Interactive Cases - CVS Flashcards
Scenario: 60 yr old man symps: chest pain - tight, 4hrs ass. symps: nausea, sweating, breathlessness PMH: HTN DH: amlodipine
What is the diagnosis?
a) pneumonia, b) pericarditis, c) MI, d) aortic dissection, e) costochondritis
MI
What symptoms are usually associated with cardiac ischaemia?
Nausea, sweating, breathlessness
What would the clinical picture for pericarditis look like?
symps: pleuritic chest pain, worse on inspiration
ass. symps: flu-like symptoms
o/e; pericardial friction rub
What is the main therapy for pericarditis (viral/idiopathic)?
NSAIDS
How would you investigate the 60yr old gentleman with chest pain above?
- ECG
- Troponin:
- if +ve –> coronary angiography
- if -ve –> ETT (=exercise tolerance test) - Echo
Why do you do an ECG before a troponin?
Have to wait 6-12hrs for troponin to rise, ECG gives instant results
What might the ECG help you differentiate between?
STEMI vs NSTEMI
What might an echo show?
regional wall motional abnormality (RWMA)
How would you manage a STEMI?
MONABASH (inc. 300mg aspirin + 300mg clopidogrel) –> PCI / CABG (cath lab)
How would you manage an NSTEMI?
MONABASH
= morphine, oxygen, nitrates, aspirin, beta blockers, ACE inhibitors, statin, heparin
What are the key differentials for chest pain?
Cardiac –> IHD, aortic dissection, pericarditis
Resp –> PE, pneumonia, pneumothorax
GI –> oesophageal spasm, oesophagitis, gastritis
Musculosekeltal –> costochondritis
When would you suspect aortic dissection?
- hear an aortic regurg. murmur when you auscultate the back with the patient leaning forward
- difference in blood pressure between L and R arm
How do you take the history for cardiac chest pain?
- The symptom (soCRAtEs)
- Other symptoms (system)
- RFs / DDx questions
What are your differentials for cardiac chest pain?
IHD –> angina pectoris, ACS (MI)
aortic dissection
pericarditis
In the above scenario, with the 60 year old with a suspected MI, you find the following:
temp: 37C, HS 1+2 present, BP: 120/80 (L), 118/75 (R), chest: clear, abdo: SNT
What is the most appropriate next investigation?
a) CK, b) CXR, c) ECG, d) echo, e) troponin
c) ECG
why? –> instant (trop. takes time to elevate), easier/quicker than echo., MI won’t show up on CXR
What are the coronary arteries and ECG changes corresponding to an anterior MI?
artery: LAD
ECG: V1-V4
What are the coronary arteries and ECG changes corresponding to a lateral MI?
artery: left circumflex
ECG: V5, V6, 1, aVL
What are the coronary arteries and ECG changes corresponding to an inferior MI?
artery: RCA
ECG: II, III, aVF
What conditions might cause an elevated troponin?
MI, sepsis, renal failurre, pneumonia
Scenario:
30 yr old man
collapse
HPC:
- before: no warning
- during: no tongue biting
- after: not confused
FH: brother died at a young age
Examination: HS S1+S2+0, BP: 120/80 (lying), 115/75 (standing), vesicular breath sounds, abdo SNT, CNs1-12 NAD
What is the most likely cause of his collapse?
a) AS, b) PE, c) postural hypotension, d) seizure, e) tachyarrhythmia
c) postural hypotension
cardiac vs neurological causes:
clinical picture points to CARDIAC cause –> no warning, no tongue biting, no incontinence (unlikely to be seizure)
unlikely to be vasovagal syncope as no precipitating factors (eg. hot weather, dehydration, posture)
What would you hear on auscultation if a patient had AS?
systolic murmur, loudest in aortic area, radiates to carotids
What are three causes of cardiac collapse?
postural hypotension
arrhythmias
AS
What are the differential diagnoses for collapse?
- hypoglycaemia (NEVER FORGET THIS!!!)
- cardiac –> vasovagal, arrhythmias, outflow obstruction, postural hypotension
- neurological –> seizure
How would you investigate a suspected cardiac-related collapse?
postural hypotension --> assess lying vs standing BP arrhythmias (eg. tachy/brady, long QT etc.) --> ECG (?long QT), cardiac monitor, 24 hour tape outflow obstruction (eg. AS, HOCM, right: PE) --> low volume/slow rising pulse, ESM, echo
