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CARDIORESPIRATORY Flashcards

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1
Q

What are the red flag symptoms to ask in a patient presenting with CHEST PAIN?

A
  1. Sudden onset
  2. Duration more than 10 mins
  3. Not relieved by GTN
  4. Associated dyspnoea
  5. Exertional
  6. Weight loss
  7. New dyspepsia if over 55y
  8. Risk factors for PE
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2
Q

What are the risk factors for PE?

A
  1. Hx of VTE
  2. Symptoms suggestive of DVT
  3. Malignancy
  4. FHx
  5. Recent fracture/immobility/surgery
  6. Long haul travel
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3
Q

List as many differentials for chest pain as you can.

A

ACUTE

  1. ACS
  2. PE
  3. Tension pneumothorax
  4. Pericarditis
  5. Aortic dissection

COMMON

  1. Angina
  2. GORD
  3. Costochondritis
  4. Pneumonia
  5. Anxiety
  6. Hyperthyroidism
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4
Q

What are the 3 typical symptoms of stable angina?

A
  1. Chest pain/pressure lasting minutes
  2. Provoked by exercise or emotion
  3. Relieved by rest or GTN
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5
Q

What investigations should be performed in a patient with suspected angina?

A
  1. ECG - should be normal
  2. FBC
  3. Lipid profile
  4. TSH
  5. CT coronary angiogram = GOLD STANDARD
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6
Q

What is the management for patients with stable angina?

A

R - refer to cardiology
A - Advice (increase physical activity, lipid goals, diet modification, smoking cessation)
M - Medical treatment
(i) Anti-anginals = GTN spray, B-blocker or CCB, long-acting nitrate, nicorandil or ivabradine
(ii) Cardio-protection = aspirin 75mg + atorvastatin 80mg
P - procedural interventions = PCI or CABG

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7
Q

What are the ECG features seen in STEMI?

A
  1. ST elevation in at least 2 continuous leads:
    - more than 2.5mm in V2-3 in men under 40y. Over 2mm if over 40y
    - more than 1.5mm in women
    - more than 1mm in other leads
  2. New LBBB (W in V1, M in V6)
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8
Q

Apart from an ECG, what other investigations should you perform in suspected STEMI?

A
  1. Troponins - baseline + 6h after
  2. FBC - r/o anaemia
  3. U+E - prior to ACEi
  4. LFT - prior to statin
  5. Lipid profile
  6. TFT
  7. HbA1c
  8. CXR - r/o MI mimics
  9. Echo - assess functional damage
  10. CT Coronary angiogram - assess for CAD
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9
Q

What is the immediate management of STEMI?

A 
Morphine as required
Oxygen if SpO2 less than 93%
Nitrates 
Antiplatelets - aspirin 300mg and ticagralor 180mg or clopidogrel 300mg
Antiemetic - if N+V present
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10
Q

What reperfusion options are there for patients presenting within 12hrs of symptom onset?

A
  1. PCI - if available within 120mins of presentation to hospital
  2. Thromblysis - if PCI not possible within 120 mins.
    - alteplase used
    - ECG 60-90 mins post-thrombolysis
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11
Q

What is the on-going medical management for STEMI?

A

The 6 A’s

  1. Aspirin 75mg OD
  2. Another antiplatelet - clopidogrel or ticagrelor for up to 12 months
  3. Atorvastatin 80mg
  4. ACEi
  5. Atenolol (or other b-blocker)
  6. ARB
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12
Q

What are the lifestyle modifications you should counsel people on post-MI?

A
  1. Smoking cessation
  2. Reduce alcohol consumption
  3. Cardiac rehabilitation
  4. Weight loss
  5. Optimise management of other conditions
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13
Q

How do you differentiate between STEMI, NSTEMI + unstable angina?

A

STEMI will have ST elevation or LBBB on ECG
NSTEMI will have troponin rise + ECG will show ST depression, inverted T waves + pathological Q waves
Unstable angina will NOT have troponin rise or any new pathological changes on ECG

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14
Q

What investigations should be performed in suspected NSTEMI?

A
  1. ECG
    - horizontal/downward ST depression more than 1mm
  2. Trial GTN - 3 doses every 5 mins
    - avoid if hypotension or RVF
  3. Troponins - baseline + 6hrs after
  4. Creatinine Kinase
  5. FBC - ?anaemia
  6. U+E - prior to starting ACEi
  7. LFT - prior to statins
  8. Lipid profile
  9. TFT
  10. HbA1c - check for DM
  11. CXR - r/o pneumonia, oesophageal rupture, dissection, pneumothorax
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15
Q

What is the acute management of an NSTEMI? (HINT: BATMAN)

A

Beta blockers (unless CI)
Aspirin 300mg STAT
Ticagrelor 180mg or Clopidogrel 300mg
Morphine IV if pain
Anticoagulate = enoxaparin 1mg/kg BD or fondaparinux 2.5mg OD
Nitrates - GTN 1-2 puffs. Repeat every 5 minutes if required

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16
Q

What is the GRACE score? What is it used for?

A

Used for deciding on use of PCI in NSTEMI

  • gives 6-month risk of death/repeat MI post-NSTEMI
  • medium/high risk patients should be considered for early PCI (within 3-days)
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17
Q

What are the risk factors for developing pericarditis?

