Before Exam Flashcards
(186 cards)
1
Q
How does complete heart block lead to heart failure
A
By decreasing contractility
2
Q
Name the severity of asthma attacks and there symptoms
A
Moderate
- 75-50%
Actue severe
- 50-33%
- tachycardia
- greater than 25 breaths per minute
Life threatening
- Normal PaCO2
- less than 92% SpO2
- Silent chest
- bradycardia
- hypotension
Near fatal
- rise in PaCO2
3
Q
Levels of COPD according to the gold post bronchodilator grade
A
- Mild = greater than 80
- moderate = 79-50
- severe = 49-30
- Very severe = under 30
4
Q
What glucose level do you give IV
A
20% 50ml IV
5
Q
What are Roth’s spots
A
- seen in acute bacterial endocarditis is a red spot caused by haemorrhage with a pale white centre
- present in the eye
6
Q
What is antiphopsholipid syndrome and how do you screen for it
A
- autoimmune hypercoagulabe state caused by Antiphospholipid antibodies, causes arterial or venous blood clots, and leads to recurrent miscarriages, IUGR and preterm births
Antibodies also present
- lupus anticoagulant
- Anti apolipoprotein antibodies
- Anti cardiolipin antibodies
7
Q
What is factor V Leiden disease
A
- MOST COMMON THROMBOPHILLIA
- mutation of one of the abnormal clotting factors int he blood that increases your chance of developing abnormal blood clots
- also known as resistance to activated protein C
8
Q
What is protein C deficiency
A
- disorder that increases the risk of developing an abnormal blood clot
- results in a hyper coagulable state
9
Q
What is the 3rd heart sound due to
A
- Rapid filling of the ventricles in diastole
10
Q
List the classes of anti-arrthymic drugs
A
Class 1 - nitrate channel blockers class 2 - beta blockers class 3 - potassium channel blockers class 4 - Calcium channel blockers
11
Q
What are the ECG changes in digoxin toxicity
A
- T wave inversion
- sloping ST segment depression int he lateral chest leads (delta waves)
12
Q
What conditions cause clubbing
A
Clubbing causes Lung - asbestosis - lung cancer - idiopathic pulmonary fibrosis - mesothelioma = sarcoidosis - AV fistulae
Cardiovascular
- bacterial endocarditis
- congenial heart disease
GI
- IBD
- cirrhosis
13
Q
How does a Beta blocker help in heart failure
A
Decreases diastolic filling
14
Q
How does a Beta blocker help in heart failure
A
Increases diastolic filling
15
Q
What electrolyte abrnomalitiy causes acute muscle weakness
A
hypokalaemia
16
Q
What is a side effect of adenosine
A
- Flushing
17
Q
What medications should be used in secondary prevention of an MI
A
- Dual antiplatelet therapy (aspirin plus a second anti platelet agent)
- ACE inhibitor
- beta blocker
- statin
18
Q
What does thiazide diuretics act
A
- Proximal part of distal convoluted tubules
19
Q
Name a side effect of beta blockers
A
- They may cause cold peripheries (hands and feet)
20
Q
Name an antibiotic can cause a prolonged QT interval
A
- erythromycin
21
Q
Difference between synchronised and unsynchronised DC cardio version
A
Unsycnrhonised - VT - VF - SVT dying basically
Synchronised
- everything else
22
Q
How does a posterior STEMI present on an ECG
A
- Tall R waves in V1 and V2
- ST depression
23
Q
What does a pericardial knock mean
A
constrictive pericarditis
24
Q
Nirates are….
