Thursday, November 8, 2012

Cardiology Case Scenario- Make your Diagnosis

A 60 year old gentleman with  history of hypertension and diabetes mellitus presents to the emergency room with retrosternal chest pain . He is afebrile, blood pressure is 110/70 mmHg, heart rate 70/min, and respiratory rate 18/min. Physical examination reveals normal lung sounds, normal jugular venous pressure, and an S4 heart sound. Laboratory studuies are initially normal. His ECG is below. What complication is most commonly associated with this patient's diagnosis?
















 A) Acute mitral regurgitation
 B) Left ventricular thrombus
 C) Left ventricular aneurysm
 D) Left ventricular Free Wall rupture




Please leave your Answers  in the Box Below.   

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Sunday, November 4, 2012

19 year old boy Passes out while running- Next Step in Management ?

A 19 year old boy with no past medical history passes out while running at a school evnt. He states that he was feeling a little dizzy prior to the event, but does not complains of chest pain or palpitations. His blood pressure is 120/85, heart rate 85/min, Respiratory Rate 12/min, and he is afebrile. His physical examination reveals normal lung sounds, a II/VI mid-sytolic creshendo-decreshndo murmur is heard at the right upper sternal border which increases in intensity with Valsalva, an S4 heart sound is also present. Laboratory studies are normal. What is the most appropriate treatment at this time?


 A) Start a Diuretic
 B) Permanent Pacemaker Implantation
 C) AICD Implantation
 D) Observation
 
 E) Start  Beta Blocker


Please leave your Answers in the Box Below.  

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Monday, October 29, 2012

89 year old gentleman with history of Syncope - What should be the next step in management ?

A 89 years old gentleman with a history of hypertension and osteoarthritis presents to the ED with an episode of syncope while listening to music. He has felt generally lethargic for the past one week. He denies  chest pain, shortness of breath, or fever. His medications include Metoprolol and celecoxib. The blood pressure is 120/60 mmHg, H/R 42/min, R/R 15/min, and he is afebrile. His physical examination reveals normal lung sounds, a regular, bradycardic rhythm with varying intensities of the S1 heart sound on auscultation, and intermittent large cannon A waves in the jugular venous pulsation. His laboratory studies are normal. The ECG of the patient is depicted below. What is the next step in management of this patient?













 A) Observation

 B) Stop Metoprolol
 C) Permanent pacemaker implantation
 D) AICD Implantation

Answer-
Diagnosis -2nd degree AV block - high grade - Mobitz II 
Next Step in Management - Stop Metprolol and be ready for PPI 
Thanks to all for contribution

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Saturday, October 27, 2012

A 62 year old gentleman found unresponsive - What should be the Best Course of Action?

A 62 year old gentleman with a history of diabetes mellitus, hypertension, and a renal transplant presents to the ED after being found unresponsive at office. His temperature is 37.6 C, blood pressure is 80/30, heart rate 130, respirations 25, and oxygen saturation 75% on room air. Physical examination reveals bilateral pulmonary rales, a S4 heart sound is present, and no murmurs could be auscultated. He is intubated for airway protection. ECG reveals sinus tachycardia with a LBBB. 



A Swan-Ganz catheter is inserted and the values are below:

Right atrial presssure - 8 mmHg
Right ventricular pressure - 38/8 mmHg
Pulmonary artery pressure - 42/22 mmHg
Pulmonary capillary wedge pressure - 26 mmHg
Cardiac output - 4.0 L/min
Cardiac index - 2.0 L/min/BSA

Which of the following is best course of action?


 A) Emergency Echocardiography
 B) Emergent cardiac catheterization
 C) Tissue plasminogen activator infusion (tPA)
 D) Glycoprotein IIb/IIIa infusion


Answer: B - Emergent Cardiac Catheterization

The patient depicted in the question presents with severe shock. His Swan-Ganz pressure readings shows low cardiac output and elevated PCWP which reflects cardiogenic shock.Late stage septic shock can actually appear similar when the heart begins to fail, however the presentation is more acute in case of septic shock. This patient is most likely having a large myocardial infarction causing left ventricular dysfunction and reduced cardiac output leading to hypotension. He must be taken emergently for cardiac catheterization to revascularize the culprit coronary artery. Cardiac catheterization with stenting has been shown to be superior to thrombolytics in patients with cardiogenic shock. Inotropes could sometimes be helpful to stimulate inotropy and cardiac output, however this can worsen ongoing myocardial ischemia as well. 

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