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