An 11 year old boy is brought to your OPD by his father with history of recurrent seizures

 An 11 year old boy is brought to your OPD by his father.

According to him , his son gets episodes of seizures when he becomes unresponsive and is characterized by jerking movements of his right hand and legs and they may last up to 3 – 4 minutes and he becomes confused after the seizures resolve.

He gets urinary incontinence with these fits as well and tends to bite his tongue and he has to put his wallet between his teeth to prevent this.

1 . What investigations will you like to perform?

2 . What is the investigation shown in the Figure and what are its findings ?

3. What is the most likely diagnosis ?

4. What are the causes of this disease ?

5 . How will you manage this patient ?

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Answers given in comments section.

1 . What investigations will you like to perform? 

Investigations

Full blood count

Check fever

Neurological examination including cranial nerves , visual fields eye movements and power in upper and lower limbs

Temperature Record

Exclude meningitis, check neck stiffness , Any history of photophobia

Monitoring of Sugar levels

Analysis of Serum Electrolytes : Sodium , Potassium , Calcium and Magnesium levels

Septic screen , exclude chest infection , urinary tract infections

Any history of head injury.

CT Brain and MRI brain if needed to exclude inracranial space occupying lesions.

EEG / Electroencephalogram

2 . What is the investigation shown in the Figure and what are its findings ? 

his is a picture of MRI brain which is normal.

3. What is the most likely diagnosis ? 

Grand Mal Epilepsy / Tonic clonic seizures. 

A grand mal seizure ,also known as a generalized tonic-clonic seizure — is caused by abnormal electrical activity throughout the brain. Usually, a grand mal seizure is caused by epilepsy. But sometimes, this type of seizure can be triggered by other health problems, such as extremely low blood sugar, a high fever or a stroke.

Many people who have a grand mal seizure never have another one and don't need treatment. But someone who has recurrent seizures may need treatment with daily anti-seizure medications to control and prevent future grand mal seizures. Grand mal seizures have two stages:

Tonic phase. Loss of consciousness occurs, and the muscles suddenly contract and cause the person to fall down. This phase tends to last about 10 to 20 seconds.

Clonic phase. The muscles go into rhythmic contractions, alternately flexing and relaxing. Convulsions usually last one to two minutes or less.

4. What are the causes of this disease ? 

Causes

Grand mal seizures occur when the electrical activity over the whole surface of the brain becomes abnormally synchronized. The brain's nerve cells normally communicate with each other by sending electrical and chemical signals across the synapses that connect the cells.

In people who have seizures, the brain's usual electrical activity is altered and many nerve cells fire at the same time. Exactly what causes the changes to occur often remains unknown.

However, grand mal seizures are sometimes caused by underlying health problems, such as:

Injury or infection

Traumatic head injuries

Infections, such as encephalitis or meningitis, or a history of such infections

Injury due to a previous lack of oxygen

Stroke

Congenital or developmental abnormalities

Blood vessel malformations in the brain

Genetic syndromes

Brain tumors

Metabolic disturbances

Very low blood levels of glucose, sodium, calcium or magnesium

Withdrawal syndromes

Using or withdrawing from drugs, including alcohol.

5 . How will you manage this patient ?

Medications

Many medications are used in the treatment of epilepsy and seizures, including:

Carbamazepine .

Phenytoin .

Valproic acid.

Oxcarbazepine.

Lamotrigine .

Gabapentin .

Topiramate (.

Phenobarbital

Zonisamide .

Finding the right medication and dosage can be challenging. Usually , first, a single drug at a relatively low dosage is sytarted, and then increase the dosage gradually until patients seizures are well-controlled.

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 A 45 year old man presents to your OPD with 1 month history of difficulty in breathing and cough.

On history taking you find out he had a pneumonia 2 months ago in his left lung which required intravenous antibiotics and hospital admission for 1 week.

There is no history of smoking and no blood in sputum.

On examination , he appears weak and distressed.

His Temperature is 37 C and respiratory rate is 22 / minute.

BP is 130 / 80 mmHg.

There is reduced chest expansion on left side.

On auscultation , air entry on left side of lung is reduced and a wheeze in expiration is audible.

Percussion reveals dull percussion notes.

Oxygen saturation is 90 percent.

You decide to organize a chest X ray which is given below :

1. What is the most likely Diagnosis ?

2. How will you mange this patient ?

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Answers given in comments section.

1. What is the most likely Diagnosis ?

The chest x ray shows collapse of left lung . And there is a history of recent pneumonia as well.

