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MANCHESTER YEAR 3 > TCD Cases 1-12 > Flashcards

TCD Cases 1-12 Flashcards

1
Q

What are the causes of myocardial ishaemia? (HINT there’s 6)

A
  1. Coronary artery disease (main cause)
  2. Aortic stenosis
  3. Hypertrophic cardiomyopathy
  4. Cocaine use
  5. Anaemia
  6. Thyrotoxicosis
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2
Q

What are the non-ishaemic causes of cardiac chest pain? (hint there’s 2)

A

Aortic dissection and pericarditis

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3
Q

What are the 4 upper GI causes of chest pain?

A

GORD
Gallstones
Peptic ulcer
Pancreatitis

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4
Q

What are the 4 respiratory causes of chest pain?

A

Pulmonary embolism
Pneumothorax
Pneumonia
Pleurisy

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5
Q

What are the 2 musculoskeletal causes of chest pain?

A

chostochondritis

herpes zoster

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6
Q

What does it suggest if chest pain radiates to the left arm/both arms/jaw/neck?

A

ACS

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7
Q

What does it suggest if chest pain radiates to the right shoulder?

A

cholecystitis

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8
Q

What does it suggest if chest pain radiates to the intrascapular region/back?

A

Aortic dissection, GORD, pancreatitis, peptic ulcer, ACS

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9
Q

What does it suggest if chest pain radiates to the epigastrium?

A

Pancreatitis, peptic ulcer, gallstones, ACS

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10
Q

Define angina.

A

Discomfort in the chest and or adjacent areas (jaw, shoulder, back, arm) caused by MI. Most commonly due to CAD.

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11
Q

What are the 3 characteristics of typical angina?

A
  1. Constricting discomfort in front of chest, or neck, shoulders, jaw or arms
  2. Precipitated by physical exertion
  3. Relieved by rest/GTN within about 5 minutes
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12
Q

What is atypical angina?

A

Only meets 2 of the characteristics of typical angina

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13
Q

What are the risk factors for developing CAD? (HINT there’s 6)

A 
Age
Gender
Diabetes
Hyperlipidaemia
Smoking
Hypertension
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14
Q

What factors can provoke angina? (HINT theres 4)

A

Physical exertion
Emotional stress
Exposure to cold
Eating a heavy meal

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15
Q

What 3 interventions should NOT be offered to manage stable angina?

A
  1. transcutaneous electrical nerve stimulation
  2. enhanced external counterpulsation
  3. acupuncture.
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16
Q

Does a normal ECG exclude an acute coronary syndrome (ACS)?

A

no

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17
Q

What tests, after a normal ECG, are used to exclude ACS?

A

Cardiac troponin testing

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18
Q

What treatment is given for suspected ACS?

A

loading dose of aspirin 300mg

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19
Q

What are the various clinical presentations of ACS?

A
  1. Prolonged chest pain (>20 min) at rest
  2. New onset angina pectoris
  3. Worsening of existing angina
  4. Angina following myocardial infarction
  5. Atypical presentations are common over 75 years of age
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20
Q

What 3 reasons could result in a normal ECG in ACS?

A
  1. ischaemia in circumflex territory
  2. isolated RV ischaemia
  3. transient episodes of bundle branch block
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21
Q

What are the common ECG changes for CAD to be present? (hint there’s 3 points)

A
  1. Pathological Q waves indicate current/prev MI
  2. LBBB (broad QRS, deep S wave V1, no Q wave in v5/6)
  3. ST segment and T wave abnormalities (ST depression and T wave flattening/inversion)
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22
Q

What are the 6 types of non invasive imagine used in NSTEMI ACS?

A
  1. 12 lead ECG
  2. Transthoracic (TTE) echocardiography
  3. Stress echocardiography
  4. Cardiac Magnetic Resonance (CMR)
  5. Nuclear myocardial perfusion imaging
  6. CT coronary angiography
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23
Q

What do troponins reflect? What are the 2 gold standard troponins?

A

Reflect myocardial cellular damage

I and T are gold standard

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24
Q

What invasive imaging is used in ACS?

