Gilbert's syndrome is the most common hereditary cause of raised bilirubin, affecting around 6% of the general population. The main symptom is generally harmless jaundice (which does not require treatment) caused by the increased levels of unconjugated bilirubin in the bloodstream (hyperbilirubinaemia). LFTs are otherwise normal.
The source of this hyperbilirubinaemia is reduced activity of the enzyme glucuronyltransferase, which conjugates bilirubin.
Normal levels of total bilirubin (conjugated ans unconjugated) are under 20 micromol/dl. Patients with Gilbert's synfrome may have between 20 and 80 micromol/dl.
Gilbert's syndrome can reduce the liver's ability to detoxify certain drugs.
Tuesday, 7 July 2009
Integration of Cardiovascular Learning
Integration of Cardiovascular Learning
These questions were set by my medical school based on clinical skills surrounding the cardiovascular system, and the answers are those I believe to be correct.
1. What are the murmurs of mitral stenosis, mitral regurgitation, aortic stenosis, and aortic regurgitation?
Mitral stenosis – mid-diastolic murmur
Mitral regurgitation – pansystolic murmur
Aortic stenosis – ejection systolic murmur
Aortic regurgitation – early diastolic murmur
2. Give two causes of clubbing
Cyanotic congenital heart disease, infective endocarditis
3. What are splinter haemorrhages?
Small haemorrhages within the nailbed under the nail
4. Give two causes of splinter haemorrhages. Are they embolic or vasculitic?
Infective endocarditis – vasculitic, caused by trauma
5. Describe three reasons for an irregularly irregular pulse.
Atrial fibrillation
Multiple ventricular actopic beats
Atrial flutter with variable block
6. Give two causes of asymmetrical radial pulses
Acute aortic dissection
Proximal arterial disease eg atherosclerosis
7. What is a collapsing pulse? In which condition does it occur?
The pulse vibrates down your fingers when holding the patient’s wrist, raised.
Occurs in aortic regurgitation.
8. What is radiofemoral delay? Name the condition in which it features.
Femoral and radial pulses not in time with each other, the femoral pulse is felt slightly after the radial. Sign of coarctation of the aorta.
9. What are Korotkoff sounds?
Sounds heard over an artery when pressure over it is reduced below systolic arterial pressure.
10. What is the significance of phase I, IV, V Korotkoff sounds?
I – height of systole
IV – the sounds quieten suddenly when the cuff pressure is less than diastolic pressure
V – the sounds stop completely (not always present)
11. What is malar flush and when does it occur?
Rosy cheeks with something of a bluish tinge – Occurs in mitral stenosis
12. Give two signs of hyperlipidaemia.
Xanthalesmata, corneal arcus
These questions were set by my medical school based on clinical skills surrounding the cardiovascular system, and the answers are those I believe to be correct.
1. What are the murmurs of mitral stenosis, mitral regurgitation, aortic stenosis, and aortic regurgitation?
Mitral stenosis – mid-diastolic murmur
Mitral regurgitation – pansystolic murmur
Aortic stenosis – ejection systolic murmur
Aortic regurgitation – early diastolic murmur
2. Give two causes of clubbing
Cyanotic congenital heart disease, infective endocarditis
3. What are splinter haemorrhages?
Small haemorrhages within the nailbed under the nail
4. Give two causes of splinter haemorrhages. Are they embolic or vasculitic?
Infective endocarditis – vasculitic, caused by trauma
5. Describe three reasons for an irregularly irregular pulse.
Atrial fibrillation
Multiple ventricular actopic beats
Atrial flutter with variable block
6. Give two causes of asymmetrical radial pulses
Acute aortic dissection
Proximal arterial disease eg atherosclerosis
7. What is a collapsing pulse? In which condition does it occur?
The pulse vibrates down your fingers when holding the patient’s wrist, raised.
Occurs in aortic regurgitation.
8. What is radiofemoral delay? Name the condition in which it features.
Femoral and radial pulses not in time with each other, the femoral pulse is felt slightly after the radial. Sign of coarctation of the aorta.
