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Flashcards in Alasdair Scott's notes Deck (209):
1

Anterior view ECG leads
Vessel

v1-v2
RCA

2

Septal view ECG leads
which vessel?

v3-v4
LAD

3

Lateral view ECG leads
Vessel

v5-v6
L circumflex

4

Sawtooth baseline

Atrial flutter

5

Rt axis deviation causes

Anterolateral MI
RVH, PE
ASD secundum
WPW

6

Lt axis deviation causes

Inferior MI
LVH
ASD primum

7

Absent P waves

AF
SAN block

8

Dissociated P waves

Complete heart block
Cannon a waves

9

Normal QRS complex time

<120ms

10

Wide QRS

Ventricular initiation
Conduction defect
WPW

11

PR interval length

120-200ms

12

Long PR

heart block

13

QT length

380-420ms

14

Causes of long QT

TIMME

Toxins: macrolides, antiarhythmics, TCA's histamine ant
Inherited: Romano-Ward, Jervell
Ischaemia
Myocarditis
Mitral valve prolapse
Electrolytes: dec Mg dec K dec Ca dec Temp

15

ST elevation

Acute MI
Pericarditis
Prinzmetal
aneurysm

16

ST depression

Ischaemia

17

Hyperkalaemia ECG signs

Peaked T waves High in Kathmandu
Widened QRS
Abesnt p wave
Sine wave appearance

18

Hypokalaemia ECG signs

Flattened T waves
ST depression
prolonged QT interval
prominent U waves

19

1st degree heart block

PR > 200ms

20

2nd degree heart block/mobitz I

Progressive lengthening of PR interval
One non conducted P wave

21

2nd degree heart block/mobitz II

Occasional non-conducted p waves

22

3rd degree heart block

Dissociation of p waves and QRS complexes

23

RBBB ECG changes and aetiology

MaRRow = M in v1 W in v6
Infarct
normal variant
congenital
Hypertrophy: RVH (PE, cor pulmonale)

24

LBBB ECG and aetiology

WiLLiaM = W in v1 M in v6
Fibrosis
LVH: AS HTN
Inarct
Coronary HD

25

Bifascicular block

RBBB & Left axis deviation

26

Trifascicular block

RBBB & LAFB & 1st degree AV block

27

Extra systole

Appears before anticipated beat
Atrial
Nodal
Ventricular

28

Narrow complex tachycardias Differential

AVNRT
AVRT
Atrial tachycardia
Atrial flutter
AF

29

Broad complex tachycardias

VT: no P waves, regular wide QRS, no T
Torsades de pointes
VF: Shapeless rapid oscillations and no organised complexes

30

P waves abnormalities

P pulmonale: peaked p wave = pulmonary HTN
P mitrale: broad bifid p waves = Mitral stenosis

31

Delta wave

Slurred upstroke of QRS
WPW
Can establish re-entrant circuit

32

Reverse tick

Digoxin
Down sloping ST depression
T wave inversion

33

ECG signs of PE

S1 QIII TIII

34

Bradycardias causes

DIVISIONS
Drugs: Antiarrhythmics, BB, CCB, D
Ischaemia/infarction
Vagal hypertonia
Infection
Sick sinus syndrome: damage or fibrosis of conductive tissue
Infiltration: DCM, Sarcoid, Amyloid
O: hypothy, hypoK, Hypothemia
Neuro: Inc ICP
Septal defect
Surgery

35

Rx of bradycardias

>40 and asymp = no Rx
<40
treat underlying cause
Atropine
Pacing

36

Rx of SVT

Pt compromised = sedate and cardiovert
Vagal manoeuverts
then
Adenosine 6mg 12mg 12mg =
transient AV block unmasking atrial rhythm
Cardioverts to sinus rhythm
Then
Electrical cardioversion

37

Prevention of SVT

BB
Radioablation electrophysiology studies

38

Broad complex Tachycardias
Differentials

VT until proven otherwise
Torsade
SVT w/ BBB

39

VT causes

IM QVICK
Infarction
Myocarditis
QT interval INC
Valve abnormality
Iatrogenic
Cardiomyopathy
K dec

40

Rx VT

No Pulse: CPR
Pulse: O2 and IV access
Adverse signs i.e. BP<90, HF, Pai, HR 150: DC cardioversion then amiodarone
No adverse signs: Correct electrolyte problems then Amiodarone, lidocaine or procainamide
failing this DC cardioversion, EPS or ICD

41

Causes of AF

Common
IHD
Rheumatic heart disease
Thyrotoxicosis
Hypertension
Other
ETOH, pneumonia, PE, Post-op, HypoK, RA

42

AF Rx aims

Rate/Rhythm control
based on age, onset of Sx's (<48hrs), Sx's
Reducing stroke risk CHA2DS2VASC

43

AF rate control

BB or CCB diltiazem
Then combo breaker any 2 of following
BB, diltiazem or digoxin