This is highly suggestive of left sided atelectasis secondary to pneumonia or even a para pneumonic lung effusion.

An ultrasound of chest will better help determine the cause of lung collapse / atelectasis.

Atelectasis is a complete or partial collapse of the entire lung or area (lobe) of the lung.

It occurs when the tiny air sacs (alveoli) within the lung become deflated or possibly filled with alveolar fluid.

Atelectasis may be caused by many things, including: mucus plug,foreign body,tumor inside the airway, injury,chest trauma, pleural effusion, pneumonia ,pneumothorax, and scarring of lung tissue.

2. How will you mange this patient ?

Treatment of atelectasis depends on the cause.

Mild atelectasis may go away without treatment.

Sometimes, medications are used to loosen and thin mucus.

If the condition is due to a blockage, surgery or other treatments may be needed.

Chest physiotherapy:

Techniques that help the patient breathe deeply to re-expand collapsed lung tissue are very important.

They include:

Performing deep-breathing exercises (incentive spirometry) and using a device to assist with deep coughing may help remove secretions and increase lung volume.

Positioning the body so that your head is lower than the chest (postural drainage). This allows mucus to drain better from the bottom of the lungs.

Tapping on your chest over the collapsed area to loosen mucus. This technique is called percussion. Also, mechanical mucus-clearance devices, such as an air-pulse vibrator vest or a hand-held instrument may be used.

Surgery

Removal of airway obstructions may be done by suctioning mucus or by bronchoscopy.

If a tumor is causing the atelectasis, treatment may involve removal or shrinkage of the tumor with surgery, with or without other cancer therapies (chemotherapy or radiation).

Continuous positive airway pressure (CPAP) may be helpful in some people who are too weak to cough and have low oxygen levels (hypoxemia).

A 52 year old woman comes to your OPD with complaints of dizziness on getting up.

 A 52 year old woman comes to your OPD with complaints of dizziness on getting up.

She has a past history of Myocardial infarction 7 years ago.

You decide to organize an ECG  which is given below :

1 . Comment on R wave from leads V1 - V 6.

There is poor progression of R wave from V1 - V6 .

Poor R wave progression refers to the absence of the normal increase in size of the R wave in the precordial leads when advancing from lead V1 to V6.

In lead V1, the R wave should be small. The R wave becomes larger throughout the precordial leads, to the point where the R wave is larger than the S wave in lead V4. The S wave then becomes quite small in lead V6.

2 . What are the causes of this phenomenon ?

The causes of Poor R Wave Progression are as follows:

Old anterior myocardial infarction

Lead misplacement (frequently in obese women)

Left bundle branch block or left anterior fascicular block

Left ventricular hypertrophy

Wolff-Parkinson-White syndrome

Dextrocardia

Tension pneumothorax with mediastinal shift

Congenital heart disease

A 45 year ol man presents to your ED clinic with complaints of left sided chest pain since 45 minutes.

 A 45 year ol man presents to your ED clinic with complaints of left sided chest pain since 45 minutes.

He is a known smoker and Diabetic as well.

He says it seems like a heavy stone on his chest.

You immediately order an ECG and send Tropinin T  levels as well. 

1. Comment on the ST segment in Leads V 1 , V2 and V3 :

There is ST segment elevation in Leads V1 , 2  and V 3.

2. What are the causes of ST segment Elevation :

Causes of ST Segment Elevation

Acute myocardial infarction.

Coronary vasospasm (Printzmetal's angina)

Pericarditis.

Benign early repolarization.

Left bundle branch block.

Left ventricular hypertrophy.

Ventricular aneurysm.

Brugada syndrome.

3. What is the most likely diagnosis in thes patients case ?

Acute Anterior STEMI / ST segment Elevation Myocardial Infarction.

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An 11 year old boy is brought to your clinic with occasional chest pains mainly left sided.

 An 11 year old boy is brought to your clinic with occasional chest pains mainly left sided.

You perform an ECG which is given below :

1 . Comment on R wave in this patient :

There is a tall R wave / Dominant R wave in V1.

2. What are the causes of Dominant R wave in V1?

Causes of Dominant R wave in V1

Normal in children and young adults

Right Ventricular Hypertrophy (RVH)

Pulmonary Embolus

Persistence of infantile pattern

Left to right shunt

Right Bundle Branch Block (RBBB)

Posterior Myocardial Infarction (ST elevation in Leads V7, V8, V9)

Wolff-Parkinson-White (WPW) Type A

Incorrect lead placement (e.g. V1 and V3 reversed)

Dextrocardia

Hypertrophic cardiomyopathy

Dystrophy

Myotonic dystrophy

Duchenne Muscular dystrophy

What is the Pathophysiology of this mechanism?

