Acutes

Question 1

Please summarise your case of ankle swelling?

Answer 1

Two week history of gradual onset bilateral ankle swelling. No associated shortness of breath, cough, palpatations or chest pain. Background of previous episode linked to amlodipine, aortic stenosis, hypertension, osteoarthritis and menires disease. She is currently on amlodipine for hypertension and is struggling to cope caring for her husband who has dementia.

Question 2

What is the nice recommendations for ankle swelling with amlodipine?

Answer 2

Recommends starting a thizide-like diuretic such as indapamide

Question 3

What are the differential diagnoses for ankle swelling and why are they unlikely?

Answer 3

Iatrogenic effects of amlodipine - most likely
Heart failure - no orthopnea, raised JVP, Fatigue
Hypoalbuminaemia - no signs of liver failure or history, no bleeding
Lymphoedema - ho history of pelvic surgery, less likely to be bilateral
Cellulitus - skin neither hot nor red

Question 4

What is menires disease?

Answer 4

Increased pressure in the inner ear causes repeated attacks of vertigo. Often occumpanied with sensoneurial deafness and tinnitus

Question 5

What is the mechanism of action of amlodipine?

Answer 5

Angioselective calcium channel blocker, this prevents vascular smooth muscle contraction

Question 6

Summarise your case of earache?

Answer 6

This patient presented with a four day history of gradually worsening left ear pain. She has a dry cough and sore throat following flu for the past 2 weeks. She has had no discharge but is finding it very painful. Bulging inflamed drum on examination.

Question 7

What are the nice guidelines for otitis media?

Answer 7

For most people offer reassurance or delayed antibiotics to take if the symptoms have not gone by 4 days after onset. Offer immediate antibiotics for those who hve had symptoms for 4 days.

Question 8

What are the red flag symptoms for acute otitis media?

Answer 8

Mengitis symptoms
Mastoiditis
Facial nerve paralysis

Question 9

What are the differentials for acute otitis media and why are they unlikely?

Answer 9

Otitis externa - no inflammation of the auditory canal
Acute mastoiditis - no tenderness over mastoid antrum
Furunculosis - Not a localised lesion

Question 10

What was the follow up of the patient with otitis media?

Answer 10

I celled her up and she had resolution of her symptoms following her antibiotics but finished the course.

Question 11

What was the management that was used for acute otitis media?

Answer 11

A five day course of amoxicillin 500mg three times daily

Question 12

Summarise you patient with suspeced DVT?

Answer 12

This patient presented with a three week history of gradual left calf swelling. The overlying skin was red and was non painful but itchy. One week prior to the swelling she had been on a long distance coach journey. She had no associated shortness of breath or fever. On examination there was tenderness of the deep vein system and a wells score of 4

Question 13

What are the components of a dvt wells score?

Answer 13

Active cancer
Bedridden
Calf swelling greater than 3cm from other leg
Localised tenderness to deep vein system
Collateral superficial veins present
Entire leg swollen
Pitting oedema symptomatic leg
Previous DVT

Question 14

What were the diffferentials for DVT?

Answer 14

Side effects of amlodipine - not likely to effect just one leg
Cellulitis - not tender or hot and systemically well
Lymph obstruction although unlikely as no history of pelvic surgery
2 or higher DVT likely

Question 15

What investigations are needed for people where DVT is likely? and unlikely?

Answer 15

In those who are likely need an urgent referral for a proximal vein ultrasound within 4 hours. If they can’t do this then do d dimers and give anticoagulants and get it done in 24 hours.
In patients who it is unlikely then D dimer testing can be offered

Question 16

Please summarise your case of acute knee pain

Answer 16

This patient presented with a one week history of gradual onset left knee pain. This was worse on activity and relieved by rest. There was no history of trauma. She has a history of osteoarthritis in both knees and has had arthrocopies in the past. On examination there was significant crepitus felt on movement and the knee could not extend beyond 10 degrees.

Question 17

What were the differentials for knee pain?

Answer 17

Ligament injury - no history of trauma or twisting forces
Rheumatoid arthritis - no morning stiffness and alleviated by rest
Meniscal tear - giving way is symptom but no history of popping or locking
Septic arthritis - no history of break in the surface of the skin

Question 18

What was the follow up for the patient with knee pain?

Answer 18

She still had knee pain 4 weeks later but it had alleviated enough to be managable with her pain killers

Question 19

What is co-dydrymol?

Answer 19

Is a combination of paracetamol and dihydrocodiene