Likely to come up Flashcards
(98 cards)
1
Q
What is atherosclerosis
A
The accumulation of lipids, macrophages and smooth muscle in the intima of arterial walls
2
Q
Which arteries is atherosclerosis most common ?
A
LAD
Circumflex
RCA
3
Q
What is the triad of factors that can lead to atherosclerosis ?
A
Vascular endothelial injury e.g. by smoking
Increased coagulation of blood cells e.g. DM
Reduced blood flow e.g. Obesity/lack of exercise
4
Q
What occurs when the endothelium of the blood vessel becomes damaged ?
A
It secrets chemoattractants which lead to leukocytes accumulating in the intma
5
Q
What is a foam cell ?
A
A macrophage that has tried to phagocytose low-density lipoproteins
6
Q
What make up the atherosclortic plaques
A
Foam cells
LDLs
SMCs
7
Q
What are the criteria for hypertension diagnosis
A
140/90 in clinical setting
135/85 with ambulatory or home reading
8
Q
What the types of hypertension ?
A
Essential/primary (95%) cases where cause is unknown
Unessential/secondary where cause is known
9
Q
What are 4 big causes of hypertension ?
A
ROPE Renal disease Obesity Pregnancy Endocrine: primary aldosteronism
10
Q
What are the clinical stages of hypertension ?
A
Stage 1 140/90
Stage 2 >160/100
Stage 3 >180/120
11
Q
What are the ambulatory stages of hypertension ?
A
Stage 1 135/85
Stage 2 150/95
12
Q
When should people be screened for hypertension ?
A
Every 5 years
Every year in DM
13
Q
Name complications of HTN
A
IHD Cerebrovascular accident i.e. stroke or haemorrhage Hypertensive retinopathy Hypertensive nephropathy HF
14
Q
What is 1st line management for all patients with stage 1 hypertension
A
Lifestyle change
Reduce alcohol, caffeine and salt intake
15
Q
What requires pharmacological intervention for hypertension ?
A
All patients with stage 2 or above hypertension
All patients over 80 with stage 1 hypertension that have a Q-risk score of more than 10%, DM, renal disease, CVD or end organ damage
16
Q
First line HTN under 55 caucasian
A
ACE-I e.g. ramipril
17
Q
First line HTN over 55 and Afro-Caribbean
A
CCB e.g. amlodipine
18
Q
2nd line HTN under 55 caucasian
A
ACE-I +
CCB or
Thiazide like diuretic e.g. indapamide
19
Q
2nd line HTN Afro-Caribbean
A
CCB +
Angiotensin 2 receptor blocker e.g. candesartan
or
Thiazide LD e.g. indapamide
20
Q
3rd line HTN
A
ACE-I + CCB + TLD
Ramipril + Amlodipine + indapamide
21
Q
Things to consider when treating HTN 3rd line
A
TLD e.g. indapamide can cause hypokalemia
If K < 4.5 then K sparing diuretic e.g. spironolactone
If K > 4.5 then alpha blocker or beta blocker
22
Q
HTN treatment targets
A
<80yo then <140/90
>80yo then <150/90
23
Q
Name types of heart failure
A
Systolic HF: inability of the ventricle to contract properly
Diastolic HF: inability of the ventricle to relax and fill
24
Q
What is the epidemiology of HF ?
A
Affects 1-3% of the general population
10% of the elderly affected
25
Name causes of heart disease ?
```
ISH - main cause
Cardiomyopathy
Valvular disease
Cor pulmonale
Hypertension
Alcohol excess
```
26
3 cardinal symptoms of HF
SOB
Fatigue
Ankle swelling
27
How will HF appear on a X-ray
```
ABCDE
Alveolar oedema
Kerley B lines
Cardiomegaly
Dilated upper lobes vessels
```
28
How will a blood test of someone with HF appear ?
Brain natriuretic peptide (BNP) is the key marker
| Troponin I, Troponin T and creatine kinase will be both raised
29
How can an echocardiogram be useful in HF
Assesses the dimensions of the cardiac chambers and assess for valvular disease
30
Differentials of HF
Pneumonia
COPD/pulmonary fibrosis
Ageing/physical inactivity
31
First line management HF
ACE-I e.g. ramipril
BB e.g. bisoprolol
Loop diuretic: furosemide
Plus: Revascularisation e.g. PCI appropriate
32
2nd line management HF
Add aldosterone receptor antagonist e.g. spironolactone
| GTN spray
33
What can be used if ACE-I is not tolerated ?