A
Nitrates are contraindicated in aortic stenosis
25
How do you give
- adenosine
- amiodarone
- atropine
- IV adenosine needs to be inserted via a large 16G cannula into the arm = 6mg/12mg/12mg
- IV Amiodarone = 300mg IV over 20-60 minutes and then 900mg over 24 hours
- IV atropine = 500mcg up to 3mg
26
When are beta blocks contraindicated
Beta blockers are contraindicated in patients with asthma when manging AF
27
Where do you place the ECG leads
```
Red = right arm
Yellow = left arm
Green = left leg
Black = right leg
```
28
What type of murmur does a VSD cause
Pansystolic murmur
29
What are the short term complications of an MI
1. Rupture of papillary muscles
- pulmonary oedema and hypotension
2. Left ventricular free wall rupture (1-2 weeks after)
- Muted heart sounds, low BP, raised JVP, pulsus paradoxes (presents like a tamponade) treat with pericardiocentesis
3. Arrhythmias
4. Left ventricular failure
5. VSD
- Pan systolic murmur and heart failure symptom
30
What are the short term complications of an MI
1. Rupture of papillary muscles
- pulmonary oedema and hypotension
2. Left ventricular free wall rupture (1-2 weeks after)
- Muted heart sounds, low BP, raised JVP, pulsus paradoxes (presents like a tamponade) treat with pericardiocentesis
3. Arrhythmias
4. Left ventricular failure
5. VSD
- Pan systolic murmur and heart failure symptom
31
What are the long term complications of an MI
1. Intractable left ventricular failure
2. Dressler's syndrome
- Fever, chest pain that is better when leaning forward, pleuritic chest pain, raised ESR = treated with NSAIDS
3. Ventricular aneurysm
- Persistent ST elevation and left ventricular failure
4. Recurrent MI
32
PE guidelines
PE guidelines
If someone has a PE wells score greater than 4
- CTPA
- If you cannot do a CPTA then offer interim anticoagulation
- If allergic to dye or renal issues then offer a V/Q
If CTPA positive
- then continue with anticoagulation
If CTPA negative
- Offer leg ultrasound if suspected DVT
If not suspected DVT stop anticoagulation and continue other diagnosis
33
PE guidelines
PE guidelines
If someone has a PE wells score greater than 4
- CTPA
- If you cannot do a CPTA then offer interim anticoagulation
- If allergic to dye or renal issues then offer a V/Q
If CTPA positive
- then continue with anticoagulation
If CTPA negative
- Offer leg ultrasound if suspected DVT
If not suspected DVT stop anticoagulation and continue other diagnosis
```
If PE wells score is less than 4
- D dimer
If D dimer positive
- CPTA
If D dimer negative
Stop anticoagulaiton and consider alternative diagnosis
```
34
What makes up the Wells score for PE
- Clinical signs/symptoms of DVT (3)
- Alternative diagnosis is less likely than PE (3)
- heart rate more than 100 bpm (1.5)
- immobilisation for more than 3 days or surgery in the past 4 weeks (1.5)
- previous DVT/PE (1.5)
- haemoptysis (1)
- malignancy (1)
More than 4 is indicative of CPTA
35
What makes up the wells score for DVT
- Active cancer
- paralysis, paresis or plaster immobilisation of lower extremities
- recently bedridden for 3 days or more or major surgery within 12 weeks
- localised tenderness along distribution of deep venous system
- entire leg swollen
- calf swelling at least 3 cm larger than on asymptomatic side
- pitting oedema confined to the leg
- collateral superficial veins
- previously documented DVT
- alternative diagnosis is at least as likely as DVT
2 or more then DVT is likely
36
How should you measure blood pressure in the clinic
If blood pressure measured in the clinic is 140/90 mmHg or higher:
- Take a second measurement during the consultation.
- If the second measurement is substantially different from the first, take a third measurement.
37
How does home blood pressure monitoring work
When using HBPM to confirm a diagnosis of hypertension, ensure that:
for each blood pressure recording, 2 consecutive measurements are taken, at least 1 minute apart and with the person seated and
blood pressure is recorded twice daily, ideally in the morning and evening and
blood pressure recording continues for at least 4 days, ideally for 7 days.
