Cardio Flashcards
(138 cards)
1
Q
AS
Significant negs
A
Infective endocarditis
LVF
Indicators of severity (narrow PP, quiet A2, S4)
2
Q
AS
Causes
A
- Senile calcification
- Bicuspid valve
- Rheumatic heart disease
3
Q
AS
Triad of symptoms
A
Dyspnoea
Angina
Syncope
4
Q
AS
Investigations
A
ECG (LVH, arrhythmia)
Bloods (FBC, U+E, BNP, lipids, glucose)
CXR (LVH)
Echo (severity, LV function, cause)
Coronary angiogram
5
Q
AS
Echo features of severe
A
Valve area <1cm2
Pressure gradient >40mmHg
Jet velocity >4m/s
6
Q
AS
Mx
A
General (MDT, optimise CV risk, monitor)
Surgical (valve replacement +/- CABG) - if symptomatic or
severe
Other (TAVI)
7
Q
MR
Significant negs
A
Infective endocarditis
AF
LVF
8
Q
MR
Causes
A
Functional: LV dilatation
Annular calcification
Rheumatic heart disease
Valve prolapse e.g. pap muscle rupture
9
Q
MR
Investigations
A
ECG (arrhythmias, LVH, P-mitrale)
Bloods (FBC, U+E, BNP, lipids, glucose)
CXR (LA/LV hypertrophy, oedema, calcification)
Echo (severity, LV function)
Coronary angiogram
10
Q
MR
Echo features of severe
A
Jet width >0.6cm
Systolic pulmonary flow reversal
Regurgitant volume >60ml
11
Q
MR
Mx
A
General (MDT, optimise CV risk, monitor)
Specific (AF, emboli, reduce after load)
Surgical (valve replacement/repair) if symptomatic
12
Q
AF
Significant negs
A
Murmur
Evidence of thyrotoxicosis
LVF
Bruising from warfarin
13
Q
AF
Cardiac causes
A
IHD
Rheumatic heart disease
Hypertension
Mitral valve pathology
14
Q
AF
Non-cardiac causes
A
Thyrotoxicosis
Alcohol
Pneumonia
Hypokalaemia
RA
Post-op
PE
15
Q
AF
Investigations
A
ECG (confirm Dx, look for cause e.g. ischaemia)
Bloods (FBC, U+E (K), TFTs, trops, D-dimer)
CXR (oedema, pneumonia)
Echo (valves, LV function)
16
Q
Acute AF (<48h)
Mx
A
If adverse signs: DC shock, seek help, amiodarone 300mg over 10-20 mins, repeat shock, amiodarone 900mg over 24h
If stable: control rate with b-b or diltiazem, consider digoxin or amiodarone if in heart failure, assess thromboembolic risk and consider anticoagulation
17
Q
Paroxysmal AF
Mx (need to clarify)
A
Pill in pocket
Prevention (b-b)
18
Q
Persistent AF
Rhythm control
A
Younger pts
>3w anticoagulation with warfarin, exclude thrombus with TOE
Cardioversion (DC/medical)
19
Q
Persistent AF
Rate control
A
b-b or rate limiting CCB
Can add digoxin
20
Q
AF
Other mx
A
Radiofrequency ablation of the AV node
Maze procedure
Pacing
21
Q
What are the causes of LEFT heart failure?
A
- Ischaemic heart disease
- Idiopathic dilated cardiomyopathy
- Hypertension
- Mitral and aortic valve disease
22
Q
What are the causes of RIGHT heart failure?
A
Left ventricular failure
Cor pulmonale
Tricuspid and pulmonary valve disease
23
Q
What is the NYHA classification?
A
- No breathlessness
- Breathless with moderate exertion
- Breathless with mild exertion
- Breathless at rest
24
Q
How do you investigate chronic heart failure?
A
ECG: ischaemia, hypertrophy, arrhythmia
Bloods: FBC, U+E, BNP, lipids glucose
CXR: ABCDEF
Echo - gold standard
25
What do you look for in an echo for heart failure?
Global systolic and diastolic function
Focal/global hypokinesia
Hypertrophy
Valve lesions
26
What is the management of heart failure?
