MEDICINE : Spotters

Posted On December 22, 2024

Irregular R-R interval,
Atrial fibrillation at a controlled ventricular rate 80/min
absence of p waves, replaced by fibrillary waves,
ST depression and T inversion at v5,6
s at v1+ R in v6=42
Dx= LVH with strain pattern, most likely systemic hypertension

Q. Mention 2 clinical findings

AF- absence of ‘a’ waves in JVP
LVH- apex shifted out and down, well sustained heave

Q. Modalities of t/t:

Long term anticoagulant therapy
Anti-hypertensives

Q. Complications:

Immediate- ventricular hypertrophy and Af- left sided heart failure

Long term- thromboembolism

Bizarre and Wide QRS, tachycardia rate 240/min,
concordant QRS complexes in v1-v6,
Evidence of atrial activity in between with a fusion beat
Dx=ventricular tachycardia

Q. Mention two factors that cause this?

Ischemic heart disease

Cardiomyopathy

Electrolyte abnormalities (hypokalemia, hypomagnesemia)

Q. Two modalities of t/t

Immediate: DC shock 100-200J

Drugs: Amiodarone, Lidocaine

Q. Complications:

Sudden death

Cardiogenic shock

Independent P and QRS complexes having no relationship,
ventricular rate is 45/min
Dx= complete heart block

Q. 2 Clinical features

Cannon waves in JVP

Variable intensity of S1

Q. 2 modalities of t/t

Permanent pacemaker

Isoprenaline

ST elevation in lead II III AVF,
reciprocal changes in I and AVL
Abnormal Q wave in lead III (>20% of QRS complex)
Dx= inferior wall MI

Q. How to confirm the diagnosis

Cardiac biomarkers

Echo

Q. Complications:

Various degrees of heart block

Right ventricular infarction

Q. T/t

Percutaneous angioplasty

Thrombolysis therapy (if no contraindications)

ST elevation in lead II III AVF,
reciprocal changes in I and AVL
Abnormal Q wave in lead III (>20% of QRS complex)
Dx= inferior wall MI

Q. 2 modalities of T/t

Carotid sinus massage

Valsalva maneuver

Drugs: Adenosine

Q. Likely ECG findings in this patient if in sinus rhythm?

Accelerated conduction (WPW syndrome)

Narrow QRS complexes coming at a regular interval of 250/min,
absence of P waves
Dx= PSVT
additional findings- alternate QRS are tall and small-electrical alterans

Q. 2 modalities of T/t

Carotid sinus massage

Valsalva maneuver

Drugs: Adenosine

Q. Likely ECG findings in this patient if in sinus rhythm?

Accelerated conduction (WPW syndrome)

Regular RR interval at a rate of 105/min
Right axis deviation, incomplete bundle branch block
Tall and peaked p waves in II III AVF = P pulmonale,
QR waves in V1 and persistence of S waves in lateral chest leads (v5, v6)
Dx= right atrial and Right ventrical hypertrophy most likely cor pulmonale

Q. 2 Clinical findings

Aunscultation: Loud P2

Early Diastolic murmur (Graham Steel murmur)

Q. 2 likely causes

COPD

Infarct of pulmonary artery

Q. 2 T/t modalities

Long term O2 therapy
Phlebotomy

Regular RR interval at a rate of 90/min
Left ward axis
Broad & bifid P waves in lead 2,3 & AVF = p-mitrale
SV1 + RV6 = 50mm
ST depression in V5 & V6
Dx = LVH with strain

Q. 2 likely causes

Systemic HTN

Cardiomyopathy

Q. C/F

Apex beat shifted outwards and downwards

Well sustained heave

ST elevation in V1 – V4, max at V3
High take off of T waves .
Tall & broad T waves.
Hyperacute: No reciprocal changes, No Q waves
Dx = hyperacute anterior wall myocardial infarction

Q. How to confirm the diagnosis

Cardiac biomarkers

Echo

Q. Complications:

Early- V tach, V-fib, huge pulmonary edema

Late- Dressler’s syndrome, Aneurysm of heart

Q. T/t

Percutaneous angioplasty

Thrombolysis therapy (if no contraindications)

Triangular homogenous opacity in right middle zone, sharply demarcated below by horizontal fissure
Dx= Right upper lobe segmental consolidation

Q. 2 organisms

Pneumococcus, Staphylococcus

Strep.pneumoniae, H. influenza, Klebsiella, Chlamydia, Mycoplasma,

Q. 2 Complications

Parapneumonic effusions

DIC

Low – 11 posterior ribs seen & flat diaphragm
Ribs are wide & horizontal
Tubular & elongated heart
Giant bullae seen in right lower & left middle zone with compression of lungs
Dx= emphysema with giant bullae

Q. 2 Likely clinical findings

Pursed lip breathing

Hyper-inflated lungs on percussion

Q. T/T

Bullectomy

Incentive spirometer

Non homogenous opacity in left upper zone with fibrous bands
Thin walled cavity/ abscess , no air-fluid levels
Dx= post primary pulmonary TB with fibro cavitary lesions.

