Passmedicine*

Anaesthetics*and*perioperative*care* 2*
Breast*surgery* 6*
Cardiology* 9*
Contraception* 19*
Dermatology* 22*
Endocrinology* 32*
ENT* 42*
Ethics* 47*
Gastroenterology* 48*
General*surgery* 59*
Gynaecology* 68*
Haematology* 75*
Infectious*disease* 83*
Metabolic*medicine* 95*
Nephrology* 99*
Neurology* 104*
Neurosurgery* 116*
Obstetrics* 118*
Oncology* 129*
Ophthalmology* 131*
Orthopaedics* 135*
Paediatrics* 147*
Pharmacology* 167*
Psychiatry* 179*
Respiratory* 184*
Rheumatology* 193*
Urology* 198*
Vascular*surgery* 204*
*
Anaesthetics*and*perioperative*care*
ASA*classification:*assessment*tool*to*stratify*risk*for*patients*undergoing*surgery.*
• ASA*I:*normal*healthy*patient*–*nonUsmoker,*minimal*alcohol*intake.*
• ASA*II:*patient*with*systemic*disease*–*smoker,*pregnant,*social*alcohol*intake,*obese,*controlled*diabetes,*
controlled*hypertension.*
• ASA*III:*patient*with*severe*systemic*disease*–*poorly*controlled*diabetes,*COPD,*morbid*obesity*(BMI*>*40),*
liver*disease,*endUstage*renal*disease.*
• ASA*IV:*patient*with*severe*systemic*disease*that*has*a*high*risk*of*death*–*IHD,*recent*MI,*severe*heart*
failure,*sepsis.*
• ASA*V:*patient*who*is*not*expected*to*survive*without*surgery*–*ruptured*aneurysm,*massive*trauma,*
intracranial*bleed,*ischemic*bowel,*multiple*organ*failure.*
• ASA*VI:*brainUdead*patient*whose*organs*are*harvested*for*donor*purposes.*
Surgery*preparation*
• Patients*should*be*starved*for*6*hours*and*have*no*clear*fluids*for*2*hours*before*operation.*
• COC:*cease*use*4*weeks*prior*to*surgery*if*possible*and*restart*2*weeks*postUop.*
• COC:*if*unable*to*be*stopped*before*surgery*(eg.*emergency),*thromboprophylaxis*should*be*given*before*
surgery.*
• LMWH*should*be*given*to*patients*with*a*high*risk*of*thromboembolic*disease*prior*to*surgery.*
• Anaemia:*very*low*haemoglobin*should*be*corrected*with*a*preoperative*blood*transfusion.**
Iron*transfusion*(days)*or*oral*iron*(weeks)*takes*a*long*time*to*take*effect.*
• Emergency*cases*require*antibiotics*and*group*and*hold.*
• Poorly*controlled*diabetics*require*IV*insulin*infusion*before*surgery.*
PostUop*care*
• Venous*thromboembolism*prophylaxis:*TED*stockings*and*LMWH*for*6U12*hours*after*surgery.*
• Wound*dehiscence:*when*the*wound*ruptures*along*the*surgical*incision.*Emergency*repair*is*required.*
• PostUop*wound*cleaning:*use*sterile*saline*for*the*first*48*hours.*
• Drugs*that*impair*wound*healing*include*NSAIDs,*steroids,*immunosuppressants.*
Surgery*complications*
• Poorly*controlled*diabetes*increases*risk*of*wound*infection*and*slows*healing.*
• Ureter*injury*may*occur*during*colonic*resection*and*gynaecological*surgery.*
• PostUop*urinary*retention:*presents*with*severe*pain*after*removal*of*catheter.*
• PostUop*urinary*retention:*risk*factors*include*removal*of*urinary*cathether,*constipation,*imobility,*opioids.*
• Paralytic*ileus:*common*complication*of*bowel*surgery.*Absent*peristalsis*causes*pseudoUobstructive*
symptoms*such*as*obstipation,*vomiting,*abdominal*distention*and*absent*bowel*sounds.**
• PostUop*ileus:*common*complication*of*colorectal*surgery;*management*is*nil*by*mouth*and*nasogastric*
feeding.*
• PostUop*anastomotic*leak:*typically*occurs*5U7*days*postUop.*Presents*with*fever,*oliguria,*diarrhoea,*
peritonitis*and*may*lead*to*sepsis.*
• PostUop*portal*vein*thrombosis:*can*lead*to*sepsis*(due*to*coagulopathy)*and*deranged*LFTs.*
• Venous*thromboembolism:*presents*5U10*days*after*surgery*and*is*accompanied*by*shortness*of*breath.*

* 2*
• Venous*thromboembolism:*risk*factors*include*surgery,*old*age,*cancer,*thrombophilia,*reduced*mobility,*
obesity,*COC*use,*vascular*disease,*dehydration,*previous*thrombosis.*
• Damage*to*lungs*may*cause*an*air*leak*that*manifests*itself*as*a*persistent*pneumothorax*that*fails*to*settle*
despite*chest*drainage.**
• Damage*to*lymphatic*ducts*may*cause*a*chyle*leak,*which*shows*as*a*pale*opalescent*liquid*when*drained*
from*a*chest*drain.*
• Laparoscopy:*associated*with*fewer*adhesions*than*open*surgery.*
• Laparoscopy:*complications*include*risks*of*GA,*vasovagal*reaction*(in*response*to*abdominal*distension),*
surgical*emphysema*(extraUperitoneal*gas*insufflation),*injury*to*GI*tract,*injury*to*blood*vessels.*
• Gastrectomy:*a*common*complication*is*dumping*syndrome*–*food*of*high*osmotic*potential*moves*into*small*
intestine*causing*a*fluid*shift;*this*also*may*cause*rebound*hypoglycaemia*as*the*high*glucose*value*in*small*
intestine*causes*an*overshoot*of*insulin*release.*
• Gastrectomy:*other*complications*include*iron*deficiency,*weight*loss,*early*satiety,*osteoporosis,*
osteomalacia,*vitamin*B12*deficiency;*increased*risk*of*gallstones*and*gastric*cancer.*
• PostUgastrectomy*syndrome:*complications*include*small*capacity*(early*satiety),*dumping*syndrome,*bile*
gastritis,*anaemia*(B12*deficiency),*metabolic*bone*disease,*loop*syndrome.*
• Thyroid*surgery:*complications*include*laryngeal*nerve*damage,*bleeding*(haematoma*formation),*damage*to*
parathyroid*glands*(hypocalcaemia).*
• Hysterectomy:*longUterm*complications*of*vaginal*hysterectomy*with*anteroUposterior*repair*include*
enterocoele*and*vaginal*vault*prolapse.*
• Hypertrophic*scar:*caused*by*excessive*collagen*deposition*within*scar*and*remains*confined*to*boundaries*
of*the*original*wound.*
• Keloid*scar:*caused*by*excessive*collagen*deposition*within*scar*and*passes*beyond*boundaries*of*original*
wound.*May*be*treated*with*steroids*or*excision.*
• Malignant*hyperthermia:*condition*often*seen*following*administration*of*anaesthesia*and*is*characterised*
by*hyperpyrexia*and*muscle*rigidity.*
• Malignant*hyperthermia:*causative*agents*include*halothane,*suxamethonium,*antipsychotics;*reversing*
agent*is*dantrolene.*
• Infections*of*surgical*site:*use*antibiotic*prophylaxis*if*placing*prosthesis*or*valve,*cleanUcontaminated*
surgery,*contaminated*surgery.*
Surgical*transfusion*
• In*surgeries*where*tranfusion*is*unlikely,*group*and*save.**
Examples:*hysterectomy,*appendicectomy,*elective*caesarean*section,*laparoscopic*cholecystectomy.*
• In*surgeries*where*transfusion*is*likely,*crossUmatch*2*units.**
Examples:*total*hip*replacement,*salpingectomy*for*ruptured*ectopic*pregnancy.*
• In*surgeries*where*transfusion*is*certain,*crossUmatch*4U6*units.**
Examples:*total*gastrectomy,*oophorectomy,*oesophagectomy,*AAA*repair,*cystectomy,*hepatectomy.*
• If*crossUmatched*blood*is*unavailable,*transfuse*type*O*negative*for*blood*and*type*AB*for*plasma.*
Blood*products*
• Packed*red*cells:*used*for*transfusion*in*chronic*anaemia*and*cases*where*infusion*of*large*volumes*of*fluid*
may*cause*cardiovascular*compromise.*

