Hot cases in Acute Medicine

Faculty of Physician Associates Conference

Shuaib Quraishi

ST6 Acute Medicine and RCP Education FellowMRCP (UK ) (Acute Medicine) BMedSci FHEA DGM

@SaqDr

Case 1 – Mr X

PC

– 17 M, presented to GP after a collapse and seizure

– Witnessed seizure. Initially absence tonic clonic 30 sec. No tongue biting. No incontinence

– Was body building at the gym for the first time 3 days prior.

Mr XPMH

– epilepsy – 2010, stopped antiepileptics 2 years agoDH

– Nil. No recreational drugs

FH

– Mother Caucasian, father Chinese. Lives in Luxemburg– Uncle died at 40 (unsure of cause)

Investigations

WCC 11.5 Hb 15.7Trop 4CRP 7

Normal U/EALT 293ALP 94

Bil 7CK 46000

Investigations

Thoughts

?

Differential Diagnosis

• Epilepsy

• Rhabdomyolysis

• Cardiac syncope

Subsequently

• ECHO: no structural abnormality

• Admitted to CCU for Monitoring

• For Ajmaline testing and consideration of ICD (for suspected Brugada syndrome)

Brugada Syndrome

• Autosomal dominant

• 8-10 times more common in men than women

• Mean age of sudden death (41 years)

• Most common in people from Asia

Brugada Syndrome

Case 2 – Miss P34 year old

PC– Tiredness– Weight loss– Depression– Unable to concentrate

Case 2 – Miss PHPC

– 12 month history

– Feels unsteady and dizzy in the mornings

– Has had two antidepressants with no effect

DH - Nil

SH - Non Smoker/No ETOH, off sick from work for 3 months

Examination and Investigations

• Looks worried

• BP 90/60

• Tanned

• Na 130

• K 6.5

• Synacthen test positive- Inadequate rise in

cortisol

• ACTH raised

Treatment

• Replace steroids

• Hydrocortisone and fludrocortisone

• Steroid warning cards, bracelets

• If unwell advise to double steroids

• Check TFT, autoimmune screen

Case 3 – Mrs T77 year old

PC– Breathlessness

HPC– 12 month history– Worse over the past 2 weeks. Now limited to steps and

housebound.– Was very active and normally fit and well

DH - Amlodipine

SH - Non Smoker/No ETOH/Japanese. No recent travel

Mrs T

• A: Intact

• B: RR 30 Sats 88% on room air Decreased AE bases

• C: Cool peripheries, Quiet heart sounds HR 120 BP 120/80 JVP elevated

• D: GCS 15/15 oC 37.5

• E: Abdomen SNT, Calves soft

What Investigations would you like to do?

Investigations• ABG on 15L

• pH 7.13, pC02 4.1, p02 10.1, Na 109, K 5.3, glc 8.3, lactate 8.8, BE -17, HC03 10.9

• Haematology• Hb 126, plt 291, neut 12.2, INR 1.8

• Biochemistry• Na 110, K5.3, Ur 12.2, Crt 132, eGFR 34, Ca 2.24, phos 2.31, albumin 43,

Normal LFT, CRP 71, WCC 14.9, Troponin 66 (normal <14)

Investigations

Thoughts

Clinical courseImpression

• CCF

• Pneumonia

• Pleural effusions

Not responding to antibiotics, fluids and diuretics

What would you do?

Ultrasound

Ultrasound

Diagnosis

Cardiac tamponade with right ventricular collapse

Required emergency admission and urgent pericardial drain

CARDIAC TAMPONADE

PERICARDIOCENTESIS

Diagnosis

• Lung Adenocarcinoma (eGFR positive)

•Pleural and Pericardial Effusion

•RV Collapse and Cardiac Tamponade

• Discharged home with outpatient oncology and chemotherapy

Case 4 – Mr W45 year old Sri Lankan malePC

– Headache, Muscle Pain and Fever (40 oC)

HPC– One week history – worse over past 3 days– Retroorbital headache– Developing rash

DH - ParacetamolSH - Non Smoker/No ETOH/. Returned to UK from Colombo 4 days ago.

Rash

What Investigations would you like to do?

Investigations

Treatment

Supportive (fluids)

No specific treatment

Dengue shock syndrome – Need ICU support

Avoid NSAIDS risk of bleeding in DSS

Vaccine is partially effective

Dengue fever• 80% asymptomatic

• Transmitted by the aedes mosquito

• Incubation period 3-14 days

• DSS occurs in 5% of children

• Supportive treatment

• Prevention

Case 5 – Mr W66 year old Indian male, BMI 32

PC– Chest Pain

HPC– Sudden onset chest pain – started one hour ago– 10/10 severity– Associated SOB– Radiating to neck and jaw– Retrosternal radiating to shoulder blade

Case 5 – Mr W

PMH

– NIDDM

– HTN

DH - Metformin

SH - Smoker 40/day, ETOH 30 Units/week

Thoughts

ECG

Investigations

•ECG

•Bloods – Cardiac enzymes (Troponin – 12000)

•ECHO (Inferior RWMA)

ECHO

Management

• Cardiology for reperfusion (within 2 hours of symptoms)

• Thrombolyse if no PCI available

• Secondary prevention (BB/DAPT/ACEI if poor LV function)

Case 6 – Mr S

47 year old manWorsening cough for 8 weeks

• Cough is mainly nocturnal• Barely sleeping• Dry – no sputum• No chest pain• No breathlessness

• Previously saw GP who prescribed a salbutamol inhaler in case diagnosis was asthma

• Using several times a day with no effect

Case 6PMH

– Type 2 diabetes

– Hypertension

– No previous respiratory diagnosis

DH– Amlodipine

– Metformin

Case 6

SH– Smokes 3 cigarettes/day

– Drinks 50 units/week

– Occasionally smokes shisha

FH– Nil significant

Thoughts?

Case 6Examination

– Overweight – 110kg (BMI 32)

– Not breathless at rest

– Normal temperature

– CVS

• BP 164/91

• HR 98 regular

• Heart sounds normal

Case 6– Respiratory

• Chest clear

• RR 20

• Saturations 96% on air

– Gastro

• Abdomen soft and non tender

• No masses

• Normal bowel sounds

Case 6

– Na 141

– K 3.7

– Urea 5.9

– Creat 101

– CRP 1

– ESR 7

• Bloods results– Hb 142

– MCV 86

– Hct 0.42

– WCC 9.3

– Neutro 7.5

– Hb 142

– MCV 86

– Hct 0.42

– WCC 9.3

– Neutro 7.57.5

What next?

Case 6• PEFR chart

– No variability or reversibilty

– Peak flow rate = 440 l/m

• Lung function testing

– FEV1 = 3.1 (predicted = 3.9)

– FVC = 3.9 (predicted = 4.4)

– FEV1/FVC = 79%

Case 6• Patient started on 30mg lansoprazole morning and night

• Asked to sleep at 45% angle

CURED

• Gastro-oesophageal reflux disease is one of commonest causes of chronic cough

Questions