9. What are Korotkoff sounds?
Sounds heard over an artery when pressure over it is reduced below systolic arterial pressure.
10. What is the significance of phase I, IV, V Korotkoff sounds?
I – height of systole
IV – the sounds quieten suddenly when the cuff pressure is less than diastolic pressure
V – the sounds stop completely (not always present)
11. What is malar flush and when does it occur?
Rosy cheeks with something of a bluish tinge – Occurs in mitral stenosis
12. Give two signs of hyperlipidaemia.
Xanthalesmata, corneal arcus
Respiratory Questions, Cox and Roper Clinical Skills
These are the answers I believe to be correct for questions on P122-123 Clinical Skills, by Cox and Roper
1. Give three causes of chronic cough not due to chest disease
- Gastro-oesophageal reflux disease
- Post-nasal drip
- Angiotensin-converting enzyme inhibitor
2. Does the cough of lung cancer have clear characteristic features?
- Not necessarily, however a new, persistent cough, or patients with a chronic cough who present with a change in cough pattern should have an X-Ray performed.
- cough + weight loss, anorexia, or haemoptysis
3. What might foul-smelling sputum be indicative of?
- Anaerobic infections
4. What is the nail-bed angle?
- Angle from the nail to the nail-bed on the fingers
5. What are the three commonest causes of clubbing?
- Bronchiectasis
- Lung cancer
- Idiopathic pulmonary fibrosis
6. Name another six causes of clubbing
- Infective endocarditis
- Asbestosis
- Lung abscess
- Empyema
- Mesothelioma
- Congenital heart disease with right-to-left shunt
7. Why does clubbing occur?
- Unknown, possibly megakaryocytes gaining access to systemic circulation, becoming trapped in the capillaries in the fingers, where they release growth factors into surrounding tissue.
8. What is hypertrophic pulmonary osteoarthropathy?
- Rare inflammation of periosteum at the ends of long bones
- May cause tenderness and swelling over fingers and wrists
9. Give two features that suggest that an acute asthma attack is severe.
- Pulsus paradoxus
- Pulse rate >110/min
10. What are the three key features of Horner’s syndrome?
- Small pupil (miosis)
- Drooping of eyelid (partial ptosis)
- Reducing sweating on the same side of the face (anhydrosis)
11. Give four causes of haemoptysis.
- Heart failure
- Tuberculosis
- Pulmonary infarction
- Bronchiectasis
12. What circumstances would require urgent action in a case of haemoptysis?
- Any suggestion of pulmonary embolism
- If there is evidence of infection
- If heart failure appears a possibility
13. What is pigeon fanciers’ lung?
- Chronic breathlessness
- Hypersensitivity pneumonitis
14. What is a flapping tremor and what is its possible significance in respiratory cases?
- Irregular, coarse, jerky movement of the wrist
- Sign of CO2 retention, indicative that the patient is in a critical condition. Can occasionally be present in mild illness and absent in severe illness. May also be found in liver failure or kidney failure.
15. Give three causes of Horner’s syndrome.
- Stroke
- Lung tumour
- Skull fracture, cavernous sinus thrombosis
16. What is the difference between a lung lobe and zone?
- Zone: chest divided into thirds – used to describe the radiological situation of any lung abnormality.
- Lobe: parts the lungs are divided into anatomically, right lung has 3 lobes, left lung has 2 lobes.
17. Give three causes of tracheal deviation.
- unilateral upper lobe fibrosis or collapse
- tension pneumothorax
- large pleural effusion
18. If one side of the chest is duller than the other, it is usually that side that is abnormal. What is the exception to this rule?
- Left side of the chest at the front – this is the patient’s heart
19. What is the tobacco exposure in pack years for a patient who has smoked 40 cigarettes a day for 30 years?
- 2 x 30 = 60 pack years
20. What conditions can be associated with asbestos exposure?
- fibrosis (asbestosis)
- lung cancer
- mesothelioma
21. What respiratory infection would you suspect if the patient’s bird had recently died following an illness?
- Chlamydia psittaci infection, causing psittacosis, a form of pneumonia
22. Give one cause of increased tactile vocal fremitus and three causes of reduced tactile vocal fremitus.
- Consolidation increases TVF
- Effusion, collapse and pneumothorax reduce TVF
23. Describe the difference between bronchial and vesicular breath sounds.
- Bronchial breath sounds are harsher and tend to sound louder than vesicular breath sounds, and the gap is between inspiration and expiration instead of the vesicular expiration then inspiration gap.
