First Step In Managing An Agitated Patient Brought In The Emergency Department

Regarding the first step in managing an agitated patient brought in the emergency department answer the following question: 

Answer And Discussion:

Prostate specific antigen (PSA)

A 60-year-old man presents with lower urinary tract symptoms and is offered a PSA test. According to NHS guidelines, which one of the following could interfere with the PSA level?

A. Vigorous exercise in the past 48 hours
B. Poorly controlled diabetes mellitus
C. Smoking in the past 48 hours
D. Current constipation
E. Drinking more than 4 units of alcohol in the past 48 hours

Answer:

A 29-year-old woman presents complaining of weakness, particularly of her arms....

A 29-year-old woman with a past history of hypothyroidism presents to the surgery complaining of weakness, particularly of her arms, for the past four months. She has also developed double vision towards the end of the day, despite having a recent normal examination at the opticians. What is the most likely diagnosis?

A. LambertEaton myasthenic syndrome
B. Polymyositis
C. Polymyalgia rheumatica
D. Multiple sclerosis
E. Myasthenia gravis

Answer: E. Myasthenia gravis

Discussion: 

Myasthenia gravis is an autoimmune disorder resulting in insufficient functioning acetylcholine receptors. 

Antibodies to acetylcholine receptors are seen in 85-90% of cases.(antibodies are less commonly seen in disease limited to the ocular muscles)

 Myasthenia is more common in women (2:1) 

Clinical Features: The key feature is muscle fatigability - muscles become progressively weaker

Bronchiectasis - Case Study

Case History: Mr. …, 28 years old, day laborer, normotensive, nondiabetic, smoker, hailing from …, presented with frequent cough with profuse expectoration of mucoid sputum for ... months. It is more marked in the morning after waking from sleep. Occasionally, the sputum is purulent or yellowish and foul smelling, relieved after taking antibiotics. The patient also noticed small amount of blood occasionally mixed with sputum. For the last ... months, he also complains of loss of about 5 kg body weight, weakness, malaise, occasional fever and night sweating. There is no history of chest pain,
breathlessness or swelling of the ankle. His bowel and bladder habits are normal. There is history of
measles during childhood. He also gives history of recurrent chest infection for the last 2 years. There
is no history of whooping cough, pulmonary TB or foreign body impaction. There is no family history suggestive of such illness. He smokes about 30 sticks a day for last 10 years but nonalcoholic. He used to take cough syrup frequently, treated with antibiotics several times due to chest infection.

General Physical Examination: 

• The Patient is slightly emaciated
• There is generalized clubbing involving both toes and fingers, but no hypertrophic osteoarthropathy
• No anemia, jaundice, cyanosis, edema, koilonychia or leukonychia
• No thyromegaly or lymphadenopathy
•  Pulse: 88/min
• BP: 120/75 mm Hg
• Respiratory rate: 30/min
• Examination of the sputum cup: Always look at the cup at the side of the patient, if any).

Systemic Examination:

Respiratory System

Inspection:

Explanation to a patient of the need for investigations

Case Scenario: You are a junior doctor working on a cardiology ward. Mr  ABC, aged 23 years,
has congenital heart disease. He was admitted from clinic for further investigations into the cause of his breathlessness. The view of the cardiac team is that it will not be possible to give best advice about prognosis and treatment without information from a cardiac catheterisation study, but he is refusing to consent.

Your task: is to determine what concerns Mr ABC has and explain the purpose of further investigation.

Key issues to explore

• First find out what the patient knows about his condition: he may be concerned that nothing can be done or be in denial about the seriousness of the problem. 
• Then establish what he knows about cardiac catheterisation and his fears about the procedure: some patients are worried about pain and discomfort, whereas others worry about complications. Try and put any such fears in perspective.
• Explain any alternative investigative strategies that are available, but also why a cardiac catheterisation study is needed to give him best advice about his condition. 
• If possible offer him information booklets and if there is a specialist nurse available, ask him or her to speak with the patient.

