Medicine Alasdair Scott BSc (Hons) MBBS PhD 2012 [email protected] Table of Contents 1. Cardiology ........................................................................................................................................... 1 2. Pulmonology ..................................................................................................................................... 35 3. Endocrinology ................................................................................................................................... 59 4. Gastroenterology ............................................................................................................................... 78 5. Nephrology ...................................................................................................................................... 103 6. Haematology ................................................................................................................................... 118 7. Infectious Disease ........................................................................................................................... 137 8. Neurology ........................................................................................................................................ 153 9. Rheumatology ................................................................................................................................. 198 10. Clinical Chemistry ......................................................................................................................... 211 11. Oncology ....................................................................................................................................... 222 12. Immunology ................................................................................................................................... 227 13. Dermatology .................................................................................................................................. 232 14. Epidemiology ................................................................................................................................. 240 15. Emergencies ................................................................................................................................. 246 Cardiology Contents Cardiac Electrophysiology ............................................................................................................................................................. 2  ECG Analysis ................................................................................................................................................................................ 3  ECG Abnormalities ........................................................................................................................................................................ 4  Bradycardias ................................................................................................................................................................................ 10  Narrow Complex Tachycardias = SVT ........................................................................................................................................ 11  Atrial Fibrillation ........................................................................................................................................................................... 13  Acute Coronary Syndromes ........................................................................................................................................................ 14  MI Complications ......................................................................................................................................................................... 15  STEMI Management.................................................................................................................................................................... 16  Angina Pectoris ........................................................................................................................................................................... 18  Heart Failure: Concepts and Causes .......................................................................................................................................... 19  Chronic Heart Failure .................................................................................................................................................................. 20  Severe Pulmonary Oedema ........................................................................................................................................................ 21  Cardiogenic Shock ...................................................................................................................................................................... 22  Hypertension ............................................................................................................................................................................... 23  Aortic Stenosis ............................................................................................................................................................................. 24  Aortic Regurgitation ..................................................................................................................................................................... 25  Mitral Stenosis ............................................................................................................................................................................. 26  Mitral Regurgitation ..................................................................................................................................................................... 27  Mitral Valve Prolapse (Barlow Syndrome) .................................................................................................................................. 27  Right Heart Valve Disease .......................................................................................................................................................... 28  Infective Endocarditis .................................................................................................................................................................. 