Report

Course 2021e2_Cases - 2021e2_Cases

Lesson eCase 08 - Tutorial 1 - 2021
Student email thojo765@student.otago.ac.nz

Symptoms

Mr Wise - history notes:

unsteady gait (thinks age)

breathlessness(hard work 12 story buildings)

sleep ne 

3months ago feeling tired

irregular heat beat at GP

no palpatations other than every 6 weeks no concern

no chest pain

Now summarise what you know about Mr Wise's presenting symptoms. This is an important skill for you to practise.

unsteady gait (thinks because of age)

Dyspnoea  (hard work 12 story buildings)

3months ago feeling fatigue 

irregular heat beat 

no palpatations other than every 6 weeks but no concern

no chest pain

While Mr Wise denies experiencing any "concerning" palpitations, what might that feeling of "something" in his chest
indicate when considered with his other symptoms?

atrial brilation?

blood pumping issue?

Patient History
 Mr Wise - past medical, family, and social history
notes:

hypertensive (no medication)

no previous cardio issues

High cholesterol (no medication)

changed diet to cut back cholesterol

no diabetes or FH

engineer

wife was health professional 

mother had uid retention in legs

younger brother down syndrome and heart failure

died

youngest brother 2 strokes died

father arthritis

How might his family history and past medical history link with the symptoms he reports?

could possibly familial hypercholesterolemia as there is evidence to suggest high levels of thrombi or atherosclerosis 

What further information do you need to better establish what might be causing Mr. Wise's symptoms?

Mr Wise has been referred to Cardiology by his GP and shortly, on reading his clinical record, you will learn more about
him. For now, however, list some questions that you would have asked Mr Wise if you were his GP, in order to better
inform your ideas around the reason(s) for his original presentation. 

What medications are you on ?

Is there anything that makes it worse or better?

How has this e ected your day to day life?

What do you think is causing it?

What were you expecting the GP to do for you today?

 
Make a list of the possible causes for Mr Wise’s presentation that you consider need exploring further.

Trauma

atrial brilation

atrial stenosis?

mitral stenosis?

Arrhythmia 

RHD

infective endocarditis

hypercholesterolemia leading to atherosclerosis 

Details

Re ection: Make a note of the areas that you missed. Have a think about how you could remember to
include these areas.

Consider previous times you've completed exercises like this, how is your learning progressing in
comparison.

Unsteadiness: need to know more about the nature of Mr Wise’s "unsteadiness of gait". Is he is losing his balance or
feeling dizzy/faint? Has he ever passed out / nearly passed out? Has he had any other symptoms accompanying the
unsteadiness (e.g. visual changes, speech di culties, altered sensation, nausea, vomiting)? How often does he have
these “unsteady” spells? Has the frequency increased?

Hypertension & Lipids: how hypertensive is he? When did he last have his blood pressure measured and his lipids
checked? How have these values changed over time and with his dietary e orts? Does he have any pain in his calves
when he walks / exercises? If he does, what makes it better? (looking for intermittent claudication - a sign of
peripheral vascular disease linked to hyperlipidaemia and the deposition of atheromatous plaque)

'Chest sensations': ask him to describe his 'chest sensations' again. If “pain” does not describe this, what words
(tightness, uttery) would he use to describe it?

Shortness of Breath: ask speci cally about respiratory pathology. Has he ever had asthma or chronic bronchitis?
Does he presently or has he ever smoked? If so, what, how many and for how long?

Medicines: does he take any medications or over the counter supplements at all? Which ones? Does he have any
known allergies (to what and what sort of reaction does he have?)

Social: Is he still working - part or full time? What e ect have his symptoms had on his capacity to work? How
worried does he think his wife is about him and what is it like at home? How has he been feeling in himself generally?
Is he nancially pressed with not being able to work presently? If he does smoke cigarettes, how ready is he to
quit? Does he drink alcohol - what and how much?