Key points to establish
The patient does not have to undergo any investigation or treatment unless he agrees to it. He will still receive care even if he does not undergo the investigations recommended, but a proper investigation may improve the care that can be given to him and thus alleviate some of his symptoms.

Appropriate responses to likely questions

Patient: I feel fine.
Doctor: I hear what you say, but you went to the doctor because your breathing isn’t as good as it should be and it looks as though this is due to a problem with your heart.

Regarding Gastroenteritis....

A 23-year-old man develops watery diarrhoea whilst travelling in Egypt. Which one of the following is the most likely responsible organism?

A. Salmonella
B. Shigella
C. Campylobacter
D. Escherichia coli
E. Bacillus cereus

Answer:

A 67 Year Old Woman With Known Diabetes And Hypertension Presents With Severe shortness of Breath - Case Study

A 67-year-old woman is in town visiting her children when she presents to your office complaining of severe symptoms of shortness of breath that has worsened over the last 12 hours. She tells you that she has had diabetes mellitus for the last 20 years and hypertension that has been fairly well controlled for 15 years.
Your examination reveals an S3 gallop and rales to her midscapular area. She also tells you that she has experienced recurrent chest heaviness over the last 2 days. When the ECG is done, there are Q waves in leads V2, V3, V4, and V5. A call to her regular physician reveals she had a normal ECG when he saw her 1 month ago.

Answer the following questions:
1. At this point, what should you do?
2. What therapeutic interventions should be instituted at the time of admission?
3. Before discharge, she has an echocardiogram performed. What findings would favor long-term anticoagulant therapy with sodium warfarin?
4. Should this patient undergo coronary angiography or should she have a submaximal exercise test?
5. Would you recommend PTCA, surgery, or medical therapy?

Answers:

1. At this point, what should you do?
Your patient has had a recent anterior MI w ith left ventricular failure causing her symptoms. She needs to be hospitalized immediately, treated for HF, monitored for arrhythmias and recurrent ischemia, and risk-stratified. Thrombolytic therapy or PCI is not indicated because this is a completed
infarction, nearly 48 hours old.

Regarding Indications For Insertion Of A Chest Tube...

A 46-yr -old woman is admitted to hospital with a left basal, community-acquired pneumonia. She is on the appropriate antibiotics. She is still pyrexial four days after admission and a CXR confirms a left pleural effusion. The house officer has performed a diagnostic tap.

Which of the following is an indication to insert a chest drain?
A. Pleural fluid protein level more than 50% of serum protein level
B. Pleural fluid LDH more than 60% of serum LDH
C. Haemorrhagic pleural fluid
D. Pleural fluid pH < 7.2
E. Pleural fluid glucose < 1.6 mmol/l.

Answer:

Regarding Scrotal Problems....

Regarding Patients With Scrotal problems select a diagnosis from the list below for the given case scenario:

A. Varicocele
B. Testicular cancer
C. Epididymo-orchitis
D. Epididymal cyst
E. Inguinal hernia
F. Hydrocele
G. Femoral hernia
H. Hydatid of Morgagni
I. Fournier's gangrene
J. Cardiac failure

1. A 31-year-old man presents as he and his wife have been having problems conceiving. On examination there is a diffuse lumpy swelling on the left side of his scrotum. This is not painful and the testicle, which can be felt separately, is normal.

Diagnosis: Varicocele

2. A 44-year-old man notices a pea-sized lump on his right testicle. On examination a discrete soft mass can be felt posterior to the right testicle.

Diagnosis: Epididymal cyst

3. A 75-year-old man presents with a swelling in his right scrotum. On examination a large, non-tender swelling is found in the scrotum. You cannot palpate above the swelling during the examination.

Diagnosis: Inguinal hernia
(A hydrocele is less likely as you cannot 'get above' the swelling on examination.)

