Year One Flashcards
Describe the key aspects of (non-acute) asthma.
Presentation: reversible bronchodilation, wheeze, dyspnoea, cough, atopy/allergy
Investigations: spirometry, peak flow
Treatment: SABA initially, then ICSs. Then consider LABA, increased steroids, methylxanthines, IgE monoclonal antibodies
Describe the key aspects of acute asthma.
Presentation: if life threatening, A CHEST
Arrhythmia, cyanosis (normal PaCO2), hypoxia/hypotension, exhaustion, silent chest, threatening PEFR (<33%)
Investigations: spirometry, ABG
Treatment: O SHIT MAN
Oxygen, salbutamol, hydrocortisone, ipratropium bromide, magnesium sulfate, anaesthetist, nebulizer
Describe the key aspects of COPD.
Presentation: non-reversible dyspnoea, use of accessory muscles, reduced exercise tolerance, cough and sputum
Investigations: spirometry, CXR, ABG, Chest CT
Treatment: domicilliary oxygen, SABA. then consider triple therapy (SABA/LAMA/LABA). rofumilast and carboxysteine. SMOKING CESSATION VITAL
Describe the key aspects of COPD exacerbation.
Presentation: more mucus, different colour, worse cough, fever
Treatment: as for COPD, with antibiotics
Describe the key aspects of cystic fibrosis, along with a brief indication of its scientific basis.
Science: defect in the CFTR gene on chromosome 7, blocking Cl secretion making secretions thicker.
Presentation: skin prick test, sweat test, karyotyping
Symptoms: male infertility, chronic lung infections, steatorrhoea, poor weight gain, failure to thrive, meconium ileus
Treatment: airway clearance, antibiotics, pancreatic enzyme supplementation, ivacaftor, trikefta
Describe the key aspects of bronchiectasis. Which pathogen are patients more likely to culture?
Presentation: copious coughing up mucus in the morning, recurrent chest infections
Investigations: HRCT (showing signet rings and mucus)
Treatment: airway clearance, antibiotics, azithioprine, ciprofloxacin.
Key culture: P aeruginosa
Describe the key aspects of obstructive sleep apnoea.
Presentation: excessive sleepiness, personality change, difficulty driving, cognitive impairment, loud snoring
Investigations: overnight pulse oximetry (showing a sawtooth pattern), or overnight sleep studies
Treatment: BiPAP or modafinil (a short term CNS depressant), or if young mandibular advancement
Describe the key aspects of ARDS, including pathology.
Pathology: trauma causes diffuse alveolar damage (DAD), leading to myofibroblasts leaking fibrous exudate and attracting neutrophils
Investigations: CXR, ABG
Treatment: oxygen, prone positioning, fluid management
Describe the key aspects of small cell lung cancer. Describe also the paraneoplastic syndromes associated with SCLC.
Presentation: weight loss (cachexia), night sweats, haemoptysis, lethargy, anorexia. Most likely smokes
Investigations: CXR, ABG, CT, bronchoscopy
Management: chemotherapy, radiotherapy, palliative, smoking cessation
Paraneoplastic: Cushing’s (increased cortisol, ACTH, blood glucose, BP), SIADH (hypernatremia, increased BP, oedema), and Lambert Eaton syndrome (causing myasthenia gravis).
Name the types of tumour in the lung, describe their location (peripheral or central), and describe their paraneoplastic actions.
Small cell: central, Cushings/SIADH/Lambert Eaton
Squamous: central, hypercalcaemia, increased PTHrP and keratin
Adenocarcinoma: peripheral, most common in non-smokers, HPOA and trosseau’s sign
Pancoast: peripheral (lung apex), Horner’s syndrome
Describe the key aspects of interstitial pulmonary fibrosis.
Presentation: insidious dyspnoea, crackles, clubbing, cyanosis and hypoxia
Investigations: CXR, bloods (assess for immune cause), spirometry, CT scan, bronchoscopy
Management: antifibrotics, nintendamib, transplant
Describe the key aspects of extrinsic allergic alveolitis.
Inflammation of the alveoli. Social history is key to determine what this is. Treatment is with removal of the antigen, or prednisone.
Describe the key aspects of anaphylaxis.
Presentation: sudden dyspnoea, stridor, wheeze, respiratory failure
Treatment: COBRA
corticosteroids, oxygen, beta2-agonists, rush of adrenaline, antihistamine
Describe the key aspects of sarcoidosis.