Timeline: need to establish a better timeline around the nature, onset, duration, and severity of his symptoms; are
the symptoms worsening and if so, what brings them on, what eases them and over what time frame? What does he
hope will happen with cardiology referral?

Examination: needs a full physical examination.

Think of the disease speci c symptoms to include

Examining
Drag the parts of the Cardiovascular Exam you would like to complete from the white section below (on the left) across
to the blue section. Order these appropriately.

Observe for
Pedal pulses Observe for
distress Carotid pulse
distress
Observe face
Inspect hands
especially colour
Inspect hands Inspect chest

Lower limb oedema Radial pulse

Radial pulse Apex beat

Apex beat Heart sounds

Blood pressure Heart sounds

Palpate knee Blood pressure

Observe face
Pedal pulses
especially colour
JVP Carotid pulse

Ripple sign Inspect chest JVP Lower limb oedema

Exam results & Investigations

How about now that you have more information?

Explain the signi cance of Mr Wise’s examination ndings. What do you think the most likely diagnosis is now?

his pulse was irregularly irregular so sign of arrhythmia 

he also had a pulse pressure of 140 which is showing great di erence between diastolic and systolic pressures (could
indicate atrial problem  as systolic pressure is high)

there was no  murmurs so unlikely to be a valve issue?

no ankle swelling so no peripheral odema so most likely not right heart failure

no chest pain or crushing sensations so probably not angina or arthersclerosis possibly palpitations as they are
described as uttering

Here are some investigations for you to consider. For each investigation, drag those you would like to order on to the
image of Mr Wise while those you consider not needed can be dragged into the bin.

Complete Bin

Lung Function Test Chest x-ray FSH

Chest x-ray ECG Lung Function Test

Urea, Creatinine, Na, K Lipid pro le Arterial blood gas

ECG Urea, Creatinine, Na, K

Full or Complete Blood count Full or Complete Blood count

Arterial blood gas

Lipid pro le

FSH
Investigation results

Look at Mr Wise’s observation chart and test / investigation results.

Comment on anything you see that could help you narrow down the list of causes for Mr Wise’s presentation towards
forming a de nitive diagnosis. Ensure that you include both positive and negative ndings.

all blood counts were in normal range unlikely to be an infection and bleeding times were normal

chest xray showed signs of enlarged heart as heart was greater than 50% of diaphragm

possible hypertrophy

likely to be atrial brillation as most common cause of irregular irregular pulse.

would explain dspnoea on exertion and fatigue and the unusual uttering sensation in the chest

Mr Wise's rhythm

The Rhythm Strip Template:

Emergency dept

Item Summary & Normal / Abnormal Explanations

Patient Name and Date John Wise 6-Jun-2015

ECG speed and calibration 25mm/sec 10.0mm/mV

P Wave no clear P wave

- Rate (atrial) iregullar 140 per min

- Regularity irregular irregular  Atrial issue

- Morphology (shape and many little waves irregular

appearance)

P-R Interval 0.36-0.52

QRS Complex

- Rate (ventricular) 150 BPM

- Regularity irregular irregular 

- Morphology (shape and no clear q or s wave( (possibly disrupted by p wave

appearance)

P Wave - QRS Complex p wave must come rst before QRS

Relationship

Other notes

This rhythm is ... irregular irregular

Explain your interpretation of Mr Wise's rhythm strip.

Mr. wise has an irregular irregular rythym with a absent p wave(f wave) which indicates atrial
brilation
De nitive diagnosis
 Record of the Patient History

Mr John Wise - eCase 8

Presenting complaint (PC) / Presenting symptoms:

male 63 years old

unsteady gait (thinks because of age)

Dyspnoea  (hard work 12 story buildings)

3months ago feeling fatigue 

irregular heat beat 

no palpatations other than every 6 weeks but no concern

no chest pain

History of Presenting complaint (HPC) 

Biomedical perspective:
Sequence of events

3months ago feeling more fatigued than usual so came to GP for help. Now referred to cardiologist

Symptom analysis

unsteady gait (thinks because of age)

Dyspnoea  (hard work 12 story buildings)

3months ago feeling fatigue 

irregular heat beat 

no palpatations other than every 6 weeks but no concern

no chest pain

Relevant systems review

Patient's perspective:

Ideas

gait could be due to age

Concerns

fatiuge breathless easily

Expectations

Dr to check things up?