A
  • Male
  • 20-50yrs old
  • Transmural MI
  • Cardiac surgery
  • Neoplasm
  • Viral/bacterial illness
  • Uraemia/on dialysis
  • Systemic autoimmune conditions
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18
Q

What are the signs + symptoms you would expect in a patient presenting with pericarditis?

A
  1. Chest Pain
    - central
    - worse on lying flat/inspiration
    - relieved by lying forward
  2. Non-productive cough
  3. Myalgias
  4. Pericardial hub
  5. Muffled heart sounds
  6. Signs of RHF = fatigue, angle oedema
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19
Q

What investigations should you perform in a patient presenting with pericarditis?

A

Must R/O sinister causes of chest pain!!!

  1. ECG - upward sloping concave ST elevation (saddle shaped) with PR depression
  2. Troponins - may be slightly elevated
  3. ESR + CRP
  4. Serum urea - R/O ischaemic cause
  5. FBC - elevated WCC
  6. CXR normal OR water-bottle shaped cardiac silhouette
  7. ECHO - may show pericardial effusion, absence of LV wall motion
  8. Pericardiocentesis - if TB is suspected
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20
Q

How do you manage pericarditis?

A

Tamponade or sympomatic effusion = pericardiocentesis

Purulent:

(i) pericardiocentesis (confirms diagnosis)
(ii) IV Abx
(iii) NSAID
(iv) PPI - due to high dose NSAID use
(v) Exercise restriction

Non-purulent = NSAID, PPI, cochicine, exercise restiction, anti-viral therapy

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21
Q

What are the investigations for a patient with suspected PE?

A

Use PERC rule out criteria - if no criteria satisfied then PE unlikely
Wells criteria for PE:
- PE likely = perform CTPA
- PE unlikely = perform D-dimer

  1. ECG - sinus tachycardia, RBBB, RA deviation, S1Q3T3
  2. CXR
  3. D-dimer
  4. CTPA = GOLD STANDARD (V/Q if renal impairment)
  5. ABG - respiratory alkalosis
  6. Coag studies
  7. FBC
  8. U+E - before contrast used in CTPA
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22
Q

How is a PE managed? (i) non-massive PE (ii) Massive PE with haemodynamic compromise.

A

(i) Oxygen + Analgesia as required. Start LMWH before CTPA
(ii) Oxygen, morphine + anti-emetic, Thrombolysis (unfractionated heparin or alteplase if critically ill)
Check sBP
- if over 90mmHg = commence warfarin loading regime
- if under 90mmHg = commence rapid colloid infusion and ICU

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23
Q

What is the long term anticoagulation treatment for post-PE?

A

Use LMWH in women who are pregnant

  • DOAC otherwise. Apixaban 10mg BD for 7-days then 5mg BD
  • stop LMWH as soon as this started

Duration:

  • 3-months if provoked PE
  • Beyond 3 months if unprovoked PE or recurrent VTE or irreversible underlying cause (e.g. cancer, thrombophilia)
  • 6-months in active cancer
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24
Q

What is the difference between primary + secondary spontaneous pneumothorax?

A

Primary = occurs in young people without known respiratory illness

Secondary = occurs in association with existing lung pathology e.g. infection, COPD, asthma, TB, abscess, sarcoid, fibrosis, CTD, malignancy

