Cardiac

Question 1

Chest pain/ACS

Answer 1

HPI
Central chest pain last several mins
Pressure, fullness, squeezing
Radiation to shoulder, neck, arm, jaw, back
Dizziness, LOC, sweating, nausea, vomiting
Exertional/ relieve by TNG

Palpitation
orthopnea, PND
NYHA (1 - jog/ carry 36kg; 2 - walk upstairs; 3 - fix bed/wash windows; 4 - symptoms at rest)

Fever, cough, sputum, hemoptysis
Regurgitation, bloating, abd pain, diarrhea
Postural, a/w movement
New onset rash
LOW/LOA/malaise

Ix
ECG:
STEMI - ST elevation in 2+ contiguous lead/ new LBBB (greater than 2mm in V2/3 or 1mm in other lead)
NSTEMI - ST depression 0.5mm + or dynamic T wave inversion
Low/ intermediate risk: TWI <=2mm or STD <0.5mm

Admission:

• Bed rest
• Cardiac monitor
• Obs 1qH
• Chart I/O
• Foley to BSB, UO q4H (if strict IO)
• 2-4L O2 through nasal cannula to maintain SaO2 >92%
• Bld x CBC LRFT bone clotting INR RG
• Bld x TnI, CK, ECG q6H x3
• Bld x FG, FL mane
• CXR
• Resume usual meds
• NSTEMI:
  &raquo_space;» PO aspirin 160mg daily x1, then 80mg daily
  &raquo_space;» SC enoxaparin .4mL q12H (q24H if renal)
  &raquo_space;» +- morphine for pain relief (0.1mL/10 kg)
• high bp:
  &raquo_space;» IV isoket (isosorbide dinitrate) 2mg/H, then titrate against BP
  &raquo_space;» change to PO isodil (isosorbide dinitrate) 10mg daily if BP stabalize

Ward complain:

• Bed rest
• Cardiac monitor
• BP/P q1H
• blood x trop, CK, LDH, ECG q8H x3
• SL TNG 500mcg stat x1
• PO pepcidine 20mg BD
• check Trop/ ECG/ chest pain (2 out of 3, think ACS)
• think GERD/cancer pain

Question 2

CHF

Answer 2

Admission:
 - Prop up
 - Low salt diet (NPO if severe SOB)
 - FR 1.2L/D
 - Cardiac monitor
 - Chart I/O (foley to BSB if APO)
 - BW x1, then alt day
 - O2 supplement to keep SaO2 >92%
 - Bld x CBC LRFT bone clotting RG
 - +- ABG if require high flow O2/ hx of COPD
 - Bld x TnI CK ECG q6H x3
 - Bld x FG FL HbA1c mane
 - Urine x multistix
 - Sputum x C/S
 - CXR
 - Lasix
 >>>> IV lasix 40mg stat for moderate to severe SOB
 >>>> then increase lasix e.g. 40mg q12H to q6H
 >>>> increase FREQUENCY before DOSAGE
 - Resume usual meds
 - High BP: 
 >>>> IV nitrocaine (nitroglycerin) 30mg in 50mL NS, 4mL/H

• Ventilator support
  &raquo_space;» APO: CPAP (10cm H2O, FiO2 10, then wean off)
  &raquo_space;» severe resp distress: BiPAP

Question 3

Fast AF

Answer 3

Admission

• DAT (warfarin diet if on warfarin)
• Cardiac monitor
• Obs q4H
• Bld x CBC LRFT bone clotting INR RG
• TSH
• +- Bld x TnI CK ECG q6H x3
• Sputum x C/S
• MSU x C/S
• CXR
• ECG + long lead II
• Resume usual meds
• Antiarrhythmics
  1. Amiodarone
  &raquo_space;» loading: IV amiodarone 150mg in 100mL D5 q30min x1
  &raquo_space;» maintenance: IV amiodarone 600mg in 500mL D5 q24H

2. Digoxin
   &raquo_space;» loading: PO digoxin 0.25mg q8H x3/ IV 0.25mg in 50mL NS over 10min x3
   &raquo_space;» PO digoxin 0.25mg daily

Treat hyperK (K>=4)
Treat underlying exacerbating factor (sepsis, ACS)

Question 4

Dizziness

Answer 4

Ward complain

• check vitals (BP/P), vertigo in nature, cerebellar signs
• postural bp x3
• Hstix stat x1
• ECG +- long lead II
• CTB If suspected cerebellar stroke
• +- PO stemetil (prochlorperazine maleate) 5mg tds prn
• +- PO merislon (betahistine mesilate) 1 tab tds prn
• +- PO motilium (domperidone) 10mg tds prn
• +- PO maxolon (metoclopramide hydrochloride) 10mg tds prn

Question 5

Infective endocarditis

Answer 5

Admission

• DAT
• Obs q4H
• O2 supplement to keep SaO2 >=92%
• Bld x CBC LRFT bone clotting RG
• +- ABG if require high flow O2/ severe SOB
• Bld x C/S x3 at different site different time
• Sputum x AFB x3, C/S
• Urine x multistix
• CXR
• ECG
• Resume usual meds
• • PO panadol 500mg q4H prn
• IV cloxacillin 2g q4H + IV gentamycin 1mg/kg q8H
• ECHO x emboli mane

Question 6

Palpitation

Answer 6

Admission

• DAT
• Obs q4H
• Neuro-obs q4H x 1/7
• Postural BP x3
• +- cardiac monitor
• Bld x CBC LRFT bone clotting INR RG
• +- Bld x TnI CK ECG q6H x3
• +- TFT
• CXR
• ECG + long lead II
• Urine x multistix
• +- urine x toxicology
• Book IP holter
• Resume usual meds (W/H theophylline, ventolin)

Ward complain

• check pulse to see if real or not
• ECG + Long lead II

Question 7

SVT

Answer 7

Ward complain

• Obs q1H x3, if stable q4H
• cardiac monitor
• +- Bld x trop, CK, LDH
• +- Bld C/S if fever >38

ECG
- IV ATP 10mg push stat x1, e-trolley
- not responded, repeat ATP 10mg push stat x1 (or ATP 20mg stat x1)
- Amiodarone
&raquo_space;» loading: IV amiodarone 150mg in 100mL D5 q30mins x1
&raquo_space;» maintenance: IV amiodarone 600mg in 500mL D5 q24H
&raquo_space;» w/h amiodarone if HR <60

• Treat undelying sepsis

Question 8

STE vs high take off (benign early repolarization)

Answer 8

BER

• rare >50yo with IHD RF
• widespread concave ST elevation, most prominent V2-5
• Notching or slurring J-point (fishhook appearance at V4)
• Prominent, asymmetrical T concordant with QRS (pointing in the same direction).
• ST elevation is <24% TW height (esp V6)
• ST elevation < 2mm in the precordial leads and < 0.5mm in the limb leads
• No reciprocal STD to (except in aVR).
• ST changes stable over time