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Clinical Medicine Case Series Obs, GI, and
Cardiology Exam Revision Notes
You are an FY2 doctor on your obstetrics placement. A 32-year-old G2P1 lady, who is 36 weeks pregnant, attends the antenatal clinic. She reports a one-day history of severe vomiting and yellowing of the eyes. She has vomited over five times, bringing up bilious liquid and no blood. She denies any abdominal pain, diarrhoea or fever. She denies any recent travel, although reports dining at a restaurant 3 days ago. She has no past medical history or notable family history. She has one 3-year-old child who was delivered via normal vaginal delivery, with no complications during pregnancy or labour. She denies any medication use other than some multivitamins prescribed by her midwife. On examination, she is alert and oriented. There is no asterixis. There are no peripheral stigmata of chronic liver disease, but there is obvious scleral icterus. Her abdomen is distended in keeping with pregnancy, and there is mild RUQ tenderness on palpation. It is difficult to assess for organomegaly on abdominal examination due to pregnancy. Observations BP 106/ HR 110 Sats 100% OA RR 16 Temp 36. Bloods Hb 145, WCC 8.6, Plt 600 Na 139, K 5.2, Ur 4.2, Cr 72, eGFR > 90 ALT 1320, ALP 160, Bil 130, Alb 40 PT 12, INR 1. CRP 97. Urine dip – Negative for protein, leukocytes, and nitrites Q1: What additional blood tests would you request urgently? Q2: What imaging test would you request? Q3: What are your differential diagnoses? The further blood tests you conduct show a positive HEV IgM. Imaging shows hepatomegaly, normal renal tract, and a single live foetus with no complications. Q4: What is the most appropriate initial management of this patient? Answer to Question 1
You would request an urgent non-invasive liver screen. This includes, but is not limited to, the following tests: Immunoglobulins Liver autoimmune profile (Anti-LKM, ANA, ANCA, AMA, anti- smooth muscle antibodies) Viral hepatitis screen Hepatitis A IgM and IgG Hepatitis B core AB, sAg, eAg, eAB, sAB, and if indicated, viral load Anti-HCV antibody Hepatitis E IgM and IgG Hepatitis D testing is only indicated if there is evidence of active Hepatitis B infection Iron and transferrin saturations Copper and caeruloplasmin Alpha-fetoprotein Answer to Question 2 This patient requires urgent imaging of her liver and of the foetus. An ultrasound scan is the safest and most readily available initial imaging modality, which will allow visualization of the patient’s liver, spleen, and the foetus. It carries no radiation risk to the foetus. Answer to Question 3 The following are potential differential diagnoses: Acute fatty liver disease of pregnancy HELLP syndrome Acute viral hepatitis Drug-induced liver injury Ischaemic hepatitis Acute fatty liver disease of pregnancy is a rare and potentially fatal complication that occurs due to abnormalities in foetal fatty acid metabolism. It presents in the third trimester of pregnancy or early post-partum period and has a high risk of morbidity and mortality associated with fulminant liver failure. Patients typically present with fever and jaundice, or signs of fulminant liver failure such as encephalopathy, deranged clotting and occasionally multi-organ failure. Laboratory investigations typically reveal a raised WCC, deranged clotting with elevated PT and INR, significantly raised ALP
failure, as there is a significant risk of this in pregnant patients with Hepatitis E. This involves close monitoring of her laboratory markers (liver function, renal function and coagulation), as well as clinical monitoring for signs of encephalopathy You are an FY1 in A&E. A 32-year-old woman presents with a one-week history of bloody diarrhoea, urgency and fatigue. She reports opening her bowels up to 10 times a day, passing stool that is very loose and has large amounts of blood mixed in. She reports left-sided abdominal pain that was initially relieved by opening her bowels but has now become more constant. She feels generally tired and unwell but has not lost any weight. She denies any recent travel, takeaways or illnesses requiring antibiotics. She reports several similar episodes of symptoms over the past 6-months which were self-limiting. She has no past medical history and takes no regular medication. She reports that her mother suffers with ‘bowel issues’. On examination, she is tender in the left iliac fossa. A PR examination revealed no palpable masses and an empty rectum. Observations BP 102/ HR 130 Sats 100% on air RR 14 Temp 37. Bloods Hb 98, WCC 11.1, Plt 450 Na 142, K 4.3, Ur 3.5, Cr 75, eGFR > 90 ALT 12, ALP 34, Bil 7, Alb 36 CRP 15.7, ESR 23 Β-HCG < 2 Q1: What initial imaging test would you request? The patient’s imaging test is unremarkable, and her abdominal pain is relieved by some Paracetamol. Your registrar requests you to send off the appropriate stool tests.