44

AF pharmacological cardioversion

Maintenance of sinus rhythm

Amiodarone
Flecainide

Soltalol
Amiodarone
Flecainide

45

ACS
Def
Divded into

ACS = unstable angina + evolving MI

STEMI
NSTEMI

46

Risk factors for ACS

Modifiable
HTN, DM, Smoking, inc Chol, Obesity
Non-modifiable
Age, male, FH

47

Ix for ACS

Blds
Troponin T/I elvated 3-12 hrs (need 12 hour trop to exclude MI)
FBC, U&E's glucose lipids clotting

48

Rx for ACS

Prevent worsening of presentation
Revascularize
Treat pain
MONA (O2 only for sats<94%)
STEMI Rx
2nd antiplatelet e.g. clopidogrel
PCI
STEMI Mx
Angiography

49

Secndary prevention of ACS

Aspirin
Clopidogrel
Statin
Beta blocker
ACEi

50

Complications of MI

Death passing PRAED st
Death
Pump failure
Pericarditis
Rupture: myomalacia cordis
Arrhythmias
Aneurysm: ventricular
Embolism
Dressler's: recurrent pericarditis

51

Aetiology of angina

Atheroma
Anaemia
AS
Tachyarrhythmias
Arteritis

52

Angina Ix

Bloods: FBC, U&E'slipids, glucose, ESR, TFT's
ECG: normally normal, consider exercise ECG
Stress echo
Perfusion scan
Angiography gold standard

53

Angina Mx

Cons: stop smoking, wt loss and exercise, diet
Med
secondary prevention: aspirin, statin etc.
Anti-anginals: GTN, BB or CCB
3rd line BB&CCB (not verapamil)
4th line Ivabradine, nicorandil, ranolazine

54

CABG indications

L main stem disease
Triple vessel disease
Refractory angina
Unsuccessful angioplasty

55

Low output HF causes

Pump failure: ischaemia/MI, DCM, HTN, myocarditis, arrhythmias.
Excessive pre-load: AR, MR, Fluid overload
Excessive afterload: AS, HTN HOCM

56

High output HF causes

Anaemia
Thyrotoxicosis, thiamine def
Pregnancy, paget's

57

RVF signs

Inc JVP
Tender smooth hepatomegaly
Pitting oedema
Ascites

58

LVF causes

1st IHD
2nd Idiopathic dilated cardiomyopathy
3rd systemic HTN
4th Mitral/aortic valve disease
Spec cardiomyopathies

59

LVF signs

Cold peripheries +/- cyanosis
AF
Cardiomegaly w/ displaced beat
Bibasal creps

60

Diagnosis of CCF

Framingham criteria 2 major or 1 major and 2 minor
Neck vein distension, abdominojugular reflex, basal creps
minor: bilat ankle oedema, SOBOE, inc HR >120

61

HF signs on CXR

Alveolar shadowing
Kerley B lines
Cardiomegaly
Upper lobe diversion
Effusions
Fluid in fissures

62

Ix for HF

Blds: FBC (anaemia), U&E's (arrhythmias), BNP!!! TFTs glucose
ECG: ischaemia, hypertrophy, AF
Echo KEY:Systolic and diastolic function, ejection fraction, focal hypokinesia, hypertrophy, valve lesions, intercardiac shunts

63

Biomarker of HF

BNP or NTproBNP

64

HF Mx

Cons: stop smoking, dec salt intake, optimise wt
Med: aspirin, statins, BB, ACEi, spironolactone, hydralazine w/ nitrates
Furosemide not shown to improve long term mortality
Surg: LVAD, heart transplant

65

Pulmonary oedema Mx

Sit pt up
O2 15L/min via reservoir mask
IV access
Diamorphine 2.5-5mg & metoclopramide 10mg
Frusemide 40-80mg
GTN

66

Causes of cardiogenic shock

MI HEART
MI
HyperK
Endocarditis
Aortic dissection
Rhythm disturbances
Tamponade


Obstructive: tension pneumo, massive PE

Treat underlying cause morphine

67

HTN diagnosis

>180/110 treat immediately
~140/90 = ambulatory BP mointoring or Home BP monitoring
Stage 1 HTN = clinic >140/90 and ABPM/HBPM >135/85
Stage 2 HTN = clinic >160/100 and A/HBPM >150/95
Severe HTN = clinic >180sys or >110diasys

68

HTN Mx

Cons: Less salt, diet, ETOH
Stage 1 HTN: treat if <80 and have organ damage, renal disease, CVD, diabetes or CVD risease risk >20%
Med:
1st ACEi or CCB
2nd A + C (/D)
3rd A + C + D
resistant HTN: A + C + D + further diuretic, expert help

69

Aortic stenosis causes

Senile calcification: commonest
Congenital: bicuspid valve
Rheumatic fever

70

Aortic stenosis Triad

Dyspnoea, syncope, chest pain

71

Aortic stenosis Signs

Slow rising pulse
Narrow PP
Ejection systolic
Ejection click
Radiates to carotid

72

Aortic stenosis Ix

LV strain: tall r ST depression T inversion
CXR calcified AV
Echo: diagnostic, LV function, assess coronaries for surgery

73

Aortic Stenosis Mx

Cons
Observe if asymp
Manage RF's: statins antiHTNive, DM
Med:
BB for angina
Avoid nitrates
Surg:
Valve replacement indications: Severe symptomatic AS, dec EF <50%, Severe AS w/ CABG
Baloon valvuloplasty

74

AS valve replacement types

Mechanical: last longer, need anticoag
Bioprosthetic: don't require anticoag but fail sooner

75

Aortic regurg
Ax

Px

Ax: Infective endo, Aortic dissection, congenital, rheumatic, connective tissue.

