Important OSCE topics Flashcards
(204 cards)
1
Q
What are the first rank features of schizophrenia?
A
Auditory hallucinations (running commentary, 2+ voices discussing the patient, thought echo)
Delusions (e.g. persecutory)
Thought disorders (thought insertion, broadcasting and withdrawal)
Passivity phenomena (bodily sensations controlled by external influence, feelings/thoughts/mood/actions under someone else’s control)
2
Q
What are other features of schizophrenia?
A
Negative symptoms (catatonia, blunting, anhedonia, alogia (poverty of speech), avolition
Impaired insight
Incongruency/blunting
Neologisms
3
Q
What should you initially offer for pain relief in palliative care?
A
Regular MR morphine PO (can also give immediate release) and immediate release PO for breakthrough pain
4
Q
What dose of morphine should patients generally start at?
A
20-30mg MR morphine PO daily dose
5mg breakthrough, e.g. 15mg MR morphine PO BD + 5mg breakthrough PRN
5
Q
When prescribing morphine what side effects should you make the patient aware of and how can you counteract these?
A
Drowsiness
Nausea - antiemetic
Constipation - always give laxative
6
Q
What fraction of the total daily dose of morphine should the breakthrough dose be?
A
1/6th
7
Q
What opioid is preferred in patients with mild-moderate renal impairment?
A
Oxycodone
8
Q
What opioid is referred in patients with severe renal impairment?
A
Fentanyl, buprenorphine, alfentanil
9
Q
What is the management of metastatic bone pain?
A
Strong opioids
Bisphosphonates
Radiotherapy
10
Q
When you are increasing the dose of morphine, by how much should you increase it at a time?
A
30-50%
11
Q
What is the conversion rate for:
oral codeine –> oral morphine?
A
/10
12
Q
What is the conversion rate for:
oral tramadol –> oral morphine?
A
/10
13
Q
What is the conversion rate for:
oral morphine –> oral oxycodone?
A
/1.5
14
Q
What is the conversion rate for:
oral morphine –> IV morphine?
A
/2
15
Q
What is the morphine dose equivalent of a 12 microgram fentanyl patch?
A
30mg
16
Q
What is the morphine dose equivalent of a 10microgram buprenorphine patch?
A
24mg
17
Q
What are important points to remember for administering morphine?
A
It is in a locked cupboard, use needs to be logged in logbook, two people need to sign out the morphine
18
Q
What are features of an UGI bleed?
A
Haematemesis, malaena, epigastric discomfort, sudden collapse
19
Q
What are causes of UGI bleed?
A
Mallory weiss tear Oesophageal/gastric cancer Peptic ulcer Oesophagitis Oesophageal varices (tends to be large vol, haemodynamic compromise)
20
Q
How is UGI bleed managed?
A
Admit
Cross match, FBC, UE, LFT, clotting
Airway management, A–>E
Suspected varices –> terlipressin + prophylactic antibiotics, endoscopy within 24 hours, banding/sclerotherapy, sengstaken-blakemore tube, portal pressure should be managed with medical therapy +/- TIPSS
All those who received intervention should be on continuous PPI IV for 72 hours
21
Q
How long can a sengstaken-blakemore tube stay in?
A
Only for 12 hour, after that risk of necrosis
22
Q
How is risk assessed in UGI bleed?
A
Blatchford score at risk, then with full rockall score after endoscopy
23
Q
What vital signs/blood results would you expect to see in UGI bleed?
A
High urea, low Hb, low BP, high pulse
Remember patients likely to have hepatic dx hx
24
Q
What are the causes of meningitis in ages 0-3 months?
A
Listeria monocytogenes
E. coli
GBS
25
What are the main causes of meningitis in ages 3 months-6 years?
H. influenzae
Strep pneumonia
N. meningitidis
26
What are the main causes of meningitis in ages 6 months-60 years?
Strep pneumonia
| N. meningitidis
27
What are the main causes of meningitis in those >60?
Strep pneumonia
N. meningitidis
Listeria
28
What is a common cause of meningitis in those who are immunocompromised?
Listeria
29
What does the CSF analysis look like in someone with a bacterial meningitis?
Appearance: cloudy
White cells: polymorphs
Glucose: <50% plasma
Protein: high
30
What does the CSF analysis look like in someone with a viral meningitis?
