Title | Paces-Guide-2012 - medicine |
---|---|
Author | Halima Mohamud |
Course | Making Medicines |
Institution | Kingston University |
Pages | 228 |
File Size | 4.8 MB |
File Type | |
Total Downloads | 17 |
Total Views | 134 |
medicine
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PACES Alasdair Scott BSc (Hons) MBBS PhD
2012 [email protected]
Contents
Medicine
Cardiology .................................................................................................................................................................................. 3 Pulmonology ............................................................................................................................................................................ 16 The Medical Abdomen ............................................................................................................................................................. 30 Neurology................................................................................................................................................................................. 49 Shorts....................................................................................................................................................................................... 71
© Alasdair Scott, 2012
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Cardiology Contents General Cardio Tips................................................................................................................................................................... 4 Aortic Stenosis ........................................................................................................................................................................... 5 Mitral Regurgitation .................................................................................................................................................................... 6 Aortic Regurgitation ................................................................................................................................................................... 7 Mitral Stenosis ........................................................................................................................................................................... 8 Rheumatic Fever........................................................................................................................................................................ 9 Infective Endocarditis ................................................................................................................................................................. 9 Valve Replacement .................................................................................................................................................................. 10 Valve Prostheses: Key Facts ................................................................................................................................................... 11 Atrial Fibrillation ....................................................................................................................................................................... 12 AF: Key Facts .......................................................................................................................................................................... 13 Pacemakers ............................................................................................................................................................................. 14 Chronic Heart Failure............................................................................................................................................................... 15
© Alasdair Scott, 2012
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General Cardio Tips Examination
Viva
Midline Sternotomy
Completion Observation chart Drug chart 12-lead ECG
Positive Finding Metallic click Murmur Vein harvest on legs Old scar, young pt. Immunosuppression Nothing
Indications Mechanical valve Tissue valve Valvotomy CABG Repair of congenital defect Heart transplant Trauma: tamponade, aortic IMA CABG Tissue valve
Cardiac Causes of Clubbing Infective endocarditis Congenital cyanotic heart disease Fallot’s Tetralogy VSD Pulmonary stenosis RVH Overriding aorta Transposition of the Great Vessels Atrial myxoma Assoc. c¯ Carney Complex / LAME Syndrome Lentigines: spotty skin pigmentation Atrial Myxoma Endocrine tumours: pituitary Schwannomas
Collapsing Pulse Caused by hyperdynamic circulation AR Thyrotoxicosis Pregnancy Anaemia
Absent Radial Pulse
Dead Trauma Thrombosis or embolism Coarctation of the aorta Takayasu’s Arteritis
Impalpable Apex Beat: COPD
COPD Obesity Pericardial effusion Dextrocardia
Features of Pulmonary HTN
↑ JVP Left parasternal heave Loud P2 + PSM of TR Pulsatile hepatomegaly Ascites and peripheral oedema
Heart Sounds
S1: mitral valve closure S2: aortic valve closure S3: rapid ventricular filling of dilated left ventricle S4: atrial contraction against stiff ventricle © Alasdair Scott, 2012
Presentation On peripheral inspection… The pulse… On examination of the precordium… Significant negatives Absence of CCF Disease severity Evidence of cause Differential Dx Hx Discussion Ix Rx
Hx