Px: exertional dyspnoea, collapsing pulse, wide PP, early diastolic murmur,

76

AR Mx

Optomise RF's
Aortic valve replacement

77

Mitral regurg Ax

Mitral valve prolapse
LV dilatation
Annular calcification
Post-MI
RF
Connective tissue

78

Mitral regurg Px

Apex beat displaced
Pan systolic murmur
radiates to axilla

79

Infective endocarditis Ax

S viridans most common, dentist
S bovis, S aureus
-ve:
Haemophilus
Actinobacillus
Cardiobacterium

80

nfective endocarditis Px

Fevers,
Rigors
Clubbing
Anaemia
Wt loss
New onset murmur
Micro haematuria
Janeway lesions, Oslers nodes

81

Infx Endo criteria for diagnosis

Duke criteria: 2 major, 1 major + 3 minor, 5 minor
Major: +ve bld culture, endocardium involved (+ve echo, new valvular murmur)
Minor: Predisposition, fever >38, Emboli, immune phenomenon, +ve bld culture not meet major criteria

82

Infx endocarditis Rx

Acute severe: Fluclox + gent IV
Subacute: Benpen +gent IV

83

Rheumatic fever Ax

T2 cross reactive hypersensitivity reaction following infx w/ group A beta haemolystic strep (GAS)

84

Criteria for assessing rheumatic fever

Duckett jones criteria
2 major or 1 major and 2 minor
Major: pancarditis, arthritis, subcut nodules, erythema marginatum, syndenham's chorea
Minor: fever, inc ESR/CRP, arthralgia, prev rheumatic fever

85

Rheumatic fever Px

pacarditis
Arthritis
erythema marginatum
syndeham's chorea

86

Rheumatic fever Ix

Blds: strep Ag, ASOT, ESR, CRP
ECG
Echo

87

Rheumatic fever Rx

Bed rest until normal CRP for 2 wks
Benpen for 10 days
Analgesia
Oral pred

88

Prognosis of rheumatic fever

Valve diseas
Mitral 70%
Aortic 40%
Tricuspid 10%
Pulmonary 2%
60% develop chronic rheumatic heart disease

89

Pericarditis causes

Viral: coxsackie, flu, EBV, HIV
Bacterial: pneumonia, RF, TB, Staph
Fungal
MI, Dressler's
Drugs: penicillin, isoniazid, procainamide, hydralazine
Other: uraemia, RA, SLE, sarcoidradiotherapy

90

Pericarditis Px

Chest pain: sharp, pleuritic, worse lying down, radiates to shoulder, relieved by sitting forward
Pericardial rub
Fever
Effusion of tamponade

91

Pericarditis Ix

ECG: saddle-shaped ST elevation
Blds: FBC, ESR, trop, cultures, virology

92

Pericarditis Mx

Analgesia: ibuprofen 400mg
Rx cause

93

Signs of tamponade (eponymous)

Beck's triad
dec BP
inc JVP
dec heart sounds

Pulsus paradoxus: dec pulse on inspir
Kussmaul's sign: Inc JVP on inspir

94

Tamponade diagnostic Ix

Echo: echo free zone around heart

95

Tamponade Rx

Pericardiocentesis
Treat cause
Send fluid for cytology ZN stain and culture

96

Myocarditis causes

Idiopathic 50%
Viral: coxsackie B flu, HIV
Bacterial: S. aureus, syphillis
Drugs: cyclophosphamide, herceptin, CBZ, phenytoin
Autoimmune: Giant cell myocarditis assoc w/ SLE

97

HOCM
Ax

Px

LVOT obstruction from hypertrophy, AD inheritance, beta-myosin heavy chain mutation

Angina, dyspnoea, palpitaations, eretional syncope, sudden death,
Jerky pulse, double apex beat

98

HOCM Rx

Medical: BB, CCB, Amiodarone, anticoagulate
Non-medical: consider ICD

99

Benign cardiac tumour causing clubbing

Cardiac myxoma, most likey Lt Atrial 90%

100

Congenital heart defects

Bicuspid aortic valve
ASD
Coarction of the aorta
VSD
Tertalogoy of Fallot: VSD, Pulmonary stenosis, RVH, overriding aorta

101

Marfan's Px

AD inheritance
Cardiac: dissection, aneurysm, AR
Ocular: lens dislocation
MSK: high arched palate, arachnodactyly, arm span>ht, pectus excavatum, joint hypermobility

102

Ehler's-Danlos Px

Hyperelastic skin, hypermobile joints, MVP, MR, AR aneurysm, Fragile blood vessels

103

Causes of clubbing

Resp:
Bronchial Ca, mesothelioma
Chronic - lung suppuration empyema, bronchiectasis, Fibrosis - IPA, TB
Cardiac:
Inf endo
Congenital cyanotic heart disease
Atrial myxoma
GIT: C's
Cirrhosis
Crohn's/UC
Coeliac
Ca - GI lymphoma

