AKT answers
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AKT answers on cardiovascular disease |
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 TOP AKT answers on cardiovascular... AKT answers on child... |
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Answers
- H
- A
- B
- A
- A
- B
- F
- I
Discussion
Chest pain in primary care is sometimes straight forward but can be one of the most challenging tests of decision making in primary care. Generally speaking there is limited use made of the Troponins (specific and sensitive for myocardial damage) and the D Dimer (sensitive but too non specific). Too often the results of the latter are telephoned through to a hapless out of hours doctor who has no clinical details to guide him! Although I might occasionally do a Troponin T (for instance in an elderly person with co-morbidity, full safety netting and reliable social support) I would only do so after a full clinical assessment, ECG and in the knowledge that an MI was clinically unlikely. I would take personal responsibility for checking the result.
Biliary pain (case 1) is occasionally confused with cardiac pain, as is the characteristic left-sided pain of the stressed executive (case 2). Such a patient will often end up with an exercise test for his own reassurance but, since this is not totally specific or sensitive may be superseded by cardiac CT in the future. Myocardial infarction is the likely cause of the problems encountered by case 3. There is no mileage in delaying admission these days but it important that the patient (or representative) is spoken to directly. If there is an aspirin in the house he should be advised to take it. Cases 4 & 5 both have musculo-skeletal chest pain. The young lady in case 4 is clinically unlikely to have a pulmonary embolus (but this should be considered) and a D Dimer of course could well be a distractor in the presence of a URTI. She is most likely to have pulled an intercostal muscle coughing. The police cadet in case 5 does not need further investigation (the most worrying consequence of his injuries is a tension pneumothorax which in this scenario is unlikely – A&E doctors may argue with this but it is unlikely to change management in primary care). Case 6 is seriously ill. Check the BP in both arms (it may be different), insert a venflon if you have one and stay with the patient until the ambulance arrives. He probably has an aortic dissection (has he got Marfan's syndrome?) and your action could be life-saving. I would be concerned lest case 7 had a carcinoma of the bronchus and would order a chest X-Ray. If this was normal I would review her and, if not settling either repeat or perform spirometry. Arthur (case 8) probably has chronic stable angina and should be referred to the rapid access chest pain clinic. Age is not a bar to effective treatment and while he is waiting it would be sensible to check his lipids,Hb and electrolytes as well as a resting ECG. It would be reasonable to commence symptomatic treatment (eg Nitrate) as well as commencing Aspirin and a Statin – if not already taking them.
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AKT answers on child health |
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TOPAKT answers on cardiovascular...AKT answers on child... |
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Answers
- C
- A
- B
- E
Discussion
There is no place for Penicillin V in any of these cases. It does not cover most common urinary tract pathogens and case 1 does not require antibiotics at this stage. case 3 could have a urinary tract infection the fact that her perineum looks excoriated points more to a vulvo-vaginitis or threadworms. case 4 probably has a UTI but since it appears to be uncomplicated a three day course of antibiotic is recommended. case 2 is high risk for the following reasons:
- His age
- His non specific presentation
- His history of previous jaundice. We do not know why he was jaundiced – it may have been a urinary tract infection
He needs hospital admission
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