Interactive Cases in General Internal Medicine 1

Question 1

If a patient has chest pain, what is the most important next investigation?

Answer 1

ECG - differentiates STEMI/NSTEMI

if STEMI- give aspirin and clopidogrel and send for PCI

Question 2

What are the CARDIAC differential diagnoses of chest pain?

Answer 2

IHD (angina/MI)
Aortic dissection
Pericarditis

Question 3

What are the RESPIRATORY ddx of chest pain?

Answer 3

PE
Pneumonia
Pneumothorax

Question 4

What is a giveaway for aortic dissection

Answer 4

MAIN ONE = Difference in BP between both arms

• Sudden onset
• HTN
• Listen for aortic regurgitation (early diastolic murmur, collapsing pulse)

Question 5

What are the GI ddx of chest pain

Answer 5

Oesophageal spasm

Oesophagitis, gastritis

Question 6

What are the MSK ddx of chest pain

Answer 6

Costochondritis

Question 7

With chest pain, what is the order of investigations to do

Answer 7

ECG
Troponin (positive = coronary angiography, negative = ETT)
Echocardiography

Question 8

What are some giveaway signs of pericarditis (infection of outer layer of heart)

Answer 8

Worse on inspiration
Better when leaning forward
Fever/flu like illness preceding

Question 9

What are some giveaway signs of PE

Answer 9

Acute onset breathlessness
Chest pain worse on breathing
Tachypnea
Haemoptysis
Cough

Question 10

What is an example of someone who has GI related chest pain

Answer 10

Eg oesophagitis due to oesophageal candidiasis (if they are on steroid treatment)

Question 11

Anterior MI will show changes in which leads?

Answer 11

V1-4

LAD

Question 12

Lateral MI will show changes in which leads

Answer 12

V5, V6, 1, aVL

Circumflex

Question 13

Inferior MI will show changes in which leads

Answer 13

2, 3, aVF

RCA

Question 14

Seizure is a cause of collapse - after the episode what usually occurs?

Answer 14

Confusion

Question 15

What are the Ddx of collapse

Answer 15

1. Hypoglycaemia
2. Cardiac - vasovagal, arrhythmia, outflow obstruction, postural hypotension
3. Brain - seizure

Question 16

Arrhythmia as a cause of collapse can be tachycardia or bradycardia. What investigations should be done

Answer 16

ECG - look for long QT. If so, put them on cardiac monitor, 24 hour tape

(Long QT = abnormal ventricular repolarisation, congenital or acquired (if low K+/drugs), FH of sudden death)

Question 17

Outflow obstruction can be a cause of collapse. What are the left and right sided outflow obstructions?

What are the next investigations

Answer 17

Left: Aortic stenosis, HOCM (cardiomyopathy)

Right: PE

Investigations: low volume/slow rising pulse, ESM, echocardiogram

Question 18

For postural hypotension as a cause of collapse, what investigation must be done

Answer 18

Lying/standing BP

Question 19

Right sided murmurs are louder on (inspiration/expiration)?

Answer 19

Inspiration

Left sided murmurs louder on expiration

Question 20

What are the Ddx of raised JVP

Answer 20

R heart failure
Tricuspid regurgitation
Constrictive pericarditis

Question 21

Which 3 things can cause a pan-systolic murmur

Answer 21

Tricuspid regurgitation
Mitral regurgitation
Ventricular septal defect

Question 22

What are the causes of R heart failure

Answer 22

1. L heart failure

2. Pulmonary hypertension (PE/COPD)

Question 23

What are the causes of tricuspid regurgitation

Answer 23

Damaged valve leaflets

Right ventricle dilatation

Question 24

What may be the cause of constrictive pericarditis

Answer 24

Infection (TB)
Inflammation (CTD)
Malignancy

Question 25

What are 4 causes of systolic murmurs and how can one distinguish them

Answer 25

1. Aortic stenosis - carotids, slow rising pulse in neck 2. Mitral regurgitation - displaced apex beat radiating to axilla 3. Tricuspid regurgitation - loudest in tricuspid area 4. Ventral septal defect -usually in young person with no other features of cardiac disease

Question 26

SVT and sinus tachycardia have (regular/irregular) pulse rate

Answer 26

Regular (but fast)

Question 27

What are the causes of sinus tachycardia

Answer 27

Sepsis, hypovolaemia, endocrine causes

Question 28

No p-waves, fast, regular ECG indicates?