Brief Discussion On Scrotal Swellings:

A 53 year Old Man Presents With A Complain Of Chest Pain - Approach To The Case With Study Questions.

A 53-year-old male with a history of hypertension and smoking, but no family history of cardiac disease, presents to your office complaining of a chest pain.
The pain is substernal, radiates to his left arm, and is associated with exertion. The patient notes that this same pain has been going on for the last 6 months and has not changed at all in duration, intensity, or characteristic. It generally lasts 5 minutes or so and resolves with rest.

You tell the patient that:
A) Without doing any test, you know that the probability that this pain is cardiac is greater than 85%.
B) If his ECG in the office is normal, his pain is unlikely to represent cardiac disease.
C) Even with risk factors, his probability of having CAD with “typical angina” is still only 50% or so.
D) The only intervention indicated at this point are life style modifications (e.g., stop smoking) and
addressing his cholesterol and hypertension.
E) It is likely that he has unstable angina.

Answer and Discussion
The correct answer is “A.”
A 50-year-old male with “classic” angina symptoms has greater than a 90% probability of having CAD.
“B” is incorrect because patients with angina who are pain free may have a normal electrocardiogram (as will many patients with active angina or even a myocardial infarction). Thus, his pain could still be cardiac in origin.
“C” is incorrect because, based on demographic data, his risk of CAD is much higher than 50%. “D” is incorrect because he needs a further evaluation and treatment of his chest pain.
“E” is incorrect since this pain represents “stable angina.” There has been no change in quality, duration, amount of exertion required to bring on symptoms, etc., eliminating unstable angina as a diagnosis.

You send the patient home on aspirin with a prescription for sublingual nitroglycerin for PRN use and arrange for a stress test.
All of the following are considered absolute contraindications to exercise stress testing EXCEPT:
A) LBBB.
B) Presence of severe CHF.
C) Critical aortic stenosis.
D) Myocarditis.
E) Unstable angina.

Answer And Discussion

A 28 Year Old Man Presents With Six Month History of Weight Loss, Abdominal discomfort and Diarrhea.

A 28-year-old male presented with a six-month history of weight loss of 8 kg, generalized abdominal discomfort and diarrhea. On examination he was pale and slim, but there were no other significant abnormalities.
Investigations are given below:

• Hb 9 g/dl
• WCC 4.6 109/l
• Platelets 200 109/l
• MCV 76 fl
• ESR 38 mm/h
• Sodium 141 mmol/l
• Potassium 4 mmol/l
• Urea 3 mmol/l
• Creatinine 68 mol/l
• Corrected calcium 2.02 mmol/l
• phosphate 0.8 mmol/l
• Alkaline phosphatase 190 iu/l
• Albumin 38 g/l
• IgA <0.1 g/l (NR 0.8–4.0 g/l)
• IgG 9.0 g/l (NR 7.0–18.0 g/l)
• IgM 0.6 g/l (NR 0.4–2.5 g/l)
• IgA anti-endomyosial antibody:  Absent 

What is the diagnosis?

a. Crohn’s disease.

b. Intestinal lymphangiectasia.

c. Coeliac disease.

d. Small bowel lymphoma.

e. Hypogammaglobulinaemia

Answer:

Regarding A Baby born To A Mother With A History Of Syphillis

You are caring for a newborn infant of a mother who reports a history of syphilis but had uncertain treatment and no follow-up evaluation for her disease. Which of the following is most useful in determining whether the child has congenital syphilis?