A

Coronary angiography

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25
What are the 3 categories of drug treatments for ACS?
1. anti-ischaemic = b blockers, nitrates, ca channel block, nicorandil, ivabradine, ranolazine 2. antiplatelet = aspirin, P2Y12 receptor inhibitors, clopidogrel, prasugrel, ticagrelor 3. anticoagulation = LMWH, fondiparinux, apixaban, rivaroxaban
26
Name 2 risk scoring systems commonly used in the management of acute coronary syndromes
1. ischaemic risk = GRACE score | 2. bleeding risk = CRUSADE score
27
What are the ECG criteria to diagnose a ST elevation MI?
1. LBBB | 2. at least 1mm elevation in leads II and III
28
What is an ejection systolic murmur, heard loudest in the aortic area, radiating to the carotids?
aortic stenosis
29
What is a mid-diastolic rumbling murmur, heard best with the bell of the stethoscope at the apex with the patient in the left lateral position?
Mitral stenosis
30
What is a pansystolic murmur, best heard at the apex of the heart, radiating to the axilla?
Mitral regurgitation
31
What is an early diastolic murmur heard best at the 4th ICS with the patient sat forward in expiration?
aortic regurgitation
32
Why is it important to get the flu vaccination when you have asthma?
Influenza (flu) can be more serious for people with asthma, even if their asthma is mild or their symptoms are well-controlled by medication. This is because people with asthma have swollen and sensitive airways, and influenza can cause further inflammation of the airways and lungs. Influenza infection in the lungs can trigger asthma attacks and a worsening of asthma symptoms. It also can lead to pneumonia and other acute respiratory diseases.
33
Define the peak expiratory flow rate (PEFR).
maximal rate that a person can exhale during a short maximal expiratory effort after a full inspiration.
34
What are the 3 important questions to ask in an asthma review?
1. in the last month/week have you had difficulty sleeping due to your asthma? 2. Have you had your usual asthma symptoms during the day? 3. Has your asthma interfered with your usual daily activities?
35
What conditions can a wheeze be heard in? (hint there's 6)
``` asthma COPD cardiac failure pulmonary disease foreign body aspiration eosinophilic lung disease ```
36
What are various triggers of asthma?
cold, pollen, exercise, dust, stress, cigarettes, pollution, anxiety, animals, alcohol, chest infections, flu
37
What parts of a clinical history support asthma as an appropriate diagnosis?
1. episodic symptoms 2. wheeze on auscultation 3. evidence of diurnal variability 4. atopic history 5. absence of symptoms, signs, clinical history to siggest an alternative diagnosis
38
What are the features of moderate acute asthma?
increasing symptoms PEF 50-75% of predicted no features of acute severe asthma
39
What are the features of acute severe asthma?
Any one of: 1. PEF 33-50% predicted 2. RR greater than 25 3. HR more than 110/min 4. Inability to complete sentences in one breath
40
What are the features of life-threatening asthma?
A pt with symptoms of severe plus any one of: 1. PEF less than 33% 2. SpO2 less than 92% 3. PaO2 less than 8kPa 4. Normal PaCO2 5. Silent chest 6. Cyanosis 7. Poor respiratory effort 8. Arrhythmia 9. exhaustion 10. Hypotension 11. Altered conscious level
41
What is involved in the initial assessment of asthma? (HINT 5 things)
``` Clinical features assessed PEV or FEV1 Pulse oximetry ABGs CXR ```
42
What treatments are involved in acute asthma?
B2 agonsts, steroids and oxygen initially | 2nd line = nebulised ipratropium bromide and consider IV magnesium sulphate
43
What are 2 common side effects of salbutamol?
Tachycardia and tremor
44
When should a follow up be arranged following a severe asthma exacerbation?
2 working days
45
When is jaundice clinically apparent?
when bilirubin concentration exceeds 50 micromoles per litre
46
How much bile is produced each day? When is it released from the gallbladder?
500 – 1000 ml/day. | Released in response to hormonal (CCK-PZ) and vagal response to food.
47
What is added to conjugate bilirubin? Making it water soluble
Glucoronic acid | - this process is controlled by the enzyme glucuronyl transferase
48
What type of hyperbilirubinaemia gives pale stools and dark urine?
conjugated aka obstructive or hepatocellular jaundice
49
What are the (i) common and (ii) uncommon causes of OBSTRUCTIVE jaundice?
(i) gallstones = biliary colic, cholecystitis/cholangitis carcinoma of the head of the pancreas (ii) sclerosing cholangitis, cholangiocarcinoma
50
What are the (i) common and (ii) uncommon causes of HEPATOCELLULAR jaundice?
(i) alcohol hepatitis or cirrhosis, viral hepatitis, drug induced eg paracetamol OD, NAFLD (ii) autoimmune liver disease, haemochromatosis, Wilson's disease
51
What type of pain is biliary colic? If it is associated with jaundice and fever what does it suggest?
RUQ pain | - indicates cholangitis aka sepsis in the biliary ducts
52
What type of pain arises in pancreatitis? What is is usually caused by?
severe epigastric pain, radiating to the back | - usually caused by alcohol excess or a stone blocking the CBD
53
What are the important LFTs and what are they indicative of?
1. clotting factors (INR and PT) 2. Albumin - monitors degree of liver damage 3. Liver enzymes = bilirubin, transaminases (ALT, AST), ALP note: if rise in ALT, AST is greater than rise in ALP then HEOATOCELLULAR but if rise in ALT, AST is less than the rise in ALP then OBSTRUCTIVE cause
54
What is delirium tremens?
Acute confusional state from immediate/abrupt alcohol withdrawal If left untreated, it can result in seizures, and even death
55
What is the treatment for acute alcohol withdrawal?
1. Benzodiazepine or carbamazepine - alternative = clomethiazole To treat delirium tremens use oral lorazepam (2nd line = parenteral lorazepam or haloperidol) *dont use phenytoin to treat alcohol withdrawal seizures* lastly, thiamine is used for suspected/at risk individuals for Wernicke's encephalopathy
56
What two things does cirrhosis typically consist of?
1. fibrosis of the liver | 2. nodule formation
57
What is fulimant hepatitis?
acute hepatitis with liver failure and encephalopathy within 28 days of jaundice - poor prognosis, often needs transplantation
58
What are the symptoms associated with the two areas cirrhosis damages (i) loss of function (ii) portal hypertension?
(i) jaundice, coagulopathy, decreased drug metabolism, decreased hormone metabolism and increased sepsis (ii) varices, piles, ascites, encepphalopathy, renal failure