104

Pneumonia classification

CAP: Pneumococcus, mycoplasma, haemophilus, S. aureus, moraxella, chlamydia, legionella
HAP: >48hrs after hospital admission, g-ve enterobacteria, S. aureus
Aspiration: Inc rsk in stroke, achalasia, bulbar palsy, GORD
Immunocompromised: PCP, TB, Fungi, CMV/HSV

105

Pneumonia Px

Fevers
Malaise
Dysnoea
Cough, purulent sputum, haemoptysis
Pleuritic pain

Ex
inc RR/HR, confusion
Consolidation: Dec expansion, dull percussion, bronchial breathing, dec air entry, crackles, pleural rub

106

Investigating pneumonia

FBC: WCC inc, inflammatory markers, aneamia
ABG if low SpO2
U+E's: Urea + creatinine
Sputum: MC+S
CXR: infilitrates, consolidation, effusion
Urine: legionella antigen test
CURB-65 used if XR changes

107

Pneumonia Mx

O2
Abx
Fluids
Analgesia
Chest physio
F/up

108

Abx Rx for Pneumonia

Mild: Amoxicillin 5 day course
Mod: beta-lactamase stable penicillin and macrolide 7-10 day course

Macrolide or tetracycline if allergic

N.B. Macrolide = Clarithromycin, Erythromycin

109

Differences between Type I and Type II resp failure

Type 1
Low O2 Normal CO2
e.g. Dec drive, Fluid, fibrosis

Type 2
Low O2 High CO2
e.g. COPD, Asthma, Bronchiectasis

110

Complications of pneumonia

Empyema
Hypotension: dehydration and septic vasodilatation
Pleural effusion
Lung abscess

111

SIRS def

Inflammatory response to a variety of insults.
2 of following criteria
Temp >38 or <36
HR >90
RR >20 or PaCO2 <4.6
WCC >12x10^9 or <4x10^9

112

Pneumococcus pneumonia
RF
Features
Mx

Elderly, ETOH, immcomp, CHF

Lobar consolidation

Amox, benpen, cephalosporins (ceftriaxone)

113

S aureus pneumonia
RF
Features
Mx

Influenza infx, IVDU

bilateral cavitating

Fluclox, Vanc

114

Klebsiella pneumonia
RF
Features
Mx

ETOH, DM

Cavitating esp. upper lobes

Cefotaxime

115

Pseudomonas pneumonia Rx

Tazosin

116

Mycoplasma pneumonia
Features
Mx

Dry cough, flu like prodrome, erythema multiforme

Clarithromycin, ciprofloxacin

117

Legionella
RF
Features
Tests

Air conditioning, travel

dry cough, dyspnoea, flu like prodrom, D+V, SIADH
Urinary specific Ag

118

Chlam psittaci
Assoc

Birds, horders spots, rose spots

119

PCP pneumonia
Assoc
Rx

Immcomp

Trimoxazole

120

Bronchiectasis Ax

Permanent dilatation due to chronic infx of bronchi

121

Bronchiectasis Px

Persistant cough w/ purulent sputum, haemoptysis, fever, wt loss
Clubbing, coarse insp creps, wheeze, purulent sputum

122

Bronchiectasis Ix

CXR: thickened bronchial walls/tramlines
Spirometery: obstructive pattern
HRCT: dilated and thickened airways

123

Bronchiectasis Rx

Inspiratory muscle training
Postural drainage
Abx for infx
Bronchodilators
Immunisations
Surgery in selected cases

124

CF Ax

Auto recessive 1:2000
Mutation in CFTR commonly deltaF508

125

CF Px

Neonate: Meconium ileus, rectal prolapse
Children: Nasal polyps, cough, wheeze, infx, haemoptysis, steatorrhoea, infertility
Ex
Clubbing, cyanosis, bilat coarse creps

126

CF Ix

Sweat test Na+Cl>60mM
Faecal elastase diagnostic
Genetic screening
Spirometery

127

CF Mx

Gen: MDT approach, GP, resp, diet, spec nurse
Chest: Physio, Abx, Mucolytics, Bronchodilators
GI: Enzyme replacement, Vit sups,

128

Pulmonary aspergillosis features

Wheeze, cough, dyspnoea
Aspergilloma: round opacityw/in cavity, apical on CXR
Rx
Pred

129

Lung Ca types

SCC: Central, locally invasive, late mets, inc Ca
Adeno: Peripherally located, early mets
Large-cell: Large poorly differentiated
Small-cell: chemosensitive, ectopic hormone secretion

130

Lung Ca Px

Cough, haemoptysis, dyspnoea, wt loss

Consolidation, collapse, pleural effusion, cachexia, clubbing, axillary LN's, bone tenderness, hepatomegaly, confusion

131

Lung Ca Ix

CXR: coin lesion, hilar enlargement, conoslidation collapse, effusion
Contrast enhanced CT: staging, consider brain
PET
Radionucleotide bone scan

