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Case 1: Common Things Occur Commonly

Case 1: Common Things Occur Commonly. Gareth Jones HO in Cardiology. Arthur Pound. 66 year-old man Obese Ex-smoker ‘Flu’ for 3-4 weeks – went onto his chest SOB Productive cough Palpitations. Ideas?. Increasingly SOB Orthopnoea Ankle swelling. Dr Armstrong’s Assessment. More Ideas?.

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Case 1: Common Things Occur Commonly

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  1. Case 1: Common Things Occur Commonly Gareth Jones HO in Cardiology

  2. Arthur Pound • 66 year-old man • Obese • Ex-smoker • ‘Flu’ for 3-4 weeks – went onto his chest • SOB • Productive cough • Palpitations Ideas?

  3. Increasingly SOB Orthopnoea Ankle swelling Dr Armstrong’s Assessment More Ideas?

  4. Dr Armstrong’s Examination • Anxious, cyanosed, breathless • HR 128 (irregularly irregular); BP 85/50; Temp 39.2°; RR 30 • Elevated JVP • Moderate pitting ankle oedema • Pansystolic murmur (Grade 4) • Dullness to percussion @ bases • Bilateral basal crepitations

  5. Investigations • Blood tests – FBC, U&Es, INR, CRP • Blood Cultures • ECG • CXR • Echocardiogram • ? TOE

  6. Atrial Fibrillation • Irregularly irregular pulse • ECG: • Absent P waves • Irregular QRS complexes • Causes: • Thyrotoxicosis • IHD/heart failure/MI • Hypertension • Pneumonia • Treatment: • Beta blocker • Digoxin • Amiodarone • DC cardioversion • Anticoagulation

  7. Elevated JVP • = measure of right atrial pressure • Look at waveform and height • Elevated > 4cm above sternal angle • Causes: • Fluid overload • Right heart failure • SVC obstruction

  8. Pansystolic murmur • Uniform intensity throughout systole, and merges with S2 • Causes: MR or TR • Grading 1 to 6 • Other murmurs: • Ejection Systolic • Early Diastolic • Mid-diastolic

  9. Heart Failure • Impaired ability of ventricles to fill with or eject blood • Caused by any condition that overloads or damages heart muscle: • MI/IHD • HTN • Valvular disease • arrhythmias

  10. Heart Failure - Classifications • Anatomical: • LVF; RVF; CCF • By cause: • Pump failure • Excessive preload • Chronic excessive afterload • Clinically: • NYHA

  11. Heart Failure - Symptoms

  12. Heart Failure - X-ray features • F = Failure • U = upper lobe diversion • C = cardiomegaly • K = Kerley B line • E = Effusions • d = (bat wings)

  13. Heart Failure - Treatment • Treat cause • Remove risks • Acute: • Oxygen • Diamorphine • Furosemide • GTN, or ?nitrate infusion • Chronic • Diuretics (furosemide, spironolactone) • ACEi • Beta-blocker • Digoxin

  14. Infective Endocarditis • Suspect in any patient with pyrexia and new murmur • Cause: strep viridans • Signs and symptoms • Infection • Murmur • Immune Complex deposition • Ix: • Blood cultures • Echocardiogram • Mx: • Antibiotics • ? Surgery

  15. Summary • Heart and Lung conditions overlap - easy to mix-up • AF = irregularly irregular; no P waves • JVP = measure of right atrial pressure. Look at height and waveform • Learn different sorts of murmurs, grading and where to hear them • Heart failure: • SOB; Orthopnoea; peripheral oedema • FUCKED X-ray • Treatment = Treat cause; diuresis • Murmur + pyrexia = infective endocarditis

  16. Thank You Any Questions?

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