Mr Jack Smith is a 67-year-old male who lives with his wife, Deirdre, in a semi-detached house. He has been quite stressed for about a year now due to his two children both going through difficult divorces. For the past few months he has been experiencing a pounding in his chest and a feeling of breathlessness, both of which get worse after going up the stairs to the bedroom. He found that he had to rest on the landing for a few minutes to catch his breath after each ascent and felt lightheaded. Deirdre became concerned after Jack nearly fainted one morning, and she took him to the hospital the next day for a check-up, even though he thought it was probably nothing.
On arrival, the doctors ran an ECG and took blood and urine samples. Serum creatinine was found to be raised, and the urine was low in volume and very dark. Troponin levels and liver function were normal.
On examination, Jack had a raised BMI and capillary refill time was >5 seconds. His mouth and mucus membranes were very dry, and his legs were slightly swollen. His blood pressure was 80/50.
On auscultation, heart sounds: I + II + 0 and there were fine crackles at the base of each lung.
The doctors decided to put Jack on Warfarin and drugs for heart rate and rhythm control, gave him plenty of fluids, and kept him in hospital for monitoring. Jack began to feel better.
However, 3 days later in the morning while he was reaching for a glass of water by his bed, he realised that he couldn’t move his right arm properly and knocked the glass over onto the floor. He also experienced tingling and numbness in that hand, as well as tunnel vision. He felt as though he was drunk, even though he had not had any alcohol recently. The doctors were alerted immediately, and Jack was taken for a CT scan of his head.
After treatment for thrombolysis and several weeks of physiotherapy, Jack was able to return home with Deirdre, albeit with several more medications that he had to take.
Exercise
You must:
- Revise the gross anatomy of the heart from your A level textbooks
- Research any terms in the case that you haven’t come across before
- Research what a stroke is and how it occurs and presents
- What is the structure of a medical history?
- Discuss the positives and negatives of a CT scan. Why was it used in this case?
- What are the impacts of chronic stress on health and wellbeing?
- How do you clinically assess someone for dehydration?
- What is meant by a reference range?
- What condition are the doctors hoping to rule out by checking Jack’s troponin levels?
- What are the two types of stroke and how do the treatments differ?
You should:
- Revise the electrical conduction system of the heart from your A level course.
- Research what the normal ECG waveform looks like and link this to atrial and ventricular contraction and relaxation.
- Research some common arrhythmias and pathologies that show up on the ECG trace.
Questions:
- Why might someone not present to hospital with symptoms? What types of health behaviours is Jack showing in delaying seeking treatment?
- What type of arrhythmia does the ECG show?
- What complications can this condition cause?
- What is the Jack’s range in heart rate on the ECG trace?
- What does serum creatinine help diagnose?
You could:
- Research the causes of breathlessness on exertion. Which of these have you heard of before?
- Research causes of different heart sounds and pulmonary crackles.
Questions
- What is likely to have caused Jack’s bi-basal crackles?
- Are there any other things that can cause a rise in serum troponin?
- Suggest why Jack’s liver function has been checked and why his serum creatinine is raised.
- What is likely to have caused Jack’s dehydration?
- Summarise what you think has happened to Jack and suggest how his chronic condition has caused acute problems to develop.
We encourage students to research and post answers in the comments below and Medical Student Scholar Chris Geddie, will be answering your questions and reviewing your answers in a live discussion on the upcoming Virtual Medical Society Meeting on the 19th May.
Just to make sure, when it says “revise the gross anatomy of the heart at A Level standard” does that means that it’s at higher or advanced Higher level for Scottish students?
Hi Bethany yes it does it would be to a Highers level.
BW
Dr Siva
For the first set of questions I have got these ideas:
1.
2. I believe the ECG conveys, Atrial fibrillation due to the apparent ‘twitching’ of the atria. It could be an atrial flutter, but I do not think so due to the fact that in the atrial flutter the rhythm would be regular whereas here it appears more erratic.
3. Atrial fibrillation can result in the formation of blood clots. These can be pumped into the general blood circulation and may cause strokes should the clots block arteries in the brain.
4.
5. Creatinine levels can be used to diagnose kidney failure. This is because should the kidney functions inadequately then it will not filter as much creatinine out of the blood as normal. As a result, a failing kidney will display raised creatinine levels in the blood.
