CSW2 clinical cases conundrums

Question 1

What drugs can be used for diabetes?

Answer 1

Metformin
DPP4 inhibitors
Pioglitazone
Sulphonylureas

Question 2

What should be given to a patient with diabetes who has atherosclerotic cardiovascular disease?

Answer 2

Empagliflozin

Liraglutide

Question 3

When is a second medicine added for diabetes when someone is already on non insulin therapy? What is added?

Answer 3

If glucose control is not adequate on noninsulin treatment for 3 months and a second oral agent, GLP1 receptor agonist or basal insulin

Question 4

Why are empaglifozin and liraglutide indicated in some diabetic patients? Include who they are given to

Answer 4

They reduce mortality in those with atherosclerotic cardiovascular disease so should be given to these patients

Question 5

If you have an arterial problem what is given?

Answer 5

Aspirin

Question 6

What type of drug is aspirin and how does it work?

Answer 6

It is an antiplatelet that prevents a platelet plug forming

Question 7

If you have a venous problem what medication is useless?

Answer 7

Aspirin- never give it, turning off platelets is useless

Question 8

What is arterial vs venous prophylaxis?

Answer 8

Arterial= aspirin
Venous= warfarin, apixaban, rivaroxiban

Question 9

What drug for AF rhythm control will not cause a fall in BP and may be given instead of a beta blocker?

Answer 9

Digoxin

Question 10

What are the catagories for chadsvasc score

Answer 10

Congestive HF
Hypertension
Age >75
Age 65-74
Diabetes mellitus
Stroke/TIA
Vascular disease
Female sex

Question 11

What score does a male v female need on the chadsvasc score to need anticoagulation

Answer 11

Male= 2
Female= 3

Question 12

How will you explain to a patient with AF what they have and what drugs they need?

Answer 12

Irregular pulse
Dont worry about it- very common
Small risk of stroke due to your score
We think it would be helpful to give you a drug to thin your blood a bit and then give you a beta blocker to control your HR and it will return to normal

Question 13

What is fast vs slow AF?

Answer 13

Slow= HR under 60

Question 14

What 2 drugs can someone with AF be given and sent home if they are not very unwell ie the simplest treatment?

Answer 14

Blood thinner eg apixaban

Beta blocker

Question 15

How is pericarditis managed?

Answer 15

NSAIDs if in pain

Reassurance

Question 16

Why are antivirals contraindicated in pericarditis?

Answer 16

The virus has come and gone and the inflammation is causing the changes so antivirals are not needed as they wont be effective

Question 17

Explain william and marrow in rbbb vs lbbb?

Answer 17

RBBB- MarroW
V1= m
V6= w

LBBB- WilliaM
v1= w
v6= m

Question 18

Which way round is william and marrow in lbbb and rbbb? How do you remember this

Answer 18

rbbb= marrow
lbbb= william

w comes after m in the alphabet and less people are left handed

Question 19

What segment is uninterpretable in someone with lbbb? What effect does this have?

Answer 19

ST

They may have an MI because you dont know if there is actually ST segment elevation

Question 20

What do you treat a first presentation of lbbb as when there is no previous ecg?

Answer 20

MI

Question 21

In what type(s) of heart block is syncope seen?

Answer 21

Only third degree (complete heart block)

Question 22

What is seen on first, second degree mobtiz 1, second degree mobtiz II and third degree heart block on ECG?

Answer 22

First= prolonged PR interval
Second degree mobitz I= prolonged PR interval and then dropped p wave
Second degree mobtiz II= dropped p wave with no prior PR interval elongation
Third degree= no relation between p waves and QRS

Question 23

What are first, second degree mobtiz 1, second degree mobtiz II and third degree heart block by definition?

Answer 23

First= reduced conduction through AV node
Second degree mobitz I= varying conduction through AV node
Second degree mobtiz II= unexpected non conducted atrial impulse
Third degree= complete lack of conduction through AV node

Question 24

How are first, second degree mobtiz 1, second degree mobtiz II and third degree heart block managed?

Answer 24

First= no treatment needed, give cardiac monitor
Second degree mobitz I= no treatment, give cardiac monitor, give atropine if bradycardic, revoew medication
Second degree mobtiz II= fit pacemaker and review meds
Third degree= fit pacemaker and review meds

Question 25

What is seen in the neck in complete heart block?

Answer 25

Cannon wave

Question 26

What sign is diagnostic of complete heart block?

Answer 26

Cannon wave on neck

Question 27

In what type(s) of heart block does a pacemaker need to be fitted?

Answer 27

Second degree mobitz II

Third degree

Question 28

How does a cannon wave arise?

Answer 28

In complete heart block the ventricle wont contract and so the blood comes shooting back into the atria and up into the jugular vein

Question 29

What is the role of physiotherapists?

Answer 29

Balance 
Muscle strengthening
Practise transfer from bed to chair
Practise mobility
Build confidence
Teach them techniques to get up if there is another fall 
Help with walking aids
Practice with stairs 
Non drug pain management

Question 30

What does OT do?

Answer 30

Basic adls
They check if people can wash, dress, shop
Plan environmental adaptations eg handrail fitting, toilet adaptations, chair/stool in shower
Commnication aids erc

Question 31

How well does consolidation conduct sound? What will happen to tactile vocal fremitus and breath sounds?

Answer 31

Very well, you will hear both loudly

Question 32

What is bronchial breathing?

Answer 32

Loud breath sounds conducted loudly and rapidly through consolidation