E ects on life

can't walk ights of stairs as engineer

exercise indused breathlessness

Feelings

tired and not happy with beta blockers

Background Information
Past medical history (PMH)

hypertensive (no medication)

no previous cardio issues

High cholesterol (no medication)

no diabetes or FH

Medications

none
 Allergies:

none

Family history

mother had uid retention in legs

younger brother down syndrome and heart failure died

youngest brother 2 strokes died

father arthritis

Personal and social history

changed diet to cut back cholesterol, engineer, wife was health professional 

non smoker light drinker

Review of systems

Physical Examination

On examination he was described as a relatively thin 63 year-old gentleman who presents in no distress. He has
slight facial ushing - no signs of anaemia or jaundice.

BP 143/86. Pulse 140 (irregularly irregular).

Apex beat in the 5th ICSMCL (thrusting). S1, and S2 normal. No murmurs.

No carotid or renal bruit heard.  

No ankle swelling. 

Lung elds clear (normal).

Temp 36.8 (normal).

hypercholesteolima

high chol to HDL ratio

high LDL

Di erential diagnosis and/or Problem list

Atrial brilation

Plan of management

metoprolol (beta blocker)(for hypertension and arrhythmia )

wa rin( anticoagulant to prevent thrombolisim)

Explanation and planning

What now do you think is Mr Wise's de nitive diagnosis?

Atrial Fibrillation

Explaining
The registrar looks in to see how the admission is progressing. She reads over your summary (nodding approvingly!);
then asks you to:
"Explain the 'irregularly irregular' pulse that the GP commented on. How does this observation relate to the rhythm strip
from ED?"

the heart beats are irregular and there is no pattern to their irregularity . This is seen in the ECG as the f waves and Qrs 
complex times vary irregularly. This is because when an f wave depolarises the SA node enough to trigger the AV node
then only will a QRS complex start

Her next questions are:

"What's wrong with being in long-standing AF?

Are there any dangers for the patient - if so what are they?"

irregular heart beats impacts the bodies ability to supply blood through the body which would explain the exercise
induced dyspnoea. 

.Thrombi could form caused by turbulent ow due to the arrhythmia 

"So based on those dangers, tell me about treatments for AF.

What are we trying to treat? How do we do that? Why are those our goals for treatment?"

wa rrin is used as an anticoagulant that blocks vitamin K which is crucial for many coagulation factors. This prevents
thrombi from forming.

metoprolol is a beta blocker which causes decrease in heart contractility and stroke volume decreasing the HR and
reducing the hypertensive e ects on the left ventricle .

use something to control the rythym such as a pacemaker 

Is that a problem?
The registrar continues ...

"How will cardioversion procedure x the atrial brillation?" 

shock to the patients heart which causes the heart to go back to the sno atrial node pace

As she prepares to leave, the registrar comments that this is some of the information Mr Wise will need before he
consents to cardioversion.

As well as explaining the cardioversion procedure to Mr Wise, how else would you prepare him for giving informed
consent? What extra information might he need or want?

the risks

the bene ts 

what will happen after treatment

the costs

side e ects

how e ective it will be

recovery time

other options (no treatment )

The next morning

REFLECTION: Record your initial impressions of cardioversion.

very quick non invasive process.

lets the body return back to its normal mechanism

Review

Having now seen how cardioversion is actually carried out and heard the Cardiologist's explanation, add to your
notes any further details you would have like to have discussed with Mr Wise before he consented to the procedure.

cardioversion may not work and other treatments might be necessary

it can also cause super cial burns even if it does work

it could potentially dislodge thrombi and caus a stroke but as you are on anticoagulants it is minimized
The Cardiologist mentioned that the shock in cardioversion is synchronised to coincide with the R-wave of the ECG. 

