Faculty of Physician Associates Conference
Transcript of Faculty of Physician Associates Conference
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Hot cases in Acute Medicine
Faculty of Physician Associates Conference
Shuaib Quraishi
ST6 Acute Medicine and RCP Education FellowMRCP (UK ) (Acute Medicine) BMedSci FHEA DGM
@SaqDr
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Case 1 – Mr X
PC
– 17 M, presented to GP after a collapse and seizure
– Witnessed seizure. Initially absence tonic clonic 30 sec. No tongue biting. No incontinence
– Was body building at the gym for the first time 3 days prior.
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Mr XPMH
– epilepsy – 2010, stopped antiepileptics 2 years agoDH
– Nil. No recreational drugs
FH
– Mother Caucasian, father Chinese. Lives in Luxemburg– Uncle died at 40 (unsure of cause)
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Investigations
WCC 11.5 Hb 15.7Trop 4CRP 7
Normal U/EALT 293ALP 94
Bil 7CK 46000
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Investigations
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Thoughts
?
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Differential Diagnosis
• Epilepsy
• Rhabdomyolysis
• Cardiac syncope
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Subsequently
• ECHO: no structural abnormality
• Admitted to CCU for Monitoring
• For Ajmaline testing and consideration of ICD (for suspected Brugada syndrome)
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Brugada Syndrome
• Autosomal dominant
• 8-10 times more common in men than women
• Mean age of sudden death (41 years)
• Most common in people from Asia
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Brugada Syndrome
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Case 2 – Miss P34 year old
PC– Tiredness– Weight loss– Depression– Unable to concentrate
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Case 2 – Miss PHPC
– 12 month history
– Feels unsteady and dizzy in the mornings
– Has had two antidepressants with no effect
DH - Nil
SH - Non Smoker/No ETOH, off sick from work for 3 months
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Examination and Investigations
• Looks worried
• BP 90/60
• Tanned
• Na 130
• K 6.5
• Synacthen test positive- Inadequate rise in
cortisol
• ACTH raised
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Treatment
• Replace steroids
• Hydrocortisone and fludrocortisone
• Steroid warning cards, bracelets
• If unwell advise to double steroids
• Check TFT, autoimmune screen
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Case 3 – Mrs T77 year old
PC– Breathlessness
HPC– 12 month history– Worse over the past 2 weeks. Now limited to steps and
housebound.– Was very active and normally fit and well
DH - Amlodipine
SH - Non Smoker/No ETOH/Japanese. No recent travel
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Mrs T
• A: Intact
• B: RR 30 Sats 88% on room air Decreased AE bases
• C: Cool peripheries, Quiet heart sounds HR 120 BP 120/80 JVP elevated
• D: GCS 15/15 oC 37.5
• E: Abdomen SNT, Calves soft
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What Investigations would you like to do?
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Investigations• ABG on 15L
• pH 7.13, pC02 4.1, p02 10.1, Na 109, K 5.3, glc 8.3, lactate 8.8, BE -17, HC03 10.9
• Haematology• Hb 126, plt 291, neut 12.2, INR 1.8
• Biochemistry• Na 110, K5.3, Ur 12.2, Crt 132, eGFR 34, Ca 2.24, phos 2.31, albumin 43,
Normal LFT, CRP 71, WCC 14.9, Troponin 66 (normal <14)
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Investigations
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Thoughts
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Clinical courseImpression
• CCF
• Pneumonia
• Pleural effusions
Not responding to antibiotics, fluids and diuretics
What would you do?
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Ultrasound
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Ultrasound
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Diagnosis
Cardiac tamponade with right ventricular collapse
Required emergency admission and urgent pericardial drain
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CARDIAC TAMPONADE
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PERICARDIOCENTESIS
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Diagnosis
• Lung Adenocarcinoma (eGFR positive)
•Pleural and Pericardial Effusion
•RV Collapse and Cardiac Tamponade
• Discharged home with outpatient oncology and chemotherapy
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Case 4 – Mr W45 year old Sri Lankan malePC
– Headache, Muscle Pain and Fever (40 oC)
HPC– One week history – worse over past 3 days– Retroorbital headache– Developing rash
DH - ParacetamolSH - Non Smoker/No ETOH/. Returned to UK from Colombo 4 days ago.
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Rash
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What Investigations would you like to do?
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Investigations
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Treatment
Supportive (fluids)
No specific treatment
Dengue shock syndrome – Need ICU support
Avoid NSAIDS risk of bleeding in DSS
Vaccine is partially effective
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Dengue fever• 80% asymptomatic
• Transmitted by the aedes mosquito
• Incubation period 3-14 days
• DSS occurs in 5% of children
• Supportive treatment
• Prevention
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Case 5 – Mr W66 year old Indian male, BMI 32
PC– Chest Pain
HPC– Sudden onset chest pain – started one hour ago– 10/10 severity– Associated SOB– Radiating to neck and jaw– Retrosternal radiating to shoulder blade
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Case 5 – Mr W
PMH
– NIDDM
– HTN
DH - Metformin
SH - Smoker 40/day, ETOH 30 Units/week
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Thoughts
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ECG
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Investigations
•ECG
•Bloods – Cardiac enzymes (Troponin – 12000)
•ECHO (Inferior RWMA)
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ECHO
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Management
• Cardiology for reperfusion (within 2 hours of symptoms)
• Thrombolyse if no PCI available
• Secondary prevention (BB/DAPT/ACEI if poor LV function)
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Case 6 – Mr S
47 year old manWorsening cough for 8 weeks
• Cough is mainly nocturnal• Barely sleeping• Dry – no sputum• No chest pain• No breathlessness
• Previously saw GP who prescribed a salbutamol inhaler in case diagnosis was asthma
• Using several times a day with no effect
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Case 6PMH
– Type 2 diabetes
– Hypertension
– No previous respiratory diagnosis
DH– Amlodipine
– Metformin
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Case 6
SH– Smokes 3 cigarettes/day
– Drinks 50 units/week
– Occasionally smokes shisha
FH– Nil significant
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Thoughts?
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Case 6Examination
– Overweight – 110kg (BMI 32)
– Not breathless at rest
– Normal temperature
– CVS
• BP 164/91
• HR 98 regular
• Heart sounds normal
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Case 6– Respiratory
• Chest clear
• RR 20
• Saturations 96% on air
– Gastro
• Abdomen soft and non tender
• No masses
• Normal bowel sounds
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Case 6
– Na 141
– K 3.7
– Urea 5.9
– Creat 101
– CRP 1
– ESR 7
• Bloods results– Hb 142
– MCV 86
– Hct 0.42
– WCC 9.3
– Neutro 7.5
– Hb 142
– MCV 86
– Hct 0.42
– WCC 9.3
– Neutro 7.57.5
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What next?
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Case 6• PEFR chart
– No variability or reversibilty
– Peak flow rate = 440 l/m
• Lung function testing
– FEV1 = 3.1 (predicted = 3.9)
– FVC = 3.9 (predicted = 4.4)
– FEV1/FVC = 79%
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Case 6• Patient started on 30mg lansoprazole morning and night
• Asked to sleep at 45% angle
CURED
• Gastro-oesophageal reflux disease is one of commonest causes of chronic cough
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Questions