24. Give two mechanisms by which crackles occur.
- Due to changes in gas pressure causing sudden opening of small airways that had collapsed during previous expiration – pulmonary fibrosis cause
- Due to air bubbling through fluid in small airways and alveoli – left ventricular failure cause
25. What two features of wheezes correlate with the severity of obstruction?
- Pitch
- Duration
26. Which lymph node site does lung cancer usually spread to?
- Supraclavicular nodes
27. Which lymph node site does breast cancer usually spread to?
- Nodes in the axilla
28. What are the two main categories of pleural effusion?
- Transudates and exudates according to protein content of the fluid.
29. Give 10 causes of pleural effusion.
- Heart failure
- Pulmonary emboli
- Hypoalbuminaemia
- Pneumonia
- Tuberculosis
- Tumour – bronchial carcinoma, breast cancer, lymphoma, mesothelioma
- Collagen vascular disease
- Pulmonary infarction
- Asbestos exposure
- Abdominal pathology
30. What is Schamroth’s sign?
- If a patient places their terminal phalanges of corresponding fingers of both hands back to back, it produces a small diamond shaped aperture between both nail beds. When clubbing is present, this window is abolished.
31. What is Cheyne- Stokes respiration? Name two associations.
- Patient’s breath becomes gradually deeper and deeper and then more and more shallow. As the breathing becomes more and more shallow, it slows down and there may be apnoeic pauses for several seconds before the cycle resumes.
- May occur in heart failure or in reduce levels of consciousness e.g. stroke, opiate overdose, head injury.
32. How is cyanosis produced?
- Deoxygenated Hb gives blood a blue colour. Skin and mucous membranes appear blue due to excess deoxygenated Hb
33. What is methaemaglobinaemia?
- Blue discolouration of the skin due to abnormal haemoglobin. The iron ion is the ferric 3+ form rather than ferrous 2+ form. Enzyme deficiencies can result in increased levels.
34. Give four physical signs of superior vena cava obstruction.
- Head and neck veins become engorged, and loss of jugular pulsations. Raised non-pulsatile JVP. Face and neck become oedematous. May be visible distended veins on chest wall.
35. Compare percussion note, breath sounds, and tactile vocal fremitus in lung consolidation, lung collapse and pleural effusion.
- Lung consolidation: dull percussion note, bronchial breath sounds with coarse crackles, increased TVF
- Lung collapse: normal or dull percussion, decreased breath sounds, may have bronchial breathing, decreased TVF
- Pleural effusion: very dull percussion, breath sounds vesicular but decreased, decreased TVF
36. What is Cor Pulmonale?
- Advanced pulmonary disease causing right heart failure, hence and elevated JVP
37. What is Kussmaul’s respiration?
- Hyperventilation as a compensatory response to metabolic acidosis and renal failure
- Occurs in diabetic ketoacidosis and renal failure
38. What are the accessory muscles of breathing?
- Sternocleidomastoid
- Scalene muscles
- Trapezius
39. What happens to the FEV1/FVC in small airways obstruction and pulmonary fibrosis?
- In small airways obstruction, both FEV1 and FVC are reduced, but the FEV1 disproportionately so, so that the FEV1/FVC is reduced.
- In pulmonary fibrosis, again both FEV1 and FVC are reduced, but the FVC disproportionately more so, so that the FEV1/FVC is increased.
40. What examination features would you expect with a left-sided pneumothorax?
- Central trachea, decreased expansion on the LHS, hyper-resonant on LHS, decreased vocal resonance and tactile vocal fremitus on the LHS, reduced breath sounds on LHS
41. What is surgical emphysema?
- Characteristic crackling sensation under the hand in the upper chest and neck
42. What is pectus excavatum?
- Funnel chest, a depressed sternum, congenital, usually idiopathic
43. What is pectus carinatum?
- Pigeon chest, a prominent sternum, develops in childhood in patients with rickets or severe chest disease
44. Describe the characteristics of bronchial breathing. In which conditions might you encounter it?
- Bronchial breathing has a harsh, blowing quality to the sound. The loudest component is expiratory. The sound originates in the large airways.