38
Name the NICE guidelines for hypertension
- If blood pressure in clinic is between 140/90 and 180/110 then offer ABPM to confirm diagnosis (if cannot do ABPM then use HBPM)
Whilst waiting for the confirmation of diagnosis of hypertension carry out
- Investigations for target organ damage
- Formal assessment of cardiovascular risk using cardiovascular risk assessment tool
Confirm diagnosis of hypertension with people with a
- Clinic blood pressure greater than 140/90 and
- ABPM greater than 135/85
Assess cardiovascular risk and end organ damage
- Greater than 10% consider medication
- Test for presence of protein in urine by sending urine sample for estimation of the albumin: creatinine ratio
- Take blood sample to measure HbA1C, electrolytes, creatinine, eGFR, total cholesterol and HDL
- Examine the fundi for presence of hypertensive retinopathy
- Arrange ECG lead
If a person has severe hypertension greater than 180/120 but no sign and symptoms indicating same day referral then carry out investigations for target organ damage as soon as possible
- If target organ damage then start anti hypertensive without waitng for ABPM results
- If no target organ damage identified then repeat clinic blood pressure measurement within 7 days
Medication
- Offer antihypertensive medication to those with Stage 1 hypertension (140/90 or 130/85) if they have target organ damage, established cardiovascular disease, renal disease, diabetes, 10 year cardiovascular risk greater than 10%
- Offer antihypertensive medication to those with stage 2 hypertension (160/100 or 150/95)
Consider antihypertensive drug treatment in addition to lifestyle advice for people aged over 80 with stage 1 hypertension if their clinic blood pressure is over 150/90 mmHg
39
When do you refer for specialist same day treatment in hypertension
Refer people for specialist assessment, carried out on the same day, if they have a clinic blood pressure of 180/120 mmHg and higher with:
• signs of retinal haemorrhage or papilloedema (accelerated hypertension) or
• life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury
40
Hypertensive target for people over aged 80
Consider antihypertensive drug treatment in addition to lifestyle advice for people aged over 80 with stage 1 hypertension if their clinic blood pressure is over 150/90 mmHg
41
Hypertensive target for people over aged 80
Consider antihypertensive drug treatment in addition to lifestyle advice for people aged over 80 with stage 1 hypertension if their clinic blood pressure is over 150/90 mmHg )(or 145/85 in ABPM)
42
when do you give alpha and beta blockers for hypertension versus spironolactone
Consider an alpha-blocker or beta-blocker for adults with resistant hypertension starting step 4 treatment who have a blood potassium level of more than 4.5 mmol/l.
- Spironolactone if under 4.5mmol/l
43
Name some alpha and beta blockers used in hypertension
Alpha = doxazosin
44
Name drugs used in heart failure
- beta blockers
- ACE inhibitors
- Spironolactone
Loop diuretics are purely symptomatic and do not improve survival
45
Name some thiazide like diuretics
indapamide
46
Angina medication
- 1st line = beta and calcium channel blocker
- then add a nitrate
if taking all three should be on pathway for CABG
47
Is a 3rd or 4th heart sound heard in heart failure
3rd heart sound is heard in heart failure
48
What does digoxin do
- Digoxin is a cardiac glycoside that increases the force of Myocardial contraction and reduces conductively within the AV node
49
What is pulses paradoxus
there will be an abnormally large drop in BP during inspiration,
- can happen in cardiac tamponade
50
what bronchus are inhaled foreign objects likely to be found in
- right inferior lobe bronchus
51
What genetics is hypertrophic obstructive cardiomyopathy
- Autosomal dominant
52
Thiazides can worsen...
glucose tolerance
53
What two beta blockers have been shown to reduce mortality in stable heart failure
- Carvedilol and bisoprolol
54
at what QRISK score do you offer a statin
- greater than 20%
55
In IV drug use the ...
