B2B Deck

4-2-1 rule: What are the 4 heart-related emergencies to consider for a chest pain presentation?

1. ACS

2. Aortic dissection

3. Pericardial effusion/tamponade

4. Peri/myocarditis

4-2-1 rule: What are the 2 lung-related emergencies to consider for a chest pain presentation?

PE and pneumothorax

4-2-1 rule: What is the 1 esophagus-related emergency to consider for a chest pain presentation?

Perforation

If your chest pain differential is ACS, what should you ask about? (2 things)

• Hx of angina

• Risk factors

If your chest pain differential is aortic dissection, what should you ask about? (3 things)

RIsk factors

HTN hx

Connective tissue disease hx

If your chest pain differential is pericarditis, what should you ask about? (3 things)

Positional changes

Recent viral illness

Recent vaccinations

If your chest pain differential is PE, what should you ask about? (4 things)

Recent immobilisation (travel, surgery)

Calf pain

COCP

Hx of clots, self and family

If your chest pain differential is Boerhaave syndrome, what should you ask about? (2 things)

Recent binge drinking

Vomiting

Name some dyspnoea differentials that are cardiac in cause:

• HF

• CAD/ACS

• Valvular disease

• Arrhythmias

• Tamponade

• Constrictive pericarditis

Name some dyspnoea differentials that are respiratory in cause:

• Asthma

• COPD

• Bronchiectasis

• PE

• Pulmonary HTN

• Vasculitis

• Effusion

• Pneumothorax

• Pneumonia

Name some other causes of dyspnoea that are less commonly thought of:

• Acidosis

• Thyrotoxicosis

• Anxiety

• Deconditioning

Name 3 neuromuscular causes of dyspnoea:

• Myasthenia gravis

• Guillain barre syndrome

• ALS

What features in a dyspnoea hx would make you suspect exacerbation of CCF?

• Oedema

• Orthopnoea

• Paroxysmal nocturnal dysponea

What features in a dyspnoea hx would make you suspect arrythmia?

• Palpitations

• Pre-syncope or syncope

What features in a dyspnoea hx would make you suspect exacerbation of COPD?

• Smoking hx

• Chronic cough

• ± COPD diagnosis

What features in a dyspnoea hx would make you suspect anaemia?

• Bleeding especially melaena, haematemesis

In a febrile child >3 months, how can we easily differentiate betwen infectious and non-infectious?

Fever >5 days more commonly non-infectious.

Infectious think acute onset and recent fever (<5 days)

What are some autoimmune/inflammatory causes of fever in a child?

• Kawasaki disease

• IBD

• SLE

• Juvenile idiopathic arthritis

If you’re doing an osce exam and the patient has really abnormal vitals, looks unwell or you’re concerned, what do you say?

• I will do an A-E assessment

• Ensure airway patency

• Gain IV access

• Start O2 therapy

• Start fluids

What is the A-E assessment?

• Airway

• Breathing

• Circulation

• Disabilities → GCS, pupils, BGL, abdo/neuro

• Environment → temp, exposures

Name 5 exam findings consistent with ACS:

• Diaphoresis

• Pallor

• Dyspnoea

• Increased cap refil time

• S4 heart sound

Name 3 exam findings consistent with Aortic dissection:

• RR delay

• RF delay

• Asymmetrical BPs

Name 2 exam findings consistent with Pericarditis:

Pericardial rub

Fever

Name 3 exam findings consistent with PE:

• Swollen, tender calves

• Elevated JVP

• SOB

Name 2 exam findings consistent with pneumothorax:

• Tracheal deviation

• Hyper-resonance

Name an exam finding that would suggest Boerhaave syndrome:

Subcutaneous emphysema

Name 4 differentials for SOB, swollen legs, and reduced exercise tolerance in a 69yo:

• Pulmonary oedema due to RHF

• Fluid overload due to LHF

• Distributive shock

• Hypovolemic shock

Name 2 exam findings suggestive of acute pulmonary edema:

• Fine crackles

• Increased WOB

Name 4 exam findings suggestive of fluid overload due to LHF:

• Elevated JVP

• Peripheral oedema

• Ascites

• HTN

Name 3 exam findings suggestive of distributive shock:

• Warm peripheries

• Wide pulse pressure

• Tachycardia

Name 5 exam findings suggestive of hypovolemic shock:

• Increased cap refil

• Hypotension

• Tachycardia

• Dry mucus membranes

• Decreased turgor

Name 5 differentials for unwitnessed fall in a 50yo M:

• Seizure

• Syncope

• Hypoglycemia

• Stroke/TIA

• Intoxication

Name 5 differentials for palpitations in a 70yoM:

• AF

• Atrial flutter and other arrythmias

• Alcohol use

• Thyrotoxicosis

• Anxiety

Name 5 differentials for beet-red urine, dysuria, and dropping BP:

• UTI causing urosepsis

• Nephrolithiasis

• Cystitis

• Pyelonephritis

• Prostatitis

If you’re asked to ASSESS a patient, what does this entail?

