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Flashcards in Prof Meerans Lectures Deck (90):
1

Infective Endocarditis causative organism?

Strep Viridians
S. Aureus after IVDU

2

Infective Endocarditis signs?
(Hand, eyes, chest, abdomen)

Hand = Clubbing, petichiae, splinter haemorrhages, Jane ways lesions and Olsen nodes

Eyes = Roth spots

Chest = changing murmur

Abdomen = microscopic haematuria and splenomegaly.

3

What is acute rheumatic fever?

An immunological response to to strep pyogenes.

4

Major criteria for acute rheumatic fever?

Carditis
Arthritis
Sydenham chorea
Erythema marginatum
Subcutaneous nodules

5

Minor criteria for acute rheumatic fever?

Fever
Arthralgia
Raised ESR
Leuocytosis
Prolonged PR on ECG
Hx of rheumatic fever

6

Mitral stenosis murmur?

Blowing mid diastolic murmur with presystolic accentuation

7

Clinical features of mitral stenosis?

Middle aged female
Malar flush
AF
Tapping, non-displaced apex
Right ventricular heave

8

What murmur is mitral regurgitation?

Pansystolic murmur, radiating to the axilla

9

Examination findings of mitral regurgitation?

Displaced apex
Apical thrill
Quiet S1, but S3 present

10

Why is S1 loud in mitral stenosis?

Mitral valve can’t close properly, so force of the ventricles closes it loudly.

11

What murmur is aortic regurgitation?

Early diastolic murmur at left sternal edge

12

What are the clinical features of aortic regurgitation?

Collapsing pulse
Corrigans sign = visible neck pulses
De Mussets = head bobbing
Dynamic apex
Quinckes = capillary pulsation in the nail bed

13

Causes of AF?

IHD
Thyrotoxicosis
Rheumatic Heart Disease

Also alcohol, PE, cardiomyopathy or lone AF.

14

What are the different MI leads, and the artery supplying them?

II, III, aVF - inferior MI = right coronary

V1-V4 - anterior MI = LAD

I, V5 and V6 - lateral = circumflex artery

15

Management of an acute MI?

Sit up and give oxygen if <94%
GTN
Aspirin 300mg and Clopidogrel
Diamorphine IV 2.5-5mg
If no PCI = Streptokinase 1.5MU over 1 hour (tPA has clear mortality benefits)
If PCI = LMWH

16

Complications if MI?

Arrhythmia
Cardiac failure
Embolism
Rupture / aneurysmal dilation
Pericarditis: early = full thickness anterior MI
Late = Dressler’s at 6 weeks

17

What would left ventricular aneurysm look like on CXR and ECG?

Like a bubble, vs the uniform enlargement of cardiomegaly
ST elevation

18

Pulmonary embolism ECG?

Most common is normal or sinus tachycardia
S1Q3T3 = deep S and Q, with t wave inversion (in V1-V4).

19

Signs of heart failure?

Tachycardia and tachypnoea
Wheeze and bilateral crepitations
3rd heart sound
Raised JVP and peripheral oedema

20

Causes of S3?

Rapid ventricular filling
Can be normal in <35
Heart failure, MR and constrictive pericarditis

21

Causes of S4?

Atrial contraction against a stiff ventricle

Hypertension and aortic stenosis

22

Heart failure vs cardiogenic shock ?

Heart failure is where CO is insufficient to meet tissue demands.

Cardiogenic shock is where heart failure is so severe that there is not enough pressure to perfume even the heart/brain

23

Management of cardiogenic shock?

Dobutamine or dopamine

24

Is apex beat displaced by dilatation or hypertrophy?

Dilatation

Caused by volume overload;

Aortic regurgitation
Mitral regurgitation
ASD/VSD

25

What causes hypertrophy?

Pressure overload:

Aortic stenosis
HTN
Coarctation of the aorta.

26

What to look for an an exercise ECG?

Enlarged V4/V5 = angina

27

Management of SVT?

Vasovagal manoeuvres
Then IV adenosine 6mg then 12 then 12.

28

What are the clinical examination findings in consolidation?

Decreased expansion ipsilaterally
Dull to percuss
Increased tactile vocal fremitus
Bronchial breathing

29

Management of pneumonia?

Amoxicillin and clarithromycin

30

Are hand warm or cold in septic shock?

Warm
Due to severe endotoxins release = vasodilation

31

Treatment of septic shock?

Fluids
Noradrenaline to cause vasoconstriction.

32

Causes of respiratory clubbing?

Bronchogenic carcinoma
Cystic fibrosis
Bronchiectasis
Empyema
Fibrosis alveolitis

33

Signs of hypercapnoea?

Retention flap
Bounding pulse
Vasodilation = warm hands
Papilloedema
Mental changes
Drowsiness

34

Types of obstructive airway disease?