General: MDT, optimise CV risk (conservative and medical), monitor
Specific (medical): b-b + ACEi, spiro, digoxin, cardiac resynchronisation therapy
Surgical: LVAD, heart transplant
27
What are the three clinical signs of hyperexpansion?
Reduced cricosternal distance
Loss of cardiac dullness
Palpable/displaced liver edge
28
What are the significant negatives in a COPD exam?
CO2 retention flap
Cor pulmonale i.e. signs of right heart failure
Clubbing (could indicate cancer)
29
Differentials for COPD?
Chronic asthma
| Bronchiectasis
30
What is the definition of chronic bronchitis?
Cough productive of sputum for >/= 3months on >/= 2 consecutive years
31
What is the definition of emphysema?
Histological description of alveolar wall destruction with airway collapse and air trapping
32
Investigations in COPD?
Bedside: PEFR, BMI, sputum mc&s
SPIROMETRY: obstructive
Bloods: FBC (polycythaemia), ABG (T2 resp failure), CRP (infective exacerbation), Albumin (malnutrition), a1-AT
Imaging: CXR, echo (cor pulmonale)
33
What do you find on spirometry with COPD?
```
Obstructive pattern
Increased total lung capacity and residual volume
FEV1 <80%
FEV1/FVC <0.7
Reduced transfer factor
```
34
What are you looking for on a CXR in COPD?
Acute: consolidation, pneumothorax
Chronic:
- Hyperinflation (>10 posterior ribs), flat diaphragm
- PHT (prominent pulmonary arteries, peripheral oligaemia)
- Bullae
35
What is the general management of COPD?
MDT: dietician, physio, resp physician, specialist nurses
SMOKING CESSATION: specialist nurse and support programme, nicotine replacement therapy (varenicline = partial nicotinic agonist)
Pulmonary rehab therapy: tailored exorcise programme, disease education and psychosocial support
Comorbidities: nutrition, CV risk, vaccination (pneumococcal and seasonal flu)
36
What is the medical management of COPD?
Anti muscarinics
b2 agonists
ICS
Theophylline
Home emergency pack for exacerbations
LTOT (aiming for PaO2 >8 for >15h/day) if stable non smokers with PaO2 <7.3 OR <8 with cor pulmonale or polycythaemia
37
What is the GOLD classification?
Based on mMRC dyspnoea score (1-5) and airflow limitation (based on FEV1) and no. of exacerbations per year
38
What is the mMRC dyspnoea score?
1. SOB on vigorous exertion
2. SOB on hurrying or walking up stairs
3. Walks slowly or has to stop for breath
4. Stops for breath after <100m / few mins
Too breathless to leave the house or SOB on dressing
39
How is airflow limitation classified?
Mild >80%
Moderate 50-79%
Severe 30-49%
Very severe <30%
40
What are the significant negatives for pulmonary fibrosis exam?
Cyanosis
Cor pulmonale
Specific cause e.g. rheumatoid hands or sclerodactyly
41
What are some differentials for pulmonary fibrosis?
Bronchiectasis
| Chronic lung abscess
42
What are the causes of UPPER zone fibrosis?
APENT
```
Aspergillosis (ABPA)
Pneumoconiosis (coal, silica)
EAA/hypersensitivity pneumonitis
Negative sero-arthropathy (ank spond)
TB
```
PPFE
43
What are the causes of LOWER zone fibrosis?
STAIR
```
Sarcoid (mid zone)
Toxins: BANS ME
Asbestosis
IPF
Rheum: RA, SLE, SS, sjogren's PM/DM
```
44
What are the drug causes of pulmonary fibrosis?
BANS ME
```
Bleomycin
Amiodarone
Nitrofurantoin
Sulfasalazine
Methotrexate
```
45
What are the investigations for pulmonary fibrosis?
Bedside: PEFR, ECG (RVH)
Bloods: FBC, ABG, ESR and CRP (IPF)
Imaging: CXR (reticulonodular shadowing and reduced lung volume), HRCT (fibrosis and honeycomb lung)
SPIROMETRY: restrictive
Other: echo (PHT), BAL (for disease activity), biopsy
46
What is the management of pulmonary fibrosis?