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25
What investigations are required in pneumothorax?
1. CXR: visceral pleura line typically identified - BTS guidance for measurement = measure horizontally from lung edge to inside of chest wall at level of hilum 2. CT Thorax: can detect small pneumothoraces
26
How are spontaneous pneumothoraces managed?
1. PRIMARY SPONTANEOUS + UNDER 50Y (i) Visible rim under 2cm + no SOB = supplemental oxygen + observation (ii) Visible rim over 2cm OR SOB = percutaneous aspiration and reassessment - if aspiration fails twice, then a chest drain will be required 2. SECONDARY SPONTANEOUS OR OVER 50Y (i) Rim under 1cm + no SOB = supplemental O2 + observe (ii) Rim 1-2cm + no SOB = supplemental O2, percutaneous aspiration (iii) Rim over 2cm or SOB = chest drain
27
How is a tension pneumothorax treated?
Treat before CXR 1. Insert large bore cannula into 2nd ICS mid-clavicular line 2. Attach syringe half-filled with saline and remove plunger 3. Chest drain provides definitive management
28
What are some risk factors for developing GORD?
1. FHx of heartburn/GORD 2. Older age 3. Hiatus hernia 4. Obesity 5. Zollinger-Ellison 6. Pregnancy 7. Alcohol + smoking 8. Drugs = TCAs, anticholinergics, nitrates
29
What are the red flag ALARMS symptoms?
``` A - anaemia (IDA) L - Loss of weight A - Anorexia R - Recent onset/progressive symptoms M - Malaena/haematemesis S - Swallowing difficulty ```
30
When should a pt be referred on a 2ww for urgent endoscopy?
``` 1. Dyspgagia OR 2. Aged over 55 with weight loss + any of: - upper abdominal pain - reflux - dyspepsia ```
31
What investigations should be performed in a patient with suspected GORD?
1. PPI trial - if ALARMS symptoms are absent 2. Endoscopy if over 55, ALARMS symptoms present or symptoms for more than 4 weeks despite treatment 3. 24hr oesophageal pH monitoring is the GOLD STANDARD if endoscopy is normal 4. Barium swallow - may show hiatus hernia
32
How is a patient with GORD managed?
1. Initial presentation - Standard dose PPI for 8wks - Lifestyle = weight loss, avoid late night eating 2. PPI responsive - continue standard dose PPI - surgery = fundoplication (laparoscopic) 3. PPI unresponsive - high-dose PPI + for further testing for 4 weeks - try H2 antagonist if pt experiences nocturnal symptoms
33
What is Barrett's Oesophagus? What is its significance?
Constant reflux of acid causes metaplasia from squamous to columnar epithelium in lower oesophagus - pts will often experience an improvement in reflux symptoms with this change Pre-malignant condition which risks development of adenocarcinoma of oesophagus => pts monitored with regular endoscopy
34
How are patients with Barrett's monitored?
1. No pre-malignant changes found: - PPI + endoscopy with biopsy every 1-3 yrs 2. Pre-malignant/High-grade dysplasia - Oesophageal resection - Eradicative mucosectomy - Mucosal ablation = epithelial laser, HALO, photodynamic ablation
35
What are the 2 types of hiatus hernia? Describe them. Which is most common?
1. SLIDING = gastro-oesophageal junction slides up into chest. Reflux often occurs as LES is less competent. Constitutes 80% of hiatal hernias 2. ROLLING = gastro-oesophageal junction remains in abdomen but bulge of stomach (usually antrum) herniates up into chest. Reflux is less common
36
What investigation is done to diagnose a hiatus hernia?
Barium swallow is best diagnostic test
37
How do you manage hiatus hernias?
1. Lose weight 2. Treat reflux 3. Surgery: - indicated if symptoms cannot be managed medically - rolling hernias are repaired prophylactically due to risk of strangulation
38
Describe what happens in thoracic artery dissection.
Blood splits the aortic media with sudden tearing chest pain radiating to the back. A false lumen is created. As it extends, branches of the aorta are occludes sequentially
39
What are the types of thoracic aortic dissection?
Type A = Ascending aorta (2/3rds) | Type B = Descending aorta, distal to left subclavian
40
What are the clinical features you would expect in a patient with aortic dissection?
1. Tearing chest pain which radiates to back 2. HTN 3. Hypotension as dissection becomes more severe 4. Aortic regurgitation (from proximal dissection) 5. No or non-specific ECG changes - non ST elevation seen in a minority
41
What is the immediate management for aortic dissection?
1. Resuscitation 2. CXR + ECG 3. Confirm diagnosis by immediate imaging - CT, MRI, TOE 4. Urgent vascular input! 5. Crossmatch 10U blood 6. Keep sBP <100mmHg with labetalol 7. Urgent surgical stenting or repair
42
What are the red flag symptoms for patients presenting with palpitations?
1. Associated with exertion 2. Chest pain 3. Collapse 4. FHx of sudden cardiac death
43
What are some differentials for a patient presenting with palpitations?
CARDIAC CAUSES = VT, AF, SVT, Ectopic beats NON-CARDIAC CAUSES = Anxiety, Hyperthyroidism, Phaeochromocytoma
44
What are some causes of atrial fibrillation?