Symptoms: dyspnoea, chest pain, palpitations, syncope LVF: PND, orthopnoea IE: fever, wt. loss, night sweats CV Risk: smoking, DM, lipids, HTN, FH PMH: rheumatic fever DH: antiplatelet agents, statins
Ix ECG Evidence of ischaemia Arrhythmia Blood FBC: anaemia exacerbates cardiac symptoms U+E: renovascular disease NT-proBNP: heart failure Fasting lipids and glucose: cardiac risk Imaging CXR Cardiomegaly Pulmonary oedema Valve calcification Echo Dx Valve function LV Function Cardiac catheterisation Evaluate coronary arteries
Mx General MDT: GP, cardiologist, cardiothoracic surgeon, dietician, specialist nurses Optimise CV risk: statins, anti-HTN, DM, anti-plat Monitor: regular f/up and echo Specific Surgical 4
Aortic Stenosis Examination
Viva
Peripheral Inspection
Hx: Clinical Symptoms of Severe AS Angina: 50% dead in 5yrs Syncope: 50% dead in 3yrs Dyspnoea: 50% dead in 2yrs
Often nothing specific
Pulse Slow-rising (anacrotic) Narrow pulse pressure (4m/s Cardiac Catheterisation Valve gradient Assess coronaries (needed if surgery planned)
Mx General MDT: GP, cardiologist, cardiothoracic surgeon, dietician, specialist nurses Optimise CV risk: statins, anti-HTN, DM, anti-plat Monitor: regular f/up and echo Surgical: Valve Replacement ± CABG Indications Symptomatic AS Severe asymptomatic AS c¯ ↓ EF (0.6cm Systolic pulmonary flow reversal Regurgitant volume >60ml
Clinical Signs of Severe MR LVF AF
Cardiac Catheterisation Assess coronaries (needed if surgery planned)
Significant Negatives
Mx
Infective endocarditis Indicators of severity: AF, LVF
Differential AS VSD Right-sided: TR
Causes
Functional: LV dilatation (e.g. 2O to HTN or idiopathic) Annular calcification → contraction Rheumatic heart disease Mitral valve prolapse
General MDT: GP, cardiologist, cardiothoracic surgeon, dietician, specialist nurses Optimise CV risk: statins, anti-HTN, DM, anti-plat Monitor: regular f/up and echo Specific AF: rate control and anticoagulate Emboli: anticoagulate ↓ afterload ACEi or β-B (esp. carvedilol) Diuretics Surgical Valve replacement or repair Aim to replace the valve before significant LV dilation and dysfunction. Indications Symptomatic
Prognosis Often asymptomatic for >10yrs Symptomatic: 25% mortality @ 5yrs
© Alasdair Scott, 2012
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Aortic Regurgitation Examination
Viva
Peripheral Inspection
Ix
Eponymous Signs Quincke’s: capillary pulsation in nail beds Corrigan’s: visible vigorous carotid pulsation De Musset’s: head nodding Traube’s: pistol-shot sound over femorals Duroziez’s Systolic murmur over the femoral artery c¯ proximal compression. Diastolic murmur ¯ c distal compression Mueller’s: systolic pulsations of the uvula Rosenbach’s: systolic pulsations of the liver
ECG LVH LV strain: lateral T wave inversion
Cause Marfanoid: tall, thin, long arms, high-arched palate Ank spond: cervical kyphosis
Pulse Collapsing pulse Wide pulse pressure: e.g. 180/45
Precordium Aortic thrill Apex: displaced (volume overload) Heart Sounds Soft S2 ± S3 Murmur High-pitched EDM LLSE (3rd left IC parasternal) Sitting forward in end-expiration Possible Additional Murmurs Ejection systolic flow murmur Austin-Flint murmur Rumbling MDM @ apex 2O regurgitant jet fluttering the anterior mitral valve Clinical Signs of Severe AR Collapsing pulse Wide pulse pressure LVF
Significant Negatives Infective endocarditis Indicators of severity, LVF, wide PP, collapsing pulse
Differential MS Right-sided: PR, TS
Blood Standard: FBC, U+E, NT-proBNP, lipids, glucose AI disease: ESR, HLA-B27, ANA CXR Cardiomegaly Pulmonary oedema Echo + Doppler Severity Jet width (>65% of outflow tract = severe) Regurgitant jet volume Premature closing of the mitral valve Cause: bicuspid valve, vegetations, dissection LV function Other valve function Cardiac Catheterisation Assess coronaries (needed if surgery planned) Grade severity
Mx General MDT: GP, cardiologist, cardiothoracic surgeon, dietician, specialist nurses Optimise CV risk: statins, anti-HTN, DM, anti-plat Monitor: regular f/up and echo Specific ↓ afterload ACEi or β-B (esp. carvedilol) Diuretics Surgical: Valve Replacement Aim to replace the valve before significant LV dilation and dysfunction. Indications Symptomatic: NYHA >2 LV dysfunction Pulse pressure >100mmHg ECG changes: T inversion in lateral leads LV enlargement on CXR or EF 50mmHg Cardiac Catheterisation Assess coronaries (needed if surgery planned) Grade severity
Mx General MDT: GP, cardiologist, cardiothoracic surgeon, dietician, specialist nurses Optimise CV risk: statins, anti-HTN, DM, anti-plat Monitor: regular f/up and echo Specific Consider rheumatic fever prophylaxis: e.g. Pen V AF Rate control: β-B Anticoagulate (4% stroke risk /yr) Diuretics provide symptom relief Surgical Indicated in mod–severe MS (asympto and symptomatic) Percutaneous balloon valvuloplasty Rx of choice Suitability depends on valve characteristics Pliable, minimally calcified CI if left atrial mural thrombus Surgical valvotomy / commissurotomy: valve repair Valve replacement if repair not possible
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Rheumatic Fever
Infective Endocarditis
Pathophysiology
Normal Valves → Acute Endocarditis
Ab cross-reactivity following S. pyogenes infection → T2 hypersensitivity reaction (molecular mimicry). Abs cross-react c¯ myosin, muscle glycogen and SM cells Path: Aschoff bodies and Anitschkow myocytes.
