Finals Conceptual Overview Flashcards
1
Q
Doses of antiplatelet drugs?
A
- Clopidogrel = 600mg if cath lab (300mg if not) then 75mg OD
- Ticagrelor = 180mg then 90 mg BD
- Prasugrel = 60mg then 10mg OD
2
Q
Features which make VT likely diagnosis?
A
Previous IHD (re-entry circuit around scar tissue)
- A:V dissociation (p waves not linked to QRS)
- Abnormal RBBB pattern (first QRS peak in V1 is highest)
- Presence of capture (normal QRS randomly) or fusion beats (normal sinus beat + ventricular beat)
- QRS concordance in V1-V6 (all pointing up)
3
Q
Definitions of AF?
A
- Paroxysmal = <7 days
- Persistent = 7 days to 12 months
- Permanent = >12 months or failed cardioversion
4
Q
Causes of AF?
A
Ischaemic HD
Alcohol excess
Mitral valve disease
HTN
5
Q
Rate and rhythm control in AF?
A
Rate
- Beta blockers
- Non-dihydropiridine CCB
- Digoxin - only in old people (doesn’t drop BP, needs to be sedentary)
Rhythm
- Amiodarone - lots of SEs (thyroid)
- Flecanide - CI in structural abnormal heart (young patients)
- Sotalol
6
Q
Pressure changes in AS and MR?
A
AS = LV pressure higher at start of systole –> ejection systolic
MR = LV pressure always higher than LA –> pan systolic
7
Q
What is ivibradine?
A
SA node inhibitor
8
Q
How to accentuate left and right sided murmurs?
A
Left = expiration + hold
Right = inspiration + hold
9
Q
Midline sternotomy scar?
A
- CABG
- VSD repair
- Valve replacement
10
Q
- Williams Syndrome
- Noonan’s Syndrome
- Marfan’s Syndrome
- Down’s Syndrome
- Turner Syndrome
Chromosomes and what they are associated with?
A
- Williams Syndrome - chr 7 = AS
- Noonan’s Syndrome - chr 12 = PS
- Marfan’s Syndrome - chr 15 = AR/MR
- Down’s Syndrome - trisomy 21 = AVSD
- Turner Syndrome - 45XO = coarctation/bicuspid AV
11
Q
Clues from legs in CV exam?
A
If midline sternotomy and scar on legs, CABG. If not, valve replacement.
12
Q
What Ig is most common in myeloma?
A
IgG
13
Q
What comes from myeloid cells?
A
Megakaryocytes, erythrocytes (–> reticulocytes –> RBCs), mast cells, MYELOBLASTS
Myelocytes produce…
- Basophils, neutrophils, eosinophils (granulocytes) and monocytes
14
Q
Diagnostic criteria for myeloma?
A
- Monoclonal protein (serum or urine)
- Plasma cells in bone marrow (>20%)
- Osteolytic lesions on skeletal survey
2/3 required for diagnosis
(Normal serum Ig is reduced)
15
Q
Features of myeloma?
A
- Pancytopenia
- Hypercalcaemia
- Normal ALP
- Raised urea/creatinine (deposition of Ig in kidney)
- Pseudohyponatraemia
- B2-microglobulins
16
Q
Management options in myeloma?
A
Radio/chemo
Interferons
Stem cell transplant
Thalidomide
17
Q
Types of myeloid leukaemia?
A
Acute
AML
Chronic
- CML
- Polycythaemia Rubra Vera
- Myelofibrosis
- Myelodysplasia
- Can all transform to AML
18
Q
Types of lymphoid leukaemia?
A
Acute
ALL
Chronic
- CLL - can transform to the others
- Hodgkin’s Lymphoma
- Non-Hodgkin’s Lymphoma
- Multiple Myeloma
19
Q
Causes of anaemia?
A
-
Microcytic
- Iron deficiency (intake, malabsorption, bleeding)
- Thalassaemia
-
Normocytic
- Acute blood loss
- Haemolytic anaemia
- Bone marrow failure (no response to EPO)
- Renal failure (no production of EPO)
-
Macrocytic
- Megaloblastic (B12/folate)
- Non-megaloblastic
- Smoking, alcohol, liver disease, hypothyroid, cytotoxics
20
Q
Causes of haemolytic anaemia?
A
-
Hereditary (abnormal architecture)
- Spherocytosis (too spherical)
- Eliptocytosis (too eliptical)
- Sickle cell anaemia (Glutamic acid –> valine)
- Rare = G6PD and PKD
-
Acquired
- Autoimmune (SLE, CLL)
- Alloimmune (ABO, Rh)
- Drugs
-
Paroxysmal Nocturnal Haemoglobinuria
- Immune system targets red cells for lysis
21
Q
Blood results in haemolytic anaemia?
A
High reticulocytes
Low haptoglobin
22
Q
Definition of a haemolytic anaemia?
