Case-based MCQ

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AIVR: regular wide complex rhythm. The patient has anterior STEMI

Bidirectional VT: QRS axis is changed in every other beat

What is the most probable diagnosis? Chronic kidney disease – 16 👍👍👍👍👍👍👍 80% Digoxin toxicity – 4 👍👍 20% Anterior STEMI ▫️ 0% Primary hyperaldosteronism ▫️ 0% 👥 20 people voted so far. Poll closed.

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Explanation: Correct Answer Is C Exercise-associated postural hypotension Pathophysiology Cessation of exercise results in sudden decrease in venous return to the heart (preload) Manifestations Athlete collapses immediately after cessation of exercise No loss of consciousness Dizziness or lightheadedness Normal to minimally elevated core temperature Management Trendelenburg positioning (ie, feet inclined above the head) Oral hydration This patient who collapsed after running a marathon but did not lose consciousness most likely has exercise-associated postural hypotension (EAPH). EAPH is thought to occur due to physiologic adaptations in endurance athletes, who have significantly higher cardiac output than unconditioned individuals due to hypertrophy and hyperplasia of the left ventricle (ie, athlete’s heart).  During strenuous exercise, skeletal muscles, particularly in the lower extremities, exert significant pressure on the venous system, which increases venous return to the heart.  When an athlete abruptly stops exercising (eg, finishes a marathon), the muscles are no longer exerting pressure, and venous return dramatically decreases.  The sudden decrease in cardiac preload fails to meet increased cardiac demand and results in transient postural hypotension and collapse.  This condition may be compounded by inhibition of the baroreflex and dehydration, which often occur with intense exercise. Unlike many other causes of exercise-associated collapse (eg, exertional heat stroke, sweat-induced hyponatremia), patients with EAPH remain alert with normal mental status.  Collapse or inability to walk is typically associated with a sensation of lightheadedness or dizziness.  Core temperature may be normal or mildly elevated (as in this patient) from prolonged exercise.  Management of EAPH is primarily supportive; patients should be placed in Trendelenburg position and offered oral hydration. Although severe asthma exacerbations can cause tachypnea, and hypoxia or hypercarbia may result in altered mentation with collapse, patients are expected to develop severe dyspnea and wheezing. Cardiac arrhythmia is a rare but potentially fatal cause of collapse in athletes.  However, cardiac arrhythmia typically occurs during exercise, not immediately afterward; patients may lose consciousness (unlike this patient who collapsed without losing consciousness); and arrhythmia would not explain the patient’s inability to stand or walk. Exertional heat stroke presents with elevated core temperature (>40C) associated with altered mental status (eg, confusion, syncope, seizure).  Although this patient’s core temperature is mildly elevated, his mental status is normal, making this diagnosis unlikely. Exertional hyponatremia results from excessive fluid intake (weight gain).  It presents with confusion, headache, and swollen hands after prolonged heat exposure during an athletic event; a resultant seizure may induce collapse.  This patient’s normal mental status and consciousness make this diagnosis unlikely. Exercise-associated postural hypotension occurs in conditioned athletes and is caused by the sudden decrease in venous return after cessation of exercise, which fails to meet increased cardiac demand.  It is characterized by collapse (with no loss of consciousness) immediately after completion of exercise.

A 39-year-old man is brought to the emergency department after immediately collapsing at the finish line when he completed a marathon.  Although he was unable to stand or walk, the patient did not lose consciousness.  He says he has run multiple marathons in the past without any problems.  Medical history includes mild intermittent asthma.  He uses albuterol as needed and last took it a week ago.  Temperature is 38 C, blood pressure is 98/52 mm Hg, pulse is 118/min, and respirations are 22/min.  The patient is alert and oriented and does not report any pain.  Neurologic examination is normal.  Which of the following is the most likely cause of this patient’s collapse? A. Acute severe asthma exacerbation B. Cardiac arrhythmia C. Exercise-associated postural hypotension D. Exertional heat stroke E. Exertional hyponatremia

Correct Answer Is D This patient’s acute-onset pleuritic chest pain, hemoptysis, and tachycardia are suggestive of pulmonary embolism (PE).  Hemoptysis is a result of pulmonary infarction.  Low-grade fever and mild leukocytosis may also occur with PE.  This patient’s risk factors for venous thromboembolism include HIV and hemoconcentration due to dehydration in the setting of a recent gastrointestinal illness. Chest CT scan shows the characteristic wedge-shaped, pleural-based opacification that is likely to occur distal to a completely occluded pulmonary artery.  Pulmonary infarct areas may also occasionally be seen on chest x-ray as a Hampton hump.  An associated pleural effusion is often present on the same side as the infarct (ie, exudative effusion resulting from infarction-induced inflammation).  On contrast-enhanced CT scan, the PE itself will appear as a pulmonary artery filling defect. Bacterial pneumonia presents with rapidly progressing chest pain, fevers, chills, cough, and dyspnea.  Alveolar infiltrates may be seen on chest x-ray and CT scan but are not typically wedge-shaped as they follow bronchial rather than vascular distribution.  Symptom onset is less likely to be as dramatic, and hemoptysis can occur but is uncommon. Lung cancer can cause cough, chest pain, dyspnea, and hemoptysis.  However, symptoms are generally gradually progressive and imaging is more likely to show a discrete, spiculated mass rather than a peripheral, wedge-shaped lesion. Pneumocystis pneumonia is a common cause of dyspnea in patients with HIV/AIDS.  However, it typically occurs in patients with CD4+ counts <200/mm3 and tends to be subacute in presentation.  Imaging commonly shows a diffuse interstitial pattern. Although patients with HIV are at increased risk for pulmonary tuberculosis, this woman has a recent negative PPD, and the classic cavitary lesions are not seen (a false-negative PPD is unlikely in a patient with a CD4+ count of 350/mm3).  In addition, pulmonary tuberculosis does not typically cause wedge-shaped lesions. Pulmonary emboli classically present with sudden-onset pleuritic chest pain, cough, and dyspnea.  Hemoptysis can occur as a result of pulmonary infarction.  Chest CT scan showing a peripheral, wedge-shaped infarction is virtually pathognomonic for pulmonary embolism.

A 34-year-old woman comes to the emergency department after noticing hemoptysis.  Yesterday, the patient developed sudden-onset right-side chest pain and mild dyspnea while getting out of bed.  For the last 4 days, she has had diarrhea as well as nausea and vomiting after eating in a new restaurant.  The patient feels weak and thought her respiratory symptoms were due to being in bed and inactive.  Her chest pain increases with deep breathing.  Her other medical problems include HIV, heroin use, and a prior episode of cellulitis on the right arm.  The patient’s last CD4+ cell count 2 months ago was 350/mm3, and PPD at that time showed 2 mm of induration.  She has a 15-pack-year smoking history.  Temperature is 38.1 C (100.6 F), blood pressure is 110/70 mm Hg, and pulse is 112/min.  Mucous membranes are dry.  Breath sounds are diminished at the right lung base.  Chest CT scan is shown below. Which of the following is the most likely diagnosis? A. Bacterial pneumonia B. Lung cancer C. Pneumocystis pneumonia D. Pulmonary thromboembolism E. Pulmonary tuberculosis

N-acetylcysteine should be started immediately or empirically in following situations: – When a patient presents 8 hours or more after ingestion. – When serum paracetamol level is not available within an 8-hour time window. – When there is uncertainty as to the timing of the overdose. – When the patient is unconscious or has a suspected overdose