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Amir Sam Lectures > Cardiology Cases > Flashcards

Cardiology Cases Flashcards

1
Q

Case
Hx: 60 yo man, chest pain, tight, 4h, nausea and sweating, HTN, DH: amlodipine.
O/E: temp 37, S1 + S2, BP 120/80 (L), 118/75 (R), clear chest, abdomen SNT
What is it?
Pneumonia, Pericarditis, Myocardial infarction, Aortic dissection, Costochondritis

A

Myocardial infarction

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2
Q

What are the three layers of investigation for MI?

A
  1. ECG
  2. Troponin
  3. Echocardiogram
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3
Q

Why is an ECG important for MI?

A

To find out if it is a STEMI or NSTEMI as they have different treatments

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4
Q

What do if troponin comes back as postive or negative?

A

+ve - coronary angiogram (whether STEMI/NSTEMI)

-ve - exercise tolerance test

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5
Q

Why do an Echocardiogram?

A

To check for ventricular dysfunction and regional wall motion abnormality, blockage of one of the coronaries can be seen in a territory (RWMA)

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6
Q

Management of STEMI/NSTEMI?

A

Both you give aspirin and clopidogrel
STEMI - and then send to cath lab to do percutanous coronary intervention to do balloon angioplasty or stenting
NSTEMI - add LMWH and then risk-stratify and sent for an angioplasty

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7
Q

Differential diagnosis of chest pain (cardiac)

A

Ischaemic heart disease
Aortic Dissection
Pericarditis

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8
Q

Differential diagnosis of chest pain (Respiratory)

A

Pulmonary embolism
Pneumonia
Pneumothorax

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9
Q

Characteristics of Ischaemic heart disease

A

radiation to jaw, left arm
pressure-like pain
Associated symptoms: sweating, nausea

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10
Q

Characteristics of Aortic Dissection

A

Chest pain radiates to back
BP difference in both arms (>20)
Aortic Regurgitation murmur

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11
Q

Characteristics of Pericarditis

A

pleurtic pain (worse when breathing in, sharp)
relieved when leaning forward
flu-like illness
(young person with no other risk factors)

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12
Q

Characteristics of PE

A 
Pleuritic
Sudden SOB
Swollen leg
Haemoptysis
Risk factors: immbolility or pill
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13
Q

Characteristics of Pneumonia

A

Pleuritics chest pain
cough
sputum
Temp

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14
Q

Characteristics of Pneumothorax

A

Sudden onset of SOB

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15
Q

Differential diagnosis of chest pain (GI, Musculoskeletal)

A

GI - Oesophageal spasm
Oesophagitis
Gastritis
Musc - Costochondritis

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16
Q

Cause of pleurtic pain (all Ps)

A 
PE
Pericarditis
Pneumonia 
Pneumothorax
Pleural pathology
Sub-diaphragmatic pathology 
(could also be due connective tissue disease e.g. sjogren's, SLE or pleurtic tumour)
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17
Q

Cardiac Chest pain associated symptoms

A

Pain, palpitations, dizziness, breathlessness, ankle swelling

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18
Q

ECG features of Anteriolateral STEMI

A

ST elevation V2-4, V5,6 + I, aVL

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19
Q

ECG features of inferior STEMI

A

ST elevation in II, III, aVF

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20
Q

Artery supply of heart anterior, lateral, inferior

A

Anterior -Left anterior descending
Lateral - Circumflex (branch of left main stem)
Inferior - Right coronary artery

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21
Q

Causes of collapse

A

Hypoglycaemia
Cardiac - Vasovagal, Arrhythmia, Outflow obstruction, postural hypotension
CNS-seizures

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22
Q

Features of Vasovagal (3P)

A

Posture
Prodrome
Provoking factors - hot weather, dehydration, cough refelx, micturition reflex

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23
Q

Features of Arrhytmia (causes, requirements etc)

A

Either brady or tachy
ECG-long QT predisposes to VT - abnormal ventricular repolarisation
Causes: congenital - mutations in K channels (depolarisation porblems), FH of sudden death Acquired: low K/Mg, drugs
Cardiace monitor and 24h tape required to catch an episode

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24
Q

How to measure QT interva

A

Draw line between two R waves, then draw a line half way and the T-wave shoudl finish before half way point, if not long QT

25
Q

Examples of Outflow obstruction

A

Left-Aortic Stenosis, Hypertrophic cardiomyopathy

Right- PE

26
Q

O/E and Investigations for outflow obstruction

A

Exam: low volume/slow rising pulse (thrill under fingers on the carotid pulse), ESM
Echo-to see stenosis and pressure gradient across valve

27
Q

O/E and Investigations for postural hypotension

A

Lying and standing blood pressure

28
Q

Differential diagnosis of raised JVP

A

R-heart failures
Tricuspid Regurgitation
Constrictive pericarditis

29
Q

Cause of R heart failure

A

Secondary to left - CCF, previous ischaemic heart disease, MI
Pulmonary hypertension - PE, COPD,

30
Q

Causes of Tricuspid regurgitations

A

carcinoid, valve leaflet damage due infective endocarditis, R-ventricle dilation of the valve ring

31
Q

Causes of Constrictive pericarditis

A

calcification of the pericardium due TB seen on CX
Infection - TB
Inflammation - Connective tissues disorder lupus, sarcoid
Malignancy

32
Q

Differential Diagnosis of a Systolic murmur

A

Aortic Stenosis
Mitral Regurgitation
Tricuspid Regurgitation
Ventricular septal defect

33
Q

Why could troponin be raised?