MDT: GP, pulmonologist, palliative care, physio, psych, specialist nurses, family
Rx specific cause: STEROIDS for EAA, sarcoid and CTD
Supportive care: STOP SMOKING, pulmonary rehab, LTOT, symptomatic tx e.g. anti tussives (codeine) and heart failure medication
Surgery: Lung transplant is only cure in IPF
47
What are the significant negatives in a bronchiectasis exam?
cor pulmonale
| specific causes e.g. RA hands, yellow nails, CF, IBD
48
What is the differential for bronchiectasis?
IPF
| Chronic lung abscess
49
How can you classify the causes of bronchiectasis
Congenital or acquired
50
What are the CONGENITAL causes of bronchiectasis?
CF
PCD/Kartagener's
Young's: azoospermia and bronchiectasis
Hypogammaglobulinaemia: XLA, CVID, SAD
51
What are the ACQUIRED causes of bronchiectasis?
Idiopathic
Post infectious: pertussis, TB, measles
Obstruction: tumour, foreign body
Associated: RA, IBD (UC), ABPA
52
What are investigations for bronchiectasis?
Bedside PEFR and urine dip (proteinuria - amyloid)
Bloods: FBC (ACD), serum Ig, Aspergillus (RAST, precipitins, IgE, eosinophilia), RA (anti CCP, RF)
CXR: tramlines and ring shadows (grapes)
HRCT: SIGNET RING SIGN: thickened dilated bronchi and smaller adjacent vascular bundle. Pools of mucus in saccular dilatations
Spirometry: obstructive
Other: bronchoscopy and mucosal biopsy, CF sweat test, aspergillum skin prick testing
53
What are the complications of bronchiectasis?
```
Cachexia
PHT
Massive haemoptysis
T2 respiratory failure
Amyloidosis
```
54
What is the CONSERVATIVE management of bronchiectasis?
MDT: GP, resp consultant, physio, dietician, immunologist
Physio: postural drainage, active cycle breathing, rehab
55
What is the MEDICAL management of bronchiectasis?
ABX for exacerbations
Bronchodilators: nebuliser b-agonists
Tx underlying cause: CF (creon, ADEK), ABPA (steroids), Immune deficiency (IVIG)
Vaccination: flu, pneumococcus
56
What is the SURGICAL management of bronchiectasis?
Indicated in severe localised disease or obstruction
57
Significant negs for pleural effusion exam?
Absence of:
- Fever
- Clubbing
- Raised JVP and peripheral oedema
- Features of CTD
58
Causes of pleural effusion (transudate)?
```
CCF
Renal failure
Reduced albumin
Hypothyroidism
Meig's syndrome
```
59
Causes of pleural effusion (exudate)?
```
Infection: pneumonia, TB
Malignancy
Inflammation: RA, SLE
Infarction: PE
Trauma
```
60
Investigations for pleural effusion?
Sputum MC&S and cytology
Imaging: CXR, US to guide pleurocentesis, volumetric CT
Bloods: FBC (low Hb), U+E (high Cr), LFTs: (low albumin), TFT (high TSH), ESR (CTD), raised Ca
Diagnostic pluerocentesis
61
Expand on diagnostic pleurocentesis
Percuss upper border and go 1-2 spaces below, infiltrate town to pleura with lignocaine and aspirate with a 21G needle
Send for
- Chemistry: protein, LDH, pH, glucose, amylase
- Bacteriology: MCS, auramine stain, TB culture
- Cytology
- Immunology: RF, ANA, complement
62
Features of empyema?
turbid fluid
low glucose
pH <7.2
63
What is the management of pleural effusion?
Tx underlying cause
Drainage if symptomatic (<2L/24h) - repeated aspiration or ICD
Pleurodesis with talc if recurrent malignant effusion
Persistant effusions may require surgery
64
Indications for lobectomy/pneumonectomy?
90% for non-disseminated bronchial carcinoma
Bronchiectasis
COPD (lung reduction surgery)
TB
65
Operative mortality of lobectomy/pneumonectomy?
7% / 12%
66
Location of lung Ca?
SCC: central
Adeno: peripheral
Small cell: central
67
Complications of lung Ca?
