Wednesday 29th Flashcards
1
Q
First step Mx to treating 24w pregnant mother with first exposure to chickenpox [1]
A
Arrange a blood test for varicella antibodies and await result
2
Q
When and what should be given to mother if exposed to chickenpox post 20w? [2]
A
Antivirals or VZIG should be given 7-14 days after exposure, not immediately
3
Q
Which virus causes chickenpox? [1]
A
Varicella-zoster
4
Q
What is shingles in relation to chickenpox? [1]
A
Reactivation of dormant chickenpox virus in the dorsal root ganglion
5
Q
Features of fetal varicella syndrome? [2]
A
skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
6
Q
Risk of FVS following maternal varicella exposure before 20w [1]
A
Around 1%
7
Q
Mx of pregnant women if <=20 gestation and first exposure to chickenpox? [1]
A
Should be given varicella-zoster immunoglobulin [VZIG] ASAP
8
Q
Where on the body are keloid scars most likely to form? [1]
A
Sternum
9
Q
Predisposing factors for keloid scars [3]
A
- ethnicity: more common in people with dark skin
occur more commonly in - young adults, rare in the elderly
- common sites (in order of decreasing frequency): sternum, shoulder, neck, face, extensor surface of limbs, trunk
10
Q
Tx keloid scars [2]
A
- early keloids may be treated with intra-lesional steroids e.g. triamcinolone
- excision is sometimes required
11
Q
Which anti-diabetic drug causes weight loss and what are the conditions for its Rx? [2]
A
Exenatide [GLP1 mimetic]
- needs to be BMI of 35kg/m2
12
Q
When should you add another drug to metformin for T2DM? [1]
A
- Aim for 48mmol/mol [6.5%] with metformin and lifestyle
- Add second drug if HbA1c rises to 58mmol/mol
13
Q
How often should HbA1c be checked in T2DM? [1]
A
HbA1c should be checked every 3-6 months until stable, then 6 monthly
14
Q
Which drugs can be added to metformin if HbA1c increases to 58mmol/mol? [4]
A
sulfonylurea
gliptin
pioglitazone
SGLT-2 inhibito
15
Q
Which drugs to start on if metformin is not tolerated or CI? [3]
A
Gliptin, sulfonurea, Piogliatzone
16
Q
When to offer a statin to a patient? [1]
A
following the 2014 NICE lipid modification guidelines only patients with a 10-year cardiovascular risk > 10% (using QRISK2) should be offered a statin. The first-line statin of choice is atorvastatin 20mg
17
Q
HOCM findings on Ix [2]
A
Asymmetric septal hypertrophy and systolic anterior movement [SAM] of the anterior leaflet of mitral valve on ECHO or cMR
18
Q
Which murmur does mitral stenosis cause? [1]
A
Mid-diastolic murmur
19
Q
Another name for Broken heart syndrome? [1]
A
Takotsubo cardiomyopathy
20
Q
Appearance and presentation of Broken heart syndrome [2]
A
Takotsubo cardiomyopathy aka Broken heart syndrome describes a stress-induced cardiomyopathy; its appearance on CMR resembles an octopus put (ballooning of the apical segment of the heart). Its presentation may mimic acute coronary syndrome
21
Q
Which murmur does mitral regurgitation cause? [2]
A
Pansystolic murmur
Radiates to the axilla
22
Q
Presentation of aortic stenosis [2]
A
Aortic stenosis may cause LV hypertrophy but this typically affects the whole of the left ventricle. Aortic stenosis is not associated with the SAM of the anterior leaflet of the mitral valve
23
Q
What causes the first heart sound? [1]
A
The first heart sound (S1) is caused by the closure of the mitral and tricuspid valves. It marks the start of ventricular systole, and a peripheral pulse is felt at the same time (or shortly after) S1
24
Q
What causes the second heart sound? [2]
A
The second heart sound (S2) is caused by the closure of aortic and pulmonary valves. It marks the end of ventricular systole, and the start of diastole.
The pulmonary valve may close just after the aortic valve. Closure of the pulmonary valve just after the aortic valve is prolonged during inspiration, or in defects which cause more blood to be pumped out of the right ventricle
25
Which scale is used to grade murmurs? [1]
Levine scale
26
Grades 1-3 on the levine scale [3]
One
- Very faint. Heard by an expert in optimum conditions
Two
- Heard by a non-expert in optimum conditions
Three
- Easily audible, no thrill
27
Grades 4-6 on the levine scale [3]
Four
- A loud murmur, with a thrill
Five
- Very loud, often heard over a wide area, with thrill
Six
- Extremely loud, heard without a stethoscope
28
What is a thrill? [1]
A thrill is a palpable vibration caused by turbulent blood flow through a heart valve. Thrills may be felt when palpating the anterior chest wall during a cardiovascular examination.