* 3*
• Packed*red*cells:*if*two*or*more*units*of*packed*red*cells*are*administered,*frusemide*should*be*prescribed*
between*units*to*prevent*fluid*overload.*
• Platelet*rich*plasma:*contains*lots*of*platelets.*
• Platelet*rich*plasma:*used*for*patients*who*have*thrombocytopaenia*and*are*bleeding*or*require*surgery.*
• Prothrombin*complex*concentrate:*used*for*emergency*reversal*of*anticoagulation*in*patients*with*severe*
bleeding*or*intracerebral*haemorrhage.*
• Platelet*concentrate:*used*for*patients*with*thrombocytopaenia.*
• Fresh*frozen*plasma:*contains*clotting*factors,*albumin*and*immunoglobulin.*
• Fresh*frozen*plasma:*used*for*patients*with*clinically*significant*bleeding*and*a*prolonged*APTT;*can*be*used*
prophylactically*before*surgery*for*patients*with*risk*for*significant*bleeding*(eg.*clotting*deficiency).*
• Cryoprecipitate:*rish*source*of*factor*VIII,*vWF*and*fibrinogen.*
• Cryoprecipitate:*used*to*replace*fibrinogen;*firstUline*treatment*for*DIC*or*emergency*situations*for*
haemophiliacs*when*specific*factors*are*not*available.*
Airway*adjuncts*
• Oropharyngeal*airway:*used*as*a*bridge*to*provide*more*definitive*airway*access.*
• Nasopharyngeal*airway:*inserted*into*nostril*to*provide*a*patent*airway*in*patients*with*reduced*GCS*or*
seizure*activity.*Contraindicated*in*base*of*skull*fractures.*
Laryngeal*mask*
• Device*that*lies*in*the*pharynx*and*aligns*to*keep*the*airway*open*during*anaesthesia*or*unconsciousness.*
• Offers*poor*control*against*reflux*of*gastric*contents*to*patients*must*be*fasted.*
• Sizes:*1*for*neonates;*2*for*small*children;*3*for*30U50*kg;*4*for*50U70*kg;*5*for*70U100*kg.*
Endotracheal*tube*
• Used*in*major*surgeries*or*operations*that*has*a*high*risk*of*regurgitation.*
• Error*in*insertion*may*result*in*oesophageal*intubation,*paralysis*is*required.*
Tracheostomy*
• Used*to*facilitate*longUterm*weaning*(eg.*for*ongoing*respiratory*distress*syndrome).*
Cannulas*
• Avoid*cannulating*feet*in*patients*with*poorly*controlled*diabetes*as*it*may*develop*into*a*diabetic*ulcer.*
• Sizes:*orange*=*14*g*(largest);*grey*=*16*g;*green*=*18*g;*pink*=*20*g;*blue*=*22*g*(smallest).*
• Larger*cannulas*provide*rapid*fluid*infusion.*
Intravenous*access*
• Central*line:*access*to*central*veins.*Allows*multiple*infusions*but*is*not*suitable*for*rapid*infusions*and*is*
prone*to*infection.*
• Peripherally*inserted*central*canal*(PICC)*line:*central*venous*access*that*is*inserted*peripherally*and*is*less*
prone*to*infection*that*conventional*central*lines.*
• Hickman*line:*access*to*internal*jugular*vein*and*is*the*most*reliable*longUterm*venous*access.*
• Intraosseous*access:*provides*access*to*veins*in*marrow*cavity*and*is*preferred*secondUline*access*in*
paediatrics.*
• Intraosseous*access:*in*children,*guidelines*recommend*intraosseous*access*in*emergency*situations*where*
IV*access*has*failed*after*two*attempts.*

* 4*
Fluid*solutions*
• 0.9%*saline:*used*to*treat*fluid*volume*deficit,*shock,*metabolic*acidosis.*
• 0.9%*saline:*excessive*infusion*of*NaCl*solution*may*cause*hyperchloraemic*acidosis*and*fluid*volume*
overload.*
• Hartmann*solution:*contains*Na,*K,*Cl,*lactate.*
• Hartmann*solution:*contains*less*NaCl*than*0.9%*saline*but*more*K*(5*mmol/l).*
• Hartmann*solution:*useful*in*patients*that*require*electrolyte*replacement*(GI*tract*loss,*burns,*postUop).*
• Dextrose*5%:*sugar*containing*fluid*that*can*replace*lost*fluids*and*provide*calories.*
• Dextrose*5%:*used*to*treat*fluid*volume*deficit,*hypoglycaemia,*insulin*shock.*
• Dextrans*solution:*primarily*used*in*sepsis.*
Fluid*therapy*
• Maintenance*fluid:*daily*requirement*is*25U30*ml/kg*of*water;*1*mmol/kg*of*potassium,*sodium*and*chloride;*
50U100*g*of*glucose.*
• Maintenance*fluid:*an*example*of*a*standard*daily*fluid*regime*is*25U30*ml/kg*of*NaCl*0.18%*with*4%*glucose*
and*27*mmol/l*of*potassium.*
• Maintenance*fluid:*children*require*4*ml/kg/hr*for*first*10*kg,*2*ml/kg/hr*for*next*10*kg*and*1*ml/kg/hr*for*
every*subsequent*kg*of*weight.*
• Fluid*resuscitation:*use*0.9%*saline*with*an*initial*bolus*of*500*ml*over*15*minutes.*
• PostUop*resuscitation:*treat*hypovolaemia*with*IV*fluids*first*and*then*treat*the*resulting*oedema*with*a*
negative*balance*of*sodium*and*water.*Monitor*using*urinary*sodium.*
• Fluid*challenge:*500*ml*of*0.9%*saline*STAT;*if*patient*has*heart*failure*then*give*250*ml.**
Feeding*
• Oral*route:*associated*with*faster*recovery.*
• Enteral*feeding:*offer*to*patients*who*are*malnourished*(BMI*<*18.5*or*unintentional*weight*loss*of*>*10%*
over*3U6*months);*or*at*risk*of*malnutrition*(eaten*little*for*more*than*5*days,*poor*absorptive*capacity,*high*
nutrient*losses,*high*metabolism).*
• Nasogastric*feeding:*for*patients*who*are*unable*to*eat*orally*but*whose*upper*GI*tract*is*still*active.*
• Nasogastric*feeding:*contraindicated*in*basal*skull*fractures.*
• Nasogastric*feeding:*if*gastric*feeding*will*last*>*4*weeks,*consider*long*term*gastrotomy.*
• Gastrotomy:*used*for*gastric*decompression*or*enteral*feeding*into*stomach;*site*of*access*is*epigastrium.*
• Percutaneous*jejunostomy:*for*patients*whose*GI*tract*proximal*to*the*jejunum*is*impaired*(eg.*after*
oesophageal*surgery,*gastrectomy);*site*of*access*is*LUQ.*
• Total*parenteral*nutrition:*commonly*used*in*nutritionally*compromised*surgical*patients*where*enteral*
feeding*is*contraindicated;*longUterm*infusions*should*be*administered*into*a*central*vein*(PICC*line).*
• Total*parenteral*nutrition:*complications*include*sepsis,*reUfeeding*syndromes,*fatty*liver,*deranged*LFTs.**
Anaesthesia*
• Local*anaesthesia:*provides*selective*analgesia*for*surgery,*especially*useful*where*spinal*or*epidural*
blockade*is*contraindicated.*
• Local*anaesthesia:*lidocaine*is*the*most*widely*used*LA*due*to*its*rapid*onset*of*action*and*duration*of*action*
(1*hour);*maximum*safe*dose*is*3*mg/kg.*

