SC CCT Flashcards
A 50-year-old male presented to the A&E department with acute central chest pain. He had a history of diabetic nephropathy. BP 180/90. ECG done.
1)Dx (2)
2) pharmacological Tx (4)
3)Definitive Tx (2)
4)1 Electrophysiological abnormality (2)
1) Acute inferior STEMI (ST elevation in leads II, III, aVF)
2) Aspirin + (with/without fibrinolysis = clopidogrel. With PCI = ticagrelor = preferred if PCI hospital) for DAPT, UFH/LMWH, B blockers (ischemic therapy –> proven survival benefits in STEMI), nitrates (symptomatic relief)
Analgesics: IV morphine
ACEI/ARB in all patients
Satins in all patients regardless of baseline LDL-C for secondary prevention of MI: atorvasatin
3) PCI/ (thrombolysis only indiated in STEMI and chest pain <12 hours (max) –> is an alternative to PCI)
4) Prolonged PR –> 1st degree heart block
A 65-year man presented to the AED for gait disturbance and fall. On examination, his power is 4/5 over 4 limbs and there is hyperreflexia.
The doctor treated the patient as ischaemic stroke and gave IV thrombolytic. No improvement in signs and symptoms. MRI brain showed no abnormalities. Subsequently, he developed acute urinary retention. The doctor ordered another neuroimaging to suggest an alternative diagnosis.
1) Name this imaging modality
2) What is the abnormality and where is the abnormality most severe?
3) Dx
4) Definitive Tx
1) cervical spine T2W MRI (CSF is bright)
2) Spondylotic changes of the spinal cord and obliteration of CSF anteriorly and posteriorly due to herniation of intervertebral disc. (C3-5)
3) Cervical spondylotic myelopathy
4) Surgical decompression with anterior spinal fusion
History of MI, present with palpitation. Blood pressure 90/60.
What is the rhythm abnormality in the ECG
2 therapeutic interventions
2 follow up Ix after the patient is stabilized
What permanent device would the patient need
a) No P waves (not sinus rhythm), regular wide complex tachycardia, negative concordance (all QRS complexes pointing down)
b) As this is monomorphic VT: give amiodarone or lidocaine than synchronized DC cardioversion
c) ECG, cardiac troponins, echocardiography, and cardiac imaging (cardiac MRI)
d) Post MI and spontaneous sustained ventricular tachycardia with/without syncoep requires implantable cardioverter defibrillator (ICD) implantation
a) 2 CT abnormalities
b) Dx of the peritoneal fluid analysis: WBC high, protein and albumin low
c) 2 common pathogens for the condtion
d) 1st line management
a) Ascites, splenomegaly
b) spontaneous bacterial ascites
c) e.coli, k.pneumoniae
d) IV ceftriaxone
- Name 2 ECG abnormalities
- What is the most likely dx
- Name 2 medications to be avoided
- What is the definitive treatmnet?
- Short PR interval, delta wave, wide QRS complex
- WPW (type B due to widened QRS complex = right pathway)
- AVN blockers: adenosine, B blocekrs, DHP CCB: verapamil, diltiazem, digoxin
- RFA of accessory pathway
- Please describe the salient findings of the non-contrast CT scan. (4 marks)
- Give 2 differential diagnoses. (4 marks)
- Name a further investigation to confirm the diagnosis. (2 marks)
1.Cortical hypodense lesion involving the right frontal and parietal lobe
2. Brain tumor (primary/secondary), cerebral abscess
3. MRI brain (with/without contrast) CT brain with contrast
(a) Name 3 ECG abnormalities (3 marks)
(b) What is the ECG diagnosis (1 mark)
(c) Most appropriate investigation to confirm diagnosis (1 mark)
(d) What is the immediate treatment (1 mark)
(e) Patient later deteriorated, severe hypotension, how to manage? (2 marks)
(f) 2 possible long-term pharmacological treatment (2 marks)
(a) S1Q3T3, sinus tachycardia (most common), V1 ST elevations
(b) Pulmonary embolism
(c) CT pulmonary angiogram
(d) LMWH
(e) Thrombolytics, surgical embolectomy
(f) Warfarin, NOAC
F/80, HT, DM, taking warfarin 1.5mg per day (recently started? For AF?)
