Flashcards
Cardio, resp, derm
Cards in this deck (112)
- 1Dual platelets to use following and MITicagrelor OR Prasugrel
And aspirin - 2NYHA classification of heart failure1 - asymptomatic
2 - shopping around ASDA
3 - put bin out
4 - symptoms at rest, get out of bed and sit in chair - 3Causes of raised BNPHeart failure
AF or increased HR
LVH
Age >70
COPD
CKD - not excreting it - 4MI drugsDual anti platelet
Fondaparinux
beta blocker
statin
Acei - 5CHADSVASC 2 score for?risk of stroke in AF
- 6Lipid risk scores, Qrisk 2 and JBS210 year risk percentage of cardiovascular event
At 10% you can offer treatment
Statin or ezetimibe
primary prevention atorvastatin 20mg and secondary prevention - atrovastatin 80mg
Also offer statin in type 1 diabetes if:
-are older than 40 years or
-have had diabetes for more than 10 years or
-have established nephropathy or
-have other CVD risk factors.
Offer it in those with CKD for primary and secondary prevention. - 7HAS-BlEDestimates major bleeding when on anti-coagulation for AF
- 8Broad complex regular tachycardia is whatVT until proven otherwise
Could also be AF with aberrant conduction or LBBB - 9Causes of narrow complex regular tachycardiaSinus tachycardia, AV nodal tachycardia, atrial flutter, atrial tachycardia, AV re-entrant tachycardia - in WPW
- 10Narrow complex irregular tachycardiaAF
AF with variable block
Multifocal atrial tachycardia - 11Wide complex irregular tachycardiaAny irregular supra ventricular tachycardia with aberrant conduction
Any irregular super ventricular tachycardia with pre-existing bundle branch block
AF with WPW syndrome
polymorphic ventricular tachycardia - 12What would the p wave look like in lead II in a junctional rhythmInverted
- 13How to diagnose right ventricular hypertrophy on ECGDominant R wave in V1, R axis deviation, P pulmonale + normal width QRS, deep S wave in V6, severe cases T wave inversion
- 14Intermittent RBBB, why?called aberration
Mechanism is that RBB and LBB have different refractory periods, LBB is shorter so at certain rates there is an RBBB an some impulses only transmitted through LBB - 15Leads to look for LVH strainSagging QT in V5 and V6
- 16What happens in AVNRT and features of itDepolarisation of ventricles but goes back up the node to depolarise the atria and works in a reentry way to propogate
80% cannot see a p wave
20% might see a QRS right after
Can see Inverted p waves right after QRS - 17What happens in an escape rhythmT wave then pause a no SA node depolarisation. Then something else takes over after the pause and then resumes as normal
- 18What is it called when the heart is controlled by a ventricular rhythm which is faster than in heart blockaccelerated idioventricular rhythm
often associated with acute MI, appearance similar to VT but actually benign and should not be treated
Do not diagnose VT unless HR >120 - 19Difference between extrasystole and an escape beatExtrasystole comes early
Escape beat comes late - 20Compensatory pause in what?extrasystoles
- 21Out of atrial flutter, AVNRT and AVRT, which is the most commonAVNRT
- 22What is sick sinus syndromeA disease characterised by abnormal sinus node functioning with resultant bradycardia and cardiac insufficiency
Variable ECG abnormalities:
Sinus Bradycardia.
Sinus Arrhythmia — associated with sinus node dysfunction in the elderly in the absence of respiratory pattern association.
Sinoatrial Exit Block.
Sinus Arrest — pause > 3 seconds.
Atrial fibrillation with slow ventricular response.