Pathophysiology

Tall R waves in V1 can be caused by abnormal electrical conduction (RBBB or left-sided VT, which slowly spreads across the right ventricle, or a left-sided accessory pathway), loss of posterior myocardium (old or acute posterior MI) or chronic anterior hypertrophy (HCM), chronic or acute RV strain (RVH, PE), congenital anomalies (dextrocardia or dystrophy), misplaced leads, or a normal variant (persisting juvenile pattern). This differential can be remembered by the mnemonic R-WAVED

RBBB (RsR’, QRS>120, wide S in V6, secondary repolarization abnormalities in anterior leads) or left-sided VT/ventricular ectopy

WPW left sided pathway: PR<120, QRS>110, delta wave, tall R in V1-2 with discordant ST/T wave changes.

Acute MI – posterior: tall R wave V1 or V2 and ST depression +/- inferior or lateral ST elevation +/- posterior ST elevation.

Ventricular hypertrophy: RVH (R/S >1 in V1 and <1 in V6, right axis deviation, secondary repolarization changes) or HCM.

Embolism: +/- sinus tach, RBBB, S1Q3T3, anterior/inferior TWI.

Dextrocardia (negative P wave, reversed R wave progression), dystrophy, or displaced leads (eg V1 and V3 switched)

You perform an ECG in a 45 year old woman that has presented to you with left sided chest pain.

 You perform an ECG in a 45 year old woman that has presented to you with left sided chest pain.

Her ECG Is given below :

1 . What are the findings in the ECG ?

There is a qR complex in lead V1.

There is "Appropriate discordance " which refers to abnormal depolarisation being followed by abnormal repolarisation, which appears discordant to the preceding QRS complex.

In RBBB, this manifests as ST depression and/or T-wave inversion in leads V1-3.

2 . What is the most likely diagnosis?

Right bundle branch block.

3 . What are the causes of this condition?

Causes of Right Bundle Branch Block :

Right ventricular hypertrophy / cor pulmonale

Pulmonary embolus

Ischaemic heart disease

Rheumatic heart disease

Congenital heart disease (e.g. atrial septal defect)

Myocarditis

Cardiomyopathy

Lenègre-Lev disease: primary degenerative disease (fibrosis) of the conducting system.

4. What is the pathiphysiology of this disease.

In normal cardiac conduction, impulses travel equally down the left and right bundles, with the septum activated from left to right and the formation of small Q waves in lateral leads

In RBBB, the left ventricle is activated normally, thus the early part of the QRS complex correlating to septal depolarisation is unchanged.

There is delayed activation of the right ventricle as depolarisation originates from the left ventricle across the septum. This produces a secondary R wave (R’) in the precordial leads, and a wide, slurred S wave in lateral leads.

Normal activation of the left ventricle means that cardiac axis remains normal in isolated RBBB

A 56 year old female with known history of hypertension presents to your clinic with fainting spells over the last 3 months.

 A 56 year old female with known history of hypertension presents to your clinic with fainting spells over the last 3 months.

Her Blood pressure is 150/100 mmHg.

She does not take her antihypertensive medications regularly.

You ask for an ECG which is given below :

1 . What are the findings in the ECG?

2 . What is the most likely diagnosis ?

3 . What are the causes of this condition?

Answers given in comments section.

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Anonymized data and permission taken from patient for teaching purposes.

1 . What are the finding in the ECG :

The QRS complex in V1 is of QS morphology with no preceding R wave

There is “Appropriate discordance” in lead V1 with ST elevation and upright T wave

Appropriate discordance refers to the fact that abnormal depolarisation should be followed by abnormal repolarisation, which appears discordant to the preceding QRS complex.

Lateral leads with tall, broad R waves will often have associated ST-segment depression and T-wave inversion, and those with deep S waves can have an allowable amount of ST elevation that does not indicate ischaemia (generally viewed as < 25% of the size of the preceding S wave).

2 . What is the most likely diagnosis ?

Left Bundle Branch block most likely due to hypertension in this patient.

3 . What are the causes of this condition?

It is unusual for LBBB to exist in the absence of organic disease. Causes are varied and include:

Aortic stenosis

Ischaemic heart disease

Hypertension

Dilated cardiomyopathy

Anterior MI

Lenègre-Lev disease: primary degenerative disease (fibrosis) of the conducting system

Hyperkalaemia

Digoxin toxicity

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