```
RLNP
Phrenic nerve palsy
SVCO
Horner's
AF
```
68
Lung cancer paraneoplastic syndromes? ENDO
ADH --> SIADH
ACTH --> cushings syndrome
Serotonin --> carcinoid
PTHrP --> raised Ca
69
Lung cancer paraneoplastic syndromes? RHEUM
Dermato/polymyositis
70
Lung cancer paraneoplastic syndromes? NEURO
Cerebellar degeneration
| Peripheral neuropathy
71
Lung cancer paraneoplastic syndromes? DERM
Acanthosis nigerians
| Trousseau's syndrome: thrombophlebitis migrans
72
Features of metastatic lung Ca?
Pathological #
Hepatic failure
Confusion, fits, focal neuro
Addison's
73
Ix in lung cancer?
Bloods
Dx of mass: CXR + volumetric CT
Determine cell type: cytology and histology
Staging: CT (neck, thorax, abdo brain), PET, radio nucleotide bone scan, thoracoscopy, mediastinoscopy and LN sampling
Pulmonary function tests
74
Blood tests in lung cancer?
FBC: anaemia, raised WCC
U+E: low Na
LFTs: deranged due to mets
Bone profile: raised Ca
75
CXR and CT findings in lung cancer?
CXR: coin lesions, effusions, consolidation or collapse, hilar LNs, bony mets
76
Determining cell type in lung cancer?
Cytology: induced sputum and US guided pleurocentesis
Histology: percutaneous FNA (adenocarcinoma), endoscopic transbronchial biopsy (SCC)
77
General management for ALL lung cancers?
MDT
STOP SMOKING
Optimise nutrition and CV function
78
NSCLC management?
Surgery if no mets - wedge resection, lobectomy, pneumonectomy
Curative radio: if poor cardio/resp function
Chemo
79
SCLC management?
Usually disseminated at presentation
Some benefit with chemo
80
Palliative care in lung cancer?
Analgesia: opiates for pain and cough
Radiotherapy: haemoptysis, bone or CNS mets
SVCO: dex and radio or intravascular stent
Persistent effusions: chemical pleurodesis
81
Parkinsons examination, inspection?
Asymmetrical resting tremor: 5Hz (exacerbated by counting backwards)
Hypomimia
Extrapyramidal posture
82
Parkinsons examination, ARMS?
Demonstrate bradykinesia
Tone: cogwheel
NORMAL power and reflexes
Coordination: abnormal in MSA
83
Parkinsons examination, EYES?
Movements: nystagmus (MSA), vertical gaze palsy (PSP)
Saccades: slow initiation and movement
84
Parkinsons examination, EXTRAS?
Glabellar tap
GAIT (make sure you walk with them and support): slow initiation, shuffling, hurrying (festination), absent arms swing
Write sentence and draw spiral
BP lying and standing
85
Parkinsons examination, COMPLETION?
MMSE
86
Causes of parkinsonism?
Idiopathic PD
Parkinsons plus: MSA, PSP, CBD
Multiple infarcts in substantia nigra
Wilson's disease
Drugs: neuroleptics, anti-emetics (metoclopramide)
87
PD history?
Symptoms: tremor, rigidity, bradykinesia
Autonomic: post hypotension, urinary probs
ADLs: handwriting, buttons etc
Sleep: turning in bed, insomnia, daytime sleepyness
Complications: depression, drug SEs esp. motor fluctuations
Cause: sudden onset, eye or balance problems
88
Parkinsons investigations?
Bloods: caeruloplasmin (reduced in Wilsons)
Imaging
- CT/MRI to exclude vascular cause
- DaT scan if unsure about diagnosis (ioflupane123 injection which ends to dopaminergic neurons and allows visualisation of the substantia nigra)
89
GENERAL management of parkinson's?
MDT: neurologist, PD nurse, physio, OT, social worker
Assess disability e.g. unified PD rating scale
Physiotherapy: postural exercises
Depression screening
90
SPECIFIC management of parkinson's?
L DOPA + carbidopa
Da agonists
MOA-O inhibitor
COMT inhibitors
91
Adjunctive therapy in parkinson's?