Angiotensin receptor blockers e.g. spironolactone
34
3rd line management HF
Cardiac resynchronisation
| Digoxin
35
What are some compensatory mechanisms for HF
Venous return
Outflow resistance
Sympathetic system activation
Renin-Angiotensin System
36
What is Cor Pulmonale
Right sided heart failure due to respiratory disease
37
What can cause cor pulmonale ?
COPD - most common cause of chronic symptoms
PE - most common cause of acute symptoms
Chronic bronchitis
Pulmonary fibrosis
Cystic fibrosis
38
What is the pathology of cor pulmonale ?
Increased resistance in the pulmonary arteries results in the right ventricle being unable to effectively pump blood out of the ventricle and into the PA
This leads to a back pressure of blood in the right side of the heart which then has to pump harder to maintain pulmonary circulation eventually leading to hypertrophy and dilation
39
What are specific symptoms of cor pulmonale ?
```
Hypoxia
Cyanosis
Raised JVP (due to backlog)
Peripheral oedema
Third heart sound
```
40
What is the NICE criteria for AKI
Rise in creatinine > 25 micromol/L in 48 hours
Rise in creatinine > 50% in 7 day s
Urine output of <0.5ml/kg/hour for >6 hours
41
What are pre-renal causes of AKI ?
Dehydration
Hypotension
HF
42
What are the renal causes of AKI ?
Glomerulonephritis
Interstitial nephritis
Acute tubular necrosis
43
Post-renal causes
Kidney stones
Malignancy
Ureter or urethral strictures
Enlarged prostate or prostate cancer
44
What investigations can be used to try and determine a cause ?
```
FBC
U&Es
LFT
Urinalysis
Urinary tract ultrasound
Abdominal CT or MRI
```
45
DD for AKI
Chronic kidney disease
Increased muscle mass
Drug side effects
46
What are potential complications of AKI ?
```
Hyperkalaemia
Fluid overload
Heart failure
Metabolic acidosis
Uremia → can lead to encephalopathy or pericarditis
```
47
Name RFs for AKI
```
CKD
HF
DM
Liver disease
Age > 65
Cognitive impairment
Nephrotoxic medications such as NSAIDs and ACE-I
Contrast mediums
```
48
What are the stages of renal failure by eGFR ?
```
Stage 1 100-90
Stage 2 89-60
Stage 3a 59-45
Stage 3b 44-30
Stage 4 29-15
Stage 5 <15
```
49
Concerning AKI from creatinine and urine what are the levels of stage 1 (risk) AKI ?
Creatinine- increased serum level >0.3mg/dl or 150-200% from baseline
Urine - production <0.5ml/kg/hour for >6 horus
50
Concerning AKI from creatinine and urine, what are the levels of stage 2 (injury) AKI ?
Increased serum creatinine level >200-300%
| Urine production <0.5ml/kg/hour for > 12 hours
51
Concerning AKI from creatinine and urine what are the levels of stage 3 (failure) AKI ?
Increased serum level from baseline >0.5ml/dl
| Urine production <0.3ml/kghour x24 hours
52
What is RA
A chronic and severe inflammatory autoimmune disorder of the synovial lining of the joints, tendons sheaths and bursa
Typically presents symmetrically and affects multiple joints
53
What is the epidemiology of RA
Affects ~1% of the population
2-3 times more common in women
Most often develops in middle age
Hands and feet are impacted in >80% of cases
54
Which genes are associated with RA ?
HLA DR4 - often present
| HLA DR1 - sometimes present
55
What is the cellular pathology of RA ?
RF is an autoantibody that targets the Fc portion of the IgG antibody causing activation of the immune system against patients own IgG causing systemic inflammation
56
What is the classical RF presentation
Symmetrical distal polyarthropathy
Pain
Swelling
Stiffness which improves as the day progresses
57
What joints are typically affected in RA ?
```
Metacarpal phalangeal (MCP)
Proximal interphalangeal (PIP)
Metatarsophalangeal joints
Can also affect the larger joints such as knees, shoulders and elbows
```
58
What is a surgical emergency at can occur with RA ?
Atlantoaxial subluxation
Caused by damage to the ligaments and bursa around the odontoid peg
Subluxation can lead to spinal cord compression
59
What are the classical signs of RA in the hands ?
Z shaped deformity of the thumb (sometimes called hitchhikers deformity)
Swan neck deformity
Boutonniere's deformity
Ulnar deviation of the fingers at the MCP (knuckle) joints
60
What is swan neck deformity ?