* 5*
• Local*anaesthesia:*lidocaine*can*be*preUmixed*with*adrenaline*which*increases*its*duration*of*action*and*
reduces*blood*loss*due*to*vasoconstriction;*should*never*be*used*near*extremities*due*to*risk*of*ischaemia.*
• Spinal*anaesthesia:*provides*excellent*analgesia*for*lower*half*of*body*and*pain*relief*can*last*many*hours*
after*completion*of*operation.*
• Epidural*anaesthesia:*provides*excellent*anesthesia*for*major*open*abdominal*procedures*by*providing*a*
continuous*infusion*of*analgesic*agents;*an*indwelling*epidural*cather*is*required.*
Propofol*
• Indications:*widely*used*for*induction*and*maintenance*of*sedation*due*to*its*rapid*onset*properties;*also*has*
antiUemetic*properties.*
• Dose:*1.5*mg/kg.*
Suxamenthonium*
• Muscle*relaxant*with*fast*onset*and*short*duration*used*during*sedation.*
• Adverse*effects:*hyperkalaemia,*malignant*hyperthermia,*suxamenthonium*apnoea*(respiratory*arrest).*
• Pseudocholinesterase*deficient*patients*are*at*a*higher*risk*of*respiratory*arrest*because*they*have*reduced*
metabolism*of*suxamenthonium.*
Drugs*
• Sevofluorane:*anaesthetic*agent*commonly*used*to*maintain*sedation.*
• Sodium*thiopentone:*used*for*rapid*onset*induction.**
• Sodium*thiopentone:*main*risk*is*myocardial*depression.*
• Ketamine:*used*during*sedation*for*its*strong*analgesic*properties*and*moderate*anaesthetic*properties.*
• Ketamine:*adverse*effects*include*myocardial*depression*and*nightmares.*
Advanced*life*support*
• Chest*compression*to*ventilation*ratio*is*30:2*(paediatrics*15:2).*Assess*rhythm*after*each*cycle.*
• NonUshockable*rhythm:*includes*asystole*and*pulseless*electrical*activity.*
• NonUshockable*rhythm:*give*adrenaline*1*mg*immediately*(then*every*2nd*cycle);*one*resuscitation*cycle*
consists*of*2*minutes*of*CPR.*
• Shockable*rhythm:*give*adrenaline*1*mg*after*2nd*shock*(then*every*2nd*cycle);*amiodarone*0.5*mg*after*3*
shocks;*one*resuscitation*cycle*consists*of*an*electrical*shock*and*2*minutes*of*CPR.*
Choking*
• Mild*obstruction*(patient*can*speak,*breathe)*can*be*managed*with*coughing.*
• Severe*obstruction*requires*5*back*blows*and*if*unsuccessful,*5*abdominal*blows;*repeat*if*unsuccessful.*
Brain*death*
• Test*for*brain*death*is*the*patient*is*in*a*deep*coma*of*known*aetiology*and*all*reversible*causes*have*been*
excluded,*patient*is*not*under*sedation*and*has*normal*electrolytes.*
• Criteria:*no*pupil*reflex,*no*corneal*reflex,*no*response*to*supraorbital*pressure,*no*cough*or*gag*reflex,**
no*respiratory*effort.**
• Must*be*confirmed*by*two*doctors*on*two*separate*occasions.*
*
Breast*surgery*
Breast*cancer*

* 6*
• Most*common*type*is*invasive*ductal*carcinoma,*may*also*arise*from*lobular*tissue.*
• Carcinoma*in*situ:*cancer*that*has*not*spread*beyond*local*tissue,*may*develop*into*invasive*carcinoma.*
• Risk*factors:*BRCA*gene,*firstUdegree*premenopausal*relative*with*breast*cancer,*nulliparity,*early*menarche,*
late*menopause,*COC,*HRT,*past*breast*cancer,*ionising*radiation,*obesity,*past*benign*breast*disease.*
• Screening:*women*between*45U69*years*can*receive*a*mammogram*free*every*2*years.*
• Screening:*refer*for*early*screening*if*patient*has*one*firstUdegree*relative*with*breast*cancer*and*the*
relative’s*age*of*diagnosis*was*<*40*years*or*they*had*bilateral*breast*cancer*or*male*breast*cancer*or*
additional*ovarian*cancer.*
• Screening:*refer*for*early*screening*if*patient*has*two*firstUdegree*relatives*or*one*firstUdegree*and*one*
secondUdegree*relative*diagnosed*with*breast*cancer.*
• Features:*painless*lump*that*is*hard*and*irregular*(90%);*may*be*associated*with*axillary*lymphadenopathy*
and*nipple*changes*(discharge,*retraction,*distortion).*
• Referral:*refer*patients*who*are*aged*>*30*years*and*have*an*unexplained*breast*lump*or*are*aged*>*50*years*
and*have*abnormal*nipple*changes.*
• Referral:*consider*referral*in*any*patients*who*have*skin*changes*that*suggest*breast*cancer*or*are*aged*>*30*
years*and*have*an*unexplained*lump*in*axilla.*
• Management:*most*cases*are*surgically*managed*and*all*should*be*offered*breast*reconstruction*afterwards.*
• Management:*mastectomy*is*offered*to*multifocal*or*central*tumours*that*are*large*in*size*compared*to*breast*
size*or*DCIS*that*is*>*4*cm.*
• Management:*wide*local*excision*(WLE)*is*offered*to*solitary*lesions*or*peripheral*tumours;*typically*cases*
where*the*lesion*is*small*compared*to*breast*size*or*DCIS*that*is*<*4*cm.*
• Management:*whole*breast*radiotherapy*is*recommended*after*a*WLE*to*reduce*risk*of*recurrence;*
mastectomy*patients*are*offered*radiotherapy*for*cancer*that*is*lateUstage*or*has*metastasized.*
• Management:*hormonal*therapy*is*offered*for*cancer*that*is*hormone*receptor*positive.*A*5Uyear*course*of*
tamoxifen*is*given*to*premenopausal*women;*aromatase*inhibitors*are*used*in*postmenopausal*women.*
• Management:*herceptin*treatment*is*offered*to*women*with*HER2*positive*cancer.*
• Management:*cytotoxic*chemotherapy*may*be*used*after*surgery*for*highUgrade*tumours*or*axillary*nodal*
metastases.*
Paget’s*disease*of*nipple*
• Eczematoid*change*(reddening,*thickening)*of*nipple*associated*with*underlying*breast*cancer.*
• Present*in*1U2%*of*patients*with*breast*cancer*and*requires*urgent*investigation.*
Inflammatory*breast*cancer*
• Rare*type*of*breast*cancer*where*cancerous*cells*block*lymph*drainage*which*results*in*an*inflamed*
appearance*of*breast*in*the*absence*of*systemic*symptoms.*
• Associated*with*elevated*CA15U3.*
Fibroadenoma*
• Benign*lesion*that*is*common*in*women*<*30*years.*
• Features:*discrete,*highly*mobile*and*nonUtender;*may*be*tender*prior*to*menstruation.*
• Surgically*excised*if*>*3*cm.*
Breast*cyst*
• Benign*lesion*that*is*usually*caused*by*infection*of*Staph&aureus.*

* 7*
• Features:*smooth,*discrete*lump*that*is*mobile.*
• Investigations:*mammography*may*show*a*‘halo*appearance’.*
• Management:*all*cysts*should*be*aspirated*for*investigation;*bloodUstained*or*recurring*cysts*should*be*
biopsied*and*excised.*
• Management:*treat*with*antibiotics*and*drainage.*
Sclerosing*adenosis*
• Benign*lesion*that*presents*as*a*breast*lump*or*with*breast*pain.*
• Mammographic*changes*may*mimic*breast*carcinoma.*
• Lesions*should*be*biopsied.*
Epithelial*hyperplasia*
• Unexpected*growth*of*epithelium*of*breast;*increased*cellularity*of*terminal*lobular*unit.*
• Presentation*may*range*from*generalised*lumpiness*of*breast*to*a*discrete*lump.*
• If*atypical*features*are*present*histologically*and*there*is*a*family*history*of*breast*cancer,*risk*of*malignancy*
is*greatly*increased.*
• If*there*are*no*atypical*features*then*management*may*be*conservative;*if*atypical*features*are*present*then*
close*monitoring*or*surgical*resection*is*required.*
Fat*necrosis*
• 40%*of*cases*have*traumatic*aetiology,*more*common*in*obese*women*with*large*breasts*(more*fat).*
• Presents*with*an*initial*inflammatory*response*followed*by*a*lesion*that*is*typically*firm*and*round*but*may*
develop*into*a*hard,*irregular*breast*lump.*
• Management:*imaging*and*core*biopsy.*
Fibroadenosis*
• Benign*condition*that*is*most*common*in*middleUaged*women.*
• Features:*lumpy*breasts*that*may*be*painful,*symptoms*worsen*prior*to*menstruation.*
Mastitis*
• Affects*10%*of*breastfeeding*women*and*may*develop*into*an*abscess*if*untreated.*
• Causes:*milk*stasis*causing*obstruction*in*ducts,*infection*of*Staph&aureus.*
• Features:*red,*hot,*tender*breast*swelling;*breast*pain,*pyrexia.*
• Management:*antibiotic*treatment*(flucloxacillin*500*mg*qid*for*14*days,*erythromycin*if*penicillinUallergic)*
should*be*given*if*mother*has*an*infected*nipple*fissure,*symptoms*do*not*improve*after*12U24*hours,*has*
systemic*symptoms*or*the*bacterial*culture*is*positive.*
• Management:*firstUline*is*milk*removal;*breastfeeding*should*continue.*
• Management:*secondUline*is*flucloxacillin*for*10U14*days.*
Breast*abscess*
• Collection*of*pus*inside*breast*that*is*associated*with*lactational*mastitis*and*is*usually*caused*by*infection*of*
Staph&aureus.*
• Features:*red,*hot,*tender*breast*swelling*with*a*tender*fluctuant*mass.*
• Management:*treat*with*antibiotics*and*ultrasound*guided*aspiration.*
Nipple*discharge*

