CR EOYS4

Question 1

Name 4 risk factors for calcification of aortic valve? [4]

Answer 1

Risk factors: hypercholesterolaemia, hypertension, smoking and diabetes.

Question 2

Name this symptom

Janeway lesion
Oslers node
Splinter haemorrhage
Normal wear n tear

Answer 2

Name this symptom

Janeway lesion
Oslers node: Osler’s nodes are on the tip of the finger or toes and painful
Splinter haemorrhage
Normal wear n tear

Question 3

Name this symptom

Janeway lesion
Oslers node
Splinter haemorrhage
Normal wear n tear

Answer 3

Name this symptom

Janeway lesion transient, nontender macular papules on palms or soles. NOT PAINFUL
Oslers node
Splinter haemorrhage
Normal wear n tear

Question 4

A 17-year-old intravenous drug user presents to the hospital with low-grade fever, lethargy, and general malaise. He has tender, red, raised lesions on his palms and soles, which he reports appeared a few days ago. Cardiac auscultation reveals a pansystolic murmur in the tricuspid area. Lab investigations reveal a white blood cell count of 19000/microlitre. What is the most likely diagnosis for the lesions described?

A. Heberden nodes
B. Bouchard nodes
C. Osler nodes
D. Janeway lesions

Answer 4

A 17-year-old intravenous drug user presents to the hospital with low-grade fever, lethargy, and general malaise. He has tender, red, raised lesions on his palms and soles, which he reports appeared a few days ago. Cardiac auscultation reveals a pansystolic murmur in the tricuspid area. Lab investigations reveal a white blood cell count of 19000/microlitre. What is the most likely diagnosis for the lesions described?

A. Heberden nodes
B. Bouchard nodes
C. Osler nodes
Janeway lesions can also occur on the palms in infective endocarditis but are not painful.
D. Janeway lesions

Question 5

Janeway lesions and Osler nodes are supporting criteria for a diagnosis of [].

Answer 5

Janeway lesions and Osler nodes are supporting criteria for a diagnosis of infective endocarditis

Question 6

Pott’s disease is when pulmonary TB has spread to

Lymph system
Gastrointestinal system
Genitourinary system
Bone & joints
Meninges

Answer 6

Pott’s disease is when pulmonary TB has spread to

Lymph system
Gastrointestinal system
Genitourinary system
Bone & joints - Spinal
Meninges

Question 7

Myxomatous degeneration of the cardiac valves (MDMV) occurs due to remodelling of which type of collagen?

Collagen I
Collagen II
Collagen III
Collagen IV
Collagen V

Answer 7

Myxomatous degeneration of the cardiac valves (MDMV) occurs due to remodelling of which type of collagen?

Collagen I
Collagen II
Collagen III
Collagen IV
Collagen V

Question 8

Cerebral oedema is associated with

Respiratory alkalosis
Respiratory acidosis
Metabolic alkalosis
Metabolic acidosis

Answer 8

Cerebral oedema is associated with

Respiratory alkalosis
Respiratory acidosis
Metabolic alkalosis
Metabolic acidosis

Question 9

A wide pulse pressure is associated with:

aortic stenosis
mitral stenosis
aortic regurgitation
mitral regurgitation

Answer 9

A wide pulse pressure is associated with:

aortic stenosis
mitral stenosis
aortic regurgitation
mitral regurgitation

Question 10

A low volume pulse is associated with

aortic stenosis
mitral stenosis
aortic regurgitation
mitral regurgitation

Answer 10

A low volume pulse is associated with

aortic stenosis
mitral stenosis
aortic regurgitation
mitral regurgitation

Question 11

How could a HRV nasopharyngitis infection impact asthma patients?

Answer 11

The host reaction to HRV in atopic asthmatic subjects is characterised by a T-helper (Th)2-type immune response.

Causes increased synthesis and release of cytokines, such as interleukin (IL)-4, IL-5, IL-10 and IL-13, which are capable of increasing the expression of intercellular adhesion molecule (ICAM)-1, the major HRV receptor, on the surface of bronchial epithelial cells (BECs)

Causes BECS more sus. to infection.

Question 12

How would decide if you need to treat an acute sore throat from pharyngitis?