Biopsy
FNA
Bronchoscopy
Endoscopic bronchial US biopsy
Mediastinoscopy

Lung function tests

132

CXR coin lesion differential

Foreign body
Abscess: staph, TB, Kleb
Neoplasia
Granuloma: RA, Wegener's, TB, Sarcoid
Structural: AVM

133

Grade vs staging

Grade: how cancerous, how poorly differentiated
Stage: where is it

134

Lung Ca Mx

MDT approach: pulmonologist, oncologist, radiologist, histopathologist etc
Chemo for advanced disease
Radio adjunct
Surgery for early and peripheral lesions i.e. NSCLC

135

O2 therapy
Principles

Critically ill pts high flow 02 via non rebreath
O2 targets
94-98% in most pts
88-92% in those w/ hypercapnic resp failure (hypoxic drive)
Those at risk of above start at 24% via venturi, do ABG, if CO2 falls inc target sats to >94%

136

Instruments for O2 therapy

Nasal cannula 1-4L/min = 24-40% O2
Face mask
Non rebreath: reservoir bag = 60-90% at 10-15L/min
Venturi: precise conc - 5%-60%

137

Asthma
Triggers

Features

Atopy: dust, pollen, food, animals , fungal
Stress: cold, viral, exercise, emotion

Cough, wheeze, dyspnoea, diurnal variation
Tachypnoea, tachycardia, widespread polyphonic wheeze, hyperinflated, dec air entry

138

Asthma Ix

Inhaled silver nitrate test
FEV1
Peak flow

Sirometery

139

Asthma Mx

TAME
Technique w/ inhaler
Avoid triggers
Monitor: peak flow diary
Educate

Drug ladder
SABA+ICS
+Leukotriene receptor antagonist
+LABA
+Oral steroids

140

Acute asthma assessment

Severe:
PEFR<50%, RR >25, HR>110, can't complete sentences
Life threatening:
PEFR<33%, SpO2<92%, cyanosis, hypotension, exhaustion, silent chest, tachy/brady arrhythmias

141

Acute asthma Mx

Sit up
100% O2 via non-rebreathe
Neb salb 5mg and ipratropium 0.5mg
Hydrocortisone 100mg IV or Pred 50mg PO
Mg Sulphate 1.2-2g IV over 20mins
ITU

142

COPD def

Airway obstruction FEV1<80%
Chronic bronchitis: cough and sputum production on most days for 3mnths over 2 years
Emphysema: histological diagnosis of enlarged airspaces

143

COPD Px

Cough, sputum, dyspnoea, wheeze, wt loss

Tachypnoea, hyperexpanded, prolonged expiratory phase, wheeze, cyanosis, pursed lip, leaning forward

Pink Puffers in emPhysema: breathless but not cyanosed
Blue Bloaters in Bronchitis: cyanosed but not breathless

144

COPD Mx

Assess severity
Gen: stop smoking, pulmonary rehab, Mx poor nutrition and obesity, Vaccinate, rv,

1st line: SABA/SAMA
FEV1>50%: LABA/LAMA
FEV1<50%: LABA+ICS/LAMA

145

Acute exacerbation of COPD
Ax

Px

Hx

Ix

Ax
Viral URTI (30%), Bacterial Infx
Px
Cough+sputum
Breathlessness
Wheeze
Hx
Smoking status, exercise capacity, disease control
Ix
PEFR, Blds (FBC, ABG, CRP, culture), Sputum culture, CXR, ECG

146

Acute exacerbation of COPD Mx

Controlled O2 therapy: sit up, 24% venturi 88-92% SpO2
Nebulised bronchodilators: salb, Ipratropium
Steroids: Hydro 200mg IV, Pred 40mg PO
Abx: Doxy 200mg STAT
NIV

147

PE
RF

SPASMODICAL
Sex F
PregC
Age inc
Surgery 10 days post op
Malignancy
Oestrogen
DVT/PE previous Hx
Immobility
Colossal size
Antiphospholipd Abs
Lupus anticoag

148

PE features

Hx
Dyspnoea, pleuritic pain, haemoptysis, syncope
Px
Fever, cynosis, Tachycardia/pnoea, RHF, evidence of cause

149

PE Ix

Blds: Clotting, D-dimers
ABG: alkalotic
CXR: normal
ECG: Sinus tachycardia, RBBB, rt ventricular strain, s1, q3, t3
Doppler: thigh + pelvis +ve in 60%
CTPA

150

Well's scoring sytem

Likliehood of having a DVT

151

PE Mx

Sit up, 100 O2 via non-rebreathe mask
Analgesia: morphine +/- metoclopramide if distressed
Thrombolysis for critically ill/massive PE
LMWH: intially after dagnosis
Warfarin for at least 3 mnths
Compression stockings

152

Pneumothorax
Ax

Px

Ax
Spontaeneous: no underlying lung disease - young thin men, smokers. Underlying lung disease - COPD, Marfan's, Ehler's danlos
Px
Sudden onset, dyspnoea, pleuritc chest pain, tension=resp distress, cardiac arrest
↓Chest expansion, hyperresonant, ↓breath sounds, Tension = ↑JVP, mediastinal shift

153

`Pneumothorax Ix

ABG, US
CXR: Translucency, collapse, mediastinal shift, surgical emphysema, cause, rib #, pulmonary disease