Bradycardia – tachycardia syndrome - 23Causes of clockwise rotationRight ventricular hypertrophy
Lead placement - 24When is a T wave tallWhen it is more than 2/3rds of the R
- 25Things that can happen at a rapid access chest pain clinic based on coronary riskBlood tests and chest X-ray
An Exercise ECG test which involves walking on a treadmill at increasing speed while your pulse, blood pressure and heart trace are monitored by a cardiac technician. In case you need this test please wear loose clothing, with an easily removable top and trainers or flat shoes - no high heels or sling back shoes
CT calcium scoring ( a very short CT scan (X-ray)
CT coronary angiogram (an outpatient X- ray of the arteries of the heart)
Echocardiogram (an ultrasound of the heart)
Stress echocardiogram (a specialised heart ultrasound during exercise )
Myocardial perfusion scan ( a special heart muscle X ray – out patient test)
24hr ECG (a heart rhythm recording for 24hr. you take a small recording box home)
Coronary angiogram ( see separate info sheet- an inpatient X-ray of the heart arteries) - 26Where is pericarditis pain and where does it radiate toCentral, radiates to shoulders (trapezius ridge pain)
- 27Initial investigation in ACSECG
12 hr Trop T or I
FBC and other bloods
hyperglycaemia
CXR - 28Management of ACS in first 12 hoursABCDE
Continuous cardiac monitoring
300mg Aspirin, clopidogrel
Glycoprotein IIb/IIIa receptor antagonists in high risk NSTEMI - eptifibatide, tirofiban or abciximab
Anticoagulants in ischaemic changes or elevated cardiac markers - LMWH (dalteparin) or fodaparinux (8 days, hop discharge or coronary revascularisation)
Beta blockers
glycaemic control - 29Time limit for when you would use thrombolysis instead120 mins of ECG diagnosis
- 30When is a rescue PCI usedSTEMI that fails to reperfuse following thrombolysis
- 31in addition to long term aspirin, what and how long do you give other anticoagulants forclopidogrel or ticagrelor for 12 months
- 32When to give ACEi in MILong term, as soon as haemodynamically stable
- 33When to give an aldosterone receptor antagonist such as eplerononeMI complicated by LV dysfunction (ejection fraction less than 0.4) in presence of clinical signs of heart failure or diabetes mellitus --> long term eplerenone
- 34Hypoxia and shock in ACSCardiogenic pulmonary oedema and hypoxia, can eventually go to NIV
Can volume load in ACS with hypotension and cariogenic shock - 35In angina history when to offer angiographyWhen not satisfactorily controlled by medication
when you have newly diagnosed stable angina and:
When coronary artery disease risk is 61-90% (can use NICE risk table)
IF coronary revascularisation is being considered and invasive angio is acceptable - 36What tests to do in 30-60% risk of coronary artery disease in chest pain'functional imaging'
- 37what to do in 10-29% Likelihood of coronary artery diseaseCT calcium scoring (score based on the amount of calcium on a CT scan)
if 0 then consider other causes of chest pain
1-400 offer 64-slice or above CT coronary angiography
>400 offer invasive coronary angio - 38Examples of non-invasive functional imagingmyocardial perfusion scintigraphy with single photon emission CT
Stress echo
First pass contrast enhanced MR
MR imaging - 39Secondary prevention of CV disease in anginaAspirin 75mg daily
ACEi for people with stable angina and diabetes
Statin
Blood pressure - 40Drugs for anginaGTN to relieve attacks
Beta blocker or calcium channel blocker first line (modified release dihydropiridine e.g. nifedipine)
-if poor response then go to max dose
If cannot use the above then consider one of the following as mono therapy (these can also be added for dual therapy)
Long acting nitrate (isosorbide mononitrate, ivabradine, nicorandil, ranolazine
Consider a third drug if awaiting revascularisation or revascularisation not acceptable
beta-blockers should not be prescribed concurrently with verapamil (risk of complete heart block) - 41Cardiac syndrome Xangiographically normal coronary arteries and continuing anginal symptoms, consider a diagnosis of cardiac syndrome X