Domperidone for nausea
Quetiapine for psychosis
Citalopram for depression
92
Features of parkinson's? TRAPPS PD
```
Tremor
Rigidity
Akinesia
Postural instability
Postural Hypotension
Sleep disorder
```
Psychosis
Depression
93
Sleep disorder in parkinson's?
Affects 90%
Insomnia and frequent waking leading to EDS
REM sleep disorder (loss of muscle atonia and violent enactment of dreams)
Da side effects: insomnia, drowsiness, EDS
94
Autonomic dysfunction seen in PD
```
Postural hypotension
Constipation
Hypersalivation
Urgency, nocturia, frequency
ED
Hyperhidrosis
```
95
L-DOPA SEs (DOPAMINE)
```
Dyskinesia
On-off phenomena
Psychosis
ABP reduced
Mouth dryness
Insomnia
N/V
EDS
```
96
MSA pathology
Papp-lantos bodies: a-synuclein inclusions in glial cells
97
MSA features
Autonomic dysfunction: postural hypotension
Parkinsonism
CEREBELLAR ataxia
NB: if autonomic features predominate, may be referred to as Shy Drager Syndrome
98
PSP features?
Postural instability: FALLS
Vertical gaze palsy
Pseudobulbar palsy: speech and swallowing problems
Parkinsonism: symmetrical and tremor is unusual
99
CBD features?
Unilateral parkinsonism ESPECIALLY RIGIDITY
Aphasia
Astereognosis: cortical sensory loss --> alien limb phenomenon: autonomous arm movements
100
Lewy body dementia pathology?
a-synuclein and ubiquitin lewy bodies in brainstem and neocortex
101
Features of lewy body dementia?
Fluctuating cognition
Visual hallucinations
Parkinsonism
102
Vascular parkinsonism features?
Sudden onset
Parkinsonism worse in LEGS
Pyramidal signs
Prominent gait abnormality
103
Causes of tremor?
Resting: parkinsonism
Intention: cerebellar
Postural - worse with arms outstretched: endocrine (hyperthyroid), alcohol withdrawal, Toxins (b-agonists), sympathetic (anxiety)
104
Benign essential tremor features?
AD
Occur on movement and worse with anxiety or caffeine
Doesn't occur with sleep
Better with alcohol
105
UMN signs?
Increased tone
Pyramidal distribution of weakness: legs - extensors > flexors, arms - flexors > extensors
Hyper-reflexia
Extensor plantars
106
Common causes of spastic paraparesis?
MS
Cord compression
Cord trauma
Cerebral palsy
107
Less common causes of spastic paraparesis?
Familial
Vascular e.g. aortic dissection --> beck's syndrome
Infection: HTLV1
Tumour: ependymoma
Syringomyelia
108
Causes of mixed upper and lower motor neurone?
Friedrich's ataxia
Tabes dorsalis
Cord compression/conus
SCDC
MND
Also polio (anterior horn cells)
109
Causes of spastic hemiparesis?
Stroke
MS
SOL
Cerebral palsy
110
Investigation of UMN signs
MRI cord and brain
Further Ix depends on cause e.g. MS (LP, Abs, evoked potentials), compression (FBC, CXR, DRE), SCDC (B12 level, PA Abs)
111
Mx of UMN stuff
Supportive:
MDT: GP, neurologist, radiologist, neurosurgeon, specialist nurses, physio, OT
Orthoses
Mobility aids
Urinary: ICSC
Contractures: baclofen, botulinum injection, physio
112
Causes of cerebellar syndrome? DAISIES
```
Demyelination
Alcohol
Infarct: brainstem stroke
SOL
Inherited
Epilepsy meds: phenytoin
System atrophy, multiple
```
113
Cerebellar syndrome, key causes?
```
LMS
Vestibular schwannoma
VHL
Friedrich's ataxia
Ataxia telangiectasia
Wilson's
```
114
Definition of MS?
Chronic inflammatory condition of the CNS characterised by multiple plaques of demyelination disseminated in time and space
115
Presentation of MS?
TEAM
Tingling
Eye: optic neuritis, bilateral INO
Ataxia and other cerebellar signs
Motor: usually spastic paraparesis
116
Optic neuritis in MS?