Tricuspid valve is the most commonly affected
56
How does renal function affect BNP
Renal dysfunction (eGFR <60) can cause a raised serum natriuretic peptides
57
in bradycardia if hypotensive do you DC cardio version
no
| - atropine
58
What drugs are used for primary prevention in MI
- Antihypertensive therapy
| - Lipid lowering therapy - statins
59
What do you do if you have a major bleed on warfarin
stop warfarin, give intravenous vitamin K 5mg, prothrombin complex concentrate
60
When do you do aortic valve surgery
if symptomatic then valve replacement
if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery
61
When do you do aortic valve surgery
if symptomatic then valve replacement
if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery
62
When do you a balloon valvuloplasty in aortic valve surgery instead
balloon valvuloplasty is limited to patients with critical aortic stenosis who are not fit for valve replacement
63
When do you refer due to chest pain
- current chest pain or chest pain in the last 12 hours with an abnormal ECG: emergency admission
- chest pain 12-72 hours ago: refer to hospital the same-day for assessment
- chest pain > 72 hours ago: perform full assessment with ECG and troponin measurement before deciding upon further action
64
What are the common causes of bacterial endocarditis
Streptococcus viridans
Staphylococcus aureus (in intravenous drugs uses or prosthetic valves)
Staphylococcus epidermidis (in prosthetic valves)
65
What is the order of investigations for aortic dissection
- go CT angiogram 1st line
| - if patient is too unstable for this then transoesophageal echocardiography
66
How long post MI can you not drive for
DVLA advice post MI - cannot drive for 4 weeks
67
what is another name for polymorphic ventricular tachycardia
Torsade de pointes
68
What type of antibiotics can cause tornado de pointes
- Macrolides
69
if you are unstable in an NSTEMI what is the treatment plan
NSTEMI management: unstable patients should have immediate coronary angiography
70
Write down the CHADVASC score
- CCF
- Hypertension
- Age 65-74 or over 75 (2)
- Diabetes
- Vascular disease
- Previous stroke or TIA (2)
- Female Sex
71
Causes of torsade de pointes
- hypothermia
| - hypokalaemia
72
all patients with type 2 diabetes get (in hypertension)
ACE
73
What is bifasciular block
- right bundle branch block and left axis deviation
74
what does digoxin toxicity look like on an ECG
- downscoping ST depression
- inverted T waves
- short QT interval
75
What condition is hypertrophic cardiomyopathy associated with
- Wolff Parkinson white
76
When taking warfarin what are the results of PT and APPT
- Prolonged PT
| - normal APTT
77
When is digoxin used in AF
used if you have AF and heart failure
78
What is boerhaave syndrome
The Mackler triad for Boerhaave syndrome: vomiting, thoracic pain, subcutaneous emphysema. It commonly presents in middle aged men with a background of alcohol abuse
79
What medication do you give to an NSTEMI management conservatively
aspirin, plus either:
- ticagrelor, if not high bleeding risk
- clopidogrel, if high bleeding risk
80
One day following a thrombolysed inferior myocardial infarction a 72-year-old man develops signs of left ventricular failure. His blood pressure drops to 100/70mmHg. On examination he has a new early-to-mid systolic murmur.
Papillary muscle rupture
81
ECG changes of hypothermia
- Long QT interval
- bradycardia
- J wave
- first degree heart block
- atrial and ventricular arrhythmias
82
What is orthostatic hypotension
Orthostatic hypotension can be diagnosed when there is a drop in SBP of at least 20 mmHg and/or a drop in DBP of at least 10 mmHg after 3 minutes of standing
83
what is the mechanism of action of alteplase
Thrombolytic drugs activate plasminogen to form plasmin
84
name an example of a glycoprotein IIb/IIIa receptor antagonist
Tirofiban
85
What part of the QRS complex is used for synchronisation in DC cardioversion
R wave
86
Name some SABA
- salbutamol
| - tetrabutaine
87
Name some LABA
- salmeterol
| - formeterol
88
name some SAMA
- ipratropium
- glycopyrronium
- aclidinium
- umeclidinium
89
Name some LAMA
- tiotropium
90
Non haemolytic febrile reaction
- causes
- features
- treatment
Causes
- thought to be caused by antibodies reacting with white cell fragments in the blood product and cytokines that have leaked from the blood cell during storage
Features
- fever
- chills
Management
- slow or stop transfusion
- paracetamol
- monitor
91
Minor allergic reaction
- cause
- features
- management
Cause
- through to be caused by foreign plasma proteins
Features
- Pruritus
- urticaria
Management
- temporarily stop the transfusion
- antihistamine
- monitor
92
Anaphylaxis in blood transfusion reaction
- cause
- features
- management
cause
- can be caused by patients with IgA deficiency
Features
- hypotension
- dyspnoea
- wheezing
- angioedema
management
- stop the transfusion
- IM adrenaline
- ABC support = oxygen, fluids
93
Acute haemolytic reaction
- cause
- features
- management
Cause
- ABO-incompatible blood e.g. secondary to human error
Features
- fever
- abdominal pain
- hypotension
```
Management
- stop transfusion
Confirm diagnosis
- check the identity of patient on blood product
- send blood for direct Coombs test
Supportive care
- fluid resuscitation
```
94
Transfusion-associated circulatory overload
- cause
- features
- management
Cause
- Excessive rate of transfusion, pre-exisiting heart failure
Features
- Pulmonary oedema
- hypertension
Management
- slow or stop transfusion
- consider IV loop diuretic and oxygen
95
Transfusion related acute lung injury
- cause
- features
- management
Cause
- Non-cardiogenic pulmonary oedema thought to be secondary to increase vascular permeability caused by host neutrophils that become activated by substance sin donated blood
Features
- hypoxia
- pulmonary infiltration on CXR
- fever
- hypotension
Management
- stop the transfusion
- oxygen and supportive care
96
which oral contraceptive pill increases the risk of breast cancer
progesterone pill increases the risk of breast cancer (thus the combined pill does as well)
97
What is the management of atelectasis
- Positioning the patient upright
| - Chest physiotherapy with mobilisation and breathing exercise
98
What is altelctasis
Atelectasis is a common postoperative complication in which basal alveolar collapse can lead to respiratory difficulty. It is caused when airways become obstructed by bronchial secretions.
