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Amir SAM > Interactive Cases in General Internal Medicine (1) > Flashcards

Interactive Cases in General Internal Medicine (1) Flashcards

1
Q

60 yr old man

Chest pain

Tight, 4 hrs

Nausea

Sweating

Breathlessness

HTN

DH: amlodipine

What is the diagnosis?

A. Pneumonia

B. Pericarditis

C. Myocardial infarction

D. Aortic dissection

E. Costochondritis

A

C. Myocardial infarction

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2
Q

If someone presents with chest pain (you think is of cardiac origin) what are the investigations you would want to do

A
  1. ECG
  2. Troponin
  • +ve: coronary angiography
  • -ve: ETT
  1. Echocardiography
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3
Q

How soon should you do a troponin?

A

6 hours after they started having pain

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4
Q

What are the differentials of chest pain?

A

Cardiac:

  • IHD: Stable & unstable angina, STEMI, NSTEMI
  • Aortic disseaction
  • Pericarididtis

Resopiratory

  • PE
  • Pneumonia
  • Pneumothorax

GI

  • Oesophageal spasm
  • Oesophagitis, Gastritis

Muscluloskeletal

  • Costochondritis
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5
Q

What are differentiating feature of chest pain of cardiac origin

A

IHD: jaw, radiating down the arm

pericarditis: worse on inspiration, better on leaning forward

Aortic dissection: tearing, along the back, difference between the blood pressure in both arms

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6
Q

What are differentiating feature of chest pain of repiratory origin

A

PE:

Pneumonia:

Pneumothorax:

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7
Q

Patient has had mwlanoma metastaiszed to th brain and now on high dexamethasone.

Complains now of chest pain.

What is the chest pain due to

A

steriod: immunosupression - infection

oesophagitis - fungal infection

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8
Q

History:

60 yr old man • Chest pain • tight, 2 hrs • nausea & sweating • PMH: HTN • DH: amlodipine

Examination:

Temp: 37.0oC • HS: S1 + S2 • BP: 120/80 (L), 118/75 (R) • Chest: clear • Abdomen is soft, nontender

What is the most appropriate investigation?

A. CK

B. CXR

C. ECG

D. Echocardiogram

E. Troponin

A

C. ECG

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9
Q

feature of viral pericarditis

A

fever, sweating

better when leaning forward

pleuritic chest pain

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10
Q

What does this ECG show?

What should happen to this patient?

A

anteriorlateral MI

Should be sent inmmidiatly to a cathlab for percutaneus coronary intervention

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11
Q

What does this ECG show?

A

inferior STEMI

2, 3, AVF

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12
Q

What are teh ECG changes and artery affected in an:

  • anterior MI
  • Lateral MI
  • Inferior MI
A

anterior MI:

  • LAD
  • V1-V4

Lateral MI:

  • Circumflex
  • V5, V6, I, aVL

Inferior MI:

  • RCA
  • II, III, aVF
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13
Q

what are the cardiac enzymes

A
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14
Q

When do you measure troponin and when does it rise and when does it fall

A

troponin goes up within 6-121 hour

but is up for several days (3-4)

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15
Q

History:

30 year 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 • Abdomen: soft, non-tender • CN I-XII: NAD, Normal I, T, P, R, C, S, G

What is the most likely cause of his collapse?

A. Aortic stenosis

B. Pulmonary embolism

C. Postural hypotension

D. Seizure

E. Tachyarrhythmia

A

E. Tachyarrhythmia

EXLUSION: says normal sounds (no ejection systolic murmur)

no drop in blood pressure when standing(not postural hypotension)

no post ictal period, no tongue biting (no seizure)

no risk factors for PE, or breathlessness (no PE)

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16
Q

What do you look out for in a person that collapsed?

What are differentiating symptoms?

A

Cardiac: no warning, sudden

Seizure: tongue biting, confused afterwards (post ictal period)

Vasovagal: feel dizzy come around quickly and

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17
Q

What are differentials of collapse?