Hyperextended PIP with flexed DIP
61
Boutonniere's deformity
Hyperextended DIP with flexed PIP
62
Name some key extra-articular manifestations of RA
```
Pulmonary fibrosis
Bronchiolitis obliterans
Felty's syndrome
Anaemia of chronic disease
CTS
Amyloidosis
```
63
What investigations would be ordered for a patient with RA ?
```
Bloods
Check RF
If RF negative then check anti-CCP
Other markers e.g. ESR and CRP
X-ray
Ultrasound
```
64
X-ray changes seen in RA
Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Bony erosions
65
1st line management in RA
Disease modifying anti-rheumatic drugs (DMARDs)
Methotrexate, hydroxychloroquine, leflunomide
Adjunct: NSAIDs, corticosteroids at first presentation
66
2nd line RA
2 DMARDs used in combination
67
3rd line RA
Methotrexate +
| Biological therapy -usually a TNF-I e.g. adalimumab
68
4th line RA
Methotrexate +
| Rituximab (CD20 MCAB)
69
Complications of RA
```
Extra-articular eye
Extra-articular neurological
Extra-articular haematological
Extra-articular lungs
Extra-articular kidneys
```
70
Haematological complications of RA
Anaemia of chronic disease
| Fealty's syndrome
71
Lung complications of RA
Pleural effusion
Diffuse fibrosing alveolitis
Rheumatoid nodules
72
Extra-articular kidneys
Amyloidosis - in advance RA - responsible for 10% of RA deaths
73
What is OA ?
An age related dynamic reaction pattern of the synovial joints in response to insult and injury
Often described as wear and tear
74
Symptoms of OA
Pain and stiffness which tends to get worse as the day goes on
75
X-ray signs for OA
LOSS
Loss of joint space
Osteophytes - bone spurs
Subchondral sclerosis - increased density of the bone along the joint line
Subchondral cysts - fluid filled holes in the bone
76
Signs in the hands OA
```
Heberden's nodes
Bouchard's nodes
Squaring at the base of the thumb at the carpometacarpal joints
Weak grip
Reduced range of motion
```
77
What are Herberden's nodes ?
Small bony growths which affect the distal interphalangeal (DIP) joints
78
What are Bouchard's nodes ?
Small bony growths that affect the proximal interphalangeal (PIP) joints
79
What investigations would you order for a patient with suspected OA ?
1st: X-ray affected joints
Serum C-reactive protein (CRP)
Serum erythrocyte sedimentation rate (ESR)
80
DDs for OA
Gout/Pseudogout
| Buritis
81
Management of OA non-pharmacological
Weight loss
Physiotherapy
Occupational therapy
Orthotics
82
Management of OA 1st line
Topical analgesia
Plus: non-pharmacological management
Adjunct: intra-articular CS injections
83
Management of OA 2nd line
1st line + paracetamol
84
Management of OA 3rd line
2nd line + NSAIDs
| Consider PPI
85
Management of OA 4th line
3rd line + opioid
86
RF for OA
Age
Female sex
Genetic predisposition
Obesity
87
Complications of NSAIDs
GI -gastric and peptic ulcers
Renal - AKI e.g. tubular necrosis or progressive kidney disease
Cardiovascular e.g. hypertension, HF , MI and stroke
Respiratory - exacerbate asthma
88
What type of respiratory condition is asthma ?
Obstructive
89
Triggers for asthma attack
```
Infection
Exercise
Animals
Cold/damp
Dust
Strong emotion
Night time and early morning
```
90
Features of a Hx that may suggest asthma
Episodic symptoms
Typically worse at night
Dry cough with wheeze and shortness of breath
Hx of atopic conditions such as eczema, hayfever and food allergies
FHx
Bilateral ''polyphonic wheeze''
91
NICE recommended diagnosis
1st line investigations
Fractional exhaled nitric oxide
Spirometry with bronchodilator reversibility
92
Long term management in order
```
Short acting beta 2 adrenergic receptor agonists
Inhaled corticosteroids
Long acting beta 2 agonists
Long-acting muscarinic antagonists
Leukotriene receptor antagonists
Maintenance and reliever therapy
```
93
Give an example of a SABA
E.g. Salbutamol
94
Give an example of a low dose inhaled corticosteroid
Ipratropium bromide or beclometasone
95
Give an example of an oral leukotriene receptor antagonist
Montelukast
96
Give an example of an LABA
Salmeterol
97
What kind of therapy is considered if SABA, LDICS, OLRA and LABA are not working ?
Maintenance and reliever therapy (MART)
98
What is MART ?
Using a combination inhaler containing a LDCS and a fast acting LABA
E.g. ipratropium bromide and salmeterol