154

Mx Pneumothrax

Tension
Resus, no CXR, large bore Vanflon into 2nd ICS, Mid clavicular line, ICD

Traumatic
Resus, analgesia, ICD, 3 sided wet dressing

1ry or 2ry pneumothorax
>2cm = aspiration followed by ICD if unresolved
<2cm = consider d/c

155

Pleural effusion
Transudate vs exudate

Transudate <25g/L of protein
Exudate >35g/L of protein

Ex = Extra protein

156

Pulmonary effusion Ax

Exudates
Infx (pneumonia/TB), Neoplasm, Inflamm (RA/SLE), Infarction
Transudates
CCF, renal failure, ↓albumin, ↓thyr

157

Pulmonary effusion features

Ix

Asymptomatic, dyspnoea, pleurtic chest pain
Signs
Tracheal deviation away, ↓expansion, stony dull, ↓air entry, bronchial breathing, ↓VR
Assoc disease
Ix
CXR blunt costophrenic angles, cause e.g. coin lesion
US fascilitates tapping

158

Pulmonary effusion Mx

Diagnostic tap
Percuss upper border and go 1-2 spaces below
Infilitrate down to pleura w/ lignocaine
Aspirate w/ 21G needle and 50ml syringe
Send aspirate for:
Chemistry - protein, LDH, pH, Glucose, Amylase
Micro - MCS, auramine stain, TB culture
Cytology
Immunology - SF ANA, complement

159

Extrinsic allergic alveolitis
Def

Ax

Px

Def
Acute allergen exposure in sensitised pts. T3HS Chronic exposure = granuloma formation
Ax
Bird fancier's lung, farmers/mushroom worker's, Malt worker's lung
Px
Acute - Fevers, rigors, malaise, dry cough, dyspnoea, crackles
Chronic - dyspnoea, wt loss, T1 resp failure, cor pulmonale

160

Extrinisc allergic alveolitis
Ix

Mx

Blds - ↑ESR
CXR - upper zone reticulonodular opacification or fibrosis
Mx
Avoid exposure
Steroids

161

Idiopathic pumonary fibrosis
(previously cryptogenic fibrosing alveolitis)
Px

Ix

Mx

Px
Dry cough, dyspnoea, malaise, wt loss, arthralgia, OSA, cyanosis, clubbing, crackles - fine, end-inspiratory
Ix
Blds: ↑CRP, ↑Ig, ABG: ↓PaO2, ↑PaCO2 T2RF
CXR: ↓lung volume, honeycomb lung
Spiro: restrictive
Mx
Stop smoking, pulmonary rehab, O2 therapy, Rx of HF

162

Causes of Pulmonary HTN

Lt heart disease
Mitral stenosis, Mitral regurgitation, LV failure, L→R shunt
Lung parenchymal disease
Hypoxia→vasoconstriction, COPD, asthma, CF
Pulmonary vascular disease
Pulmonary vasculitis (SLE/wegener's), SCC, PE, Portal HTN
Hypoventilation
Neuromuscular

163

Cor Pulmonale
Def

Px

RHF due to pulmonary HTN

Px
Dyspnoea, fatigue, syncope, ↑JVP, parasternal heave, pulsatile hepatomegaly, ascites

164

Sleep apnoea
Def

RF

Rx

Def
Intermittent closure/collapse of pharyngeal airway
Rf
Obesity, male, smoker, ETOH, IPA
Rx
Wt loss, avoid smoking and ETOH, CPAP

165

Smoking cessation
Advice

Facilitating quitting

Ask - Smoking status
Advise - stop w/ support and medication
Act - provide details of where to get help
Facilitating quitting
Refer to specialist stop smoking services
Nicotine replacement - GUM, Patches
Varenicline - partial nicotine receptor agonist
Buprion

166

DM def

Multisystem disorder due to an absolute or relative lack of endogenous insulin→metabolic and vascular complications

167

T1DM and T2DM differences
Path
Age
Px
Assoc/
Abs

T1DM T2DM
Autoimmune destruction Insulin resistance→relative def
of beta cells→absolute
insulin def

Before puberty Older

Polyuria, polydipsia, ↓wt Polyuria, polydipsia, comp's
DKA

HLA-D3/4, AI disease Obesity

Anti-islet, anti-GAD

168

Glucose testing

Fasting
Normal<6.1 IFG = 6.1-6.9 Diabetes >7.0
75g OGTT
Normal<7.8 IGT = 7.8-11 Diabetes >11.1

169

Secondary causes of DM

Drugs: steroids, anti-HIV, atypical neuroleptics, thiazides
Pancreatic: CF, chronic pancreatitis, HH, pancreatic Ca
Endo: phaeo, cushings, acromegaly, T4
Other: glycogen storage diseases

170

DM conservative Mx pt1

Monitoring 4 C's

MDT

Monitor 4 C's:
Control, glycaemic: record of complications, capillary bld glucose (4.5-6.5mM fasting, 4.5-9mM 2h post prandial), HbA1c - aim for 7.5-8%, BP, lipids

Complications: macro - pulses, BP, cardiac auscultation, micro - fundoscopy, ACR U/E's, sensory testing

