)
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1st line management low severity CAP
amoxicillin 5/7
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1st line management moderate to severe severity CAP
dual Abx therapy amoxicillin and macrolide
7-10/7
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Mesothelioma vs asbestosis
Asbestosis: severity of asbestosis is related to the length of exposure, doesn't cause a mass
Mesothelioma: cancer of the mesothelial layer of the pleural cavity , only limited exposure needed, causes a mass
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treatment for regular broad complex tachycardias without adverse features
REGULAR = IV amiodarone (loading dose of amiodarone followed by 24 hour infusion)
IRREGULAR = seek expert help ?Torsade de pointes/ AF with odd rhythms
162
1st line treatment COPD
SABA or SAMA (ipratropium)
163
Formoterol and salmeterol are examples of
LABA
164
Tiotropium is a...
LAMA ( used as a second-line treatment for COPD (alongside a LABA) in patients with no features of asthma/steroid responsiveness.)
165
Shockable rhythms
pulseless VT
VF
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when to give 3 successive shocks before comencing CPR
if the cardiac arrested is witnessed in a monitored patient (e.g. in a coronary care unit) then the 2015 guidelines recommend 'up to three quick successive (stacked) shocks', rather than 1 shock followed by CPR
167
Pericarditis vs Dressler's
Pericarditis in the first 48 hours following a transmural MI is common (c. 10% of patients). The pain is typical for pericarditis (worse on lying flat etc), a pericardial rub may be heard and a pericardial effusion may be demonstrated with an echocardiogram.
Dressler's syndrome tends to occur around 2-6 weeks following a MI. The underlying pathophysiology is thought to be an autoimmune reaction against antigenic proteins formed as the myocardium recovers. It is characterised by a combination of fever, pleuritic pain, pericardial effusion and a raised ESR. It is treated with NSAIDs.
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life threatening asthma attack
PEFR < 33% best or predicted
Oxygen sats < 92%
'Normal' pC02 (4.6-6.0 kPa)
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
169
A 66-year-old woman suddenly develops dyspnoea 10 days after having an anterior myocardial infarction. Her blood pressure is 78/50 mmHg, JVP is elevated and the heart sounds are muffled. There are widespread crackles on her chest and the oxygen saturations are 84% on room air.
left ventricular free wall rupture
170
side effects beta blockers
bronchospasm
cold peripheries
fatigue
sleep disturbances, including nightmares
erectile dysfunction
171
contraindications of beta blockers
uncontrolled heart failure
asthma
sick sinus syndrome
concurrent verapamil use: may precipitate severe bradycardia
172
Tachycardia - HISS features:
how many times to shock? (1)
what do try after? (1)
3 times
if failed:
- amiodarone 300mg IV over 10-20mins
- repeat synchronised DC shocks
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STEMI: when to offer fibrinolysis
within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 minutes
174
STMI: what to do it PCI available with 120mins
give praugrel
give unfractionated heparin + bailout glycoprotein
drug eluting stems used in preference
175
PCI: what to do if patient presenting >12hr post symptom starting
consider PCI if cariogenic shock/ ongoing myocardial ischaemia
176
Cr increase in ACEi acceptable
<30%
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what causes LOWER BNP levels
ALL HEART DRUGS + BMI
Obesity
Diuretics
ACE inhibitors
Beta-blockers
Angiotensin 2 receptor blockers
Aldosterone antagonists
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interpreting BNP
if levels are 'high' arrange specialist assessment (including transthoracic echocardiography) within 2 weeks
if levels are 'raised' arrange specialist assessment (including transthoracic echocardiography) echocardiogram within 6 weeks
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what causes higher BNP reading
Left ventricular hypertrophy
Ischaemia
Tachycardia
Right ventricular overload
Hypoxaemia (including pulmonary embolism)
GFR < 60 ml/min
Sepsis
COPD
Diabetes
Age > 70
Liver cirrhosis
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dihydropyridine CCB
nifedipine or amlodipine
181
AF what are the reversal agents (2)
<48hr
If the atrial fibrillation (AF) is definitely of less than 48 hours onset patients should be heparinised. Patients who have risk factors for ischaemic stroke should be put on lifelong oral anticoagulation. Otherwise, patients may be cardioverted using either:
electrical - 'DC cardioversion'
pharmacology - amiodarone if structural heart disease, flecainide or amiodarone in those without structural heart disease
Following electrical cardioversion if AF is confirmed as being less than 48 hours duration then further anticoagulation is unnecessary
182
AF >48HR reversal
If the patient has been in AF for more than 48 hours then anticoagulation should be given for at least 3 weeks prior to cardioversion. An alternative strategy is to perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus. If excluded patients may be heparinised and cardioverted immediately.