Continue drug treatment if it improves symptoms - 42Score and risk stratification for considering angio revascularisationGRACE, SYNTAX or EuroScore
- 43Coronary artery disease can be scored using...SYNTAX
- 44What should you refer most people to who have had a MI, heart surgery or procedureCardiac rehab
- 45Right hear failure vs L heart failureR heart failure - raised JVP and oedema
L heart failure - raised pulmonary capillary pressure and breathlessness - 46ALternative cause of fluid overload in suspected heart failureRenal failure
- 47Treatment of HFDrugs - diuretic, ACEi and/or ARB, beta blocker, aldosterone receptor antagonist (unless on ACEi and ARB)
AF - warfarin or digoxin
LBBB - consider cardiac resynchronisation therapy
LVEF <35% - consider ICD unless pt die of HF or other disease in 5 years - 48How heart failure can be classified based on ejection fractionHF with reduced ejection fraction
HF with preserved ejection fraction - 49When to refer heart failureTransthoracic doppler 2D echo and specialist assessment
Refer for the above also if BNP >400 pg/ml or NTproBNP level above 2000 pg/ml
BNP 100-400 or NTproBNP 400-2000 in 6 weeks - 50Relevance of serum BNP <100 or NT proBNP <400unlikely to be heart failure
- 51How to grade symptomatic limitation of heart failureNYHA I-IV
- 52At what NYHA level is spironolactone consideredIII-IV
- 53When to use digoxin in heart failureSevere or worsening LVSD despite first and second line treatment
- 54How to diagnose hypertension3 clinic readings over 140/90 --> ambulatory BP monitoring (ABPM) or home BP monitoring over 135/85
In the mean time look for end organ damage - LVH, CKD, hypertensive retinopathy - 55testing for end organ damage in hypertensionurine for albumin creatinine ratio
Bloods for kidney and lipids
examine fundi
12 lead ECG - 56What is hypertension a risk factor forCVA
CAD
heart failure
CKD
peripheral vascular disease
dementia
AF
eye disease - 57BP aims for those aged 80 and overclinic BP 150/90
ABPM or HBPM - 145/85 - 58Thiazide diuretics to offer instead of bendroflumethiazideChlortalidone or indapamide
- 59Drugs that are bad in asthmaNSAIDs, Aspirin, beta blocker
- 60When do you have critical limb ischaemiaLimb with ischaemic rest pain and/or tissue loss (ulcers or gangrene) that unless revascularised will result in limb loss
- 61How to calculate ankle brachial index pressure for estimating risk of peripheral artery diseaseBP at the ankle divided by BP and the brachial
Clinical status ABPI
Symptom free 1 or more
Intermittent claudication 0.95 - 0.5
Rest pain 0.5 - 0.3
Gangrene and ulceration <0.2 - 62Drug treatment to reduce withdrawal symptoms in smokingNicotine replacement therapy
Bupropion - reuptake inhibitor of dopamine, norepinephrine and serotonin
varenicline - competitive inhibitor of nicotine, a partial agonist also, eases withdrawal symptoms - 63Pink frothy cough?pulmonary oedema seconday to heart failure
- 64Pleuritic pain is more common with broncho or lobar pneumoniaLobar pneumonia
- 65Common and rarer causes of haemoptysisCommon - acute bronchitis, TB Rarer - bronchiectasis, lobar pneumonia
- 66Smokers cancer cell typesquamous
- 67Pulmonary oedema vs idiopathic pulmonary fibrosis cracklesPulmonary oedema - fine and at end of inspiration
Idiopathic pulmonary fibrosis - coarser and heard earlier in inspiration - 68Pleural fluid exudateProtein >30g/l, lactic dehydrogenase >200 IU/L
- 69How to grade COPDFEV1 as a percentage of expected for age/sex/height
Mild 80%, Moderate 50-79%, severe 30-49%, very severe <30% - 70What is pneumoconiosisGroup of lung diseases caused by inhalation and retention of dust in the lung. causes a range of granulomatous and fibrotic change. Asbestosis is an example
- 71What is allergic fibrosing alveolitisantigen-antibody reaction (type III). Chronic exposure eventually leads to granulomas and chronic interstitial pneumonitis
