Interactive Cases in General Internal Medicine (1) Flashcards by Francesca B

60 yr old man

Chest pain

Tight, 4 hrs

Nausea

Sweating

Breathlessness

HTN

DH: amlodipine

What is the diagnosis?

A. Pneumonia

B. Pericarditis

C. Myocardial infarction

D. Aortic dissection

E. Costochondritis

C. Myocardial infarction

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If someone presents with chest pain (you think is of cardiac origin) what are the investigations you would want to do

ECG
Troponin

+ve: coronary angiography
-ve: ETT

Echocardiography

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How soon should you do a troponin?

6 hours after they started having pain

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What are the differentials of chest pain?

Cardiac:

IHD: Stable & unstable angina, STEMI, NSTEMI
Aortic disseaction
Pericarididtis

Resopiratory

PE
Pneumonia
Pneumothorax

Oesophageal spasm
Oesophagitis, Gastritis

Muscluloskeletal

Costochondritis

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What are differentiating feature of chest pain of cardiac origin

IHD: jaw, radiating down the arm

pericarditis: worse on inspiration, better on leaning forward

Aortic dissection: tearing, along the back, difference between the blood pressure in both arms

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What are differentiating feature of chest pain of repiratory origin

PE:

Pneumonia:

Pneumothorax:

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Patient has had mwlanoma metastaiszed to th brain and now on high dexamethasone.

Complains now of chest pain.

What is the chest pain due to

steriod: immunosupression - infection

oesophagitis - fungal infection

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History:

60 yr old man • Chest pain • tight, 2 hrs • nausea & sweating • PMH: HTN • DH: amlodipine

Examination:

Temp: 37.0oC • HS: S1 + S2 • BP: 120/80 (L), 118/75 (R) • Chest: clear • Abdomen is soft, nontender

What is the most appropriate investigation?

A. CK

B. CXR

C. ECG

D. Echocardiogram

E. Troponin

C. ECG

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feature of viral pericarditis

fever, sweating

better when leaning forward

pleuritic chest pain

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What does this ECG show?

What should happen to this patient?

anteriorlateral MI

Should be sent inmmidiatly to a cathlab for percutaneus coronary intervention

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What does this ECG show?

inferior STEMI

2, 3, AVF

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What are teh ECG changes and artery affected in an:

anterior MI
Lateral MI
Inferior MI

anterior MI:

LAD
V1-V4

Lateral MI:

Circumflex
V5, V6, I, aVL

Inferior MI:

RCA
II, III, aVF

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what are the cardiac enzymes

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When do you measure troponin and when does it rise and when does it fall

troponin goes up within 6-121 hour

but is up for several days (3-4)

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History:

30 year 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 • Abdomen: soft, non-tender • CN I-XII: NAD, Normal I, T, P, R, C, S, G

What is the most likely cause of his collapse?

A. Aortic stenosis

B. Pulmonary embolism

C. Postural hypotension

D. Seizure

E. Tachyarrhythmia

EXLUSION: says normal sounds (no ejection systolic murmur)

no drop in blood pressure when standing(not postural hypotension)

no post ictal period, no tongue biting (no seizure)

no risk factors for PE, or breathlessness (no PE)

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What do you look out for in a person that collapsed?

What are differentiating symptoms?

Cardiac: no warning, sudden

Seizure: tongue biting, confused afterwards (post ictal period)

Vasovagal: feel dizzy come around quickly and

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What are differentials of collapse?

Hypoglycaemia:

cardiac:

vasovagal
ouflow obstruction: PE, HOCM, aortic stenosis
postural hypotension

neurological:

seizure

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What are the investigations you would do for the different causes of collpase

Arrhythmias –

Tachycardia, bradycardia

DO an ECG (? Long QT), cardiac monitor, 24 hour tape

Outflow obstruction

Left: Aortic stenosis, HOCM
Right: PE

Do a Low volume/slow rising pulse, ESM, Echocardiogram

Postural hypotension

Lying/standing BP

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What is a long QT syndrome?

Abnormal ventricular repolarization
Congenital e.g. mutations in K+ channels
FH of sudden death
Acquired: low K+ / Mg2+ , drugs

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History:

• 45 year old man • Fever • Malaise • IV drug use

Examination:

Temp: 38oC • raised JVP to earlobes • HS: S1 + S2 + PSM (louder on inspiration) • Hepatomegaly

What is the cause of his raised JVP?

A. Constrictive pericarditis

B. Congestive cardiac failure

C. Aortic regurgitation

D. Mitral regurgitation

E.Tricuspid regurgitation

Tricuspid regurgitation

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Which murmurs are heard louder on inspiration and expiration?

Left - expiration

right- inspiration

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What are differentials of a raised JVP

R heart failure:
- Secondary to L heart failure (CCF)
- Pulmonary HTN (PE, COPD etc.)
Tricuspid regurgitation:
- Valve leaflets
- R ventricle dilatation
Constrictive pericarditis:
- Infection e.g. TB
- Inflammation: CTD
- Malignancy

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What give you a pan systolic murmur?

tricuspid regurgitation

mitral regurgitation

Differentiate if louder on inspiration or experiation

What are all the systolic murmurs?

Aortic stenosis

Mitral regurgitation

Tricuspid regurgitation

VSD

how do you differentiate an aortic stenosis from an mitral regurgutation?

