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
- Describe the abnormality
- Diagnosis
- 2 pharma treatment
- Bradycardia, ST elevation in leads II, III, aVF with reciprocal ST depression in leads I, aVL. ST elevation in lead III >lead II therefore RCA occlusion
- Inferior STEMI with complete heart block (there is AV dissociation as there is no QRS complex for every P wave)
- Acute treatment of STEMI and transvenous pacing (normally after revascularization heart block will disappear and no need for permanent pacemaker)
60 y/o woman DM, HT complained of chest pain. BP normal, tachycardia (110)
1. What is dx?
2. Where is site of lesion?
3. What 2 drugs to be given?
4. What is the most appropriate treatment?
- Acute anteroseptal STEMI (ST elevation of V1-2 (septal), anterior (V3-4))
- Left anterior descending artery
- Antiplatelet (aspirin, clopidogrel), LMWH
- Primary PCI
M/~60 followed up in cardiac clinic
1. ECG abnormality
2. Dx
3. RF
- Poor R wave progression (small R wave in V1-4 than sudden large R wave in V5). May also have Q waves in V1-3, T wave inversion in lead I, V2-6
- Old anterior MI (Q waves normally only in latereal leads)
- Male gender, HT, DM, hypercholesterolemia, obesity, chronic renal failure, positive family history of premature CVD
- What ECG abnormalities
- Blood Ix
- Pharmacological Tx
- Diffuse ST depression, whilst aVR, V1 ST elevation due to proximal LAD occlusion
- High sensitive cTnI, cTnT. CKMB, myoglobin.
- Same principle as STEMI but less urgent. Anti thrombotic: aspirin, clopidogrel, LMWH. Anti-ischemic therapy: nitrates, BB, CCB
What is the diagnosis (1)
What are 2 causes of this condition? (2)
What is your immediate management? (1)
Give 1 drug to control this condition? (1)
- VT (regular wide complex tachycardia with AV dissociation, concordant waves)
- AMI, IHD, hypoK, DCM, brugada. Note that the cause of VT will be AMI if patient age is cold
- Defibrillation is pulseless VT, synchronized cardioversion
- Acute: class 1 fast Na+ channel blockers (IV lignocaine, pronainaimide). Class 3 K channel blockers (IV amiodarone, IV bretylium). Long term: PO class I and III OAA
- Diagnosis
- 2 predisposing causes
- 1 Blood Ix
- 1 immediate management
- 1 medical management that has long term survival benefit
- 1 complication of drug
- 1 complication
- AF due to thyrotoxicosis
- Valular HD (MS), hyperthyroidism, AMI
- TFT
- IV digoxin, IV class 2 (CCB) and class 4 OAA (BB: esmolol + slow Ca channel blocker diltiazem), PTU (for the thyroid symptoms)
- NOAC (for non valvular AF –> rivaroxaban), warfarin (valvular AF)
- Increase bleeding tendency (risk of intracranial hemorrhage)
- Acute heart failure, cardioembolic stroke
- What is ECG abnormality
- Name 2 Ix
- Why SOB
- Name 1 immediate medical treatment for AFlu
- Non pharmacological
- Complication
- Sawtooth appearance: atrial flutter. Inverted flutter waves in leads II, III, +aVFR, upright flutter waves in V1-2 (anticlockwise circuit), 4:1 block. Relatively slow ventricular response suggests treatment with an AVN agent.