Answer 28

SVT

Question 29

Atrial fibrillation shows what signs on ECG

Answer 29

Fast, irregular

Question 30

SVT can take 2 forms which are

Answer 30

AVNRT (re-entry circuit at AVN) AVRT (up accessory pathway - this is faster. Delta wave present but won't see it if they're in tachycardia. You will see delta wave after treating them though)

Question 31

What are the causes of Atrial fibrillation

Answer 31

Thyrotoxicosis, ischaemia, chest infection, alcohol Heart: IHD, valve, pericardium Lungs: pneumonia, PE, cancer

Question 32

What are the ECG features of atrial fibrillation

Answer 32

No p waves, irregular | Atrial flutter = saw-tooth

Question 33

What are the signs of a ventricular tachycardia

Answer 33

Ischaemia, electrolyte imbalance, long QT VT has fast and broad QRS

Question 34

How do you manage someone with SVT and BP of 120/80

Answer 34

Vagal manoeuvres - immense face in cold water e.g. Adenosine (cardiac monitor) - contraindicated in asthmatics DC cardioversion if evidence of haemodynamic compromise (e.g. low BP)

Question 35

How do you manage someone with AF and BP of 120/80

Answer 35

``` Rhythm control (if onset >48 hours, anticoagulant for 3-4 weeks before cardioversion) Rate control - beta blocker, digoxin ```

Question 36

How do you manage someone with VT

Answer 36

If no haemodynamic compromise - IV amiodarone Look for and treat underlying cause (low K/Mg) ICD - implantable cardioverter defibrillator If they are pulseless with VT, defibrillate

Question 37

What does a deep S wave in V1 and a tall R in V5/6 indicate?

Answer 37

LVH - often caused by hypertension | whichever is larger >7 large squares

Question 38

How can you tell 1st degree heart block from an ECG?

Answer 38

Prolonged PR interval (should be less than 1 large square)

Question 39

How can you tell 2nd degree heart block from an ECG?

Answer 39

P waves without a following QRS complex

Question 40

How can you tell 3rd degree heart block from an ECG?

Answer 40

Complete dissociation between atria and ventricles (no relationship between P and QRS)

Question 41

What pathology does this suggest: ST elevation T inversion Q waves

Answer 41

Ischaemia (Q waves signify old MI)

Question 42

What should you look at to identify arrhythmias or conduction defects on an ECG

Answer 42

Rate, rhythm | PR, QRS, QT

Question 43

What on an ECG may show signs of ventricular strain/hypertrophy

Answer 43

Axis, R, S

Question 44

A prominent R wave in V1 shows strain to what part of the heart?

Answer 44

Right (e.g. caused by PE)

Question 45

What are each heart sounds associated with?

Answer 45

``` S1 = Closure of mitral valve S2 = Closure of aortic valve ``` ``` S3 = associated with ventricular filling S4 = Associated with ventricular hypertrophy ``` Atrial septal defect = fixed wide splitting of S2

Question 46

How do you manage acute heart failure

Answer 46

1. Sit them up and high flow oxygen 2. Furosemide GTN infusion/diamorphine 3. GTN infusion/diamorphine

Question 47

How do you manage someone with VF / pulseless VT | ALS question

Answer 47

``` Shock CPR (2 min) Assess rhythm Adrenaline every 3-5 mins Correct reversible causes ```

Question 48

How do you manage someone with asystole

Answer 48

CPR | Correct reversible causes

Question 49

What are the Ddx of pleuritic chest pain | Pleuritic chest pain worse when breathing in

Answer 49

``` Pericarditis PE Pneumonia Pneumothorax Pleural pathology ``` Sub-diaphramatic pathology