Answer 12

Use FeverPAIN or Centor scoring systems:

• If FeverPAIN score is 0-1 or Centor score 0-2: No antibiotic
• FeverPAIN score 2-3: back up antibiotic / no antibiotic prescription
• FeverPAIN score 4-5 or Centor score 3-5: immediate antibiotic or backup antibiotic prescription
• If symptoms are systemic (e.g. fever) and not resolved by immediate antibiotic refer to hospital.

(more common symptoms are likely to be viral, but if hospitlisation occurs then likely to be bacterial)

Question 13

Which drugs would you use to treat a Ptx who had acute sore throat with pharnygitis?

Answer 13

Start of treatment is determined by hospital’s microbiology protocol
But:

First choice: Phenoxymethylpenicillin

If allergic:

Clarithromycin
Erythromycin

Question 14

Treatment of which drug type is a risk factor for TB re-activation?

Answer 14

Prolonged therapy of corticosteroids

Question 15

Investigations for TB? [5]

Answer 15

CXR (mainstay)
Sputum sample: ZN stain AND culture
Histology
Mantoux test
IFN-y assay

Question 16

How do you diagnose if you’ve got latent TB or not? [2]

Answer 16

Tuberculin sensitivity Test – aka PPD (Purified Protein Derivative) (Manteux) test:

• Tuberculin is injected between layers of the dermis, tuberculin is a component of the bacteria, and if a person has previously been exposed to TB, the immune system reacts to the tuberculin and produces a small, localized reaction within 48 to 72 hours; if the reaction creates a large enough area of induration (rather than just redness), it’s considered to be a positive test.

DOESNT DISTINGUISH BETWEEN LATENT AND ACTIVE TB

IFN-γ assay

• If patient has had TB infection, T lymphocytes produce interferon gamma in response – measured and compared with control sample.

Question 17

First line treatment for TB? [4]

Answer 17

Standard treatment of TB disease is four-drug therapy - treatment with single drug can lead to development of a bacterial population resistant to that drug:

RIPE !

• Rifampicin
• Isoniazid
• Pyrazinamide
• Ethambutol

Question 18

Hessel bank equation xxx

Question 19

What are the two leading causes of respiratory acidosis? [2]

Name 3 others causes [3]

Answer 19

Hypoventilation and ventilation-perfusion mismatch resulting in inadequate excretion of CO2

Drugs suppress breathing (powerful pain medicines, such as narcotics, and “downers,” such as benzodiazepines), especially when combined with alcohol

Brain injury impairing CNS respiratory centres

Diseases of gas exchange (such as asthma and chronic obstructive lung disease)

Diseases of the chest (such as scoliosis), which make the lungs less efficient at filling and emptying

Diseases affecting the nerves and muscles that drive lung ventilation

Severe obesity, which restricts how much lungs can expand

Question 20

How do you treat respiratory acidosis? [4]

Answer 20

Treat cause !:

• Bronchodilator drugs to reverse some types of airway obstruction
• Noninvasive positive-pressure ventilation (sometimes called CPAP or BiPAP) or mechanical ventilation if needed
• Opioid drug overdose reversal with naloxone
• Oxygen if the blood oxygen level is low – BUT must be careful with oxygen

Question 21

Why do you need to monitor when giving O2 to Ptx with respiratory acidosis? Especially if have COPD

Answer 21

• Giving oxygen to these patients may lead to worsening CO2 retention from ventilation-perfusion mismatch: causes more acidosis.
• Can lead to CO2 narcosis and cardio-pulmonary arrest

Question 22

What disease does excessive excretion of phosphate ions lead to? [1]

Answer 22

This requires phosphate which comes from breakdown of calcium phosphate in bone, which can lead to bone weakening and osteoporosis.

Question 23

How does resp. alkalosis cause syncope? [1]

What happens to O2 dissociation curve in resp alk? [1]

Describe what happens to Ca2+ levels during alkalosis and what effect this has [2]

Answer 23

1) Decrease CO2 content: of blood causes constriction of cerebral blood vessels – may cause syncope

2) Alkalaemia shifts the haemoglobin O2 dissociation curve to the left:, impairing O2 delivery to tissues.

