Hot cases in Acute Medicine Faculty of Physician Associates Conference Shuaib Quraishi ST6 Acute Medicine and RCP Education Fellow MRCP (UK ) (Acute Medicine) BMedSci FHEA DGM @SaqDr
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
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.
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)
Investigations
WCC 11.5 Hb 15.7Trop 4CRP 7
Normal U/EALT 293ALP 94
Bil 7CK 46000
Investigations
Thoughts
?
Differential Diagnosis
• Epilepsy
• Rhabdomyolysis
• Cardiac syncope
Subsequently
• ECHO: no structural abnormality
• Admitted to CCU for Monitoring
• For Ajmaline testing and consideration of ICD (for suspected Brugada syndrome)
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
Brugada Syndrome
Case 2 – Miss P34 year old
PC– Tiredness– Weight loss– Depression– Unable to concentrate
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
Examination and Investigations
• Looks worried
• BP 90/60
• Tanned
• Na 130
• K 6.5
• Synacthen test positive- Inadequate rise in
cortisol
• ACTH raised
Treatment
• Replace steroids
• Hydrocortisone and fludrocortisone
• Steroid warning cards, bracelets
• If unwell advise to double steroids
• Check TFT, autoimmune screen
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
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
What Investigations would you like to do?
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)
Investigations
Thoughts
Clinical courseImpression
• CCF
• Pneumonia
• Pleural effusions
Not responding to antibiotics, fluids and diuretics
What would you do?
Ultrasound
Ultrasound
Diagnosis
Cardiac tamponade with right ventricular collapse
Required emergency admission and urgent pericardial drain
CARDIAC TAMPONADE
PERICARDIOCENTESIS
Diagnosis
• Lung Adenocarcinoma (eGFR positive)
•Pleural and Pericardial Effusion
•RV Collapse and Cardiac Tamponade
• Discharged home with outpatient oncology and chemotherapy
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.
Rash
What Investigations would you like to do?
Investigations
Treatment
Supportive (fluids)
No specific treatment
Dengue shock syndrome – Need ICU support
Avoid NSAIDS risk of bleeding in DSS
Vaccine is partially effective
Dengue fever• 80% asymptomatic
• Transmitted by the aedes mosquito
• Incubation period 3-14 days
• DSS occurs in 5% of children
• Supportive treatment
• Prevention
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
Case 5 – Mr W
PMH
– NIDDM
– HTN
DH - Metformin
SH - Smoker 40/day, ETOH 30 Units/week
Thoughts
ECG
Investigations
•ECG
•Bloods – Cardiac enzymes (Troponin – 12000)
•ECHO (Inferior RWMA)
ECHO
Management
• Cardiology for reperfusion (within 2 hours of symptoms)
• Thrombolyse if no PCI available
• Secondary prevention (BB/DAPT/ACEI if poor LV function)
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
Case 6PMH
– Type 2 diabetes
– Hypertension
– No previous respiratory diagnosis
DH– Amlodipine
– Metformin
Case 6
SH– Smokes 3 cigarettes/day
– Drinks 50 units/week
– Occasionally smokes shisha
FH– Nil significant
Thoughts?
Case 6Examination
– Overweight – 110kg (BMI 32)
– Not breathless at rest
– Normal temperature
– CVS
• BP 164/91
• HR 98 regular
• Heart sounds normal
Case 6– Respiratory
• Chest clear
• RR 20
• Saturations 96% on air
– Gastro
• Abdomen soft and non tender
• No masses
• Normal bowel sounds
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
What next?
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%
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
Questions