A

Hypoglycaemia:

cardiac:

  • vasovagal
  • ouflow obstruction: PE, HOCM, aortic stenosis
  • postural hypotension

neurological:

  • seizure
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18
Q

What are the investigations you would do for the different causes of collpase

A

Arrhythmias –

  • Tachycardia, bradycardia

DO an ECG (? Long QT), cardiac monitor, 24 hour tape

Outflow obstruction

  • Left: Aortic stenosis, HOCM
  • Right: PE

Do a Low volume/slow rising pulse, ESM, Echocardiogram

Postural hypotension

Lying/standing BP

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19
Q

What is a long QT syndrome?

A
  • Abnormal ventricular repolarization
  • Congenital e.g. mutations in K+ channels
  • FH of sudden death
  • Acquired: low K+ / Mg2+ , drugs
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20
Q

History:

• 45 year old man • Fever • Malaise • IV drug use

Examination:

Temp: 38oC • raised JVP to earlobes • HS: S1 + S2 + PSM (louder on inspiration) • Hepatomegaly

What is the cause of his raised JVP?

A. Constrictive pericarditis

B. Congestive cardiac failure

C. Aortic regurgitation

D. Mitral regurgitation

E.Tricuspid regurgitation

A

Tricuspid regurgitation

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21
Q

Which murmurs are heard louder on inspiration and expiration?

A

Left - expiration

right- inspiration

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22
Q

What are differentials of a raised JVP

A
  • R heart failure:
    • Secondary to L heart failure (CCF)
    • Pulmonary HTN (PE, COPD etc.)
  • Tricuspid regurgitation:
    • Valve leaflets
    • R ventricle dilatation
  • Constrictive pericarditis:
    • ​Infection e.g. TB
    • Inflammation: CTD
    • Malignancy
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23
Q

What give you a pan systolic murmur?

A

tricuspid regurgitation

mitral regurgitation

Differentiate if louder on inspiration or experiation

24
Q

What are all the systolic murmurs?

A

Aortic stenosis

Mitral regurgitation

Tricuspid regurgitation

VSD

25
Q

how do you differentiate an aortic stenosis from an mitral regurgutation?

A

Where is it the loudest?

Mitral regurgitation: loudest at the left 5th intercostal space mid clavicular line and radiates to the axilla

Aortic stenosis: louddest at the right 2nd intercostal space radiates to the carotids

What are assosiated feature?

aortic stenosis: slow rising pulse

mitral regurgitation: displaced apex beat

VSD: young and no other features

26
Q

History:

65 year old man • Breathlessness • Palpitations • PMH: HTN • DH: Bendroflumethiazide

Examination

Temp: 38oC • PR: 160, irregular • BP: 110/80 mmHg • Dull percussion note & coarse crackles L base

What would you expect to see on his ECG?

A. Atrial fibrillation

B. Sinus tachycardia

C. SVT

D. VF

E. VT

A

AF

27
Q

What are the different types of tachycardias/ palpitations?

What are the differential for those

A

Sinus tachycardia:

Sepsis, hypovolaemia, endocrine (thyrotoxicosis, phaeochromocytoma)

SVT

Re-entry circuit

Atrial fibrillation

Thyrotoxicosis, ischaemia, chest infection, alcohol

VT

ischaemia, electrolyte abnormality, long QT

28
Q

What does this ECG show?

What could have caused this?

A

Sinus tachycardia (p wave before every QRS)

Causes:

  • Sepsis
  • hypovolaemia
  • endocrine (thyrotoxicosis, phaeochromocytoma)
29
Q

What does this ECG show?

What are the causes of it?

A

SVT

re entry circuit

30
Q

What are the 2 different types of SVT?

A
31
Q

When do you see the delta wave and when do you see tachycardia?

A

delta wave: when it is going down (from atria down into the ventricles) the accessory pathyway but you won#t have tachycarida

tachycardia: when the electrical impulse comes back up the accessory pathway into the atria

32
Q

What is an ECG that is regular, no p wave and tachycardia

A

SVT

33
Q

What does this ECG show?

What causes it?

A

AF

causes

Thyrotoxicosis, alcohol

Heart: muscle, valve, pericardium

Lungs: Pneumonia, PE, cancer

34
Q

What does this ECg show?

A

atrial flutter

35
Q

What does this ECG show?

What are the causes for it

A

Ventricular tachycardia

causes:

  • Ischaemia
  • electrolyte abnormality
  • long QT
36
Q

What is the management of SVT?