Presentation: SARCOID
skin (erythema nodosum), arthritis, respiratory (bilateral hilar lymphadenopathy, raised ACE), cardiac (arrhythmia, heart block), occular (uveitis), intracranial (haemorrhage), derangement of liver and kidney (hypercalcaemia)
Investigations: CXR, ACE levels, calcium levels, HRCT, biopsy
Treatment: watch and wait (particularly for shins), then offer methotrexate, azathioprine, hydrochloroquine, TNF therapy
Describe the key aspects of granulomatosis with polyangiitis. What is the difference between this and Churg-Strauss syndrome?
Presentation: haemoptysis, glomerulonephritis, rhinitis, and haematuria. More likely to affect Scandanavians
Investigations: antibody screening (cANCA, PR3)
Treatment: immunosuppression (methotrexate, cyclophosphamide, steroids)
Churg-Strauss: all of the above plus eosinophillia (i.e. late onset asthma)
Describe the key aspects of Goodpasture’s syndrome. (Hint: investigation involves scientific basis)
Presentation: glomerulonephritis, fibrosis
Investigation: look for a3 autoantibodies against collagen IV, CXR
Treatment: plasmapheresis to remove antibodies, immunosuppression
Describe the key aspects of bronchiolitis.
Presentation: young, cough, crackles, wheeze, cough, apnoea
Cause: RSV or metapneumovirus (secondary)
Cohort nursing and hygiene prevents
Describe the key aspects of pulmonary embolism.
Presentation: rapid onset of dyspnoea, haemoptysis, pleuritic pain, collapse, signs of DVT
Scores: consider Well’s score
Investigations: CXR, ECG (normal, or rarely S1Q3T3), ABG (alkalosis). Then depending on probability:
Well’s < 4: D-dimer, Well’s > 4: CT-PA (or V/Q if allergic to iodine contrast or obese)
If positive, commense heparin or LMWH
Long term: consider HERDOO2 for women (hyperpigmentation, edema, redness, D-dimer, obesity, old age > 65) - 2+ means long term anti-coag. Men must remain anti-coag
Describe the key aspects of tension pneumothorax.
Presentation: rapid dyspnoea, sharp chest pain, dyspnoea, raised JVP, hyper-resonant, tracheal deviation
Investigations: clinical suspicion MUST overrule
Treatment: thoracocentesis 2nd ICS, mid-clavic, then chest drain 5th ICS anterior axillary line
Describe the key aspects of mesothelioma.
Presentation: exposure to asbestos (crocolite), chest pain, dyspnoea
Investigations: CXR, bloods, drain, bronchoscopy
Treatment: cisplatin, premextred, talc slurry
Describe the key aspects of pneumonia. Also complete the ‘pneumonia microbiology’ deck.
Presentation: fever, cough, chest pain, dyspnoea, rigor
Investigations: CXR, ABG, sputum culture
Management: consider CURB65 (confusion, urea > 8, resp rate > 30, BP < 90/60, 65+). Empirical treatment for 1-2 is amoxicillin. 3-4 is co-amoxiclav. Resistant cases offered clarithromycin or erythromycin if pregnant.
Other treatment: oxygen, fluid resus, LMWH if likely to stay mobile, physiotherapy. Abx class switch after sputum culture.
Describe the key aspects of pulmonary tuberculosis.
Presentation: night sweats, constitutional, haemoptysis, fever, history of travel or previous TB, immunocompromised
Investigations: sputum x3, bronchoscopy if not possible. CXR
Management: negative pressure room, barrier nursing, contact tracing, immediate start on RIPES treatment, direct observation treatment (DOT), HIV test
Describe the drugs and side effects of TB treatment.
Rifampicin - hepatitis, raised bilirubin, thrombocytopenia, pink secretion
Isoniazid - rash/Itch, B6 deficiency
Pyramidaine (first Pass metabolism) - hepatitis, gout
Ethambutamol - (Eyes): red-green colour deficiency
Streptomycin - vestibular nerve damage
Describe the key aspects of pertussis.
Presentation: paroxysms of whooping coughs, throat swelling, gasping, swelling, cyanosis
Investigation: PCR
Treatment: vaccine, macrolides
Describe the key aspects of hypertension. This includes staging and presentation, investigation, then treatment.
Presentation: usually idiopathic
Investigations: ABPI, fundoscopy, bloods, urinalysis, ECG
Staging: 1: 140/90+, 135/85+
2: 160/100+, 150/95+
3: 180/110+
Malignant: > 130 diastolic
Treatment: diet, smoking, alcohol, exercise, weight
Drugs: < 55: ACEi, CCB, Thiazide diuretic
Drugs: > 55: CCB, ACEi, Thiazide diuretic
Black and diabetic: hydralazine
Describe the key aspects of angina pectoris.