- 72Drugs not recommended in pulmonary hypertension and cor pulmonaleACEi
CCBs
Alpha blockers
Digoxin (unless there is AF) - 73Magic number for home o2 consideration<7.3 kpa or < 8 with certain morbidities
- 74Notable blood results in PEPolymorphonuclear leucocytosis
Elevated ESR
increased lactate dehydrogenase - 75When to suspect empyema in pneumoniafever and leukocytosis after 4-5 days of abs
- 76Common causes of transudateheart failure
cirrhosis
hypoalbuminaemia
peritoneal dialysis - 77how to investigate suspected DVTUltrasound and if result negative then a D-dimer test
Repeat test 6-8 days later in - 78What do the following tests assess RAST Prick test Patch testRAST and Prick - type 1 hypersensitivity
Patch test - delayed hypersensitivity - 79Derm, two types of herpes simplex virusType 1 - usually facial or non genital
Type 2 - commonly genital, although distinction is not absolute - 80How to treat genital herpesoral famciclovir or valaciclovir
- 81Chicken pox timingviral replication in lymph nodes over 2-4 days
4-6 days later a primary viraemia
after a week a secondary viraemia to the viscera and skin eliciting the typical lesions
New lesions erupt for 4-5 days
fever usually 2-3 days from 38.5 to 40 - 82Pharm management of fungal infectionsTerbinafide 250 daily or itraconazole 100mg daily
- 83Problems with turbinated and keotconazolehepatotoxicity
- 84Drugs that can exacerbate psoriasisNSAIDs, ACEi, lithium, chloroquine
- 854 main varieties of melanomaSuperficial spreading
Lentigo
Acral lentiginous
Nodular - 86Melanoma staging Tis to T4Tis - very top layer
T1 - 1mm thick
T2 - between 1-2mm thick
T3 - between 2 and 4 mm thick
T4 - melanoma more than 4mm thick - 87How to diagnose type 1 and type 4 hypersensitivity reactionsType 1 - rast and skin prick tests
Type 4 - patch testing - 88systemic treatments in eczemaTetracyclines such as oxytetracycline, lymecycline
Isotretinoin - 89Problems in Gorlins syndromeMultiple BCC, jaw cysts, palmoplantar cutaneous pits, skeletal abnormalities
- 90Topical options for actinic keratosis3% diclofenac gel (solaraze)
Fluorouracil (efudix, actikerall)
Ingenol mebutate - 91ABCD of melanomaAsymmetry
Irregular border
Irregular colour
Diameter >1cm
Also inflammation, itch, bleeding or weeping - 92Diagnosis and initial management of asthma in children
- 93Obstructive and restrictive lung diseases and their FEV1/FVCObstructive - FEV1/FVC <0.7
-COPD, asthma, bronchiectasis, CF
Restrictive - FEV1/FVC >0.7
-fibrosis, Sarcoidoisis, pneumoconiosis, interstitial pneumonia, connective tissue disorders, pleural effusion, obesity; kyphoscoliosis, neuromuscular problems, ARDS, Amiodarone, methotrexate - 94Investigation of Asthma in adults and initial management
- 95Management of asthma in adults 12 years and up
- 96Management of Asthma in 5-12 years old
- 97Management of asthma in under 5 years old
- 98Non-pharmacological management of asthmaStop smoking
Weight loss
Breathing exercise programmes (can be physic taught) - 99What is this: most commonly affects trunk patches may be hypopigmented, pink or brown scale is common mild pruritusPityriasis versicolor, also called tinea versicolor, is a superficial cutaneous fungal infection caused by Malassezia furfur (formerly termed Pityrosporum ovale)
patches may be hypopigmented, pink or brown (hence versicolor) - 100Management of heart failureNICE issued updated guidelines on management in 2010, key points include:
first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker
second-line treatment is now either an aldosterone antagonist, angiotensin II receptor blocker or a hydralazine in combination with a nitrate
if symptoms persist cardiac resynchronisation therapy or digoxin* should be considered
diuretics should be given for fluid overload
offer annual influenza vaccine
offer one-off** pneumococcal vaccine - 101Main indications for chest drain in pleural infectionsPatients with frankly purulent or turbid/cloudy pleural fluid on sampling should receive prompt pleural space chest tube drainage.