3) pH related changes in free Ca2+ blood levels can lead to an increase in neuromuscular excitability- increased risk arrythmias and tetany (involuntary and sustained muscle contractions)

Question 24

Explain the mechanism of renal compensation of chronic resp. alkalosis [2]

Answer 24

1. Kidney increases bicarbonate excretion by reducing levels of carbonic anhydrase.
2. The minimum plasma [HCO3-] achievable is about 12 mmol/L).

Question 25

What is the basic pathophysiology behind type 1 and 2 respiratory failures? [2] Name common causes of type 1 resp. failure [3] Name one common cause of type 2 resp. failure [1]

Answer 25

**Type 1:** respiratory failure occurs when the respiratory system cannot adequately provide oxygen to the body, leading to hypoxemia **Type 2:** when the respiratory system cannot adequately remove carbon dioxide from the body, leading to hypercapnia Name common causes of type 1 resp. failure [3] **3 Ps: PE, Pulmonary oedema, Pneumonia** Name one common cause of type 2 resp. failure [1] **Severe COPD**

Question 26

Name 3 reasons that could be the pathology behind mitral valve prolapse [3] Describe the physiology occuring in mitral valve prolapse [1] What are symptoms and severity of mitral valve prolapse? [1] Whats a sign of mitral valve prolapse? [1]

Answer 26

**Pathology**: - histologically normal valves - myxomatous degeneration (efect in the mechanical integrity of the leaflet due to the altered synthesis and/or remodeling by type VI collagen) - Marfan, Ehlers danlos **Physiology**: - valve leaflet(s) prolapses back into LA during systole, sometimes producing Mitral Rerguit. Symptoms: - Usually asymptomatic Sign: - Late ejection click Severity: -

Question 27

Define aortic stenosis [1] Name 3 causes of aortic stenosis [3]

Answer 27

**Definition**: Narrowing of the aortic valve resulting in obstruction to the left ventricular stroke volume, leading to symptoms of chest pain, breathlessness, syncope and fatigue **Causes**: - **Calcific disease** (hardening of aortic valve) - **Congenital bicuspid aortic valve (BAV)** (valve has 2 leaflets instead of 3 due to genetic disease - this is the most common congenital heart disease) resulting in stenosis - **Rheumatic heart disease**

Question 28

Signs [5] & Symptoms [4] of Aortic stenosis?

Answer 28

**Symptoms**: - **Dyspnoea** - increase in diastolic pressure in stiff non-compliant LV. LV is thicker because has to use more energy to expel blood (hypertrophy) - **Angina** - increase O2 demand of hypertrophied LV - **Syncope** - either paroxysmal ventricular arrhythmias or exertional cerebral hypoperfusion (less blood is leaving) - **LVF** - contractile failure as ventricle dilates – causes heart failure - **Sudden death** - ventricular arrhythmias **Signs**: - **slow rising carotid pulse** - **S4 ejection click** - **Late diastole** (trying to eject blood)

Question 29

Describe the murmur that occurs from aortic stenosis [4]

Answer 29

Systolic ejection murmur (S1 --> S2) Prominant S4 ejection click High pitched Crescendo / decresendo Radiates to carotids

Question 30

What would indicate need for surgery for AS? [3]

Answer 30

- Any symptoms of AS - Echocardiographic evidence of worsening LV dilatation - Peak systolic pressure gradient (the difference between peak left ventricular [LV] and peak aortic systolic pressures) >50 mmHg **TAVI** now taking over from heart surgery for people not suitable (frail).

Question 31

What are 4 causes of aortic valve lealeft disease [4]

Answer 31

Calcific disease – stiffness of valve (hard to open / close) Congenital bicuspid valve Rheumatic disease Infective endocarditis. Infection of aortic valve

Question 32

What are 3 causes of aortic regurgitation caused by aortic root dilating disease? [3]

Answer 32

**Ankylosing spondylitis** (is an inflammatory disease that, over time, can cause some of the bones in the spine (vertebrae) to fuse) **Marfan syndrome** (cant make strong CT) **Aortic dissection**

Question 33

Describe signs of aortic regurgitation

Answer 33

**Heart murmur**: - Early diastolic, soft / subtle murmur at left sternal border - Systolic ejection murmur; due to increased flow across the aortic valve - Corrigans pulse / collapsing pulse: rapidly appears then dissapears - Apex beat displaced laterally

Question 34

What investigations for aortic regurgitation?

