Week 4 Flashcards
What are the core values of doctors as they relate to the doctor/patient relationship? 9 (5 c’s)
Compassion Commitment Caring Competence Confidentiality Spirit of enquiry Responsibility Integrity Advocacy
Explain what sympathy and empathy are, and appreciate their value and limits
Sympathy: Being affect by the condition of another with a feeling similar to that of the other
Empathy: The ability to understand and appreciate another person’s feelings/experiences
Limits
- Sympathy can be received as**
- Empathy is limited by medical education and practice
Name the 4 key attributes of care which must be maintained, whatever one’s values, as defined by GMC
Doctors may practice medicine in accordance with their beliefs but they:
- Must act in accordance with relavent legislation
- Must not treat patients unfairly
- Must not deny patients access to appropriate services or care
- Must not cause patients distress
Name the areas in which BMA support conscientious objection, and know which of these are legally protected
- Emphasise the balancing act between doctors’
freedom & the rights of the patient to receive
appropriate care - A treating doctor’s primary obligation is to their
patient - They support CO in 3 cases: abortion), fertility treatment & withdrawal of life-sustaining treatment
- For other case may request but not a right
State 4 reasons why some argue that conscientious objection should not be allowed in medical practice.
- Inefficiency and inequity
- Inconsistency
- Commitments of a doctor
- Discrimination
Ie Doctors values should not determine medical care
Explain the value of a patient’s narrative (4)
Value of narrative:
- To decrease diagnostic and therapeutic error
- Increase personal connections from shared experiences
- Increases empathic opportunities
- Patients feel understood/cared for
Limits of conscientious objection as described by the GMC
You are allowed to refuse participation in a particular procedure. But cannot refuse to treat a patient/group of patients.
What are the two main components that influence afterload?
Vascular resistance
Ventricular wall tension
Increased contractility increases CO ______ of preload and afterload
Increased contractility increases CO INDEPENDENT of preload and afterload
What are the 4 classes of heart failure in the NYHA (New York Heart Association)?
Class I
-No limitation of physical activity. Ordinary physical activity does not undue fatigue, dyspnea
Class II
-Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitations, dyspnea
Class III
-Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation or dyspnea.
Class IV
-Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases
Difference in ejection fraction between systolic and diastolic ventricular dysfunction?
Systolic ventricular dysfunction: Impaired cardiac contractility therefore decrease ejection fraction
Diastolic ventricular dysfunction: Normal ejection fraction but impaired diastolic ventricular relaxation and decreased filling therefore decrease in SV and CO
Systolic dysfunction:
Results from conditions that affect…. (4)
Consequences on CVS?
Systolic dysfunction results from conditions that affect:
- Contractility e.g. IHD, cardiomyopathy, MI
- Chronic volume overload
- Pressure overload e.g. Valvular stenosis, hypertension
- Advanved aortic stenosis
Consequences to CVS:
- Increased EDV (preload)
- Ventricular dilation
- Increased ventricular wall tension
Diastolic dysfunction:
Causes? 5
Causes:
- Impedance of ventricular expansion e.g. constrictive pericarditis etc
- Increased wall thickness
- Delayed diastolic relaxation
- Increase HR
- Transient myocardial ischemia
What are the tissue consequences of:
- Right heart failure?
- Left heart failure?
Right heart failure:
- Congestion of peripheral tissues
1. Oedema and ascites
2. Liver congestion –> Impaired liver function
3. GI tract congestion –> Anorexia, GI distress, weight loss
Left heart failure:
- Right heart failure
- Decrease cardiac output
- Activity intolerance
- Signs of tissue perfusion
- Cyanosis and signs of hypoxia - Pulmonary congestion
- Cough with frothy sputum
- Orthopnea
- Paroxysmal nocturnal dyspnea
Causes of right ventricular dysfunction (4)
1. Conditions impeding flow into the lungs – Pulmonary hypertension – Valve damage / stenosis / incompetence 2. Pumping ability of right ventricle – Cardiomyopathy – Infarction 3. Left ventricular failure 4. Congenital heart defects
Cause of left ventricular dysfunction (4)
- Hypertension (↑TPR)
- Acute myocardial infarction
- Aortic or mitral valve stenosis or regurgitation
- Increase in pulmonary pressure can lead to
right ventricular failure
In the early stages of heart failure, what is the aim of the compensatory mechanisms?
To maintain CO
Although long term they worsen the condition
What are the 4 main compensatory mechanisms directly acting on the heart?
- Frank-starling mechanism
- Increase HR
- Increase contractility
- Increase in vascular resistance
All a result of decrease in CO
Explain the following problems with the compensatory mechanisms for cardiac faulure:
- Frank-starling
- Sympathetic activity
- Renin-Angiotensin
- Frank-starling mechanism
- Increase in vascular tone leads to increase in EDV
- Increase in muscle strength and O2 consumption - Sympathetic activity: Initially helpful but long term…
- Tachycardia, vasoconstriction, decrease perfusion of tssues, cardiac arrhythmias, renin release
- Increase workload of the heart
- Desensitization of beta but not alpha receptors (TPR remains high but HR eventually decreases) - Renin-angiotensin
- Decrease in renal blood flow stimulates release of renin
- Increase renin release therefore increase angiotensin II formation: Vasoconstrictor, stimulates aldosterone release
- ->Na and H2O reabsorption is increased directly (decreased flow to kidneys_ and indirectly (via aldosterone)
- Angiotensin II and aldosterone: Involved in inflammatory responses leading to deposition of fibroblast and collagen in the ventricles
- -> Stiffness and decreased contractility of the heart hence progressing dysfunction
Strategies for treatment of heart failure (4)
- Increase cardiac contractility
- Decrease preload and/or afterload to decrease cardiac work demand
- By relaxing vascular smooth muscle
- By reducing blood volume - Inhibit the RAAS
- Prevent inappropriate increase in HR
Name 8 systemic diseases that affect the CVS
- Diabetes mellitus
- Hypertension
- COPD
- Amyloidosis
- Vasculitides and SLE
- Rheumatoid arthritis
- Thyroid disease
- Sarcoidosis
Comment briefly on the CVS effects of Diabetes mellitus
Diabetes Mellitus causes microvascular disease due to basement membrane thickening. This impairs O2 diffusion into respiring tissues (particularly the retina)
BM thickening due to glycation.
Diabetes leads to accelerated vascular damage
Comment briefly on the CVS effects of hypertension
Left ventricular hypertrophy leads to hypertension
Hypertension causes vascular damage. E.g:
1. Promotes atherosclerosis
2. Increase TPR
3. Coronary ischemia
4. Aneurysm
Comment briefly on the CVS effects of Chronic obstructive pulmonary disease
In COPD there is emphasyma present. These are areas of lung tissue involved in gas exchange that are destroyed/ imparied. This limits the vascular bed available for gas exchange.