What is the structure of a medical history?
Introduce yourself, presenting complaint, history of presenting complaint (what happened…), past medical history, drug history, family history, social history, review of systems, summary, patient questions + feedback.
Discuss the positives and negatives of a CT scan. Why was it used in this case?
Positives = more accurate and precise than X-rays, painless, only takes 30mins, noninvasive with no down time needed.
Negatives = not used for pregnant women – radioactive tracers dangerous for babies, radioactive material combined with glucose so may be concern for diabetic patients.
Used to provide a series of images of Jack’s brain.
What are the impacts of chronic stress on health and wellbeing?
Chronic stress can lead to consistently higher levels of cortisol. This can lead to a higher risk of heart disease, strokes… (Moreover, high cortisol levels can shorten telomere length and this is linked to faster ageing and a shorter “healthy-life”).
How do you clinically assess someone for dehydration?
Check for thirst, dry mouth and mucus membranes, slow capillary refill.
What is meant by a reference range?
Reference range is compared to the patient’s results to check for normality. (The reference range is the average value for a group, accounting for natural variation).
What condition are the doctors hoping to rule out by checking Jack’s troponin levels?
Detects levels of troponin proteins in blood. – These proteins are released when the heart muscle has been damaged so doctors are ruling out a heart attack when checking Jack’s troponin levels.
What are the two types of stroke and how do the treatments differ?
Clots – when blood vessels in the brain are blocked; thrombolysis (clot-busting treatment).
Bleeds – when a blood vessel ruptures; craniotomy (to remove blood and relieve pressure that was built up), medication to lower blood pressure.
This is what I found is involved in taking a medical history: 1. introduce yourself to the patient
2. Ask about the presenting complaint
3.Gather the history of the presenting complaint (when did it start, how long does it last, what is the pain like, how severe is it does the pain move anywhere, does anything make it better and if so what)
4. Ask about the patients past medical, drug and family history.
5. Social history (find out about the patient’s lifestyle, any risk factors such as smoking, what their day to day life is like if they are a carer where they work etc.)
6. Review each of the main symptoms such as circulatory and endocrine.
7. Review the history and check with the patient that all information is correct and there is nothing that they wish to add. Ask what they think is wrong, if they have any concerns
8. Give the patient time to ask any questions, answer and provide relevant information and ask if they have any concerns and try to reassure them.
I’m not sure if this is entirely correct and there is probably information I left out, hope it’s useful
1. Patient Demographics
Presenting Complaint
History of Presenting Complaint
Past Medical/Surgical/Psychiatric History
Drug History
Social History
Family History
End pieces (review of systems, summary and questions, examination and investigations, referral, safety netting and follow up, differential diagnoses and management plan)
2. Some positives of CT scans are: fast imaging, shows clear and specific information, and looks at a large portion of the body. A negative is that it delivers a high dose of radiation. The CT scan was used in this case because the symptoms looked like a stroke therefore the CT scan detected it and to diagnose what type of stroke it is – haemorrhagic or ischemic.
3. Some impacts of chronic stress on health are heart disease, obesity, depression, fatigue, digestive problems, difficulty concentrating and sleeping. Therefore the person’s wellbeing is affected negatively.
4. Look for symptoms like dry lips, dizziness, thirst, dark urine, fatigue. Additionally, blood tests and urinalysis can be used to confirm the diagnosis and show how dehydrated the patient is.
5. A reference range is a range of values which is normal for a physiological measurement for a healthy person.
6. Troponin levels indicate a problem with the heart, such as a heart attack, so they were trying to rule out this.
7. Ischemic strokes are a blockage in the blood supply which leads a penumbra to an area of the brain that lacks blood supply and so it can’t work effectively.
Haemorrhagic strokes are a bleed in the tissue of the brain which can lead to pressure on the surrounding areas.
If it isn’t an haemorrhagic stroke and a suspected ischemic stroke and it is in the 4 hour window then they can get medicine, thrombolysis, to dissolve the clot and resolve blood flow to the brain. Also, the treatment can’t be used if there are contraindications. After the 4 hour window they may get antiplatelet therapy with aspirin as they are too late to get the medicine above. An haemorragic stroke can be treated by surgery to remove the blood from the brain. There are other methods of treatment but these are just a few examples.