Why is this important? Is this di erent to de brillation?

it is important for carrdioversion to be on the r wave otherwise ventricularr brilation can be triggered

de b shocks during refractorry period of heart?

That afternoon

Here is a rhythm strip recorded through a cardioversion procedure.

Move the labels to the correct place on the sequence.

Sinus Rhythm Sinus Rhythm

Asystole
Atrial Fibrillation

Shock sequence

Asystole

Atrial Fibrillation Shock sequence

As you start to interpret these ECGs what is the FIRST thing you notice about the post-cardioversion ECG?

heart rate has dropped post cardioversion and there is still an irregular irregular heart beat

That afternoon - part 2

The Rhythm Strip Template
Post cardioversion

Item Your Answer

Patient Name and Date John Wise

ECG speed and calibration normal

P Wave visible now  

    Rate (atrial) 50 BPM

    Regularity Regular until the end?

    Morphology normal until the end

P-R Interval 0.2

QRS Complex

    Rate (ventricular) 50

    Regularity regular till the end?

    Morphology normal until the end?

P Wave - QRS Complex Relationship p wave occurs than QRS

Other notes bradychardia

This Rhythm is ... normal till the end

Identify the rhythm on each ECG and explain any di erences.

rst it was f waves due to atrial brillation  with irregular irregular rhythm  but now its regular with normal p waves and
contracion

Answer Mr Wise's question here.

"Did it work?"

It solved the atrial brillation and now have normal sinus rhythm

Ongoing management
Do you have any concerns about the latest observations?

What are you concerned about?

Mr. Wise elevated blood pressure (possibly due to beta blocker wearing o )

Medications!

Going back to your preparation material, which would be the most suitable class of anti-hypertensive agent for Mr
Wise? Which class/es would be contraindicated for him?

Use this class Contraindicated class/es

John Wise ACE Inhibitor or ARB? none

If Mr Wise had any of the following co-morbidities, sometimes seen in people with hypertension, which classes of anti-
hypertensive agents would be suitable and which would be used with caution or contraindicated for him; and why?

Co-morbidity Can use this class/es Caution or Contraindicated class/es &

RATIONALE

Renal artery stenosis ACE inhibitors or ARB ACE Inhibitors may make acute kidney
injury in sever aortal stenosis
CCB
Beta blockers

Asthma cardio selective beta blockers Betablochers as they casue

bronchoconstriciton by blocking B2
ACE
receptors
ARB

Gout CCB diurectics may make gout worse

ACE
ARB

Peripheral vascular disease (PVD) ACE  Beta blockers not as  e ective as they
slow HR and CO which slows peripheral
ARB
perfusion
CCB

Heart block ACE Beta blockers could make Heart block

worse
CCB

ARB

Adherence
 Mr Wise - medicines notes:

medicine free until present

wa rin 

beta blocker (made him emotional and tired wants to

rest in afternoon

Using your notes and all the other information you have gathered on Mr Wise, identify issues that may create a problem
for Mr Wise adhering to the medicine and blood test regime.
How are you going to help him adhere to therapy and how will the family be able to help?

economic- nancial impact on Mr Wise making sure he can a ord the treatment

social- family how is his family feel about the medication and their support

adress Mr. wise concerns about beta blocker and how they make him feel tired maybe talk about the bene ts overr
the negatives

get his wife who is in the healthcare to support his adherence

ease access of pharmacy and GP clinic 

Mr Wise takes up your o er of "do you have any questions?" with:

"How is the high blood pressure related to the atrial brillation?"

hypertension causes extra stress on the heart and can cause the signiling of the heart to muck up casuing atrial
rbirlation

Popup - eCase 8 - Palpitations - John Wise - Personal

Notebook
My personal notes on my learning in this case