SMITH: - Sepsis - Mitral valve pathology - IHD - Thyrotoxicosis - HTN Others: - Hypokalaemia, hypomagnesaemia - PE, pericardial disease, pre-excitation syndromes, cardiomyopathies - Drugs - Phaemochromocytoma
45
What investigations should you perform in a patient with suspected AF?
1. ECG - absent P waves, narrow QRS, tachy, irregularly irregular 2. 24h ECG - if presenting with paroxysmal AF 3. FBC - R/O anaemia 4. TFT - r/o thyroid disease 5. U+E - r/o hypokalaemia 6. LFT + coag profile - needed prior to anticoagulation 7. CXR - signs of HF or valvular disease 8. TTE - do TOE if needs further confirmation
46
What is the management of patients in AF who are haemodynamically stable?
Rate control 1st line unless: - reversible cause for AF - AF onset less than 48h - AF is causing HF - remain symptomatic despite rate control Rate control options: 1. B-blocker 2. Diltiazem (avoid in HF) 3. Digoxin - only if sedentary + elderly
47
If a patient with AF presents + is haemodynamically unstable, how are they managed?
1. If onset less than 48h = IMMEDIATE CARDIOVERSION (i) Give heparin (ii) Cardiovert using either DC cardioversion or pharmacological = amiodarone (if structural heart disease), flecainide or amiodarone (iii) Following cardioversion, if the duration of AF is confirmed as less than 48h, then anticoagulation is NOT required 2. Onset more than 48h = DELAYED CARDIOVERSION (i) Anticoagulate for 4 weeks or perform TOE to exclude LAA thrombus (ii) DC cardioversion (iii) Anticoagulate for at least 4 weeks post-cardioversion (iv) Review coag risk after 4 weeks
48
What scoring system is used to determine need for anticoagulation in AF?
``` CHADSVaS Score C - Congestive cardiac failure H - HTN A - Age: over 65 = 1, over 75 = 2 D - Diabetes S - Stroke or TIA Va - Vascular disease (IHD, PAD) S - Sex = female ``` Consider anticoagulation in men with CHADSVASc of 1 or more and in women with a score of 2 or more
49
What treatment is given for paroxysmal AF?
Flecainide = 'pill in pocket'
50
What are the causes of atrial flutter?
``` PIRATES P - Pulmonary disease/embolus, pericarditis I - IHD, Idiopathic R - Rheumatic fever A - Anaemia, Age, Alcohol T - Thyrotoxicosis E - Elevated BP S - Sepsis, Sleep apnoea ```
51
What investigations should you perform in a patient with suspected atrial flutter?
1. ECG - saw-tooth appearance, narrow complex tachycardia 2. FBC - r/o anaemia 3. U+E 4. TFT - r/o thyrotoxicosis 5. CXR - identify any underlying pulmonary disease 6. ECHO - used to assess structure + function of heart
52
How is atrial flutter managed acutely if patient is (i) Haemodynamically unstable (ii) Haemodynamically stable?
(i) EMERGENCY DC CARDIOVERSION - If they have symptomatic hypotension, CCF or MI (ii) 1st = beta-blockers + anticoagulate Treat co-existing disease process Synchronised DC cardiovert if no response to pharmacological therapy
53
What is the on-going management for patients with recurrent atrial flutter or failed cardioversion?
1. Catheter ablation of cavotricupsid isthmus | 2. Anticoagulation
54
What are the common clinical features of SVT?
More likely in those with underlying heart disease - Syncope - Palpitations which start + end abruptly - Fatigue - Chest discomfort - Tachycardia
55
What investigations should you perform in a patient with suspected SVT?
1. ECG: narrow complex tachycardia, no visible P waves, pseudo R-waves 2. 24h ECG 3. Troponins - if chest pain present 4. U+E 5. FBC - determine if anaemia contributing to tachycardia 6. TFT 7. Digoxin levels if pt on digoxin 8. CXR 9. ECHO
56
What is the acute management of patients with SVT who are haemodynamically (i) unstable + (ii) stable?
(i) DC Cardiovert! (ii) Vagal manoeuvres (valsalva, carotid sinus massage), Adenosine IV 6mg - 12mg - 12mg (CI in asthmatics, use verapamil), then if still SVT electrical cardioversion
57
What preventative treatment is used in SVT?
1. Beta blockers | 2. Radio-frequency ablation
58
How is Ventricular Tachycardia managed?
1) If pt has adverse signs e.g. sBP below 90mmHg, chest pain, heart failure, syncope then IMMEDIATE CARDIOVERSION is indicated 2) Pulseless VT = ACLS protocol, immediate unsynchronised defibrillation, CPR, O2, adrenaline If stable + normal VT = Give amiodarone
59
How is heart block managed?
Stable = observation Unstable or risk of asystole: 1. Atropine 500mcg IV - up to 6 doses (3mg) 2. Other inotropes e.g. noradrenaline 3. Transcutaneous cardiac pacing High Risk of Asystole (Mobitz type 2 + 3rd degree) = temporary transvenous cardiac pacing + then permanent implantable pacemaker
60
What investigations should be performed in a patient with suspected hyperthyroidism?
1. TSH - suppressed (unless TSH secreting tumour) 2. T3 + T4 raised 3. FBC may have normocytic anaemia 4. ESR may be elevated 5. Deranged calcium + LFTs Graves specific: 1. TSH receptor antibody = present in 90% 2. Anti-TPO = present in 70%
61
How do you manage patients with hyperthyroidism?