1. The person with the symptoms might not know they have any, so don’t think that there are any problems. In delaying going to the hospital Jack has developed dehydration, swollen legs, bi-basal crackles and a stroke. By delaying seeking treatment he has developed low blood pressure,
2. Atrial Fibrillation because the heart beats are irregular and faster than normal.
3. Some complications of atrial fibrillation are heart attacks, stroke, cardiac arrest, blood clots, cognitive impairment.
4. ?
5. If there are high levels of serum creatinine then this indicates kidney damage because the kidneys normally get rid of this substance but it isn’t so it isn’t working properly.
1. I think the atrial fibrillation is the cause of the bi-basal crackles because if the blood isn’t leaving the heart as quickly as it should, fluid builds up and then lies in the bottom of the lungs, creating a crackle.
2. Some other reasons for why there could be a rise in serum troponin are sepsis, kidney failure or a traumatic injury to the heart.
3. There was swelling in the legs, darkening of urine, fatigue, these all could indicate that Jack has liver failure. However he doesn’t and so I think he has kidney failure because of the swelling in the legs, urine volume was low and dark, shortness of breath and fatigue these symptoms relate more to kidney failure. If kidneys lose their function, kidney failure, then high levels of serum creatinine would be produced because they can’t get rid of this substance as they aren’t working properly.
4. As you age you don’t feel as thirsty and your ability to conserve water is reduced so I think this could be the cause of Jack’s dehydration.
5. I think that kidney failure is the main problem with branched off to others because he wasn’t seen immediately. His chances of getting a stroke were increased by kidney disease.
1) Taking Patient History:
a) Introductions and consent to ask questions/take notes
b) Patient demographics ( confirm details e.g. name/DOB)
c) Presenting complaint (patient voices their complaint uninterrupted)
d) History of presenting complaint (SOCRATES; site, onset, characteristics, radiation, associated symptoms, timing, exacerbating and relieving factors, severity – of pain)
e)Past medical history (previous conditions may give clues to current condition)
f) Drug history ( gives idea of medication patient takes, could indicate if complaint is a drug allergy)
g) Family history ( insight into patient’s genetic risk factors)
h) Social history (living environment, relationships, occupation,diet, alcohol/smoking/recreational drugs)
i) Ideas, concerns, and expectations (to manage patients thoughts surrounding treatment)
2) CT Scans
Benefits:
-reduces need for exploratory surgeries
-quick scan time in emergencies
-non-invasive
-commonly used to assess strokes
Negatives:
-image affected by nearby bone
-high doses of radiation
-bad for diabetics as radiation is combined with glucose
A CT scan was used in Jack’s case as it was done quickly in an emergency and is a common stroke assessment tool. The head doesn’t contain many bones which would overlap the brain and make the scan appear confusing, making it an ideal location to CT scan.
3) Chronic stress :
Chronic stress often causes or exacerbates mental health problems, cardiovascular disease, high blood pressure, abnormal heart rhythms, heart attacks, stroke, obesity, eating disorders, menstrual problems, sexual dysfunction, and GI problems. Jack was stressed for around a year, increasing his risk of stroke along with his high BMI, the stress also could have contributed to the abnormal heart rhythm which showed up on the ECG.
4) Clinical Assessment for Dehydration:
-capillary refill test : fingernail held for 5 seconds, pressure released, time taken to regain colour taken (1-3 seconds if hydrated, as jacks took >5 seconds he was dehydrated)
-skin turgor test : skin fold gently pinched, skin should move easily and return to original position shortly after release ( not reliable in older patients due to decreased elasticity, not tested on loose or thin skin as it behaves differently)
-dark, low volumes of urine
– thirst (sensation decreases with age so not always accurate)
-dry mucous membranes
Jack’s capillary refill time, dry mucous membranes, and dark low urine volume indicate dehydration.
5) Reference range is a range of values which is deemed ‘normal’ for a physiological measurement in a healthy person. Its the basis of comparison to interpret test results.
6) Ruling out Conditions:
the doctors are trying to rule out a heart attack as Jack is presenting some of the symptoms (light-headedness and breathlessness) Troponin is a group of proteins which regulate contractions of the heart, high levels indicate a heart attack, as Jack’s levels were normal, a heart attack was ruled out.
