A 54 year old man is brought to ED by his 2 sons with complaints of increasing drowsiness , distress and confusion.

 A 54 year old man is brought to ED by his 2 sons with complaints of increasing drowsiness , distress and confusion. 

They also bring a chest X ray done 1 day ago. According to his son , he has been unwell since 4 days but they provided him treatment at home. 

You attach him to a cardiac monitor. His oxygen saturation propped up on air is 42 percent and on right lateral position is 55 Percent and left lateral position is 48 percent. 

You put on high flow oxygen of 6 litre with non rebreathing mask and reach a saturation of 68 percent.

1. What is the most likely Diagnosis?

2 . What are your next steps in management of this patient?

Answers given in comments section.

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1. What is the most likely Diagnosis?: 

Severe Acute Respiratory Distress Syndrome secindary to Covid 19 Pneumonitis

2 . What are your next steps in management of this patient? 

The patients oxygen saturation is not improving more than 80 percent on high flow oxygen . 

He should be intubated and put on a ventilator to support his ventilation and shifted to designated Covid ITU with further management including giving Dexamethasone , Tocilizumab, Remdesivir and monitoring of vitals signs and inflammatory parameters like CRP , Procalciltonin and Interleukin 6 levels with care given to treatment of Acute kidney injury as well.

A ventilator pumps air,usually with extra oxygen, into patients' airways when they are unable to breathe adequately on their own. If lung function has been severely impaired—due to injury or an illness such as COVID-19 patients may need a ventilator. It is also used to support breathing during surgery.If the body’s immune system does not fight off the infection, it can travel to the lungs and cause a potentially fatal condition called acute respiratory distress syndrome (ARDS). In ARDS, the alveoli (tiny air sacs that allow oxygen to reach the blood stream and remove carbon dioxide) fill with fluid, which diminishes the lungs’ ability to provide vital organs with enough oxygen.

ARDS entails severe inflammation of the lungs, but the main problem is that it makes portions of the lungs unusable, Normally, when someone takes a breath, their chest wall expands, which creates negative pressure (i.e., a vacuum) inside the lungs that draws air in. When a person is sick and weak and can’t pull the breaths in on their own, a ventilator creates positive pressure that forces air into the lungs. The first step in putting a patient on a ventilator is general anesthesia. Then, a medical professional will place a tube into the mouth or nose and snake it into the windpipe. This is called intubation.

The tube is connected to an external machine that blows air and oxygen into the lungs. The machine can help do all or just some of the breathing, depending on the patient’s condition. The ventilator can also help hold the lungs open so that the air sacs do not collapse.

While patients are on a ventilator, doctors will monitor their heart and respiratory rates, blood pressure, and oxygen saturation. Other tests, such as X-rays and blood draws, may be done to measure oxygen and carbon dioxide levels (sometimes called blood gases). For more useful information , read the link

 below : https://www.yalemedicine.org/news/ventilators-covid-19

A 55 year old female presents to ED Department with complaints of left sided chest pain over a period of 3-4 months (Angina).

 A 55 year old female presents to ED Department with complaints of left sided chest pain over a period of 3-4 months (Angina).

The pain is worse on walking or going up hill and at times of stress and is accompanied by sweating and apprehension.

The patient also complains of swelling over both her ankles.

On examination,

Her Blood pressure is 150/90 mmHg

Her BMI is 34.

She also has Bilateral pitting oedema of feet.

Otherwise unremarkable Neurological, CV , Resp or GI examination.

1. Which initial investigations will you like to perform?

2. What are the findings on the ECG.

3. Which additional investigations would you like to perform after looking at the ECG results.

4. What is the most likely Diagnosis?

5. How will you manage this patient?

Answers given in comments section.

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1. Which initial investigations will you like to perform? 

In order to find out the underlying cause of the complaints including Angina , it would be a good idea to undertake an ECG to see if there are any findings suggestive of Ischaemic heart disease. 

Also cardiac enzymes Troponin T and Myoglobin levels are needed. A chest X ray to look for presence of Cardiomegaly suggestive of Congestive Cardiac failure as well as an Echocardiogram and BNP levels would also be useful. 

We need to look for other risk factors of IScahemic Heart disease such as raised sugar levels ( HbA1C and RBS levels ) and Serum cholesterol as well as full Renal Profile and Liver profile to determine other causes of swelling of feet.

2. What are the findings on the ECG.: 

There is t waves inversion in leads V1 - V6 which indicates ischaemia of cornary arteries supplying Anterior and lateral walls of left ventricle and interventricuar septum.

3. Which additional investigations would you like to perform after looking at the ECG results.

 Angiography , echocardiogram , Cardiac enzymes : Tropnin T and I and myoglobin , BNP , Sugar levels.

4. What is the most likely Diagnosis? 

scahemic Heart Disease / Non ST Elevation MI

5. How will you manage this patient? : 

After investigations and angigraphy, the extent and limit of coronary artery blockage is detremined and management consists of medications +/- angioplasty +/-stent insertion.

