Other clinical case conundrums Flashcards
Treatment for type 2 diabetes
Everyone start with metformin (low dose and build up)
Add flozin or glutide
Before it was metformin and then add anything in any order but evidence is now if you have vascular disease add flozin or glitide but as glitide is injection, post people get glitide which is SGLT-2 inhibitor
I get palpitations what does ecg show?
=Atrial fibrillation
RR interval in rhythm strip is irregular. So irregularly irregular pulse, as every RR interval is different. Nice narrow complex so otherwise good ECG except rhythm.
Now think what should the patient be on?
Now think what should the patient who is in AF be on?
- Anticoagulant to prevent stroke. Give warfarin or DOAC like apixaban
- Control patient’s palpitations, depending on their age give beta blocker or digoxin which blocks
- Beta blocker might cardiovert them to sinus rhythm so you’ll have the atrial reserve and so good if young person and wanting to play tennis they can carry on. But if older person, they won’t ever need extra 20%. Digoxin just leaves you in AF but doesn’t give you extra reserve.
If BP is low people are scared of beta blockers so in emergency give digoxin as doesn’t affect BP.
If arterial problem eg atheroma, give antiplatelet eg aspirin which prevents platelet block from forming. So if partly blocked arteries give aspirin but if something on venous side including atria or DVT, then aspirin is useless! Don’t confuse arterial prophylaxis (aspirin and clopidogrel) for venous prophylaxis (warfarin or DOAC)
Scoring system for warfarin vs apixaban?
Warfarin-only if risk of stroke really is there, if young might not really have high risk of stroke.
Use CHAD-VASC score
Healthy Females score 1. This gives annual risk of 1% of stroke. As score goes up, it causes greater risk of stroke.
So if score of 0 then risk of going on warfarin is greater
Common OSCE station so learn. In station say-you have an irregular pulse, but don’t worry this is a very common condition that many people have. There is a very small risk of stroke, I have added your score up and your score is low, but we will put you on a drug to reduce the risk.
Will send you home on two drugs-beta blocker and apixaban
Do you have any questions
27 year old 2 days of chest pain and patient wants an ECG.
=Viral Pericarditis
Think this is a young man. 27 year old-unlikely to have 2 STEMIs at the same time!
Also it would be unlucky to have so many STEMIs, it would be very unlucky to have so many vessels affected.
Also 2 days are too long to be MI. MIs happen in under 6 hours and then there are q waves everywhere.
Sitting forward relieves pain
If it was bacterial, you’d have systemic sepsis so heart wouldn’t be major problem. Whereas viral pericarditis comes and goes.
27 year old 2 days of chest pain and patient wants an ECG. What is treatment for viral pericarditis?
=NSAIDs if patient is really in pain, and colchicine
Just give pain relief and reassurance
This is now post viral so antivirals aren’t used at all in viral pericarditis as mostly immune system attack after due to inflammation.
Brother had MI:
=This is typical left bundle branch block
Very common and needs to be recognised. Firstly they are really broad complexes.
V1-broad complex looks like an W pattern, in V6-broad complex which is 2 r waves superimposed on each other looking like a M.
R wave is because AVN lets contraction through and it goes down both bundle branches to allow ventricle to contract
If infarct in left bundle, then wave will go down RBBB first and cause an R wave, and then comes across to other side causing another R wave superimposed.
Some people may have a blocked RBB and that is normal for them but ischaemia of LBB is more commonly pathological and causes trouble.
Explain william and marrow
If have LBBB they are at risk of MI in the future
Same LBBB diagnosis
=uninterpretable
Not due to acute infarct. When patient has LBBB, need to document that they are fine but they will look like they have ST elevations. Patient is fine now but when they have a real ST elevation MI you won’t be able to tell. If have severe central crushing chest pain and they have LBBB, treat as acute MI based on history.
Look in patient for old ECG as see if it looks different, but can’t wait for an hour. Must treat as an infarct before result comes back.
=Complete/third degree heart block
2nd and 3rd wouldn’t make you faint
Looks like random p waves but they aren’t random, they are hidden. P waves and R waves are regular, they are just at different rates so there are independent atria and ventricular contractions. There is a new pacemaker at the AV node. If narrow complex it must be a nodal rhythm, so AVN is source (must be supraventricular as it below it would be broad). AVN is slower causing bradycardia and BP will be low causing fainting and falls
Sometime p wave and r wave occur at same time ie atria and ventricular
third degree block treatment
=permanent pacemaker
They need a pacemaker
Atropine speeds up atria but it will not get to the ventricles.
Amiodarone won’t work as it is not an arrythmia
DC cardioversion won’t work as nothing fibrillating
This person needs a permanent pacemaker. Only give temporary one if it is an emergency
third degree block what would you see when atria and ventricle contract at same time
=Cannon A waves
Only occurs in complete heart block
From time to time randomly the p and r wave will occur together. Blood can’t go down due to high ventricle pressures and closed valve so it shoots up back into the neck
DIAGNOSTIC of complete heart block! So can diagnose from this
OSCE station
Actor is given this
OSCE station-What is point of seeing a physio?
Practice mobility, build up confidence and teach them techniques to get up if they have another fall. Help assess needs of walking aids.
They also cover pain management that doesn’t cover drugs eg heat therapy, splints etc).
The physio will help them go home if it is safe for them to go home. If we can sort this quickly then they can go home straight away.
Occupational therapy (green outfit)-asked in last year osce
- Find out what patient wants
- remember to include drugs and family
- Then check what these people do
- Assess your ability to wash and dress yourself
- They can get chairs installed at home to make sure that you can safely wash
Some patients need rehabilitation
-Time to build up their muscles and preserve function and build up independence
Red flags-don’t do this is an OSCE!
-Never dismiss patient concerns
Chest X-ray
=left sided pneumothorax
Not tension as midline is fixed
Lung has just collapsed unilaterally on the left. Put chest drain in
Both sides are resonant, no breath sounds on left, vesicular breathing on the right, ask patient to say 99 and it will be more muffled on the left.
=left upper lobe pneumonia
Bronchial breathing, dull to percuss and increased tactile vocal fremitus
Equal expansion, percussion dullness over consolidation area, breath sounds over consolidation will be loud and the solid conducts very well=bronchial breathing, increase tactile vocal fremitus on left
vesicular normal sound is muffled due to lots of alveoli.
=cannon ball metastases
There are lots of different discrete bits here.
Possible to be infection eg TB
Asbestosis causes pleural plaques so white bits around the pleura eg edges
No signs as symmetrical and doesn’t affect the periphery
Yes-breasts
What do you want to do for this patient?
=left sided pleural effusion
Expansion: reduced L expansion compared to the right
Percussion: Stoney dull percussion on left side
Auscultation: Reduced or absent breath sounds on left
Tactile vocal fremitus: Decreased tactile vocal fremitus
Pleuritic tap-send for microscopy and culture as we don’t know diagnosis. Top diagnosis in out of blue effusion would be cancer that has mets in pleural space so will see malignant cells in tap, other possibility is infection eg TB
Random-PE gives normal chest X-ray