99
Name a contraindication for chest drain insertion
INR greater than 1.3
100
Diagnostic tests for asthma
- Peak flow - variability of 20% - twice daily readings
- Reversibility bronchodilator FEV1 = improvement of 12% /200ml post bronchodilator FEV1
- Eosinophil = raised eosinophil count
- FENO = greater than 40ppb
- Spirometry = obstructive picture, less than 0.7
Direct challenge with histamine = should show a 20% fall in FEV1 of 8mg/ml or less
101
What tests do you need to do before starting azithromycin
- Do an ECG to rule out prolonged QT interval and baseline liver function tests
102
What is the gold standard investigation to confirm diagnosis of mesothelioma
Diagnosis of a mesothelioma is made on histology, following a thoracoscopy
103
What is the mechanism of action of bupropion
a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
104
What is the mechanism of action of Varenicline
a nicotinic receptor partial agonist
105
When should NIV be considered in patients with COPD
NIV should be considered in all patients with an acute exacerbation of COPD in whom a respiratory acidosis (PaCO2>6kPa, pH <7.35 ≥7.26) persists despite immediate maximum standard medical treatment
106
What is the difference between Churg-strauss syndrome and granulomatosis with polyangitis
Churg-strauss = pANCA
Granulomatosis with polyangitis = cANCA
107
What is the first step in management of pleural effusion
Pleural aspiration = 21G needle and 50ml syringe
- if the fluid is purulent or turbid/clody then a chest tube should be placed to allow drainage
- If the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection then a chest tube should be placed
108
describe how the chest drain rises and falls on inspiration and expiration
Chest drain swinging: Rises in inspiration, falls in expiration
109
What is the most common cause of an exudative pleural effusion
Pneumonia
110
What is the difference in rash you get in sarcoidosis versus SLE
Sarcoidosis
- affects nose, cheeks, lips, ears, and digits
- purple plaque raised
111
What do you expect to find a raised TLCO
. You would only expect to find a raised TLCO in asthma or a left-to-right cardiac shunt. This is because in these conditions, the problem is not affecting the alveoli directly or gas exchange and so the lungs try to compensate for the problem by improving gas exchange.
112
What is the most common valve effected in infective endocarditis
Mitral valve
113
What is the most appropriate way to measure the QT interval on the ECG?
Time between the start of the Q wave and the end of the T wave
114
ST segment
end of S wave start of T wave
115
PR
start of P wave to start of Q wave
116
Platelet transfusions levels
Offer platelet transfusions to patients with a platelet count of <30 x 10 9 with clinically significant bleeding (World Health organisation bleeding grade 2- e.g. haematemesis, melaena, prolonged epistaxis)
Platelet thresholds for transfusion are higher (maximum < 100 x 10 9) for patients with severe bleeding (World Health organisation bleeding grades 3&4), or bleeding at critical sites, such as the CNS.
117
What is a high risk with platelet transfusions
It should be noted that platelet transfusions have the highest risk of bacterial contamination compared to other types of blood product.
118
Difference in statin dose between primary and secondary prevention of cardiovascular disease
Atorvastatin 20mg is a high-intensity statin and should be started as primary prevention against cardiovascular disease. Atorvastatin 80mg is used in secondary prevention.