1. Beta-blockers (labetalol) or carbimazole (agranulocytosis) 2. PTU - small risk of hepatic reactions 3. Radioiodine - must have no thyroid eye disease, avoid kids for 3 wks and avoid pregnancy for 6 months 4. Thyroidectomy - risks damage to RLN + causing hypoparathyroidism
62
What is a thyroid storm?
AKA Thyrotoxic crisis More severe presentation of hyperthyroidism presenting with pyrexia, tachycardia + delirium Requires admission + close monitoring. Managed as for other causes of thyrotoxicosis
63
What is DeQuervian's Thyroiditis? How is it managed?
Viral infection with fever, neck pain + tenderness, dysphagia + features of thyroid disease - hyperthyroid phase followed by hypothyroid phase as TSH falls - Self limiting. Manage with NSAIDs + b-blockers
64
What is a phaeochromocytoma? What is it associated with?
Rare catecholamine secreting tumour - tumour of chromaffin cells which secrete excessive + unregulated amounts of adrenaline 10% bilateral, 10% cancerous, 10% outside adrenal gland May be associated with MEN type 2, neurofibromatosis and von Hipper-Lindau syndrome
65
What are the clinical symptoms and signs in a patient with phaeochromocytoma?
SYMPTOMS - Headache - Palpitations (paroxysmal AF) - Sweating - Anxiety SIGNS - HTN - Pallor - Impaired glucose tolerance
66
What investigations should be performed in suspected phaeochromocytoma?
1. 24h urine catecholamines = elevated | 2. Plasma free metanephrines = raised
67
How do you manage patients with suspected phaeochromocytoma?
1. Alpha-blockers e.g. phenoxybenzamine 2. B-Blockers once established 3. Adrenalectomy is the definitive treatment to remove the tumour
68
What type of pneumonia is associated with alcoholics?
Klebsiella
69
How does mycoplasma pneumonia present?
Dry cough + atypical chest signs | - AIHA + erythema multiforme may be seen
70
What investigations should be performed in a patient with suspected pneumonia?
1. CXR - new infiltrates gives definitive diagnosis 2. FBC - raised WCC 3. U+E 4. Blood glucose 5. Urea - required for CURB-65 6. ABG - indicates severity (low pO2) 7. Blood culture 8. Sputum culture 9. Urinary antigen - legionella or pneumococcus 10. CRP
71
What makes up the CURB-65 score? What scores mean what?
``` C - confusion (MSE below 8) U - Urea over 7mmol/L R - RR above 30 B - sBP below 90 or dBP below 60 Aged 65 or over ``` 0 or 1 = home treatment possible 2 = hospital care 3 = consider ICU
72
How do you manage low severity CAP?
Amoxicillin for 5 days | - if penicillin allergic use clarithromycin
73
How do you manage moderate-severe CAP?
Dual therapy Amoxicillin AND clarithromycin for 7-10 days - if severe consider IV co-amoxiclav
74
What are the most common causes of an acute exacerbation of COPD?
1. Haemophilus influenza 2. Streptococcus pneumonia 3. Moraxella catarrhalis 4. Rhinovirus
75
What investigations should be performed in an AECOPD?
1. SpO2 - consider O2 if below 90% 2. CXR - r/o alternative DDx 3. ECG 4. ABG - respiratory acidosis (+ may have metabolic compensation if type 2 chronic) 5. FBC - raised Hct, raised WCC, anaemia 6. U+E 7. Sputum culture
76
How do you manage an AECOPD at home?
1. Prednisolone 30mg for 7-14 days 2. Regular inhalers/nebuliser 3. Abx, if evidence of infection
77
How do you manage an AECOPD in the hospital?
1. Nebulised salbutamol + ipratropium 2. 200mg hydrocortisone 3. Abx if evidence of infection 4. Physio
78
How do you manage severe AECOPD?
1. IV aminophylline 2. NIV 3. Intubate + ventilate
79
What investigations should be performed in an acute exacerbation of asthma?
1. Peak flow measurement (PEFR or FEV1) 2. O2 saturation 3. SABA trial - positive response 4. ABG - CO2 retention = severe attack 5. CXR - hyperinflation
80
What parameters class it as a severe asthma attack?
- PEFR 33-50% - RR over 25 - HR over 110 - unable to complete sentences
81
What parameters class it as a life-threatening asthma attack?
At least one of: - PEFR below 33% - Sats below 92% - becoming tired (raised pCO2) - Silent chest (no wheeze) - Haemodynamic instability (hypotension, cyanosis, tachycardia)
82
How do you manage an acute asthma attack? (HINT: O SHIT MI)
1. O - oxygen to maintain sats 94-98% 2. S - salbutamol - nebulised 3. H - hydrocortisone IV 4. I - ipratropium bromide nebuliser 5. T - theophylline 6. M - magnesium sulphate 7. I - intubation - must monitor serum K+ on salbutamol as can cause hypokalaemia
83
How do you manage a MILD exacerbation of asthma?
SABA 4-8 puffs ever 20 mins for up to 4h | Oral prednisolone
84
What are causes of (i) de novo (ii) decompensated acute heart failure/pulmonary oedema?
(i) MI, Sepsis | (ii) ACS, hypertensive crisis, acute arrhythmia, valvular disease, fluid overload therapy
85
How does acute heart failure tend to present?
Rapid onset SOB exacerbated by lying flat, will have T1RF - oedema, fatigue, cough with frothy pink sputum - cyanosis, displaced apex, bibasal crackles, tachycardia, raised JVP
86
What investigations should be performed in acute heart failure?
