Interactive Cases - CVS

Question 1

Scenario:
60 yr old man
symps: chest pain - tight, 4hrs
ass. symps: nausea, sweating, breathlessness
PMH: HTN
DH: amlodipine

What is the diagnosis?
a) pneumonia, b) pericarditis, c) MI, d) aortic dissection, e) costochondritis

Answer 1

MI

Question 2

What symptoms are usually associated with cardiac ischaemia?

Answer 2

Nausea, sweating, breathlessness

Question 3

What would the clinical picture for pericarditis look like?

Answer 3

symps: pleuritic chest pain, worse on inspiration
ass. symps: flu-like symptoms
o/e; pericardial friction rub

Question 4

What is the main therapy for pericarditis (viral/idiopathic)?

Answer 4

NSAIDS

Question 5

How would you investigate the 60yr old gentleman with chest pain above?

Answer 5

1. ECG
2. Troponin:
   - if +ve –> coronary angiography
   - if -ve –> ETT (=exercise tolerance test)
3. Echo

Question 6

Why do you do an ECG before a troponin?

Answer 6

Have to wait 6-12hrs for troponin to rise, ECG gives instant results

Question 7

What might the ECG help you differentiate between?

Answer 7

STEMI vs NSTEMI

Question 8

What might an echo show?

Answer 8

regional wall motional abnormality (RWMA)

Question 9

How would you manage a STEMI?

Answer 9

MONABASH (inc. 300mg aspirin + 300mg clopidogrel) –> PCI / CABG (cath lab)

Question 10

How would you manage an NSTEMI?

Answer 10

MONABASH

= morphine, oxygen, nitrates, aspirin, beta blockers, ACE inhibitors, statin, heparin

Question 11

What are the key differentials for chest pain?

Answer 11

Cardiac –> IHD, aortic dissection, pericarditis
Resp –> PE, pneumonia, pneumothorax
GI –> oesophageal spasm, oesophagitis, gastritis
Musculosekeltal –> costochondritis

Question 12

When would you suspect aortic dissection?

Answer 12

• hear an aortic regurg. murmur when you auscultate the back with the patient leaning forward
• difference in blood pressure between L and R arm

Question 13

How do you take the history for cardiac chest pain?

Answer 13

1. The symptom (soCRAtEs)
2. Other symptoms (system)
3. RFs / DDx questions

Question 14

What are your differentials for cardiac chest pain?

Answer 14

IHD –> angina pectoris, ACS (MI)
aortic dissection
pericarditis

Question 15

In the above scenario, with the 60 year old with a suspected MI, you find the following:
temp: 37C, HS 1+2 present, BP: 120/80 (L), 118/75 (R), chest: clear, abdo: SNT
What is the most appropriate next investigation?
a) CK, b) CXR, c) ECG, d) echo, e) troponin

Answer 15

c) ECG

why? –> instant (trop. takes time to elevate), easier/quicker than echo., MI won’t show up on CXR

Question 16

What are the coronary arteries and ECG changes corresponding to an anterior MI?

Answer 16

artery: LAD
ECG: V1-V4

Question 17

What are the coronary arteries and ECG changes corresponding to a lateral MI?

Answer 17

artery: left circumflex
ECG: V5, V6, 1, aVL

Question 18

What are the coronary arteries and ECG changes corresponding to an inferior MI?

Answer 18

artery: RCA
ECG: II, III, aVF

Question 19

What conditions might cause an elevated troponin?

Answer 19

MI, sepsis, renal failurre, pneumonia

Question 20

Scenario:
30 yr old man
collapse
HPC:
- before: no warning
- during: no tongue biting
- after: not confused
FH: brother died at a young age
Examination: HS S1+S2+0, BP: 120/80 (lying), 115/75 (standing), vesicular breath sounds, abdo SNT, CNs1-12 NAD
What is the most likely cause of his collapse?
a) AS, b) PE, c) postural hypotension, d) seizure, e) tachyarrhythmia

Answer 20

c) postural hypotension

cardiac vs neurological causes:
clinical picture points to CARDIAC cause –> no warning, no tongue biting, no incontinence (unlikely to be seizure)
unlikely to be vasovagal syncope as no precipitating factors (eg. hot weather, dehydration, posture)

Question 21

What would you hear on auscultation if a patient had AS?

Answer 21

systolic murmur, loudest in aortic area, radiates to carotids

Question 22

What are three causes of cardiac collapse?

Answer 22

postural hypotension
arrhythmias
AS

Question 23

What are the differential diagnoses for collapse?

Answer 23

1. hypoglycaemia (NEVER FORGET THIS!!!)
2. cardiac –> vasovagal, arrhythmias, outflow obstruction, postural hypotension
3. neurological –> seizure

Question 24

How would you investigate a suspected cardiac-related collapse?

Answer 24

postural hypotension --> assess lying vs standing BP
arrhythmias (eg. tachy/brady, long QT etc.) --> ECG (?long QT), cardiac monitor, 24 hour tape
outflow obstruction (eg. AS, HOCM, right: PE) --> low volume/slow rising pulse, ESM, echo

Question 25

What is long QT syndrome?

Answer 25

abnormal ventricular repolarisation (T wave >50% away from end of QRS complex)

Question 26

What is long QT syndrome caused by?

Answer 26

congenital eg. K+ channel mutations

acquired eg. low K+/Mg+, drugs

Question 27

What are some features of mitral regurg?

Answer 27

pan-systolic, louder in mitral area, radiates to axilla, louder on expiration

Question 28

What are some features of tricuspid regurg?

Answer 28

loudest in tricuspid area, v. elevated JVP, louder on inspiration

Question 29

Which murmurs are loudest on expiration and inspiration?

Answer 29

lEft-sided murmurs are louder on Expiration (eg. aortic, mitral)
rIght-sided murmurs are louder on Inspiration (pulmonary, tricuspid)