A. Venereal Disease Research Laboratory test (VDRL)
B. Blood culture
C. Dark field microscopy of a vaginal swab specimen
D. Physical examination for abnormalities
E. Umbilical cord culture

Answer :

Chronic Bronchitis - Case Study

Case Scenario: 

Mr. XYZ 52 years old, truck driver, normotensive, nondiabetic, smoker, hailing from …, presented
with frequent attack of cough with profuse expectoration of mucoid sputum for … years. Initially,
cough was present during winter only and persisted for 2 to 3 months. For the last … month, it is
present throughout day and night, more marked in the morning and also on exposure to cold and
dust. The patient also complains of occasional tightness all over the chest, which is worse on coughing.
He also complains of difficulty in breathing, more marked during moderate to severe exertion, relieved by taking rest. There is no history of chest pain, hemoptysis, paroxysmal nocturnal dyspnea. He does not give any history of fever, swelling of the ankle or weight loss. His bowel and bladder habits are normal.
 2 years back he was admitted in the hospital due to severe attack of cough and breathlessness.
He smokes 30 sticks a day for last 35 years. All the family members are in good health. No such
illness in family. He used to take tablet aminophylline, cough syrup, salbutamol inhaler,
beclomethasone inhaler and sometimes local doctor prescribed antibiotics, the name of which he
cannot mention.

On examination –
General examination

•  The patient is emaciated
•  Central cyanosis present
•  No anamia, jaundice, edema, clubbing, koilonychia or leukonychia
•  No lymphadenopathy or thyromegaly
•  Pulse: 120/min, high volume
• B.P: 120/70 mm Hg
• Respiratory rate: 20/min
• JVP: not raised

Systemic examination .
Respiratory system

• Inspection:
• Shape of the chest: Normal
• Movement of the chest: Bilaterally restricted
• Intercostal space: Appears full.

Palpation: 

• Trachea: Central
• Apex beat: in the left 5th intercostal space in the midclavicular line, normal in character
• Chest expansion: Reduced
• Vocal fremitus: Normal.

Percussion:

• Percussion note: Normal resonance
• Area of liver dullness: In the right 5th ICS in midclavicular line
• Area of cardiac dullness: Impaired

Auscultation:

• Breath sounds: Vesicular with prolonged expiration
• Added sounds: Plenty of rhonchi, in both lung fields, present in both inspiration and expiration
• Vocal resonance: Normal

FET (forced expiratory time): 8 seconds (normally <6 seconds).

Examination of other systems reveals no abnormalities.

Diagnosis: Chronic Bronchitis.

Q1. What are your differential diagnoses?. As follows:

A 64-year-old man presents with a eight-month history of generalised weakness...

A 64-year-old man presents with a eight-month history of generalised weakness. On examination he has fasciculation and weakness in both arms with absent reflexes. Examination of the lower limbs reveal increased tone and exaggerated reflexes. Sensation was normal and there were no cerebellar signs. What is the most likely diagnosis?

A. Lead poisoning
B. Motor neuron disease
C. Vitamin B12 deficiency
D. Syringomyelia
E. Multiple sclerosis

Answer:

ST Segment Elevation Acute Myocardial Infarction - Case Study

A 62-year-old man with a history of hypertension is mowing his law n at 9:00 a.m. on a Saturday morning when he experiences a heavy sensation in his chest. He stops mowing the lawn and within 10 minutes his symptoms resolve, and he resumes cutting the grass. Approximately 10 minutes later, he experiences severe, crushing chest pain associated with shortness of breath and pain radiating down his left arm. As he walks to his house, he becomes diaphoretic and nauseated, and vomits twice. At this point, he calls an ambulance and is taken to the ER. When you arrive to examine him, he is still experiencing severe pain. A 12-lead ECG reveals 3-mm ST-segment elevation in leads V2, V3, V4, and V5 w ith inferior ST-segment depression. The pain has been present for a total of approximately 45 minutes.

\1. What initial actions should be taken in this patient?
2. Is this patient's hypertension a contraindication to thrombolytic therapy?
3. What are the risks associated w ith thrombolytic therapy and how long after the onset of acute MI is therapy beneficial?
4. Which is the better reperfusion therapy for acute MI—thrombolytic therapy or primary percutaneous transluminal coronary angioplasty (PTCA)?
5. What therapies should be administered acutely w ith thrombolysis or primary PTCA?
6. What measures should be carried out before this patient is discharged?
7. Under w hat circumstances should the patients undergo coronary angiography if they did not undergo acute angioplasty and/or stenting on admission?


