Transcript
OSCE
DR SUBHASISH DEB
Burdwan Medical College and Hospital
Department of General Medicine
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CASE 1
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A 72 year old man presented with
generalized erythroderma with palmer and
planter hyperkeatosis and enlarged Lymph
nodes.
WBC= 24,000/ul (mico lit)
Peripheral smear shows the following
atypical cell.
Skin biposy showed epidermotropism of the
atypical cells
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(A)Typical erythroderma of Sézary syndrome, and
(B) solitary mycosis fungoides plaque,
(C) tumour nodule of large cell lymphoma (LCL). Histology reveals
(D) an upper band-like infiltrate with epidermotropism of atypical
lymphocytes and
(E) a typical Pautrier microabscess
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SEZARY SYNDROME
An aggressive form of CTCL (cutaneous T
cell Lymphoma)
Triad:
1. Erythroderma (diffuse)
2. Lymphadenopathy
3. Circulating atypical lymphocytes (Sezary
cells)
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DIAGNOSTIC CRITERIA
1 or more of the following should be present:
1. An absolute Sézary cell count of least 1000 cells/µL
2. Demonstration of an expanded CD4+ T-cell population CD4/CD8 > 10; loss of any or all of the T-cell antigens CD2, CD3, CD4, and CD5; or loss of both CD4 and CD5)
3. Identical T-cell clone in blood and skin. (by molecular assay like pcr)
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Mycosis fungoides and SS are the m/c
CTCLs
Lineage: Mature (peripheral) T cells
SS differentiated from MF by presence of
atypical lymphocytes in blood.
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CASE 2
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A 70 year old woman came with a c/o of
chest pain with radiation to left shoulder. She
has a medical h/o of hypercholesterolemia.
Her ECG showed the following.
Trop T – positive
CXR- NAD
Ur-30, Cr-1.0
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POSTERIOR WALL MI
PMI also called ‘dead angle infarction’
One of the m/c missed types of AMI
The term PMI is used for necrosis of the
dorsal infraatrial part of the left ventricle
located between the atrioventricular sulcus
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Occurs due to stenosis/ occlusion of RCX
Often accompanied by inferior and/or lateral
wall MI
Pts with ecg of isolated PMI often do not
receive the appropriate reperfusion t/t due to
lack of classical ST-segment elevation in
normal 12 lead ecg
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ECG FINDINGS
V1 and V2 are mirror images of V1 and V2 of
anterior wall MI
Vector cardiogram points ventrally due to
loss of the electrical forces normally aimed
dorsally, resulting in a prolonged R wave –
R/S >1 in V1 and V2
ST depression in precordial leads in acute
phase + tall upright T waves
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USE OF DORSAL LEADS
Mortality reduction is max when reperfusedwithin 6hrs if pain onset
POSTERIOR LEADS:
V7 – at the level of V6 at post Axillary line
V8 – left side of back at the tip of scapula
V9 – half way between V8 and the left paraspinal muscles
ST elevation >1mm in post leads is suggestive of PMI
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Sensitivity increases from 32% to 57% and
specificity 98% for RCX on the 15 lead ecg
instead of the normal 12 lead ecg
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CASE 3
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A 83 year old man with h/o heart disease
with repeated symptomatic episodes of CHF
presented with c/o cough and progessive
orthopnea and 3 weeks of PND. CXR
showed A
Pt was treated with iv furosemide, t. digoxin,
iv nitroglycerine and captopril. He improved
in 3 days and 6 days later, repeat CXR
showed B
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A B
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PHANTOM TUMOUR
The term phantom tumour is applied to a transudative interlobar pleural fluid collection in CHF which disappears spontaneously with compensation and may reappear on decompensation
USUALLY SEEN IN:
CHF
Renal Failure
Hypoalbuminemia
Due to transudation from pulmonary vasculature
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PATHOGENESIS
Involves the adhesion and obliteration of the
pleural space due to pleuritis that may be
transient, thereby preventing the free
accumulation of fluid.
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CASE 4
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A 56 year old woman with past h/o of HTN presented with flue like symptoms that were ongoing for last 3 days. While waiting in the observation room for 6 hrs, she developed chest pain. No family h/o of any cardiac problems.
ECG - showed the follwing
TROP t – positive
ECHO – hypokinetic walls with EF – 35%
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MYOCARDITIS
NON ISCHEMIC myocardial inflammation
resulting from a variety of infectious, immune
and toxic insults.
DCM and Chronic Heart Failure are the
mojor long term sequla of myocarditis.
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M/c/c in Europe and North America – VIRUS
m/c/c Worldwide – chagas disease
Less common non viral pathogens:
1. Borrelia Burgdorferi
2. Trypanosoma Cruzi
3. Hypersensitivity to drugs
4. Autoimmune reaction
(Streotococcal M protein and Coxsakie virus B epitopes are similar to cardiac myosin)
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As definitive diagnosis requires a heart
biopsy,which doctors are reluctant to do,
statistics on the incidence of myocarditis vary
widely.
Among HIV patients, myocarditis is the m/c
cardiac pathological finding at autopsy.
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SIGNS AND SYMPTOMS
1. Chest pain (stabbing)
2. CHF
3. Palpitation
4. Sudden death
5. Fever
6. Flue like symptoms
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DIAGNOSIS
ECG- diffuse t wave inversions, saddle
shaped ST-segment elevations (also in
pericarditis)
Gold standard – biopsy of myocardium
Generally done in a setting of angiography. A
small tissue sample of te endoand
myocardium is taken
Also useful are IgM against virus, ESR, CRP
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TREATMENT
Viral infections cannot be treated with direct
therapy – symptomatic
People who do not responf to convesional
therapy are candidayes for bridge thrapy with
Left ventricular assist device
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CASE 5
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A 20 years old man presented with this
rash and 1st degree heart block.
What is the diagnosis and what is the
treatment ?
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LYME DISEASE
Borrelia burgdorferi is transmitted to humans by the bite of infected hard ticks.
Early symptoms may include fever, headache, fatigue, depression, and a characteristic circular skin rash called erythema migrans(bull's eye rash) .
Left untreated, later symptoms may involve the joints, heart, and central nervous system.
Treatment: antibiotics-doxycycline, if have later complications- cefotaxime or ceftriaxone.
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