**Where is it the loudest?** **Mitral regurgitation:** loudest at the left 5th intercostal space mid clavicular line and radiates to the axilla **Aortic stenosis:** louddest at the right 2nd intercostal space radiates to the carotids **What are assosiated feature?** **aortic stenosis:** slow rising pulse **mitral regurgitation:** displaced apex beat **VSD:** young and no other features

**History:** 65 year old man • Breathlessness • Palpitations • PMH: HTN • DH: Bendroflumethiazide Examination Temp: 38oC • PR: 160, irregular • BP: 110/80 mmHg • Dull percussion note & coarse crackles L base **What would you expect to see on his ECG?** A. Atrial fibrillation B. Sinus tachycardia C. SVT D. VF E. VT

What are the different types of tachycardias/ palpitations? What are the differential for those

**Sinus tachycardia:** Sepsis, hypovolaemia, endocrine (thyrotoxicosis, phaeochromocytoma) **SVT** Re-entry circuit **Atrial fibrillation** Thyrotoxicosis, ischaemia, chest infection, alcohol **VT** ischaemia, electrolyte abnormality, long QT

What does this ECG show? What could have caused this?

**Sinus tachycardia (p wave before every QRS)** **Causes:** * Sepsis * hypovolaemia * endocrine (thyrotoxicosis, phaeochromocytoma)

What does this ECG show? What are the causes of it?

SVT re entry circuit

What are the 2 different types of SVT?

When do you see the delta wave and when do you see tachycardia?

delta wave: when it is going down (from atria down into the ventricles) the accessory pathyway but you won#t have tachycarida tachycardia: when the electrical impulse comes back up the accessory pathway into the atria

What is an ECG that is regular, no p wave and tachycardia

SVT

What does this ECG show? What causes it?

AF **causes** Thyrotoxicosis, alcohol **Heart**: muscle, valve, pericardium **Lungs:** Pneumonia, PE, cancer

What does this ECg show?

atrial flutter

What does this ECG show? What are the causes for it

Ventricular tachycardia **causes:** * Ischaemia * electrolyte abnormality * long QT

What is the management of SVT?

vagal maneuvers Adenosine (cardiac monitor) DC cardiovesion if evidence of haemodynamic compromise

What is the management of AF

_Rhythm control_ * If onset \> 48hours, anticoagulate for 3-4 weeks before cardioversion _Rate control_ * beta blocker * Digoxin Think of the underlying Cause Think of the Complications (Anticoagluation)

What is the management of VT?

If no haemodynamic compromise: IV Amiodarone Look for & treat underlying cause ICD Pulseless VT: defibrillate

What does this ECG show?

HYPERTENSION LVH by voltage criteria (Remember SR) Deep S in V1/2 Tall R in V5/6 S in V1 + R in V5 or V6 (whichever is larger) ≥ 7 large squares

What drug used to treat AF does not work in infections?

digoxin

What is the difference between cardioversion and defibrillation

defibrillation: you don't sync it with the rhythm you just shock

What does this ECG show?

1 st degree heart block

What does this ECG show

2nd degree heart block p wave no QRS

What does this ECG show

3rd degree heart block

**What are the ECG's that can be seen in the following conditions?** * Ischaemia * Arrhythmia or conduction defects * Ventricular strain or hypertrophy

**Ischaemia** ST, T, Q **Arrhythmia or conduction defects** Rate, Rhythm PR, QRS, QT **Ventricular strain or hypertrophy** Axis, R, S

What would a tall R wave in V1 indicate

right heart side strain - PE

history: 65 year old woman • Breathlessness • Onset: over a few hours • Orthopnoea • PMHx: 2 X MIs • DH: aspirin, simvastatin, ramipril, bisprolol Examination: Temp : 36.5oC • raised JVP • HS: S1 + S2 + S3 • Chest: fine crackles • Peripheral oedema **What is the 3rd heart sound due?** A. Is due to closure of mitral valve B. Is due to closure of aortic valve C. Is due to an atrial septal defect D. Is associated with ventricular hypertrophy E. Is associated with ventricular filling

E. Is associated with ventricular filling

What are the heart sounds associated with?

Closure of mitral valve B - S 1 Closure of aortic valve C - S 2 Atrial septal defect - Fixed wide splitting of S2 Associated with ventricular filling - S3 Associated with ventricular hypertrophy - S4

What is the Management of this patient?

**Management of acute heart failure** 1. Sit up 2. Oxygen 3. Furosemide (IV) 4. GTN infusion) 5. Treat the underlying cause

CASE: History: 78 year old man • Brought in by ambulance • Unconscious • Not breathing • Carotid pulse is absent • Temp 29oC What does the ECG show? A. Asystole B. AF C. VF D. VT E. SVT

CASE: History: 78 year old man • Brought in by ambulance • Unconscious • Not breathing • Carotid pulse is absent • Temp 29oC How would you manage this patient?

HE is cold don't administer any drugs until he is warmed up

How do manage VF/ pulseless VT

1. Shock 2. CPR (2 min) 3. Assess rhythm 4. Adrenaline every 3-5 min 5. Amiodarone after 3 shocks 6. Correct reversible causes

how do you manage someone with Asystole

CPR (2 min) Adrenaline every 3-5 min Correct reversible causes

30 yr old woman • URTI • Pleuritic chest pain • Better when leaning forward What is the diagnosis?

pericarditis

What are the reversible causes of pulseless VT

4H: Hypovolaemia, Hypothermia, hypokalaemia, Hypoxia 4T: Tamoponade, Tension pneumothorax, Toxins, Thrombosis

Do you shock a patient in asystole?

NO just give adrenaline

What are the differentials for pleuritic chest pain

5 P's PE Pericarditis Pneumonia Pleural patholofy Sub diaphragmatic pathology