What are the 7 red flags associated with chest pain?
- exertional
- sudden onset
- breathlessness
- haemoptysis
- unintentional weight loss
- new onset dyspepsia (>55years)
- History of leg swelling, long haul flights, or immobility (PE)
What are some common differentials in someone presenting with chest pain?
- stable angina
- GORD
- myocardial infarction (ACS)
- pulmonary embolism
- pneumothorax
- aortic dissection
What are the 8 red flags associated with breathlessness?
- associated chest pain
- sudden onset
- visible physical signs = cyanosis or confusion
- stridor/audible wheeze
- worsening orthopnoea
- history of immobility
- unintentional weight loss
- hoarseness of voice
What are some common differentials in someone presenting with breathlessness?
- asthma
- pneumonia
- COPD
- interstitial lung disease
- congestive cardiac failure
- lung malignancy
less common include ACS, tension pneumothorax, PE, acute pulmonary oedema
What are the 4 red flags associated with palpitations?
- associated exertion
- chest pain
- collapse
- family history of sudden unexpected death
What are some common differentials in someone presenting with palpitations?
- ventricular tachycardia (most serious)
- atrial fibrillation
- supraventricular tachycardia
- ectopic beats
- anxiety
- hyperthyroidism
- phaeochromocytoma
What are the 8 red flags associated with a cough?
- unintentional weight loss
- hoarse voice
- more than 3 weeks onset
- recurrent infection
- haemoptysis
- pleuritic chest pain
- breathlessness
- persistent nocturnal cough
What are some common differentials in someone presenting with a cough?
- URTI (most common)
- pneumonia
- ACEi - switch to ARB
- lung malignancy
- GORD
- asthma
- COPD
- bronchiectasis
What are the 7 red flags associated with haemoptysis?
- weight loss
- heavy smoking history
- drenching night sweats
- foreign travel
- chest pain
- sudden onset dyspnoea
- risk factors for PE
What are some common differentials in someone presenting with haemoptysis?
- acute bronchitis (most common)
- lung malignancy
- pulmonary embolism
- pneumonia
- tuberculosis
- lung abscess
- bronchiectasis
What are the (i) investigations and (ii) management for someone with suspected stable angina?
(i) ECG - usually normal but may show past MI
Exclude precipitating factors = anaemia, DM, thyrotoxicosis, hyperlipidaemia, temporal arteritis
(ii) 1. Modify risk factors = smoking, exercise, weight loss. If cholesterol greater than 4 prescribe statin
2. GTN spray
3. Aspirin 75-150mg/day
4. b-blockers (ivabradine if cannot tolerate)
What are the investigations for someone with suspected ACS?
1) ECG: within hours = tall T waves, ST elevation or new LBBB. Within days = T wave inversion, pathological Q waves
2) CXR = cardiomegaly, pulmonary oedema, widened mediastinum
3) Troponin T+I = rise within 3-12hrs and peaks at 24-48hrs
How do you treat a STEMI?
FIRST = MONAC - morphine + metclopramide - if sats less than 90% give oxygen - IV nitrates - Aspirin - clopidogrel Then 1) Primary angioplasty OR thrombolysis with alteplase 2) IV b-blocker (atenolol) 3) ACEi (lisinopril) 4) clopidogrel 300mg loading dose followed by 75mg/day for 30 days Review at 5 wks and 3 months post MI
How do you treat an NSTEMI?
1) if sats less than 90% give oxygen
2) IV morphine + metclopramide
3) Nitrates (IV/PO)
4) Aspirin lifelong (lose if low GRACE score) + clopidogrel (12 months)
5) Antithombotic fondaparinux if low bleeding + no angioplasty planned
6) b-blocker
7) ACEi
8) statin + address modifiable risk factors e.g. smoking, exercise, DM, HTN, hyperlipidaemia
Review at 5 wks and 3 months post MI
What are the investigations for someone with suspected Heart Failure?
