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Y4 CCTs > The Breathless patient > Flashcards

The Breathless patient Flashcards

1
Q

A patient who stops for breath after walking about 100 metres or after a few minutes on level ground is demonstrating which Grade on the MRC dyspnoea scale?

A

4

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2
Q

What score is used to assess a patient with suspected PE?

A

Well’s score

Score more than 4 points → PE is likely → immediate CTPA (if CPTA is not available immediately →treat with LMWH or fondaparinux until CTPA)

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3
Q

What’s long-term management of PE

A

Warfarin or IVC filter

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4
Q

What to do for people with 4 points or less on Well’s score?

A

PE is unlikely → perform D-dimmer

  • if D - dimmer is positive → immediate CPTA ( fondaparinux or LMWH if a delay in performing CPTA)#
  • if D-dimmer negative → think of diagnosis different to PE
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5
Q

What drugs may worsen heart failure? (3)

A

Drugs to stop or reduce in a suspected HF:

  • NSAIDs
  • beta-blockers (e.g. Bisoprolol)
  • calcium channel blockers (e.g. diltiazem)
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6
Q

What’s initial management of a suspected HF? (symptomatic) - before HF is confirmed

A

Initial management is with a loop diuretic. For example:

  • Furosemide 20-40 mg daily.
  • Bumetanide 0.5-1.0 mg daily.
  • Torasemide 5-10 mg daily
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7
Q

What to prescribe (apart from loop diuretics earlier, when suspected) for a confirmed HF (2)

A
  • B-blocker that is licensed for HF
  • ACE-inhibitor

Prescribe one drug at a time

_____________________________

  • ACE-inhibitor first if a patient has diabetes or signs of fluid overload
  • Beta-blocker first if a patient has an angina
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8
Q

What to start first in the treatment of HF: a beta-blocker or ACE-inhibitor?

A
  • ACE-inhibitor first if a patient has diabetes or signs of fluid overload
  • Beta-blocker first if a patient has an angina
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9
Q

New York Heart Association HF scale

A
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10
Q

When to refer a patient with HF to cardiology?

A

If the person is still symptomatic (New York Heart Association classification II-IV) despite optimal treatment with an ACE-inhibitor (or AIIRA) and beta-blocker

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11
Q

What else to consider in the management of HF (apart from loop diuretics, ACE-inhibitor and beta-blocker)? (6)

A
  • Antiplatelets if ischaemic heart disease
  • Statins if high cholesterol
  • Annual flu vaccination
  • One-off pneumococcal vaccination
  • Exercise program referral
  • Screening for depression and anxiety
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12
Q

True or False

Spirometry or peak flow diary once a child is old enough to cooperate with the test can exclude a diagnosis of asthma in a symptomatic child

A

False

In a child <5 years old, we can diagnose asthma based on history and examination findings

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13
Q

Asthma in a child <5 years old

Levels of probability and initial management

A

Based on symptoms:

  • Highly probable → we give a trial of treatment for 2-3 months and then review
  • Low probability →further investigation and/or referral
  • Immediate probability → trial of treatment (continue if symptoms improve); watchful waiting, spirometry and reversibility
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14
Q

Symptoms that may be suggestive of asthma diagnosis

A
  • Wheeze, cough, difficulty breathing, chest tightness together with a personal or family history of atopy
  • Symptoms are frequent, worse in the night/early morning and with exercise
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15
Q

5 steps in adult asthma management

A

Step 1: short-acting beta2-agonist e.g. salbutamol (SABA)

Step 2: inhaled corticosteroid e.g. beclometasone (Clenil) 200-800 micrograms/day (usual dose 400 micrograms/day).

*alternatives if steroid not tolerated: leukotriene receptor antagonist or chromone (block mast-cell degranulation).

Step 3: long-acting beta2-agonist (LABA)

If poor control on of beclometasone 800micrograms/day and LABA, add in leukotriene receptor antagonist or modified release theophylline before moving to step 4

Step 4: either increase ICS to the maximum dose (2000 micrograms/day beclometasone (Clenil)) or start a fourth drug that the person is not already using, such as a leukotriene receptor antagonist, modified release theophylline, or an oral modified-release beta2-agonist.

