Day: April 15, 2024

#Histories

Cardiovascular history

By Sama Mohamed

Introduction The cardiovascular history should focus on key system-specific symptoms related to the heart and cardiovascular system. A cardiovascular history should focus the consultation on the cardiovascular system. This is usually because a patient presents with a cardiovascular problem such as chest pain or palpitations. The idea of a system-specific history is to explore key factors that are relevant to the affected system during the consultation. In cardiovascular disease, this may include cardiovascular risk factors, medications (i.e. that prevent or provoke cardiovascular disease), lifestyle factors (e.g. obesity, smoking), and relevant family history. History of presenting complaint Chest pain can be described using the SOCRATES mnemonic.

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#Histories

Breast history

By Sama Mohamed

Overview The breast history should focus of system-specific questions relating to disease of the breast. A breast history focuses the consultation on key clinical features that affect the breasts. The hallmark of breast disease is a breast lump and you should feel confident in exploring the features of a breast lump in full detail. It is important within your history to determine any systemic features that may indicate an underlying malignancy (e.g. fever, weight loss, loss of appetite) and to tease out any significant risk factors for breast disease. For example, mastitis is more likely to occur if the patient is

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#Histories

Basic history

By Sama Mohamed

Introduction The art of medicine is to determine why a patient has sought help. The key skills to help establish the underlying cause of a patients’ symptoms (the diagnosis) is based on talking to the patient (the history), examining the patient (the examination) and requesting tests like bloods and x-rays (the investigations). The information gathered from the history and examination is used to form a hypothesis of the possible underlying diagnosis. Investigations can then be used to either confirm or refute this diagnosis. Some diagnoses can be made just by talking to a patient, while others are reliant on a specific test. As a medical student, student nurse, physician associate, or allied

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#ECGs

9. Reporting an ECG

By Sama Mohamed

Introduction It is important to have a good structure for analysing and subsequently reporting an ECG. When reporting an ECG, you should use the same structured approach every time. This is particularly important when first learning about ECGs. A structured approach allows you to systematically assess the ECG in order and not forget any key elements. Once you improve, you’ll start to develop pattern recognition for classic ECG features.  We propose the following structure for analysing and reporting an ECG: Confirm correct patient details Rate Rhythm Cardiac axis P waves, Q waves & QRS complexes ST segments & T waves  QT interval Putting it all together This

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#ECGs

8. ST segment & T waves

By Sama Mohamed

Introduction It is important we analyse each aspect of the ECG morphology including P wave, QRS complex, ST segment and T wave. Abnormalities of the P wave, QRS complex, ST segment and T wave can tell us a lot about the patient. Analysing these parts of the ECG should always be taken in context of the rate, rhythm and clinical status of the patient.  Certain changes to the ECG morphology are classical of an underlying pathology. For example, ST elevation is the characteristic feature of an acute ST-elevation myocardial infarction (STEMI). Other changes are non-specific and can be suggestive of multiple pathologies. For

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#ECGs

7. P wave, QRS & QT interval

By Sama Mohamed

Introduction It is important we analyse each aspect of the ECG morphology including P wave, QRS complex, ST segment and T wave. Abnormalities of the P wave, QRS complex, ST segment and T wave can tell us a lot about the patient. Analysing these parts of the ECG should always be taken in context of the rate, rhythm and clinical status of the patient.  Certain changes to the ECG morphology are classical of an underlying pathology. For example, ST elevation is the characteristic feature of an acute ST-elevation myocardial infarction (STEMI). Other changes are non-specific and can be suggestive of multiple pathologies. For

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#ECGs

6. Tachycardias

By Sama Mohamed

Introduction Tachycardia refers to an abnormally fast heart rate. Tachycardia is usually defined as an abnormally fast heart rate greater than 100 bpm. We refer to all the abnormally fast heart rhythms as tachyarrhythmias. When a tachyarrhythmia occurs intermittently, we call it paroxysmal. Tachyarrhythmias may develop due to an ectopic foci of electrical activity within the atria, atrioventricular node (AVN) or ventricles. The aetiology of these ectopic foci can get quite complex, but is broadly due to problems with impulse conduction (i.e. transmission of electrical activity) or impulse formation (i.e. generation of electrical activity). Impulse conduction problems: caused by conduction blocks (discussed in our Bradycardia notes) and formation of reentrant

