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“Mr Anderson has been referred to general medical outpatients on account of feeling unwell. Please take a full history and discuss your findings with the examiners.”
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Left sided heart valves are most commonly affected in infective endocarditis, and infection of the heart valves, apart from patients who are intravenous drug users, who have a 50:50 chance of having right sided infective endocarditis. The most common organisms are Streptococcus viroid and and Staphylococcus aureus. Empirical treatment should begin with intravenous benzylpenicillin and gentamicin.
The most common clinical signs are splinter haemorrhages in the nails, Janeway lesions (palmar macules), Osler’s nodes (painful finger pulps) and Roth’s spots (black spots on the fundus).
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With which cancer is
Streptococcus bovis endocarditis associated with?
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questions for PACES
Clinical Skills Pro
Nidhi Gupta < [email protected]>
questions for PACES
Which of the following are causes of microcytic anaemia?
1. Combined deficiency
2. Iron deficiency
Answers 2 and 3
Anaemia should be defined by size, whether microcytic, normacytic or macrocytic. An MCV of over 110 fL is typical of either a vitamin B12 or folate deficiency. Another cause of macrocytic anaemia is thalassaemia, and this typically presents with a microcytosis and high red cell count above 5 x 10^9/L. Normocytic anaemias tend to be caused by chronic disease, such as cancer or renal disease.
Which of the following is not a cause of a macrocytic anaemia?
1. Liver disease
2. B12 deficiency
4. Combined deficiency
5. Aplastic anaemia
Match the following investigations with the sign and diagnosis
(I've written the right ones)
Blood film for spherocytes of haemolytic anaemia
Blood film for elliptocytes for haemolytic anaemia
Direct Coombs' test for autoimmune haemolysis
Which of the following triad is correct for Congenital haemolytic anaemia?
Anaemia, splenomegaly and jaundice
Anaemia, splenomegaly and purpura
Anaemia splenomegaly and renal failure
Anaemia, liver disease and renal failure
Anaemia, jaundice and thrombocytopenia
Congenital haemolytic anaemia can be divided by geographical type of defect. Membrane defect causes: spherocytosis and elliptocytosis. Enzyme defect: glucose-6-phosphate dehydrogenase deficiency and haemaglobinopathies are thalassaemia and sickle cell disease.
Congenital haemolytic anaemia is suggested by a positive family history and a triad of anaemia, splenomegaly and jaundice. The most common one is hereditary spherocytosis, with an autosomal dominant inheritance. G6PD is essential in maintaining cell integrity to oxidative stress (in drugs such as dapsone, quinine and nitrofurantoin) which when deficient then leads of haemolysis of red blood cells when exposed to such oxidative stress.
Which of the following are natural anti-coagulants in the body?
The body contains three natural anti-coagulants: anti-thrombin 3 , Protein C and Protein S. If any of these are deficient, this pre-disposes to impaired function. Factor V Leiden is by far the most frequent genetic deficiency that leads to a failure of Protein C in being able to bind to a defective factor 5 which then stops the clotting cascade and leads to a thrombotic state. Factor V Leiden NAND the less commonly seen Protein S and Protein C deficiencies are autosomal dominantly inherited.
Which of the following is associated with anti-thrombin 3 deficiency?
End stage renal failure due to diabetes
Nephrotic syndrome increases the risk of thromboembolic phenomena in the arteries and veins due to anti-thrombin 3 loss from the kidneys.
Define the three types of atrial fibrillation. Free text
Permanent, persistent and paroxysmal.
Persistent atrial fibrillation is different to permanent, because the former is amenable to cardioversion.
Which of the following are found in an Atrial Septal Defect?
Right bundle branch block
Left Atrial hypertrophy
Right Ventricular hypertrophy
Loud systolic murmur
Left bundle branch block
Left axis deviation on ECG
Right axis deviation on ECG
Which direction does the blood flow in an atrial septal defect?
Left to right
Right to left
What percentage of adults have an unfused foramen ovale?
Which is correct?
Ostium primum ASD is present in the low atrium
Ostium primum ASD is present in the high atrium
Ostium secundum ASD is present in the low atrium
Ostium secundum ASD is present in the high atrium
In an ASD, in which order is the second heart sound split?
Pulmonary then aortic
Aortic then pulmonary
Which genetic condition is Ostium primum ASD associated with?
Ostium Secundum atrial septal defects (ASD) typically have a quiet systolic murmur with right axis deviation, a right bundle branch block and evidence of right ventricular hypertrophy, with a secundum. Ostium primum ASD have the same features but with a left axis deviation rather than right. ASDs are classified from the ventricles upwards and so Ostium primum ASDs are in the lower part of the atrium and Ostium secundum ASDs are present in the upper part.
The second heart sound is a fixed split because the normal splitting, which varies with inspiration due to increased negative pressure is not present. There is an equal distribution of blood on go the sides of the heart and so the splitting is fixed.
What percentage of congenital heart conditions are caused by ventricular septal defects?
Do small asymptomatic VSDs require prophylaxis for subacute bacteria, endocarditis
Answer is yes
What is the normal QT?
< 0.40 ms
< 0.42 ms
< 0.44 ms
< 0.46 ms
< 0.48 ms
Which of the following drugs causes a shortening of the QT interval?
Digoxin is the only cardiac drug that is known to cause QT shortening. It can also cause xanthopsia which is yellow tinged vision. It can cause a reverse tick ST depression which is not a sign of toxicity. Toxicity symptoms include nausea, vomiting, diarrhoea and atrioventricular (AV) block. It is contra-indicated in Wolff-Parkinson-White syndrome because it is an AV-node blocker (along with verapamil) which would then encourage the use of the accessory pathway. Both these drugs are also contra-indicated in cardiac amyloid. It should be used with caution in renal impairment as it is renally excreted.
Eisenmenger's syndrome is a condition caused most commonly by a large ventricular septal defect (VSD). It is characterised by right ventricular hypertrophy, elevated right sided heart pressures and pulmonary hypertension. If there are any left-to-right shunts, these are then reversed. Mortality is high once set in, and so early surgery is indicated to recent its onset. The clinical findings are of cyanosis, clubbing and pulmonary hypertension with a loud pulmonary second heart sound, a left parasternal heave and a prominent 'a' wave seen in the jugular venous pressure (JVP). The 12-lead electrocardiogram will show right ventricular hypertrophy (combination of R in V1 and S in V5 greater than 12 small squares). There will be prominent vascular markings on a plain chest radiograph with peripheral pruning indicating pulmonary hypertension.
With which cancer is Streptococcus bovis endocarditis associated with?
2 of 2
What is the normal duration of treatment for infective endocarditis?