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For discussion with final year medical students (March to July 2015)
What is the heart disease?
A patient was discharged with the diagnosis of: Fast AF with congestive cardiac failure.
When I reviewed the patient, I noted:
a. The patient had evidence of AF in the ECG.
b. The Echocardiogram showed mitral stenosis, tricuspid regurgitation and left atrial enlargement.
A 71 year old man presented for his routine appointment in the clinic. He has diabetes and hypertension. His blood urea was 27.4mmol/L; serum creatinine was 633umol/L; serum Na and K were 136mmol/l and 3.6mmol/L respectively. Does he require admission for urgent dialysis?
- A 67 year old man presented with fever, weakness of lower limbs, swelling of the right knee joint and a very high plasma glucose value. He was not known to have any medical illness in the past.
- He was noted to have proximal muscle weakness of both lower limbs and was unable to stand up from a sitting position without assistance. The right knee joint was swollen but patient was able to flex and extend the knee fully without pain.
- He was started on Cefuroxime and insulin along with supportive care.
- 4 days later there was increasing strength in his legs. He was now able to stand and walk independently. The swelling of the right knee was still present and fever persisted. An orthopaedic consult considered the swelling in the right knee to be due to osteoarthritis and not septic arthritis.
- Urine culture and blood culture reports were obtained on the 4th day after admission. Staph aureus was present in both blood and urine. The sensitivity of the organism to various antibiotics was given. Cloxacillin was not in that list.
- He was started on Cloxacillin.
- 8 days later fever still persisted and was spiking. The right knee remained swollen but movements were free and painless. The patient refused aspiration of synovial fluid from the right knee joint saying that the knee was not troubling him.
What do you think is the likely cause of the fever in this patient?
A. Staph aureus septicaemia from an unidentified source
B. Staph aureus septicaemia from urinary infection
C. Septic arthritis
D. Pyrexia of unknown origin
What do you think is the best way to treat this patient at this point of time (8 days after admission)?
A. Increase the dose of Cloxacillin
B. Stop the Cloxacillin and choose a culture-specific antibiotic
C. Continue the Cloxacillin and add a culture specific antibiotic
D. Choose a very potent antibiotic (example: Ceftriaxone, Ceftazidime, Imipenem, Meropenem) irrespective of the culture and sensitivity reports.
An 80 year old thin and frail woman presented with chest discomfort and giddiness. Her pulse is 40 per minute and regular in rhythm. All peripheral pulses are palpable. Her blood pressure is 110/78mm Hg in the supine position. She is not pale or jaundiced. Her body temperature is normal. Her peripheries are warm. The lungs are clear on auscultation. A notable finding on physical examination is an audible ejection systolic murmur over the upper sternal border on both left and right sides.
What will you do next?
a. Check her standing blood pressure
b. Order an Echocardiogram
c. Order an ECG
d. Start an intravenous infusion of saline
e. Get information about the medication that she is taking.
Subsequently you find out that she is not on any medication at all and she does not have any postural hypotension. Her ECG does not show any evidence of ischemia or infarction and there is no dilatation or hypertrophy (based on voltage criteria) of any of the cardiac chambers. The rhythm seen in the ECG is shown in Lead 2 below.
What do you think is the rhythm?
a. Sinus bradycardia
b. Escape junctional rhythm
c. Complete heart block with an escape ventricular rhythm
d. A-V dissociation with an idioventricular rhythm
Her x-ray chest is normal. She undergoes an echocardiogram. What do you think the echocardiogram will show?
a. Mitral valve prolapse
b. Pulmonary stenosis
c. Calcification of aortic valve
d. Dilatation of pulmonary artery
e. Dilatation of ascending aorta
Dr Velayudhan Menon, MD
Clinical Associate Professor of Medicine
International Medical University, Malaysia