Asthma = reversible

Emphysema = irreversible, destruction of lung distal to terminal bronchiole

Chronic bronchitis

35

Signs of acute severe asthma?

Not talking
Peak flow <150
Cyanosis
Tachycardia
Silent chest
Normal carbon dioxide
Pulsus paradoxus = inspiratory systolic pressure fall >20mmHg.

36

Management of acute severe asthma?

High flow oxygen
Nebulised salbutamol 5mg driven by oxygen
Ipratropium bromide 0.5mg
Steroids 100mg IV hydrocortisone and 40mg prednisolone

If bad ITU and aminophylline 100-200mg IV bolus

37

Blood gases in asthma?

Oxygen and carbon stay normal until it hits severe

Severe = low Oxygen and high carbon

38

Features of pancoasts tumour?

Horners syndrome = ptosis, mitosis and anhydrosis

Thenar wasting

39

Endocrine manifestations of lung cancer?

Cushings = cortisol from oat cell carcinoma

SIADH = ADH from oat cell carcinoma
- high urine osmolality, low serum osmolality
- low sodium

PTH from squamous cell carcinoma = hypercalcaemic

40

Signs of obstructive airway disease?

Hyperexpansion
Barrel chest = reduced cricosternal distance
Tracheal tug
Decreased expansion
Resonant
Expiration you wheeze

41

Signs of pleural effusion?

Decreases expansion
Normal trachea
Reduced air entry and vocal fremitus
Stony dull to percuss

42

Signs of stable chronic liver disease?

Spider naevi >5, in distribution of SVC
Palmar erythema
Gyanecomastia
Dupuytren’s

43

Signs of liver cell failure?

Jaundice
Leuconychia = low protein
Brushing = clotting deranged
Ascites and oedema = hypoalbuminaemia
Encephalopathy

44

Signs of portal HTN?

SAVE
Splenomegaly
Ascites
Varices- oesophageal or caput medusa
- blood goes away from the umbillicus
Encephalopathy

45

Causes of ascites?

Portal HTN
IVC / hepatic vein obstruction
Constrictive pericarditis
Malignancy / TB
Meigs syndrome = ascites, pleural effusion and benign ovarian tumour

46

How do you clinically distinguish obstructive jaundice from hepatic?

Pale stool, dark urine and pruritic
Urine negative for urobilinogen
LFT’s cholestatic = ALP very high
PBC = AMA+ve, with high IgM
CAH = ANF+ve, high IgG

47

Distinguishing kidney mass vs spleen in LUQ?

Spleen:
- moves across not just down like kidney
-find a notch
-dull to percuss
-can’t get above the spleen
-not ballotable

48

Cardiogenic vs Septic vs Hypovolaemic shock?

Blood pressure low in all of them
JVP will be raised in cardiogenic, low in other two.
Peripheries warm in septic shock, cold in other two

Management:
Cardiogenic = dobutamine
Septic = noradrenaline
Hypovolaemic = Blood

49

Erythema nodusum - what is it and causes?

Painful red lesions on shins

Sarcoid
Sulphonamides
Salicylates
Streptococcal infection
IBD

50

Erythema multiforme - what is it and what causes it?

Typical target lesion

Usually in children or young adults, 7-14 days after herpes simplex virus
Mycoplasma
Drugs e.g. sulphonamides and sulphonylureas

If severe = Stevens Johnson’s syndrome
- associated mucosal ulceration
- liver failure

51

Erythema ab igne - what is it and causes?

Brown pigment art discolouration caused by chronic heat over skin

Often seen in cases with chronic pain.

52

Erythema marginatum - what is it and causes?

Annular eruption with well defined erythematous borders and central clearing

Rheumatic fever

53

Diabetic ketoacidosis features?

No insulin = glucose cannot enter cells
Blood glucose high as cannot enter cells

Body makes ketones to fuel brain = high blood ketones

Severe dehydration and air hunger

54

Diabetes glucose definitions?

Fasting > 7.0
- impaired 6.0 - 7.0

OGTT > 11.1

55

Is HONKC more likely to occur in type 1 or type 2?

Type 2

Significant hyperglycaemia in the absence of ketosis, as insulin is sufficient to suppress ketogenesis but not hyperglycaemia.

Management: rehydrate slowly with normal saline

56

DKA management?

Rehydrate with normal saline and IV insulin infusion
Replace total body potassium

If pH falls below 7.0 May try small amount of bicarbonate 1.26%

57

Stages of diabetic retinopathy?

What you see in each stage....

Background = venodilation, microaneurysms and hard exudates

Pre-proliferative = soft exudates (cotton wool spots)

Proliferative = new vessels

58

Hypertensive retinopathy stages ?

