Medicine Osce Compiled and Solved - Ecgs
Medicine Osce Compiled and Solved - Ecgs
Medicine Osce Compiled and Solved - Ecgs
1. Hx of chest pain :
2. Diagnosis of chest pain, types of angina,management and treatment
Chest pain can be differentiated into heart-related and non heart related chest pain
Cardiac chest pain is called angina pectoris. Some causes of noncardiac chest pain
include gastrointestinal, musculoskeletal, or lung issues.
DD; cardiovascular
A blockage of coronary arteries can lead to a heart attack
Acute coronary syndrome
Stable or unstable angina
Illustration depicting angina
Stable angina
Also known as 'effort angina', this refers to the classic type of angina related to myocardial
ischemia. A typical presentation of stable angina is that of chest discomfort and associated
symptoms precipitated by some activity (running, walking, etc.) with minimal or non-
existent symptoms at rest or after administration of sublingual nitroglycerin.[4] Symptoms
typically abate several minutes after activity and recur when activity resumes. In this way,
stable angina may be thought of as being similar to intermittent claudication symptoms.
Other recognized precipitants of stable angina include cold weather, heavy meals,
and emotional stress.
Unstable angina]
Unstable angina (UA) (also "crescendo angina"; this is a form of acute coronary syndrome)
is defined as angina pectoris that changes or worsens.[5]
It has at least one of these three features:
1. it occurs at rest (or with minimal exertion), usually lasting more than 10 minutes
2. it is severe and of new onset (i.e., within the prior 4–6 weeks)
3. it occurs with a crescendo pattern (i.e., distinctly more severe, prolonged, or
frequent than before).
UA may occur unpredictably at rest, which may be a serious indicator of an impending
heart attack. What differentiates stable angina from unstable angina (other than
symptoms) is the pathophysiology of the atherosclerosis. The pathophysiology of unstable
angina is the reduction of coronary flow due to transient platelet aggregation on apparently
normal endothelium, coronary artery spasms, or coronary thrombosis. The process starts
with atherosclerosis, progresses through inflammation to yield an active unstable plaque,
which undergoes thrombosis and results in acute myocardial ischemia, which, if not
reversed, results in cell necrosis (infarction).[7] Studies show that 64% of all unstable
anginas occur between 22:00 and 08:00 when patients are at rest.[7][8]
In stable angina, the developing atheroma is protected with a fibrous cap. This cap may
rupture in unstable angina, allowing blood clots to precipitate and further decrease the
area of the coronary vessel's lumen. This explains why, in many cases, unstable angina
develops independently of activity.
Myocardial infarction ("heart attack") - People usually complained of a pressure or
squeezing sensation over the chest. Other associated symptoms are: excessive
sweating, nausea, vomiting, and weakness. Chest pain is more commonly associated
with anterior infarction because of left ventricular impairment; inferior infarction is
more commonly associated with nausea, vomitng, and excessive sweating due to
irritation of vagus nerve; lateral infarction is associated with left arm pain.
• An electrocardiogram (ECG)
• Chest radiograph or chest x rays are frequently performed
• Echocardiography can be useful in patients with known cardiac disease or aortic
dissection
• CT scanning is used in the diagnosis of aortic dissection
• V/Q scintigraphy or CT pulmonary angiogram (when a pulmonary embolism is
suspected)
• Blood tests:
• Troponin I or T (to indicate myocardial damage)
• Complete blood count
• Electrolytes and renal function (creatinine)
• Liver enzymes
• Creatine kinase (and CK-MB fraction in many hospitals)
• D-dimer (when suspicion for pulmonary embolism is present but low)
• serum lipase to exclude acute pancreatitis
Management: ANTI ANGINAL THERAPY
nitrates (glyceryl trinitratd GTN)
beta blockers (metprolol)
calcium channel blocker
potassium channel activation(nicorandil)
If channel antagonists (ivabradine)
3. Cxr of cardiomegaly:
Cardiothoracic ratio =
where,[4]
MRD = greatest perpendicular diameter from midline to right heart border
MLD = greatest perpendicular diameter from midline to left heart border
ID = internal diameter of chest at level of right hemidiaphragm
If the cardiac thoracic ratio is greater than 50%, pathology is suspected
# possible causes include:
The most common causes of Cardiomegaly are congenital (patients are born with the
condition based on a genetic inheritance), high blood pressure which can enlarge the left
ventricle causing the heart muscle to weaken over time, and coronary artery disease
• Pacemaker: Coordinates the contractions between the left and right ventricle. In
people who may be at risk of serious arrhythmias, drug therapy or an implantable
cardioverter-defibrillator (ICD) may be used.