Appearance: clear/cloudy
White cells: lymphocytes
Glucose: 60-80% plasma
Protein: normal/high
31
What does the CSF analysis look like in someone with a TB meningitis?
Appearance: fibrin webs
White cells: lymphocytes
Glucose: <50%
Protein: high
32
What does the CSF analysis look like in someone with a fungal meningitis?
Appearance: cloudy
White cells: lymphocytes
Glucose: low
Protein: high
33
How should you investigate suspected meningitis?
FBC, UE, LFT, CRP, coag, PCR, blood gas, blood cultures
| LP if no signs of raised ICH (do not do LP in suspected meningococcal disease)
34
How should you manage suspected meningococcal disease?
IM benzylpen
35
What is the empirical management of meningitis in those aged <3 months?
IV cefotaxime + amoxicillin
36
What is the empirical management of meningitis in those aged 3 months-50 years?
IV cefotaxime
37
What is the empirical management of meningitis in those aged >50?
IV cefotaxime + amoxicillin
38
How is known listeria meningitis managed?
IV gentamicin and amoxicillin
39
What other non-antibiotic drug is sometimes given in meningitis?
IV Dex (not if septic shock, immunocomp or following surgery)
40
What drug is used instead of amoxicillin in meningitis if there is a pencillin allergy?
Chloramphenicol
41
Who should be offered prophylaxis for meningitis? What drugs is it?
```
Close contacts (<7 days) of meningococcal meningitis
Rifampicin or ciprofloxacin (one dose)
```
42
What are the ECG changes in hyperkalaemia?
Tall tented T waves
Small p waves
Broadened QRS complexes
43
What are causes of hyperkalaemia?
```
AKI
Drugs - spironolactone, K sparing diuretics, ACEi, ARB, heparin, ciclosporin
Addisons disease
Massive transfusion
Metabolic acidosis
```
44
How is hyperkalaemia managed?
Stabilise myocardium - calcium gluconate
Shift K intracellularly - NEB salbutamol, insulin/dextrose infusion
Excrete K - calcium resonium, dialysis (for persistent hyperkalaemia in AKI), loop diuretics
45
What are the three types of causes of AKI?
Pre-renal
Intrinsic
Post-renal
46
What are some pre-renal causes of AKI?
Hypovolaemia, e.g. due to vomiting/diarrhoea
| Renal artery stenosis
47
What are some intrinsic causes of AKI?
```
Glomerulonephritis
ATN
Acute interstitial nephritis
rhabdomyolysis
Tumour lysis syndrome
```
48
What are some post-renal causes of AKI?
External compression of ureter
| Kidney stone in bladder/ureter
49
Name some drugs with nephrotoxic potential?
NSAIDs, ACEi, ARB, diuretics, aminoglycosides, iodinated contrast
50
What are features of AKI?
Fluid overload
Oliguria (<0.5ml/kg/h)
Rise in molecules kidney usually excretes (Cr, U, K) --> arrhythmias, uraemia (pericarditis, encephalopathy)
51
How should you investigate AKI?
UE - rise in serum Cr >26micromol/l in last 48h, rise in serum cr >50% in last 7 days, oliguria (<0.5ml/kg/h)
Urinalysis
Imaging - USS renal tract (within 24h)
52
How should you manage AKI?
Stop drugs - those making AKI worse (aminoglycosides, NSAIDs, ARBs, ACEi, diuretics), and those putting at risk of toxicity (lithium, metformin, digoxin)
Only use loop diuretics for significant fluid overload
Management hyperkalaemia
Referral (urologist/nephrologist)
RRT if not responding to medical management of complications (e.g. hyperkalaemia, uraemia..)
53
What is acute tubular necrosis?
Necrosis of renal tubular epithelial cells
54
What are the two main causes of ATN?
Toxins - aminoglycosides, myoglobin secondary to rhabdomyolysis, contrast agents, lead)
Ischaemia - sepsis/shock
55
What do you see in the urine of someone with ATN?
Brown muddy casts
56
What can cause acute interstitial nephritis?
Drugs, esp antibiotics (rifampicin, penicillin, NSAIDs, allopurinol, furosemide)
Systemic dx: SLE, sjogrens
Infections: Hanta virus, staph
57
What are features of acute interstitial nephritis?
Fever, rash, eosophilia, arthalgia, mild renal impairment, HTN
White cell casts, sterile pyuria
58
What is the CHADSVASC score?