Sustained fall 3 weeks ago with periorbital haematoma
A&E 2 weeks later for malaise(…)
PE: right side 4-/5, left side 4/5
(a) describe lesion, laterality, chronicity, location, and correlation with surrounding structures (5 marks)
(b) 2 important haematological parameters to check (2 marks)
(c) 3 important steps in management (3 marks)
(a)Subacute (1-3 weeks) subdural hemorrhage causing midline shift
Isodense lesion (if it was chronic –> hypodense)
(b) PT/INR, CBC for thrombocytoepnia
(c)
ABC first
Give transamin (prevent breakdown of clots)
Reverse bleeding tendency by stopping anticoagulant
Prevent seizure/fever
Burr hole drainage
(a) ECG diagnosis (2 marks)
(b) Clinical diagnosis (2 marks)
(c) Two relevant investigations (2?)
(d) Two pharmacological treatment (4)
(a) AF
(b) Thyrotoxicosis
(c) TFT for TSH, fT4, fT3
USG thyroid for thyrotoxicosis causes
(d): anti thyroid medications e.g. carbimazole
B blocker: propranolol (control tremor, palpitations and anxiety)
Lugols solution is only used prior to surgery (not for long term as there is desensitization): used to make euthyroid by decreasing the size aend vascularity of hyperplastic thyroid gland. Decreased risk of bleeding during surgery.
(a) Describe CT (4 marks)
(b) What is the diagnosis? (2 marks)
(c) Doctor tested eye movement on the patient, what is the most likely finding? (2 marks)
(d) 1 neurological complication (2 marks)
(a) acute hypodense lesion involving right frontal, parietal and temporal region
Sulcal effacement (local secondary sign of mass effect displacing the CSF)
(b) Acute R MCA ischemic stroke with hemorrhagic transformation
(c) Left homonymous hemianopia
(d) Compression of CN3: pupil dilatation
a) What is ECG dx?
b) Name one non pharmacological maneuver
c) Name 1 immediate pharmacological treatment
d) What are 2 contraindications of the above pharmacological treatment?
a) PSVT (absent P waves: hidden in the QRS complex)
b) Valsalva maneuvre
c) Adenosine injection
d) Contraindications to adenosine use: COPD, 2nd/3rd degree heart block, sick sinus syndrome, decomepensated heart failure, long QT syndrome, hypotension
A man presented with 3 hours of severe chest pain. BP 135/8X. His ECG is as follows:
a) Most striking feature
b) What is dx
c) What anatomical structure affected
d) list 3 pharmacological treatments to handle the clinical situation
a) ST elevation in leads V2-5
b) STEMI
c) LAD occlusion
d) Nitrate (symptom relief), aspirin (DAPT in certain high risk patients), anti anginal (B blocker is 1st line), statin
a) Describe 2 abnormalities
b) What is the most likely cardiac rhythm of this patient?
c) An ascending physician can detect murur, what murmur?
d) What is the most likely valvular abnormality?
e) 2 pharmacological treatment for condition
a) Small aortic knuckle from decreased cardiac output, double density of left atrial enlargement
b) Atrial fibrillation
c) Characteristic: mid/late diastolic, rumbling, low pitch
Location: apex
d) mitral stenosis
e) B blockers (sotalol), amiodarone
1a) Name the ECG abnormality. (4 marks)
1b) What is the diagnosis? (2 marks)
1c) give two tx
1a) ST depression V3-6, I, II, III, aVF)
b) Myocardial ischemia affecting LAD
c) Anti thrombotic (aspirin + P2Y12 antagonist), antiischemic (nitrates + B blocker), other therapy: ACEI + statins, coronary revascularization if NSTEMI/UA
a) CT findings
b) What is dx?
c) What could have caused this?
d) Tx?
a) Right sided lentiform shaped hyperdense lesion, mid line shift, sulci effacement (indicating mass effect)
b) epidural haematoma
c) Trauma
d) craniotomy to relieve intracerebral pressure
a) What is the abnormality shown on CXR?
b) Give 2 most likely dx
c) Further Ix?
a) Massive right radioopacity covering entire lung field
b) Massive pleural effusion, right sided pneumonia
c) Diagnostic thoracentesis for pleural effusion (gross appearance, culture, biochemistry (glucose, protein, LDH, microscopy, cell count), cytology (will require pleuroscopy to obtain high yield results)
Contrast CT thorax for underlying lesion
Sputum culture and cytology
Worker who complained of retrosternal chest pain radiating to the back after lifting a heavy load. On A&E admission a faint early diastolic murmur was heard in the aortic area. CXR was done showing cardiothoracic ratio of 0.5, mediastinum 9cm, lungs clear. BP190/90, pulse 90.Bloods were tested CBC, LRFT, cardiac enzymes.