59
What are the causes of cirrhosis?
hazardous alcohol, chronic hep B and C, autoimmune liver disease, haemachromatosis, Wilsons disease, chronic obstruction
60
What are the typical stigmata of cirrhosis?
palmar erythema, leuconychia, spider naevi, caput medusae
61
What are the two things bile consists of? Where are these two things derived from?
Bile pigments - from haemoglobin breakdown | Bile salts - from cholesterol
62
What are the causes of haemolytic jaundice?
Due to increased RBC breakdown: 1. RBC abnormality eg sickle cell disease 2. Incompatible blood transfusion 3. Drug reaction 4. Hypersplenism
63
What type of bilirubin is in abundance in haemolytic jaundice? Explain
Liver function is normal but glucuronyl transferase is saturated. The liver compensates by increasing conjugated bilirubin output, therefore, dark stools - the excess of unconjugated in plasma results in little to no colour in urine
64
What are the causes of hepatocellular jaundice?
- congenital "neonatal" jaundice - acquired (as a result of liver damage) = infection, cirrhosis 2o to alcohol, cirrhosis 2o to steatohepatitis, damage by toxins/drugs
65
Why can neonatal jaundice be fatal?
In babies, unconjugated bilirubin can penetrate the BBB. It is toxic to neural tissue and can cause short and long term neurological dysfunction
66
What are the common causes of obstructive jaundice?
1. obstruction of duct by stone 2. obstruction of duct by tumour 3. intra-hepatic cholestasis
67
What are the imaging techniques used to diagnose jaundice?
USS is first line - if duct dilatation then CT - if ducts normal on USS then must be pre-hep or hepatocellular
68
What are the 4 categories of causes of 'hepatitis'?
1. Hereditary = haemochromatosis, Wilson's 2. Drug induced = medications, paracetamol OD, alcohol 3. Infection 4. Autoimmune
69
What are the (i) infective (ii) lifestyle (iii) drug (iv) extrahepatic (v) autoimmune and (vi) hereditary causes of liver disease?
(i) INFECTIVE = EBV, CMV, Hep A, B or C (ii) LIFESTYLE = alcohol excess, obesity, diabetes mellitus (iii) DRUGS = methotrexate, flucloxacillin, anti-epileptics, rifampicin, paracetamol OD (iv) EXTRAHEPATIC = cancer of pancreas, gallstones (v) AUTOIMMUNE = PSC, PBC, autoimmune hepatiis (vi) HEREDITARY = haemchromatosis, Wilson's, alpha-1-antitrypsin deficiency
70
What are risk factors for poor pancreas health?(HINT there's 5)
1. alcohol consumption 2. high fat diet 3. overweight 4. tobacco products 5. Genetics (eg cystic fibrosis)
71
What pathological process happens in acute pancreatits? (HINT autodigestion). What do patients experience symptom wise?
The enzymes used to breakdown food are activated early and begin to digest pancreatic tissue V. painful, radiating to the back. Also experience nausea and vomiting
72
What are the causes of acute pancreatitis? What test(s) confirm its diagnosis?
CAUSES: 40% heavy alcohol use 40 % gallstones 20 % other = abdominal trauma, medications, infections, tumours, genetic/anatomical variants, high triglyceride or calcium levels Diagnosis by raised blood amylase and lipase, plus CT to confirm
73
What are the causes of chronic pancreatitis?
Common = lifestyle factors in predisposed patients aka long standing heavy alcohol use or long term heavy smoking Less common = medications, increased triglycerides, autoimmune conditions, inherited/genetic conditions (CF, hereditary pancreatitis)
74
What are the symptoms which result from chronic pancreatitis?
Affects nutrient absorption so can cause weak bones or vision loss - some patients have persistent pain and can struggle to gain or maintain weight - the pain in chronic is the same as acute - risk of developing diabetes
75
What are the symptoms of a migraine?
Paroxysmal headaches that are usually severe and unilateral (occassionally bilateral) - photophobia, vomiting, phonophobia, pulsating, visual disturbances (flickering lights, spots or zig zag lines, fortification spectra, blind spots), paraesthesia, unilateral numbness, hemiplegia
76
What medication is used to treat migraines? What can be used as prophylaxis?
Triptans (oral) used acutely | - prophylaxis = propranolol, or topiramate (2nd line)
77
What are the symptoms of a tension type headache?
bilateral/generalised mild-moderate headache - often described as pressing/tightening/band like/vice like pain - occur at/shortly after waking - multiple (more than 10) previous episodes
78
What is used to treat tension type headaches? What can be done as prophylaxis?
Analgesia - NSAID, aspirin, paracetamol | - 10 sessions of acupuncture over 5 to 8 weeks
79
What are the symptoms of a cluster headache?
Severe unilateral pain often starting in sleep and waking the patient - frequent recurrence in short periods followed by months of remission - ipsilateral lacrimation - rhinorrhoea/nasal blockage, often ipsilateral - ipsilateral conjunctival redness
80
How are cluster headaches treated?
Oxygen and/or subcutaneous or nasal triptan
81
What are the symptoms of a sub arachnoid haemorrhage?
sudden onset severe headache without any alteration in consciousness/neurological signs - vomiting/seizure/confusion/neck stiffness can be present but not commonly
82
What are the tell tale symptoms of meningitis?
photophobia, neck stiffness, fever, drowsiness
83
What are the symptoms of temporal arteritis (GCA)?
Temporal headache, myalgia, fever, maybe malaise | - jaw claudication, diplopia, scalp tenderness and occasionally blindness
84
What class of drugs are used to treat temporal arteritis?
corticosteroids - high dose as soon as possible
85
What are the symptoms of a sinus headache/sinusitis?
``` Nasal congestion/rhinitis Frontal/maxillary headache May have fever/flu symptoms Fullness/headache worse when bending forward May feel unsteady ```
86
What are the symptoms of a brain tumour?
Papilloedema, new seizure, cancer diagnosis (esp lung and breast), abnormal neurological signs, change in consciousness/confusion/lack of coordination
87
What are the symptoms of trigeminal neuralgia?
Sudden onset but severe stabbing pain lasting a few seconds to 2 minutes - often described as 'electric shock like' in one or more branches of the trigeminal nerve - triggered by vibration/skin contact/wind/oral intake/brushing teeth
88
What percentage of migraine sufferers experience aura?
20-30%
89
What are some triggers for migraines?
``` flickering lights on tv screen jet lag relaxing after stress cheese menstruation contraceptive pills ```
90
When are the 2 times that triptans are contraindicated?