• ICDs: Small devices implanted in the chest to constantly monitor the heart rhythm and
deliver electrical shocks when needed to control abnormal, rapid heartbeats. The
devices can also work as pacemakers.
Surgical procedures: Heart valve surgery, Coronary bypass surgery, Left ventricular assist
device , Heart transplant.
4. Ct scan of intracranial bleeding.
After completing the examination, examiner ask the question about positive findings,
Q: D/f btw upper and lower motor and causes of upper and lower motor:
Q : Causes:
Station2: female present with joint pain and stiffness in morning,there is
erythromatous rash over her cheeks.
Q1:diagnosis: SLE
Station 05 : lfts was given and patient present with mild jaundice and tender
hepatomegaly and resident of hostle
Q3:vaccination schedule :
for individuals between ages 1 and 18 years : Give vaccine I/Min two doses of 0.5 ml..
separated by 6-12 months, then booster 0.5ml after 6-12months
For individuals older than 18 years : high vaccine dose of 1ml then, booster dose of 1ml
6-12 months following initial dose
Q4:furthur investigations to make the diagnosis : Anti HAV IgM and Anti HAV IgG.
1. Station 6 : DM COUNCELLING :
1- Chest xray pleural effusion :
Q: Findings?
Q: Clinical findings in diarrhea? Dehydration, dry mouth (eager to drink), sunken eyes,
LOW
Q; Test for diarrhea? CBC, blood and stool culture and sigmoidscopy
Q: Most common cause of diarrhea in our setup? Parasites such as Giardia lamblia and
cryptosporidium can cause diarrhea. Common bacterial causes of diarrhea include
campylobacter, salmonella, shigella and Escherichia
Q: Giardiasis drug of choice? metronidazole
Q: Difference between acute and chronic diarrhea :
ACUTE less than14 days
chronic more than14 days
4- Perform relevent examination for patient with hx of headache
Q: d/d?
SA NODE PROBLEMS:
Rate : 30 bpm
Cause: MI, inc: vagal tone, hypothermia, hypothyroidism, hypoxia, raise intracranial
pressure, drugs(b-blocker, Ca Channel blockers, amiodarone.)
Management : asymptomatic : no treatment
symptomatic : atropine (initial), pacemaker (effective)
1. NSR with premature atrial contraction: Atrial cells fire occasionally from a focus.
Rate : 70 bpm
causes : caffeine.
2. Atrial flutter (saw tooth): Atrial cell fire continuously from a loop re-entrant circuit.
Rate : 70 bpm
causes : Ischemia
Management : beta blockers , calcium channel blockers, electrical cardioversion
3. Atrial fibrillation: Atrial cells fire continuously from multiple foci. (OR) From multiple
micro re-entrant wavelets.
Rate : 60 bpm
causes : alcohol , antihistamines, tobacco
Management : amiodarone, flecainide.
Rate : 60 bpm
PR interval : >0.20
Causes: AV nodal disease, inc: vagal tone, acute inferior MI and electrolyte imbalance.
Management : asymptomatic : no treatment
symptomatic : atropine (initial), pacemaker (effective).
3. 2nd degree AV block (mobitz type-I)
Rate : 50 bpm
causes : Mi, myocarditis, mitral valve surgery , athletes.
Management : asymptomatic : no treatment
symptomatic : atropine (initial), pacemaker (effective)
Rate : 40 bpm
Occasionally P waves are completely blocked
causes : ant : wall MI, degeneration of conductive system, aortic valve surgery
management : asymptomatic : parmanant pacemaker
symptomatic : parmanant pacemaker
5. 3rd degree AV block
Rate : 40 bpm
P waves are completely blocked and no relation with QRS complex
Causes: MI, severe hyperkalemia, cardiomyopathy, congenital with SLE mothers, acute and
chronic inflammations.
Management : asymptomatic : parmanant pacemaker
symptomatic : parmanant pacemaker
MYOCARDIAL INFARCTION
Anterior portion
of the heart
Inferior portion
of the heart
# Anterior wall seen through (V1-V4).