BNP - raised
CXR - alveolar oedema, kerley B lines, cardiomegaly, dilated prominent upper lobe vessels, pleural effusion
ECG - determine cause and degree of LV function
Diagnose using Framingham criteria and classify based on NYHA classification
What is the management for someone with heart failure?
Stop smoking, eat less salt, optimise weight and nutrition
Then treat cause. Treat exacerbating factors (anaemia, thyroid, infection, HTN) and avoid drugs that can exacerbate (NSAIDs, verapimil)
1. Loop diuretics e.g. furosemide
2. ACEi/ARB
3. B blocker
4. Spironolactone
5. Digoxin (if in AF and have HF)
6. Vasodilators (hydralazine and isosorbide dinitrate) if intolerant to ACEi/ARB or used in standard therapy for patients of black ethnic origin
What are the (i) investigations and (ii) management for someone with suspected atrial fibrillation?
(i) ECG = irregular QRS, absent P waves
Bloods = U+E, cardiac enzymes (trops), TFTs
(ii)
ACUTE AF (less than 48h)
- O2, U+E, emergency DC cardioversion (if unavailable then amiodarone IV)
- treat associated illness
- control rate (1st line = verapimil or bisoprolol
- anticoagulate with LMWH
CHRONIC AF (prioritise rate control + anticoag)
- anticoagulation = warfarin, aspirin, dabigatran
- rate control = b-block or verapimil or diltiazem
PAROXYSMAL AF = flecainide ‘pill in pocket’
What are the (i) investigations and (ii) management for someone with suspected infective endocarditis?
(i) blood cultures - 3 separate occasions
bloods - normocytic normochromic anaemia
urinalysis - microscopic haematuria
ECG - prolonged PR interval/complete AV block
Echo = vegetations
Use DUKE’s criteria for diagnosis
(ii) Antibiotics (amoxicillin +- vancomycin/gentamicin)
Consider surgery.
Dental and oral hygiene is important
What are the 3 stages of hypertension?
- clinic BP over 140/90 or ABPM over 135/85
- clinic BP over 160/100 or ABPM over 150/95
- clinic: diastolic over 110 or systolic over 180
What is the management for hypertension?
UNDER 55:
ACEi - ACEi+CCB or ACEi+diuretic, then ACEi+CCB+diuretic
- add further diuretic/alpha blocker/beta blocker
OVER 55 or black ethnicity:
CCB/diuretic - ACEi+CCB or ACEi+diuretic - ACEi+CCB+diuretic
- add further diuretic therapy/alpha blocker/beta blocker
What are the investigations involved in severe pulmonary oedema?
CXR = cardiomegaly, ‘bat wings’, effusion and kerley B lines
ECG = signs of MI, dysarrhythmias
U+E, troponins, ABG, plasma BNP
Consider ECHO
What is the management in severe pulmonary oedema?
- sit patient UPRIGHT
- oxygen 100% if no pre-existing lung disease
- IV access and ECG
- Diamorphine IV
- Furosemide IV
- GTN spray
- If SBP over 100mmHg start a nitrate infusion (isosorbide nitrate). If sys is under 100mmHg, treat as cardiogenic shock
What are the investigations involved in suspected pneumonia?
CXR
Oxygen sats + BP plus maybe ABGs
Bloods = U+E, FBC (leucocytosis), LFT, CRP
Blood culture
Sputum culture
Urine anitgen testing for legionella and pneumococcus
What is the criteria of the CURB-65 score? How is it used to base treatment of pneumonia?
Confusion
Urea over 7mmol
Resp rate over 30 breaths/min
BP sys under 90mmHg or diastolic under 60mmHg
Aged over 65
0-1 = home treatment (mild) with amoxicillin or clarithromycin
2 = amoxicillin and clarithromycin
3-5 = severe, co-amoxyclav and clarithromycin
- consider oxygen and fluids, plus VTE prophylaxis
- analgesia if in pleuritic pain