A history of TIA or IHD
91
What can woman who suffer from menstrual migraines take?
Transdermal oestrogen patches
92
What is the criteria for considering prophylactic migraine treatment? (hint there's 4)
1. QoL/business duties/school attendance severely affected 2. 2 or more attacks a month 3. Attacks dont respond to acute drug treatment 4. Frequent, v.long or uncomfortable auras occur
93
What are the differential diagnoses for meningitis?
- encephalitis - no infectious causes (blood, trauma, drugs) of meningeal irritation - subdural empyema
94
What does a rapid onset of meningitis suggest?
that it is bacterial
95
What are some risk factors for developing meningitis? (HINT there's 4)
1. extremes of age 2. living in close proximity 3. vaccination history (absence of) 4. immunosuppression/deficiency
96
What investigations are performed in suspected meningitis?
1. CSF 2. blood culture 3. serology for viruses 4. throat swab (n. meningitides, strep. pneumoniae) 5. urine pneumococcal antigen
97
What are the 2 tests performed to diagnose encephalitis?
1. CT or MRI - oedema of temporal lobes | 2. EEG - characteristic slow waves
98
What is the treatment for meningitis?
If suspected bacterial = IV ceftriaxone (If GP setting use IM benzylpenicillin) - if listeria is suspected ADD ampicillin If h. influenzae or n. meningitis are the cause then household contacts offered antimicrobials (rifampicin) as prophylaxis
99
What does pronator drift suggest?
subtle pyramidal tract dysfunction
100
What are the presentations of brain cancer?
1. symptoms due to raised ICP - headache, vomit. blurred vision, decreasing conscious level - bradycardia. hypertension, papilloedema 2. symptoms of neurological deficit due to compression/damage 3. symptoms of cortical/meningeal irritation 4. hormonal effects 5. systemic effects/generally unwell
101
What is the typical presentation in a frontal lobe lesion?
weakness dysphagia personality changes dementia
102
What is the typical presentation in a parietal lobe lesion?
sensory symptoms dressing ataxia visual field
103
What is the typical presentation in a temporal lobe lesion?
dysphagia | visual field defects
104
What is the typical presentation in a occipital lobe lesion?
visual fields
105
What is the typical presentation in a posterior fossa lesion?
``` dysmetria in-coordination gait ataxia cranial nerve palsies tremors nystagmus ```
106
What is the most common primary brain tumour?
glioblastoma multiforme (GBM)
107
What is the most common benign brain tumour?
meningioma
108
Describe a vestibular schwannoma.
Benign lesion usually affects 5th, 7th or lower cranial nerves - ipsilateral hearing problems and tinnitus
109
What is normal ICP? When is it pathological? What can happen when standing?
less than 15 mmHg pathological when greater than 20 mmHg It can be negative when standing
110
What are the symptoms of raised ICP?
- nausea and vomiting - headache - visual problems - decreasing consciousness - respiratory depression - HT and bradycardia
111
How do you manage a sustained acute rise in ICP? (there's 6 steps)
1. heavy sedation and paralysis 2. CSF drainage 3. osmotic therapy (mannitol) 4. hyperventilation 5. barbituate therapy 6. decompressive craniotomy
112
What are the general signs of an extradural haematoma?
Usually bleed of middle meningeal artery - pt regains consciousness after brief loss at time of injury - conscious level then slowly starts to decline. The initial 'lucid interval' can cause delayed/missed diagnoses
113
What are the general signs of a subdural haematoma?
Venous in origin, elderly and alcoholics at increased risk - develops v slowly so latent period can be weeks to months - headache, drowsy and confused at later stages - fluctuating conscious levels are common
114
What is an important side effect of sumatriptan?
can cause drowsiness
115
Name the 1 anabolic and 4 catabolic hormones.
``` catabolic = insulin anabolic = glucagon, catecholamine, cortisol, growth hormone ```
116
Not all hyperglycaemia is diabetes, what is the definition of diabetes mellitus?
the level of hyperglycaemia sufficient to cause diabetic microvascular complications (retina, kidney, nerve)
117
What do lesser degrees of hyperglycaemia cause a risk of?
Increased chance of developing into T2DM - increased risk of macrovascular disease - in pregnancy it causes gestational diabetes
118
What HbA1c levels indicate (i) diabetes (ii) non-diabetic hyperglycaemia?
(i) more than 48mmol/mol | (ii) 42-47 mmol/mol
119
What ethnicities are more at risk of developing T2DM?
Black africans and carribeans are 3x more likely | - south asians are 6x more likely
120
What drugs are used to treat T2DM?
1st line = metformin (biguanide) 2nd line = add one of - sulfonylurea (glicazide, glipizide, glibenclamide) - DPP-4 inhibitor (sitagliptin, vildagliptin, linagliptin, alogliptin) - SGL2 antags (dapagliflozin, canagliflozin, empagliflozin) 3rd line = triple therapy with combos of above + pioglitazone 4th line = GLP1 agonists (incretins = exenatide, liraglutide) with metformin + sulfonylurea
121
What is the salvage therapy used for diabetic eye disease?
vitrectomy
122
What are the complications of diabetes in pregnancy?
1st trimester = congenital anomalies | 2nd and 3rd trimester = accelerated growth (IUGR)
123
What is diabetic cheiroarthropathy?
thickened skin and limited joint mobility of the hands and fingers leading to finger contractures
124
What is the association between depression and diabetes?
Depression is increased 2-3x risk for people with diabetes
125
What are the clinical features of DKA?
- hyperventilation - vomiting - dehydration - hypotension with warm peripheries - decreased conscious level (CV shock)
126
With DKA/HHS, what 5 steps are used to treat urgently?
1. Hypovolaemic shock = FLUID RESTRICTION 2. Aspiration Pneumonitis = AIRWAY PROTECTION IF COMATOSE (GCS less than 9) 3. Cerebral Oedema (F) = CAREFUL IV FLUIDS 4. Fatal arrhythmia = MONITOR/REPLACE K+ 5. Pulmonary embolism = PROPHYLACTIC LMWH
127
What are the symptoms of severe hypoglycaemia?
1. Adrenergic symptoms = sweating, trembling, hunger | 2. Neuroglycopenia = paraesthesiae, blurred vision, confusion
128
When is severe hypoglycaemia more likely?
- alcohol excess - v young or v old - long duration DM - recent severe hypo - pregnant - autonomic neuropathy - renal/hepatic impairment
129
What is a side effect of irbesartan (angiotensin 2 receptor antagonist)?
Hyperkalaemia
130
If APTT corrects when mixed with plasma, what does this mean?
