Flashcards in Prof Meerans Lectures Deck (90):
Infective Endocarditis causative organism?
S. Aureus after IVDU
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.
What is acute rheumatic fever?
An immunological response to to strep pyogenes.
Major criteria for acute rheumatic fever?
Minor criteria for acute rheumatic fever?
Prolonged PR on ECG
Hx of rheumatic fever
Mitral stenosis murmur?
Blowing mid diastolic murmur with presystolic accentuation
Clinical features of mitral stenosis?
Middle aged female
Tapping, non-displaced apex
Right ventricular heave
What murmur is mitral regurgitation?
Pansystolic murmur, radiating to the axilla
Examination findings of mitral regurgitation?
Quiet S1, but S3 present
Why is S1 loud in mitral stenosis?
Mitral valve can’t close properly, so force of the ventricles closes it loudly.
What murmur is aortic regurgitation?
Early diastolic murmur at left sternal edge
What are the clinical features of aortic regurgitation?
Corrigans sign = visible neck pulses
De Mussets = head bobbing
Quinckes = capillary pulsation in the nail bed
Causes of AF?
Rheumatic Heart Disease
Also alcohol, PE, cardiomyopathy or lone AF.
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
Management of an acute MI?
Sit up and give oxygen if <94%
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
Complications if MI?
Rupture / aneurysmal dilation
Pericarditis: early = full thickness anterior MI
Late = Dressler’s at 6 weeks
What would left ventricular aneurysm look like on CXR and ECG?
Like a bubble, vs the uniform enlargement of cardiomegaly
Pulmonary embolism ECG?
Most common is normal or sinus tachycardia
S1Q3T3 = deep S and Q, with t wave inversion (in V1-V4).
Signs of heart failure?
Tachycardia and tachypnoea
Wheeze and bilateral crepitations
3rd heart sound
Raised JVP and peripheral oedema
Causes of S3?
Rapid ventricular filling
Can be normal in <35
Heart failure, MR and constrictive pericarditis
Causes of S4?
Atrial contraction against a stiff ventricle
Hypertension and aortic stenosis
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
Management of cardiogenic shock?
Dobutamine or dopamine
Is apex beat displaced by dilatation or hypertrophy?
Caused by volume overload;
What causes hypertrophy?
Coarctation of the aorta.
What to look for an an exercise ECG?
Enlarged V4/V5 = angina
Management of SVT?
Then IV adenosine 6mg then 12 then 12.
What are the clinical examination findings in consolidation?
Decreased expansion ipsilaterally
Dull to percuss
Increased tactile vocal fremitus
Management of pneumonia?
Amoxicillin and clarithromycin
Are hand warm or cold in septic shock?
Due to severe endotoxins release = vasodilation
Treatment of septic shock?
Noradrenaline to cause vasoconstriction.
Causes of respiratory clubbing?
Signs of hypercapnoea?
Vasodilation = warm hands
Types of obstructive airway disease?
Asthma = reversible
Emphysema = irreversible, destruction of lung distal to terminal bronchiole
Signs of acute severe asthma?
Peak flow <150
Normal carbon dioxide
Pulsus paradoxus = inspiratory systolic pressure fall >20mmHg.
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
Blood gases in asthma?
Oxygen and carbon stay normal until it hits severe
Severe = low Oxygen and high carbon
Features of pancoasts tumour?
Horners syndrome = ptosis, mitosis and anhydrosis
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
Signs of obstructive airway disease?
Barrel chest = reduced cricosternal distance
Expiration you wheeze
Signs of pleural effusion?
Reduced air entry and vocal fremitus
Stony dull to percuss
Signs of stable chronic liver disease?
Spider naevi >5, in distribution of SVC
Signs of liver cell failure?
Leuconychia = low protein
Brushing = clotting deranged
Ascites and oedema = hypoalbuminaemia
Signs of portal HTN?