The presence of organisms identified by Gram stain and/or culture from a non-purulent pleural fluid sample indicates that pleural infection is established and should lead to prompt chest tube drainage.
Pleural fluid pH < 7.2 in patients with suspected pleural infection indicates a need for chest tube drainage. - 102What to do about a pneumothoraxPrimary pneumothorax
Recommendations include:
if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered
otherwise aspiration should be attempted
if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men
Secondary pneumothorax
Recommendations include:
if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.
otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours
if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours
avoid diving - 103When to consider referral for familial hypercholesterolaemiaa total cholesterol concentration more than 7.5 mmol/litre and
a family history of premature coronary heart disease.
Refer anyway in people with - a total cholesterol concentration of more than 9.0 mmol/litre or a non‑HDL cholesterol concentration of more than 7.5 mmol/litre - 104secondary causes of dyslipidaemia to be excluded before specialist referralexcess alcohol, uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome
- 105Bloods, assessments and management of which conditions in someone considered for dyslipidaemiasmoking status
alcohol consumption
blood pressure (see hypertension [NICE guideline CG127])
body mass index or other measure of obesity (see obesity [NICE guideline CG43])
total cholesterol, non‑HDL cholesterol, HDL cholesterol and triglycerides
HbA1c
renal function and eGFR
transaminase level (alanine aminotransferase or aspartate aminotransferase)
thyroid‑stimulating hormone. - 106Cholesterol goal in those started in statinMeasure total cholesterol, HDL cholesterol and non‑HDL cholesterol in all people who have been started on high‑intensity statin treatment at 3 months of treatment and aim for a greater than 40% reduction in non‑HDL cholesterol. If a greater than 40% reduction in non‑HDL cholesterol is not achieved:
discuss adherence and timing of dose
optimise adherence to diet and lifestyle measures
consider increasing the dose if started on less than atorvastatin 80 mg and the person is judged to be at higher risk because of comorbidities, risk score or using clinical judgement
Acceptable conservative LDL level ?4mmol/l - 107deep vs superficial venous ulcersDeep venous insufficiency is related to previous DVT and superficial venous insufficiency is associated with varicose veins
- 108When to start an inhaled corticosteroidInhaled steroids should be considered for patients with any of the following asthma-related features:
exacerbations of asthma in the last two years
using inhaled β2 agonists three times a week or more
symptomatic three times a week or more
waking one night a week - 109when to use an aldosterone antagonist in heart failurepatients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction, treatment with an aldosterone antagonist licensed for post-MI treatment (e.g. eplerenone) should be initiated within 3-14 days of the MI, preferably after ACE inhibitor therapy
- 110PCI window of opportunity90 minutes
- 111thrombolysis window of opportunity12 hours
- 112simple step up management for acnesingle topical therapy (topical retinoids, benzyl peroxide)
topical combination therapy (topical antibiotic, benzoyl peroxide, topical retinoid)
oral antibiotics: e.g. Oxytetracycline, doxycycline. Improvement may not be seen for 3-4 months. Minocycline is now considered less appropriate due to the possibility of irreversible pigmentation. Gram negative folliculitis may occur as a complication of long-term antibiotic use - high-dose oral trimethoprim is effective if this occurs
oral isotretinoin: only under specialist supervision
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- undergraduate Medicine Flashcards on Cardio, resp, derm, created by Sameet Govan on 29/04/2015.
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