Presentation: chest pain on exertion, relieved by rest
Investigations: ECG, FBC, U&E, Glucose tests
Treatment: Beta-blockers/CCB, GTN, 4 A’s
(atorvastatin, aspirin, atenolol, ACEi), lifestyle modification. Advise on when to seek emergency medical treatment (2x GTN w/out relief)
Describe the key aspects of acute coronary syndrome.
Presentation: central crushing chest pain, radiating to jaw or left arm. Onset at rest/after 2x GTN
Investigations: ECG, cardiac troponin level
Management: MOVE
Monitor, Oxygen, Venous access, ECG
MONA
Morphine (+ anti-emetic), O2, Nitrates, Aspirin (+ prasugrel/ticagrelor/clopidogrel)
Discharge: SABA
Statin, aspirin, B-blocker, ACEi
Describe the key aspects of acute congestive heart failure.
Presentation: dyspnoea, orthopnoea, chest pain, wheeze, crackles, elevated JVP, cardio megaly, hepatomegaly, ascites
Investigations: CXR (ABCDE - alveolar bat wings, kerly B lines, cardiomegaly, dilation of vessels, edema), FBC, LFTs, BNP pre echo, ECG, U&Es
Treatment: OMFG (oxygen, morphine, furosemide, GTN). Then: A Bad Surgeon Does Not Intubate Diseased, Hypoxic Patients (ACEi + Bb, Steroids, Diuretics, Neprilysin inhibitor, Ivabradine, Digoxin, Hydralazine + Isosorbide Dinitrate)
Briefly describe bradyarrhythmias and their management.
Sinus, sick sinus, ectopics, tachy-brady. Use atropine (antimuscarinic) or adrenaline/dobutamine (B1 agonists)
Briefly describe the classification of AVN block and the management of these. In addition, name the main drugs responsible for AVN block.
Presentation - syncope, palpitations. ECG
1st degree - prolonged PR (5 boxes +), every P wave associated with a QRS. N/A
2nd, Mobitz I (Wenkebach) - PR enlongates until beat is dropped. N/A
2nd, Mobitz II - every nth beat is dropped. Consider vagal manoeuvres if stable, or atropine/transvenous pacing if unstable
3rd degree - complete seperation, may result in blackout attacks (Stoke-Adams). Pacing indicated
Drug blockers: adenosine, amiodarone, B-blockers, CCBs, digoxin
Describe the key aspects of bundle branch block.
Both L and R have a QRS > 0.12s.
LBBB - WiLLiaM - V1 has a W shape, V6 an M shape
RBBB - MaRRoW - V1 has a M, V6 a W
Describe the key aspects of atrial fibrillation.
Presentation: dyspnoea, chest pain, palpatation, syncope, light-headedness, irregularly irregular pulse
Investigations: ECG, FBC, U&E
Management (acute): hemodynamic instability: cardioversion. Relevant heart disease: amiodarone. No relevant disease: ‘pill in the pocket’: flecanide
RHYTHM control: same as above long term (but dronedarone may be considered in place of amiodarone except in CHF due to side effects) or cardiac ablation
RATE control: inactive lifestyle (digoxin), or if active consider B-blocker or CCB.
Use CHA2DS2-VASc and HAS-BLED to consider anticoagulation
Describe the key aspects of arterial aneurysms. Include also the three main risk factors.
Dilation in the arteries due to wall weakness, encompassing all three layers. 60% are abdominal, 40% thoracic.
Presentation: 75% asymptomatic, 25% with bruising and pain radiating to lower back.
Risks: infection, infective endocarditis, Marfans
Investigations: USS screening: normal, small, medium, large (< 3cm, 3-4.4cm, 4.5-5.4, > 5.5cm) should be treated as (N/A, yearly USS, 3 monthly USS, 2 week referral). CT may also be used
Treatment: Lifestyle advice and EVAR (endovascular aneurysm repair) for large aneurysms.
Describe the key aspects of arterial dissections.
Presentation: ripping chest pain with different BP measurements in each arm.
Classifications: Stanford A (ascending aorta) and B (descending).
Investigations: CXR, CT angiography, transesophageal echo, MRI
Treatment: type A by surgery (emergency which may progress to shock), B by B-blockers and nitroprusside
Describe the key aspects of peripheral arterial disease (PAD).
Presentation: intermittent claudication (‘leg angina’) or critical limb ischaemia (pain at rest).
Examination: ARTS (absent pulses/hair, red/round ulcers, toe or ankle ulcers, sharp leg pain).
6 P’s: pain, pallor, parathesis, polar (cold), pulses, paralysis.
Investigations: ABPI ( < 0.4 = CLI, > 0.4 = IC), or angiography (CT/MRI/catheter, where ABPI is falsely elevated)
Treatment: pain management, statins, smoking cessation, anticoagulation, THEN surgery/amputation