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#ECGs

5. Bradycardias

By Sama Mohamed

Introduction Bradycardia refers to an abnormally slow heart rate. Bradycardia is usually defined an abnormally slow heart rate less than 60 bpm. We refer to all the abnormally slow heart rhythms as bradyarrhythmias. Bradyarrhythmias may develop due to a variety of intrinsic or extrinsic factors. Intrinsic Within the heart, a slow rate may occur due to failure to initiate, or transmit, electrical activity. Failure to initiate electrical activity can cause another part of the heart to take over as the primary pacemaker. This is called an escape rhythm. For example, if the sinoatrial note (SAN) fails to undergo spontaneous depolarisation the atrioventricular node (AVN) may initiate

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#GUM

4. Conduction

By Sama Mohamed

Introduction Normal cardiac conduction starts with electrical impulses that are initiated within the sinoatrial node. The hearts pacemaker cells are organised into specialised structures including the sinoatrial node (SAN), atrioventricular node (AVN), bundle of His, the right and left bundle branches and Purkinje fibres. These are important for the coordinated spread of depolarisation (i.e. electrical impulses) that allows the heart to contract.  Hierarchy of spontaneous depolarisation Each of the specialised structures involved in cardiac conduction has an intrinsic rate of autorhythmicity. This refers to the rate of spontaneous depolarisation, and therefore, the number of times the heart beats per minute.  SAN: 60-100 bpm AVN:

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#GUM

3. Cardiac axis

By Sama Mohamed

Introduction The cardiac axis refers to the net effect of all of the generated action potentials.  When looking at the electrical activity of the heart, leads aVR and II look at the heart from opposite directions. The normal wave of depolarisation passes from 11 o’clock (aVR) to 5 o’clock (lead II). This means aVR has a predominantly downward deflection (negative lead) and lead II has a predominantly upward deflection (positive lead).  The average spread of depolarisation passing through the ventricles (visualised from the front) is termed the cardiac axis. In different disease states, the axis can be shifted to the left or the right. Normal

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#Coma

Uremic Encephalopathy

By Dr. Ahmed Hafez

Practice Essentials Uremic encephalopathy is an organic brain disorder. It develops in patients with acute kidney injury or chronic kidney disease, usually when the estimated glomerular filtration rate (eGFR) falls and remains below 15 mL/min.  Manifestations of this syndrome vary from mild symptoms (eg, lassitude, fatigue) to severe signs (eg, seizures, coma). Severity and progression depend on the rate of decline in kidney function; thus, symptoms are usually worse in patients with acute kidney injury. Prompt identification of uremia as the cause of encephalopathy is essential because symptoms are readily reversible following initiation of dialysis. Pathophysiology Uremic encephalopathy has a

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#Coma

Pneumothorax coma

By Dr. Ahmed Hafez

Practice Essentials Pneumothorax is defined as the presence of air or gas in the pleural cavity (ie, the potential space between the visceral and parietal pleura of the lung), which can impair oxygenation and/or ventilation. The clinical results are dependent on the degree of collapse of the lung on the affected side. If the pneumothorax is significant, it can cause a shift of the mediastinum and compromise hemodynamic stability. Air can enter the intrapleural space through a communication from the chest wall (ie, trauma) or through the lung parenchyma across the visceral pleura. See the image below. Signs and symptoms

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#Coma

Coma Due to Poisoning: Caution Urged in Intubation

By Dr. Ahmed Hafez

Tracheal intubation is recommended for comatose patients, but its use in individuals with altered consciousness due to acute poisoning remains uncertain. A French team conducted a large randomized trial to assess the risk–benefit ratio of a conservative approach in this context. Patients with altered consciousness are at high risk for respiratory distress and pneumonia. Acute poisoning, whether from alcohol, drugs, or medications, is a nontraumatic cause of altered consciousness that often leads to intubation. In the United States alone, 20,000 patients with acute poisoning are intubated annually. While this practice aims to prevent the inhalation of gastric content and, consequently,

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#Coma

Anaphylactic coma

By Dr. Ahmed Hafez

Anaphylaxis is a serious, potentially fatal allergic reaction and medical emergency that is rapid in onset and requires immediate medical attention regardless of use of emergency medication on site. It typically causes more than one of the following: an itchy rash, throat closing due to swelling that can obstruct or stop breathing; severe tongue swelling that can also interfere with or stop breathing; shortness of breath, vomiting, lightheadedness, loss of consciousness, low blood pressure, and medical shock. These symptoms typically start in minutes to hours and then increase very rapidly to life-threatening levels. Urgent medical treatment is required to prevent serious harm and death, even if the patient has used an epipen or

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