Open Resources and Online MSc from the University of Edinburgh and RCPE

An unusual ECG

November 26, 2012 — Eleri Williams

A routine pre-operative ECG is performed on a woman in her fifties. She is asymptomatic, but she tells you that she has previously been seen by the cardiologists. You are asked to review the ECG. Click on the ECG to see a bigger version.

 

 

 

  • Describe the ECG
  • What do you think is the diagnosis?
  • What one test would you like to perform to support your conclusions?

Many thanks to Dr Marc Dweck for this case. Students, let us know what you think on the discussion board.

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Thanks to all of our students who joined in this discussion. Many of our students correctly identified the key abnormalities in this ECG (superior and rightward axis, with poor progression of R waves across the chest leads) and concluded that the diagnosis in this case was dextrocardia. The one investigation that would have confirmed the diagnosis was a simple chest X-ray, though an echocardiogram would also have done the job.

This case was adapted with permission from one of the cases available at the Edinburgh Cardiovascular Imaging Website. This is a fantastic new and open resource set up by the Edinburgh Heart Centre and the Clinical Research Imaging Centre. We would strongly recommend a visit to this site to see other cases and images that are available.

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A 35 year old man with a murmur

June 10, 2012 — Eleri Williams

A 35 year-old man is admitted with a one-week history of cough, shortness of breath and fever. He has no known prior illness or cardiovascular risk factors but is known to have a longstanding heart murmur, which was not previously investigated. There is no evidence of previous intravenous drug abuse. He continues to experience episodes of diaphoresis and fever. Cardiac exam reveals an added ejection systolic and an early long diastolic murmur. His C-Reactive protein peaks at 254 mg/L and 2 sets of blood cultures are positive for Streptococcus Parasanguis.

Have a look at the transthoracic echocardiogram images in the classroom.

Questions for discussion:

  1. What is the diagnosis and what are the findings from the echocardiogram?
  2. How would you manage the condition?
  3. What are the complications of this condition?

Students, add your ideas to the class discussion board. Many thanks to Dr Nikhil Joshi and Dr Anoop Shah for this week’s case.

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This case led to a very interesting discussion in the classroom. The diagnosis was infective endocarditis. We discussed the many complications of infective endocarditis and how it should be managed. In this case, the complication was an aorto-atrial fistula, which is quite rare. We considered some very interesting images, and honed our echocardiogram interpretation skills

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A 69 year old man with breathlessness and oedema

April 29, 2012 — Eleri Williams

A general practitioner has requested hospital admission for a 69 year old retired truck driver with a 12 month history of worsening fatigue, breathlessness and peripheral oedema. The GP is concerned that despite increasing doses of loop diuretic for the last 3 months he had become progressively more oedematous and is now struggling to walk any distance. There is no previous history of cardiac disease. There is a past history of gout, renal calculi, mild asthma and testicular cancer at age 23. He is a non-smoker and takes a moderate amount of alcohol.

On examination, pulse is 105/minute and irregular, blood pressure 98/60mmHg, severe oedema from toes to mid abdomen, JVP elevated, heart sounds soft, no murmur audible. Chest is clear with slightly reduced air entry at the lung bases. Blood tests are as follows:

Na 130 mmol/L

K 4.6 mmol/L

Urea 15.1 mmol/L

Creatinine 140 micromol/L

Bilirubin 23 micromol/L

ALT 60 U/L

AST 30 U/L

Alkaline Phosphatase 120 U/L

Albumin 28 g/L

Urinalysis negative

  • What aspect of the patients past history is of key importance and requires further exploration?
  • What bedside clinical examination test could provide the diagnosis here?

Many thanks to Dr Martin Denvir for this case. Students, add your thoughts as usual to the discussion board.

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The piece of history that would have been important relates to his treatment 46 years previously. Did he have radiotherapy to the chest? The diagnosis in this man was constrictive pericarditis secondary to previous radiotherapy. The sign to look out for which would have been helpful is Kussmaul’s sign. Kussmaul’s sign is when there is a rise in jugular venous pressure on inspiration. This YouTube video shows a good example.

http://www.youtube.com/watch?v=uB1c2zvkaew

 

 

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Refractory epilepsy in a 39 year old man

October 16, 2011 — Eleri Williams

A 39 year-old man presents to A+E following an episode of collapse. On this occasion he had been shopping in Tesco when he collapsed. He himself has little recollection of events and could give no account of a prodrome. He says that he was buying cheese and the next thing he remembers is waking up on the floor just before ambulance staff arrived on the scene. He felt rather bruised and a little disorientated at first, then noticed that he had bitten the side of his tongue and his trousers were wet. An ambulance was called and he was brought in to hospital.

He had been diagnosed with epilepsy two years previously and is currently treated with sodium valproate 600mg bd. He says that he has had an MRI scan of the head which was normal and an EEG which showed “some evidence of epilepsy”. He tells you he has had six generalised seizures in total and these have occurred every 3-4 months despite starting the valproate last year. These can occur at any time of day and there is no clear pattern or precipitant to attacks, although two have occurred in stressful situations at work. Typically he has no warning, collapses to the floor and has no recollection of the event. He says that people who have witnessed the attacks say he convulses and there is typically evidence of lateral tongue biting with occasional urinary incontinence. There have been no events suggestive of focal seizures. He reports jerking of his arms as he falls asleep. He is previously fit and well and there is no significant past medical history. There is no relevant family history. He is a teacher, lives alone and denies any illicit drug use.
He is clinically well, his neurological examination is normal, he is fully orientated and he wants to go home.
  • Is he on the right medication?
  • What is the single most useful clinical undertaking in this situation?
MSc students, please add your comments to the class discussion board.
Thanks to Dr David Hunt for this case.
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