7)Strokes and Treatments:
Ischaemic Stroke- caused by blockage (clots) and cut off blood supply.
Treatments-
– As they are caused by clots they are treated with thrombolysis, a clot busting treatment.
-Thrombectomies can also be used to remove the clot with a mechanical device. Thrombectomies have a huge impact in reducing disability but very few strokes are eligible for this treatment.
– Anti-platelet medications are used to prevent the formation of clots.
Haemorrhagic Stroke-
Caused by bleeding in or around the brain. Intracerebral- artery inside the brain bursts=bleeding within brain) Subarachnoid- artery on surface bursts=bleeding in fluid filled spaces between brain and skull.
Treatments-
– Surgery to remove blood or relieve built up pressure. Craniotomy, small piece of skull is removed to get to source of bleeding. If stroke caused by burst aneurysm an operation is needed to seal it.
– Medication to lower blood pressure is given, unless the bleed was caused by anticoagulant medication, then a drug is given to reverse its effects.
1. What is the structure of a Medical History? Introduction and patients details, presenting complaints and history of presenting complaints (how they cope), past medical and surgical history, medication, drug history and allergies, smoking and alcohol history, social, occupational and family history *, systems review, conclusion, and closure.
2. Discuss the positives and negatives of a CT scan, why was it used in this case? Positives: short duration time, painless, accurate, non-invasive, images bone, tissue, and blood vessels all at once. Negatives: uses radiation. It was used in this case to determine the type of stroke Jack had experienced and the state at which his brain was in so they could assess and treat quickly and effectively.
3. What are the impacts of chronic stress on health and wellbeing? Chronic stress for a prolonged period of time can cause problems for the heart and the blood vessels. Since Jack was experiencing stress due to his children’s divorces, the consistent increased heart rate and elevated levels of stress hormones and blood pressure can take a toll on one’s body. It can cause mental health problems, cardiovascular disease, abnormal heart rhythms, heart attacks, strokes, obesity, eating disorders, and GI problems. This prolonged stress was increasing his risk of stroke along with his high BMI.
4. How do you clinically assess someone for dehydration? Likely to have lower blood pressure, a faster heart rate than normal, and a reduced blood flow to your extremities. A blood test can be done to test for dehydration to check for levels of electrolytes (sodium and potassium) and how well you’re kidneys are working. Urinalysis can also be done to show to what degree you are dehydrated and look for bladder infections. Weight Loss. Capillary filling. Pulse. Respiration. Blood pressure. Pinched skin. Appearance.
5. What is meant by a reference range? A range of values deemed normal for a physiological measurement in a healthy person.
6. What conditions are the doctors hoping to rule out by checking Jack’s troponin levels? Troponin is released after an injury of the heart so by checking Jack’s levels you can rule out a heart attack as his troponin levels were normal.
7. What are the two types of stroke and how the treatments differ? Firstly, the most common stroke is the Ischemic Stroke which is where the brain’s blood vessels narrow or become blocked, severely reducing blood flow to the brain. Treatments include intravenous tissue plasminogen activator which breaks up a clot and if this doesn’t work, clots can be removed through surgery. It can take the clot-busting drug ( thrombolysis). The second is the hemorrhagic stroke where the blood vessels are leaky or ruptured. Intracerebral – artery inside the brain bursts = bleeding within the brain. Subarachnoid – artery on surface bursts = bleeding in fluid-filled spaces between brain and skull. Treatments include: taking drugs to counteract the effects of a blood-thinning drug that you take, surgery, surgical clipping, Coiling (endovascular embolization), surgical AVM removal, or stereotactic radiosurgery.
1. Why might someone not present to hospital with symptoms? What types of health behaviours is Jack showing in delaying seeking treatment? The patient may not realise they are showing symptoms or may don’t realise how serious the symptoms could be. In delaying going to the hospital, Jack has developed dehydration, low blood pressure, crackles in the lungs, swollen legs and ultimately has suffered from a stroke.
2. What type of arrhythmia does the ECG show? Atrial fibrillation as his heart is beating irregularly and faster than usual.