Case Discussion

1. What initial actions should be taken in this patient?
The first actions that should be taken in this patient are to administer sublingual NTG, administer oxygen if oxygen saturation is below 90%, and establish venous access. IV β-blockers and aspirin should be given. Analgesics such as morphine should be given if the pain does not resolve with NTG. Immediate transfer to the cardiac catheterization laboratory for coronary angioplasty and reperfusion

Regarding Management Of A Small Pneumothorax

A 26-yr -old, previously healthy, naval diving officer is admitted to the hospital with a sudden onset,
left-sided chest pain. A CXR confirms a small left-sided pneumothorax. The pt is slightly
breathless and his oxygen saturation on air is 95%. He smokes 5–10 cigarettes a day. Which of
the following statements is true?
A. Simple aspiration is the first-line
B. Rx if the pt is symptomatic
C. If admitted for observation, he does not need oxygen
D. Once the pneumothorax has resolved he can go back to work, including resuming his diving duties
E. Smoking cessation has no role in management, apart from in the prevention of COPD in later life

Answer:

Regarding Management Of Esophageal Varices Bleeding

A 45-year-old man with a history of alcohol excess is diagnosed as having grade 3 esophageal varices during an outpatient endoscopy. Of the following options, what is the most appropriate management to prevent variceal bleeding?

A. Propranolol
B. Isosorbide mononitrate
C. Endoscopic sclerotherapy
D. Terlipressin
E. Lansoprazole

Answer: A. Propranolol

Discussion:

Esophageal Varices - Management: 

Acute treatment of variceal haemorrhage 
 ABC: patients should ideally be resuscitated prior to endoscopy

Essential Hypertension and Hypertensive Emergencies

Regarding Essential Hypertension and Hypertensive Emergencies answer the following questions;

1. What is the estimated prevalence of systemic hypertension in the U.S. population?
2. What is the most common cause of systemic hypertension?
3. How is hypertension classified?
4. What is the natural history of untreated hypertension?
5. Does medical therapy improve outcomes in hypertension?
6. What is a hypertensive crisis?

Answers;

1. What is the estimated prevalence of systemic hypertension in the U.S. population?
Hypertension in the United States affects approximately 65 million Americans. How ever, the prevalence increases with age, so that more than 60% of the population older than 70 years has hypertension. The Framingham Heart Study has demonstrated that 55-year-old normotensive
individuals have a 90% lifetime risk of developing hypertension. The incidence of hypertension and its severity is greater in blacks than whites in every age-group beyond adolescence.

2. What is the most common cause of systemic hypertension?
No cause is found for approximately 90% of patients with hypertension. These patients are said to have essential hypertension. Although the mechanism of essential hypertension is unknown, there are apparently both genetic and environmental factors.

Regarding Anti-Depressant Medications...

Regarding Anti-Depressant Medications answer the following question

Answer And Discussion:

Regarding Testicular Cancer

Which one of the following scenarios is the most common presentation of testicular cancer?

A. Painful testicular lump in a 56-year-old man
B. Painless testicular lump in a 27-year-old man
C. Painless testicular lump in a 43-year-old man
D. Painful testicular lump in a 25-year-old man
E. Painful testicular lump associated with dysuria in a 38-year-old man

Answer:

Bronchial Asthma - A Long Case Study Approach

Chief Complaints: 

• Difficulty in breathing for … years
• Cough for … months
• Wheeze and tightness in the chest … months.