Q. Most likely complication

Aspergilloma

Q. T/T

Surgical removal/drainage

Q. Etiology of upper lobe abscess

Klebsiella

Cardiomegaly
Straightening of left border of heart with enlarged left atrial appendage
Shadow behind shadow seen on right side of heart
Dilated upper lobe pulmonary veins both lung fields
Dx= MITRAL STENOSIS

Q. Mention 2 C/F

Mid-diastolic murmur…presystolic accentutation…(describe murmur)
Opening snap
Tapping apex beat

Q. Complications

Pulmonary hypertension

IHD

Q. 2 modalities of T/T

Mitral valvulotomy

Valve replacement

Digitalis

Complete loss of lung markings in the outer 2/3 of right lung fields
Collapsed lungs seen on right side
Mediastinum shifted to left side
Dx = right sided tension pneumothorax

Q. 2 modalities of T/T

Needle aspiration at right second intercostal space in MCL
Closure of the bronchopleural fistula

Q. 2 Etiology

Trauma

Emphysema

Q. 2 C/F

Collapsed lung- Low Bp

Central cyanosis

Hyper resonant lung with absent breath sounds

Cardiomegaly
Straightening of left border of heart with enlargement of main pulmonary artery trunk
Enlargement of right pulmonary artery
Peripheral pruning of pulmonary artery
No prominent pulmonary veins on upper lobe
No double shadow on right heart border
Dx = Pulmonary arterial hypertension with right ventricular hypertrophy

Q. 2 symptoms which she can develop later

Hoarseness of voice

Dysphagia

Hemoptysis

Dense homogenous opacity in right lower zone
Opacity goes extends in a straight line towards axilla
Mediastinum shifted to right
Right hemithorax smaller with crowding of ribs
Evidence of loss of lung markings (translucency) on left lower zone
Evidence of hyperinflation of lung on left lung- wide and horizontal ribs
Dx = right sided pleural effusion with decreased lung volume on right side and compensatory emphysema on left side

right sided pleural effusion with decreased lung volume on right side and compensatory emphysema on left side

Oxygen catheter
Indications:
Documented hypoxemia as evidenced by:

PaO2 < 60 mmHg or SaO2 <90% on room air
PaO2 or SaO2 below desirable range for a specific clinical situation

Acute care situations in which hypoxemia is suspected (dyspnea, tachypnea, bradypnea, pallor, cyanosis, lethargy, use of accessory muscles of respiration
Severe trauma
Acute MI
Pulmonary HTN
Short term: Post anesthetic recovery

Contraindications:

Patient not giving consent
Nasal obstruction
Complications:

Oxygen toxicity
Oxidative stress
Absoprtion atelectasis
combustion

Cuffed endotracheal tube
Indications:

Protection of airways
Removal of respiratory secretions
Drug and anesthesia administration
Cardiopulmonary resuscitation
To prevent aspiration in unconscious/ comatose patients
Connected to AMBU bag for mechanical ventilation

Contraindications:

Severe airway obstructions
Laryngeal edema
Cervical spine injuries

Advantages:

Prevent aspiration
Better fixation
Less chance of accidental expulsion
For +ve pressure ventilation
Disadvantages:
Provide persistent necrosis
Complications:

Airway obstruction
Stricture formation
Pressure necrosis
If it goes inside: collapse of other site
Infections
Pneumothorax

Naso gastric tube
Indication:

Diagnostic:

Upper GI bleeding
Upper GI obstruction

Therapeutic:

Feeding in unconscious patient
Nasogastric suction in intestinal obstruction
GI bleeding
Acute abdomen
Post operative
Medication in comatose
GI wash or lavage in pyloric stenosis
Non-corrosive poisoning, drug overdose

Contraindications:

Corrosive poisoning
Kerosene oil poisoning

Complications:

Rhinitis, pharyngitis, ulcerations in esophagus
Aspiration pneumonia/death if tube enters trachea
Blockage of tube
Perforation of esophagus
Chance of respiratory tract infections on prolonged intubation

Bone marrow biopsy needles
Most common site: posterior superior iliac spine
Indications:

Assess marrow cellularity accurately
To diagnose: aplastic anemia, hypoplastic leukemia, hypoplastic myelodysplatic syndrome
Lymphoproliferatice disorders
Myelorpoliferative disorders
Diagnosis and staging of:

Non Hodjkin’s lymphoma
Hodjkin’s lymphoma
Malignancy
Metastatic carcinoma

Stromal changes: fibrosis, necrosis
Pyrexia of unknown origin
Amyloidosis
Metabolic bone diseases
Contraindications:
Bleeding disorders
Complications:

Hemorrhage
Pain
Infection
Perforation of major vessels

Bone marrow aspiration needle .
Q. Most common Site

Sternum

Indications:

Diagnostic:

Hematological malignancy
ITP
Aplastic anemia
Leukemia
Megaloblastic anemia
Infections: Kala Azar

Therapeutic:

Bone Marrow Transplantation
Contraindications

Infection at site
Bleeding disorders
Bone Disorders: osteomyelitis, osteogenesis imperfecta

Biopsy needle (Trucut)
Contraindications:
- Bleeding disorders
- Overlying skin or peritoneal infections
- Suspected hemangioma of liver
Indications:
- Suspicious lesions/lump in breast
- Liver biopsy:
Complications:
- Injury to blood vessels, bile ducts causing hemorrhage, intrahepatic hematoma, hemophilia, bile pigments

Lumbar Puncture needle / spinal needle
Level: L2-L3
Indications:

Diagnosis of CNS infections
Spinal anesthesia
Diagnosis of Guillain-Barré syndrome
Diagnosis of aplastic anemia
For intrasosseous infusion

Contraindications:

Raised intracranial tension
Infection at site
Spinal deformity
Bleeding disorders
Subarachnoid hemorrhage

Nebulizer
Indications:
Delivery of bronchodilator drugs – in:

Acute asthma
Bronchospasm
Chest tightness
Pneumonia
Atelactasis

To aid in expectoration- inhalation of hypertonic saline
Administration of antibiotics and antifungal agents in some resistant chest infections – Cystic fibrosis
To aid in expectoration- inhalation of hypertonic saline
Local analgesia- to relieve dyspnea