* 8*
• Bilateral,*minimal*discharge*that*is*pale*or*colourless*in*a*young*woman*is*likely*to*be*associated*with*
hormonal*changes*around*puberty.*
• BloodUstained*discharge*or*the*presence*of*an*underlying*mass*or*axillary*lymphadenopathy*requires*a*
referral*for*further*investigation*for*breast*carcinoma.*
Duct*papilloma*
• Most*common*cause*of*bloodUstained*nipple*discharge*in*young*women.*
• Features:*clear*or*bloodUstained*nipple*discharge;*large*papillomas*may*present*with*a*mass.*
• Management:*microdochectomy.*
Duct*ectasia*
• Dilation*of*terminal*breast*ducts,*most*common*at*around*menopause.*
• Features:*tender*lump*around*areola,*nipple*retraction,*creamy*brownUgreen*nipple*discharge.*
Periductal*mastitis*
• Strongly*associated*with*smoking.*
• Presents*with*features*of*inflammation,*abscess*or*mammary*duct*fistula.*
• Management:*antibiotics;*abscess*requires*drainage.*
Cyclical*mastalgia*
• Common*cause*of*breast*pain*in*younger*females*that*varies*in*intensity*according*to*phase*of*menstrual*
cycle.*
• Management:*treatment*of*any*existing*breast*disease;*advise*to*wear*a*supportive*bra.*
Drugs*
• Tamoxifen:*selective*estrogen*receptor*modulator*that*acts*as*an*estrogen*receptor*antagonist.*
• Tamoxifen:*used*in*treatment*of*estrogen*receptor*positive*breast*cancer.*
• Aromatase*inhibitors:*eg.*anastrozole,*letrozole.*
• Aromatase*inhibitors:*reduces*peripheral*estrogen*synthesis,*which*accounts*for*the*majority*of*
postmenopausal*estrogen*production.*
• Aromatase*inhibitors:*used*in*treatment*of*estrogen*receptor*positive*breast*cancer*in*postmenopausal*
women.*
*
Cardiology*
Hypertension*
• If*clinic*BP*reading*is*>*140/90*mmHg*offer*ambulatory*or*home*BP*monitoring.*
• BP*>*200/120*mmHg*may*cause*symptoms*such*as*headache,*visual*disturbance*and*seizures.*
• Causes*of*secondary*hypertension*are*often*renal*–*glomerulonephritis,*pyelonephritis,*renal*artery*stenosis.*
• If*ambulatory*or*home*BP*monitoring*is*above*135/85*mmHg,*only*treat*with*medication*if*patient*is*less*
than*80*years*old*and*has*target*organ*damage,*established*cardiovascular*disease,*renal*disease*or*their*10U
year*cardiovascular*risk*is*at*least*20%.*
• If*ambulatory*or*home*BP*monitoring*is*above*150/95*mmHg,*treat*all*with*medication.*
• Lifestyle*advice*for*hypertension:*low*salt*diet,*reduced*caffeine*intake,*smoking*cessation,*less*alcohol*
intake,*more*exercise,*weight*loss.*
• FirstUline*drug:*ACE*inhibitor*for*patients*<*55*years;*CCB*for*patients*>*55*years*or*AfroUCarribean*origin.*

* 9*
• If*ACE*inhibitor*is*intolerable*then*an*angiotensin*receptor*blocker*(eg.*losartan)*should*be*used.*
• SecondUline*drug:*ACE*inhibitor*+*CCB.*
• ThirdUline*drug:*add*a*thiazide*diuretic*to*existing*therapy.*
• FourthUline*drug:*add*another*diuretic*to*existing*therapy*–*spironolactone*if*potassium*<*4.5*mmol/l;**
higher*dose*thiazideUlike*diuretic*if*potassium*>*4.5*mmol/l.*
• FifthUline*drug:*add*an*alpha*or*beta*blocker*to*existing*therapy.*
• Blood*pressure*target*is*140/90*mmHg*if*<*80*years;*150/90*mmHg*if*>*80*years.*
• Newly*diagnosed*patients*should*receive*fundoscopy,*urine*dipstick*and*ECG*to*look*for*endUorgan*damage;*
as*well*as*U&E,*HbA1c,*and*lipid*blood*tests.*
Hypertension*in*diabetes*
• Blood*pressure*target*is*<*130/80*mmHg*if*there*is*endUorgan*damage;*<*140/80*mmHg*if*none.*
• FirstUline*drug:*ACE*inhibitor*as*it*has*a*renoprotective*effect.*
• Further*management*is*identical*to*nonUdiabetics.*
Malignant*hypertension*
• Diagnosis*requires*>*180/120*mmHg*and*evidence*of*acute*organ*damage.*
• Signs*include*papilloedema,*increased*cranial*pressure*(headache,*nausea),*retinal*bleeding,*chest*pain,*
haematuria,*epistaxis.*
Idiopathic*pulmonary*arterial*hypertension*
• Features:*progressive*shortness*of*breath,*cyanosis.*
• Signs:*right*ventricular*heave,*loud*P2,*tricuspid*regurgitation,*raised*JVP*with*prominent*‘a’*waves.*
• Investigations:*firstUline*is*echocardiography;*diagnosis*of*exclusion.*
• Management:*diuretics*for*RHF;*anticoagulation;*IV*prostaglandin;*CCBs;*bosentan*(endothelinU1Ureceptor*
antagonist).*
Postural*hypotension*
• A*fall*in*systolic*BP*of*>*20*mmHg*on*standing,*accompanied*by*increase*in*HR.*
• If*postural*hypotension*does*not*cause*a*rise*in*heart*rate,*the*patient*probably*has*neurogenic*orthostatic*
hypotension*or*autonomic*neuropathy*as*this*indicates*dysfunction*of*the*autonomic*system.*
• If*postural*hypotension*is*accompanied*by*an*exaggerated*increase*in*heart*rate*they*may*have*anaemia*or*
hypovolaemia.*
• Management:*adequate*hydration,*discontinuation*of*vasoactive*drugs*(nitrates,*antihypertensives,*
neuroleptic*agents,*dopaminergic*drugs).*
• Drug*therapy*includes*fludrocortisone*and*midodrine.*
Heart*failure*
• Causes:*ischaemic*heart*disease,*hypertension,*arrhythmias,*cardiomyopathy,*valvular*disease.*
• Classifications:*I)*no*symptoms;*II)*mild*symptoms*on*exertion;*III)*moderate*symptoms*on*normal*activity;*
IV)*severe*symptoms*at*rest.*
• Features:*dyspnoea,*pink*frothy*sputum;*bilateral*basal*crackles,*elevated*left*ventricular*impulse,*S3*heart*
sound,*decreased*ejection*fraction*(normal*is*>*55%),*low*O2*sat.*
• Features*of*rightUsided*HF:*elevated*JVP,*oedema,*hepatomegaly,*ascites.*
• May*cause*a*wheeze*on*auscultation*(cardiac*asthma)*as*a*result*of*congestion*caused*by*oedema*in*lungs.*