Step 5: Refer to a specialist in respiratory medicine.

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16
Q

Signs of poor asthmatic control

A
  • having symptoms three times weekly or more
  • awakening with symptoms one night weekly or more
  • having an exacerbation in the past 2 years
  • using inhaled beta2-agonist three times weekly or more

If control poor move to next step

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17
Q

Components of CRB-65 score

A
  • Confusion (new disorientation in person, place, or time)
  • Raised respiratory rate (30 breaths per minute or more)
  • Low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)
  • Age 65 years or more
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18
Q

Management of CAP in regards to CRB-65

A

Score of 3 or more → arrange urgent admission to hospital

Score of 2 → hospital admission is usually advised. Treat with amoxicillin 500 mg TDS and clarithromycin 500 mg BD for 7-10 days, or monotherapy with doxycycline for 7-10 days

Score of 0 or 1 → treatment at home may be appropriate with amoxicillin 500 mg TDS for 5 days OR doxycycline 200mg OD on day 1 then 100mg OD for a total of 5 days

Score of 1 → consider dual therapy as per Score of 2.

*Smokers over 60 years old need a chest Xray to exclude lung cancer

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19
Q

Treatment of CAP scored as CRB-65 of 2

A

Score of 2 → hospital admission is usually advised

Treat with amoxicillin 500 mg TDS and clarithromycin 500 mg BD for 7-10 days, or monotherapy with doxycycline for 7-10 days

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20
Q

Treatment of pneumonia in CRB-65 score 0 and 1

A

Score of 0 → treatment at home may be appropriate:

with amoxicillin 500 mg TDS for 5 days OR doxycycline 200mg OD on day 1 then 100mg OD for a total of 5 days

Score of 1 → consider dual therapy (like in score2):

Treat with amoxicillin 500 mg TDS and clarithromycin 500 mg BD for 7-10 days, or monotherapy with doxycycline for 7-10 days

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21
Q

What Peak Expiratory Flow results are typical of asthma?

A

Diurnal variability of peak expiratory flow rate (PEFR) greater than 20% for at least three days in a week for two weeks

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22
Q

What condition is characterised by a tapping apex beat?

A

Mitral stenosis

23
Q

What condition is characterised by a pansystolic murmur at the apex?

A

Mitral regurgitation

24
Q

Causes of ‘high - output’ heart failure

A

Anything that increases demand on cardiac output

Examples:

Anaemia, pregnancy, hyperthyroidism, Paget’s disease of bone, arteriovenous malformations

*if the underlying cause is treated → HF resolves

25
Q

Causes of ‘low-output’ heart failure?

A

Causes:

valve disease (aortic stenosis, aortic regurgitation, mitral regurgitation), coronary artery disease, arrhythmias (AF, heart block), hypertension, cardiomyopathies, alcohol, beta blockers, sarcoidosis, Chaga’s disease

low output = cardiac output is inadequate to perfuse the body (ejection fraction is <40%) or can be only adequate with high filling pressures

26
Q

What happens in low-output HF?

A

low output = cardiac output is inadequate to perfuse the body (ejection fraction is <40%) or can be only adequate with high filling pressures

27
Q

Modes of investigations of heart failure

A
  • Raised BNP suggests heart failure (>100)
  • ECHO is diagnostic
  • ECG should also be performed in patients with suspected cardiac failure
28
Q

3 possible categories of BNP levels and what to do

A
  • BNP over 400: Echocardiogram within 2 weeks
  • BNP 100-400: Echocardiogram within 6 weeks
  • BNP less than 100 heart failure is unlikely
29
Q

Causes of falsely reduced BNP levels (2)

A

BNP can be reduced by:

  • obesity
  • drugs e.g. diuretics, ACE inhibitors, beta-blockers, aldosterone antagonists (e.g. spironolactone)
30
Q

Causes of falsely elevated BNP levels (3)

A

BNP can be falsely elevated in:

  • the elderly (age over 70)
  • females
  • conditions such as LVH, tachycardia, myocardial ischaemia, hypoxia, PE, CKD, COPD, diabetes, liver cirrhosis
31
Q

What to treat with symptomatic suspected HF?

