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American Family Physician October 15 th 2010

American Family Physician October 15 th 2010. Oguchi O.A. Nwosu MD FAAFP Assistant Prof. Emory Family Medicine December 9 th 2010. Articles. Common Types of SVT: Diagnosis and Management ACL injury: Diagnosis, Management, and Prevention Postpartum Major Depression

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American Family Physician October 15 th 2010

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  1. American Family PhysicianOctober 15th 2010 Oguchi O.A. Nwosu MD FAAFP Assistant Prof. Emory Family Medicine December 9th 2010

  2. Articles • Common Types of SVT: Diagnosis and Management • ACL injury: Diagnosis, Management, and Prevention • Postpartum Major Depression • Radiologic Evaluation of Chronic Neck Pain

  3. Paroxysmal SVT Types • Atrioventricular Nodal Reentrant Tachycardia (AVNRT) -Most common 50 – 60%, more in younger women -Reentry via nodal pathways • Atroventricular Reciprocating Tachycardia (AVRT) -30%, more in younger women and children -Reentry via accessory pathways -May be comorbid with WPW syndrome , delta wave with NSR • Atrial Tachycardia (AT) -10%, AT and Multifocal AT -MAT more often in middle aged or HF or COPD, variable P waves

  4. SVT: Not from article

  5. SVT: Figure 1 A: AVNRT – pseudo R B: AVRT – short PR C: AT – variable PR & RT D: NSR

  6. SVT: Symptoms • Common: - Chest discomfort or pressure; dyspnea; fatigue; lightheadedness or dizziness; palpitations (including neck pulsations) • Uncommon: - Chest pain (more severe than discomfort); diaphoresis; nausea; presyncope or syncope • Rare: - Sudden death (may occur with WPW syndrome)

  7. SVT • Examine: Vitals including orthostatics, Heart, Lungs, Neck • Tests: EKG, CBC, TSH, BMP, BNP, CE’s, CXR, Holter or Event monitor, graded Exercise test, Echo, • Perform EKG in hemodynamically stable patients R, R, PR interval, RP interval, Hypertrophy, Q waves, Prolonged QT & evidence of preexcitation

  8. SVT: Figure 2 Electrocardiogram of a narrow complex tachycardia with a 1:1 atrioventricular association in a 16-yearold girl with tachypalpitations. The differential diagnosis includes atrial tachycardia, atrioventricular nodal reentrant tachycardia, and orthodromic atrioventricular reciprocating tachycardia. Rhythm was terminated with 6 mg of intravenous adenosine (Adenocard).

  9. SVT: Figure 3 Postconversion electrocardiogram demonstrating the typical features of ventricular preexcitation with short PR interval and prominent delta wave. This finding supports orthodromic atrioventricular entry as the likely mechanism of supraventricular tachycardia. Diagnostic electrophysiology confirmed the mechanism

  10. SVT: Figure 4 Electrocardiogram of a narrow complex tachycardia with a 1:1 atrioventricular association. This example represents atrioventricular reciprocating tachycardia, which has a high cure rate with catheter ablation therapy.

  11. SVT: Indications for prompt referral to cardiologist • Severe dyspnea • Syncope • Preexcitation on resting 12 lead EKG • High risk occupations like pilot, truck driver, heavy metal operator ??doctor • Worsening symptoms/Hemdynamically unstable • Wide QRS

  12. SVT:Short term management Figure 6

  13. Effective Valsalva maneuver

  14. SVT:Long term management • ?

  15. ACL injury: Diagnosis, Management and Prevention: Anatomy

  16. ACL injury:What you really need to know: • ACL is primary stabilizer of knee • 1.4 to 9.5 x more likely to tear in women • Contact 30%, fixed lower leg & torque • Non contact 70%, involve sudden deceleration: skiers, soccer and basketball • Gait/Asymmetry (effusion, hemarthrosis)/guarding & spasm of hamstring/loss of hyperextension of knee

  17. ACL injury:What you really need to know: Diagnosis and Management • Examination • Lachman’s test – most accurate • Anterior drawer test • Pivot shift test • Imaging- Xray and MRI • Management is surgical or conservative • Lets go to the videos

  18. ACL Exam Videos • http://www.aafp.org/online/en/home/publications/journals/afp/afp-oct-15-videos.html

  19. Preventing ACL injuries

  20. Postpartum Major Depression:What you really need to know: • 5 -7% incidence within first 3 months • Screen in the 6 weeks PP check or 2/12 infant check • Edinburgh Postnatal Depression Scale • Up to 60% have obsessive thoughts focus on aggression toward the infant • Risk factors • Previous postpartum major depression-most common • Antenatal depressive symptoms RR 5.6 • Hx of major depressive disorder RR 4.5 • Poor social support RR 2.6 • Major life events of stressors during pregnancy 2.5 • FH of postpartum major depression RR 2.4 • Gestational DM/Multiple pregnancy

  21. Postpartum Major Depression vs Baby Blues Baby Blues Postpartum Major Depress. • Less than 10 days • Within 2-3 days Postpartum • 80% prevalence • Mild dysfunction • Suicidal ideation not present • More than 2 weeks • Within first month, may be up to 1 year • 5 -7 % • Mod – Severe dysfunction • May be present • Rx. with Psychotherapy and Pharmacotherapy – safe with breastfeeding.

  22. Baby blues!!

  23. Radiologic Evaluation of Chronic Neck pain • Article reviews the ACR Appropriateness Criteria for chronic neck pain • ACR Expert panel on Musculoskeletal Imaging reviewed 27 studies • 3 Largest evaluated 7,270, 5,440 and 3,014 respectively • One study – pts with spondylosis, pain more closely related to personality, neuroticism and previous injury • No statistically significant ass. b/w MRI findings and changes in clinical symptoms • MRI still useful in pts with disk herniations, canal encroachment by osteophytes, tumor, infection, fractures, posttraum. ligament ruptures of lower C spine

  24. Radiologic Evaluation of Chronic Neck PainClinical Example: • 52, man, progressive chronic neck pain. 10 years ago trauma to back of head during ice hockey game. Immediate pain, subsided after several days from heat and Ibuprofen. 5 years later morning neck stiffness improved with movement Last 6 months constant dull ache responds to ibuprofen. Last month paresthesias along median nerve distribution L hand Exam unremarkable. X rays showed narrowing of C5-C6, osteophytes protruding into canal. CT showed narrowing of the vertebral canal by osteophytes. MRI showed a herniated disk. Of note, only Xray and MRI would have been indicated

  25. Radiologic evaluation of chronic neck pain Axial CT through C5-C6 Bone window showing osteophytes post. margin of body and narrowing of neural foramen (arrow) Soft tissue window showing bilateral osteophytes narrowing the vertebral canal (arrows)

  26. Radiologic evaluation of chronic neck pain T 1 weighted sagittal magnetic resonance image showing disk herniation at the C5-C6 disk level (arrow)

  27. Radiological Evaluation of Chronic Neck PainMy (hopefully your) Key take home points: • Start with X-ray regardless of etiology. • With normal radiographs but neuro. S or S get MRI • If MRI contraindicated get CT myelography • Normal radiographs, no neuro. S or S – no further imaging • Radiographs show bone or disk margin destruction – get MRI • Radiographs show bone or disk margin destruction- MRI contraindicated – CT (?epidural abscess) • Although MRI does not always detect the cause of chronic pain, it is the preferred method for making most diagnoses See Table 1 of article for detailed guidelines

  28. Questions?

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