CR EOYS9 Flashcards

Question

Treatment of which drug type is a risk factor for TB re-activation?

Answer 1

Prolonged therapy of corticosteroids

Answer 2

**Reactivation of latent TB causes: Post primary TB** - If the host becomes **immunocompromised** the initial infection may become reactivated. Reactivation generally occurs in the apex of the lungs and may spread locally or to more distant sites. - In lungs characterized by **cavitary lesions**, typically in **oxygen rich upper lobes**. Relates to hosts previous exposure to MTB and immune response.

Answer 3

**SYMPTOMS** Fever Night sweats Weight loss and anorexia Tiredness and malaise Cough (most common symptom) > 3 weeks duration Haemoptysis (occasionally) Dyspnoea (Breathlessness) if pleural effusion **Signs** - Pyrexia - Often no chest signs despite CXR abnormality - Maybe crackles in affected area - In extensive disease: i) signs of cavitation (if large) – hyperresonance ii) fibrosis – decreased lung expansion - If pleural involvement: typical signs of effusion – decreased breath sounds over effusion, stony dullness to percussion, loss of tactile fremitus

Answer 4

CXR (mainstay) Sputum sample: ZN stain AND culture Histology Mantoux test IFN-y assay

Answer 5

BCG: Bacille Calmette-Guerin vaccine Given to children: little evidence protecting adults

Answer 6

**Tuberculin sensitivity Test – aka PPD (Purified Protein Derivative) (Manteux) test:** - Tuberculin is injected between layers of the dermis, tuberculin is a component of the bacteria, and if a person has previously been exposed to TB, **the immune system reacts to the tuberculin and produces a small, localized reaction within 48 to 72 hours**; if the reaction creates a large enough area of **induration** (rather than just redness), it’s considered to be a positive test. DOESNT DISTINGUISH BETWEEN LATENT AND ACTIVE TB **IFN-γ assay** - If patient has had TB infection, T lymphocytes produce interferon gamma in response – measured and compared with control sample.

Answer 7

Apex of the lung often involved (more aerobic!) Ill defined patchy consolidation Cavitation usually develops within consolidation Healing results in fibrosis Hilar lymphadenopathy

Answer 8

Standard treatment of TB disease is four-drug therapy - treatment with single drug can lead to development of a bacterial population resistant to that drug: RIPE ! - **Rifampicin** - **Isoniazid** - **Pyrazinamide** - **Ethambutol**

Answer 9

Quinolones (Moxifloxacin) Injectables Capreomycin, kanamycin, amikacin Ethionamide/Prothionamide Cycloserine PAS ( Para-aminosalicylic acid) Linezolid Clofazamine

Answer 10

6 months total treatment duration **First two months**: Rifampicin, Isoniazid (with pyridoxine), Pyrazinamide, Ethambutol **Next 4 months** – if MTB drug susceptibility conforms- isoniazid (with pyridoxine) and rifampicin

Answer 11

**Lymphadenitis** Cervical LNs most commonly Abscesses & sinuses **Gastrointestinal** Swallowing of tubercles in mucous coughed up – any part gut Peritoneal Ascitic or adhesive **Genitourinary** Slow progression to renal disease Subsequent spreading to lower urinary tract **Bone & joint Haematogenous spread** Spinal TB most common- called Pott’s disease **Tuberculous meningitis** Chronic headache, fevers CSF – markedly raised proteins, lymphocytosis

Answer 12

**Hypoventilation** and **ventilation-perfusion mismatch** resulting in **inadequate excretion of CO2** **Drugs** suppress breathing (powerful pain medicines, such as narcotics, and "downers," such as benzodiazepines), especially when combined with alcohol **Brain injury** impairing CNS respiratory centres **Diseases of gas exchange** (such as asthma and chronic obstructive lung disease) **Diseases of the chest** (such as scoliosis), which make the lungs less efficient at filling and emptying **Diseases affecting the nerves and muscles** that drive lung ventilation **Severe obesity**, which restricts how much lungs can expand

Answer 13

**Increased** CO2 causes **cerebral arterial vasodilation** **increased intracranial pressure** with **oedema** – net result is a **dreceased** brain blood flow

Answer 14

Treat cause !: - **Bronchodilator drugs** to reverse some types of airway obstruction - **Noninvasive positive-pressure ventilation** (sometimes called CPAP or BiPAP) or mechanical ventilation if needed - Opioid drug overdose reversal with **naloxone** - **Oxygen if the blood oxygen level is low** – BUT must be careful with oxygen

Answer 15

- Giving oxygen to these patients may lead to worsening CO2 retention from **ventilation-perfusion mismatch**: causes more acidosis. - Can lead to **CO2 narcosis and cardio-pulmonary arrest**

Answer 16

- Controlled oxygen therapy with **24% or 28% O2** - with target **haemoglobin saturation of 88 – 92%** as hypoxaemia is life threatening. - - If CO2 does go up and pH falls may need to mechanically ventilate patient.