Answer 34

**Echocardiogram**: - Aortic root size compared to LV. Aortic root often much larger than normal) - LV dimensions (LV dilation) **Doppler** - detection and quantification of regurgitant flow

Question 35

Describe the pathophysiology behind aortic rurgigation

Answer 35

Aortic regurgitation is reflux of blood from the aorta through the aortic valve into the left ventricle during diastole - If net cardiac output is to be maintained, **the total volume of blood pumped into the aorta must increase** and, consequently, the **left ventricular size must enlarge** resulting in **left ventricle dilation and hypertrophy** - Progressive dilation leads to heart failure - Furthermore due to the fact that the remaining blood in the root of the aorta supplies the coronary arteries via the coronary sinus during diastole - regurgitation **causes diastolic blood pressure to fall and thus coronary perfusion decreases** - Also the large left ventricular size is mechanically less efficient, so that the demand for oxygen is greater and **cardiac ischaemia** develops

Question 36

Describe the pathophysiology of mitral stenosis

Answer 36

- Thickening and immobility of the valve leads to obstruction of blood flow from the **left atrium to the left ventricle** - In order for sufficient cardiac output to be maintained, the **left atrial pressure increases and left atrial hypertrophy and dilatation occur** - Consequently **pulmonary venous, pulmonary arterial and right heart pressures also increase** - The increase in pulmonary capillary pressure is followed by the development of **pulmonary oedema** - this is seen particularly when **atrial fibrillation occurs**, due to the elevation of **left atrial pressure and dilatation**, with tachycardia and loss of coordinated atrial contraction

Question 37

What are the causes [1] and symptoms [4] of mitral stenosis?

Answer 37

Causes: - Rheumatic fever Symptoms: - **Afib** - lead to **palpitations** - **Progressive dyspnoea** - due to left atrial dilation resulting in pulmonary congestion - **Systemic emboli** - due to atrial fibrillation. - **Right ventricular failure:** due to the development of pulmonary hypertension

Question 38

What are the signs of mitral stenosis?[5]

Answer 38

- **Mid-diastolic rumbling murmur**: low velocity of blood flow (due to narrow area - rumbles way through). LENGTH OF RUMBLE CORRELATES TO THE INTENSITY - **Loud S1** caused by thick valves closing - **Tapping apex beat** that is palpatable (due to loud S1) - **Atrial fibrillation**: left atrium can't push through stenotic valve - disrupts electrical signal - **Increase in JVP, basal creps, ankle oedema**

Answer 39

noncalcified valve no mitral regurgitation LA thrombus

Question 40

What are classifications of pathologies that cause mitral regurgitation? [3] State which specific disease causes these within the classifications

Answer 40

**Mitral valve leaflet disease** - Mitral valve prolapse (leaflets prolapse during systole) - Rheumatic disease - Infective endocarditis – infection. Disease / bacteria stop closure of the valve) **Subvalvar disease** - Chordal rupture (chordae tendinae) - Papillary muscle dysfunction (usually ischaemic) - Papillary muscle rupture **Functional MR** - LV dilatation

Question 41

Describe the signs of mitral regurgitation [5]

Answer 41

- Pan-systolic murmur - **Prominent third extra heart sound (S3)** in congestive heart failure/left atrium overload - High pitched whistling - increased JVP, basal creps, ankle oedema due to backlog of blood - radiates to the **left axilla**

Question 42

What are symptoms of mitral regurgitation? [3]

Answer 42

**Symptoms** Dyspnoea, orthopnoea due to increase in left atrial pressure Palpitations due to atrial fibrillation Systemic emboli due to static blood within dilated fibrillating left atrium predisposes to thrombosis

Question 43

What would indicate someone is suitable for mitral regurgitation surgery? [3] What medical treatment would you conduct for mitral regurgitation? [3]

Answer 43

**Surgery:** Symptoms that fail to respond to medical treatment Worsening cardiovascular complications pulmonary hypertension (MS) LV dilatation (MR) **Medication:** Fluid retention - **diuretics** AF (MS, MR) - **digoxin, beta-blockers, verapamil** **Anticoagulants** to protect against systemic embolisation (AF)