* 10*
• Investigations:*if*patient*has*a*history*of*myocardial*infarction,*arrange*echocardiogram*within*2*weeks.*
• Investigations:*serum*BNP*is*firstUline;*if*raised*(>*400*pg/ml)*arrange*echocardiogram*within*2*weeks,*if*
slightly*raised*(100U400*pg/ml)*arrange*echocardiogram*within*6*weeks.*
• BNP:*may*be*raised*in*CKD*due*to*reduced*excretion;*may*be*reduced*with*use*of*ACE*inhibitors,*diuretics*
and*angiotensin*II*receptor*blockers.*
• Management:*treat*fluid*overload*with*frusemide.*
• Management:*firstUline*is*ACE*inhibitor*and*beta*blocker.*
• Beta*blockers*that*reduce*mortality*in*heart*failure*are*bisoprolol,*carvedilol*and*metoprolol.*
• Management:*secondUline*is*aldosterone*antagonist,*angiotensin*II*receptor*blocker*or*a*hydralazine*in*
combination*with*a*nitrate.*
• Spironolactone*only*improves*mortality*in*patients*with*NYHA*class*III*or*IV*heart*failure.*
• Management:*thirdUline*is*digoxin*or*cardiac*resynchronisation*therapy.*
• Management:*Ivabradine*may*be*used*in*patients*with*symptomatic*heart*failure*and*are*already*on*ACE*
inhibitor,*beta*blocker*and*aldosterone*antagonist*therapy*and*have*HR*>*75*and*EF*<*35%.*
• Management:*patients*who*do*not*respond*to*medical*management*and*have*severe*dyspnoea*should*be*
considered*for*CPAP.*
• Management:*patients*should*be*offered*an*annual*influenza*vaccine.*
Ischaemic*heart*disease*
• Modifiable*risk*factors:*smoking,*diabetes,*hypertension,*hypercholesterolaemia,*obesity.*
• Typical*angina*has*3*diagnostic*features*–*a)*constricting*discomfort*of*chest,*neck,*shoulders,*jaw*or*arms;**
b)*precipitated*by*physical*activity;*c)*relieved*by*rest*or*GTN*in*<*5*minutes.*
• Patients*with*only*two*features*of*the*above*have*atypical*angina;*if*one*feature*then*nonUcardiac*chest*pain.*
• Investigate*patients*with*nonUcardiac*chest*pain*with*ischaemic*ECG*changes*as*stable*angina.*
Stable*angina*
• Typical*angina*that*only*occurs*on*activity*and*not*at*rest.*
• Investigations:*firstUline*is*CT*coronary*angiography;*secondUline*is*nonUinvasive*functional*imaging;**
thirdUline*is*invasive*coronary*angiography.*
• PCI*does*not*improve*survival*in*stable*angina;*useful*for*ACS.*
• Management:*sublingual*GTN*for*acute*attacks;*aspirin*and*statin*for*cardiovascular*risk.*
• Management:*firstUline*drug*therapy*is*either*a*beta*blocker*or*CCB;*secondUline*is*the*addition*of*the*other*
drug.*
• Management:*if*using*CCB*alone,*use*verapamil*or*diltiazem;*if*using*CCB*in*combination,*use*nifedipine*
(verapamil*is*contraindicated*with*beta*blockers*and*heart*failure;*diltiazem*has*risk*of*bradycardia).*
• Management:*for*patients*who*cannot*tolerate*both*beta*blocker*and*CCB*together,*consider*adding*a*longU
acting*nitrate,*ivabradine,*nicorandil*or*ranolazine.*
Acute*coronary*syndrome*
• Includes*unstable*angina*and*myocardial*infarction;*due*to*decreased*blood*flow*through*coronary*arteries.*
• Unstable*angina:*chest*pain*that*occurs*at*rest*and*is*often*severe;*may*have*a*crescendo*pattern.*
• Signs:*patient*may*appear*pale,*clammy*or*show*signs*of*heart*failure;*vital*signs*are*often*normal.*

* 11*
• Patients*presenting*with*current*chest*pain*or*chest*pain*<*72*hours*ago*with*an*abnormal*ECG*should*be*
admitted*to*hospital*as*an*emergency;*chest*pain*>*72*hours*ago*requires*ECG*and*troponin*testing*and*if*
abnormal*should*be*admitted*to*hospital*as*an*emergency.*
• Acute*management:*ECG,*300*mg*aspirin,*glyceryl*trinitrate,*morphine,*oxygen*if*sat*<*94%.*
• Poor*prognostic*factors:*heart*failure,*lung*crackles,*pulmonary*oedema,*cardiogenic*shock.*
• Diabetics*admitted*for*ACS*should*be*treated*with*IV*doseUadjusted*insulin*infusion*with*regular*monitoring*
of*blood*glucose*levels*(<*11.0*mmol/l)*and*cease*other*diabetic*drugs.*
Myocardial*infarction*
• Features:*heavy,*central*chest*pain*that*may*radiate*to*neck*and*left*arm;*often*accompanied*by*dyspnoea,*
nausea,*sweating.*
• Presentation*may*be*atypical*or*painless*in*elderly*or*people*with*diabetes.*
• Investigations:*firstUline*is*ECG*and*troponin.*
• Management:*firstUline*is*beta*blocker,*300*mg*aspirin,*300*mg*clopidogrel*and*statin;*consider*use*of*ACE*
inhibitor.*
STEMI*
• Management:*all*STEMI*patients*should*be*given*aspirin*(100U150*mg)*for*life*and*clopidogrel*for*12*months*
(300*mg*loading*dose*then*100U150*mg*maintenance).*
• Management:*STEMI*patients*who*have*an*ejection*fraction*of*<*0.40*and*either*heart*failure*or*diabetes*
should*be*given*an*aldosterone*antagonist*(eg.*eplerenone)*within*14*days*of*MI.*
• Management:*primary*percutaneous*coronary*intervention*(PCI)*is*gold*standard*treatment*for*STEMI.*
• PCI:*indicated*if*there*is*ST*elevation*of*>*2*mm*in*2*or*more*consecutive*anterior*leads*(V1UV6);**
or*ST*elevation*of*>*1*mm*in*3*or*more*inferior*leads*(II,*III,*avF,*avL);*or*a*new*LBBB.*
• PCI:*give*patients*who*are*going*to*have*a*PCI*unfractionated*heparin*or*LMWH.*
• PCI:*fibrinolysis*should*be*performed*if*PCI*is*unavailable;*tenectaplase*is*easier*to*administer*than*alteplase.*
An*ECG*should*be*performed*after*90*minutes*to*assess*whether*there*has*been*>*50%*resolution*of*ST*
elevation,*if*not,*rescue*PCI*is*superior*to*repeat*thrombolysis.*
NSTEMI*
• Investigations:*CT*coronary*angiography*is*firstUline.*
• Management:*all*NSTEMI*patients*should*be*given*aspirin*(100U150*mg)*for*life*and*clopidogrel*for*12*
months*(300*mg*loading*dose*then*100U150*mg*maintenance);*nitrates*PRN.*
• Management:*consider*coronary*angiography*within*72*hours*of*first*admission*in*patients*with*a*predicted*
6*month*mortality*above*3%*or*that*are*clinically*unstable;*give*IV*glycoprotein*IIb/IIIa*receptor*antagonist*
(eptifibatide,*tirofiban)*to*these*patients.*
• Management:*antithrombin*(fondaparinux)*should*be*offered*to*patients*who*are*not*high*risk*of*bleeding*
and*who*are*not*having*angiography*within*24*hours;*if*angiography*is*likely*within*24*hours,*administer*UF*
heparin.*
Myocardial*infarction*ECG*changes*
• Location:*changes*in*leads*V1U4*indicate*left*anterior*descending*artery*territory*(anterior*MI);**
leads*II,*III,*aVF*indicate*right*coronary*artery*territory*(inferior*MI);**
leads*I,*V5,*V6*indicate*left*circumflex*artery*territory*(lateral*MI);**