Dx: revised Jones Criteria Evidence of GAS infection plus: 2 major criteria, or 1 major + 2 minor Evidence of GAS infection +ve throat culture Rapid strep Ag test ↑ ASOT or DNase B titre Recent scarlet fever Major Criteria Pancarditis Arthritis Subcut nodules Erythema marginatum Sydenham’s chorea
Minor criteria Fever ↑ESR or ↑CRP Arthralgia not if arthritis is a major Prolonged PR interval not if carditis is a major Prev rheumatic fever
Ix Bloods: FBC, ESR, ASOT ECG Echo
Rx
Bed rest until CRP normal for 2wks Benpen 0.6-1.2mg IM for 10 days Analgesia for carditis/arthritis: aspirin / NSAIDs Add oral pred if: CCF, cardiomegaly, 3rd degree block Chorea: Haldol or diazepam
Prognosis Attacks last ~ 3mo 60% c¯ carditis develop chronic rheumatic heart disease. Recurrence ppted by Further strep infection Pregnancy OCP Valve disease: regurgitation → stenosis Mitral (70%) Aortic (40%) Tricuspid (10%) Pulmonary (2%)
Secondary Prophylaxis Prevent recurrence Pen V 250mg/12h PO for 5-10yrs
Risk Factors IVDU Skin wounds Immunosuppression: CRF, DM Organisms S. aureus S. epidermidis
Cardiac Disease → Subacute Endocarditis Risk Factors Prosthetic valves Valve disease Organisms S. viridans S. bovis (do colonoscopy for colonic neoplasm) HACEK → culture negative IE
Clinical Features Hands Clubbing Splinters Janeway lesions Oslers nodes
Other Fever Roth spots Splenomegaly Haematuria
Cardiac New / changing murmur MR: 85% AR: 55%
Dx: Duke Criteria 2 major 1 major + 3 minor All 5 minor Major 1. +ve Blood Culture Typical organism in 2 separate cultures, or Persistently +ve cultures, e.g. 3, >12h apart 2. Endocardial Involvement +ve echo: vegetation, abscess, dehiscence or New valvular regurgitation Minor 1. Predisposition: cardiac lesion, IVDU 2. Fever >38 3. Emboli: septic infarcts, splinters, Janeway lesions 4. Immune: GN, Osler nodes, Roth spots, RF 5. +ve blood culture not meeting major criteria
Empiric Rx Acute severe: Fuclox / vanc + gent IV Subacute: Benpen + gent IV
Prophylaxis Abx prophylaxis solely to prevent IE not recommended © Alasdair Scott, 2012
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Valve Replacement Examination
Viva
Peripheral Inspection
Hx
General Audible valve click Anticoagulation → bruising Warfarin alert bracelet Anaemia Scars Midline sternotomy: CABG, AVR, MVR Left lat. inf. thoracotomy: MVR, mitral valvotomy Neck scars from line insertion Groin / femoral scars from angiography Vein harvesting scar on the medial leg May have had CAGB too
Pulse Variable AF suggests mitral valve replacement due to MS Time prosthetic clicks c¯ pulse Occur in time = mitral valve
Precordium Two Main Questions 1. When and where is the closing prosthetic sound? 2. Are there any murmurs? Starr-Edwards: 3 artificial sounds Quieter click as valve opens Loud thud as valve closes Rumbling sound as ball rolls in cage
DH: warfarin dosing + interactions Look @ pts. yellow warfarin book
Ix Bedside ECG Blood FBC: anaemia – MAHA, bleeding U+E: renovascular disease NT-proBNP: heart failure Fasting lipids and glucose: cardiac risk INR: warfarin Imaging CXR: heart failure Echo + Doppler Valve regurgitation or stenosis Peri-valvular leak Vegetations LV function Other valve function
Discussion Valve complications Valve types Infective endocarditis
Tilting disc or bileaflet: 1 artificial sound High-pitched click as valve closes Biological Valve Often normal heart sounds Aortic Lub-Click ± systolic flow murmur Abnormal: AR (EDM) Mitral Click-Dub ± diastolic flow murmur Abnormal: MR (PSM) Murmurs Well-seated valves may have soft flow murmurs Aortic: systolic Mitral: diastolic Poorly-seated valves → regurgitation Aortic: diastolic Mitral: systolic
Significant Negatives
Signs of infective endocarditis Signs of heart or valve failure Anaemia Bruising © Alasdair Scott, 2012