The individual has a coagulation factor deficiency
131
What clotting factors affect APTT?
Factors VIII, IX, XI, XII and Von willebrand factor
132
What type of deficiency is (i) haemophilia A (ii) haemophilia B?
(i) Factor VIII deficiency | (ii) Factor IX deficiency
133
What factors make up the (i) extrinsic (ii) intrinsic coagulation pathway?
(i) VII | (ii) XI and XII
134
What are causes of a prolonged prothrombin time (PT)?
warfarin | factor II, V, VII (most common) and X
135
What are causes of a prolonged APTT?
heparin | Factor VIII, IX, XI, XII and von willebrands disease
136
What should you think of if both APTT and PT are prolonged?
``` with low fibrinogen: - vit K deficiency - DIC With normal fibrinogen: - heparin toxicity - rarely; factor V or X deficiencies ```
137
What is the diagnostic triad of bleeding disorders?
1. personal history of bleeding 2. family history of bleeding 3. supportive lab tests = platelets (FBC, PFA), tests of coagulation (PT, APTT, TT, Clauss, 50/50 mix), tests of clot stability (euglobin clot lysis, factor XIII assay, PAI-D)
138
What is the 50/50 tests? What does it distinguish?
If a patient had a prolonged APTT or PT, redo the test with a 50/50 mix of normal plasma - if it CORRECTS = factor deficiency - if it FAILS to correct = factor inhibitor
139
How is haemophilia A treated?
Factor VIII (half life is 8hrs so taken 1-3x daily) OR Desmopressin (DDAVP) which releases stored factor VIII
140
How is haemophilia B treated?
Factor IX (half life 18-24hrs so taken 1x daily)
141
How do you treat mixed haemophilia A and B?
Tranexamic acid (an anti-fibrinolytic)
142
What are the 3 types of Von Willebrand's disease?
TYPE 1 = decreased amount of normal vW protein TYPE 2 = abnormal vW protein TYPE 3 = little or no vW protein
143
How is Von Willebrands tested for? How are type 1 and type 2 differentiated?
Tested for by Factor VIII, vW antigen and vW activity | - if the ratio of vWF activity: vWF antigen is MORE than 0.6 it is type 1 and if it is LESS than 0.6 it is type 2
144
What is used to treat the 3 types of Von Willebrand's disease?
``` 1 = DDAVP + tranexamic acid 2 = vWF concentrate (avoid DDAVP in 2b) 3 = vW factor ```
145
How is venous thromboembolism prevented?
- anti embolism stockings or intermittent pneumatic compression sleeves - LMWH (SC), low dose UFH (IV), direct anti-xa and anti-thrombin drugs (oral) (DOACs)
146
How are venous thromboembolisms managed?
Wells score Don't investigate first (1hr for PE, 4hr for DVT) Use heparin (LMWH) Start oral warfarin (takes 48-72 hrs to take effect, then discontinue heparin)
147
What is homan's sign?
A tender calf which is worse with ankle dorsiflexion
148
What do you do in a suspected VTE if the wells score is low?
D-dimer | - if positive then further imaging is required; doppler of leg or CTPA
149
What is a massive PE? How does it present and how is it treated?
Large clot lodges in R side of heart or in both pulmonary arteries (saddle embolus) - presents with syncope and other PE symptoms - presence of arterial hypotension or cardiogenic shock/cardiac arrest - medical emergency that requires urgent thrombolysis
150
When are anti-embolus stockings contraindicated?
In pts with intermitted claudication | - they can exacerbate pre existing PAD
151
What electrolyte levels should be closely monitored when patients are on LMWH (enoxaparin) for more than 7 days?
Potassium levels | - pts with diabetes, chronic renal impairment and on meds that can increase K are at risk of hyperkalaemia
152
What are the 3 most common causes of hyperthyroidism?
1. Grave's disease (autoimmune) 2 Toxic multinodular goitre 3. solitary toxic adenoma - another cause is drugs (interferon + amiodarone)
153
What are some of the symptoms of hyperthyroid (thyroroxicosis)
Increased pulse and BP, risk of AF - warm, moist hands - exophthalmos, lid lag, goitre - agitation, tremor, oncholysis, acropachy - conjunctival oedema, opthalmoplegia, pretibial myxoedema - prox myopathy, hyperreflexia, frequent bowel actions
154
What are the risks associated with thyroid eye disease?
- intraocular pressure - optic nerve damage exposure - corneal ulceration
155
What are the treatments used in thyroid eye disease?
- steroids - immunosuppression - surgical decompression - radiotherapy
156
What are the treatment options for thyrotoxicosis?
1. Beta adrenergic blockers 2. Antithyroid drugs = Carbimaxole, Propylthiouracil - usually pts receive carbimazole or propylthiouracil for 6-24 months 3. Radioactive iodine (cancer risk) 4. Surgery (sub-total/near-total thyroidectomy) - complications = parathyroid damage, vocal cord paralysis, bleeding, keloid scars
157
What are the side effects of antithyroid drugs?
Most important (severe) are agranulocytosis or leucopenia - rash, itching, arthralgia - nausea and vomiting
158
What symptoms are only found in Graves disease?
- opthalmoplegia - exopthalmos - pretibial myxoedema - thyroid acropachy
159
What is neonatal hyperthyroidism?
Thyroid stimulating antibodies (in Graves) can cross the placenta and stimulate the thyroid gland of the foetus
160
When is RAI-131 contraindicated?
In pregnancy or women who are breastfeeding
161
What is the most common cause of hypothyroidism in the UK? Who does it tend to affect?
Hashimotos (chronic autoimmune thyroiditis) | - Women over 40
162
What is secondary hypothyroidism?
Due to TSH deficiency due to pituitary or hypothalamic disease - TFTs show low T4 and low TSH
163
What are the features of hypothyroidism?
- weight gain, lethargy, cold intolerance - cool dry skin, dry brittle hair, nail changes - constipation, heavy periods, muscle cramps
164
How is hypothyroid treated?
Thyroxine (t4) | usually 100-125 micrograms a day
165
What are the side effects of over-replacement of thyroxine?
AF and osteoporosis
166
What are the 6 red flags for thyroid malignancy? What investigations are performed?
1. growing mass 2. dysphagia 3. neck pain 4. hoarseness 5. Hx of neck radiation 6. FHx of thyroid cancer - USS followed by FNA of lump
167
What are the types of thyroid malignancy? How are they treated?
``` Papillary carcinoma (70%) Follicular carcinoma (20%) - anaplastic carcinoma, lymphoma, medullary cell carcinoma treatment = surgery - post op RAI treatment - thyroid hormone suppression ```
168
Describe medullary cell carcinoma.
Can be inherited | - associated with phaeochromocytoma (adrenal tumour) and hyperparathyroidism
169
What is Sheehan's syndrome?