29
Aortic stenosis on examination [3]
Aortic stenosis is associated with an ejection systolic murmur heard loudest over the aortic valve. The murmur is described as having a ‘crescendo-decrescendo’ quality (it appears as diamond-shaped on a phonogram). The murmur of aortic stenosis commonly radiates to the carotid arteries.
30
Causes of aortic stenosis [3]
Calcification of the aortic valves: this is the most common cause of AS in developed countries, typically occurring in elderly adults.
Congenital abnormality of the aortic valve: the aortic valve is normally composed of three cusps (known as a tricuspid valve), but in some cases, individuals have only two cusps (known as a bicuspid valve) which predisposes them to the development of AS as well as aortic regurgitation.
Rheumatic heart disease: a rare cause of AS in developed countries.
31
Causes of mitral regurgitation [5]
```
Infective endocarditis
Acute myocardial infarction with rupture of papillary muscles
Rheumatic heart disease
Congenital defects of the mitral valve
Cardiomyopathy
```
32
Type of murmur aortic regurgitation [2]
Aortic regurgitation is associated with an early diastolic murmur heard loudest at the left sternal edge
33
How does chronic AR often present? [1]
Asymptomatic
34
Simple PP of how AR works [1]
AR can occur due to a disease process affecting the valve itself, or due to dilatation of the aortic root.
35
Diseases affecting the valve include what [3]
Congenital bicuspid aortic valve
Rheumatic heart disease
Infective endocarditis
36
Diseases affecting the aortic root dilation include what [3]
Aortic dissection: can result in acute aortic regurgitation
Connective tissue diseases (e.g. Marfan’s)
Aortitis
37
name an eponymous clinical sign associated with AR [1]
- Corrigan’s sign: visible distention and collapse of carotid arteries in the neck
- De Musset’s sign: head bobbing with each heartbeat
- Quincke’s sign: pulsations are seen in the nail bed with each heartbeat when the nail bed is lightly compressed
- Traube’s sign: ‘pistol shot’ sound heard when stethoscope placed over the femoral artery during systole and diastole
- Muller’s sign: uvula pulsations are seen with each heartbeat
38
Type of murmur in MS [2]
Mitral stenosis is associated with a low-pitched, rumbling, mid-diastolic murmur heard loudest over the apex.
39
Most common cause of MS [1]
Rheumatic heart disease
40
Other causes of MS [4]
Congenital
Left atrial myxoma
Connective tissue disorders
Mucopolysaccharidosis
41
Where does the mitral valve prolapse into? [1]
A mitral valve prolapse occurs when the mitral valve leaflets prolapse into the left atrium during systole.
42
Type of murmur mitral valve prolapse [2]
Mitral valve prolapse is associated with a combination of a mid-systolic click and mid to late-systolic murmur.
Heard loudest at the apex.
43
How common in mitral valve prolapse? [1]
Mitral valve prolapse is the most common valvular abnormality with a prevalence of approximately 5%.
44
Aetiology of mitral valve prolapse [1]
The exact underlying cause of mitral valve prolapse is unknown. Primary mitral valve prolapse is caused by myxomatous degeneration of the mitral valve and is associated with connective tisuse diseases. Secondary mitral valve prolapse occurs when a ‘normal’ valve prolapses
45
Tricuspid regurgitation occurs when? [1]
Tricuspid regurgitation occurs when there is backflow of blood from the right ventricle into the right atrium during ventricular systole. This causes an increase in right atrial pressure and elevated venous pressures
46
Murmur associated with tricuspid regurgitation [1]
Tricuspid regurgitation is associated with a pansystolic murmur heard loudest over the tricuspid region
47
Causes of triscuspid regurgitation [2]
Causes of tricuspid regurgitation include:
Right ventricular dilatation (e.g. secondary to pulmonary stenosis or pulmonary hypertension)
Rheumatic fever
Infective endocarditis (intravenous drug users are at high risk of endocarditis affecting the tricuspid valve)
Carcinoid syndrome
Congenital (e.g. atrial septal defect, AV canal, Ebstein anomaly)
The Ebstein anomaly (i.e. congenital isolated tricuspid regurgitation) is abnormal attachment of tricuspid valve leaflets causes the tricuspid valve to displace downwards into the right ventricle.