1. ECG - arrhythmia, ischaemic changes 2. CXR - ABCDE 3. BNP over 500mg/L is diagnostic 4. FBC to R/O anaemia 5. TFT 6. Troponin 7. Echo
87
How do you manage patients with acute HF? (POUR SOD)
POUR away aka stop fluids S - sit up O - oxygen D - diuretics = IV furosemide 40mg STAT - find + treat underlying cause!!!
88
If a patient with acute HF is hypotensive, what additional management is required?
Inotropes | Intra-aortic balloon pump
89
What is the best investigation to determine an anaphylactic reaction?
Serum mast cell tryptase level - raised
90
What is the management of a patient presenting with anaphylactic reaction?
A-E ASSESSMENT - treat accordingly 1. IM adrenaline 1:1000 (under 6yrs = 0.15ml, 6-12 = 0.3ml, adult = 0.5ml) 2. High flow O2 + crystalloid 3. Nebulised salbutamol if brconhospasm 4. Bloods for mast cell tryptase 5. Observe for 6-12hrs from onset as may be biphasic
91
What is Beck's Triad? In what condition is it seen?
1. Falling BP 2. Rising JVP 3. Muffled heart sounds - indicated CARDIAC TAMPONADE
92
What investigations should be performed in suspected cardiac tamponade?
1. CXR - enlarged globular cardiac silhouette 2. ECG - low voltage QRS + electrical alternans 3. ECHO 4. FBC 5. ESR 6. Cardiac enzymes
93
How do you manage cardiac tamponade?
1. Pericardiocentesis | 2. Surgical drainage
94
How do you manage SVC obstruction?
1. Dexamethasone 2. PPI + BM monitoring 3. Sit upright 4. Oxygen + analgesia - if dyspnoeic can give 5mg morphine sulphate 5. Stenting provides immediate relief 6. Cancer management
95
Where does infective endocarditis most commonly affect? What organism?
Mitral valve | - staphylococcus aureus is chief cause
96
What investigations should be performed in suspected infective endocarditis?
1. Bloods - FBC, U+E, CRP, ESR, LFT 2. Blood cultures - 3 sets 1 hr apart 3. VBG - Lactate 4. Urinalysis - may have haematuria from GN 5. CXR 6. ECG 7. Echo - TOE is most sensitive
97
What criteria can be used to diagnose infective endocarditis? What are the major criteria?
``` DUKES CRITERIA Major: - 2+ve blood cultures with evidence of common IE organisms - Echo evidence Minor: - predisposition (cardiac lesion/IVDU) - fever over 38 - vascular/immunological signs - +ve culture or echo not meeting major criteria ``` Need either 2 major OR 1 major + 3 minor OR 5 minor
98
How do you manage infective endocarditis?
1. Early microbiology intervention | 2. May need surgery - cardiology will determine
99
What are the signs + symptoms of asthma?
Symptoms: - SOB, cough, diurnal variability, wheeze Signs: - expiratory polyphonic wheeze, nasal polyps, recent URTI
100
What are some common asthma triggers?
- infection - night/early morning - exercise - animals - dust or cold
101
How do you diagnose asthma in (i) under 5s (ii) 5-16 yrs?
(i) Clinical diagnosis (ii) Symptoms suggestive of asthma + - FeNO over 35 + peak flow variability - obstructive spirometry + BDR
102
How do you diagnose asthma in over 16s?
Symptoms suggestive of asthma and: - FeNO over 40 with +ve BDR or PEFR - FeNO 25-39 and +ve bronchial challenge test - +ve BDR and peak flow variability irrespective of FeNO
103
How do you manage asthma in adults? (aged 17+)
1. SABA 2. SABA + ICS 3. Add LTRA - review at 4-8wks 4. Add LABA (consider stopping LTRA) 5. MART (= ICS + LABA in one inhaler) 6. MART escalation - increase ICS to high dose - trial LAMA or theophylline 7. Specialist referral - remember asthma action plan - annual flu jab + annual asthma review - advice on exercise + smoking cessation
104
What triad is EGPA composed of?
1. Adult-onset asthma 2. Eosinophilia 3. Vasculitis (small vessel)
105
What investigations should be performed in EGPA?
1. FBC - eosinophilia 2. pANCA raised in 30-40% 3. U+E - renal involvement? 4. ESR/CRP raised 5. Urinalysis - blood/protein 6. Serum IgE raised 7. HIV test - can be a cause of mild eosinophilia 8. PFTs - reversible airway obstruction 9. CXR - eosinophilic pneumonia or alveolar haemorrhage 10. Joint aspiration
106
What are the symptoms + signs of COPD?
Symptoms: - chronic cough - exertional SOB - regular sputum - wheeze - frequent winter bronchitis Signs: - barrel chest - hyper-resonance over bullae - distant breath sounds - wheeze - coarse crackles
107
What investigations should be performed in suspected COPD? How is it diagnosed?
Diagnosis made on symptoms + obstructive spirometry! 1. Spirometry - FEV1/FVC less than 0.7 2. FBC - polycythaemia, anaemia, leucocytosis 3. SaO2 - low 4. ABG - T2RF, acidosis 5. CXR - hyperinflation 6. Serum alpha-1 antitrypsin 7. Transferrin factor for CO - low in COPD (high in asthma) 8. Sputum culture 9. ECG + Echo
108
What general measures should be educated to patients with COPD?
1. Smoking cessation 2. Annual influenza vaccine 3. One-off pneumococcal vaccine 4. Pulmonary rehab if functionally disabled
109
What pharmacological management can be used in COPD?