- Small airway and alveolar damage. Consolidated lung.
45. When might you hear a pleural rub?
- Friction rub, due to rough thickened pleural surfaces rubbing together. Pleural inflammation e.g. pneumonia, pulmonary infarction, malignancy
46. What is whispering pectoriloquy and when might you encounter it?
- Patient whispers words, similar to vocal resonance test. Normally whispered words cannot be heard during auscultation with a stethoscope.
-Consolidated lung conducts high frequencies so in places of consolidation, whisper can be heard well. Can also be heard at the top of large pleural effusions where some collapse or consolidation can be found
1. Give three causes of chronic cough not due to chest disease
- Gastro-oesophageal reflux disease
- Post-nasal drip
- Angiotensin-converting enzyme inhibitor
2. Does the cough of lung cancer have clear characteristic features?
- Not necessarily, however a new, persistent cough, or patients with a chronic cough who present with a change in cough pattern should have an X-Ray performed.
- cough + weight loss, anorexia, or haemoptysis
3. What might foul-smelling sputum be indicative of?
- Anaerobic infections
4. What is the nail-bed angle?
- Angle from the nail to the nail-bed on the fingers
5. What are the three commonest causes of clubbing?
- Bronchiectasis
- Lung cancer
- Idiopathic pulmonary fibrosis
6. Name another six causes of clubbing
- Infective endocarditis
- Asbestosis
- Lung abscess
- Empyema
- Mesothelioma
- Congenital heart disease with right-to-left shunt
7. Why does clubbing occur?
- Unknown, possibly megakaryocytes gaining access to systemic circulation, becoming trapped in the capillaries in the fingers, where they release growth factors into surrounding tissue.
8. What is hypertrophic pulmonary osteoarthropathy?
- Rare inflammation of periosteum at the ends of long bones
- May cause tenderness and swelling over fingers and wrists
9. Give two features that suggest that an acute asthma attack is severe.
- Pulsus paradoxus
- Pulse rate >110/min
10. What are the three key features of Horner’s syndrome?
- Small pupil (miosis)
- Drooping of eyelid (partial ptosis)
- Reducing sweating on the same side of the face (anhydrosis)
11. Give four causes of haemoptysis.
- Heart failure
- Tuberculosis
- Pulmonary infarction
- Bronchiectasis
12. What circumstances would require urgent action in a case of haemoptysis?
- Any suggestion of pulmonary embolism
- If there is evidence of infection
- If heart failure appears a possibility
13. What is pigeon fanciers’ lung?
- Chronic breathlessness
- Hypersensitivity pneumonitis
14. What is a flapping tremor and what is its possible significance in respiratory cases?
- Irregular, coarse, jerky movement of the wrist
- Sign of CO2 retention, indicative that the patient is in a critical condition. Can occasionally be present in mild illness and absent in severe illness. May also be found in liver failure or kidney failure.
15. Give three causes of Horner’s syndrome.
- Stroke
- Lung tumour
- Skull fracture, cavernous sinus thrombosis
16. What is the difference between a lung lobe and zone?
- Zone: chest divided into thirds – used to describe the radiological situation of any lung abnormality.
- Lobe: parts the lungs are divided into anatomically, right lung has 3 lobes, left lung has 2 lobes.
17. Give three causes of tracheal deviation.
- unilateral upper lobe fibrosis or collapse
- tension pneumothorax
- large pleural effusion
18. If one side of the chest is duller than the other, it is usually that side that is abnormal. What is the exception to this rule?