1. History

2. Examination

3. Investigations

4. DDx and initial management

If you’re asked to REVIEW a patient, what does this entail?

1. Check notes

2. Hx

3. Examination

4. Investigations

5. Review management ± make any changes

If you’re asked to MANAGE a patient, what does this entail?

1. History

2. Examination

3. Investigations

4. Immediate management

5. Supportive management

6. Long term management and MDT

What is the TUNA FISH mnemonic for back pain red flags?

Trauma

Unexplained weight loss

Neuro sx

Age >50

Fever

IVDU

Steroid use

History of cancer

List the investigations to order for ?ACS:

• Troponin and Serial Troponin

• FBC

• UEC

• CXR

• Serial ECGs

Which groups are at high risk for infective endocarditis?

• Congenital heart disease

• Prosthetic valves

• Hx of IE

• IVDU

What are the 2 major Duke criteria for infective endo?

1. 2x Blood cultures positive for IE → typical microorganisms

2. Imaging positive for IE → Echo, cardiac CT, or PET

What are the minor Duke criteria for infective endo? (5)

• Predisposing factors/RFs

• Fever >38

• Vascular changes (janeway/osler, emboli, haemorrhages)

• Immune changes (glomerulonephritis, osler’s nodes, RF, roth’s spots)

• Micro evidence (blood culture but with an uncommon bug)

The Duke criteria say definite IE if which conditions are met?

• Both major criteria

• 1 major and 3 minor

• 5 minor criteria

What are some other lower/uncommon risk factors for Infective endo?

• Bicuspid aortic valve

• Mitral valve prolapse

• Calcific aortic stenosis

When is a TOE indicated for investigation of infective endo?

• Current prosthetic valve

• Positive or inconclusive TTE

• Negative TTE but high suspicion of IE

What are the main complications of infective endocarditis?

• Ongoing infection → abscess, fistula, enlarging vegetations

• Haemodynamic deterioration → HF, valvular regurg, obstruction

• Emboli

In a patient with infective endocarditis, when would you suspect perivalvular extension?

• Ongoing unexplained fever

• New AV block

What are some neurological complications of infective endocarditis?

• Ischaemic strokes

• Transient ischaemic attack

• intracerebral or subarachnoid haemorrhage,

• brain abscess,

• meningitis

• toxic encephalopathy

___ infarcts are common and usually asymptomatic in infective endocarditis. What would make you concerned about this?

Splenic

• Recurrent fever

• Abdo pain

• Bacteraemia

Suggests splenic abscess or rupture secondary to it

What are 3 cardiac complications of infective endocarditis?

• Myocarditis due to abscess or immune rxn

• Pericarditis due to inflammation

• Arrythmias eg) AF, Ventricular

Infective endocarditis can present with mainly ____ manifestations and antibody positivities

Rheumatological

What patients need urgent ssurgery to manage infective endo?

• Severe obstruction causing HF or fall in EF shown on echo

• Uncontrolled infection eg) abscess, false aneurysm

• Weird bugs

• Prosthetic valve not responding to antibiotics

IVDU-associated infective endo is typically ___-sided.

What organism is usually responsible?

Right

S. aureus

What pathogen causes rheumatic fever/RHD?

Strep A

Strep A is a gram ____. What shape?

Positive

Coccus

Name 2 non-invasive strep A clinical syndromes:

Skin infection

Pharyngitis

Name 4 invasive strep A clinical syndromes:

Bacteraemia/Septicaemia

Necrotising fasciitis

Bone/joint infection

Empyema

Meningitis

Name 2 toxin-mediated strep A clinical syndromes:

Toxic Shock syndrome

Scarlet fever

Name 3 immune-mediated strep A clinical syndromes:

Rheumatic fever

Rheumatic heart disease

Glomerulonephritis

Standard investigations (2) for strep A infection

Culture and serology

With group A strep, ___ is the gold standard for investigation. It is most useful for ___ infection, and not as effective for ____

Culture

Acute

Post-infection complications

Group A strep colonizes the throat in ____% of the population

5-15%

___ is the most useful investigation for post-infectious complications of group A strep

Serology

Which serology is used for group A strep? (2 things)

Anti-Streptolysin O (ASOT) → 3-6 weeks post-infection

Anti-DNase B → 6-8 weeks post-infection

What are the 5 major manifestations of rheumatic fever? ACESS

Arthritis

Carditis

Erythema marginatum

Subcut nodules

Sydenham chorea

What is the classic arthritis pattern for rheumatic fever?