History Of Presenting Complaints: According to the statement of the patient, he has been suffering from difficulty in breathing for the last … years. Initially, for a few years, it was episodic, occurring mainly during the winter seasons, and he was asymptomatic in between the attacks. But for the last … years, it is persistent with occasional exacerbations. His breathlessness is worse at night and sometimes during the daytime. It is aggravated by cold, dust and activity. There is no history of orthopnea or paroxysmal nocturnal dyspnea.

The patient also complains of cough which is usually dry, with occasional scanty mucoid sputum

expectoration, but no history of hemoptysis. Cough is present throughout the day and night, more on

exposure to dust or cold. He also experiences wheeze and tightness of the chest during coughing.

For severe attack of breathlessness and cough, he was hospitalized twice within the last ... months.

On query, the patient agreed that he has occasional attack of running nose and sneezing, more

marked on exposure to dust. There is no history of chest pain, weight loss or fever. His bowel and

bladder habits are normal.

History of past illness: He is non-hypertensive, no history suggestive of cardiac illness or reflux

esophagitis.

Family history: His brother is suffering from bronchial asthma and food allergy.

Personal history: He is a school teacher, smokes 10 to 15 cigarettes daily for the last 10 years. There

is no history of exposure to cotton, coal, etc.

Drug history: He uses bronchodilator and steroid inhalers, and used to take tablets like aminophylline, ketotifen and montelukast.

General Examination: 

• The patient is dyspneic
• Decubitus is propped up
• No anemia, jaundice, cyanosis, edema, clubbing, koilonychia or leukonychia
• No lymphadenopathy or thyromegaly
• Neck vein: Not engorged
• Purse lip: Absent
• Nasal polyp: Present on both sides

Vital signs: 

• Pulse: 120/min
• BP: 120/70 mm Hg
• Respiratory rate: 24/min.

Systemic Examination: 

1. Respiratory examination: 

Inspection:

• Shape of the chest—Normal
• There is indrawing of intercostal spaces, suprasternal and supraclavicular excavation and prominent accessory muscles of respiration.

Palpation:

• Trachea: Central. Tracheal tug absent
• Apex beat: In the left 5th intercostal space in midclavicular line, 8 cm from midsternal line, normal in character
• Chest expansion: Reduced
• Vocal fremitus: Normal.

Percussion:

• Percussion note: hyperresonance in both sides
• Area of liver dullness: In 5th ICS in the right midclavicular line
• Area of cardiac dullness: Normal.

Auscultation:

• Breath sound: Vesicular with prolonged expiration
• Vocal resonance: Normal
• Added sounds: High pitched rhonchi are present in both sides of the chest, more marked on expiration.

FET (forced expiratory time): > 6 seconds (normally <6 seconds).

Examination of other systems reveals no abnormalities.

Provisional Diagnosis: Chronic bronchial asthma.

Differential Diagnosis: COPD (Chronic obstructive pulmanary disease).

Questions likely to be asked by the examiner: 

Characteristic Features Of Conditions Causing Diarrhea

For the case scenarios of patients presenting with diarrhea chose a diagnosis form the list below:

A. Gastroenteritis
B. Crohn's disease
C. Ulcerative colitis
D. Colorectal cancer
E. Laxative abuse
F. Constipation causing overflow
G. Lactose intolerance
H. Diverticulitis
I. Irritable bowel syndrome
J. Coeliac disease

1. A 24-year-old smoker presents with intermittent diarrhea for the past 6 months. She feels bloated, especially around her periods. Bloods tests are normal.

Answer: Irritable bowel syndrome

2. A 23-year-old student is admitted due to a two-week history of bloody diarrhoea. He is normally fit and well and has not been abroad recently. His CRP is raised at 56 on admission

Answer: Ulcerative colitis
(The duration of his symptoms make a diagnosis of gastroenteritis less likely. The presence of blood in the diarrhoea points to a diagnosis of ulcerative colitis rather than Crohn's.)

3. A 72-year-old woman presents with a two day history of diarrhoea and pain in the left iliac fossa. Her temperature is 37.8ºC. She has a past history of constipation.