1. SAMA (ipratropium) or SABA 2. Steroid responsive = LABA + ICS - start triple therapy if still SOB = LAMA + LABA + ICS 3. Steroid unresponsive = LABA + LAMA - can add ICS for 3 months if severe exacerbation 4. Oral theophylline - after trials of SABA + LABA or to people who can't used inhaled therapy 5. LTOT - must no longer smoke! 6. Mucolytics (carbocistiene) 7. Abx prophylaxis (azithromycin 250mg 3x week)
110
What are causes of a transudate pleural effusion?
LOW PROTEIN (below 25g/L) - Heart failure - Low albumin = liver disease, nephrotic syndrome, malabsorption - Hypothyroidism - Meig's syndrome
111
What are causes of a exudative pleural effusion?
HIGH PROTEIN (over 35g/L) - infection = pneumonia, TB, abscess - CTD = RA, SLE - Neoplasia = lung cancer, mesothelioma, metastases - Pancreatitis - PE - Dressler's syndrome
112
What are the signs + symptoms of pleural effusion?
Symptoms: - dyspnoea, pleuritic CP, cough Signs: - decreased chest expansion, stony dull percussion, diminished breath sounds, decreased/absent vocal fremitus
113
What are some risk factors of pleural effusion?
- CCF - Pneumonia - Malignancy - Recent CABG
114
What investigations are required in pleural effusion?
1. CXR - blunt costophrenic angles 2. Pleural USS 3. Diagnostic aspiration - protein, glucose, pH, amylase, LDH + bacteriology 4. Pleural biopsy 5. FBC 6. CRP 7. U+E 8. BNP + echo if HF suspected
115
What are some causes of upper zone fibrosis? (HINT: SCATO)
``` S - Silicosis or Sarcoidosis C - Coal workers pneumoconiosis A - allergic alveolitis, allergic aspergillosis, ankylosing spondylitis T - TB O - Other e.g. Radiotherapy ```
116
What are some causes of lower zone fibrosis?
1. IPF 2. Most CTDs e.g. SLE, RA 3. Drug induced - amiodarone, bleomycin, methotrexate, nitrofurantoin 4. Asbestosis
117
What are the signs + symptoms of idiopathic pulmonary fibrosis?
Symptoms: - progressive exertional dyspnoea + dry cough Signs: - bibasal fine-end inspiratory crackles + clubbing
118
What investigations should be performed in pts with idiopathic pulmonary fibrosis?
1. Spirometry - restrictive 2. CXR - ground-glass to honeycombing 3. High resolution CT = gold standard 4. Serology - ANA +ve in 30% - RhF +ve in 10%
119
How do you manage IPF acutely?
1. ADMIT + high dose steroids | 2. Cytotoxics
120
How do you manage IPF long-term?
1. Antifibrotic therapy e.g. perfenidone 2. Smoking cessation 3. Pulmonary rehab 4. O2 5. Lung transplant
121
What would be the typical sarcoid patient presentation on MCQ?
20-40y black female presenting with dry cough + SOB | - may have nodules on shins (erythema nodosum)
122
What is the gold standard test for sarcoidosis?
Histology via EBUS | - non-caesiating granulomas with epitheloid cells
123
How is sarcoidosis managed?
1. No treatment - 60% resolve spontaneously within 6 months 2. Oral steroids for 6-24 months (+ bone protection) 3. Methotrexate or azathioprine 4. Lung transplant
124
What criteria is used to diagnose congestive heart failure?
Framingham criteria
125
What are some causes of congestive heart failure?
``` C - Coronary syndrome (ACS) H - Hypertension A - Arrhythmias M - Mechanical cause (valvular heart disease) P - PE ```
126
What investigations should be performed in a patient with suspected CCF?
1. NT-proBNP (over 2000 requires specialist referral) 2. Echo 3. ECG - HF unlikely if ECG normal 4. CXR - ABCDE 5. Basic bloods - FBC, U+E, LFT, TFT
127
How do you manage CCF? Include lifestyle + pharmacological.
LIFESTYLE: - Cardiac rehab - smoking cessation. Decrease alcohol - Diet: low salt, lose weight - flu + pneumococcal vaccine ``` MEDICATION - ABAL A - ACEi B - Beta-blocker A - Aldosterone antagonist = spironolactone L - Loop diuretics = symptomatic relief ```
128
What murmur is heard in aortic stenosis?
Ejection systolic crescendo-decrescendo murmur
129
What are some causes of aortic stenosis? (HINT: CRABS)
``` C - congenital e.g. Williams syndrome R - Rheumatic fever A - Atherosclerosis B - Bicuspid AV calcification S - Senile calcification degeneration (= most common cause in developed world) ```
130
What symptoms + signs are present in aortic stenosis?
Symptoms: - dyspnoea, exertional CP, syncope Signs: - Ejection systolic murmur which radiates to carotids - slow rising pulse + narrow pulse pressure - heaving apex beat
131
What investigations should be performed in suspected valve disease?
1. ECG 2. CXR 3. Echo 4. Cardiac catheterisation = gold standard
132
How is aortic stenosis managed? Both acute + chronically
``` Acute = balloon valvuloplasty Chronic = surgical valve replacement (+ warfarin if prosthetic valve) ```
133
What murmur is heard in mitral regurgitation?
Pansystolic blowing murmur
134
What are the symptoms + signs which may be present in mitral regurgitation?
Symptoms: - fatigue - dyspnoea on exertion, decreased exercise tolerance Signs: - Pansystolic murmur radiates to axilla - lower extremity oedema - thrusting apex beat, apical thrill - parasternal heave - S2 splitting
135
What murmur is heard in aortic regurgitation?
Early diastolic breath-like murmur | - at LSE