Asymmetric

Migratory

Large joints especially knees and ankles

Polyarthritis

What clinical features would suggest carditis secondary to rheumatic fever?

• Murmur

• Cardiomegaly

• Cardiac decompensation

• Pericardial friction rub

Carditis in rheumatic fever is mainly due to inflammation of the ____. It mainly causes ___ -sided valve issues

Endocardium

Left

What would the ECG and echo show with rheumatic-fever induced carditis:

Ecg → Prolonged PR interval, ± 2nd degree heart block

Echo → Valvulitis

If other causes of ___ are excluded, this feature is diagnostic for acute rheumatic fever

Chorea

Name the 4 clinical signs of ARF-induced chorea:

• Milkmaid’s grip

• Spooning

• Pronator sign

• Darting tongue

Subcut nodules in ARF usually occur in which areas?

Extensor surfaces

Elbows, wrists, knees, ankles, achilles, cervical vertebrae

List some differentials for ARF:

• Septic arthritis

• Reactive arthritis

• Congenital heart disease

• Infective endocarditis

• SLE

• Encephalitis

What are the main investigations for ARF?

Bedside → ECG

Labs → FBC, ESR/CRP, ASOT, AntiDNAB

Imaging → Echo

Management of group A strep infection:

Penicillin, single IM dose or 10 days PO dose

Cephalexin or Azithromycin if allergy

Management of arthritis caused by ARF:

Paracetamol and NSAIDs

Management of chorea in ARF:

Carbamazepine

Valproate

Steroids

Management of carditis in ARF:

Diuretics

ACEi

Rheumatic heart disease has peak prevalence age:

30-40

Which valve is the most commonly affected in RHD?

Mitral

Name 5 clinical features of rheumatic heart disease:

• Asymptomatic

• Dyspnoea

• Fatigue

• Weakness

• Angina

• Syncope

Signs of rheumatic heart disese:

• Murmur

• Heart failure

• Arrhythmia

What is the gold standard to diagnose RHD?

Echocardiograph

Primary prevention of RHD:

• Recognize and treat Strep A infection before they can cause ARF/RHD

• Treat strep throat with antibiotics (penicillin or cephalexin)

Describe the secondary prevention of RHD:

Consisent and regular administration of abx to people who have had ARF/RHD to prevent recurrence and limit RHD progression

IM benzathine penicillin G

What drug is used for secondary prevention of RHD?

IM benzathine penicillin G

How long is the prophylaxis for secondary prevention of RHD?

If possible ARF with no cardiac involvement → 12 months

If probable ARF based on echo → minimum 5 years or until age 21

If definite ARM based on echo → as above

What is ethnomedicine?

Translating health-related knowledge and theories that people inherit by living in a culture.

Causes of illness, health seeking behaviour, diagnosis and tx

Migrant and refugee women are at greater risk of what 3 things?

• Poor maternal and child health outcomes

• Contracting STIs

• Experiencing FDV

What is type 1 female genital cutting/mutilation?

Part of or all of cl*toris is removed

What is type 2 female genital cutting/mutilation?

Most of cl*toris removed, and some of or all of the l*bia min*ra

Most common form (80%)

What is type 3 female genital cutting/mutilation?

Cl_toris, la*bia min*ra, and la*bia maj*ora (most of or part of)

What is type 4 female genital cutting/mutilation?

All other procedures for non-medical reasons. Including pricking/incising, stretching, cauterization of cl*toris, introduction of corrosive substances

What are some immediate complications of FGM?

• Pain

• Haemorrhage

• Infection/sepsis

• Death

• Psychological trauma

• Swelling

• Urinary retention

• Incontinence

What are some long term complications of FGM?

• Keloid scars, abscesses and painful cysts.

• Severe pain, Vulvodynia, Dyspareunia, Chronic Pelvic Pain.

• Psychological trauma, PTSD, Depression and Anxiety

• Vaginal retention of menstrual blood. Painful periods.

• Voiding dysfunction, incomplete emptying, urinary infections, bladder stretch, urinary retention, incontinence

• Infertility.

• Decreased access to preventative health care eg. Cervical Cancer screening

• Decreased sexual arousal, pleasure.

Urological complications of FGM:

• Recurrent UTIs especially type ¾

• LUTS esp. frequency and uregency

• Urinary retention

• Urogenital fistula

• Meatus stenosis

Obstetric complications of FGM:

• Obstetric fistulas

• PPH

• Perinatal mortality increased (55% in type 3)

• Newborns needing resus (>66%)

What is the LIVES model for trauma-informed care?

Listen

Inquire

Validate

Enhance safety

Support with referral

What is de-infibulation? When is it indicated?

Surgical procedure to re-open the va*ginal opening

Indicated for women with LUTS/UTIs, dyspareunia