Answer 17

This requires phosphate which comes from breakdown of calcium phosphate in bone, which can lead to bone weakening and **osteoporosis.**

Answer 18

Respiratory alkalosis generally occurs when person **hyperventilates**. Increased breathing produces increased alveolar respiration, **expelling CO2 from circulation**

Answer 19

Increase in pH (alkaemia), promotes increased calcium protein binding, which **decreases free calcium.** **Acidaemia** decreases protein binding, resulting in **increased free calcium.**

Answer 20

1) **Decrease CO2 content:** of blood causes **constriction** of cerebral blood vessels – may cause **syncope** 2) Alkalaemia shifts the haemoglobin **O2 dissociation curve to the left:**, **impairing O2 delivery** to tissues. 3) pH related changes in free Ca2+ blood levels can lead to an increase in neuromuscular excitability- increased risk arrythmias and tetany (involuntary and sustained muscle contractions)

Answer 21

1. Kidney increases bicarbonate excretion by **reducing levels of carbonic anhydrase.** 2. The minimum plasma [HCO3-] achievable is about 12 mmol/L).

Answer 22

**Type 1:** respiratory failure occurs when the respiratory system cannot adequately provide oxygen to the body, leading to hypoxemia **Type 2:** when the respiratory system cannot adequately remove carbon dioxide from the body, leading to hypercapnia Name common causes of type 1 resp. failure [3] **3 Ps: PE, Pulmonary oedema, Pneumonia** Name one common cause of type 2 resp. failure [1] **Severe COPD**

Answer 23

**Pathology**: - histologically normal valves - myxomatous degeneration (efect in the mechanical integrity of the leaflet due to the altered synthesis and/or remodeling by type VI collagen) - Marfan, Ehlers danlos **Physiology**: - valve leaflet(s) prolapses back into LA during systole, sometimes producing Mitral Rerguit. Symptoms: - Usually asymptomatic Sign: - Late ejection click Severity: -

Answer 24

**Definition**: Narrowing of the aortic valve resulting in obstruction to the left ventricular stroke volume, leading to symptoms of chest pain, breathlessness, syncope and fatigue **Causes**: - **Calcific disease** (hardening of aortic valve) - **Congenital bicuspid aortic valve (BAV)** (valve has 2 leaflets instead of 3 due to genetic disease - this is the most common congenital heart disease) resulting in stenosis - **Rheumatic heart disease**

Answer 25

**Symptoms**: - **Dyspnoea** - increase in diastolic pressure in stiff non-compliant LV. LV is thicker because has to use more energy to expel blood (hypertrophy) - **Angina** - increase O2 demand of hypertrophied LV - **Syncope** - either paroxysmal ventricular arrhythmias or exertional cerebral hypoperfusion (less blood is leaving) - **LVF** - contractile failure as ventricle dilates – causes heart failure - **Sudden death** - ventricular arrhythmias **Signs**: - **slow rising carotid pulse** - **S4 ejection click** - **Late diastole** (trying to eject blood)

Answer 26

Systolic ejection murmur (S1 --> S2) Prominant S4 ejection click High pitched Crescendo / decresendo Radiates to carotids

Answer 27

**Echocardiogram** - **area of valve**: if less than 1cm2 - **Speed / gradient of LV into aorta** more than 64 mm Hg **ECG:** - **Inverted T wave** in lateral leads (LV hypertrophy) **CXR** - imaging of valve **Pressure signals**: (put a catheter into LV and measure gradient of LV --> aorta) - **prominant a wave**

Answer 28

- Any symptoms of AS - Echocardiographic evidence of worsening LV dilatation - Peak systolic pressure gradient (the difference between peak left ventricular [LV] and peak aortic systolic pressures) >50 mmHg **TAVI** now taking over from heart surgery for people not suitable (frail).

