Case History : A 63 year old female presents to your OPD with complaints of Dizziness, palpitations a

 A 63 year old female presents to your OPD with complaints of Dizziness, palpitations and apprehension. She also complaints of difficulty in breathing , a dry cough and retro sternal discomfort.

Her pulse is 130 beats/ minute and Blood pressure is 145/90 mmHg. Oxygen saturation is 92 percent .

Temperature is 37 C.

Chest is clear on auscultation.

On examination :

She has a goitre visible, mainly in the midline.

There is mild putting oedema of the feet.

An ECG is done, which is shown below:

1. What are the findings in the ECG?

2. What further investigations should be performed?

3. What is the most likely Diagnosis?

4. How should this patient be managed?

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Anonymized data with consent taken for teaching purpose.

Answers in comments section.

1. Findings in the ECG:

Irregular R-R interval.

Absent p waves.

Heart rate varying between 110-125 BPM.

2. Further investigation:

Thyroid function Tests

Ultrasound of Thyroid gland and Radio iodine uptake scan if Thyroid function Tests show Thyrotoxicosis.

Chest X rayFull blood countSugar and Cholesterol levelsPro BNP and Echocardiogram.

3. Most Likely Diagnosis

Atrial fibrillation.

Most likely Thyrotoxicosis

4 .Management

Since patients Blood pressure is stable, first line of management would be chemical cardioversion. Medication of choice include:

Bisoprolol 2.5 - 5 mg BD Other options include: Digoxin. and IV Metoprolol 5 mg .

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A 55 year old lady presents to you with back ache after a fall at home.

 A 55 year old lady presents to you with back ache after a fall at home.

X ray Lumbosacral spine is done that shows partial Sacral S1 fracture , however after seeking an opinion from Neurosurgical and orthopaedics team , they advise mobilize as per pain allows.

You note that on conducting a Full blood count, the results are normal and Electrolytes show her potassium levels are 5.7 mmol/l

Serum Sodium and chloride levels are normal.

Her inflammatory markers and Urea + Creatinine / Renal function tests are normal.

You decide to conduct protein electrophoresis and Urine for Bence Jones proteins / Myeloma screen , but that turns out to be negative as well.

You undertake an ECG that is shown below :

What should be next management step?

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What should be next management steps ?

This patient has hyperkalemia as can be seen in the blood test where her potassium level is 5.7 mmol/l. ECG also shows typical finding of hyperkalemia which include tall tented t waves.

In order to lower potassium levels , usual management consists of steps below :

Administer Calcium Chloride 10 ml of 10 % over 10 minutes slowly:

This stabilizes the myocardium and prevents against arrhythmias due to hyperkalemia

10 units of insulin Actrapid in 50 ml of 50 % dextrose over 30 minutes :

This will move excess potassium ions into the cells.

Salbutamol nebs 5 mls qds

These can also drive potassium into the cells and help in management of hyperkalemia.

After doing all of the above , you notice her potassium levels become normal , however after 2 days again they become 5.6 mmol/l.

You decide to review her medications and find out she is taking the prescription below :

She has Type 2 Diabetes Mellitus and is on Metformin 1000 mg twice a day for that.

Her BM levels are normal including her HBa1c.

She is taking the following treatment

Doxazosin once a day.

Omeprazole 20 mg once a day

Vit D / Adcal one tablet twice a day.

Paracetamol 1 Gm qds.

Tab Solifenacin 5 mg OD

Which further steps will you take :

The patient is taking 3 medications that can cause hyperkalemia :Metformin :

The patient has stable BM / Blood glucose levels , it might be a good idea to reduce the dose of Metformin to 500 mg once a day and keep monitoring blood glucose levels.

Omeprazole :

Omprazole can cause high potassium levels.

It might be a good idea to substitute Omeprazole with another anti gastritis medication that do not cause high potassium levels such as famotidine.

Doxazosin :

This patient is on Doxazosin which has been started to control her Blood pressure.

It can cause hyperkalemia and hence should be replaced by another medication such as Amlodipine that will not affect her serum potassium levels.

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Dr Gillani at 11:19

76 year old female presents to your OPD with 3 hours history of weakness of right hand, headache and problem with her vision.

  76 year old female presents to your OPD with 3 hours history of weakness of right hand, headache and problem with her vision.

She also complains of lightheadedness, numbness and tingling on right arm and leg , and difficulty with her speech.

You take her BP which is found to be high at 160/89 mmHg.

She is also having a severe headache that has not responded to analgesics.

You suspect the patient could be having stroke in evolution and decide to order a CT scan of head and ECG and send bloods for further investigations.

Her CT scan is given below:

What are the findings in the CT scan.

Why do you want to conduct/ organize and ECG?

Which bloods should you send?

What is the most likely Diagnosis?

How would you manage this patient?

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Answers given in comments section.

1. What are the findings in the CT scan. 

The CT of the head is showing a left occipital infarct. Infarct are visible as dark opacities on CT scan without contrast . 

This is a CT scan without contrast. CT images are conventionally viewed from below,as if looking up into the top of the head. 

This means the right side of the brain is on the left side of the viewer. So as you look at the axial CT images, your left is the patients right side. 

So the right side of the image depicts the left side of the patient. Hence in this case , the occipital appears to be on the right side of the viewer but actually its showing the left side of patient , so the Occipital infarct is on the left side of the patients brain.

2. Why do you want to conduct/ organize and ECG? 

We need to mak sure the patient is not having a disturbed / irregular rhythm / atrial fibrillation as it can lead to development of cardiac thrombi and lead to stroke / cerebral infarcts.

3. Which bloods should you send? 

It is vital to determine underlying cause of stroke , most common on which include cardiac causes, diabetes mellitus, 

Hyoercholesterolemia and hypertension. 

Bloods should be sent for Full blood count , CRP ( to determine underlying sepsis ) sugar levels , Lipid profile, urea, creatinine, and clotting profile , INR < PT , APTT , Proteic C and S levels , Factor V leiden mutations to exclude pro thrombotic diseases and lups antic coagulant. Other investigations.

4. What is the most likely Diagnosis? 

Most likely diagnosis is acute occipital infarct / CVA

5. How would you manage this patient? 

Since it has been less than 4.5 hours and patient is developing an acute infarct , she should be managed by thrombolysis once exclusions of haemorrhage on neuro imaging has been done. 

The drug of choice is Alteplase : 

ALTEPLASE DOSING FOR ACUTE ISCHAEMIC STROKE

 0.9mg / kg body weight to maximum of 90mg

 10% total dose should be given as initial iv bolus

 remainder (90%) should be infused iv over 60 mins in 0.9% sodium

chloride (or can be given neat via a syringe pump).