136
What murmur is heard in mitral stenosis?
Mid-diastolic rumbling murmur
137
What is the most common cause of mitral stenosis?
Rheumatic fever
138
What are the 3 main pathological causes of a chronic cough?
1. Post-nasal drip 2. Asthma 3. GORD
139
What are the symptoms + signs of TB?
Symptoms: - fever, night sweats, cough (with haemoptysis), weight loss, spinal pain Signs: - lymphadenopathy, erythema nodosum, infected chest signs
140
What investigations should be performed in suspected TB?
1. CXR 2. Cultures - sputum, blood, lymph node aspirate - ZIEHL NEELSON STAIN SHOWS BRIGHT RED 3. NAAT - faster than cultures 4. Histology - cavitating granulmata 5. Immunological evidence - mantoux test - IGRA
141
What are the main side effects of all 4 TB drugs?
Rifampicin - red/orange secretions - decrease effect of COCP Isoniazid - peripheral neuropathy Pyrazinamide - Hyperuricaemia, causing gout Ethambutol - Colour blindness + decreased visual acuity
142
What are the types of lung cancer?
1. SCLC - 20% - paraneoplastics e.g. SIADH, Cushing's, Lambert Eaton 2. NSLC -80% - adenocarcinoma - squamous cell carcinoma (PTH-rp) - large cell adenocarcinoma
143
When do you do a 2ww referral for suspected lung cancer?
1. CXR findings consistent with lung cancer | 2. Aged over 40 with unexplained haemoptysis
144
What investigations should be performed in suspected lung cancer?
1. CXR 2. Contrast enhanced CT 3. FBC 4. U+E (fitness for chemo) 5. Bone profile ?mets ?PTH-rp 6. LFT ?liver mets 7. PFTs - lung reserve 8. Bronchoscopy + biopsy - histological diagnosis + staging 9. PET CT
145
How is small cell lung cancer treated (generally)?
Usually metastatic at diagnosis - surgery if T1-2a, N0, M0 Chemo-radio is typical - palliative chemo if extensive
146
How is non-small cell lung cancer treated (generally)?
Only 20% suitable for surgery - mediastinoscopy prior to surgey Curative or palliative radiotherapy - poor response to chemo
147
What investigations are performed in suspected SIADH?
1. Fluid status - euvolaemic or hypervolaemic 2. Serum osmolality - LOW (hyponatraemia) 3. Urine osmolality - HIGH (hypernatraemia) 4. TSH + T3/4 - r/o hypothyroidism 5. Serum cortisol - r/o adrenal insufficiency 6. CXR - small-cell lung cancer
148
What is the main metabolic abnormality in PTH-rp lung cancer?
Hypercalcaemia - PTH is low or normal (PTH-rp not detected in assay)
149
If a known cancer pt presents with headaches + confusion, what tests should be done?
1. MRI brain - contrast enhanced 2. CXR - determine status of underlying cancer 3. Bone profile - hypercalcaemia from bone mets can cause confusion
150
What are some of the features associated with granulomatosis with polyangitis?
- vasculitis - sinusitis - dyspnoea - epistaxis/haemoptysis - renal failure
151
What tests should be performed in GPA?
1. cANCA 2. Raised ESR + CRP 3. Urinalysis - protein/blood 4. CXR - may show nodules + infiltrates of pulmonary haemorrhage 5. CT - diffuse alveolar haemorrhage
152
What is the general management of GPA?
1. Corticosteroids + cyclophosphamide for disease induction 2. Methotrexate + azathioprine for maintenance 3. if severe renal disease may need plasma exchange 4. Co-trimazole for PCP prophylaxis
153
What are the clinical features of MPA? What ANCA is associated? What management?
``` Rapidly-progressive GN + pulmonary haemorrhage - pANCA Management: - meticulous BP control - corticosteroids - cyclophosphamide ```
154
What is (i) stage 1 (ii) stage 2 (iii) stage 3 hypertension?
(i) STAGE 1 = BP over 140/90mmHg or ABPM 135/85 (ii) STAGE 2 = BP over 160/100mmHg or ABPM 150/95 (iii) STAGE 3 = sBP over 180 or dBP over 110mmHg
155
What are the causes of primary + secondary HTN? (HINT: PREDICT)
P - primary = no single disease but series of physiological changes R - renal disease E - endocrine = Cushing's, Conns, Phaeochromocytoma, acromegaly D - Drug-induced = cocaine, amphetamines, alcohol, NSAID, steroids, COCP I - ICP raised or Infarction (MI) C - Coarctation of aorta T - Toxaemia of pregnancy e.g. pre-eclampsia or pregnancy induced HTN
156
What tests should be performed in suspected HTN?
1. BPM = ABPM 2. Urinalysis - r/o adrenal disease, CKD, DM 3. ECG 4. Fundoscopy 5. U+E - ?renal disease 6. HbA1c 7. Lipids
157
When do you treat stage 1 hypertension?
If under 80yr AND any of: - target organ damage - CVD - Renal disease - diabetes - QRISK over 10%
158
What is the treatment for HTN?
If under 55 or T2DM: 1. ACEi or ARB 2. A + CCB or A + thiazide Diuretic 3. A+C+D 4. If K over 4.5 use alpha or beta blocker. if under 4.5 add low-dose spironolactone If 55 or over, or Black, use CCB first line, then follow rest of previous steps
159
What are the reversible causes of cardiac arrest? (4H's + 4T's)
1. Hypoxia 2. Hypovolaemia 3. Hypothermia 4. Hypo/hyperkalaemia or Hydrogen ions (acidosis) 1. Tension pneumothorax 2. Tamponade 3. Thrombus - coronary + pulmonary 4. Toxins

FINALS (14 decks)

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