```
Used to assess need for anticoagulation (DOAC or warfarin) in those with AF
C - congestive cardiac failure (1)
H - HTN (1)
A2 - age >=75 (2)
D - DM (1)
V - vascular disease (1)
A - age 65-74 (1)
Sc - sex - female (1)
```
Score 0 = no anticoagulation, score 1 + male - consider Rx, score 2 - start treatment
59
What are the two types of bleeds causing epistaxis?
Anterior bleeds - usually from kiesselbacks plexus, often visible
Posterior bleeds - usually not visible, bleeding from deeper structures
60
What can cause epistaxis?
Trauma
| Platelet disorder - ITP, thrombocytopenia, splenomegaly, leukaemia
61
How is epistaxis managed?
Haemodynamically stable --> sit forward, mouth open, pinch cartilaginous region of nose -- if stops --> naseptin (peanut/soy/neocmycin allergy --> use mupirocin) to prevent crusting/vestibulitis
If doesn't stop bleeding after 10-15 min attempt packing/cautery
Haemodynamically unstable/posterior/unknown bleeding source --> ED
62
What are causes of SBO?
Intrabdominal adhesions, hernias, neoplasms, IBD
63
What are features of SBO?
NV, bloating, constipation, abdominal pain
64
How do you image SBO?
Abdominal x-ray
65
How do you manage SBO in the first instance?
NG tube to decompress
A-E
Foley catheter to measure urine output
Fluids
66
What things can you not do on an AV fistula arm?
Cannulas
Take bloods
Do BP on that arm
67
What are causes of parkinsonism?
```
PD
Drug induced, e.g. metoclopramide, antipsychotics
Progressive supranuclear palsy
Multiple system atrophy
Wilson's disease
Post-encephalitis
```
68
What causes parkinsons disease?
Progressive degeneration of dopaminergic neurons in the substantia nigra
69
What are the classic triad of features in PD?
Bradykinesia
Tremor
Rigidity
70
What features of PD symmetrical?
Classically asymmetrical
71
What are the features of bradykinesia in PD classically?
Poverty of movement (hypokinesia)
Short, shuffling steps
Reduced arm swing
Difficulty initiating movement
72
What kind of tremor is seen in PD?
Pill rolling, asymmetrical, low frequency, at rest
73
What are other features of PD?
```
Mask like facies
Stooped posture
Micrographia
Drooling
Psychiatric features - depression, sleep disturbance
Impaired olfaction
REM sleeping disorder
Fatigue
Postural hypotension
```
74
What may give clues that parkinsonism is drug induced?
Rapid onset, bilateral
| Rigidity and tremor uncommon
75
How is parkinsons disease diagnosed?
Clinically
If uncertainty SPECT can be used
76
What drugs can be used in the management of PD?
Levodopa with carbidopa
Dopamine receptor agonists, e.g. bromocriptine, ropinirole
MAO-B inhibitors, e.g. selegiline
Amantadine
COMT inhibitors, e.g. entacapone
Anti-muscarinics, more used for drug induced parkinsonism
77
What is the most common type of cancer in the west?
Basal cell carcinoma
78
What is the most common type of BCC?
Nodular
79
What do BCC look like?
Exist in sun exposed sites, especially head and neck
Initially pearly, flesh coloured papule with telangiectasia
May ulcerate leaving central cater
80
How are BCC managed?
```
Referral to derm
Surgical removal
Curettage
Cryotherapy
Topical cream - imiquimod, fluorouracil
Radiotherapy
```
81
What is compartment syndrome?
Raised pressure within a closed anatomical space
| Raised pressure --> compromises tissue perfusion --> necrosis
82
What are the two main fractures that are implicated in compartment syndrome?
Supracondylar fractures
| Tibial shaft injuries
83
What are the features of compartment syndrome?
Pain (especially on movement, even passive)
Excessive use of breakthrough analgesia
Paraesthesia
Pallor
Arterial pulsation may still be felt as necrosis occurs due to microvascular compromise
Paralysis
84
How is compartment syndrome diagnosed?
Measurement of intracompartmental pressure (excess of 20mmHg abnormal, >40 diagnostic)
85
How is compartment syndrome managed?