Answer 29

Aortic leaflet disease [1] Aortic root dilating disease [1]

Answer 30

Calcific disease – stiffness of valve (hard to open / close) Congenital bicuspid valve Rheumatic disease Infective endocarditis. Infection of aortic valve

Answer 31

**Ankylosing spondylitis** (is an inflammatory disease that, over time, can cause some of the bones in the spine (vertebrae) to fuse) **Marfan syndrome** (cant make strong CT) **Aortic dissection**

Answer 32

**Heart murmur**: - Early diastolic, soft / subtle murmur at left sternal border - Systolic ejection murmur; due to increased flow across the aortic valve - Corrigans pulse / collapsing pulse: rapidly appears then dissapears - Apex beat displaced laterally

Answer 33

**Echocardiogram**: - Aortic root size compared to LV. Aortic root often much larger than normal) - LV dimensions (LV dilation) **Doppler** - detection and quantification of regurgitant flow

Answer 34

Aortic regurgitation is reflux of blood from the aorta through the aortic valve into the left ventricle during diastole - If net cardiac output is to be maintained, **the total volume of blood pumped into the aorta must increase** and, consequently, the **left ventricular size must enlarge** resulting in **left ventricle dilation and hypertrophy** - Progressive dilation leads to heart failure - Furthermore due to the fact that the remaining blood in the root of the aorta supplies the coronary arteries via the coronary sinus during diastole - regurgitation **causes diastolic blood pressure to fall and thus coronary perfusion decreases** - Also the large left ventricular size is mechanically less efficient, so that the demand for oxygen is greater and **cardiac ischaemia** develops

Answer 35

- Thickening and immobility of the valve leads to obstruction of blood flow from the **left atrium to the left ventricle** - In order for sufficient cardiac output to be maintained, the **left atrial pressure increases and left atrial hypertrophy and dilatation occur** - Consequently **pulmonary venous, pulmonary arterial and right heart pressures also increase** - The increase in pulmonary capillary pressure is followed by the development of **pulmonary oedema** - this is seen particularly when **atrial fibrillation occurs**, due to the elevation of **left atrial pressure and dilatation**, with tachycardia and loss of coordinated atrial contraction

Answer 36

Causes: - Rheumatic fever Symptoms: - **Afib** - lead to **palpitations** - **Progressive dyspnoea** - due to left atrial dilation resulting in pulmonary congestion - **Systemic emboli** - due to atrial fibrillation. - **Right ventricular failure:** due to the development of pulmonary hypertension

Answer 37

- **Mid-diastolic rumbling murmur**: low velocity of blood flow (due to narrow area - rumbles way through). LENGTH OF RUMBLE CORRELATES TO THE INTENSITY - **Loud S1** caused by thick valves closing - **Tapping apex beat** that is palpatable (due to loud S1) - **Atrial fibrillation**: left atrium can't push through stenotic valve - disrupts electrical signal - **Increase in JVP, basal creps, ankle oedema**

Answer 38

noncalcified valve no mitral regurgitation LA thrombus

Answer 39

**Mitral valve leaflet disease** - Mitral valve prolapse (leaflets prolapse during systole) - Rheumatic disease - Infective endocarditis – infection. Disease / bacteria stop closure of the valve) **Subvalvar disease** - Chordal rupture (chordae tendinae) - Papillary muscle dysfunction (usually ischaemic) - Papillary muscle rupture **Functional MR** - LV dilatation

Answer 40

- Pan-systolic murmur - **Prominent third extra heart sound (S3)** in congestive heart failure/left atrium overload - High pitched whistling - increased JVP, basal creps, ankle oedema due to backlog of blood - radiates to the **left axilla**

Answer 41

**Symptoms** Dyspnoea, orthopnoea due to increase in left atrial pressure Palpitations due to atrial fibrillation Systemic emboli due to static blood within dilated fibrillating left atrium predisposes to thrombosis

Answer 42

**Surgery:** Symptoms that fail to respond to medical treatment Worsening cardiovascular complications pulmonary hypertension (MS) LV dilatation (MR) **Medication:** Fluid retention - **diuretics** AF (MS, MR) - **digoxin, beta-blockers, verapamil** **Anticoagulants** to protect against systemic embolisation (AF)

CR EOYS9 Flashcards

(67 cards)