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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

3

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

11

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 ........................................................................................................................................................................................