a 40-year-old African-Caribbean man with chest pain

lukas presented in interesting (?!) case of a man with a short history of chest pain going through to his back

we discussed likely culprits in this age group

we came up with:

- IHD
- aortic dissection
- PE (large & sma
- GORD
- musculo-skeletal

the full list is longer [how many does the C&O list?]

we said this is a common presenting complaint - so it should be known intimately
_ _ _

this gentleman was actually pretty fit with not much atherosclerotic risk

it would have been good to get a better description of the pain from him

& also to know whether he has any illicit (cocaine) drug use [why?]
_ _ _

there was not much to the history

we thought about questions to be answered on examination

we considered:

- does he have signs of aortic dissection?
- is he in heart failure?
- does he have evidence of high cholesterol or diabetes?
- might he have a DVT?

we would like to take the blood pressure in both arms
_ _ _

the diagnostic probabilities had not shifted too much, although PE was less likely

we thought about tests that might help, both in casualty & on monday morning

the ECG is key [we mentioned dissection causing inferior MI]

a CXR might help, although a normal CXR does not rule out dissection

a CT aortogram or trans-oesphageal echo would be needed

Dr Donna D'Souza: radpod.org

we also considered blood tests (FBC - to look for anaemia, creatinine - to check out his kidneys before we give him nephrotoxic contrast, TFTs as hyperthtyroidism might trigger ischaemia)
_ _ _

it turns out that his initial ECGs showed complete heart block with a rate of 30

this was treated with atropine (back to sinus??)

he had a wenkebach-type of heart block



[this is a second degree block - because some p waves are not conducted]

[wenkebach is type 1 second degree, also called Mobitz 1]

[wenkebach is not usually dangerous, compared to second degree type 2 (Mobitz II) which is]

he had a normal echo (apparently) & was discharged with a view to a 24-hour tape & cardiology follow up
_ _ _

we very briefly thought about why a 40-year-old man might have complete heart block (IHD or ...)
_ _ _

things to learn:

- the assessment of people with chest pain
- stuff about aortic dissection
- stuff about complete heart block (CHB)
- echo features of imminent cardiac tamponade
- CT anatomy of the thorax


Salaam


sabih

a 45-year-old man with vomiting and light-headedness

last week charlie presented the case of a man with a short history of vomiting what he thought was blood

(he also had left-sided upper abdominal pain - we very briefly thought about what might cause this but the main focus of our enquiry was GI bleeding)
_ _ _
we discussed the important issue of not assuming this is a GI bleed

1) it could be from the mouth or possibly respiratory tract
2) be sceptical about the fluid being blood: either see it yourself (having seen it before) or only believe someone you trust (eg experienced nurse) [the story of the lady with the femoral hernia]
_ _ _

we then talked about 1) assessing severity & 2) possible diagnoses
_ _ _

1) severity

questions about the vomit, eg volume, frequency
questions representing volume depletion and /or anaemia, eg dizziness on standing, syncope

2) the potential diagnoses:

- ulcer disease
- drug-induced erosions
- liver disease (abnormal clotting/varices)
- cancer
- Mallory-Weiss tears

we briefly explored the questions that might let us differentiate between these conditions
_ _ _

we then went to the bedside & wondered what broad questions clinical examination should try to answer

- is this patient hypovolaemic?
- does this patient have chronic liver disease?
- does this patient have cancer?

we did not manage to examine the patient
_ _ _

we discussed then discussed the key investigations, emphasing the need for a group & save/cross-match sample, and the requirement to fill a blue-top (citrate) bottle to the brim

we also mentioned that the Hb concentration might not be reliable initially
_ _ _

it turned out that the patient had an urgent OGD which showed oesophageal varices

he was also given a large volumes of intravenous colloid & crystalloid & he subsequently went into pulmonary oedema, for which a small dose of diuretic was required
_ _ _

it would be ideal if we can follow him up & see how his varices are managed in the long-term


Salaam


sabih

on call @ UCLH

having been on call on monday night i thought i would share with you what went on

2100-0900 we had:

- a 46-year-old lady with a large pneumothorax (which needed an emergency drain) and 'crack lung'
- a 70-something malaysian lady with HONK & a Na of 178
- a 20-something lady with a fever & headache who we LP'd
- a 40-something lady from ghana with a fever and an ALT >3,000 (bilirubin around 200)
- an 80-something man with an INR of 4 & PR bleeding
- a 70-something man with metal mitral & aortic valves with worsening heart failure
- 2 men needing urinary catheters
- a 30-something lady 34 weeks pregnant ?PE

+ lots of other stuff

we had 2 hardy students (sheena & andy) stay beyond 0300 (but actually that was before a lot of the interesting stuff!)
_ _ _

the reason i put this up is:

1) to demonstrate that clinical problems like these are our stock in trade
2) to encourage you to be on call at night (all night if possible)
 - the hospital is different at night, there are fewer people around & if you make friends there is a lot going on
_ _ _

i will put up the radiographs of the pneumothorax lady up next week


Salaam


sabih

a 20-year-old man with dizziness on standing

ben a presented a very interesting case of a young man in the UK for a course in political science as part of an Erasmus programme who presented to casualty with marked lightheadedness on standing of 1 days duration

we discussed (again) the issue of pinning down what a patient means by dizziness

here our patient was fine lying flat but became lightheaded with altered vision on standing

there was also associated nausea & abdominal pain

he was able to move into his flat (with the attendant box lugging) on the saturday

any ideas as to diagnosis?
_ _ _

there seems to be a clear story of postural symptoms, most likely secondary to hypovolaemia

[causes orthostatic hypotension?: diabetes, drugs, parkinsons, autonomic dysfunction, addisons]

we briefly talked about blood loss

(1 pint is actually a US pint or 473mL, not the UK (imperial) pint of 568mL)

catastrophic blood loss might occur into the gut, lungs, abdomen, pelvis

lethal bleeding (without exsanguinating) into the pericardium or brain
_ _ _

we mentioned the surface markings of the pleura but did not finish the conversation

see here for more
_ _ _

we then went to chat to our patient who has addisons disease

click here for thomas addison's own pictures (he was a physician at guys)

[NB why do people with addisons exhibit hyperpigmentation?]

JFK had addisons

our patient was first diagnosed in the US 2 months ago

he takes 20mg of hydrocortisone daily as his normal regimen (which he tripled over the weekend)
_ _ _

on examination he had no hyperpigmentation in the buccal mucosa or palmar creases

he had a 15mmHg systolic drop on admission (?now)

his abdomen was soft & non-tender with no masses or organomegaly
_ _ _

on arrival he had a Na of 120mmol/L with a K of 6.8

his ECG showed peaked T waves

he was given calcium gluconate & insulin/dextrose
_ _ _

we briefly mentioned causes of addisons disease:

autoimmune, infection (incl TB), hameorrhage, cancer, congential adrenal hyperplasia, pituitary problems

investigations:

importantly electrolytes, septic screen
_ _ _

things to read about:

1) addisons
2) emergency treatment of hyperK
3) hydrocortisone


Salaam


s