- CXR, echocardiogram, cTnI, cTnT, electrolytes, CBC, TFT
- Heart failure causing acute pulmonary edemea
- IV digoxin. IV class 2 (diltiazem), class IV (BB: esmolol). Long term medical manageemnt: PO of immediate treatment, anticoagulants: NOAC/warfarin
- Non pharmacological: direct cardioversion. Definitive: catheter ablation, pacing
- Complication: acute pulmonary edema
- ECG abnormalities
- 2 non pharmacological manouvres
- Immediate treatment
- Name 1 Ix
- 1 definitive treatment
- Narrow complex tachycardia: SVT (likely AVNRT)
- Carotid sinus massage, vagal manouvers (increase vagal tone to slow AVN conduction and termination of SVT), valsalva manoure (gagging, drinking ice water, cold water immersion of face)
- IV ATP, IV class II (diltiazem/verapamil) and class 4 AAD (esmolol)
- Holter ECG, electrophysiology study, CBC, electrolyte, +/- CXR, echocardiogram
- RF catheter ablation of ectopic foci, PO immediate treatment
- Name 2 ECG abnormalities
- 2 causes
- ECG dx
- Drugs to be given
- What treatment if drug fails
- Long term treatment
- Bradycardia, AV dissocation (no P wave for every QRS complex), slow ventricular rhythm. Ventricular escape rhythm (ectopic rhythm) is the intrinsic beating of the ventricle, because signal blocked from AVN)
- AMI, hypothyroidism, drugs (ABCD) (antiarrhythmics, AVN blockers: BB, DHP CCB (diltiazem, verapamil), digoxin), electrolyte disturbance (hyperK)
Cardiomypathy, myocarditis, AV septal defect
Lenegres disease, Levs disease (fibrosis of conduction system) - Complete heart block
- IV atropine (bradycardia), IV isoprosterenol (B agonist)
- Temporary transvenous/transcutaneous pacing
- Permanent pacemaker implant
- 2 ECG abnormalities
- Dx
- Name 1 drug that is contraindicated
- Immediate treatment
- Shortened PR interval, delta wave, wide QRS (type B WPW)
- Type B WPW syndrome (goes through the right pathway is less common)
- All AVN blockers are contraindicated (if patient is in AF –> it will block the circuit pathway and the AF can be carried into the ventricle inducing VF): digoxin, DHP CCB (verapamil/diltiazem), metoprolol
- Vagal manouvre, IV adenosine, IV ATP
Acute
Unstable: synchronized DC shock
Stable –> antiarrhythmics (prolongation of accessory pathway: sotalol, amiodarone, flecainide, procainamide)
Drugs that shorten refractory period are contraindicated (digoxin)
Drugs taht increase ventricular rate avoid (verapamil and lignocaine)
Drugs that have no effect on refractory period of accessory pathway are useless (BB)
- Long term: RFA of bundle of Kent
- What is ECG abnormalities
- Ix
- Treatment
How to differentiate between this dx and another similar ddx?
- J wave amplitude (no S wave –> proceeds to J wave) or an ST segment elevation of .2mm or 0.2mV at its peak. A negative T wave with little or no isoelectric separation. RBBB/RSR’
- Procainamide or flecainide (Na channel blocker) –> induce brugada syndrome –> polymorphic VT. Electrophysiological study.
- Implantable cardioverter defibrillator
What ECG abnormalities?
What is the patient at risk of developing?
Treatment/prevention?
- LQTS: >450ms (F and children), >450ms (M)
- At risk of Torsades de pointes (polymorphic VT)
- Treatment: avoid strenuous excercise, avoid LQT drugs (macrolides, antiepileptics, 1st gen antihistamines), give BB, ICD
- Dx?
- ECG abnormality?
- Treatment?
- Hypocalcemia
- Prolonged ST segment, T wave unchanged
- Calcitonin, calcimimetics, bisphosphonate, danosumab (RANKL inhibitor), diuretics
ddx for shortened QT interval?
What is below?
ddx: hypercalcemia, SQTS digoxin
dx above is hypercalcemia
ECG abnormality and dx
Congenital SQTS: short QT interval (/ST segment) and peaked T waves
Dx and ECG abnormalities
Digoxin effect
* Downward sloping ST segment depression in the lateral leads (reverse tick appaerance)
* Widespread T wave flattening and inversion
* Multitude of arrhythmias (ventricular ectopy, atrial tachycardia with block, sinus bradycardia, regularized AF, any type of AV block)
- ECG abnormalities?
- Risk of developing what?
- Treatment?