Affects woman who lose a life-threatening amount of blood in childbirth OR who have a severe low BP during or after childbirth, depriving the body of O2 this can damage the pituitary gland - causing hypopituitarism, and in turn secondary hypothyroidism
170
What is the pathological process that leads to Type II respiratory failure in COPD? What physiological compensatory mechanisms occur in the body to reduce the level of acidaemia?
In COPD the elastic recoil of the lungs is lost. This causes gas trapping and reduced excretion of CO2. In the blood, the CO2 combines with water to form carbonic acid. In an acute setting, the increased acid levels in the blood would lower the pH levels and the patient would become unwell very quickly. However when CO2 retention is progressive, as is often the case in chronic COPD, the body can compensate for this by utilising the bicarbonate buffer system of the blood. The kidneys are stimulated to reabsorb more bicarbonate, which acts as a base and neutralises the carbonic acid, thus restoring the pH back to the normal range.
171
How is hypertension diagnosed?
Readings from both arms must be taken and there must be less than a 20 mmHg difference in each arm Clinic BP is 140/90 or higher than take a second measurement, if substantially different then take a third. Record the lower of the last 2 measurements as clinic BP - offer ABPM to confirm diagnosis, if patient cannot tolerate this, HBPM is a suitable alternative to confirm diagnosis
172
How is ambulatory blood pressure monitoring performed? How is home BP monitoring performed?
``` ABPM = 2 measurements per hour taken during persons normal waking hours. Use ave value of at least 14 measurements to confirm HT diagnosis HBPM = for each reading, 2 consecutive readings are taken, at least 1 min apart, with the person seated. Recording done twice daily (morning + evening), do for a min of 4 days, ideally 7. Discard day 1 measurements and take an average of the rest ```
173
What are the stages of hypertension?
``` STAGE 1 (mild) = systolic 140-159 diastolic 90-99 STAGE 2 (moderate) = systolic 160-179 diastolic 100-109 STAGE 3 (severe) = systolic greater than 180, diastolic greater than 110 ```
174
What scoring system is used to assess CVD risk in HT?
QRISK score
175
What are the 3 things involved in the short term control of blood pressure?
1. CNS response 2. Baroreceptors 3. Chemoreceptors
176
What are the clinical uses of (i) adrenaline (ii) noradrenaline?
(i) anaphylactic shock, cardiogenic shock and cardiac arrest | (ii) severe hypotension and septic shock
177
What are the clinical uses of (i) dopamine (ii) dobutamine?
(i) acute HF and cardiogenic shock | (ii) acute HF, cardiogenic shock, refractory HF
178
How is BP controlled long term?
1. Renin angiotensin aldosterone system | 2. Vascular remodelling and contractility
179
What does primary hyperaldosteronism cause? What 2 things can cause it? What do patients present with?
Causes raised BP 1. Unilateral aldosterone producing adenoma aka Conns syndrome (50-60%) 2. Bilateral adrenal hyperplasia (40-50%) - pts present with: hypokalaemia, muscle weakness, cramping, palpitations
180
What do people with Addison's disease present with?
- lethargy, weight loss, fainting, hyperpigmented skin creases, postural hypotension, dehydrated - hyponatraemic, hyperkalaemic and acidotic
181
What are the investigations and treatment in Addison's disease?
``` Investigations = short synACTHen test treatment = replace glucocorticoid, mineralocorticoid and sex steroid production ```
182
What are the organ damages that hypertension can cause?
``` EYES = hypertensive retinopathy BRAIN = hypertensive cerebrovascular disease HEART = IHD with or without HF, LVH KIDNEYS = hypertensive nephropathy ```
183
List diseases/conditions/drugs that can cause secondary hypertension.
- renovascular disease - primary renal disease - oral contraceptives, NSAIDs, stimulants (caffiene + methylphenidate), calcineurin inhibitors, antidepressants - phaeochromocytoma - primary aldosteronism - cushing's syndrome - sleep apnea syndrome - coarctation of the aorta - hypothyroid and primary hyperparathyroidism
184
What is the treatment strategy for patients with hypertension and UNDER 55?
1st line = ACEI or ARB if ACEI not tolerated - then add calcium channel blocker - if still hypertensive add thiazide type diuretic eg indapamide, chlortalidone - then add further diuretics or alpha blocker or beta blocker
185
What is the treatment strategy for patients with hypertension and OVER 55 or African/Caribbean?
Start with calcium channel blocker - then add ACEI or ARB - followed by C+A+D - then add further diuretics or alpha blocker or beta blocker
186
What are the healthy lifestyle interventions recommended to reduce BP?
``` healthy diet decrease salt intake decrease coffee intake quit smoking decrease alcohol intake regular exercise relaxation therapies (not available on NHS) ```
187
What is the most important//main side effect for the following drugs; (i) ACEI (ii) beta blockers (iii) ca channel blocker (iv) thiazide diuretics (v) loop diuretics (vi) aldosterone antagonists?
(i) tickly cough (ii) bradycardia (iii) ankle oedema (iv) hyponatraemia + increased K (v) gout attack (vi) hyperkalaemia
188
What drugs can be used in pregnancy to treat HT?
labetolol, nifedipine, methyldopa
189
What are the symptoms which differentiate between right and left heart failure?
``` Right = ankle oedema, hepatomegaly and elevated JVP Left = bibasal crepitations ```
190
What are the 4 gradings of murmurs?
1. only heard on listening for some time 2. faint murmur heard immediately on auscultation 3. loud murmur with no palpable thrill 4. loud murmur with a palpable thrill
191
What are the 4 New York Heart association levels for staging heart failure?
``` 1 = no symptoms and no limitations in ordinary physical activity 2 = mild symptoms and slight limitation during ordinary activity 3 = marked limitation in activity due to symptoms, even during less than ordinary activity 4 = severe limitations, symptoms at rest ```
192
What are the investigations involved in diagnosing heart failure?
- bloods: FBC, haematinics, U+E, TFT, Glucose - brain natriuretic peptide (BNP): normal levels rule out HF, high levels = worse outcomes - CXR - Echocardiography: info relating to EF of LV (normal = 60%, abnormal less than 45%) - ECG
193
How is HF treated with (i) preserved LV function (EF greater than 45%) and (ii) impaired systolic function (EF less than 45%)?