Varices- oesophageal or caput medusa
- blood goes away from the umbillicus
Causes of ascites?
IVC / hepatic vein obstruction
Malignancy / TB
Meigs syndrome = ascites, pleural effusion and benign ovarian tumour
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
Distinguishing kidney mass vs spleen in LUQ?
- moves across not just down like kidney
-find a notch
-dull to percuss
-can’t get above the spleen
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
Cardiogenic = dobutamine
Septic = noradrenaline
Hypovolaemic = Blood
Erythema nodusum - what is it and causes?
Painful red lesions on shins
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
Drugs e.g. sulphonamides and sulphonylureas
If severe = Stevens Johnson’s syndrome
- associated mucosal ulceration
- liver failure
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.
Erythema marginatum - what is it and causes?
Annular eruption with well defined erythematous borders and central clearing
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
Diabetes glucose definitions?
Fasting > 7.0
- impaired 6.0 - 7.0
OGTT > 11.1
Is HONKC more likely to occur in type 1 or 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
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%
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
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
What is Graves ?
Systemic autoimmune disease involving several autoantibodies:
-growth factor receptors in extra ocular muscles
- one that stimulates growth in the pretibial region
Features of Graves?
Features of thyrotoxicosis
Weight loss with increased appetite
Why does lid lag occur?
Sympathetic innervation to the eyelid is over activated by thyroxine = open eye lid
Management of hyperthyroidism?
Medical = beta blockers, carbimazole and propyluracil
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.
Complications of acromegaly?
Pituitary macroadenoma secreting GH
- perform OGTT and measure GH, it should be suppressed.
Medical = octreotide 100-200mcg every 8 Hours, cabergoline
Cushing’s syndrome causes?
Pituitary dependant Disease = 85%
Ectopic ACTH = 5%
Adrenal adenoma secreting cortisol = 10%
Complications of cushings?
Proximal myopathy and centripetal obesity
What is pagets?
Pagets clinical features?
Warmth and tenderness over bones
- pagets of ossicles = conductive deafness
- pagets of 8th nerve canal = neurosensory deafness
Management of pagets?
None may be needed
Calcitonin injections can suppress osteoclasts
IV pamindronate every 3 months
Regular bisphosphonates .
Meningitis causative organisms?
Neonate = e.coli, GBS
Adults = streptococcal
Old = pneumococcal
What does blood in the CSF indicate?
Can manage with nimodipine to maintain brain perfusion.
Someone hit on the head by cricket ball?
Has to have a skull fracture, which will tear middle meningeal vessels
Clinically = lucid interval for an hour, then deteriorates.
Lens shape on CT
Features of Parkinson’s disease?
Pill rolling tremor
What is synkinesis?
In parkinsons, tone will increase on distraction
Features of carpal tunnel syndrome?
Sensory loss over median distribution
Pain at night, relieve by hanging hand out of bed
Tinels tap test
Clinical signs of a cerebellar lesion?
Neurofibromatosis 1 features?
Autosomal dominant inheritance
Axillary and inguinal freckling
Optic glioma and brain tumours
Small risk of phaeochromocytoma
INO: where is the pathology?
Lesion to the medial longitudinal fasiculus, a collection of neuronal fibres which co-ordinates occulomotor, trochlear and abducens.
INO: what are the clinical features?
Dissociated eye movements
Impaired adduction ipsilaterally
And nystagmus in the contralateral eye on abduction.
I ADore NYC DUCks
INO: causes ?
Vascular brainstem lesions
Argyll Robertson clinical features?
Like a prostitute = accommodates but doesn’t react.
So small irregular pupils that do not constrict to bright light
Where’s the lesion of Argyll Robertson pupil.
Lesion in the pretectal region
What is Argyll Robertson a classic sign of?
Also diabetes and MS.
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
Is MS UMN or LMN?
What are the clinical features of Marcus Gunn pupil?
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.
Cause of Marcus Gunn pupil?