Cases in general internal medicine 1 Flashcards
(45 cards)
Investigations for suspected MI
- ECG
- Troponin (perhaps 6hr or 12hr after)
(if troponin +ve then coronary angiography, if -ve exercise tolerance test) - Echocardiography
Classify the causes of chest pain
Cardiac: IHD, aortic dissection, pericarditis
Resp: PE, Pneumonia, Pneumothorax
GI: gastritis, eosophagitis, eosophageal spasm
MSK: costochondritis
Aortic dissection pain
Pericarditis pain
Aortic dissection: Tearing pain radiates to the back
Pericarditis: pleuritic pain worse on inspiration
What from an examination might help you tell if there is aortic dissection
difference in BP between two arms
What problem could a patient on steroids have with chest pain (rare case)
Possibly candidasis (fungal infection) due to immunosuppression due to steroids
First line for STEMI
PCI (percutaneous coronary intervention)
Clotbusters not first line now
What leads would show changes in:
- Anterior MI
- Lateral MI
- Inferior MI
- Posterior MI
And which artery is affected in each case
When does troponin peak with MI?
What enzymes peak much earlier than troponin
Best cardiac biomarker for assessment of reinfarction during an MI admission
• Anterior MI – LAD – V1‐V4 • Lateral MI – Circumflex – V5, V6, I, aVL • Inferior MI: – RCA – II, III, aVF • Posterior MI: – Posterior descending artery – ST depression in V1-4
It rises around 4-6 hours after, peaks at 18-24hrs. Then falls over the next 5 days for a large MI. For a small MI might only be a small increase
Myoglobin and CK isoforms will peak much sooner. and are cleared sooner.
CK-MB returns to normal within about 72hrs compared to 5-7 days for trop, so it can be useful to assess reinfarciton
DDx of collapse
- Hypoglycaemia
2. Cardiac • Vasovagal • Arrhythmia • Outflow obstruction (aortic stenosis, HOCM, pulmonary embolism) • Postural Hypotension
- Neurological
• Seizure
What investigations/what might you see on examination if you suspect the following:
- Arrhythmias
- Outflow obstruction
- Postural hypotension
- Arrhythmias- ECG (? Long QT), cardiac
monitor, 24 hour tape - Outflow obstruction (see below)- Low volume/slow rising
pulse, ESM, Echocardiogram - Postural hypotension- Lying/standing BP
Cause of long QT syndrome
Abnormal ventricular repolarization
Congenital e.g. mutations in K+ channels
Acquired: low K+/ Mg2+, drugs
What might you find in family history of patient with long QT syndrome
• FH of sudden death
How to distinguish between mitral and tricuspid regurg murmurs
Both pansystolic murmurs, RILE. Right louder on inspiration and left louder on expiration
DDx of raised JVP
- R heart failure
- Tricuspid regurgitation
- Constrictive pericarditis and cardiac tamponade
What might cause right sided failure
– Secondary to L heart failure (CCF)
– Pulmonary HTN (PE, COPD etc.)
What might cause truscupid regurg
– Valve leaflets
– R ventricle dilatation
What might cause constrictive pericarditis
– Infection e.g. TB
– Inflammation: CTD e.g. lupus
– Malignancy
What are the types of tachycardia on ECG
What heart condition is most likely with chest infection
Sinus tachycardia, SVT, AF, VT and VF
Atrial fibrillation (legionnaires in particular is likely to present with AF)
DDx for Sinus tachycardia
Sepsis,
hypovolaemia,
endocrine (thyrotoxicosis,
phaeochromocytoma)
DDx for SVT
Re‐entry circuit
DDx for Atrial fibrillation
Thyrotoxicosis, alcohol
Heart: ischaemic heart disease, muscle, valve (mitral stenosis), pericardium
Lungs: pneumonia, PE, cancer
DDx for VT
ischaemia, electrolyte
abnormality, long QT syndrome
Management of SVT
- Vagal maneuvers
- Adenosine (cardiac monitor)
- DC cardioversion if evidence of haemodynamic compromise
Management of new onset AF
-risk stratification?
TREAT REVERSIBLE CAUSE
-Haemodynamically unstable:
DC cardioversion
-Haemodynamically stable with left thrombus:
RATE control with b-blocker/CCB (or digoxin/amiodarone if HF)
+
Anticoagulate
+
DC or pharmacological cardioversion 3-4 weeks later
-Haemodynamically stable, no left atrial thrombus, symptom onset <48hrs: CHADVASC SCORE 0-1: -Rate control with b-blocker/CCB \+ -DC or pharmacological cardioversion CHADVASC SCORE >2: -Rate control with b-blocker/CCB \+ -DC or pharmacological cardioversion AND heparin \+ -Anticoagulation
Haemodynamically stable without left atrial thrombus, but symtpom onset >48hrs:
CHADVASC SCORE 0-1:
-Rate control with b blocker/CCB
-Give heparin
-Electrical or pharmacologic cardioversion once heparin established
CHADVASC SCORE >2
- Rate control with b blocker/CCB
- Anticoagulate
- Electrical or pharmacological cardioversion follwoing 3-4 weeks of anticoagulation
Then, risk stratification for future stroke:
C - Congestive heart failure (or Left ventricular systolic dysfunction)
H- Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication)
A2-Age ≥75 years
D-Diabetes Mellitus
S2-Prior Stroke or TIA or thromboembolism
V- Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic plaque)
A- Age 65–74 years
Sc- Sex category (i.e. female sex)
Low-risk patients can be managed with aspirin, and high-risk patients require anticoagulation with warfarin.
Management of VT
If no haemodynamic compromise: IV Amiodarone
• Look for & treat underlying cause
• ICD
Pulseless VT: defibrillate