Answer: Diverticulitis

Discussion:
Characteristic Features Of Conditions Causing Diarrhea:

Acute Conditions:

1. Gastroenteritis: May be accompanied by abdominal pain or nausea/vomiting

A 56 year old woman with known RA Suffers from Recurrent Hemoptysis

A 56-yr-old woman, who is known to suffer from RA, complains she has had recurrent
haemoptysis for over 5 yrs. She has never smoked and only takes NSAIDs. According to her, she
coughs up phlegm every day and at times this contains streaks of fresh blood. She has no known
respiratory disease, but tends to get frequent chest infections that are relieved by a course of
antibiotics. What is the most likely Dx?
A. Lung cancer
B. Bronchiectasis
C. TB
D. Pulmonary embolism
E. Atypical pneumonia

Answer:

Regarding a 34-year-old female presents to her GP due to a number of 'funny-dos'

A 34-year-old female presents to her GP due to a number of 'funny-dos'. She describes a sensation that her surroundings are unreal, 'like a dream'. Following this she has been told that she starts to smack her lips, although she has no recollection of doing this. What is the most likely diagnosis?

A. Myoclonic seizure
B. Simple partial seizure
C. Complex partial seizure
D. Partial seizure progressing to generalised seizure
E. Absence seizure

Answer: C. Complex partial seizure

Discussion: With simple partial seizures there is no disturbance of consciousness or awareness. Lip smacking is an example of an automatism - an automatic, repetitive act.

Basic Classification Of Epilepsy:

Heart Failure - Case Study

Case Scenario:
A 42-year-old white man is seen in the ER with a chief complaint of shortness of breath that has lasted for 1 week. He reports having had a viral syndrome approximately 3 weeks before admission. Subsequently, he noted the development of lower extremity edema, a 15-lb weight gain, dyspnea on
exertion, and orthopnea. Currently he complains of dyspnea at rest.
Physical examination reveals an irregularly irregular heart rate of 130 per minute. His blood pressure is 90/60 mm Hg, and his respiratory rate is 22 per minute.
Examination of the jugular venous pressure demonstrates a mean pressure of 12 to 14 cm of water with a prominent V wave.
Lung examination reveals bibasilar dullness with rales extending one fourth of the way up from the basal lung fields bilaterally.
Cardiac examination findings are significant for a diffuse point of maximal impulse, which is displaced to the anterior axillary line. The S1 and S2 are of variable intensity, and a prominent S3 gallop over the displaced cardiac apex is appreciated. There is a grade 2/6 holosystolic murmur that is heard best at the cardiac apex, with prominent radiation to the axilla and no change w ith respiration. On examination of the abdomen, an enlarged, tender liver is found.
The extremities are cool and exhibit 2+ pitting edema.
The ECG show s atrial fibrillation with nonspecific ST-T–w ave changes, a left bundle branch block (LBBB) and occasional ventricular premature beats.
Arterial blood gas measurements performed with the patient on 4 L of oxygen per minute by nasal cannula reveal a pH of 7.46, a PO2 of 52 mm Hg, a PCO2 of 32 mm Hg, and a bicarbonate (HCO3) concentration of 26 mmol/L.

Answer the following questions:
1. Does this patient have left, right, or biventricular failure?
2. An S3 is heard, but no S4. Why?
3. What chest radiographic findings would you expect to see in this patient?
4. What neurohormonal mechanisms are likely to be activated in this patient?
5. What diagnostic tests should be performed?
6. What treatment options would likely be beneficial in this patient?
7. Is it possible that the ventricular function w ill improve with medical therapy?

Answers:

Regarding A 30 Year Old man Feeling Symptoms Of Sweating And Shakiness Following an Accident

 A 30 year old man feels symptoms of sweating and shakiness after involved in an accident. Read the question below and chose the answer from the options given:

Answer With Discussion: