A 76 year old female with a history of controlled atrial fibrillation presents to the emergency department with severe central abdominal pain of 2 hours duration.
A. What are the aims of your assessment?
- Signs of immediate life threat
- May effect treatment options
B. List your differential diagnosis, in order of priority in this patient?
- Ischaemic gut
- Myocardial infarction
- Abscess formation/complication
- Peptic ulcer disease
- Biliary disease
- Bowel cancer
- Renal calculi
- Torted ovary
- Ovarian cancer
- Uterine cancer
(5 marks) (must have bold items)
C. List the aspects of history that you would except in ischaemic gut.
- Abrupt onset
- Severe pain
- Any site
- Any radiation
- Pain out of proportion to physical findings
- Associated symptoms
- Other thrombotic source
(4 marks; bold + 1)
D. What investigations would be the most useful in the diagnosis of ischaemic gut and why?
- 75-90% Se
- CT with arterial phase
- 96% Se
- Blood gas
- Metabolic acidosis
(3 marks; bold + some idea of Se)
A 72 year old man presents by ambulance to your ED with onset of tachycardia and shortness of breath.
A. List the main abnormalities in this ECG
- Narrow complex tachycardia
- ST depression inferiorly and V3-V6 (widespread)
- Unable to see p waves
B. List your differential diagnosis for the origin of the tachycardia?
Regular narrow complex tachycardia
- Sinus tachycardia
- Sinus node re-entry tachycardia
- Atrial tachycardia
- Atrial flutter with block
- Junctional tachycardia
- AV node re-entry tachycardia
- AV re-entry tachycardia
- Fascicular tachycardia
(3 marks bold + one other)
C. Describe your management to address the tachycardia.
- Look for other causes of tachycardia in Hx, PEx, bedside investigation e.g. sepsis, MI
- Adenosine to differentiate atrial origin from re-entry tachycardia
- May terminate SVT
- Once underlying rhythm exposed can treat.
Author: J Haire