* 12*
 leads*V1U2*indicate*left*circumflex*territory*(posterior*MI);**
leads*I,*avL,*V4U6*indicate*left*anterior*descending*or*left*circumflex*artery*territory*(anterolateral*MI).*
• Changes:*large*peaked*T*waves*(acute);*ST*elevation*(minuteUhours);*T*wave*inversion*(hoursUdays);*
pathologic*Q*waves*(hoursUdays).*
• Posterior*MI:*causes*ST*depression*(instead*of*elevation)*and*tall*R*wave*changes.*
• ST*elevation*implies*a*complete*occlusion*of*coronary*artery;*ST*depression*implies*a*partial*block*leading*to*
ischaemia.*
Myocardial*infarction*complications*
• Most*common*cause*of*death*is*ventricullar*fibrillation*leading*to*cardiac*arrest.*
• Dysfunctional*myocardium*may*lead*to*chronic*heart*failure*due*to*fluid*overload*or*cardiogenic*shock*
caused*by*reduced*ejection*fraction.*
• Tachyarrhythmias*such*as*ventricular*fibrillation*and*ventricular*tachycardia*are*common.*
• AV*block*is*common*following*an*inferior*MI.*
• Pericarditis*is*common*following*a*transmural*MI*(pain,*pericardial*rub,*pericardial*effusion).*
• Dressler’s*syndrome:*typically*occurs*2U6*weeks*following*a*MI*and*is*due*to*an*autoimmune*reaction*to*
recovering*myocardium;*features*include*fever,*pleuritic*pain,*pericardial*effusion,*raised*ESR.*
• Left*ventricular*aneurysm*due*to*weakened*myocardium;*associated*with*persistent*ST*elevation*and*left*
ventricular*failure.*
• Left*ventricular*wall*rupture:*typically*occurs*1U2*weeks*following*a*MI;*features*include*cardiac*tamponade*
that*leads*to*heart*failure.*
• Ventricular*septal*defect*due*to*rupture*of*interventricular*septum*typically*occurs*in*the*first*week;*features*
include*heart*failure*associated*with*a*pansystolic*murmur.*
• Acute*mitral*regurgitation*is*common*following*an*inferoUposterior*MI;*presents*as*an*early*midsystolic*
murmur.*
Musculoskeletal*chest*pain*
• Often*precipitated*by*trauma*or*coughing.*
• Features:*chest*pain*is*worse*on*movement*and*palpation.*
Pericarditis*
• Causes:*viral*infections*(Coxsackie),*tuberculosis,*uraemia,*trauma,*postUMI,*hypothyroidism,*malignancy,*
systemic*inflammatory*diseases*(RA,*SLE).*
• Features:*sharp,*central*chest*pain*that*is*typically*better*sitting*up*and*worse*lying*down*or*during*deep*
inspiration*(pleuritic);*nonUproductive*cough,*dyspnoea,*tachypnoea,*tachycardia,*fluUlike*symptoms.*
• Pleuritic*chest*pain:*sudden*and*intense*pain*in*chest*when*inhaling*or*exhaling.*
• Signs:*pericardial*rub,*scratchy*rubbing*S1*and*S2*sounds*on*auscultation.*
• ECG:*widespread*saddleUshaped*ST*elevation*and*PR*depression.*
Constrictive*pericarditis*
• Inflammation*of*a*thickened*and*fibrotic*pericardium*that*prevents*the*heart*from*expanding*when*blood*
enters*it.*
• Features:*dyspnoea,*rightUsided*HF,*raised*JVP,*loud*S3*heart*sound*(pericardial*knock),*Kussmaul’s*positive.*
• Kussmaul’s*sign:*a*raised*JVP*that*does*not*fall*with*inspiration.*
• CXR:*may*show*pericardial*calcification.*

* 13*
Cardiac*tamponade*
• Compression*of*heart*caused*by*fluid*collection*in*pericardium*(pericardial*effusion).*
• Features:*dyspnoea,*raised*JVP,*hypotension,*tachycardia,*diminished*heart*sounds,*pulsus*paradoxus.*
• ECG:*may*show*electrical*alternans*(alternation*of*QRS*complex*amplitude*or*axis,*specific*for*pericardial*
effusion).*
• Beck’s*triad:*falling*BP;*rising*JVP;*muffled*heart*sounds*–*characteristic*of*cardiac*tamponade.*
• Consider*cardiac*tamponade*if*symptoms*persist*despite*fluid*resuscitation*following*chest*trauma.*
• Investigations:*echocardiogram*is*firstUline.*
Aortic*dissection*
• Features:*tearing*chest*pain*radiating*through*to*the*back,*aortic*regurgitation,*hypertension.*
• Signs:*classically*presents*with*unequal*blood*pressure*measured*at*arms.*
• Types:*A*originates*from*ascending*aorta;*B*originates*from*descending*aorta.*
• Management:*type*A*is*treated*surgically;*type*B*is*treated*conservatively*with*analgesia*and*IV*beta*blockers*
to*prevent*progression.*
Palpitations*
• FirstUline*investigations*include*ECG*(arrhythmias),*thyroid*function*tests*(thyrotoxicosis),*U&E*
(hypokalaemia),*FBC.*If*results*are*normal*Holter*monitoring*is*indicated.*
Atrial*fibrillation*
• Paroxysmal*AF:*episodes*of*AF*that*terminate*spontenously.*
• Features:*palpitations,*dyspnoea,*chest*pain.*Best*sign*is*irregularly*irregular*pulse.*
• Management:*AF*is*managed*with*rate*or*rhythm*control.*Offer*rhythm*control*only*to*patients*whose*AF*has*
a*reversible*cause,*is*newUonset*or*has*coUexistent*heart*failure.*
• Management:*rate*control*with*a*beta*blocker*or*rateUlimiting*CCB*(diltiazem,*verapamil)*as*firstUline;*if*one*
drug*is*inadequate*then*two*of*the*following*drugs*should*be*used*–*beta*blocker,*diltiazem*or*digoxin.*
• Management:*rhythm*control*can*be*achieved*through*DC*electrical*cardioversion*or*drugs*(flecainide,*
amiodarone).*Use*amiodarone*if*there*is*evidence*of*structural*heart*disease.*
• Management:*DC*cardioversion*is*indicated*if*AF*has*lasted*for*>*48*hours*and*requires*patient*to*be*
anticoagulated*for*at*least*3*weeks;*during*this*period*bisoprolol*should*be*used.*
• Management:*immediate*DC*cardioversion*is*only*recommended*during*lifeUthreatening*haemodynamic*
instability*caused*by*newUonset*atrial*fibrillation.*
CHA2DS2UVASc*score*
• Scoring*system*used*to*assess*need*for*anticoagulation*in*patients*with*AF.*
• Scoring:*CHF*(1);*hypertension*(1);*age*65U74*years*(1);*age*>75*years*(2);*diabetes*(1);*prior*stroke/TIA*(2);*
vascular*disease*(1);*sex*female*(1).*
• If*score*is*0*=*no*treatment;*1=*consider*anticoagulation*in*males;*2*=*anticoagulation.*
• Dabigatran*is*drug*of*choice;*aspirin*is*not*recommended*in*reducing*stroke*risk.*
• Consider*rivaroxaban*(new*oral*anticoagulant)*in*patients*who*do*not*want*regular*monitoring.*
PeriUarrest*tachycardia*
• Tachycardias*that*may*precede*cardiac*arrest.*

* 14*
• Broad*complex*tachycardia:*treat*with*a*loading*dose*of*amiodarone*followed*by*a*24*hour*infusion*if*the*
rhythm*is*regular;*if*the*rhythm*is*irregular*treat*as*narrow*complex*tachycardia.*
• Narrow*complex*tachycardia:*treat*with*vagal*manoeuvres*(firstUline)*followed*by*IV*adenosine*(secondUline)*
and*electrical*cardioversion*if*required*(thirdUline);*if*the*rhythm*is*irregular*treat*as*atrial*fibrillation.*
Ventricular*tachycardia*
• BroadUcomplex*tachycardia;*may*develop*into*ventricular*fibrillation.*
• Management:*if*patient*has*signs*of*haemodynamic*instability*then*immediate*cardioversion*is*indicated.*
• Management:*if*patient*is*stable*firstUline*drugs*include*amiodarone,*lidocaine,*procainamide.*
Supraventricular*tachycardia*
• Narrow*complex*tachycardia;*typically*an*atrioventricular*nodal*reUentry*tachycardia*(ANVRT).*
• Management:*vasovagal*manoeuvres*(carotid*sinus*massage,*valsalva*manoeuvre)*is*firstUline.*
• Management:*IV*adenosine*is*secondUline*(requires*16G*cannula*or*central*vein*access).*
• Management:*electrical*cardioversion*may*be*used*if*required.*
Atrial*flutter*
• Form*of*supraventricular*tachycardia*characterised*by*a*succession*of*rapid*atrial*depolarisation*waves.*
• ECG:*‘sawtooth’*appearance*with*tachycardia.*
• Management:*similar*to*that*of*atrial*fibrillation.*
Long*QT*syndrome*
• Normal*QT*interval*is*360U440*ms.*
• Associated*with*delayed*repolarisation*of*ventricles*which*may*lead*to*ventricular*tachycardia.*
• May*lead*to*syncope*on*exertion.*
• Causes:*hypoU*electrolyte*imbalances,*acute*MI,*myocarditis,*hypothermia,*subarachnoid*haemorrhage.*
• Drug*causes:*amiodarone,*sotalol,*tricyclic*antidepressants,*SSRIs,*methadone,*chloroquine,*erythromycin,*
clarithromycin,*ciprofloxacin,*haloperidol,*citalopram.*
• Management:*stop*any*drug*that*may*cause*a*prolonged*QT*interval;*beta*blockers*for*rate*control.*High*risk*
patients*may*require*an*implantable*cardioverter*defibrillator.*
Torsades*de*pointes*
• Associated*with*a*long*QT*interval*and*may*lead*to*ventricular*tachycardia.*
• Management:*IV*magnesium*sulphate.*
WolffUParkinson*White*syndrome*(WPW*syndrome)*
• Caused*by*a*congenital*accessory*conducting*pathway*between*atria*and*ventricles*leading*to*an*
atrioventricular*reUentry*tachycardia*(AVRT).*
• Associated*with*HOCM,*mitral*valve*prolapse,*Ebstein’s*anomaly,*thyrotoxicosis,*secundum*ASD.*
• ECG:*shortened*PR*interval,*wide*QRS*complex*with*slurred*upstroke*(delta*wave),*left*axis*deviation.*
• Management:*definitive*treatment*is*radiofrequency*ablation*of*accessory*pathway.*
Bradycardia*
• Heart*rate*of*<*60*bpm.*
• If*patient*has*signs*of*haemodynamic*instability*(shock,*syncope,*HF)*then*IV*atropine*is*firstUline.*
• If*patient*has*at*high*risk*of*asystole*or*atrophine*is*ineffective,*transvenous*pacing*(external*pacing)*is*
indicated.*