29  Pericardial Disease...................................................................................................................................................................... 31  Myocardial Disease ..................................................................................................................................................................... 32  Congenital Heart Disease ........................................................................................................................................................... 33  Inherited Connective Tissue Disorders ....................................................................................................................................... 34  © Alasdair Scott, 2012 1 Cardiac Electrophysiology View Leads Vessel Inferior II, III, aVF RCA Anterolateral I, aVL, V5 + V6 L circumflex Anteroseptal V2-V4 LAD Anterior V2-V6 Left main stem Posterior V1, V2, V3 (recip) RCA © Alasdair Scott, 2012 2 ECG Analysis 1. Rate 6. PR interval (120-200ms)  300 / no. of large squares  Start of P wave to start of QRS  6 = 50  Long: heart block  5 = 60  Short  4 = 75  Accessory conduction: e.g. WPW  3 = 100  Nodal rhythm  2 = 150  HOCM  1 = 300  Depressed: pericarditis 2. Rhythm 7. QTc (380-420ms)  Look for P waves followed by QRS complexes  Start of QRS to end of T wave  AF  Bazett’s formula: QTc = actual QT/√R-R  No discernable P waves  Long (>420ms): TIMME  Irregularly irregular QRS  Toxins  Atrial flutter: saw-toothed baseline  Macrolides  Nodal rhythm: regular QRS but no P waves  Anti-arhythmics (Ia/III): quinidine, amiod  TCAs  Histamine antagonists 3. Axis  Inherited: e.g. Romano-Ward, Jervell (¯c SNHL)  I and II +ve = normal axis (-30 – +90)  Ischaemia  I +ve and II –ve (leaving) = LAD (-30 – -90)  Myocarditis  Mitral valve prolapse  I –ve and II +ve (reaching) = RAD (+90 – +180)  Electrolytes: ↓Mg, ↓K, ↓Ca, ↓ temp  Short (<380ms)  Digoxin RAD (> +90) LAD (<-30)  β-B Anterolateral MI Inferior MI  Phenytoin RVH, PE LVH L post. hemiblock L ant. Hemiblock WPW WPW 8. ST Segments ASD secundum ASD primum  Elevated (limbs: >1mm, chest: >2mm)  Acute MI 4. P Waves  Prinzmetal’s angina  Pericarditis: saddle-shaped  Absent: AF, SAN block, nodal rhythm  Aneurysm: ventricular  Dissociated: complete heart block  P mitrale: bifid P waves = LA hypertrophy  Depressed (>0.5mm)  HTN, AS, MR, MS  Ischaemia: flat  P pulmonale: peaked P waves= RA hypertrophy  Digoxin: down-sloping  pulmonary HTN, COPD 5. QRS 9. T-waves  Wide QRS (>120ms)  Normally inverted in aVR and V1  Ventricular initiation  + V2-V3 in blacks  Conduction defect  Abnormal if inverted in: I, II and V4-6  WPW  Strain  Pathological Q wave  Ischaemia  >1mm wide and > 2mm deep  Ventricular hypertrophy  Full Thickness MI  BBB  RVH: Dominant R wave in V1 + deep S wave in V6  Digoxin  LVH  Peaked in ↑K+  R wave in V6 >25mm  Flattened in ↓K+  R wave in V5/V6 + S wave in V1 > 35mm 10. Extras  U waves  Occur after T waves  Seen in ↓ K  J waves / Osborne wave  Occur between QRS and ST segment  Causes  hypothermia < 32OC  SAH  Hypercalcaemia © Alasdair Scott, 2012 3 ECG Abnormalities Conduction Defects Abnormality Features ECG 1st Degree Heart Block PR > 200ms 2nd Degree Heart Block Progressive lengthening of - Wenckebach /Mobitz I PR interval One non-conducted P wave Next conducted beat has shorter PR interval 2nd Degree Heart Block Constant PR - Mobitz II Occasional non-conducted P waves Often wide QRS - block is usually in bundle branches of Purkinje fibres 2nd Degree Heart Block Two P waves per QRS - 2:1 Block Normal consistent PR intervals 3rd Degree Heart Block P waves and QRS @ different rates - dissociation Abnormally shaped QRS - ventricular origin (40bpm) Abnormality Features ECG Aetiology Right BBB MaRRoW Infarct – Inferior MI Wide QRS Normal variant RSR pattern in V1 Congenital – ASD, VSD, Fallot’s Hypertrophy – RVH (PE, Cor Pulmonale) Left BBB WiLLiaM Fibrosis Wide QRS ¯c notched LVH – AS, HTN top Infarct – Inf. MI T wave inversion in lat Coronary HD leads Bifascicular Block RBBB + LAD RBBB + Left ant. hemiblock Trifascicular Block RBBB + LAFB + 1st degree AV block © Alasdair Scott, 2012 4 Escape Rhythms: appear late (after anticipated beat) Abnormality Features ECG Atrial Escape SAN fails to depolarise Abnormal P wave Normal QRS 60-80bpm Junctional Escape Usually no P waves (occasionally after QRS) Normal QRS 40-60bpm Ventricular Escape Usually result of complete AV block  regular P waves seen (top). May be SAN failure → no P waves (below). Wide QRS, 20bpm Extrasystoles: appear early (before anticipated beat) Abnormality Features ECG Atrial Extrasystole Abnormal P wave Normal QRS Nodal Extrasystole P wave buried in QRS or sometimes immediately before/after QRS. - may be negative Normal QRS Ventricular No P wave. Extrasystole Wide QRS and abnormal T wave. © Alasdair Scott, 2012 5 Narrow Complex Tachycardias Abnormality Features ECG AV Nodal Re- P wave absent or immediately entrant before/after QRS Tachycardia Normal QRS AVRT P waves usually visible between QRS complexes QRS may be narrow or wide Accessory conduction bundle Atrial Tachycardia Abnormally shaped P waves Normal QRS complexes. Rate > 150bpm May be assoc. ¯c AV block. Atrial Flutter “Saw-toothed” baseline as atria contract @ 300bpm. AVN can’t conduct > 200bpm  AV block occurs. - 2:1(150), 3:1(100), 4:1(75) Normal QRS Atrial Fibrillation No P waves – irregular line Irregularly irregular QRS © Alasdair Scott, 2012 6 Broad Complex Tachycardias Abnormality Features ECG VT No P waves Regular, wide QRS No T waves Torsades VF Shapeless, rapid oscillations and no organised complexes. Ventricular tachycardia vs. SVT with bundle branch block VT more likely if:  Hx: recent infarction  Atrioventricular dissociation  Broad QRS complexes (>140ms)  Concordant QRS direction in V1-V6  Fusion and capture beats © Alasdair Scott, 2012 7 P Wave Abnormalities Abnormality Features ECG Aetiology P pulmonale Peaked P wave RAH - pulmonary HTN - tricuspid stenois P mitrale Broad, bifid P wave LAH - mitral stenois QRS Abnormalities Abnormality Features ECG Aetiology RVH Tall R wave in V1 Cor pulmonale Deep S wave in V6 RAD Normal QRS width May be T wave inversion in V1-V3 LVH S in V1 + R in V6 >35mm HTN and/or R wave in V6 >25mm AS COA May be LAD H(O)CM May be T wave inversion in II, aVL, V5, V6 © Alasdair Scott, 2012 8