Passmedicine Questions Flashcards
(91 cards)
1
Q
What is the most common valvular disease after infective endocarditis?
A
Aortic regurgitation
2
Q
What sort of murmur is aortic regurgitation?
A
High pitched, early diastolic murmur
3
Q
What signs are seen in aortic regurgitation?
A
Murmur increased by hand gripping manoeuvre
Collapsing pulse
wide pulse pressure
quinckes sign (nailed pulsation)
4
Q
What is the management of aortic regurgitation?
A
medical management of associated heart failure
Aortic valve surgery if:
Symptomatic patients with severe AR
Asymptomatic patients with severe AR and LV systolic dysfunction
5
Q
What are examples of ACE inhibitors?
A
Rampril
6
Q
What are examples of calcium channel blockers?
A
Amlodipine
Verapamil
Diltiazem
Nifedipine
7
Q
What are examples of thiazide-like diuretics?
A
Indapamine
8
Q
What is step 4 of treating hypertension?
A
Potassium <4.5 - add low dose spironolactone
Potassium >4.5 - add alpha or beta blocker
9
Q
what does an atrial septal defect sound like?
A
Ejection systolic murmur louder on inspiration
10
Q
What does aorta stenosis sound like?
A
High pitched ejection systolic murmur (louder on expiration)
11
Q
What does pulmonary stenosis sound like?
A
Ejection systolic murmur (louder on inspiration)
12
Q
What does mitral regurgitation sound like?
A
High pitched pansystolic murmur (louder on expiration)
13
Q
What does mitral stenosis sound like?
A
Low pitched rumbling mid diastolic murmur
14
Q
What does tricuspid regurgitation should like?
A
High pitched pan systolic murmur (louder on inspiration)
15
Q
What is the medical management of stable angina?
A
- CCB or Beta-blocker
- Use in combination ^
- If patient is on mono therapy and can’t tolerate the addition of the other: Long acting nitrate, ivabradine, nicorandil or ranolazine
CCB:
- mono therapy: Use rate limiting eg verapamil or diltiazem
- if used in combination with beta-blocker: Use amlodipine or modified released nifedipine
- DONT USE BETA BLOCKER WITH VERAPAMIL (complete heart block)
16
Q
What should be done for standard release isosorbide mononitrate?
A
Asymmetric dosing to maintain nitrate free time of 10-14 hours
(not needed for once daily modified release isosorbide mononitrate)
17
Q
What is the STEMI Criteria?
A
- Clinical symptoms of ACS (>20 mins duration and >20 mins persistent ECG leads).
- ECG changes must be in > or equal to 2 continuous leads
18
Q
What should the elevation be of V2 and V3 in women?
A
1.5 mm
19
Q
What should the elevation be of V2 and V3 in men under 40 years?
A
2.5mm
20
Q
What should the elevation be of V2 and V3 in men over 40?
A
2mm
21
Q
What should the ST elevation be in any other leads?
A
1mm
22
Q
What else is classed as a STEMI?
A
A new LBBB
23
Q
What are the components of the CHA2DS2-VASc score?
A
Congestive heart failure - 1
Hypertension - 1
Age >75 - 2
Diabetes - 1
Stroke TIA or thromboembolism - 2
Vascular disease (IHD, PAD) - 1
Age 65-74 - 1
Sex (female) - 1
24
Q
How is the CHADVASc scores interpreted?
A
0 - no anticoagulation
1- consider anticoagulation in males, note females
2 or more - offer anticoagulation
25
What are the components of the ORBIT score?
Haemoglobin <130 in males and <120 in females OR Haemaocrit <40% in males and <36% in females - 2
Age >74 years - 1
Bleeding history (GI, intracranial or haemorrhage stroke) - 2
Renal impairment (GFR <60ml) - 1
Treatment with anti platelets - 1
26
How is the ORBIT score interpreted?
0-2 LOW RISK (2.4 bleeds per 100 patient years)
3 MEDIUM RISK (4.7 bleeds per 100 patient years)
4-7 HIGH RISK (8.1 bleeds per 100 patient years)
27
Which anticoagulant is used in AF?
1st line: DOAC
2nd line: Warfarin (Not LMWH)
28
What are the side effects of ACE inhibitors?
Cough (may occur up to 1 year after starting treatment)
Angioedema (may occur up to 1 year after starting treatment)
Hyperkalaemia
First dose hypotension
Renal impairment (if undiagnosed renal artery stenosis)
29
What are the causes of RBBB?
Normal variant (more common with increasing age)
Right ventricular hypertrophy
Cor pulmonale
Pulmonary embolism
MI
Atrial septal defect
cardiomyopathy
myocarditis
30
What is important to remember about ACE inhibitors?
They are BAD in AKI
They are GOOD (renoprotective) in CKD
31
What are examples or Angiotensin Receptor Blockers?
Candersartan
Losartan
32
What is the management for hypertrophic obstructive cardiomyopathy?