Q2: What stool tests would you request? The nursing staff are wondering if this patient requires admission to hospital. Q3: What is the likely diagnosis? What criteria would you use to determine if this patient requires admission? The patient is accepted for admission to the acute medical ward. Q4: What is the most appropriate initial management of this patient? As part of your management plan, you organise a flexible sigmoidoscopy to get imaging of the patient’s large bowel. The images are below. BONUS QUESTION: Based on the imaging findings, and given the likely diagnosis, what long-term treatment is indicated in this case?
The most likely diagnosis is inflammatory bowel disease (IBD), such as Ulcerative Colitis (UC), given the relapsing and remitting course of disease, left-sided abdominal pain associated with bloody diarrhoea and urgency. This patient also likely has a family history of IBD, highlighting a potential genetic risk factor. The Truelove and Witts criteria can be used to assess the severity of a UC flare. These factors include the patient’s stool frequency, volume of blood in the stool, heart rate, temperate, anemia, and inflammatory markers (CRP and ESR). UC severity is categorized into ‘mild’, ‘moderate’, or ‘severe’ using these markers. In general, mild-to- moderate flares can be managed conservatively in the community, and severe flares require admission to the hospital. Answer to Question 4 This patient should be started on intravenous steroids (hydrocortisone) at a dose of 100mg QDS. Her care should be discussed with the gastroenterology team. She should also have a flexible sigmoidoscopy within 24 hours of presentation to visually assess the bowel and obtain biopsies to confirm the diagnosis histologically. Answer to BONUS QUESTION This patient should be commenced on 5-ASA treatment with Mesalazine. This can be administered orally, rectally (using suppositories or enemas), or both. In severe cases, patients might be escalated directly to immunosuppressive biologic therapies such as Infliximab (anti-TNF monoclonal antibody). Mercaptopurines such as Azathioprine can also be used in the long-term management of IBD.
Question
You are an FY1 in A&E in a district general hospital. A 76-year-old gentleman with a history of a previous myocardial infarction presents with 8 hours of palpitations and breathlessness. He has no chest pain. He currently takes Aspirin 75mg OD, bisoprolol 2.5mg OD, Ramipril 2.5mg OD, and spironolactone 25mg OD. Observations: Saturations: 96% on room air BP: 102/ HR: 146 bpm Temp: 36. RR: 20/min On examination the patient is tachycardic with no other significant findings. He is attached to a cardiac monitor and the ECG rhythm strip is shown below
Q1: What rhythm is shown below? The nursing staff attach the patient to a defibrillator and have put out a peri-arrest call and hence the on-call medical team are on their way but are delayed at a cardiac arrest elsewhere in the hospital. The patient has large-bore IV access. Q2 : What is the most appropriate next step in management? The patient’s blood pressure drops to 80/50 mmHg and he becomes confused. The amiodarone infusion has only been running for 5 minutes. Q3: What is the next most appropriate step in management? After the previous management step, the patient returns to sinus rhythm at 85 bpm. The cardiology team will review him in the morning. Q4: What medication could you write up or change to reduce the likelihood of recurrent VT overnight? BONUS QUESTION: Which additional investigation will this patient likely require, and what would it show? Answer to Question 1 This is a regular, broad-complex tachycardia. It is most likely Ventricular Tachycardia (VT) – mainly due to the history of ischaemic heart disease, leaving scarred areas of myocardium that are pro- arrhythmic. There is also a hint of atrio-ventricular dissociation, seen most clearly in the 7th complex from the left. Answer to Question 2 Infuse amiodarone 300mg over 30 minutes. The patient has been in VT for several hours and is hemodynamically stable with no overt signs of heart failure. Therefore, the next most appropriate step is to administer amiodarone via a slow IV infusion. Ideally, this should be done through a central line, but it can also be given through a large peripheral cannula when there will likely be a delay in gaining central access. Answer to Question 3 Defibrillation with a synchronized shock. The patient now has signs of haemodynamic compromise and therefore requires defibrillation. Ideally, anaesthetic support should be summoned to sedate the patient if he is still conscious, but if there is an unacceptable delay, then it is not mandatory. Answer to Question 4 The two most important changes would be to increase his bisoprolol (initially to 5mg daily) and finish the amiodarone infusion – once
300mg has been given, a further 900mg IV is usually given over 23 hours. After the loading of 1200mg over the first 24 hours, amiodarone is often given as a loading regimen of 200mg TDS for a week, then 200mg BD for a week and then 200mg OD thereafter. BONUS QUESTION ANSWER This patient requires an echocardiogram to assess his left ventricular function, although his drug regime suggests that he has severe LV impairment. He will likely require an implantable cardioverter- defibrillator (ICD) before discharge as this VT episode was unprovoked, although he is approaching the upper end of the age-range when ICDs are usually considered. To get more information about the conditions mentioned in this case including diagnosis and management, have a look at our free cardiology notes on In2Med. Written by medical students, we have pitched them just at the right level to help you ace your exams.