48
Typical clinical features of TR [3]
Pansystolic murmur
Heard loudest over the tricuspid region
Loudest during inspiration
49
other clinical features of TR [3]
Large ‘v-waves’ visible in the jugular veins: caused by the right atrial filling of blood against a closed tricuspid valve
Visible/palpable hepatic pulsations
Signs of right-sided heart failure: right ventricular heave, peripheral oedema, hepatomegaly, ascites
50
Causes of pulmonary stenos [3]
Causes of pulmonary stenosis include:
Congenital: Turner’s, Noonan’s and Williams syndromes. Tetralogy of Fallot (pulmonary stenosis, right ventricular hypertrophy, ventricular septal defect and an overriding aorta).
Rheumatic fever
Carcinoid syndrome
51
Typical clinical features of pulmonary stenosis [3]
Ejection systolic murmur heard loudest over pulmonary area
Loudest during inspiration
Radiates to left shoulder/left infraclavicular region
In severe pulmonary stenosis, the murmur is longer and may obscure the sound of A2
52
Other clinical features of pulmonary stenosis [1]
Prominent ‘a waves’ in the jugular veins
Widely split S2: blood from the ventricles takes longer to pass through a narrow pulmonary valve, so pulmonary valve closure occurs much later than aortic valve closure
P2 may be soft and inaudible
Right ventricular dilatation can lead to a right ventricular heave, tricuspid regurgitation and peripheral signs of right-sided heart failure (e.g. peripheral oedema, ascites etc)
53
What is pulmonary regurgitation? [1]
Pulmonary regurgitation (PR) occurs when there is backflow of blood from the pulmonary artery into the right ventricle during ventricular diastole. Pulmonary regurgitation is rare.
54
Typical clinical features of pulmonary regurgitation [3]
Early decrescendo murmur heard loudest over the left sternal edge
Loudest during inspiration
Usually due to pulmonary hypertension: known as a Graham Steell murmur when associated with mitral stenosis
55
Clinical feature of tricuspid stenosis [1]
Tricuspid stenosis (TS) refers to narrowing of the tricuspid valve.
Tricuspid stenosis is associated with a soft diastolic murmur loudest at 3rd – 4th intercostal space at the left sternal edge
56
Inheritance of HOCM [1]
Autosomal dominant condition
57
What is HOCM known to cause? [1]
HOCM is important as it is the most common cause of sudden cardiac death in the young.
58
Simple PP of HOCM [1]
predominantly diastolic dysfunction
| left ventricle hypertrophy → decreased compliance → decreased cardiac outpu
59
Often, what is the presentation of HOCM? [1]
Asymptomatic
60
What symptoms may be present in HOCM if there exists any? [3]
exertional dyspnoea
angina
syncope
typically following exercise
due to subaortic hypertrophy of the ventricular septum, resulting in functional aortic stenosis
sudden death (most commonly due to ventricular arrhythmias), arrhythmias, heart failure
jerky pulse, large 'a' waves, double apex beat
61
How to increase/decrease systolic murmur in HOCM [2]
ejection systolic murmur
| increases with Valsalva manoeuvre and decreases on squatting
62
What may HOCM also cause? [1]
hypertrophic cardiomyopathy may impair mitral valve closure, thus causing regurgitation
63
Echo findings in HOCM [3]
Echo findings - mnemonic - MR SAM ASH
mitral regurgitation (MR)
systolic anterior motion (SAM) of the anterior mitral valve leaflet
asymmetric hypertrophy (ASH)
64
ECG in HOCM [4]
left ventricular hypertrophy
non-specific ST segment and T-wave abnormalities, progressive T wave inversion may be seen
deep Q waves
atrial fibrillation may occasionally be seen
65
A 25-year-old man presents complaining of dysuria and pain in his left knee. Three weeks previously he had suffered a severe bout of diarrhoea. What is the most likely diagnosis? [1]
Reactive arthritis
66
Mnemonic for reactive arthritis [1]
Can't see [conjunctivitis], can't pee [urethritis], can't climb a tree [arthritis]
67
Which antigen can be found in reactive arthritis? [1]
HLA-B27 associated seronegative spondyloarthropathies
68
Define reactive arthritis [1]
Reactive arthritis is defined as an arthritis that develops following an infection where the organism cannot be recovered from the joint
69
Causes of reactive arthritis [2]
post-STI form much more common in men (e.g. 10:1) [chlamydia]
post-dysenteric form equal sex incidence
70
Mx for reactive arthritis [2]
symptomatic: analgesia, NSAIDS, intra-articular steroids
| sulfasalazine and methotrexate are sometimes used for persistent disease
71
How long do Sx of reactive arthritis typically last? [1]
symptoms rarely last more than 12 months
72
How common are communicating hydroceles? [1]
Found in more than 3% of newborn males
73
What are the most commonly seen scrotal swellings primary care? [1]
Epididymal cysts
74