- Epsilon wave (small wiggle burried in the end of the QRS complex representing post excitation of myocytes in the right ventricle)–> characteristic finding in patients with arrhythmogenic right ventricular dysplasia. T wave inversion in V1-3, localized QRS widening and prolonged S wave uptroke in V1-3
- Risk of ventricular arrhythmia, heart failure
- BB (sotalol), amiodarone. Implantable cardioverter defibrillator (ICD), avoid strenuous excercise
- ECG abnormalities and dx
- Ix
- Treatment
- Long term treatment
- LVH (dominant S in V1 and dominant R in V6), Q waves in lateral and inferior leads (due to septal hypertrophy)–> HOCM
- Echo, cardiac MRI
- BB, CCB dispyramide
- Long term treatment: myomectomy, septal ablation. Implantable cardioverter defibrillator
- ECG abnormalities and dx
- Causes
- Treatment
- Sinus bradycardia (as there is P wave for every QRS complex): 35bpm, prominent U wave in precordial leads
- Causes: anorexia nervosa, hyperK, MI, hypothyroidism. BB, CCB, digoxin
- Treatment: IV atropine, IV isoproterenol. Temporary transvenous/transcutaneous pacing
18/F patient with a flu-like episode 1 week before, now presented with left sided chest pain
1. 2 ECG features
2. Diagnosis?
3. 2 Ix
4. Therapeutic Ix
5. Treatment
- Diffuse concave (smily face) ST elevation with PR depression. ST depression and PR elevation in lead aVR and V1
- Pericarditis
- Echocardiogram, CXR, nasopharyngeal swab for viral PCR< vira serology, troponins, cardiac MR/CT
- Pericardiocentesis
- Treatment: NSAID, colchicine, prednisolone
- Name the abnormality in the ECG?
- Dx?
- Immediate treatment?
- 1 long term treatment
- Ix
- Diffuse low voltage, tachycardia, low voltage of QRS complex: <5mm in limb leads, <10mm in precordial leads
- Pericardial effusion
- Pericardiocentesis, insertion of pericardial fluid drain under LA/GA, fluid resuscitation.
Open drainage under LA/GA
Expand IV volume (D5/NS/plasma) - Pericardidectomy
- Ix: CXR, echocardiogram
Pericarditis and pericardial effusion –> see limb leads low voltage (aVR, aVL, aVF, lead I, II, III). COPD –> see precordial leads low voltage
- What 2 abnormalities present in the ECG
- Most likely dx
- Give 1 useful Dx
- Give 1 pharmacological treatment
- S1Q3T3, RV strain pattern.
RV strain pattern: RAD, RBBB (domimant R wave in lead V1), S1Q3T3 (Deep S in lead I, Q wave in Lead III, T wave inversion in lead III (and lead V1-4) - Acute pulonary embolism
- CT pulmonary angiogram, ventilation perfusion (VQ) scan), CXR (wedge shaped infarction, Hamptons hump), duplex doppler USG for DVT
- Haemodynamically stable (anticoag with LMWH bridging to warfarin/ NOAC).
Haemodynamically unstable: thrombolytic therapy with streptokinase, followed by heparin. Surgical embolectomy - Prevention: IVC filter (if DVT)
- 3 ECG features
- Dx
- Treatment to provide survival benefit
- Sinus tachycardia (AV association with P wave present for every QRS complex), regular rhythm, right axis deviation
Peaked P waves: P pulmonale (RA enlargement due to right heart failure)
QRS low voltage in leads I,aVL (V5-6) –> left sided leads
Delayed R/S transition point: clockwise rotation of the heart
Minimal R waves in the right precordial leads - Cor pulmonale
- Long term oxygen therapy (LTOT), treat heart failure (decongest the patient: fluid and salt restriction, IV lasix. Provide haemodynamic support if haemodynamically unstable)
- ECG abnormality
- Dx
- Likely cause
- Treatment
- Peaked narrow T wave, prolonged PR interval, broad and bizzarre QRS (sine wave)
- HyperK
- History of CRF. HyperK common complication with use of ACEI (as normally aldosterone causes reabsorption of Na and water –> which casues H+ and K+ to get secreted into urine). Furthermore impaired excretion of K+.
- IV calcium gluconate/chloride, IV sodium bicarbonate, IV insulin dextrose, nebulized salbutamol, K+ restriction, diuretics, resonium
Stop ACEI
URgent HD (indicated because ECG abnormal)
What is the dx?
What are early and late ECG manifestations?
