Live Lecture - Cases Flashcards
50 year old man with chest pain. When he climbs the hill to go to Tesco he gets a severe tightness in his chest. When he rests it goes away. What is the next test that should be done.
ECG.
50 year old man with chest pain. When he climbs the hill to go to Tesco he gets a severe tightness in his chest. When he rests it goes away. His ECG on rest is normal, with a pulse rate of 99BPM. What is the next test.
Exercise ECG.
50 year old man with chest pain. When he climbs the hill to go to Tesco he gets a severe tightness in his chest. When he rests it goes away. His ECG on rest is normal.
His exercise ECG shows a pulse rate of 150BPM and ST depression.
What is the most likely diagnosis.
Chronic stable angina.
What is chronic stable angina caused by.
Partially blocked coronary artery.
What are the symptoms of angina due to.
When the heart rate rises, the ischaemic in the heart becomes significant. The lactate will accumulate causing pain.
What is the clinical sign seen on ECG in chronic stable angina.
ST depression.
What drugs are used to treat chronic stable angina. (4)
Beta blockers (atenolol).
Aspirin.
Glyceryl trinitrate (also isosorbide mononitrate ISMN can be used).
Simvastatin.
What are the surgical treatment options for chronic stable angina.
CABG (in the old days).
Angiogram to see where the block is.
Angioplasty to open up the coronary vessel.
What is the best first line treatment for STEMI.
Primary angioplasty if you can get it quickly.
What treatment should you get done if you have a STEMI and cannot get a primary angioplasty quickly.
Thrombolysis.
What causes the first heart sound (S1).
Closure of mitral valve.
What kind of MI carries a worse prognosis.
Anterior MI.
What kind of MI carries a good prognosis.
Inferior MI.
What is the name of the valve that cause the first part of the second heart sound (S2).
Aortic valve.
What is the name of the valve that cause the second part of the second heart sound (S2).
Pulmonary valve.
A patient comes into AandE with a diagnosis of an acute MI. What blood tests will confirm this diagnosis. (4)
Troponins. Creatine Kinase. AST. LDH. (from best test to worst)
What is the likely cause of an S3 in a 63 year old man who comes to AandE.
S3 is usually the first sign of heart failure. (usually even before the patient has realized).
A 64 year old man comes to AandE with what appears to be an S4. What is the likely diagnosis.
Usually caused by long term hypertension.
What is S3 caused by.
It is caused by rapid ventricular filling.
What is S4 caused by.
Atrial contraction against a stiff ventricle.
A 65 year old man turns up to AandE and you hear a decrescendo murmur after S2. What is it called.
Aortic regurgitation.
What sort of murmur is aortic regurgitation.
It is an early diastolic murmur.
What other physical signs are you likely to find in a patient presenting with aortic regurgitation.
Quinke’s sign.
What sort of pulse do you get in aortic regurgitation.
A collapsing pulse.
What is the likely systolic BP in a patient with aortic regurgitation.
It will be higher than normal, for example 220.
As the heart is pumping against a lot of pressure.
What is the likely diastolic BP in a patient with aortic regurgitation.
It will be lower than normal, for example 40.
As the blood leaks back after systole back into the heart due to the incompetent valve.
What is the sign involving the pulse pressure for aortic regurgitation.
A wide pulse pressure.
How is the circulation of aortic regurgitation described.
Dynamic.
How do you check for aortic regurgitation.
Check for a collapsing pulse.
What is Quinke’s sign.
Pulsation of the nail bed.
What does Quinke’s sign indicate.
A wide pulse pressure, indicative of aortic regurgitation.
What is the test indicated for a patient presenting with aortic regurgitation.
Echo.
How do you ideally want to treat aortic regurgitation.
Valve replacement.
All patients must be asked whether or not they have had a past history of acute rheumatic fever. True or false.
True.
Acute rheumatic fever is caused by a bacterial infection of the heart. True or false.
Yes
Acute rheumatic fever is an autoimmune disease. True or false.
Yes
What is acute rheumatic fever associated with.
It is always associated with group A haemolytic streptococcal infections.
Acute rheumatic fever is only associated with _____
pharyngeal infections
When does the initial infection with group A strep infection (which later leads to develop rheumatic fever) usually occur
In childhood
What is the genetic association with developing rheumatic fever.
HLA class 2 alleles.
What three factors predispose a person to developing rheumatic fever later on in life.
A severe initial infection.
A large immune response.
A positive family history.
Will all patients who contract a group A strep infection go on to develop rheumatic fever.
No, only a very small proportion will.
What factors predispose to developing a group A beta-haemolytic streptococcus infection. (3)
Age 4-10.
Females more likely than males.
Winter.
Lower socioeconomic background (unable to afford antibiotics in the 60s)
What antibodies do patients with rheumatic fever develop.
antibodies to M protein. (if severe infection)
What problem is there with developing M protein antibodies.
They also bind to heart muscle. (molecular mimicry by the bacteria)
What is the pathogenesis of acute rheumatic fever. (2)
It is likely to be an autoimmune disease.
Generated through molecular mimicry.
What do you see in acute rheumatic fever. (2)
Damaged heart muscle.
Sydenham’s chorea.
What is sydenham’s chorea.
Movement disorder (irregular, abrupt, relatively rapid involuntary movement). Emotional and behavioral disturbances (OCD behaviour, frequent mood changes and emotional lability).
What movements do you get with sydenham’s chorea. (4)
irregular, abrupt, relatively rapid involuntary movement
What behavioural disturbances do you see with sydenham’s chorea. (3)
OCD behaviour, frequent mood changes and emotional lability
What are the physical signs of acute rheumatic fever. (5)
Pancarditis. Arthritis. Movement disorder (sydenham's chorea). Rash. Nodules on elbows.
What part of the brain do the antibodies developed for rheumatic fever affect.
Basal ganglia.