Prompt + extensive fasciotomies
Aggressive IV fluids to avoid myoglobulinuria
Debridement of necrotic tissue, amputation may occur
Death of muscle groups occurs within 4-6 hours
86
What are the two most common causes of acute pancreatitis?
Alcohol
| Gallstones
87
What is the pathophysiology of acute pancreatitis?
Autodigestion of pancreatic tissue by pancreatic enzymes --> necrosis
88
What are features of acute pancreatitis?
Severe epigastric pain, radiating to back
Vomiting
Epigastric tenderness, low grade fever
Periumbilical discolouration (Cullens sign) and flank discolouration (Grey-Turners sign)
89
What investigations should be done in suspected acute pancreatitis?
Serum amylase - raised
Serum lipase
Imaging (diagnosis can be made without imaging if serum amylase/lipase >3x upper limit)
USS imaging important to assess aetiology
90
What scoring systems can be used to identify cases of severe pancreatitis which may require ITU management?
Ranson score
Glasgow score
APACHE II
91
What mnemonic can be used to remember the causes of acute pancreatitis?
```
GET SMASHED
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Steroids/scorpion venom
Hypertriglyceridaemia, hypercalcaemia, hypothermia
ERCP
Drugs (azathioprine, mesalazine, furosemide...)
```
92
What are local complications of acute pancreatitis?
```
Pancreatic fluid collections
Pseudocysts
Pancreatic necrosis
Pancreatic abscess
Haemorrhage
```
93
What systemic complication can occur in acute pancreatitis?
ARDS
94
What are the key aspects in the management of acute pancreatitis?
Fluid resus (aggressive)
Analgesia (IV opioids)
NBM, enteral nutrition in moderate/severe pancreatitis within 72h of presentation
Surgery -
Gallstones --> cholecystectomy
Obstructed biliary system --> ERCP
Necrosis + worsening organ failure --> debridement and FNA, surgical necrosectomy
95
What factors predispose to obstructive sleep apnoea?
Obesity
Macroglossia
Large tonsils
Marfans
96
What are consequences of sleep apnoea?
Daytime somnolence
Compensated resp acidosis
HTN
97
How can you assess sleepiness in OSA?
Epworth sleepiness scale
Multiple sleep latency test
Sleep studies
98
What is the management of OSA?
Weight loss
CPAP first line for moderate/severe OSA
Intra-oral devices (e.g. mandibular advancement) can be used in mild OSA or is CPAP not tolerated
99
Do they DVLA need to be informed if a patient has OSA?
If it is causing excessive daytime sleepiness
100
What epworth scores correlated with moderate and severe daytime sleepiness?
13-15 moderate
| 16-24 severe
101
What are differentials for OSA?
```
Asthma
COPD
GORD
Heart failure
Depression
```
102
What is sjogren's syndrome?
Autoimmune disorder affecting exocrine glands --> dry mucosal surfaces
Can be primary or secondary to RA etc.
103
What malignancy is there an increased risk of in sjogrens?
Lymphoid
104
What are features of sjogren's?
```
Dry eyes (keratoconjunctivitis sicca)
Dry mouth
Vaginal dryness
Arthralgia
Reynaud's, myalgia
Sensory polyneuropathy
Recurrent parotitis
```
105
What do investigations of sjogrens generally find?
```
RF +ve
ANA +ve
Anti Ro, Anti La
+ve Schirmer's test (filter paper near conjunctival sac to measure tear formation)
Low C4
```
106
What does histology show in sjogren's?
Focal lymphocytic infiltration
107
How is sjogren's managed?
Artificial tears and saliva
| Pilocarpine may stimulate saliva production
108
What wells score indicates a PE is likely?
>4
109
If PE is likely how is it managed/investigated?
Immediate CTPA (if delay DOAC in interim)
If CTPA +ve --> PE diagnosed
If CTPA -ve --> consider proximal leg vein USS if DVT suspected
110
If PE is unlikely how is it managed/investigated?
D-dimer
+ve --> immediate CTPA (delay --> give DOAC)
-ve --> PE unlikely, stop anticoagulation
111
What is the investigation of choice in suspected PE in renal impairment?
VQ scan
112
What are the classic ECG changes seen in PE?
Sinus tachycardia (most common)
S1T3T3 - large S wave in I, large Q in III, inverted T wave in III
RBBB and RAD may also be seen
113
What score is used to assess suitability of outpatient treatment in low risk PE patients?