3. What complications can this condition cause? The chaotic rhythm may cause blood to pool in your upper chambers and form clots. Blocking blood flow and causing a stroke.
4. What is Jack’s range in heart rate on the ECQ trace? HR≥120 bpm?
5. What does serum creatinine help diagnose? Serum creatinine will indicate that your kidneys aren’t functioning properly. An increased level will accumulate in your blood and will tell you how well your kidneys filter.
1. What is likely to have caused Jack’s bi-basal crackles? Because Jack cannot pump blood effectively, this results in fluid build-up at the bottom of the lungs, causing a crackle.
2. Are there any other things that can cause a rise in serum troponin? People who experience higher levels of mental stress are believed to have higher levels of troponin.
3. Suggest why Jack’s liver function has been checked and why his serum creatinine is raised. Darkened and low volume urine and the swelling of Jack’s legs could also be symptoms for liver failure so had to be checked. Serum creatinine is raised when there is kidney failure which also related to other symptoms he experienced like shortness of breath and fatigue along with the darkened urine and swelling of his legs.
4. What is likely to have caused Jack’s dehydration? Jack is 67 years-old and his ability to conserver water is reduced. However, it could also be because he isn’t drinking enough water or problems like diarrhea or excessive sweating?
5. Summarise what you think has happened to Jack and suggest how his chronic condition has caused acute problems to develop. I think the initial problem was to do with his kidneys which then lead to bigger problems due to him not getting it treated early on. Atrial fibrillation could’ve been caused by the stress he felt which then resulted in other problems like elevated heart rate, shortness of breath, and then ultimately the stroke.
1) Onset: Onset of the symptoms, how it started, what caused it etc.
Duration: How long have the symptoms lasted for?
Progress: How are the symptoms progressing
2) Positives: A detailed image that can be produced in 20 minutes
Negatives: It is a high dose of radiation. This can cause problems for people with kidney diseases due to the dye injected
Why was it used:
To see if the stroke was ischaemic or haemorrhagic
3) Chronic stress can result in high blood pressure, diabetes, leading to chronic heart disease and a range of other health problems. It can also contribute to certain cancers. Secondly, chronic stress is detrimental to general wellbeing, it is often associated with problems such as depression and insomnia.
4) Check the mucus membranes; if it is moist or not
Skin turgor
Capillary refill (Under the nails)
Urine output
5) A range of values that are deemed normal
6)they are trying to rule out any cardiac muscle damage as troponin is released when cardiac muscle is under stress.
7) Two types of stroke=Ischaemic and haemorrhagic
Ischaemic is treated with anti-coagulation drugs and haemorrhagic is treated based on the cause. It is mostly caused by high blood pressure or aneurysms. The latter is treated surgically.
1)Failure to recognise symptoms and self-neglect. Jack is showing signs of stress, which can result in a delay in seeking medical help.
2)Atrial fibrillation
3) It can cause a stroke and/or heart failure.
4) Unsure of how to calculate
5) Serum creatinine helps to test the kidney function
Medical History:
1. Introduction – identify patient, gain consent
2. Presenting complaint – what’s wrong
3. History of presenting complaint – SOCRATES
4. Past medical history – other medical problems
5. Drug history – what medications the patient is taking and dosage
6. Family history – genetic conditions
7. Social history – patients background, smoking, drugs, living conditions
8. Review of systems – short info about other systems not covered in HPC
9. Summary – reviewing what the patient has told you
Positives of a CT scan
• Better detail compared to ultrasound
• Relatively quick compared with MRI
• Most systems can be scanned
Negatives of CT scan
• Artefact is common
• CT’s of the brain can be affected by bones nearby
• High doses of radiation
• Risk for babies in pregnant women
When under chronic stress your heart pumps faster and cortisol (the stress hormone) make the blood vessels constrict, increasing blood pressure. This means under chronic stress your heart works too hard for too long which increases the risks of heart attacks or strokes.
Dehydation:
Symptoms include; weight loss, dry mucous membranes, sunken appearing eyes, decreased skin turgor* increased capillary refill time**, tachycardia and flat neck veins.