Pain on eye movement, rapid loss of central vision
Uhthoff's phenomenon: vision worsens with heat
O/E: reduced acuity and colour vision, white disc, central scotoma, RAPD
117
Tell me about INO?
Disruption of MLF connecting CN6 to CN3
Weak adduction of IPSILATERAL eye
Nystagmus of contralateral eye
Convergence is preserved
118
Diagnosis?
Clinical using McDonald criteria: demonstration of lesions disseminated in time and space
119
Investigations in MS?
MRI: Gd enhancing can show active inflammation, typically plaques are in the periventricular white matter
LP: IgG oligoclonal bands
Abs: Anti MBP, NMO IgG (Devic's syndrome)
Evoked potentials: delayed auditory, visual and sensory
120
Differentials for MS?
CNS sarcoidosis
SLE
Devic's: Neuromyelitis optica
- MS variant with transverse myelitis and optic atrophy
- Distinguished by presence of NMO IgG
121
Principles of treatment?
MDT: neurologist, radiologist, GP, specialist nurses, physio, OT, family
Acute attack
Preventing replace
- DMARD
- Biologicals
Symptomatic
122
MS acute attack Mx?
Methylpred, doesn't influence long term outcomes but reduces duration and severity of attacks
123
MS preventing attack mx?
DMARDs:
- INF-b
Biological
- Natalizumab
124
Symptomatic tx in MS?
Fatigue: amantadine
Depression: SSRI
Pain: amitriptyline
Spasticity: baclofen, gabapentin and physio
Urgency/frequency: intermittent self catheterisation or anticholinergics
ED: sildenafil
Tremor: clonazepam
125
Poor prognostic signs in MS?
Older female
Motor signs at onset
Many relapses early on
Many MRI lesions
126
LMN signs?
Wasting
Fasciculations
Hypotonia
Hyporeflexia
127
Bilateral, symmetrical, distal LMN?
HMSN
Paraneoplastic
Lead poisoning
Acute: GBS, botulism
128
Bilateral, symmetrical, proximal LMN?
Inherited: musc dystrophy
Inflammation: poly/dermatomyositis
Endocrine: cushing's, acrobatics, thyrotoxicosis, diabetic amyotrophy
Drugs: alcohol, statins, steroids
Malignancy: paraneoplastic
129
Unilateral LMN ddx?
Single limb with no sensory signs = polio
Group of muscles with same supply:
- segmental: nerve roots, plexus
- peripheral: mononeuropathy
130
Hand wasting ddx?
Anterior horn: syringiomyelia, MND, polio
Roots (C8 T1): spondylosis
Brachial plexus: compression/avulsion
Neuropathy: HSMN, mononeuritis multiplex (DM)
Muscle: disuse (RA), myotonic dystrophy
131
Investigations in prox myopathy?
```
Bloods: DM, muscle damage, endocrine, abs
CXR
EMG
Genetic analysis
Muscle bx
```
132
Causes of mainly sensory neuropathy?
```
DM
Alcohol
B12 def
CRF and cancer
Vasculitis
Drugs e.g. isoniazid, vincristine
```
133
Causes of mainly motor neuropathy?
HMSN
Paraneoplastic: lung ca, RCC
Lead poisoning
Acute: GBS and botulism
134
Investigations for peripheral polyneuropathy?
Dipstick (glucose)
Bloods: glucose, LFT, b12/folate, U+E, TFTs, ESR/CRP etc
Imaging: CXR to exclude paraneoplasms
Other: nerve conduction, EMG, genetic (PMP22 gene in CMT), nerve bx
135
What do nerve conduction studies show?
Reduced conduction speed = demyelination
Reduced conduction amplitude = axonal degeneration
136
General mx of peripheral polyneuropathy?
MDT
Foot care and shoe advice
Splinting to prevent contractures
137
Specific mx of peripheral polyneuropathy?
Optimise glycemic control
Replace nutritional deficiencies
Avoid alcohol etc
Treat vasculitis with steroids and other immunosuppressants
Neuropathic pain: amitriptyline
GBS: IVIG
138
Causes of facial nerve palsy?
Bell's
Ramsay Hunt
Cholesteatoma
Lyme disease