PESI (pulmonary embolism severity index) score
114
What two anticoagulants should be offered first line in PE?
Apixaban
Rivaroxaban
If renal impairment severe --> LMWH/UFH
115
How long should patients who have had a provoked PE be on anticoagulation?
3 months
116
How long should patients who have had an unprovoked PE be on anticoagulation?
6 months
117
How is PE with haemodynamic instability managed?
Thrombolysis
118
What may patients who have repeat PEs be considered for?
IVC filters
119
What wells score indicates DVT is likely?
2+ points
120
How should you manage a patient where DVT is likely?
Proximal leg vein USS within 4 hours
+ve --> DOAC
-ve --> D-dimer
If USS cannot be done in 4 hours - DOAC in interim
If scan negative, D-dimer positive -> stop DOAC and repeat USS in 6-8 days
121
How should you manage a patient where DVT is unlikely?
D-dimer
+ve --> proximal leg vein USS wihin 4h
-ve --> DVT unlikely
122
What common pathogens are implicated in cellulitis?
Strep pyogenes
| Staph aureus
123
How is cellulitis diagnosed?
Clinically
Bloods and blood cultures may be done if patient septicaemic
124
What classification is used to guide how we manage patients with cellulitis?
Eron
125
What is the first line treatment for cellulitis?
Mild/moderate - flucloxacillin
Clarithromycin/erythromycin (pregnancy) or doxycycline in penicillin allergic patients
Severe cellulitis - co-amoxiclav/clindamycin
126
What is the most common organism causing septic arthritis?
Staph aureus
127
What is the most common organism causing septic arthritis in young sexually active individuals?
N. gonorrhoea
128
Where is the commonest location to get septic arthritis?
Knee
129
What are the features of septic arthritis?
Acute, swollen joint
Restricted movement
Fluctuant
Fever
130
How do you investigate septic arthritis?
Synovial fluid sampling
Blood cultures
Joint imaging
131
How is septic arthritis managed?
IV antibiotics, e.g. flucloxacillin
Needle aspiration to decompress joint
Arthroscopic lavage may be req.
132
What are the early causes (0-5 days) of post-operative pyrexia?
```
Blood transfusion
Cellulitis
Urinary tract infection
Physiological systemic inflammatory reaction (usually next day)
Pulmonary atelectasis
```
133
What are late causes of post-operative pyrexia (>5 days)?
VTE
Pneumonia
Wound infection
Anastomotic leak
134
What dose of adrenaline is used in ALS?
1ml 1:10, 000 IV
135
What dose of adrenaline is used in anaphylaxis?
0.5ml 1:1000 IM
136
How often can adrenaline be repeated in anaphylaxis?
Every 5 minutes
137
What are the drugs and doses that should be given in anaphylaxis?
Adrenaline: 0.5ml 1 in 1000
138
What are the drugs and doses that should be given in anaphylaxis?
Adrenaline: 0.5ml 1 in 1000
Hydrocortisone 200mg
Chlorphenamine 10mg
139
What enzyme level can be measured to determine in a patient has had a true anaphylactic reaction?
Serum tryptase
140
How should you give oxygen therapy in those with COPD?
If critically unwell - 15L nonrebreath mask with reservoir bag
If not use 28% venturi mask at 4l/min to aim for sats of 88-92% before you have a blood gas (if pCO2 normal can aim for sats of 94-98%)
141
What is immune thrombocytopenia?
Immune mediated reduction in platelet count
| Abs are directed against glycoprotein IIb/IIIa
142
What is the presentation of ITP?
Petechiae, purpura
| Bleeding
143
How is ITP managed?
Oral pred
| Pooled normal human Ig
144
What are the 4 Hs in ALS?
Hypoxia
Hypovolaemia
Hyperkalaemia
Hypothermia
145
What are the 4 Ts in ALS?
Thrombosis
Tension pneumothorax
Tamponade
Toxins
146
What is involved in the diagnostic workup of acute heart failure?
Blood tests - ?anaemia ?abnormal electrolytes ?infection
CXR - ?pulmonary venous congestion, ?cardiomegaly, ?interstitial oedema
Echo - ?tamponade
BNP
147
What is involved in the management of acute heart failure?
```
Oxygen
IV loop diuretics
Opiates
Vasodilators
Inotropic agents
CPAP
Ultrafiltration
Mechanical circulatory assistance
```
148
What test should be done in all those who present with suspected chronic heart failure?