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Valve Prostheses: Key Facts Mechanical Types Ball and cage: e.g. Starr-Edwards Tilting disc: e.g. Bjork-Shiley Bileaflet: e.g. St. Jude Features Longer life-span: ~20yrs Require oral anticoagulation: Warfarin INR 3-4 Use Bileaflet valves are most commonly used Younger pts. to minimise need for revision. Already on warfarin: e.g. AF
Biological Types Porcine valves: e.g. Carpentier Edwards Bovine pericardium sewn into a metal frame Discontinued Features Less durable cf. mechanical valves: ~10yrs Don’t require long-term oral anticoagulation Take aspirin Use Older patients Women of child-bearing age Bleeding risk: e.g. peptic ulcer, frequent falls
© Alasdair Scott, 2012
Indications Mainly left-sided valve dysfunction AS most commonly Factors to consider Severity of valve dysfunction Severity of heart function Co-morbidities Pt. choice Mechanical or prosthetic Age Tolerance of long-term anticoagulation E.g. pregnancy, falls Pt. choice
Complications Complications of surgery Operative mortality: 5% Complications of valve Thromboembolism: 1-2% per annum despite warfarin Anaemia: warfarin and haemolysis Bleeding: minor – 7%/yr, major – 3%/yr Infective endocarditis Early: Staph. epidermidis Late: Strep. viridans May require 2nd valve replacement Mortality: 60% NB. avoid erythromycin if on warfarin Failure Chronic: stenosis or incompetence Acute: dehiscence, breakage, thrombus
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Atrial Fibrillation Examination
Viva
Peripheral Inspection
Hx Symptoms: palpitations, dyspnoea, chest pain Aware of specific onset Causes Warfarin: look @ yellow book
General Warfarin alert bracelet Cause ↑T4: tremor, thin, palmar erythema, sweating, eye signs MS: mitral flush
ECG Confirm Dx: irregularly irregular, no P waves Cause: ischaemia, P-mitrale
Pulse Irregularly irregular
Bloods FBC: pneumonia, sepsis U+E: ↓K TFTs: ↓TSH, ↑fT4 Troponin D-dimer: PE
Precordium MS: MDM MR: PSM Other murmurs
Completion Respiratory examination: pneumonia Exercise pt. to bring out any murmur
CXR Pulmonary oedema Calcified mitral valve Pneumonia Echo Valve pathology LV function TOE: left atrial thrombus
Significant Negatives
Ix
Murmur Evidence of thyrotoxicosis LVF Bruising from warfarin
Causes Common IHD Rheumatic heart disease Thyrotoxicosis Hypertension
© Alasdair Scott, 2012
Other Pneumonia PE Post-op Hypokalaemia Alcohol RA
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AF: Key Facts Clinical Points
Anticoagulation
Differential of Irregularly Irregular Pulse
CHA2-DS2-VAS Score
AF Multiple ventricular ectopics Clinical Distinction Exercise pt. AF: pulse stays irregularly irregular VE: ↑ HR → regular pulse ↓ diastole time closes window for ectopics
Pulse Deficit Difference in HR @ wrist and @ apex Rapid ventricular rate → ↓ diastolic filling → ↓CO
AF Control Time the apical rate: target 50%) Upper lobe Diversion Effusions Fluid in the fissures ECG Ischaemia Hypertrophy AF or other arrhythmia Echo: the key investigation Global systolic and diastolic function Ejection fraction normally ~60% Focal / global hypokinesia Hypertrophy Valve lesions
Mx General MDT: GP, cardiologist, physio, dietician, specialist nurses Optimise CV risk: statins, anti-HTN, DM, anti-plat Monitor: regular f/up and echo Specific 1st: β-B + ACEi + loop diuretic Bisoprolol Lisinopril Frusemide nd 2 : add Spironolactone rd 3 : consider digoxin 4th: consider cardiac resynchronisation therapy Surgery LVAD Heart transplant
Trials Showing Drug Benefit in Heart Failure
© Alasdair Scott, 2012
ACEi: Consensus 1 ARB = ACEi: ELITE-2 β-B: CIBIS-2, MERIT-2 Spironolactone: RALES
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Pulmonology Contents COPD ........................................................................................................................................................................................