119
Differnece in causes of aortic stenosis
younger patients < 65 years: bicuspid aortic valve
| older patients > 65 years: calcification
120
What is De Musset's sign
De Musset's sign (head bobbing) is a clinical sign of aortic regurgitation in time with heat beat
121
What investigation is used in idiopathic pulmonary fibrosis
In idiopathic pulmonary fibrosis, high resolution CT is the investigation of choice
122
Indications for harm-dialysis
AEIOU: acidosis, electrolyte imbalances e.g. severe hyperkalemia (above 6.5), intoxication e.g. methanol, overload of volume, and uraemia.
123
Who should you offer LTOT to
Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
peripheral oedema
pulmonary hypertension
124
Who should you offer LTOT to
Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
- secondary polycythaemia
- peripheral oedema
- pulmonary hypertension
125
when must statins be stopped
Statins must be temporarily stopped when a macrolide antibiotic is started
126
what drugs can cause SIADH
```
sulfonylureas*
SSRIs, tricyclics
carbamazepine
vincristine
cyclophosphamide
```
127
What is transferrin and what happens to it in iron deficiency anaemia
Transferrin is the body’s carrier of iron around the blood. In states of iron deficiency, transferrin increases as the body tries to “make the most” of what iron it has left, meaning that transferrin levels go up.
128
What is TIBC and what happens to it in iron deficiency anaemia versus anaemia of chronic disease
TIBC measures the number of binding sites on transferrin available for iron. It therefore also increases in ID and decreases in ACD
129
How do you calculate transferrin saturation
calculated by serum iron / TIBC
130
How do you treat SIADH
SIADH is treated with fluid restriction
131
What antibiotic is given against spontaneous bacterial peritonitis
Patients with ascites (and protein concentration <= 15 g/L) should be given oral ciprofloxacin or norfloxacin as prophylaxis against spontaneous bacterial peritonitis
132
In an AKI if protein is present what type of AKI is it
The urine dip shows proteinuria which would only be present with an intrinsic renal AKI
133
Acute pancreatitis causes..
Hypocalaemia
134
What tends to cause hypercholestrolaemia rather than hypertriglyceridaemia
Hypercholesterolaemia rather than hypertriglyceridaemia: nephrotic syndrome, cholestasis, hypothyroidism
135
What is the most specific ECG marker for pericarditis
PR depression: most specific ECG marker for pericarditis
136
What should all patients with pericarditis have
all patients with suspected acute pericarditis should have transthoracic echocardiography
137
What two vessels does a transjugular intrahepatic portosystemic shunt connect
A transjugular intrahepatic portosystemic shunt (TIPS) procedure connects the hepatic vein to the portal vein
138
how does hypothyroidism impact sodium
Hypothyroidism causes a euvolaemic hyponatraemia
139
What does Membranous glomerulonephritis histology look like
basement membrane thickening on light microscopy
subepithelial spikes on sliver stain
positive immunohistochemistry for PLA2
140
What overdose is flumazenil used in
Flumazenil is used in benzodiazepine overdose.
141
What electrolyte abnormalities do thiazide diuretics cause
hypokalamia
142
What electrolyte abnormalities do thiazide diuretics cause
hyponatraemia, hypokalaemia, hypercalcaemia
143
Drugs for secondary prevention in MI
All patients should be offered the following drugs:
dual antiplatelet therapy (aspirin plus a second antiplatelet agent)
ACE inhibitor
beta-blocker
statin
144
what drug is contraindicated in ventricular tachycardia
Verapamil
145
What is the only calcium channel blocker licensed for use in heart failure
amlodipine is the only calcium channel blocker licensed for use in heart failure.
146
What ECG changes are seen in hypothermia
```
bradycardia
'J' wave - small hump at the end of the QRS complex
first degree heart block
long QT interval
atrial and ventricular arrhythmias
```
147
What are the complications of CLL
anaemia
hypogammaglobulinaemia leading to recurrent infections
warm autoimmune haemolytic anaemia in 10-15% of patients
transformation to high-grade lymphoma (Richter's transformation)
148
HYPOKALAMEIA IS NOT A ..