* to test this gently pinch the patient’s skin, it should feel resilient, move easily and return to its normal position (only works usually on younger adults)
** apply pressure to patients’ fingernail for 5 seconds, release and observe the time it takes for the nail to return to normal colour
Reference range = the range of values that is deemed normal for a physiologic measurement in a healthy person
By checking Jack’s troponin levels, doctors are hoping to rule out heart conditions, specifically heart attack, as the body releases troponin after a heart attack.
Ischaemic stroke – blood clot blockage. Treatment includes thrombolysis which breaks down and disperses clots. Also, anti-platelet medication which reduces the chances of clots forming
Haemorrhagic stroke – bleed in or around the brain. Treatment includes surgery (craniotomy) to stop or relieve the bleeding.
Some people might to present to hospital with symptoms as they could think that the symptoms will pass over and that it is not serious enough for hospital. Or he could believe that it is serious but doesn’t go to hospital for fear of the worst.
The ECG shows atrial fibrillation
Atrial fibrillation can increase chances of strokes and heart failure.
Jack’s range in heart rate on the ECG trace is 75-150bpm
Serum creatine is usually eliminated from the body by your kidneys. So, if the serum creatinine levels are raised it suggests there is a problem with the kidneys not functioning properly.
Bi-basal crackles are caused by a swelling of fluid in the lungs.
A rise in troponin can also be caused by kidney disease, pneumonia and stroke
Liver function was used to check for infections such as hepatitis B and C. His serum creatinine could be raised because of his dehydration.
As Jack is older, he could not realise how much fluid he is needing a day, so is not aware he is dehydrated.
Due to the chronic stress Jack had high blood pressure, shown by heart palpitations. This could have cause chronic kidney disease (CKD). Also, Jack is shown to have atrial fibrillation (AF) on the ECG, heart palpitations are also a symptom of that too. His AF could be caused by his CKD. His CKD caused him to become dehydrated which meant a swelling of fluid in the lungs, which could be heard by the bi-basal crackles. The combination of CKD and atrial fibrillation lead to Jack having an ischaemic stroke.
Hi here are the answers I got to the first and second set of questions. I am not entirely sure about them though, so any corrections would really help. Thanks
Questions (Set 1)
1. The structure of a medical history is usually as follows:
Introduction and Consent
Patient Demographics
Presenting Complaint
History of Presenting Complaint
Past Medical History
Drugs and Allergies
Social History
Family History
ICE (Ideas, Concerns and Expectations)
2. Positives and Negatives of a CT scan:
Positives:
Painless non-invasive and accurate
Able to image bone, blood vessels and tissue all at the same time.
Provis an extremely detailed image of many types of tissue.
Negatives:
Exposure to radiation which may prove to be harmful
The dye ingested in order for contrast may be harmful to people with liver issues.
I believe that a CT scan was used in this case in order to get a more detailed image of his brain tissue in order to look at the brain tissue to help diagnose the type of stroke that occured.
nj3, Impacts of Chronic Stress on Wellbeing:
irritability, which can be extreme
fatigue
headaches
difficulty concentrating, or an inability to do so
rapid, disorganized thoughts
difficulty sleeping
digestive problems
changes in appetite
feeling helpless
a perceived loss of control
low self-esteem
nervousness
frequent infections or illnesses
4. The way to clinically assess someone for dehydration is through a capillary refill test.
5. A reference range is the range of values that is deemed normal for a certain test in a lab.
6. The condition I believe they were trying to rule out was a heart attack.
7. Ischemic strokes are strokes that are caused by the necessary arteries supplying blood to the brain being blocked. The main way to treat a stroke is to use a drug called intravenous tissue plasminogen activator (tPA) which breaks up blood clots in the arteries supplying blood to the brain. In order to treat a hemorrhagic stroke surgery seems to usually be involved in which the surgeon accesses the brain in order to the remove the blood therefore reducing the pressure on your brain.
Question (Set 2)
Questions:
1.Some people might not present to hospitals for a fear of catching a fatal infectious disease or being diagnosed with disease that they never thought they had. This behaviour is called Nosocomephobia.
2.The arrhythmia here shows Atrial Fibrillation
3.Atrial fibrillation is caused by dizziness, shortness of breath and tiredness.
4.Jack has a heart rate range of 16? I am not entirely sure at all here
Serum creatinine can help diagnose possible kidney failure or kidney damage.