NT-proBNP
149
If levels of BNP are high in suspected heart failure what should you do?
Arrange specialist assessment (including TTE) within 2 weeks
150
If levels of BNP are raised in suspected heart failure what should you do?
Arrange specialist assessment (incl TTE) within 6 weeks
151
List a few things that may also increase BNP levels other than heart failure
```
Tachycardia
Ischaemia
Hypoxaemia (incl. PE)
Sepsis
GFR <60
Diabetes
COPD
Age >70
Cirrhosis
```
152
What classification system is used to classify heart failure?
NYHA (should look over this?)
153
How is chronic heart failure managed?
1st line: ACEi and Beta blocker
2nd line: aldosterone antagonist
3rd line: start by specialist, e.g. ivabradine, digoxin, nitrates
Remember annual influenza vaccine + 1 off pneumococcal
154
What are unmodifiable risk factors for ACS?
Increased age
Male gender
FH
155
What are modifiable risk factors for ACS?
```
Smoking
DM
HTN
Hypercholesterolaemia
Obesity
```
156
What are the two most important investigations in patient presenting with suspected ACS?
Troponin
| ECG
157
What ECG changes and coronary artery are associated with an anterior MI?
V1-4
| Left anterior descending
158
What ECG changes and coronary artery are associated with an inferior MI?
II, III, aVF
| Right coronary artery
159
What ECG changes and coronary artery are associated with an lateral MI?
I, V5, 6
| Left circumflex
160
What is involved in the management of ACS?
MONA (morphine, oxygen if sats <94%, nitrates (e.g. GTN), aspirin (300mg PO))
STEMI --> give 2nd antiplatelet (e.g. ticagrelor), PCI
NSTEMI --> GRACE, high score --> coronary angiography during admission, if not at later date
161
What is standard secondary prevention in those who have had an ACS?
```
Aspirin
Second antiplatelet, e.g. clopidogrel
Beta blocker
ACEi
Statin
```
162
How is STEMI managed?
PCI possible in 120 min?
Yes - prasugrel + PCI
No - fibrinolysis, antithrombin, ticagrelor (if ongoing myocardial ischaemia consider PCI)
163
What investigations should be done in suspected COPD?
Post-bronchodilator spirometry
CXR
FBC (exclude secondary polycythaemia)
BMI
164
What are CXR signs of COPD?
Hyperinflation
Bullae
Flat hemidiaphragm
165
What FEV1/FVC is diagnostic of COPD?
<0.7
166
What are the classifications of COPD?
FEV1>80% predicted - stage 1 (mild)
FEV1 50-79% - stage 2 (moderate)
FEV1 30-49% - stage 3 (severe)
FEV1 <30% - stage 4 (very severe)
167
What is involved in the general management of COPD?
Smoking cessation advice
Annual flu, one of pneumococcal vaccine
Pulmonary rehab if functionally disabled by COPD
168
What is the first line treatment of COPD?
SABA/SAMA
169
What is the second line treatment of COPD?
Steroid responsive features (atopy, eosinophilia, variation in FEV1, diurnal variation in PEFR) --> LABA + ICS (if still breathless triple therapy (LAMA, LABA, ICS)
No asthmatic features --> LABA + LAMA
170
What other medications may be given in stable COPD?
Theophylline
Azithromycin prophylaxis in those who do not smoke, have optimised medical management and continue to have exacerbations
171
How is cor pulmonale managed?
Loop diuretics
| Long term oxygentherapy
172
Which patients with COPD should be offered long term oxygen therapy?
Those with pO2 <7.3kPa or those with pO2 7.3-8 + 1 of: secondary polycythaemia, peripheral oedema, pulmonary hypertension
173
What is the most common organism causing COPD?
H. influenzae
174
How is AECOPD managed?
Increase bronchodilator use (maybe give NEB)
30mg pred 5 days
Give amoxicillin if signs of pneumonia
175
What are causes of MR?
```
Post-MI/CAD (if papillary muscles/chordae tendinae damaged)
Mitral valve prolapse
IE
Rheumatic fever
Congenital
```
176
What are signs of MR?
Pansystolic blowing murmur best heard at apex, radiates into axilla
Quiet S1
177
What might you see on CXR in MR?