(i) diuretics followed by treatment of comorbidities eg HTN, DM (ii) DIuretics ACEI and b blockers first line - aldosterone receptor antags (elperenone + spironolactone) used in severe LV dysfunciton (NYHA II, EF less than 35%) - devices (CRT/ICD)
194
What can cause (i) increased (ii) decreased contractility?
(i) catecholamines and calcium | ii) acidosis and some negatively inotropic drugs (anaesthetic agents
195
What are the 2 most common causes of heart failure in the UK?
CHD and hypertension
196
What are the 4 causes of mitral regurgitation?
1. Rheumatic heart disease 2. IHD 3. Valvular vegetations (endocarditis) 4. Physiological MR due to dilated LA
197
When should you not cardiovert someone? Why is this the case?
Who has been in AF for more than 48 hours unless it is going to be lifesaving as the risk of clots increases after 48 hrs, therefore if normal sinus rhythm is restored by cardioversion clots could dislodge and cause an embolic stroke
198
What criteria is used for diagnosis of infective endocarditis?
Modified Duke Criteria
199
What does adrenaline do to the frank starling curve
pushes it to the left
200
What scoring system is used for AF stroke risk? What does it comprise of?
``` CHADS-2 CHF history HT history Age more than 75 DM history Stroke or TIA history (2 points) ``` Moderate risk = 1-2 high risk = greater than 3
201
Name examples of loop diuretics? (there's 4)
Bumetanide Furosemide Tosemide Ethacrynic acid
202
What kind of drug is rivaroxaban?
A direct factor Xa inhibitor
203
What are the 3 hallmark COPD symptoms?
SoB chronic cough sputum production
204
What is COPD characterised by?
Airflow obstruction that's usually progressive, NOT fully reversible and doesn't change markedly over several months - it is predominantly caused by smoking
205
What are the 3 pathological changes which occur in COPD? What symptoms do these give?
1. Goblet cell hyperplasia = cough and sputum 2. Airway narrowing = breathless and wheeze 3. Alveolar destruction = breathlessness
206
What are the symptoms of COPD?
Smoker/ex-smoker over 35 - exertional breathlessness - chronic cough - regular sputum production - winter exacerbations - wheeze
207
What are the physical signs of COPD?
tar-staining, central cyanosis, tachypnoea, chest hyperexpansion (barrel shaped), reduced lateral and increased vertical chest expansion, paradoxical lower chest motion, decreased breath sounds, wheeze, palpable liver edge
208
How are airflow obstruction and restriction differentiated?
``` Obstruction = FEV1/FVC less than 0.7 Restriction = FEV1/FVC greater than 0.7 ```
209
What are the 4 GOLD stages of COPD severity?
``` STAGE 1 (mild) = FEV1 greater than 80% predicted STAGE 2 (moderate) = FEV1 50-79% predicted STAGE 3 (severe) = FEV1 30-49% predicted STAGE 4 (v. severe) = FEV1 less than or equal to 30% predicted ```
210
What are the differences in type 1 and type 2 respiratory failure?
Type 1 = PaO2 is low but CO2 and HCO3 are normal | Type 2 = PaO2 is low but PaCO2 and HCO3 are raised
211
What is cor pulmonale?
Hypoxia - pulmonary arterial vasocontsriction - increased pulmonary arterial pressure - RV hypertrophy - causing RVF
212
What is the treatment for COPD?
1. Stop smoking advice/help 2. SABA 3. if still breathless add LABA/antimuscarinic 4. If FEV1/FVC less than 50% or frequent exacerbations, add ICS 5. If still breathless add antimuscarinic/LABA 6. If still breathless consider pulmonary rehab, increased dose bronchodilators, theophylline
213
What are the complications which can occur in COPD?
- pneumonia - pneumothorax - RVF - peripheral neuropathy - cachexia - exacerbations
214
What are the side effects of B2 agonists?
- tachycardia - arrhythmias - MI - tremor - paradoxical bronchospasm - hypokalaemia
215
What are the signs and symptoms of hypercapnia?
dilated pupils, bounding pulse, hand flap, myoclonus, confusion, drowsy, coma
216
What are the signs on a CXR of pts with COPD?
- flattened diaphragm - smaller heart size - hyperinflated lung - horizontal ribs
217
What is evident on an ECG to suggest p-pulmonale?
Peaked P waves (more than 2.5mm in lead II) | RA enlargement
218
What is target oxygen saturations in patients with COPD?
88 to 92%
219
What are the 5 most common infective causes of COPD exacerbations?
1. Strep pneumoniae 2. Viruses 3. Moraxella catarrhalis 4. H. influenzae 5. Pseudomonas aeruginosa
220
When is long term O2 therapy indicated in COPD patients?
With a PaO2 less than 7.3 kPa on air
221
What are the general signs of anaemia?
- fatigue - weakness - pale/yellowish skin - irregular heartbeats - SOB - dizzy/light-headed - chest pain - cold hands + feet - headache
222
What type of anaemia does acute blood loss cause?
Normocytic normochromic | - note that initially the Hb concentration does not alter
223
List examples of hypochromic microcytic anaemias.
1. iron deficiency anaemia: inadequate diet, malabsorption (coeliac), blood loss GI tract (NSAIDs) 2. Thalassaemia: beta major and minor, alpha thalassaemia (3 deletions = Hb H, 4 deletion = Bart hydrops fetalis)
224
How is iron deficiency anaemia diagnosed? What are problems faced with measuring ferritin? What alternatives is there?
- low Hb, MCH and MCV - ferritin = acute phase reactant protein and so can be falsely high in infections and patients with long term inflammatory conditions (rheumatoid disorders, severe skin diseases) - other ways to measure iron = serum iron, transferrin saturation, zinc protoporphyrin - gold standard = give iron and watch for effect
225
What are specific iron deficiency signs and symptoms?
- headache (especially on activity) - craving to eat non food items (called 'pica') - sore or smooth tongue - brittle nails or hair loss - spoon shaped nails (koilonychia)
226
What are the types of macrocytic anaemias?
folate and B12 deficiencies
227
Name some acquired B12 deficiencies.
1. Nutritional = vegan, poor diet, pregnancy 2. Malabsorption = gastric (surgery, pernicious anaemia), intestine (ileal resection, fish tapeworm) note you get malabsorption of B12 (not deficiency) in Crohns, coeliac, CF
228
Name some acquired folate deficiencies.
1. Nutritional = poor diet, goats milk 2. Intestinal = coeliac, jejunal resection 3. Excessive requirement = pregnancy, prematurity 4. Increased turnover = chronic haemolysis, severe skin disease 5. Drugs = methotrexate, anticonvulsants 6. Excess loss = dialysis 7. Miscellaneous = alcohol (though beer is a good source of folate)
229
What are the signs and symptoms specific to (i) B12 and (ii) folate deficiencies?