Features of epididymal cysts [2]
separate from the body of the testicle
| found posterior to the testicle
75
How to confirm Dx of epididymal cysts [1]
US
76
Define hydrocele [1]
A hydrocele describes the accumulation of fluid within the tunica vaginalis
77
Difference between communicating and non-communicating hydrocele [2]
communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life
non-communicating: caused by excessive fluid production within the tunica vaginalis
78
What may hydroceles develop secondary to? [3]
epididymo-orchitis
testicular torsion
testicular tumours
79
Features of hydrocele [4]
soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
the swelling is confined to the scrotum, you can get 'above' the mass on examination
transilluminates with a pen torch
the testis may be difficult to palpate if the hydrocele is large
80
mx of hydrocele child [1]
infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years
81
Mx of hydrocele adult [1]
in adults a conservative approach may be taken depending on the severity of the presentation. Further investigation (e.g. ultrasound) is usually warranted however to exclude any underlying cause such as a tumour
82
What is a varicocele? [1]
A varicocele is an abnormal enlargement of the testicular veins.
83
How do varicocele typically present and what are they associated with? [2]
They are usually asymptomatic but may be important as they are associated with infertility
84
Which side are varicoceles associated with? [1]
Left in over 80% of cases
85
Features of varcocele [2]
'Bag of worms'
| Subfertility
86
Dx of varcocele [1]
US with Doppler studies
87
Mx of varcocele [2]
usually conservative
occasionally surgery is required if the patient is troubled by pain. There is ongoing debate regarding the effectiveness of surgery to treat infertility
88
Inheritance of Alport syndrome [1]
X-linked dominant pattern in 85% cases
| 10-15% cases inherited in an autosomal recessive fashion with rare autosomal dominant variants existing
89
Which genetic abnormality is present in Alport syndrome? [1]
It is due to a defect in the gene which codes for type IV collagen resulting in an abnormal glomerular-basement membrane (GBM).
90
Who is Alpert's syndrome more severe in? [1]
males with females rarely developing renal failure
91
Why may a Alport's patient fail a renal transplant? [2]
A favourite question is an Alport's patient with a failing renal transplant. This may be caused by the presence of anti-GBM antibodies leading to a Goodpasture's syndrome like picture.
92
When does Alport's syndrome typically present? [1]
Childhood
93
Features of Alport's syndrome [6]
microscopic haematuria
progressive renal failure
bilateral sensorineural deafness
lenticonus: protrusion of the lens surface into the anterior chamber
retinitis pigmentosa
renal biopsy: splitting of lamina densa seen on electron microscopy
94
Dx of Alpert's syndrome [2]
molecular genetic testing
renal biopsy
electron microscopy: characteristic finding is of the longitudinal splitting of the lamina densa of the glomerular basement membrane, resulting in a 'basket-weave' appearance
95
Which clinical picture does this suggest: diabetic with severe pain, unable to defecate, spiking temperatures? [1]
Perianal abscess
96
What is perianal abscess? [1]
A perianal abscess is a collection of pus within the subcutaneous tissue of the anus that has tracked from the tissue surrounding the anal sphincter
97
Features perianal abscess [4]
Patients may describe pain around the anus, which may be worse on sitting;
They may have also discovered some hardened tissue in the anal region;
There may be pus-like discharge from the anus;
If the abscess is longstanding, the patient may have features of systemic infection
98
Ix for perianal abscess [3]
Most perianal abscesses can be detected through inspection of the anus and digital rectal examination;
When querying the underlying cause, colonoscopy and blood tests such as cultures and inflammatory markers may be of use;
Imaging such as MRI and transperineal ultrasound can be useful tools, with the former being the gold standard in imaging anorectal abscesses. They are however rarely used except for cases where the abscess has complications or is part of a more serious underlying process such as IBD.
99
Why is DM a RF for perianal abscess? [1]
Wound healing
100
Tx for perianal abscess [2]
Treatment is usually surgical, with incision and drainage being first line, usually under local anaesthetic. The wound can then either be packed or left open, in which case it will heal in around 3-4 weeks;
Antibiotics can be of use, but are only usually employed if there is systemic upset secondary to the abscess, as they do not seem to help with healing of the wound after drainage