HypoK
Early: increased amplitude and width of P wave, PR prolongation, T wave flattening and inversion, ST depression, prominent U waves (T-U fusion)
Worsening: frequent supraventricular and ventricular ectopics; AF/AFlu/AT, VF, torsades de Pointes
Stem: 65 year old smoker presenting with cachexia and productive cough. Sputum smear negative for TB
1. What is the most clinically relevant CXR finding?
2. 2 ddx of the finding?
3. 3 Ix?
4. How to obtain definitive dx?
5. Developed bil LL weakness and urinary reteniton, what Cx?
- R coin lesion at RMZ. Diffuse bilateral reticulo-nodular shadowing
- TB, CA lung
- Contrast CT thorax, sputum/BAL cytology, CT guided percutaneous biopsy (if more peripheral lesion), bronchoscopy (if central lesion)
- Bronchoscopy and biopsy
- Spainl cord compression from metastatic CA lung
Patient with weight loss of 20 lbs and malaise
1. Abnormality?
2. Likely Diagnosis?
3. 3 Ix?
- Multile coin lesions across both lung fields (cannon ball lesions). Reticulo-nodular shadow, pleural effusion, tracheal deviation, collapse, consolidation
- Lung metastases
- Contrast CT thorax, bronchoscopy and biopsy
- 3 abnormalities
- Dx
- Further Ix
- Name 1 public measure in preventing the disease
- Risk factor
- Tracheal deviation to the right, right apical fibrosis, nodular fibrocalcific foci
- TB
- AFB ZN smear, blood/sputum culture, CT thorax
- DOTS
- Old age, past TB infection, immunocompromised (DM, HIV, on immunosuppressants (if transplant patient/autoimmune disease)
80/F with long term DM, now presented with fever and weight loss
1. What finding?
2. Dx?
3. 2 Ix to guide treatment?
4. One most common etiology of the community?
5. Tx
- RLL consolidation, air bronchogram
- Pneumonia
- Sputum culture and smear with sensitivity testing, blood culture, NPA, urinary antigen test (legionella)
- Streptococcus pneumonia, haemophilus influenzae, moraxella catarrhalis. Atypical: chlamydophila pneumoniae, legionella pneumophila
- Empirical abx: augment. Legionalla coverage: clarithromycin, azithromycin
- 2 CXR abnormalities?
- Underlying condition?
- Confirmatory imaging for this condition?
- Cause of episode?
- Pathogens causing this?
- Drug Tx?
- Name 2 risk factors for her underlying condition
- Tramline, cystic shadow
- Bronchiectasis
- HRCT
- Pneumonia
- Haemophilus influenzae, staph aureus, pseudomonas aeruginosa (if long standing)
- Anti pseudomonal antibiotics. Extended spectrum penicillin (piperacillin-tazobactam), carbapenems (meropenem), aminoglcosides (gentamicin, amikacin), fluoroquinolones (levofloxacin)
- TB, ILD, GERD, connective tissue disease such as RA, IBD
- CXR abnormality
- Dx
- Ix
- Management
- Radioopque fluid, air fluid level, well defined cavity in the left middle zone
- Lung abscess
- Sputum culture, blood culture, sensitiity testing, NPA, urinary antigen test
- Prolonged antibiotics (4-6 weeks): augmentin. Percutaneous drainage (no need in most cases)(
- 2 CXR
- Dx
- 2 Ix/ diagnostic procedures that can be done for this patient
- Blunting of CP angle, meniscus sign, tracheal deviation
- Pleural effusion
- Diagnostic thoracocentesis for pleural fluid analysis: appearance, biochemistry (protein, LDH, glucose, pH), cell cout and DC, cytological, microbiology (stain, culture)
Contrast CT thorax for underlying lesion
Cytology: sputum, bronchial washing, brushing, FNAC
Biopsy: bronchoscopy, transbronchial, CT guided percutaneous biopsy (peripheral) - O2, chest drain
- 3 abnormalities
- Clinical dx
- 3 factors to consider before giving treatment
- Treatment
- RF for this condition
- Pleural line with hyperlucent right periphery: no vascular lung markers. Larger left intercostal spaces. Flattening of the L diaphragm. Mediastinal and tracheal shift in tension PTX
- Right sided non tension pneumothorax
- Symptoms: if symptomatic with dyspnea, active treatment with aspiration.drain
Size: if small pneumothoax, no breathlessness, observe.