A
RBC lifespan < 15 days
23
Q
Causes of pancytopenia?
A
Ls
- Leukaemia
- Lymphoma
Ms
- Metastases (to bone)
- Multiple myeloma
- Myelofibrosis
- Myelodysplasia
- Megaloblastic anaemia
Others
- Splenomegaly
- Aplastic anaemia
- Drugs (chemo, methotrexate, sulphasalazine, azathioprine, gold, penicillamine)
24
Q
What can you reverse heparin with?
A
Protamine sulfate
25
Haemophilia?
A = haemarthrosis
B = milder --\> epistaxis, no haemarthrosis
**Treat with factor replacement or desmopressin**
26
Causes of prolonged PT **_and_** APTT?
DIC or liver disease
27
PT?
10-15s
Factors V, VII, X, Fibrinogen, Prothrombin (**Extrinsic pathway**)
DIC, liver disease (synthetic function), warfarin
28
APTT?
18-45s
Factors V, VIII, IX, X, XI, XII, Fibrinogen, Prothrombin (Intrinsic pathway)
* DIC, liver disease
* Heparin
* Haemophilia A or B
* vWD
* Antiphospholipid Syndrome
29
What is FDPs?
Fibrin degradation products
Accelerated destruction of fibrinogen
Differentiates DIC from liver disease
30
What is microangiopathic haemolytic anaemia?
Clotting causes mechanical destruction of red cells --\> haemolytic anaemia
* TTP
* HUS
* DIC
31
What does conjugated mean?
Water soluble
32
Causes of jaundice?
1. **_Pre-Hepatic_** (unconjugated)
* Haemolytic anaemia
* Failure in conjugation (Gilbert's, Crigler Najjar)
* Physiological (newborn)
2. **_Hepatic_**
* Viruses
* Alcohol
* Drugs (amiodarone, steroids)
* Metabolic disorders
* RHF (back pressure to liver)
* Mets
3. **_Post-Hepatic_**
* Gallstones
* Pancreatic carcinoma
* Drugs (co-amox --\> cholestasis)
* LNs
* Primary/Secondary biliary cirrhosis
* Primary sclerosing cholangitis (UC)
33
Definition of jaundice?
Bilirubin \>35
34
Causes of ascites?
**_Transudate (SAAG \<1.1)_**
* Portal hypertension
* Hypoalbuminaemia
* Hypothyroidism
**_Exudate (SAAG \>1.1)_**
* Pancreatitis
* Malignancy (liver, peritoneum)
SAAG = serum-ascites albumin gradient
35
Causes of liver cirrhosis?
1. **_Alcohol_**
2. **_Viruses_**
* Hep B, Hep C, HIV, EBV, CMV, HSV
3. **_Metabolic_**
* Wilson's disease, Haemochromatosis (high transferrin sats), Alpha-1-antitrypsin deficiency (+emphysema)
4. **_Immune_**
* Primary biliary sclerosis, Primary sclerosing cholangitis, autoimmune hepatitis (needs immune screen)
36
Complications of liver cirrhosis?
1. **_Portal Hypertension_**
* Varices, haemorrhoids, splenomegaly, ascites
2. **_Hepatorenal Syndrome_**
* Splanchnic dilation --\> RAAS --\> RA constriction and hypoperfusion
* Terlipressin causes splanchnic constriction
3. **_Spontaneous Bacterial Peritonitis_**
* Neuts \>250/mm3, WCC \>500m3
* Fast treatment with broad spec abx
4. **_Hepatic Encephalopathy_**
* Low GCS/confusion, constructional apraxia, hepatic flap
* Lactulose - empties bowel and gets rid of waste (ammonia)
5. **_Hepatocellular Carcinoma_**
* Regular screening
37
Child Pugh Score?
1. Bilirubin
2. Albumin
3. INR
4. Ascites/Encephalopathy (decompensation)
38
4 most common causes of pancreatitis?
* Gallstones
* Ethanol
* ERCP
* Drugs
* Azathioprine, thiazides, sodium valproate, tetracycline
39
Complications of acute pancreatitis?
**_Early_**
* Shock
* Sepsis --\> ARF, DIC
* ARDS
* Hypocalcaemia
* Hyperglycaemia
**_Late_** (\>1 week)
* Necrosis
* Pseduocyst
* CT --\> drainage
* Bleeding
* Pleural effusion/Ascites
40
Causes of GI bleeds?
**_Common_**
* GORD
* Peptic ulcer
* Gastric cancer
* Mallory Weiss Tear
* Oesophageal varices
**_Rare_**
* Aorto-Enteric fistula (AAA repair --\> fatal)
* Angiodysplasia
* Haemobilia
* Dieulafoy lesion (arteriole erosion)
* Meckel's diverticulum (age 2, 2 inches, 2% population, 2:1 M:F, 2cm from ileocaecal valve)
* Peutz-Jegher's syndrome
* HHT
41
Management of IBD?