COMPLICATION OF BLOOD TRANSFUSION
149
Which heart sound is hypertrophic obstructive cardiomyopathy associated with
Hypertrophic obstructive cardiomyopathy - is classically associated with an S4
150
causes of a normal anion gap metabolic acidosis
```
Causes of a normal anion gap metabolic acidosis are ABCD:
Addison's
Bicarb loss
Chloride
Drugs
```
151
Management of STEMI
STEmi identified
1. Give aspirin
2. Assess whether PCI is possible within 120 minutes
if possible = PCI
3. Give praugrel
4. Give unfractionated heparin and bailout glycoprotein IIb/IIIa inhibitor
if not = Fibronolysis
3. Give antithrombin at the same time
4. following procedure give ticagrelor
5. For ongoing MI consider PCI
other
- if patient is a high bleeding risk swap prasugrel for ticagrelor/ Ticagrelor for clopidogrel
- If patient is taking oral anticogualtions swap pragrel for clopidogrel
152
When should out repeat ECG after firbonolysis
An ECG should be repeated after 60-90 minutes to see if the ECG changes have resolved. If patients have persistent myocardial ischaemia following fibrinolysis then PCI should be considered.
153
Management of NSTEMI
NSTEMI identified
1. Aspirin 300mg
2. Fondaparinux if no immediate PCI planned
3. Estimate 6 month mortality rate
4. if low risk under 3% = CONSERVATIVE MANAGEMENT
5. Give Trcagrelor
4. if intermediate/high risk >3% = PCI
5. offer immediately if clinically unstable otherwise offer within 72 hours
6. Prasugrel or ticagrelor
7. Give unfractionated heparin
8. Drug-eluting stents should be used in preference
154
What factors does the GRACE score take into account
- age
- heart rate, blood pressure
- cardiac and renal function
- cardiac arrest on presentation
- ECG findings
- troponin levels
155
What is blood pressure target for people aged over 80
- 150/90
| ABPM = 145/85
156
Name soem GLP-1 Drugs
Exenatide
| Liraglutide
157
When can you use GLP-1 Drugs
BMI >= 35 kg/m² in people of European descent and there are problems associated with high weight, or
BMI < 35 kg/m² and insulin is unacceptable because of occupational implications or weight loss would benefit other comorbidities.
158
Name some DPP-4 inhibitors
Sitaglipitin
| Vildagliptin
159
Name some sulfonylureas
Glicazide
160
Name some thiazolidinediones
Glitazones
| - pioglitazone
161
Name some SGLT2 inhibitors
- Canagliflozin
- Dapagliflozin
- Empagliflozin
162
What are the side effects of SGLT2 inhibitors
- urinary and genital infection (secondary to glycosuria). Fournier’s gangrene has also been reported
- normoglycaemic ketoacidosis
- increased risk of lower-limb amputation: feet should be closely monitored
Patients taking SGLT-2 drugs often lose weight, which can be beneficial in type 2 diabetes mellitus.
163
What result of short synacthen test
cortisol should be above 550 = this would exclude Addisons
164
What are the causes of primary hypoparathyroidism
- decrease PTH secretion
- e.g. secondary to thyroid surgery*
- low calcium, high phosphate
- treated with alfacalcidol
165
How do you treat primary hypoparathyroidsm
treated with alfacalcidol
166
What are the main symptoms of hypoparathyroidism
- tetany: muscle twitching, cramping and spasm
- perioral paraesthesia
- Trousseau's sign: carpal spasm if the brachial artery occluded by inflating the blood pressure cuff and maintaining pressure above systolic
- Chvostek's sign: tapping over parotid causes facial muscles to twitch
- If chronic: depression, cataracts
- ECG: prolonged QT interval
167
Hepatitis B shit
surface antigen (HBsAg) is the first marker to appear and causes the production of anti-HBs
HBsAg normally implies acute disease (present for 1-6 months)
if HBsAg is present for > 6 months then this implies chronic disease (i.e. Infective)
Anti-HBs implies immunity (either exposure or immunisation). It is negative in chronic disease
Anti-HBc implies previous (or current) infection. IgM anti-HBc appears during acute or recent hepatitis B infection and is present for about 6 months. IgG anti-HBc persists
HbeAg results from breakdown of core antigen from infected liver cells as is, therefore, a marker of infectivity. Marker of HBV replication and infectivity
168
How long does it take for an arteriovenous fistula to develop
The time taken for an arteriovenous fistula to develop is 6 to 8 weeks
169
What is the most common organism in SBP
Spontaneous bacterial peritonitis: most common organism found on ascitic fluid culture is E. coli
170
in 2nd degree heart block ...