(i) insidious onset, mild jaundice and anaemia, glossitis, angular chelitis, neuropathy (peripheral, SADC, optic, dementia) (ii) as for B12 but more often a sensory peripheral neuropathy only - deficiency in pre conception is associated with an increased incidence of neural tube defects in babies
230
Describe hereditary spherocytosis. What symptoms does it cause? How is it diagnosed and how is it treated?
Inherited abnormality of red cell membrane proteins. Autosomal dominant - neonatal jaundice, chronic haemolysis, jaundice, gallstones - diagnosed by FHx, FBC, reticulocyte count, blood film. And if still uncertain do EMA-binding test - treat by giving folic acid regularly, often pts require a splenectomy
231
What is Glucose-6-Phosphate deficiency? What symptoms occur? What do pts have to avoid?
X-linked. Pts feel well between attacks. Usually a FHX or a Hx of neonatal jaundice - sudden onset of feeling unwell and lacking energy, becoming pale and yellow, having backache, passing dark coloured urine - AVOID beans (broad and fava), a number of drugs and moth balls
232
What is sickle cell disease? How is it managed? What complications can occur?
Autoinfarction of the spleen with increased infection risk - management = keep warm and hydrated, keep regular hours, eat well, take penicillin and folic acid - long term management = hydroxyurea and stem cell transplant - complications include stroke, increased risk of infection, acute chest syndrome and pulmonary hypertension
233
What is beta thalassaemia MAJOR? How is it managed?
Inherit 2 abnormal beta genes. Severe anaemia from 4-6 months of age - management = long term transfusions and iron chelation (desferrioxamine or desferasirox) or stem cell transplantation
234
What is autoimmune haemolytic anaemia? What are the two types and causes of each?
2 types: warm and cold - DAT is +ve in warm and for complement in cold WARM: idiopathic - 2ndary causes = rheumatoid disease (SLE), lymphoma, chronic lymphatic leukaemia, drugs eg cephalosporins, ovarian teratoma COLD: idiopathic - 2ndary causes = EBV infections, mycoplasma pneumonia, ulcerative colitis
235
What is the main cause of death in beta thalassaemia major?
cardiac iron overload
236
What are the components of the CURB-65 score?
``` Confusion Urea greater than 7mmol/l RR 30 breaths/min or more BP systolic less than 90 mmHg or diastolic less than 60 mmHg Aged 65 or older ``` ``` 0-1 = low severity 2= moderate 3-5 = high severity ```
237
What are the types of URTI?
- common cold 'coryza' - sinusitis - pharyngitis - laryngitis ALL are mainly viral
238
What are types of LRTI?
acute bronchitis - mainly viral - pneumonia - exacerbations of COPD - exacerbations of bronchiectasis - lung abscess - empyema
239
What are the 4 main subcategories of pneumonia?
1. Community acquired = gram +ve, mycoplasma, influenza 2. Nosocomial (hospital acquired) = gram -ve bacteria, MRSA 3. The immunosuppressed (organ transplant, chemo, risk for HIV) = unusual organisms, commensals, fungi 4. Aspiration (swallowing problems, reduced consciousness) = chemical pneumonitis, anaerobic bacteria
240
What are the common symptoms and signs of pneumonia?
Cough, fever, rigors, anorexia, chest pain (pleuritic, sudden onset), dyspnoea, abdominal pain - the elderly suffer from mental dysfunction, falls and incontinence - dull to percuss, bronchial breathing, whispering pectoriloquy, aegophany, mental confusion
241
What investigations are performed in suspected CAP?
1. Gas exchange = SaO2, ABGs 2. Fluid balance = U+Es 3. Diagnosis = WCC, CRP, CXR 4. Cause = sputum gram stain (culture, sensitivity), blood culture, urine pneumococcal and legionella antigen
242
What treatment is given for CAP?
1. Place of care 2. Oxygen 3. Fluids 4. Antibiotics - low severity = amoxicillin oral - moderate = amoxicillin + clarithromycin oral - severe = co-amoxyclav + clarithromycin IV
243
What are the complications associated with pneumonia?
- simple para-pneumonic effusion - empyema - metastatic infection (joint, brain) - pulmonary VTE - antibiotic side effects
244
How is pneumonia prevented?
- smoking cessation - adult vaccination for influenza and pneumococcal - child vaccination
245
What symptoms are common in legionella or mycoplasma?
Myalgia and arthralgia
246
What is bacterial pneumonia characterised by?
Acute inflammation of the lung parenchyma
247
What are (i) typical (ii) atypical causes of CAP?
(i) Strep. pneumoniae (80%, +ve) H. influenzae (-ve) Klebsiella pneumoniae (-ve) Staph. aureus (+ve) (ii) Mycoplasma pneumoniae (treat w macrolides) Legionella pneumophilia (macrolides) Chlamydia pneumoniae (macrolides, doxycycline) Chlamydia psittaci (macrolides, doxycycline) - common in contact w birds
248
What are the (i) viral (ii) fungal causes of pneumonia?
(i) most common = influenza A+B - adenovirus, para-influenza and RSV - all diagnosed via PCR (ii) Pneumocystitis jiroveci = most common type in UK - common in immunocompromised including HIV, suppression, or those with COPD, CF
249
What is hospital acquired pneumonia classified into? What are bacterial causes?
Onset occurs 48 hrs after admission - can have early (less than 5 days) or late (more than 5 days) onset - bacterial causes of late onset = E,coli, staph. aureus, pseudomonas sp, enterococcus sp
250
Why is aspiration most likely in the right lower lobe?
As the right main bronchus is straighter than the left, and ends in the right lower lobe
251
Who are high risk populations for TB? (there's 3)
- homeless - prisoners - drug users it is a disease of low income countries
252
What are the symptoms of TB?
``` General = weight loss, night sweats, fever Lung = cough +/- sputum, haemoptysis Lymph = node enlargement Pleura = pleuritic pain Bone = bone pain ```
253
What investigations are performed in suspected TB?
- CXR - ESR/CRP - HIV testing - LFT - sample for microbiology = sputum smear and culture
254
What will the CXR of a TB post primary disease pt show?
- upper lobe consolidation - apical segment lower lobe - cavitation - volume loss - lymphadenopathy - pleural effusion - pneumothorax
255
What treatments are given in TB? In the initial phase and continuation phase.
Initial phase (2 months) = isoniazid, rifampicin, pyrazinamide, ethambutol Continuation phase (4 months) = rifampicin, isoniazid
256
How long after pneumonia should patients start to feel well again?
AFTER: - 1 week = fever resolved - 4 weeks = chest pain + sputum reduced - 6 weeks = cough + breathlessness reduced - 3 months = fatigue still present - 6 months = most feel back to normal

MANCHESTER YEAR 3 (11 decks)

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