Competency: w/ injections, check injection sites, BM's

Coping: psychological, occupation, domestic

171

DM conservative Mx pt2

Lifestyle modification: DELAYS

DELAYS

Diet: regular healthy diet, ↓calorie intake, ↓fat, ↓Na, ↑soluble fibre

Exercise

Lipids: Rx of hyperlipidaemia w/ statins

ABP: ↓Na intake and ETOH, keep BP<130/80 w/ ACEi

Aspirin

Yearly/6monthly check up

Smoking cessation

172

DM Mx Oral hypoglycaemics

Metformin (biguanide): Start if HbA1c>target after lifestyle mods
SE: nausea, diarrhoea, abdo pain, lactic acidosis
CI: GFR<30, tissue hypoxia, iodinated contrast media
Dose: 500mg after evening meal, ↑ing to 2g max

+Sulfonylurea e.g. Gliclazide
SE: hypoglycaemia, wt gain
CI: omit morning of surgery
Dose: 30mg w/ breakfast

173

DM Mx oral hypoglycaemics additional therapy

1st) lifestyle mod+metformin+sulfonylurea+Insulin
2nd) +stigliptan or pioglitazone
3rd) +Exenatide

174

Insulin
Principles

Educate pt about - self adjusment (exercise), titrate dose, family member can abort hypo w glucogel
Pre-prandial BM don't tell you how much glucose is needed
Fasting BM before meals informs re long-acting insulin
Finger-prick after meal informs re short acting insulin dose

175

Insulin regimes

BD biphasic regimes
Insulin 30 mins before breakfast and dinner. Rapid = actrapid, Intermediate = insulatard.
T1 or T2 w/ reg lifestyle

Basqal-bolus
Bedtime log acting (Glargine) and short acting before each meal (lispro)
Adjust dose accoring to meal
T1DM flexible lifestyle

OD long-acting before bed
Initial regime when switching from tablets in T2DM

176

Insuling in concurrent illness

Insulin req ↑
Maintain calories
Check BM's .4hrly and test for ketonuriainsulin dose if glucose is rising

177

Insulin therapy SE

Hyporglycaemia: ETOH, BB and eldery at risk
Lipohypertrophy: rotate injection site
Wt gain in T2DM

178

Complications of DM summary

Hyperglycaemia: DKA, HONK
Hypoglycaemia
Infx
Macrovascular: MI, CVA
Microvascular

179

Insulin complications
Macrovascular
Rx
Prevention

MI: may be silent
PVD: claudication, foot ulcers
CVA
Rx
Manage CV RF: ↓BP, smoking, lipids, HbA1c
Prevention
Regular screening (fundoscopy, feet), good glycaemic control

180

Diabetic feet
Ax = 2

Ischamia:
Critical toes, absent pulses, Ulcers - painful, punched out, pressure points

Neuropathy:
Loss of protective sensation, deformity (Charcot's joints, pes cavus), injury or Infx over pressure points, ulcers - painless, punched out, metatarsal head

181

Diabetic foot Mx

Cons:
Foot inspection daily, comfortable shoes, chiropody
Med:
Rx Infx
Surg:
Abscess, cellulitis, gangrene, suppurative arthritis

182

Diabetic nephropathy
Ax
Px

Ax
hyperglycaemia → nephron loss and glomerusclerosis
Px
Microalbuminuria = ACEi/ARB, refer if UCR>70

183

Diabetic retinopathy
Ax

Microvascular disease → retinal ischaemia → ↑VEGF → new vessels formation

184

Diabetic retinopathy
Px

Retinopathy + maculopathy
Cataracts
Rubeosis iris: new vessels on iris → glaucoma
CN palsies

185

Commonest cause of blindness up to 60yrs
Ix for this
Rx

Diabetic retinopathy and maculopathy
Ix: fluorescein angiography
Rx: laser photocoagulation

186

Signs of retinopathy
Background
Pre-proliferative
Proliferative
Maculopathy

Background: dots, blots, hard exudates
Pre-proliferative: cotton-wool spots, venous beading, haemorrhages
Proliferative: new vessels, pre-retinal or vitreous haemorrhages
Maculopathy: ↓acuity, hard exudates

187

Neuropathy
Ax

Ax: metabolic glycosylation/Ischamia of vasa nervorum
Px:

188

Neuropathy
Px = 4

Symmetrical sensory polyneuropathy
Glove and stocking, absent ankle jerks, numbess, tingling, pain
Rx: Paracetamol, amiriptyline, gabapentin, SSRI

Mononeuropathy/mononeuritis multiplex
e.g. CN3/6 palsies

Femoral neuropathyamytrophy
Painful asymmetric weakness and wasting of quds w/ loss of knee jerks. Ix = NCS/electromyomography

Autonomic neuropathy
Postural hypotension, gastroparesis, diarrhoea, urinary retention, ED

189

DKA
Pathogensis of:
Ketones
Dehydration

Ketones
↓insulin→↑stress hormone+↑glucagon→↓glucose utilisation+↑fat oxidation→↑fatty acids→↑ATP+ketone bodies