Cardiomegaly due to enlarged left atrium and ventricle
178
How is MR managed?
Nitrates, diuretics, positive inotropes, intra-aortic balloon pump
Surgery - replacement, repair
179
What are clinical features of aortic stenosis?
Chest pain
SoB
Syncope
Murmur - ejection systolic radiating to carotids
180
What are features of severe aortic stenosis?
```
Narrow pulse pressure
Slow rising pulse
Soft/absent S2
S4
Thrill
LVH or failure
```
181
What are causes of aortic stenosis?
Degenerative calification
Bicuspid aortic valve
Post-rheumatic disease
HOCM
182
How is aortic stenosis managed?
Asymptomatic --> observe
Symptomatic --> valve replacement
Asymptomatic but valvular gradient >40mmHg and LVF --> consider surgery
183
What are features of AR?
```
Early diastolic murmur
Collapsing pulse
Wide pulse pressure
Quincke sign (nail bed pulsation)
Demusset sign (head bobbing)
Austin flint (mid-diastolic murmur) in severe AR
```
184
What are causes of AR?
```
Rheumatic fever
IE
Connective tissue dx, e.g. SLE
Bicuspid aortic valve
Aortic dissection
AS
HTN
```
185
What are the signs of tricuspid regurg?
Pansystolic murmur
Pulsatile heptomegaly
Left parasternal heave
186
What are causes of tricuspid regurg?
```
RV infarction
Pulmonary hypertension
Rheumatic heart disease
IE (esp IVDA)
Ebstein anomaly
Carcinoid syndrome
```
187
What are the causes of mitral stenosis?
Rheumatic fever
Rheumatic fever
Rheumatic fever
188
What are the features of mitral stenosis?
Mid-late diastolic murmur best heard in expiration
Loud S1
Malar flush
AF
189
What might you see on CXR in mitral stenosis?
LA enlargement
190
What are the 4 features of tetralogy of fallot?
Overriding aorta
Right ventricular outflow tract obstruction
Right ventricular hypertrophy
VSD
191
What are the features of acute moderate asthma?
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
192
What are the features of acute severe asthma?
PEFR 33 - 50% best or predicted
Can't complete sentences
RR > 25/min
Pulse > 110 bpm
193
What are the features of acute life-threatening asthma?
```
PEFR < 33% best or predicted
Oxygen sats < 92%
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
Normal pCO2
```
194
What are the features of near fatal asthma?
A raised pCO2 --> req. mechanical ventilation
195
When should you do an ABG in acute asthma?
If oxygen sats <92%
196
When should you do a CXR in acute asthma?
Life-threatening asthma
Suspected pneumothorax
Failure to respond to Rx
197
How is acute asthma managed?
15L non-rebreath mask with reservoir bag (target SpO2 94-98%)
SABA - NEB
Corticosteroids - 40-50mg pred daily until 5 days post-attack
Severe/lifethreatning - ipratropium bromide NEB, Mg sulphate IV
May require intubation/ventilation/ECMO
198
Who should now have objective tests for asthma?
>=5 years
199
How is asthma diagnosed in >=17 years?
Bronchodilator reversibility test, fractional exhaled nitric oxide test
200
How is asthma diagnosed in 5-17 years?
Bronchodilator reversibility test
| If -ve --> FeNO test
201
How is asthma diagnosed in <5 years?
Clinically
202
What is a positive bronchodilator reversibility test?
Improvement in FEV1 12%+ (or 200ml+ improvement in adults)
203
What is the ladder of treatment of stable asthma in adults?
1. SABA
2. SABA + low dose ICS
3. SABA + low dose ICS + LTRA
4. SABA + low dose ICS + LABA + LTRA (if still helpful)
5. SABA +/- LTRA, switch ICS/LABA for MART that includes low dose ICS
6. SABA +/- LTRA + medium dose ICS MART
7. SABA +/- LTRA + 1 of: high dose ICS, additional drug, e.g. theophylline, specialist referral)
204
What is the stepwise treatment of asthma in kids?
1. SABA
2. SABA + low dose ICS
3. SABA + low dose ICS + LTRA
4. SABA + low dose ICS + LABA + LTRA (if helpful)
5. SABA + MART with low dose ICS
6. SABA + moderate dose ICS MART
7. SABA + 1 of: High dose ICS, theophylline, specialist referral