* 15*
Hypertrophic*obstructive*cardiomyopathy*
• Autosomal*dominant*condition*that*is*often*asymptomatic.*
• Suspect*in*sudden*death*or*unusual*collapse*in*young*person.*
• Features:*dyspnoea,*angina,*syncope;*left*ventricular*hypertrophy.*
• Investigations:*echocardiogram*is*firstUline;*shows*mitral*regurgitation,*asymmetric*septal*hypertrophy.*
• ECG:*left*ventricular*hypertrophy,*progressive*T*wave*inversion,*deep*Q*waves.*
• Management:*implantable*cardioverterUdefibrillator*can*be*inserted*to*reduce*risk*of*sudden*cardiac*death.*
Dilated*cardiomyopathy*
• Dilated*heart*leading*to*systolic*dysfunction,*left*ventricle*is*affected*most.*
• Causes:*alcohol,*hypertension,*postpartum,*Coxsackie*B*virus,*hyperthyroidism,*doxorubicin.*
• Features:*arrhythmias,*emboli,*mitral*regurgitation.*
• Results*in*a*reduced*ejection*fraction*(normal*range*is*55U70%)*and*is*not*associated*with*any*regional*wall*
motion*abnormality.*
Restrictive*cardiomyopathy*
• Causes:*amyloidosis,*postUradiotherapy,*Loeffler’s*endocarditis.*
Rheumatic*fever*
• Immunological*reaction*to*recent*(2U6*weeks*ago)*Streptococcus&pyogenes*infection.*
• Diagnosis:*requires*evidence*of*recent*streptococcal*infection*and*2*major*criteria*or*1*major*with*2*minor*
criteria.*
• Diagnosis:*evidence*of*recent*streptococcal*infection*include*history*of*scarlet*fever*(sore*throat,*fever,*rash),*
positive*throat*swab,*increase*in*DNase*B*titre,*ASOT*>200*IU/ml.*
• Diagnosis:*major*criteria*include*erythema*marginatum*(skin*rash),*Sydenham’s*chorea,*polyarthritis,*carditis*
(endoU,*myoU,*periU),*subcutaneous*nodules.*
• Diagnosis:*minor*criteria*include*raised*ESR*or*CRP,*pyrexia,*arthralgia,*prolonged*PR*interval.*
Infective*endocarditis*
• Vast*majority*of*bacterial*endocarditis*is*caused*by*gram*positive*cocci*(Staphylococcus,&streptococcus).*
• Infective*endocarditis*in*IVDU*commonly*affects*tricuspid*valve.*
• Diagnosis:*requires*any*pathological*criteria*or*2*major*criteria*or*1*major*and*3*minor*criteria.*
• Diagnosis:*pathological*criteria*include*positive*histology,*positive*microbiology.*
• Diagnosis:*major*criteria*include*two*positive*blood*cultures*showing*typical*organisms**
(eg.*Streptococcus&viridans,&HACEK*group),*persistent*bacteraemia*from*two*blood*cultures*taken*>*12*hours*
apart,*3*or*more*positive*blood*cultures*showing*less*specific*organisms*(eg.*Staph&aureus,&Staph&epidermis),*
positive*serology*(Coxiella&burnetii,&Bartonella,*Chlamydia&psittaci),&positive*molecular*assays*for*specific*gene*
targets,*positive*echocardiogram*signs*(oscillating*structures,*abscess*formation,*new*valvular*regurgitation).*
• Diagnosis:*minor*criteria*include*predisposing*heart*condition,*IV*drug*use,*microbiological*evidence*that*do*
not*meet*major*criteria,*fever*>38,*vascular*disease*(emboli,*splenomegaly,*clubbing,*splinter*haemorrhage,*
Janeway*lesions,*petechiae,*purpura),*immunological*disease*(glomerulonephritis,*Osler’s*nodes,*Roth*spots).*
• Features:*Janeway*lesion*and*Osler’s*node*are*both*erythematous,*circular*lesions*which*can*be*raised*from*
skin;*Janeway*lesion*is*nonUtender*and*found*mostly*on*hands*and*feet,*Osler’s*node*is*tender*and*found*
mostly*on*fingers*and*toes.*
• Investigations:*biopsy,*echocardiography.*

* 16*
• Management:*empirical*antibiotic*therapy*is*amoxicillin*+*gentamicin.*
• Management:*patients*with*severe*sepsis,*penicillin*allergy*or*suspected*MRSA*should*be*given*vancomycin*+*
gentamicin.*
• NICE*guidelines*do*not*recommend*antibiotic*prophylaxis*in*infective*endocarditis*for*dental*procedures.*
Heart*sounds*
• S1:*soft*in*mitral*regurgitation;*loud*if*mitral*stenosis.*
• S2:*soft*in*aortic*stenosis;*splitting*during*inspiration*is*normal.*
• S3:*normal*if*<*30*years;*suggests*left*ventricular*failure,*constrictive*pericarditis,*mitral*regurgitation.*
• S4:*suggests*aortic*stenosis,*HOCM,*hypertension.*
• Ejection*systolic*murmur:*aortic*stenosis,*pulmonary*stenosis,*HOCM.*
• Pansystolic*murmur:*mitral*regurgitation,*tricuspid*regurgitation,*ventricular*septal*defect.*
• Late*systolic*murmur:*mitral*valve*prolapse,*coarctation*of*aorta.*
• Early*diastolic*murmur:*aortic*regurgitation,*pulmonary*regurgitation.*
• MidUlate*diastolic*murmur:*mitral*stenosis,*AustinUFlint*murmur*(severe*aortic*regurgitation).*
Aortic*stenosis*
• Causes:*calcification*(>*65*years),*bicuspid*aortic*valve*(<*65*years),*William’s*syndrome,*postUrheumatic*
disease.*
• Murmur:*crescendoUdecrescendo,*lowUpitched*ejection*systolic*murmur*heard*loudest*at*aortic*area*with*
radiation*to*carotids.*
• Features:*chest*pain,*dyspnoea,*syncope;*narrow*pulse*pressure,*slow*rising*pulse,*thrill,*soft*S2,*left*
ventricular*failure,*S4*heart*sound.*
• Investigations:*echocardiogram*is*diagnostic.*
• Management:*if*asymptomatic*observe*patient;*if*symptomatic*a*valve*replacement*is*needed.*
• Management:*treat*fluid*overload*with*frusemide;*nitrates*are*contraindicated.*
Aortic*regurgitation*
• Causes:*rheumatic*fever,*infective*endocarditis,*connective*tissue*disease,*aortic*dissection,*hypertension,*
spondyloarthropathy,*Marfan’s*syndrome.*
• Murmur:*early*diastolic*murmur*heard*loudest*at*aortic*area.*
• Features:*collapsing*pulse,*wide*pulse*pressure,*Quinke’s*sign*(nail*pulsation),*Corrigan’s*sign*(exaggerated*
carotid*pulse),*De*Musset’s*sign*(head*nodding).*
Mitral*regurgitation*
• Murmur:*pansystolic*murmur*heard*loudest*at*mitral*area*with*a*soft*S1*and*split*S2.*
• Associated*with*collagen*disorders*such*as*Marfan’s*and*EhlersUDanlos*syndrome.*
Atrial*myxoma*
• Benign*tumour*of*heart;*75%*of*cases*occur*in*left*atrium.*
• Features:*dyspnoea,*fatigue,*weight*loss,*fever,*clubbing;*associated*with*emboli*(stroke),*atrial*fibrillation,*
midUdiastolic*murmur.*
• Investigations:*echocardiogram*(pedunculated*heterogenous*mass*typically*attached*to*fossa*ovalis*region*of*
interatrial*septum).*
Leriche*syndrome*(Aortoiliac*occlusive*disease)*