Dehydration
↓insulin→↓glucose utilisation+↑gluconeogenesis→severe hyperglycaemia→osmotic diuresis→dehydration

190

DKA precipitants = 3

Infx
Stress
New T1DM

191

DKA
Px = 6

Abdo pain
Vomiting
Drowsiness
Kussmaul hyperventilation
Dehydration
Ketotic breath

192

DKA diagnosis

Acidosis: pH,7.3
Hyperglycaemia: >11.1mMol
Ketonaemia: >3mM

193

DKA Ix

Urine: ketones + glucose
Cap: glucose + ketones
VBG: acidosis + ↑K
Blds: U+E's (K), FBC, Glucose, cultures (?inf)
CXR: signs of Infx

194

DKA complications = 5

Cerebral oedema: excess fluid administration
Aspiration pneumonia
Hypokalaemia
Hypopsphataemia
Thromboembolism

195

DKA mx

Fluids (SBP>90)
NaCl 1L over 1st hour
NaCl w/ K 1L over next 2 hours
'' over next 2 hours
'' over next 4 hours
'' over next 4 hours

Insulin
at 0.1units/kg/hr

Once glucose is <15mmol/l
Dextrose 5%

Hrly glucose+ketone monitoring

Aims:
↓Ketones by 0.5mM/H
↓Glucose by >3mM/h

Transfer to sliding SC insulin when eating and drinking
Pt education

196

Whipple's triad

Low plasma glucose<3mM
Sx consistent w/ hypoglycaemia
Relief of symptoms by glucose administration

197

Sx of hypoglycaemia

Autonomic 2.5-3
Sweating, anxiety, hunger, tremor, palpitations
Neuroglycopenic <2.5
Confusion, drowsiness, seizures, personality change, focal neurology, coma

198

Fasting hypoglycaemia
Causes = 7

EXPLAIIN
EXdogenous drugs
Pituitary insuficiency
Liver failure
Addison's
Islet cell tumours
Immune
Non-pancreatic neoplasms - fibrosarcomas

199

Thyrotoxicosis
Def
Ax

Def:
Clinical effect of ↑T4 usually from gland hyperfunction
Ax:
Grave's - Anti-TSHr abs
Toxic multinodular goitre - Iscan = goitre+hot nodules
Toxic adenoma - solitary hot nodule
Thyrotoxic phase of thyroiditis - then hypoThyr
Drugs - Thyr, amiodarone

200

Hyperthyroidism
Px

Diarrhoea, ↓wt, sweats, heat intolerance, palpitations,irritability, oligomenorrhoea.

Hands: Fast pulse, AF, warm moist skin, tremor, palmar erythema

Face: Thin hair, lid lag, lid retraction, goitre or nodule

Grave's specific:
Exopthalmos
Thyroid acropachy

201

Hyperthyroid Ix

TFT's: ↑T4/↑T3, ↓TSH
Abs: anti-TSHr ab, anti-TPO (Hashimoto's)
↑Ca, ↑LFT's
isotope scan ↑ in Graves/↓in thyroiditis

202

Hyperthyroidism Rx

Medical:
BB for Sx, Antithyroid = carbimazole (TPOi) in Graves Tx for 6-12Mnths then withdraw
Radio:
Radio-iodine - most become hypothyroid, CI in pregnancy, lactation.
Surg:
Thyroidectomy - may lead to hypothyroidism/parathyroidism, damage to recurrent layrngeal imp!

203

Hypothyroidism
Px

Lehargy, cold intolerance, ↑wt, constipation, menorrhagia, ↓mood
Cold hands, bradycardic, slow-relaxing reflexes, dry hair and skin, puffy face, goitre, mopathy, neuropathy, ascites, myxoedema,

204

Hypothyroidism
Ax = 8

Atrophic thyroiditis
Hashimoto's
Subacute thyroiditis
Post De quervain's
Iodine def
Drugs: carbimazole, amiodarone, lithium
Congenital
Post surgical

205

Hypothyroidism put simply
A
H
S
Q

Atrophic thyroiditis - anti-TPO/TSH, assoc w/ pernicious, anaemia
Hashimoto's - anti-TPO, goitre, initial ↑T4
Subacute thyroiditis - post-partum, painless
Post De quervain's - painful goitre, viral URTI

206

Malignant thyroid disease put simply

Papillary - 80%, 20-40y/o, follicular cells, Tg marker
Follicular - 10%, 40-60y/o, follicular cells, Tg marker
Medullary - 5%, MEN2, Men young, parafollicular cells
Anaplastic - rare F>M = 3:1, >60, undifferentiated
Lymphoma

207

PTH functions

Secreted in response to ↓Ca
↑osteoclast activity
↑Ca + ↓PO4 reabsorption in the kidney
↑1alpha-hydroxylation of 25OH vit D

208

Sx's of ↑Ca

Stones - renal, polyuria, polydipsia, nephrocalcinosis
Bones - bone pain, pathological #'s
Moans - depression
Groans - abdo pain, n/v, constipation, pancreatitis, PUD
↑BP

209

1ry HyprPTH
Ax

Adenoma - 80%
Hyperplasia - 20%
Pathyroid Ca <0.5%