Name 2 ECG abnormalities
What is the cause of chest pain
What further ix to do?
a) ST elevation in inferior leads (II, III, aVF), ST depression in lead I and aVF
b) early diastolic murmur is AR, widened mediastinum (>8cm is widened) and very high systolic BP –> aortic dissection
c) CXR, CT thorax and abdomen with contrast, MR angiogram, transthoracic or transesophageal echocardiogram (TEE)
a) Name 2 ECG abnormalities
b) What is the dx?
c) What arrhythmias associated with this condition?
a) Short PR interval, wide QRS, delta wave
b) WPW (type b as it is dominant S wave in V1 –> right sided AP)
c) Supraventricular tachycardia (especially AVRT) and AFib
- What is ECG abnormality?
- Suggest 1 ECG anomaly prior to HD.
- Name 3 possible casues for his ECG abnormality
- Explain how to manage the patient
- Torsades de pointes (polymorphic VT)
- Long QT interval
- Electrolyte disturbance (HypoC, HypoK, HypoMg), congenital long QT syndrome, antibiotics (clarithromycin), chronic renarl failure requiring dialysis
Haemodynamically unstable patients: defibrillation
Haemodynamically stable: IV magnesium sulphate, IV isoproterenol
Temporary transvenous overdrive pacing (atrial or ventricular) reserve for patients who do not respond to IV magnesium sulphate
M 65 with hypertension, diabetes mellitus, chronic renal impairment presents with shortness of breath.He was afebrile. His oxygen saturation is 92% on room air.
a) What abnormalities on CXR
b) What is most likely dx?
c) Name 2 important Ix to help managet the patient
d) Name 2 medications and their mechanisms to help improve cardiac function in the acute setting.
a) Bilateral perihilar haze (batwing appearance), upper lobe diversion (cephalization), kerley B lines
b) Pulmonary edema/congestive heart failure
c) ECG, echocardiogram, BNP
d) Furosmide (diuretic) that reduces preload, IV nitrate (venodilatation which lowers preload –> also at high dose causes arteriolar dilatation, resulting in reduced afterload and BP), morphine
If BP not stable give inotropic agents: dopamine, dobutamine
29/F, GPH, new onset SOB, withSpO2 88% on RA, hypercapnia
a) CXR finding
b) Ddx
c) Immediate management
d) 2 Ix
1) widened mediastinum (>8cm)
2) Anterior mediastinal mass: lymphoma, thymoma, thyroid goitre, teratoma
3) Secure airway, intubation
4) Biopsy of mediastinal mass, CT thorax
a) ECG abnormalities
b) dx
c) 2 Ix
d) What treatment can be givne?
e) If reccur, what can be done?
a) ECG: low voltage QRS (peak to peak QRS amplitude <5mm in limb leads or <10mm in precordial leads), tachycardia, electrical alternans (QRS amplitude is different)
b) Pericardial effusion/cardiac tamponade
c) Pericardial fluid analysis, CXR
d) Therapeutic pericardiocentesis
e) Pericardiectomy
- What are the abnormalities shown? (3 marks)
- After initial investigations, another investigation was ordered, and the scan results are shown as below. What was the investigation ordered, and what are the positive findings?
(3 marks) - Name 2 complications that can arise from the above pathology (2)
- Hyperdense area obliterating the ventricles, star sign, sulcal hyperdensity, subarachnoid hemorrhage
- Head CT contrast in arterial phase, aneurysm in posterior commuicating artery
- Hydrocephalus, seizure, cerebral edema, rebleeding of aneurysm, vasospasm causing delay in cerebral reinfarction. Coma, respiratory depression, brain herniation
- Name two abnormalities (2 marks)
- What is the diagnosis (2 marks) What is the complication? (2 marks)
- Name two drugs that can cause this abnormality (1 mark each, 2 marks total)
- The patient’s condition stabilised after your initial medical therapy. There were no reversible causes. What treatment would you give? (2 marks)
- AV dissociation (no P wave for every QRS complex), slow ventricular beat
- Dx: complete heart block. Complication: congestive heart failure
- AVN blocking agent (BB: esmolol, CCB: diltiazem), digoxin
- What is the diagnosis (2 marks)
- What treatment would you give (2 marks)
- What life-style factor is a risk factor? (2 marks)
- What hereditary condition is associated with this diagnosis? (2 marks)
- Which gender is this diagnosis associated with?
- Left pneumothorax (increased ICS space, flattening of the diaphragm, tracehal deviation to contralateral side)
- O2 therapy, chest drain
- Smoking
- Marfan syndrome
- Male
- Name 2 ECG abnormalities. (4 marks)
- Give 2 causes of this cardiac condition
- How would you manage this patient?