- Left side of the chest at the front – this is the patient’s heart
19. What is the tobacco exposure in pack years for a patient who has smoked 40 cigarettes a day for 30 years?
- 2 x 30 = 60 pack years
20. What conditions can be associated with asbestos exposure?
- fibrosis (asbestosis)
- lung cancer
- mesothelioma
21. What respiratory infection would you suspect if the patient’s bird had recently died following an illness?
- Chlamydia psittaci infection, causing psittacosis, a form of pneumonia
22. Give one cause of increased tactile vocal fremitus and three causes of reduced tactile vocal fremitus.
- Consolidation increases TVF
- Effusion, collapse and pneumothorax reduce TVF
23. Describe the difference between bronchial and vesicular breath sounds.
- Bronchial breath sounds are harsher and tend to sound louder than vesicular breath sounds, and the gap is between inspiration and expiration instead of the vesicular expiration then inspiration gap.
24. Give two mechanisms by which crackles occur.
- Due to changes in gas pressure causing sudden opening of small airways that had collapsed during previous expiration – pulmonary fibrosis cause
- Due to air bubbling through fluid in small airways and alveoli – left ventricular failure cause
25. What two features of wheezes correlate with the severity of obstruction?
- Pitch
- Duration
26. Which lymph node site does lung cancer usually spread to?
- Supraclavicular nodes
27. Which lymph node site does breast cancer usually spread to?
- Nodes in the axilla
28. What are the two main categories of pleural effusion?
- Transudates and exudates according to protein content of the fluid.
29. Give 10 causes of pleural effusion.
- Heart failure
- Pulmonary emboli
- Hypoalbuminaemia
- Pneumonia
- Tuberculosis
- Tumour – bronchial carcinoma, breast cancer, lymphoma, mesothelioma
- Collagen vascular disease
- Pulmonary infarction
- Asbestos exposure
- Abdominal pathology
30. What is Schamroth’s sign?
- If a patient places their terminal phalanges of corresponding fingers of both hands back to back, it produces a small diamond shaped aperture between both nail beds. When clubbing is present, this window is abolished.
31. What is Cheyne- Stokes respiration? Name two associations.
- Patient’s breath becomes gradually deeper and deeper and then more and more shallow. As the breathing becomes more and more shallow, it slows down and there may be apnoeic pauses for several seconds before the cycle resumes.
- May occur in heart failure or in reduce levels of consciousness e.g. stroke, opiate overdose, head injury.
32. How is cyanosis produced?
- Deoxygenated Hb gives blood a blue colour. Skin and mucous membranes appear blue due to excess deoxygenated Hb
33. What is methaemaglobinaemia?
- Blue discolouration of the skin due to abnormal haemoglobin. The iron ion is the ferric 3+ form rather than ferrous 2+ form. Enzyme deficiencies can result in increased levels.
34. Give four physical signs of superior vena cava obstruction.
- Head and neck veins become engorged, and loss of jugular pulsations. Raised non-pulsatile JVP. Face and neck become oedematous. May be visible distended veins on chest wall.
35. Compare percussion note, breath sounds, and tactile vocal fremitus in lung consolidation, lung collapse and pleural effusion.
- Lung consolidation: dull percussion note, bronchial breath sounds with coarse crackles, increased TVF
- Lung collapse: normal or dull percussion, decreased breath sounds, may have bronchial breathing, decreased TVF
- Pleural effusion: very dull percussion, breath sounds vesicular but decreased, decreased TVF
36. What is Cor Pulmonale?
- Advanced pulmonary disease causing right heart failure, hence and elevated JVP
37. What is Kussmaul’s respiration?
- Hyperventilation as a compensatory response to metabolic acidosis and renal failure
- Occurs in diabetic ketoacidosis and renal failure
38. What are the accessory muscles of breathing?
- Sternocleidomastoid
- Scalene muscles
- Trapezius
39. What happens to the FEV1/FVC in small airways obstruction and pulmonary fibrosis?
- In small airways obstruction, both FEV1 and FVC are reduced, but the FEV1 disproportionately so, so that the FEV1/FVC is reduced.
- In pulmonary fibrosis, again both FEV1 and FVC are reduced, but the FVC disproportionately more so, so that the FEV1/FVC is increased.