A

Furosemide 20-40 mg daily

Other options of loop diuretics:

  • Bumetanide 0.5-1.0 mg daily
  • Torasemide 5-10 mg daily

When heart failure is suspected review the patient’s medication and stop or reduce any drugs that may worsen heart failure, e.g. NSAIDs, beta-blockers (e.g. bisoprolol), calcium channel blockers (e.g. diltiazem

32
Q

Management of AF diagnosed in Primary Care (3)

A
  • Most patients should be rate-controlled with a beta-blocker or rate-limiting calcium channel blocker
  • Patients with new AF or AF with a reversible cause or heart failure caused by AF should be referred for rhythm control with cardioversion
  • Patients with atrial flutter may be suitable for ablation therapy
33
Q

Anticoagulation should be offered when in CHA2DS2VASc?

A

anticoagulation treatment to all people with a CHA2DS2VASc score

  • 2 or above for women
  • 1 or above for men
34
Q

What other score do we use in connection to the CHA2DS2VASc score?

A

The risk of stroke needs to be weighed against the risk of bleeding (HASBLED score

  • to determine whether anticoagulation should be used
  • for most people benefits of anticoagulation outweigh the risks
35
Q

What anticoagulation med can we use in people with AF to prevent stroke?

(assessed by CHA2D2VSc)

A

Warfarin or NOAC (dabigatran, rivaroxiban, apixaban)

36
Q

Do we need to admit to the hospital a person with HR of 48?

A

No:

  • HR ≥130 OR ≤40 → usually require hospital admission
  • HR 40-60 or 100-130 and no symptoms associated with breathlessness/chest pain/dizziness → may be managed in the community
37
Q

Sounds that can be heard during small bowel obstruction?

A

Tingling sounds

(like the pipes in a poor hotel)

38
Q

Management of small bowel obstruction

A
  • NG tube →to decompress
  • IV fluids
  • OR laparoscopic surgery (to e.g. remove adhesions)
39
Q

What signs may be elicited only with deep palpation?

A

rebound tenderness and rigidity

40
Q

What diagnosis would we consider if there is a wheeze in a child lasting for >1 month?

A

asthma

41
Q

How is aortic regurgitation best heard?

A

R sternal edge + sitting forward + expiration

42
Q

What condition is a tapping apex beat present in?

A

mitral stenosis

43
Q

Upon what % of stats do we admit to hospital with?

A
  • equal or <92% in a person without underlying COPD
  • <88% in a person with COPD
44
Q

What conditions can spirometry exclude?

A

COPD, restrictive lung conditions

45
Q

What can be heard on auscultation in a patient with PE?

A
  • often normal
  • rub → as infracted tissue collapses
  • crackles → due to inflammatory response producing fluid
46
Q

What can be seen on a CXR with PE? (2)

A
  • usually normal
  • wedge - shaped (triangle) infract
47
Q

Management of PE:

  • acute
  • long-term
A

Acute:

  • Heparin IV
  • analgesia
  • oxygen → if low sats
  • IV fluids → because a patient is losing fluids from an injured vessel

Long-term:

  • Warfarin or DOAC

(if DVT, DOAC for 3 months; if PE DOAC for 6 months)

48
Q

What blood tests to do in a patient presenting with AF? (3)

A
  • TFTs → thyroid abnormalities (hyperthyroidism) may cause AF
  • FBC → anaemia, infection
  • U&Es → potassium and other metabolic abnormalities may cause AF
49
Q

What time Warfarin should be taken at?

A

6 PM

This is due to practicalities of INR monitoring (as should be done at certain time after last dose)

50
Q

What … does to INR (pt on warfarin):

A. Kale

B. Grapefruit, cranberry

A

A. Kale → decrease INR

B. Grapefruit, Cranberry → increase INR

51
Q

What and how often do we need to monitor while taking Amiodarone?

A
  • LFTs
  • TFTs

To monitor 6-monthly

52
Q

What’s the time frame that GTN should help the patient relieve the symptoms of angina?

A

2 puffs of GTN → then again after 5 minutes and so on

  • if didn’t work after 15 minutes → call the ambulance
53
Q

Meds for angina

A

GTN - symptomatic relief, diamorphine

long-term: b-blocker or CCB or Ivabradine or Nicorandil

Y4 CCTs (14 decks)

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