A 
MI
Sepsis
Pneumonia
Fall
Renal Impairment
34
Q

3 things an ECG can tell?

A

Suggests structural problems, conduction problems, ischaemia

35
Q

4 things ECG can show with a tachycardia/palpitations

A

Sinus Tachycardia
Supraventricular tachycardia
Atrial fibrillation/Flutter
Ventricular tachycardia

36
Q

DDx of Sinus tachycardia

A

Sepsis (hypotension causing reflex tachy)
Hypovolemia
Endocrine: thyrotoxicosis, phaeochromocytoma
Can be physiological

37
Q

Features sinus tachycardia

A

Narrow QRS and p waves seen

38
Q

Features of SVT

A

missing p wave
fast and regular
QRS-T pattern
narrow complex (<3 sml squares)

39
Q

DDx of SVT

A

AVNRT - re-entry circuit at the AV node (in circles)

AVRT (Wolff Parkinson White) - big accessory bundle

40
Q

Features of AF

A

Irregular, no p-waves, narrow QRS

41
Q

Features of Atrial Flutter

A

Chaotic atrial activity, no p-waves, saw-tooth baseline

42
Q

DDx of AF/atrial flutter

A

Metabolic - Thyrotoxicosis. alcohol
Heart (by layer): pericarditis, muscle (CM, IHD, HTN, myocarditis). valves (MS, MR)
Lungs: pneumonia, PE, cancer

43
Q

Features of a ventricular tachycardia

A

Broad QRS comples (you can see pink paper between the two limbs if complex)
Regular

44
Q

DDx of VT

A 
Ischaemia - collapse with MI due to arrhythmia
Electrolyte abnormality (Check K, Mg)
Congenital: long QT (look at previous old ECG)
45
Q

Management of SVT

A

Whatever the rhytmn is if haemodynamically compromised (hypotension) -> DC cardioversion
Otherwise: start with vagal manoeuvres (immers in cold water, valsalva, massage carotid)
Give adenosine with cardiac monitor (contraindication if asthma or pt cold), print rhytmn strp and mark when adenosine given

46
Q

Management of AF

A

Treat underlyning cause
Control rate with beta-blockers or digoxin
Prevent stroke (CHADVASC)
Think of complications (anticoagulation - warfarin)
Rhytmn control: if onset >48h, do not perform cardioversion as patietn is of risk of thrombus, which may cause a stroke, hence anticoagulate for 3-4weeks before cardioversion
If less than 48h oppurtunity to do cardioversion

47
Q

Management of VT

A

If haemodynamically not compromised, give IV amiodarone (if they are speaking etc)
Look for and treat underlying cause
ICD
if pulseless VT: defibrillate

48
Q

What is the difference between cardioversion and defibrillation

A

Cardioversion is synchromised adn defibrillation is not

49
Q

What is the criteria of left ventricular hypertrophy by ECG

A

SIR: Deep S waves in V1, V2, tall R waves in V5,V6 ->suggestive of hypertension
S in V1 + R in V5/6 (which ever is bigger) ≥ 7 large squares

50
Q

DDx of left ventricular hypertrophy

A

Hypertension - as it is working high resistance
Aortic Stenosis - working against a narrow gradient
(hypertension more common tho)

51
Q

Features of 1st, 2nd, 3rd degree heart block

A

1.Prolonged PR interval (> 1 lrg sqr)
2.Missed QRS after P
waves
3. Complete dissociation of atria and ventricles, (broad QRS)

52
Q

Heart sounds:

S1, S2, fixed wide splitting of S2, S3, S4

A

S1 - closure of mitral valve
S2 - closure of aortic valve
Fixed wide splitting of S2 - atrial septal defect
S3 - associated with ventricular filling
S4 - associated with ventricular hypertrophy (atria have to constrict against stiff ventricle)

53
Q

Mangement for acute heart failure

A
  1. Sit up
  2. 60 -100% O2
  3. Furosemide(IV)- not for diuresis, venodilator as well)
    a. Given IV because they have gut oedema they will not absorb the drug orally
    b. daily weights needed
    4.Treat the underlying cause
    GTN spray are only used in rare cases, e.g. if heart failure + MI/angina
54
Q

Management of chronic heart failure

A

indicated by reduced exercise-tolerance test
Tx: Beta-blockers
ACEi & spironolactone

55
Q

Cause of cardiac arrest

A 
Hypoxia
Hypothermia
Hypovolaemia
Hypo/hyperkalaemia
Tamponade
Tension pneumothorax
Thromboembolism
Toxins/metabolic disorders: drugs, therapeutic agents, sepsis
56
Q

Management for VF/pulselessVT

A 
Shock
Do CPR for 2min
Re-assess rhytmn
Adrenaline every 3-5min
Amiodarone after 3 shocks
Correct reversible causes
57
Q

Managemenr of asystole/pulseless electrical activity

A

ECG looks fine bu pt has no pulse
CPR (2min)
Correct reversible causes
Adrenaline every 3-5min

58
Q

ECg changes for Pericarditis and management

A

Global saddle-shaped ST elevation, diffuse coronary disease
better when leaning forward
Mx: analgesics and reassurance

Amir Sam Lectures (2 decks)

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