**_Medical_**
1. **Steroids**
2. **5-ASA** (mesalazine, sulfasalazine)
3. **Azathioprine** (if TPMT low --\> CI due to risk of myelosuppression)
4. **Methorexate** (only Crohn's)
5. **Biologics** (anti-TNFs)
6. **Antibiotics** (metronidazole, cipro)
**_Surgical_**
* Limited resection
* Colectomy
42
What are carcinoid tumourS?
Appendix/Rectum
* Secrete serotonin (5-HT)
* Flushing, diarrhoea, bronchoconstriction
* Associated with R heart disease
* Chromografin low
43
Causes of gynaecomastia?
**_DISCO_**
* Digoxin
* Illicit drugs
* Spironolactone
* Cimetidine
* Oestrogen containing drugs (finesteride etc)
44
Indications for liver transplant?
Cirrhosis
Acute failure (PCM OD)
Carcinoma
45
Abdominal scars and indications (general)?
**_RUQ_**
* Gall bladder, bile ducts, liver
**_Epigastric_**
* Stomach, duodenum
**_Central_**
* Small bowel, pancreas
**_RIF_**
* Appendicitis, gynae causes
**_LIF_**
* Large bowel, gynae
**_Suprapubic_**
* GU, gynae
46
Causes of glomerular disease?
1. **_Primary_**
* Nephrotic (glomerulonephritis)
* Nephritic
* Chronic
2. **_Secondary_**
* DM
* Amyloidosis
* SLE
* Goodpastures, ANCA vasculitis
* Infective endocarditis (septic emboli)
* Thrombotic microangiopathy (HUS, DIC)
* Drugs (gold, penicillamines)
3. **_Hereditary_**
* Fabry's diseae
* Alport's syndrome (collagen mutation)
47
Causes of nephrotic syndrome?
1. **_Minimal Change Disease_**
* Most common cause in kids (Hodgkin's disease)
2. **_Membranous_**
* *Infective* - Hep B/C, syphilis
* *CT disease* - RA, SLE
* *Neoplastic* - Lung Ca, gastric Ca, lymphoma, leukaemia
* *Drugs* - gold, penicllamine, NSAIDs
3. **_Focal Segmental Glomerulonephritis_** (RARE)
* E.g. HIV
4. **_Membranoproliferative_** (RARE)
* Cryoglobulinaemia, lipodystrophy
48
Definitions of microalbuminaemia, macroalbuminaemia, nephrotic syndrome?
Microalbuminaemia = 30-300 mg/24h
Macroalbuminaemia = 300mg - 3g/24h
Nephrotic syndrome = \>3g/24h
49
Complications of nephrotic syndrome?
1. HTN (secondary) - due to RAAS activation
2. Hypercholesterolaemia
3. Hypoalbuminaemia --\> peripheral oedema
4. Thrombosis
* Loss of antithrombin III and protein S
5. Infection
* Loss of Ig
50
Biochemical changes in CKD?
**_Decreased_**
* Na+, HCO3-, Ca2+
**_Increased_**
* Urea, Creatinine, K+, H+, phosphate, Mg2+, urate
51
Causes of AKI?
1. **_Pre-Renal_**
* Low plasma volume
* Low cardiac output
* Occlusion of renal artery
2. **_Renal_**
* ATN (ischaemic or toxic - contrast, gent)
* Glomerular disease
* Tubulo-interstitial disease (penicillin, NSAIDs, diuretics)
* Pyelonephritis
3. **_Post-Renal_**
* Renal stones
* Malignancy (bladder, prostate, cervix)
* Retroperitoneal fibrosis
52
How to differentiate between pre-renal and renal AKI?
Urinary Sodium
* Pre-renal = low
* Renal = high
53
Causes of renal mass?
**_Unilateral_**
* PCKD
* Carcinoma
* Hydronephrosis
* Abscess
* Pyelo
* RA stenosis
**_Bilateral_**
* PCKD --\> may have ballotable masses if transplant but originals not removed
* Carcinoma
* Hydronephrosis
* Amyloidosis
* Tuberous sclerosis
54
Immunosuppression in kidney transplant?
1. **_Steroids_**
* Prednisolone
* Weight gain, diabetes, osteoporosis, psychosis, myopathy
2. **_Calcineurin Inhibitors_**
* Ciclosporin --\> nephrotoxicity, gum hypertrophy, hirsutism, HTN
* Tacromilus --\> tremor, diabetes
3. **_Anti-Metabolites_**
* Mycophenolate Mofetil --\> mucositis
* Azathioprine --\> rash, hepatitis, pancreatitis
55
What is cutanea tarda?
Porphyria in CKD --\> photosensitive rash
56
