Cardio - Spot Diagnosis

Question 1

70 year old woman with ischaemic heart disease presents with sudden onset palpitations. HR 149 and regular.
ECG reveals regular tachycardia with QRS 80ms.

a) Most likely diagnosis
b) Classify this tachycardia
c) Management

Answer 1

a) Atrial flutter (generally atrial rate around 300, with 2:1 AV conduction - hence HR around 150)
b) Narrow-complex (supraventricular) tachycardia
c) Rate/rhythm control (similar to AF, dependent on presentation). Electrical cardioversion generally more effective in flutter.

Question 2

25 year old male presents after sudden collapse.
ECG reveals ST elevation in leads V1-V3 and RBBB

a) Other questions to ask
b) Likely diagnosis and management
c) Give other causes of sudden cardiac death

Answer 2

a) - FHx of SCD
- Other Cardiac symptoms
- DDx: Epileptic features, diabetes etc.

b) Brugada syndrome - common cause of sudden Cardiac death in the young. No cure but may be implanted with ICD

c) - Long QT - eg Romano-Ward, commonly with hearing loss also. (electrolyte abnormalities and drugs can also prolong QT)
- Short QT
- HCM

Question 3

32 year old male presents with fever, chest pain and recent URTI. ECG shows diffuse ST elevation and PR depression.

a) Most likely diagnosis
b) Type of chest pain. Aggravating/relieving factors.
c) DDx - Qs to rule out
d) Possible findings on examination
e) Management

Answer 3

a) Acute pericarditis (usually viral, eg cocksackievirus)
b) Pleuritic - aggravated by deep inspiration and movement, relieved by leaning forward

c) Pneumonia - Cough, SOB, sputum
PE - haemoptysis, DVT, collapse

d) Pericardial friction rub (often triphasic - 1 systolic and 2 diastolic components)
e) NSAIDs (self limiting

Question 4

60 year old with history of MI. Asymptomatic but incidental murmur heard on examination.

a) Likely cause
b) Pathogenesis
c) Murmur description
d) How it can cause HF

Answer 4

a) Mitral regurgitation
b) Fibrosis causing rupture of chordae tendinae, which causes Mitral valve to become incompetent
c) Pansystolic, loudest in apex, louder on expiration, radiates to axilla
d) Increased preload causing cardiac myocyte stretching and strain over time and hence reduced cardiac output

Question 5

6 year old with harsh pansystolic murmur, loudest at L sternal edge. Asymptomatic

a) most likely diagnosis

Months later, patient presents with acute breathlessness and cyanosis.

b) What may have happened?

Answer 5

a) VSD

b) Shunt reversal (from L-R to R-L), ie Eisenmenger syndrome

Question 6

Newborn with continuous machinery like murmur throughout systole and diastole.

a) Likely diagnosis
b) Management

Answer 6

a) PDA

b) closure with prostaglandin inhibitor (eg indomethacin or aspirin)

Question 7

Patient presents breathless to ED. ECG shows sinus tachycardia with a large S wave in lead I, a Q wave in lead III and inverted T wave in lead III.

a) Likely diagnosis
b) Other possible feature on ECG
c) Investigations
d) Management

Answer 7

a) PE
b) RBBB, right axis deviation, P pulmonale

c) - 2 level PE Wells’ score to determine likelihood of PE (5 or more = PE likely; 4 or less = PE unlikely)
- VTE diagnosis - CTPA, leg doppler, D-dimer (depends on score and urgency)
- Bloods: FBC, CRP, clotting, troponins, UEs
- Other: ECG, CXR, ABG

d) - A-E: 100% oxygen, IV access, bloods, analgesia
- Anticoagulation: usually LMWH (for 5/7 or until INR >2 for 24h, whichever is longer), and warfarin for 3/12