Recurrent pneumothorax: pleurodesis (talc) or VATS to pleurodese +/-removal subpleural blebs or close leakage sites
If poor lung reserve or on positive pressure ventilation - Treatment: observe for asymptomatic. O2. Simple aspiration: thoracentesis. Chest tube insertion and drainage for failed simple aspiration. Surgical (VATS/ pleuroscopy)/chemical pleurodesis for repeated episode
- Smoking, age, COPD, TB, cystic fibrosis, asthma, Marfan syndrome, LAMsyndrome, lung diseases with bullae or cysts
Young men presented with left-sided chest pain. Arachnodactyly. Arm span: height ratio 1.1
1. Name abnormality?
2. Inheritance of underlying disease?
3. Name 2 vascular complication?
4. Name 1 ocular complication?
5. Name 1 joint complication?
6. CXR appearance
- Left sided pneumothorax
- AD
- Aortic regurgitation, aortic dissection, dilatation of aortic root. Mitral valve prolapse, mitral regurgitation, dilated mitral annulus
- Superotemporal lens dislocation (cf inferonasal in homocystinuria), high myopia (elongated globe)
- Joint hypermobility, tall stature, pectus excavatum, reduced thoracic kyphosis, scoliosis, arachnodactylyl
- Enlarged aortic knuckle
RA on methotrexate for 6 months, presents w/ SOB and dry cough
1. 3 abnormalities
2. 2 dx
3. Ix to do
4. Tx
- Bilateral reticulonodular shadowing (usu mid/lower zones), loss of lower lung volumes, shaggy heart borders and diaphragms
- MTX induced interstitial lungdisease, usual interstitial pneumonitis/ILD (due to underlying autoimmune/connective tissue disease)
- HRCT (ILD: honeycomb appearance (can even be seen on CXR)
- MTX induced. Stop MTX, change to other DMARDs of less lung effect.
Corticosteroids e.g. prednisolone
Immunosuppresant
Hypoxemia: supplemental O2
Pulmonary rehab, chest PT
- HF patient what findings would u expect on CXR?
- Dx?
- 2 Ix
- Medical treatment
- Upper lobe venous diversion
Kerley B line
Batwing Opacity
Cardiomegaly (HF)
Bilateral perihilar haze
Peribronchiolar cuffing - Pulmonary edema
- ECG, echocardiogram, cTnT/cTnI, BNP, NT-proBNP
- IV lasix
- CXR features
- Complications
- Signs of complications
- Ix
- Mx
- Widened mediastinum, irregular or wavy aortic outline (L pleural effusion)
- CVA/ stroke, ischemic limbs, acute AR: acute heart failure (acute pulmonary edema), AMI (dissecting into coronary arteries)
- BP high or low (tamponade), pulse deficits
- CT thorax and abdomen, coronary angiogram, transthoracic echocardiogram
- Control BP: IV nitroprusside, IV labetolol. Tamponade–> requires immediate surgical management (pericardootomy)
- Resection and graft (stent graft)
- Abnormalities
- what is dx
- Name 2 Ix
- Bedside procedure to avid
- Pathogens
- 2 treatments
- Hypodense lesion with rim contrast enhancement
- Brain abscess/tumor
- Imaging: MRI brain, CT contrast/plain head. septic workup: blood culture, aspirated pus for smear and culture. Look for septic foci: CXR, echocardiogram, skull and paranasal X ray
- Lumbar puncture
- S. aureus, S. pneumococcus
- Close monitoring of clinical status with CT head. Empirical antibiotics: IV benzylpenicillin + cefotaxmine/ceftriaxone
Antiepileptic: valproate
Refer to neurosurg for aspiration or excision of abscess cavity. Also external ventricular drain or VP shunt. Palliative RT/radiosurgery
- Name 2 CT abnormalities
- Cause of abnormality
- One more imaging
- 1 invasive Ix for dx
- Name 2 appropriate treatments
- Non pharmacological intervention
- Midline shift, compression of ventricles, hydrocephalus, sulcal effacement
- Lung metastasis
- MRI
- Biopsy of lesion
- IV high dose dexamethasone + PPI prophylaxis, seizure (antiepileptic (valproate)), chemotherapyf or tumor
- Surgery: hydrocephalus (VP shunt), RT, palliative: RT/radiosurgery, shunt, AED
Contraindicated treatment: non communicating hydrocephalus –> lumbar puncture
- What are the findings
- Explain possible cause of vertigo and vomiting
- Pathogenic mechanism
- Ix
- Likely ECG pattern
- If increased headache, vomiting and decreased coniusness what is cause?