ABCDE
Amiodarone
Beta blocker (or verapamil) for symptoms
Cardioverter defibrillator
Dial chamber pacemaker
Endocarditis prophylaxis
33
What is stage 1 hypertension?
Clinic BP >140/90
ABPM >135/85
Treat ONLY if <80 yrs
34
What is stage 2 hypertension?
Clinic >160/100
ABPM >150/95
Treat at any age
35
Severe hypertension?
Clinic systolic BP >180
Clinic diastolic BP >120
36
What is the cause of mitral stenosis?
Rheumatic fever
37
What are examples of thiazides?
Bendroflumethiazide
38
What are the indications for urgent valvular surgery in infective endocarditis?
Severe congestive heart failure
Infections resistant to antibiotics
Recurrent emboli after antibiotic therapy
severe valvular incompetence
aortic abscess
39
What is the major criteria for Dukes Criteria?
Persistently positive blood cultures
Specific imaging findings (like vegetation seen on ECHO)
40
What is the minor Dukes criteria
Predisposition (heart pathology or IVDU)
Fever above 38 degrees
Vascular phenomena (laneway lesions, splenic infarction or intracranial haemorrhage)
Immunological phenomena (oilers nodes, Roth spots, glomerulonephritis)
Microbiological phenomena (Positive cultures not qualifying as major criteria)
41
What is the Dukes criteria for?
To diagnose infective endocarditis
42
How many of the dukes criteria is required for a diagnosis?
One major + 3 minor criteria
OR
5 Minor criteria
43
What is the treatment for infective endocarditis?
IV broad spectrum antibiotics: amoxicillin or gentamicin
4 weeks for own heart valves
6 weeks for prosthetic heart valves
44
What is the treatment for infective endocarditis?
IV broad spectrum antibiotics: amoxicillin or gentamicin
4 weeks for own heart valves
6 weeks for prosthetic heart valves
45
When should you offer anticoagulation in AF?
Women CHADSVASc score >2
Males CHADSVASc score >1
46
What is a common cause of hypertension in young adults?
Coarctation of the aorta
Renal artery stenosis - no murmur- late systolic murmur
47
What is the WELLS score for PE?
Clinical signs of DVT (leg swelling and pain on palpation of deep veins) - 3
An alternative diagnosis is less likely than PE - 3
Heart rate >100BPM - 1.5
Immobilisation >3 days or surgery in the last 4 weeks - 1.5
Previous DVT/PE - 1.5
Haemoptysis - 1
Malignancy (on treatment, treatment in the last 6 months or palliative) - 1
48
What are the investigations for PE?
Likely >4 points:
- Immediate CTPA (ONLY give anticoagulation if there will be a delay in the scan)
- If this is negative do a proximal leg vein ultrasound if DVT is still suspected
PE Unlikely <4 points:
- Arrange a D-Dimer
- If this is positive, arrange an immediate CTPA (only give anticoagulation if theres a delay)
- If negative, PE unlikely, stop anticoagulation and consider alternative diagnosis
49
What is the treatment for Heart failure with reduced LVEF?
ABAL
1st line:
- ACE Inhibitor and Beta blocker (start one at a time)
2nd line:
- Aldosterone antagonist (spironolactone or eplerenone)
- Consider SGLT2 Inhibitor (gliflozin)
3rd line:
- Loop diuretic (symptomatic control only)
Other"
Annual flu vaccine
One off pneumococcal vaccine
50
What is normal left ventricular ejection fraction?
45-60%
51
What is allowed when starting an ACE inhibitor?
Increase in creatinine of 30% from baseline
Increase in potassium up to 5.5
52
What ECG Changes are seen in acute pericarditis?
Most commonly - Widespread ST elevation
Most specifically - PR depression
53
What test should all patients with suspected pericarditis have?
Transthoracic echocardiography
54
What is the management of acute pericarditis?
NSAIDs and Colchicine
55
what is the treatment for tornadoes des pointes?
Magnesium sulphate
56
What are common side effects of beta blockers?
Bronchospasm
Cold peripheries
Fatigue
Sleep disturbances, insomnia, nightmares
Erectile dysfunction
57
Which medication cannot be prescribed with a beta-blocker?
Verapamil - can cause severe bradycardia (complete heart block)
58
Which medication cannot be prescribed with a beta-blocker?
Verapamil - can cause severe bradycardia (complete heart block)
59
Where do the loop diuretics target?
Ascending loop of Henle
60
What is the most important risk factor for aortic dissection?
Hypertension
61
What is the most important risk factor for abdominal aortic aneurysm?
Smoking
62
What is the classic triad of symptoms that are seen in a ruptured abdominal aortic aneurysm?
