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Alasdair Scott's notes Flashcards

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1
Q

Anterior view ECG leads

Vessel

A

v1-v2

RCA

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2
Q

Septal view ECG leads

which vessel?

A

v3-v4

LAD

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3
Q

Lateral view ECG leads

Vessel

A

v5-v6

L circumflex

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4
Q

Sawtooth baseline

A

Atrial flutter

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5
Q

Rt axis deviation causes

A

Anterolateral MI
RVH, PE
ASD secundum
WPW

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6
Q

Lt axis deviation causes

A

Inferior MI
LVH
ASD primum

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7
Q

Absent P waves

A

AF

SAN block

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8
Q

Dissociated P waves

A

Complete heart block

Cannon a waves

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9
Q

Normal QRS complex time

A

<120ms

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10
Q

Wide QRS

A

Ventricular initiation
Conduction defect
WPW

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11
Q

PR interval length

A

120-200ms

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12
Q

Long PR

A

heart block

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13
Q

QT length

A

380-420ms

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14
Q

Causes of long QT

A

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

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15
Q

ST elevation

A

Acute MI
Pericarditis
Prinzmetal
aneurysm

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16
Q

ST depression

A

Ischaemia

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17
Q

Hyperkalaemia ECG signs

A

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

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18
Q

Hypokalaemia ECG signs

A

Flattened T waves
ST depression
prolonged QT interval
prominent U waves

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19
Q

1st degree heart block

A

PR > 200ms

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20
Q

2nd degree heart block/mobitz I

A

Progressive lengthening of PR interval

One non conducted P wave

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21
Q

2nd degree heart block/mobitz II

A

Occasional non-conducted p waves

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22
Q

3rd degree heart block

A

Dissociation of p waves and QRS complexes

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23
Q

RBBB ECG changes and aetiology

A 
MaRRow = M in v1 W in v6
Infarct
normal variant
congenital
Hypertrophy: RVH (PE, cor pulmonale)
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24
Q

LBBB ECG and aetiology

A 
WiLLiaM = W in v1 M in v6
Fibrosis
LVH: AS HTN
Inarct
Coronary HD
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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 ```
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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
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Cor Pulmonale Def Px
RHF due to pulmonary HTN Px Dyspnoea, fatigue, syncope, ↑JVP, parasternal heave, pulsatile hepatomegaly, ascites
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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 ```
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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
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DM def
Multisystem disorder due to an absolute or relative lack of endogenous insulin→metabolic and vascular complications
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``` 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
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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
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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
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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
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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
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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
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DM Mx oral hypoglycaemics additional therapy
1st) lifestyle mod+metformin+sulfonylurea+Insulin 2nd) +stigliptan or pioglitazone 3rd) +Exenatide
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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
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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
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Insuling in concurrent illness
Insulin req ↑ Maintain calories Check BM's .4hrly and test for ketonuriainsulin dose if glucose is rising
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Insulin therapy SE
Hyporglycaemia: ETOH, BB and eldery at risk Lipohypertrophy: rotate injection site Wt gain in T2DM
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Complications of DM summary
``` Hyperglycaemia: DKA, HONK Hypoglycaemia Infx Macrovascular: MI, CVA Microvascular ```
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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
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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
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Diabetic foot Mx
Cons: Foot inspection daily, comfortable shoes, chiropody Med: Rx Infx Surg: Abscess, cellulitis, gangrene, suppurative arthritis
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Diabetic nephropathy Ax Px
Ax hyperglycaemia → nephron loss and glomerusclerosis Px Microalbuminuria = ACEi/ARB, refer if UCR>70
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Diabetic retinopathy | Ax
Microvascular disease → retinal ischaemia → ↑VEGF → new vessels formation
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Diabetic retinopathy | Px
Retinopathy + maculopathy Cataracts Rubeosis iris: new vessels on iris → glaucoma CN palsies
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Commonest cause of blindness up to 60yrs Ix for this Rx
Diabetic retinopathy and maculopathy Ix: fluorescein angiography Rx: laser photocoagulation
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``` 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
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Neuropathy | Ax
Ax: metabolic glycosylation/Ischamia of vasa nervorum Px:
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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
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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
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DKA precipitants = 3
Infx Stress New T1DM
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DKA | Px = 6
``` Abdo pain Vomiting Drowsiness Kussmaul hyperventilation Dehydration Ketotic breath ```
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DKA diagnosis
Acidosis: pH,7.3 Hyperglycaemia: >11.1mMol Ketonaemia: >3mM
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DKA Ix
``` Urine: ketones + glucose Cap: glucose + ketones VBG: acidosis + ↑K Blds: U+E's (K), FBC, Glucose, cultures (?inf) CXR: signs of Infx ```
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DKA complications = 5
``` Cerebral oedema: excess fluid administration Aspiration pneumonia Hypokalaemia Hypopsphataemia Thromboembolism ```
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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
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Whipple's triad
Low plasma glucose<3mM Sx consistent w/ hypoglycaemia Relief of symptoms by glucose administration
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Sx of hypoglycaemia
Autonomic 2.5-3 Sweating, anxiety, hunger, tremor, palpitations Neuroglycopenic <2.5 Confusion, drowsiness, seizures, personality change, focal neurology, coma
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Fasting hypoglycaemia | Causes = 7
``` EXPLAIIN EXdogenous drugs Pituitary insuficiency Liver failure Addison's Islet cell tumours Immune Non-pancreatic neoplasms - fibrosarcomas ```
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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
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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
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Hyperthyroid Ix
TFT's: ↑T4/↑T3, ↓TSH Abs: anti-TSHr ab, anti-TPO (Hashimoto's) ↑Ca, ↑LFT's isotope scan ↑ in Graves/↓in thyroiditis
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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!
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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,
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Hypothyroidism | Ax = 8
``` Atrophic thyroiditis Hashimoto's Subacute thyroiditis Post De quervain's Iodine def Drugs: carbimazole, amiodarone, lithium Congenital Post surgical ```
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``` 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
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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
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PTH functions
Secreted in response to ↓Ca ↑osteoclast activity ↑Ca + ↓PO4 reabsorption in the kidney ↑1alpha-hydroxylation of 25OH vit D
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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
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1ry HyprPTH | Ax
Adenoma - 80% Hyperplasia - 20% Pathyroid Ca <0.5%

Final Year Flashcards (5 decks)

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