40. What examination features would you expect with a left-sided pneumothorax?
- Central trachea, decreased expansion on the LHS, hyper-resonant on LHS, decreased vocal resonance and tactile vocal fremitus on the LHS, reduced breath sounds on LHS
41. What is surgical emphysema?
- Characteristic crackling sensation under the hand in the upper chest and neck
42. What is pectus excavatum?
- Funnel chest, a depressed sternum, congenital, usually idiopathic
43. What is pectus carinatum?
- Pigeon chest, a prominent sternum, develops in childhood in patients with rickets or severe chest disease
44. Describe the characteristics of bronchial breathing. In which conditions might you encounter it?
- Bronchial breathing has a harsh, blowing quality to the sound. The loudest component is expiratory. The sound originates in the large airways.
- Small airway and alveolar damage. Consolidated lung.
45. When might you hear a pleural rub?
- Friction rub, due to rough thickened pleural surfaces rubbing together. Pleural inflammation e.g. pneumonia, pulmonary infarction, malignancy
46. What is whispering pectoriloquy and when might you encounter it?
- Patient whispers words, similar to vocal resonance test. Normally whispered words cannot be heard during auscultation with a stethoscope.
-Consolidated lung conducts high frequencies so in places of consolidation, whisper can be heard well. Can also be heard at the top of large pleural effusions where some collapse or consolidation can be found
Monday, 6 July 2009
Central Lines
Central Lines
A central line (aka central venous catheter, CVL, CVC) is a large bore cannla or catheter which is inserted into a large vein in the body. The tip of the cannula may lie in either the superior or inferior vena cava (SVC or IVC) or into the right atrium (RA).
Below is a picture of a CVL.
There are a number of indications for inserting a central line, including:
Below are examples of CVL placement.
Inserting a CVL
Firstly, the site of insertion should be cleansed, and a sterile field prepared. The following video shows a version of the procedure:
Central lines are inserted with the patient in the 'Trendelenberg position'; lying down and facing away from the site of insertion. This is to aid identification of the required vein. Guidelines now advise ultrasound to be used to ensure the needle is placed correctly, and not inserted into the internal carotid or subclavian arteries. Studies have shown that ultrasound guidance increases the success rate of correct CVL insertion and reduces liklihood of any complication.
After the vein has been correctly located a guide wire is pased through the needle into the vein. The cannula or catheter is then passed over the guide wire into the vein and the guide wire can be removed.
Below is an X-ray showing a CVL correctly inserted:
Complications
A central line (aka central venous catheter, CVL, CVC) is a large bore cannla or catheter which is inserted into a large vein in the body. The tip of the cannula may lie in either the superior or inferior vena cava (SVC or IVC) or into the right atrium (RA).
Below is a picture of a CVL.
There are a number of indications for inserting a central line, including:- Measuring central venous pressure (CVP)
- Administering drugs or products which could damage smaller vessels, i.e. chemotherapy or parenteral nutrition
- Obtaining venous access in an individual whose peripheral veins have shut down, for example a patient in shock
- Administering high slow fluids - larger vessels required, as flow in a vessel is relative to the radius of that vessel to the power of 4
- Haemodialysis in renal failure
- Ease of IV access if required for a number of days, for example post-operatively
- Internal jugular vein
- Subclavian vein
- Femoral vein
- External jugular vein
Below are examples of CVL placement.
Inserting a CVLFirstly, the site of insertion should be cleansed, and a sterile field prepared. The following video shows a version of the procedure:
Central lines are inserted with the patient in the 'Trendelenberg position'; lying down and facing away from the site of insertion. This is to aid identification of the required vein. Guidelines now advise ultrasound to be used to ensure the needle is placed correctly, and not inserted into the internal carotid or subclavian arteries. Studies have shown that ultrasound guidance increases the success rate of correct CVL insertion and reduces liklihood of any complication.
After the vein has been correctly located a guide wire is pased through the needle into the vein. The cannula or catheter is then passed over the guide wire into the vein and the guide wire can be removed.
Below is an X-ray showing a CVL correctly inserted:
Complications
- Pneumothorax
- Haemothorax
- Arterial cannulation
- Injury to the thoracic duct
- Air embolism
- Infection
- Thrombus formation
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