The usual cardiac medications include : Regular Ascard / loprin 75 mg once a day . Clopidrogel 75 mg once a day , GTN / sustac 2.6 mg once a day . Statins , Antihypertensives . Healthy life style : regular exercise , healthy food , Low salt and low cholesterol diet.

A 62 year old lady presents to your OPD with complaints of dizziness and apprehension since 3 months.

 A 62 year old lady presents to your OPD with complaints of dizziness and apprehension since 3 months.

She also occasionally complains of Angina as well.

She denies any fever or other significant problem.

Her BP is 150 / 80 mmHg

There are no other remarkable Respiratory, cardiovascular , GI or neurological system pathology

You note presence of xanthelasmas around her upper eyelids.

1. Which investigations would you like to perform :

2 . What are the findings in ECG

3 . What is the mpost likely diagnosis

4. How will you treat this patient

Answers given in comments section

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1. Which investigations would you like to perform : 

Lipid profile + Cholesterol ,Sugar Levels,ECG,Renal profile 

As patient has high BP and xanthelasmas with a cardiac problem, it would be a good approach to conduct above tests in order to find out the underlying cause of the problem.

2 . What are the findings in ECG 

P-waves have no relation to the QRS complexes. 

The QRS complexes are normal . P-waves have constant PP interval and ride straight through the strip, without any relation to QRS complexes.

3 . What is the most likely diagnosis : 

Third-degree, or complete, heart block.

4. How will you treat this patient : 

The management of complete heart block is dictated by haemodynamic condition and status of patient

As this pt is haemodynamically stable , we will focus on longer term management of the patient.

In case of acute onset and haemodynamically unstable pt, Mx is under taken in CCU and consists of transcutaneous pacing and transvenous pacing and administration of sub cut / iv atropine.

Patient should be administed oxygen.

Ascard 75 mg od should be given with GTN and Clopidrogel 75 mg. 

BP should be controlled . 

Evaluation by a cardiologist is needed and a longer term managemnt plan is required which may inlcude one of below options after evaluation Implantable Device (Pacemaker) Catheter Ablation Internal Cardioversion Implantable Cardioverter Defibrillator Biventricular Pace Maker / CRT

A 60 year old female presents to your OPD with complaints of pain in left lumbar region since 6 months and supra pubic pain .

 A 60 year old female presents to your OPD with complaints of pain in left lumbar region since 6 months and supra pubic pain .

She also gets burning of micturition from time to time.

Her BP is 140/90 mm Hg.

Temp : 37.2 C

No remarkable findings in Respiratory, Gastrointestinal , Cardiovascular and Nervous Systems.

1 .Which investigations would you like to perform?

2. What are the findings in Ultrasound ?

3. How will you treat this patient

Answers given in comments section.

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1 . Which investigations would you like to perform?

As this patient has problems with likely origins in urinary tract including pain in left lumbar region which is most likely originating from left kidney and supra pubic area which could be urinary bladder pathology,

An ultrasound of abdomen would be of good value to see any pathology in kidneys , ureter or bladder.

An x ray kub can show a bladder stone or a large kidney stone but will not be able to exclude any other kidney of bladder pathology which can only be visualized by an ultrasound.

Other investigations would be haematological such as Full blood count, Sugar levels and urea to see any presence of acute bacterial infection or find out any underlying cause of recurrent UTIS such as Diabetes Mellitus.

Urea is needed to see if any long term kidney damage has been done due to recurrent UTIs.

2. What are the findings in Ultrasound ?

Ultrasound showed small left kidney with scarring , with irregular outline and impared cortico medullary Differentiation likely due to chronic pyelonephritis secondary to recurrent UTIs leading to chronic kidney damage.

Also urinary bladder wall is thick suggestive of cystitis .

3. How will you treat this patient

This patient has got active cystitis and UTI and will require antibiotics for treatment.

Also for the left kidney we need to take opinion from urologist whether it would be of benefit to remove left kidney after determining the patients renal status and determining how much percentage of left kidney is functioning as well as determining Glomerular Filtration Rate and Creatinine clearance.

First line antibiotics:

Fosfomycin (Monurol) 3-g single dose

Nitrofurantoin (macrocrystals) 100 mg twice per day for five days

Trimethoprim/sulfamethoxazole (Bactrim, Septra) 160/800 mg twice per day for three days.

Second line antibiotics :

Ciprofloxacin (Cipro) : 250 mg twice per day for three days

Ciprofloxacin, extended release (Cipro XR) 500 mg per day for three days

Levofloxacin (Levaquin) 250 mg per day for three days

Ofloxacin 200 mg per day for three days or 400-mg single dose.

Third line antibiotics :

Amoxicillin/clavulanate (Augmentin) 500/125 mg twice per day for seven days

Cefdinir (Omnicef) 300 mg twice per day for 10 days.

Cefpodoxime 100 mg twice per day for seven days.