* 17*
• Central*artery*disease*involving*blockage*of*the*abdominal*aorta*as*it*transitions*into*common*iliac*arteries.*
• Features:*claudication*of*buttocks*and*thighs,*muscle*atrophy*of*legs,*impotence*(due*to*L1*paralysis).*
• Management:*correct*underlying*risk*factors*such*as*hypercholesterolemia*and*smoking.*
Syncope*
• Transient*loss*of*consciousness*due*to*global*cerebral*hypoperfusion*with*rapid*onset,*short*duration*and*
spontaneous*complete*recovery.*
• Reflex*syncope:*neurally*mediated*and*occurs*in*situations*such*as*coughing,*straining*while*defecating,*
having*blood*drawn;*and*triggered*by*emotions,*pain,*stress.*
• Orthostatic*syncope:*causes*include*drugs*(alcohol,*diuretics,*vasodilators),*primary*autonomic*failure,*
hypovolaemia*(haemorrhage,*diarrhoea).*
• Cardiac*syncope:*causes*include*arrhythmias,*structural*disease,*pulmonary*embolism.*
• Investigations:*24*hour*holter*monitor*can*detect*underlying*arrhythmias*causing*recurrent*collapse.*
Anaphylaxis*
• Adrenaline:*firstUline*and*is*best*given*IM*at*anterolateral*aspect*of*thigh.*Repeat*every*5*minutes*if*required.*
• Adrenaline:*dose*is*500*mcg*in*>*12*years;*300*mcg*in*6U12*years;*150*mcg*in*<*5*years.*
• Alternative*agents*to*adrenaline*are*hydrocortisone*(200*mg*adult).*and*chlorphenamine*(10*mg*adult).*
• Patients*who*have*had*emergency*anaphylactic*treatment*should*be*observed*for*6U12*hours.*
• Serum*tryptase*levels*are*elevated*for*up*to*12*hours*after*an*acute*episode.*
Hyperlipidaemia*
• Signs:*xanthomata.*
• Signs:*eruptive*xanthoma*are*due*to*high*triglyceride*levels*and*present*as*red/yellow*vesicles*on*extensor*
surfaces*(elbows,*knees).*
• Signs:*hypercholesterolaemia*causes*tendon*xanthoma,*tuberous*xanthoma*and*xanthelasma*(yellow*
deposits*on*eyelids).*
Statin*therapy*
• If*Qrisk*score*(10Uyear*risk)*is*>*20%*offer*statin*therapy*as*primary*prevention;*if*Qrisk*score*is*>*10%*and*
patient*has*established*cardiovascular*disease*then*offer*statin.*
• Patients*who*had*a*recent*cardiovascular*event*should*be*given*atorvastatin*80*mg*for*secondary*prevention.*
• Patients*with*type*1*diabetes*should*be*offered*atorvastatin*20*mg*for*primary*prevention*if*>*40*years,*had*
diabetes*for*more*than*10*years,*have*established*nephropathy*or*have*other*CVD*risk*factors.*
Antiplatelet*therapy*
• All*patients*who*require*secondary*prevention*for*cardiovascular*disease*should*be*on*an*antiplatelet.*
• Patients*who*require*anticoagulant*therapy*and*have*stable*cardiovascular*disease*may*stop*their*
antiplatelet*therapy*completely*and*use*the*anticoagulant*only.*
Pulmonary*artery*occlusion*pressure*
• Indirect*measurement*of*left*atrial*pressure*(and*thus*filling*pressure*of*left*heart).*
• Gold*standard*test*for*determining*cause*of*acute*pulmonary*oedema.*
• Interpretation:*normal*range*is*8U12*mmHg.**
• Interpretation:*hypovolaemia*is*suggested*by*<*5*mmHg;*fluid*overload*is*suggested*by*>*18*mmHg.*
• Hypovolaemic*shock*has*a*low*cardiac*output*and*low*pulmonary*artery*occlusion*pressure.*

* 18*
• Cardiogenic*shock*has*a*low*cardiac*output*and*high*pulmonary*artery*occlusion*pressure.*
Cardiac*signs*
• Pulsus*paradoxus:*abnormally*large*drop*in*BP*(>*10*mmHg)*during*inspiration*(pulse*may*disappear).*
Indicates*severe*asthma*or*cardiac*tamponade.*
• Slow*rising*pulse:*indicates*aortic*stenosis.*
• Collapsing*pulse:*indicates*aortic*regurgitation,*patent*ductus*arteriosus,*pregnancy.*
• Pulsus*alterans:*regular*alternating*force*or*arterial*pulse;*indicates*severe*left*ventricular*failure.*
• Bisferiens*pulse:*‘double*pulse’*formed*by*two*systolic*peaks;*indicates*aortic*valve*disease,*HOCM.*
ECG*interpretation*
• Normal*variants*in*athletes:*sinus*bradycardia,*junctional*rhythm,*1st*degree*heart*block,*Wenckebach*
phenomenon,*partial*RBBB.*
• Axis:*use*leads*I,*II,*aVF*to*assess*axis.*
• Left*axis*deviation:*causes*include*LBBB,*left*anterior*hemiblock,*WPW,*hyperkalaemia,*congenital*defects.*
• Right*axis*deviation:*causes*include*right*ventricular*hypertrophy,*left*posterior*hemiblock,*cor*pulmonale,*
pulmonary*embolism;*normal*in*infants*<*1*years.*
• P*wave*amplitude:*increased*by*cor*pulmonale.*
• Peaked*T*wave:*causes*include*hyperkalaemia,*MI.*
• Inverted*T*wave:*causes*include*MI,*digoxin*toxicity,*subarachnoid*haemorrhage,*pulmonary*embolism.*
• ST*elevation:*causes*include*MI,*pericarditis,*left*ventricular*aneurysm,*coronary*artery*spasm.*
• ST*depression:*causes*include*ischaemia,*digoxin,*hypokalaemia,*syndome*X,*secondary*to*abnormal*QRS*
changes.*
• Shortened*PR*interval:*causes*include*WPW.*
• Prolonged*PR*interval:*causes*include*idiopathic,*IHD,*digoxin*toxicity,*rheumatic*fever.*
• RBBB:*‘M’*shape*in*lead*V1*and*‘W’*shape*in*lead*V6;*RSR’*pattern.*
• RBBB:*causes*include*normal*variant*(old*age),*right*ventricular*hypertrophy,*cor*pulmonale,*pulmonary*
embolism,*myocardial*infarction,*atrial*septal*defect,*cardiomyopathy.*
• LBBB:*‘W’*shape*in*lead*V1*and*‘M’*shape*in*lead*V6.*
• LBBB:*causes*include*IHD,*hypertension,*aortic*stenosis,*cardiomyopathy.*
• Bifascicular*block:*combination*of*RBBB*and*left*axis*deviation.*
• Trifascicular*block:*combination*of*bifascicular*block*with*1st*degree*heart*block.*
*
Contraception*
Combined*oral*contraceptive*pill*(COC)*
• Works*by*inhibiting*ovulation.*
• Effective*after*7*days.*
• Adverse*effects:*makes*periods*regular,*lighter*and*less*painful.*
• Increases*risk*of*breast*cancer*and*cervical*cancer.*
• Reduces*risk*of*ovarian*and*endometrial*cancer.*

* 19*