Epigastric pain
Hypotension
Pulsatile mass in the abdomen
63
What should be checked when a patient is on a statin
LFTs
- At baseline
- 3 months
- 12 months
64
what should be checked when a patient is on an ACE inhibitor
U and Es
- Prior to treatment
- after increasing dose
- at least annually
65
what is the adrenaline dose for paediatric anaphylaxis
< 6 months - 100 - 150 micrograms (0.1 - 0.15 ml 1 in 1,000)
6 months - 6 years - 150 micrograms (0.15 ml 1 in 1,000)
6-12 years - 300 micrograms (0.3ml 1 in 1,000)
Adult and child > 12 years - 500 micrograms (0.5ml 1 in 1,000)
66
what are examples of things that cause transudate pleural effusions
Congestive heart failure
Liver cirrhosis
Severe hypoalbuminaemia
Nephrotic syndrome
67
what are things that cause exudative pleural effusions
Malignancy
Infection
Trauma
Pulmonary infarction
Pulmonary embolism
68
How to tell if a fluid is transudate or exudate
Transudate:
Protein <30g/L
Exudate:
Protein >30g/L
69
What is Lights criteria for exudative effusions
The fluid is considered as exudate if:
1. The ratio of pleural fluid:serum protein is >0.5
2. The ratio of pleural fluid:LDH is >0.6
3. The pleural fluid LDHH value is greater than 2/3rds of the upper limit of the normal serum value
70
what are the two types of ventricular tachycardia
1. Monomorphic VT = caused by a myocardial infarction
2. Polymorphic VT = A subtype of polymorphic is tornadoes de pointes
71
What is the management of ventricular tachycardia
if adverse signs present (systolic BP <90, chest pain, heart failure):
- Immediate cardioversion (antiarrhythmatics)
- if these fail - use electrical cardioversion
Drug therapy:
- amiodarone (through a central line)
- Lidocaine
DO NOT USE VERAPAMIL
72
what are the common tumour markers to be aware of
Ovarian cancer - CA125
Pancreatic cancer - CA19-9
Breast Cancer - CA 15-3
73
what are other common tumour markers to be aware of
Prostate carcinoma - PSA
Hepatocellular carcinoma, teratoma - AFP
Colorectal cancer - CEA
SCLC, gastric cancer, neuroblastoma - Bombesin
Melanoma, schwannoma - S-100
74
What are examples of immune checkpoint inhibitors and what do they do
They are used to treat solid tumours. They are a type of immunotherapy.
Ipilimumab
Nivolumab
Atezollizumab
75
what is trastuzumab
A monoclonal antibody directed against the HER2/neu receptor.
Cardiotoxic
flu like symptoms and diarrhoea are common
76
what imaging is used to diagnose idiopathic pulmonary fibrosis
High-resolution CT scanning
77
what is the treatment for meningitis
IV antibiotics:
- <3 months >50 years = Cefotaxime (or cefrtiaxone) + Amoxicillin (or ampicillin)
- 3 months - 50 years = Cefotaxime (or ceftriaxone)
IV Dexamethasone - AVOID in meningococcal septicaemia
78
What is the prophylactic treatment for bacterial meningitis
Given if close contact within 7 days before onset
Oral ciprofloxacin or rifampicin.
79
When should acetylcysteine be given for paracetamol overdoses
- Staggered overdose (>1 hour)
- patients who present 8-24 hours after taking more than 150mg/kg
- present >24 hours after if they are jaundiced, hepatic tenderness, ALT is upper limit of normal
- The plasma paracetamol concentration is on or above a single treatment line
80
How is acetylcysteine given
IV infusion >1 hour - to reduce the number of adverse effects.
Can cause anaphylactoid reaction - stop infusion and restart at a slower rate.
81
What is the treatment for an aspirin (salicylate) overdose?
Charcoal
82
What is the treatment for opioid overdose
PINPOINT PUPILS
Acute emergency:
IV or IM naloxone
Opioid detoxification:
Methadone or buprenorphine
83
What is the treatment for trigeminal neuralgia
First-Line:
Carbamazepine
Failure to respond to treatment or <50:
Refer to neurology
84
What is an empyema
When a pleural effusion contains pus
pH <7.2
Low glucose <3.4
High LDH >200
85
When can activated charcoal be used in a paracetamol overdose
If the paracetamol was ingested <1 hour ago
86
What is the management of carbon monoxide poisoning
100% high flow oxygen via a non-rebreathe mask, continued for at least 6 hours
Should be continued until all symptoms have resolved (rather than monitoring CO levels)
87
which antibiotic is contraindicated in G6PD
ciprofloxacin
88
what is the mechanism of action of warfarin
inhibits epoxide reductase preventing the reduction of vitamin K to its active hydroquinone form
this in turn acts as a cofactor in the carboxylation of clotting factor II, VII, IX and X (mnemonic = 1972) and protein C.
89
what is the mechanism of action of low molecular weight hepatin
Activates antithrombin III. Forms a complex that inhibits factor Xa
90
what can cause serotonin syndrome
MAOI
SSRI
St Johns wort
Tramadol
Ecstasy
Amphetamines
91
what can be used for migraine prophylaxis
Propanolol
Second line - Topiramate