- Prolonged PR interval, AV dissociation, 2nd degree heart block
- Anterior MI (septal infarction with necrosis of bundle branches), levs disease (idiopathic fibrosis of bundles), cardiac surgery (especially those close to septum e.g. mitral valve repair), inflammatory conditions (rheumatic fever, myocarditis, Lyme disease, typhoid fever), autoimmune (SLE, systemic sclerosis), infiltrative myocardial disease (amyloidosis, haemochromatosis, sarcoidosis), hyperK, drugs (BB, CCB, digoxin, amiodarone)
- IV atropine (used for bradycardia), IV isoproterenol (B agonist)
- Temporary transvenous/transucutaneous pacing
- What did the CT brain show? (2 marks)
- Name 1 bedside procedure that you can perform to confirm the diagnosis (1 mark), name the specific clinical parameter that you look for in the procedure. (1 mark)
- Assuming the above parameter is normal, what is the neurological diagnosis? (1 mark)
- What are the 3 classical clinical findings in this patient? (3 marks)
- What surgical procedure you would perform? (2 marks)
- Dilated lateral ventricles, lateral sylvian fissure, prominent cerebral sulci (cerebral atrophy)
- Lumbar puncture for opening pressure
- Normal pressure hydrocepahlus
- Gait disturbance, dementia, urinary incontinence
- Ventriculoperitoneal shunt
- What is the most striking abnormality of the ECG? (2M)
- What is the diagnosis (1M)
- What is the anatomical structure that is affected? (1M)
- List three pharmacological treatments to handle the clinical situation of this patient (6M)
- ST elevation in V1-5, aVL, I
- Anterolateral STEMI
- Proximal LAD
- rtPA, morphine/nitrate, rosuvatstatin, aspirin + ticagrelor (if proceeding to PCI. If just doing thrombolytic therapy = clopidogrel)
- What is the ECG diagnosis? (2)
- What should be the immediate management of this lady? (1)
- Name two pharmacological treatments to control her condition. (4)
- Name two underlying causes (4)
- Vtach
- Direct current cardioversion
- Flecainide, amiodarone
- IHD, electrolyte disturbance (hypoK, hypoCa, hypoMg), LQTS, Brugada syndrome
A 52-year-old gentleman with a history of Type 2 DM and hypertension presents with an acute onset of left-sided weakness. He was last seen well 30 minutes prior to admission. On physical examination, his blood pressure was 160/90 mmHg and his pulse was 96 beats per minute, which was irregularly irregular.
1. Name two salient abnormalities found on the CT brain. (2)
2. What is the neurological diagnosis? (2)
3. The House Officer on call performed an ECG. Name the abnormality found. (0.5)
4. The patient also presented with a visual disturbance. What is the most likely visual sign? (1.5)
5. What is the acute pharmacological treatment for this patient? (1)
6. What is the non-pharmacological treatment that may be suitable for the patient. (1)
7. Name two long term pharmacological treatments that may be used. (2)
- Hypodense lesion on the right frontal and parietal lobe indicating ischmeic stroke
- Ischemic stroke from cardioembolism
- AF
- Amourosis fugax (obstruction of opthalmic artery from blood supply)
- Thrombolysis with rTPA
- Mechanical thrombectomy
- Statin, anticoag (IV heparin), BB, CCB
- What is your diagnosis? (1)
- Give 2 drugs to this patient. (2)
- 1 electrophysiological problem that is associated with this problem?
- Which arrhythmia is associated with this condition? (1)
- What is the definitive treatment for this condition?
- 1 mechanical complication of the condition?
- Inferior STEMI
- Immediate treatment given in A&E: triple therapy –> DAPT (aspirin + ticagrelor). Anticoag: UFH
Post PCI: statins (regardless of LDLC), ACEI (prevent LV remodelling), B blocker (Decrease cardiac workload and vasodilation to increase coronary perfusion), nitrate - Arrhythmia
- AV block (AMI involve AVN): inferior STEMI means RCA blocked and RCA supplies the AVN through AV nodal branch before going down to inferior walls. Other arrhythmias of of inferior/anterior STEMI: VT/VF. If AMI affect SAN, it will cause sinus arrest
- Emergent primary percutaneous coronary intervention
Thrombolytic therapy with tenecteplase/tPA (if PCI hospital not available) - Papillary muscle rupture/dysfunction causing acute mitral regurgitation