- Complication
- Future prevention
- Left cerebellar hypodensity
- Left sided cerebellar infarct
- Atherosclerosis/thromboembolism/cardioembolism/small vessel disease
- CT/MRI head, USG doppler study (extra/intracranial), cerebral angiography, lumbar puncture. CBC, ESR, FBG, lipid profile, ECG, CXR, echocardiography
- AF (cardioembolic stroke)
- Increase ICP
- Cerebral edema: compression on brainstem, hemorrhagic transformation (post tPA), seizure
systemic: pneumonia, DVT/POE, pressure sore, UTI, contracture - Future treatment: aspirin, statin, anticoagulants (AF)
- CT abnormality
- Dx
- What signs on motor system
- 2 RF
- Initial treatment
- What long term treatment
- 2 neurological complications
- Large hypodense lesion in right frontoparietal area compatible with MCA territory. compresion of lateral ventricle
- Right ischemic stroke
- L hemiparesis and UMN signs
- Unmodifiable: old age, history of TIA or stroke. Modifiable: HT, DM, AF, HL, smoking, alcohol use, contraceptives
- IV thrombolysis with tPA
- Aspirin, statin, anticoagulants
- Hemorrhagic transformation, cerebral edema, seizure
- 2 abnormalities
- Dx
- Cause/underlying brain pathology/RF
- 2 other Ix to help find out the cause
- Treatment for vasospasm and aneurysm
- Name 2 complications that arise from Q3
- Star sign, hyperdense area obliterating ventricles, sulcal hyperdensity (blood collection)
- SAH
- Ruptured aneurysm of PcA (CN3 palsy). Other RF: PKD, trauma, AVM, bleeding tendency, tumor
- Contrast CT brain with CT angiography, MRI brain with MR angiography, DSA
- Vasospasm: nimodipine. Aneurysm: microsurgical clipping, endovascular coiling/stenting
- Rebleeding, vasospasm, seizure, hydrocephalus, cerebral edema
- Abnormalities
- Dx
- Ix
- Complication
- Precipitating factor
- Immediate treatment
- Crescent shaped hyperdense lesion: can cross sutures. Hyperdense thickening of interhemispheric falx. Hyperdense thickening of tentorium. Brain contusions.
- Subdural haematoma
- CBC, clotting proifile, MRI
- seizure, increased ICP, cerebral edema, hernaition, focal neurological deficit, gait disturbance
- Head injury, bleeding tendency, aging/atrophic brain
- Mannitol to control ICP, burr hole drainage
- Abnormality
- Dx
- Physical signs to be expected
- 2 Ix
- If GCS deteriorates, what to do next for Ix
- 3 medical treatment
- Surgical treatment
- Most important RF
- Irregular hypodensity in frontal lobe with cerebral edema and midline shift, obliteration of ventricle
- Right ICH near internal capsuel
- Left hemiparesis, left hemisensory loss, left facial weakness of UMN pattern
- MRI brain, cerebral angiography, INR
- Repeat NCCT for compression of ventricles
- Control ICP: mannitol. Induced hypothermia, controlled hyperventilation, enhanced venous drainage by head elevation to 30 degrees
Steroids not used in this case
Seizure treatment (not prophylaxis)
Bleeding tendency correction (e.g. warfarin): vit K, PCC (prothrombin complex concentrate) - CSF drainage, evacuation of mass lesion, decompressive craniectomy
- HT, aneurysm, AVM, bleeding tendency, tumor, moyamoya disease
Hemorrhagic infarction, amyloid angiopathy, sympathomimetic abuse, venous sinus thrombosis