A

vagal maneuvers

Adenosine (cardiac monitor)

DC cardiovesion if evidence of haemodynamic compromise

37
Q

What is the management of AF

A

Rhythm control

  • If onset > 48hours, anticoagulate for 3-4 weeks before cardioversion

Rate control

  • beta blocker
  • Digoxin

Think of the underlying Cause

Think of the Complications (Anticoagluation)

38
Q

What is the management of VT?

A

If no haemodynamic compromise: IV Amiodarone

Look for & treat underlying cause

ICD

Pulseless VT: defibrillate

39
Q

What does this ECG show?

A

HYPERTENSION

LVH by voltage criteria

(Remember SR)

Deep S in V1/2

Tall R in V5/6

S in V1 + R in V5 or V6 (whichever is larger) ≥ 7 large squares

40
Q

What drug used to treat AF does not work in infections?

A

digoxin

41
Q

What is the difference between cardioversion and defibrillation

A

defibrillation: you don’t sync it with the rhythm you just shock

42
Q

What does this ECG show?

A

1 st degree heart block

43
Q

What does this ECG show

A

2nd degree heart block

p wave no QRS

44
Q

What does this ECG show

A

3rd degree heart block

45
Q

What are the ECG’s that can be seen in the following conditions?

  • Ischaemia
  • Arrhythmia or conduction defects
  • Ventricular strain or hypertrophy
A

Ischaemia

ST, T, Q

Arrhythmia or conduction defects

Rate, Rhythm

PR, QRS, QT

Ventricular strain or hypertrophy

Axis, R, S

46
Q

What would a tall R wave in V1 indicate

A

right heart side strain - PE

47
Q

history:

65 year old woman • Breathlessness • Onset: over a few hours • Orthopnoea • PMHx: 2 X MIs • DH: aspirin, simvastatin, ramipril, bisprolol

Examination:

Temp : 36.5oC • raised JVP • HS: S1 + S2 + S3 • Chest: fine crackles • Peripheral oedema

What is the 3rd heart sound due?

A. Is due to closure of mitral valve

B. Is due to closure of aortic valve

C. Is due to an atrial septal defect

D. Is associated with ventricular hypertrophy

E. Is associated with ventricular filling

A

E. Is associated with ventricular filling

48
Q

What are the heart sounds associated with?

A

Closure of mitral valve B - S 1

Closure of aortic valve C - S 2

Atrial septal defect - Fixed wide splitting of S2

Associated with ventricular filling - S3

Associated with ventricular hypertrophy - S4

49
Q

What is the Management of this patient?

A

Management of acute heart failure

  1. Sit up
  2. Oxygen
  3. Furosemide (IV)
  4. GTN infusion)
  5. Treat the underlying cause
50
Q

CASE:

History:

78 year old man • Brought in by ambulance • Unconscious • Not breathing • Carotid pulse is absent • Temp 29oC

What does the ECG show?

A. Asystole

B. AF

C. VF

D. VT

E. SVT

A

VF

51
Q

CASE:

History:

78 year old man • Brought in by ambulance • Unconscious • Not breathing • Carotid pulse is absent • Temp 29oC

How would you manage this patient?

A

HE is cold don’t administer any drugs until he is warmed up

52
Q

How do manage VF/ pulseless VT

A
  1. Shock
  2. CPR (2 min)
  3. Assess rhythm
  4. Adrenaline every 3-5 min
  5. Amiodarone after 3 shocks
  6. Correct reversible causes
53
Q

how do you manage someone with Asystole

A

CPR (2 min)

Adrenaline every 3-5 min

Correct reversible causes

54
Q

30 yr old woman • URTI • Pleuritic chest pain • Better when leaning forward

What is the diagnosis?

A

pericarditis

55
Q

What are the reversible causes of pulseless VT

A

4H: Hypovolaemia, Hypothermia, hypokalaemia, Hypoxia

4T: Tamoponade, Tension pneumothorax, Toxins, Thrombosis

56
Q

Do you shock a patient in asystole?

A

NO

just give adrenaline

57
Q

What are the differentials for pleuritic chest pain

A

5 P’s

PE

Pericarditis

Pneumonia

Pleural patholofy

Sub diaphragmatic pathology

Amir SAM (7 decks)

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