Grade 1 = arteriolar narrowing and silver wiring

Grade 2 = AV nipping

Grade 3 = Flame shaped haemorrhages and cotton wool spots

Grade 4 = papilloedema

59

What is Graves ?

Systemic autoimmune disease involving several autoantibodies:
-TSH
-growth factor receptors in extra ocular muscles
- one that stimulates growth in the pretibial region

60

Features of Graves?

Hyperthyroidism
Exophthalmos
Pretibial myxoedema
Smooth goitre

61

Features of thyrotoxicosis

Weight loss with increased appetite
SOB, palpitations
Sweating
Heat intolerance
Diarrhoea
Lid lag

62

Why does lid lag occur?

Sympathetic innervation to the eyelid is over activated by thyroxine = open eye lid

63

Management of hyperthyroidism?

Medical = beta blockers, carbimazole and propyluracil

Radioiodine

Surgical

64

Acromegaly instant things on walking in?

Good acromegaly question for growth?

Shake hand = sweaty and doughy, large person


Any change in hat size, ring size , shoe size.

65

Complications of acromegaly?

Bitemporal hemianopia

Pituitary macroadenoma secreting GH
- perform OGTT and measure GH, it should be suppressed.

66

Acromegaly management?

Transphenoidal hypophysectomy

Pituitary irradiation

Medical = octreotide 100-200mcg every 8 Hours, cabergoline

67

Cushing’s syndrome causes?

Pituitary dependant Disease = 85%

Ectopic ACTH = 5%

Adrenal adenoma secreting cortisol = 10%

68

Complications of cushings?

Proximal myopathy and centripetal obesity
HTN
Diabetes
Osteoporosis

69

What is pagets?

Overactive osteoclasts.

70

Pagets clinical features?

Warmth and tenderness over bones
Hearing loss
- pagets of ossicles = conductive deafness
- pagets of 8th nerve canal = neurosensory deafness
Bowed legs
Frontal bossing

71

Management of pagets?

None may be needed

Simple analgesia
Calcitonin injections can suppress osteoclasts
IV pamindronate every 3 months
Regular bisphosphonates .

72

Meningitis causative organisms?

Neonate = e.coli, GBS

Adults = streptococcal

Old = pneumococcal

73

What does blood in the CSF indicate?

Subarachnoid

Can manage with nimodipine to maintain brain perfusion.

74

Someone hit on the head by cricket ball?

Extradural
Has to have a skull fracture, which will tear middle meningeal vessels
Clinically = lucid interval for an hour, then deteriorates.

Lens shape on CT

75

Features of Parkinson’s disease?

Bradykinesia
Cogwheel rigidity
Pill rolling tremor

76

What is synkinesis?

In parkinsons, tone will increase on distraction

77

Features of carpal tunnel syndrome?

Thenar wasting
Sensory loss over median distribution
Pain at night, relieve by hanging hand out of bed
Tinels tap test

78

Clinical signs of a cerebellar lesion?

Dysdiadokinesia
Ataxia
Nystagmus
Intention tremor
Staccato speech
Hypotonia

79

Neurofibromatosis 1 features?

Autosomal dominant inheritance

Axillary and inguinal freckling
Optic glioma and brain tumours
Iris hamartoma
Small risk of phaeochromocytoma

80

INO: where is the pathology?

Lesion to the medial longitudinal fasiculus, a collection of neuronal fibres which co-ordinates occulomotor, trochlear and abducens.

81

INO: what are the clinical features?

Dissociated eye movements
Impaired adduction ipsilaterally
And nystagmus in the contralateral eye on abduction.

I ADore NYC DUCks

82

INO: causes ?

MS
Vascular brainstem lesions
Encephalitis

83

Argyll Robertson clinical features?

Like a prostitute = accommodates but doesn’t react.

So small irregular pupils that do not constrict to bright light

84

Where’s the lesion of Argyll Robertson pupil.

Lesion in the pretectal region

85

What is Argyll Robertson a classic sign of?

Neurosyphilis

Also diabetes and MS.

86

What are the clinical features of Holmes Adie pupil?

Sudden onset blurred vision in a female.

Pupils are large
React very slowly to light and accommodation
Dilation also slow

Slow deep tendon reflexes

87

Is MS UMN or LMN?

Always UMN!!!

88

What are the clinical features of Marcus Gunn pupil?

RAPD

Pupil will constrict consensually when light shone on good eye

Pupil will dilate when light removes from other eye and moved to the blind eye.

89

Cause of Marcus Gunn pupil?

Multiple sclerosis

90

APTT, PT and bleeding time in:
Haemophilia
Vitamin K deficiency
Von Willebrands

Haemophilia:
APTT raised. Normal rest.

Vit K = APTT, PT raised. Normal bleeding

VWD = Prolonged bleeding, APTT raised. Normal PT