NICE recommend electrical cardioversion in this scenario, rather than pharmacological.
If there is a high risk of cardioversion failure (e.g. Previous failure or AF recurrence) then it is recommend to have at least 4 weeks amiodarone or sotalol prior to electrical cardioversion
Following electrical cardioversion patients should be anticoagulated for at least 4 weeks. After this time decisions about anticoagulation should be taken on an individual basis depending on the risk of recurrence
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restrictive lung diseases
Pulmonary fibrosis
Asbestosis
Sarcoidosis
Acute respiratory distress syndrome
Infant respiratory distress syndrome
Kyphoscoliosis e.g. ankylosing spondylitis
Neuromuscular disorders
Severe obesity
184
admission criteria in asthma
- life threatening features
- previous near fatal attack
- pregnant
presentation at night when already using oral corticosteroids
185
acute pericarditis causes
inflammation of the pericardial sac, lasting for less than 4-6 weeks.
Aetiology
viral infections (Coxsackie)
tuberculosis
uraemia
post-myocardial infarction
early (1-3 days): fibrinous pericarditis
late (weeks to months): autoimmune pericarditis (Dressler's syndrome)
radiotherapy
connective tissue disease
systemic lupus erythematosus
rheumatoid arthritis
hypothyroidism
malignancy
lung cancer
breast cancer
trauma
186
acute pericardidits investigations for all: imaging (1) bloods (2)
Transthoracic Echo
bloods
- inflammatory markers
- troponin: around 30% of patients may have an elevated troponin - this indicates possible myopericarditis
187
idiopathic or viral pericarditis first line treatment (2)
NSAIDs and colchicine
avoid evercise until symptoms resolved
188
when to admit acute pericarditis (1)
ADMIT if >38oC / elevated trop/ unwell
189
if pt having STEMI goes for PCI, what else should they get
apririn
clopidogren
IV heparin ( intravenous unfractionated heparin for anticoagulation during the procedure)
190
What to do after thrombolysis of STEMI
An ECG should be performed 90 minutes following thrombolysis to assess whether there has been a greater than 50% resolution in the ST elevation
if there has not been adequate resolution then rescue PCI is superior to repeat thrombolysis
for patients successfully treated with thrombolysis PCI has been shown to be beneficial. The optimal timing of this is still under investigation
191
Gylcaemic control in STEMI
- dose-adjusted insulin infusion with regular monitoring of blood glucose levels to glucose below 11.0 mmol/l
- intensive insulin therapy (an intravenous infusion of insulin and glucose with or without potassium, sometimes referred to as 'DIGAMI') regimes are not recommended routinely
192
If atropine fails, what is next for symptomatic bradycardia
External (transcutaneous) pacing
Atropine 500mg
isoprenaline 5mcg
adrenaline 2-10mcg
alternative
193
ST depression in a few leads
posterior MI
194
when to pick ARB over ACEi
black
195
QT interval how to measure
Time between the start of the Q wave and the end of the T wave
196
CURB-65
(Confusion = 1, Urea > 7 mmol/L = 1, Respiratory rate > 30 = 1, Diastolic BP < 60 mmHg = 1, Age > 65 = 1).
197
mechanical vs biological valves
The most common type now implanted is the bileaflet valve. Ball-and-cage valves are rarely used nowadays
Mechanical valves have a low failure rate
Major disadvantage is the increased risk of thrombosis meaning long-term anticoagulation is needed.
Warfarin is still used in preference to DOACs for patients with mechanical heart valves
198
spirolactone and decreased eGFR
be careful due to potassium - monitor closely
199
CXR in HOCM
varied, may have:
cardiomegaly (LV hypertrophy or L atrium hypertrophy) OR it may be normal
200
possible ECG changes HOCM
L verntricular hypertropy
non-specific ST segment and T wave abnormalitis
deep narrow Q wabe
L atrial enlargement
arryhythmias
201
Acute bronchiolitis management 1st line
ONLY IF SYSTEMICALLY V UNWELL or high risk of complications
usually conservative
doxycycline (amoxicillin for pneumonia)