In 2nd-degree type-II heart block, the PR interval is always the same size, it's just that the QRS complex doesn't occur after every P wave.
171
Hepaotrenal syndrome management
- vasopressin analogues, for example terlipressin, have a growing evidence base supporting their use. They work by causing vasoconstriction of the splanchnic circulation
- volume expansion with 20% albumin
- transjugular intrahepatic portosystemic shunt
172
What is the management of proximal aortic dissections
Proximal aortic dissections are generally managed with surgical aortic root replacement.
173
Third line heart failure treatment
ivabradine
- criteria: sinus rhythm > 75/min and a left ventricular fraction < 35%
sacubitril-valsartan
- criteria: left ventricular fraction < 35%
is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs
should be initiated following ACEi or ARB wash-out period
digoxin
= digoxin has also not been proven to reduce mortality in patients with heart failure. It may however improve symptoms due to its inotropic properties
it is strongly indicated if there is coexistent atrial fibrillation
hydralazine in combination with nitrate
= this may be particularly indicated in Afro-Caribbean patients
cardiac resynchronisation therapy
= indications include a widened QRS (e.g. left bundle branch block) complex on ECG
174
ALS points
ratio of chest compressions to ventilation is 30:2
chest compressions are now continued while a defibrillator is charged
during a VF/VT cardiac arrest, adrenaline 1 mg is given once chest compressions have restarted after the third shock and then every 3-5 minutes (during alternate cycles of CPR).
a single shock for VF/pulseless VT followed by 2 minutes of CPR, rather than a series of 3 shocks followed by 1 minute of CPR
if the cardiac arrested is witnessed in a monitored patient (e.g. in a coronary care unit) then the 2015 guidelines recommend 'up to three quick successive (stacked) shocks', rather than 1 shock followed by CPR
asystole/pulseless-electrical activity: adrenaline 1mg should be given as soon as possible. Should be treated with 2 minutes of CPR prior to reassessment of the rhythm
atropine is no longer recommended for routine use in asystole or pulseless electrical activity (PEA)
delivery of drugs via a tracheal tube is no longer recommended
following successful resuscitation oxygen should be titrated to achieve saturations of 94-98%. This is to address the potential harm caused by hyperoxaemia
175
When should ACE inhibitors be avoided
ACE-inhibitors should be avoided in patients with HOCM
176
When is Kussmaul's sign present
The JVP increasing with inspiration is known as Kussmaul's sign and can be a feature of constrictive pericarditis
- rare in Cardiac tamponade
177
What is the difference between cardiac tamponade and constrictive pericarditis
Cardiac tamponade
- absent Y descent
- pulsus paradoxus is present
- rare for Kussmaul's sign
Constrictive pericarditis
- X and Y present
- pulses paradoxus is absent
- Kussmaul's sign is present
- pericardial calcification on CXR
178
Addisons disease can cause..
hyponatraemia
179
A 74-year-old man is an inpatient on the care of the elderly ward having been admitted with a diagnosis of hospital acquired pneumonia.
Which one of the pathogens is the most likely cause of his illness?
Klebsiella pneumoniae
180
A patient with cystic fibrosis has a cough productive of green sputum, which grows Pseudomonas.
Which oral agent has activity against Pseudomonas?
ciprofloxacin
181
Regarding 5 amino-salicylic acid (5-ASA),
Which one of the following statements is true?
is associated with blood dyscrasias
182
aspirin cannot be used in
pregnancy
183
When do you use unsynchronised Cardioversion
pulseless VT/VF
184
difference between end and loop stoma
end - one hole
| loop = two holes
185
You are talking to a patient about the role of autoantibodies being implicated in causing her disease.
Which one of the following diseases is characterized by auto-antibodies?
auto-immune haemolytic anaemia
186
Appendix signs
Rovsing’s sign = pain > in RIF than LIF when the LIF is pressed
Psoas sign = pain on extending hip if retrocaecal appendix
Cope sign = pain on flexion and internal rotation of the right hip if appendix in close relation to obturator internus
pain on right during DRE - suggests an inflamed, low lying pelvic appendix
