Clinical pharmacology questions Flashcards
21 yr old student High fever Headache Rash Treatment?
Meningitis
IM benzylpenicillin in community
Ceftriaxone in hospital
21yr old student
high fever
headache
rash
prophylaxis for flatmate?
ciprofloxacin or rifampicin
24yr old nurse has a witnessed grand map tonic clonic seizure at work. Treatment? chlordiazepoxide diazepam flumazenil lorazepam phenobarbitone
Lorazepam
- benzo
- slightly more effective than diazepam
- lower lipid solubility so lasts longer in vascular compartment
- GABA receptor
- immediate acting
- decreases chances of recurrent seizures
24yr old nurse has a witnessed grand map tonic clonic seizure at work.
There is no clear cause of her fit. What is the most appropriate course of action
carbamazepine
diazepam
lamotrigine
no treatment
sodium valproate
no treatment as this is the first seizure
but investigate
24yr old nurse has a witnessed grand map tonic clonic seizure at work. This is her 2nd seizure. There is no clear cause carbamazepine diazepam lamotrigine no treatment sodium valproate
carbamazepine
sodium valproate is often a first line treatment but not in women of child bearing age as teratogenic (neural tube defects, hypospadias)
risk of NTDs with carbamazepine is 1% rather than 1.5% with sodium valproate
23 yr old - headache, n &v, photo and phono-phobia. preceded by by flashing lights in periphery of her vision. which of the following is the most appropriate? codeine phosphate ibuprofen paracetamol and metoclopramide morphine high flow oxygen
paracetamol and metoclopramide
47 woman - PKD headache. neck rigidity third nerve palsy. head CT normal. LP Which will refute a SAH? visual inspection for xanthachromia 3 tube test measurement of oxyhaemaglobin assessment of WCC to RBC count measurement of bilirubin
measurement of bilirubin
(RBC lyse -> haemoglobin -> oxyhaem -> bilirubin)
LP 12hrs after headache
visual inspection for xanthachromia - yellow or not
3 tube test - count RBCs in each bottle. if traumatic tap - no. of RBCs should go down - not a good test
measurement of oxyhaemaglobin - can be formed in vivo or in vitro
assessment of WCC to RBC count : normal = 1000:1
measurement of bilirubin - only formed in vivo therefore the correct answer
SAH Which artery is most likely? basilar ant communicating posterior cerebral post communicating post cerebral artery
post communicating
basilar -
bifurcation of the internal carotid
posterior cerebral
post communicating - common sites of berry aneurysms, commonly affect oculomotor nerve - correct answer
post cerebral artery - rare but may affect trochlear
42 yr old man collpases with a sudden headache. CT scan shows spidery blood (white)
What drug can delay ischaemic deficit following SAH?
amlodipine
aspirin
nimodipine
magnesium sulphate
statins
nimodipine
amlodipine aspirin - cause of SAH nimodipine - Correct - Ca2+ channel blocker - as trial done on nimodipine magnesium sulphate - not indicated statins -
75yr left facial droop, left side weakness, arm and leg, power 3/5. CT scan shows early changes of MCA infarction. WHich drug should be given? alteplase abciximab aspirin dipyridamole heparin
aspirin
alteplase - cant establish time of onset - has to be within 4.5 hrs for this Rx
abciximab - MAB against IIb/IIIa - used in ACS
aspirin - correct answer
dipyridamole - only for individuals in a 2nd stroke
heparin - not used as risk of haemorrhagic transformation
TIA - which treatment alteplase abciximab aspirin dipyridamole heparin
aspirin or clopidogrel used in TIA
24 yr old cyclist. 2 day hx of tingling in his feet. 24 hrs it has got worse and can no longer move his legs. receding URTI. preferred Rx? acyclovir azathioprine broad spectrum antibiotics IvIG IV steroids
IvIG - correct for GBS as autoantibodies (or plasma exchange)
42 yr old - confused. behaving strangely for last 36 hrs. most approp management? broad spectrum antibiotics observation CT and LP CT with contrast MRI head
CT and LP- correct answer to rule out meningitis
Differentials - encephalitis & meningitis
Tx encephalitis aciclovir amoxicillin benzypenicillin ceftriaxone
aciclovir
encephalitis is almost always viral
43. right lower motor neuron 7th palsy. Rx aciclovir amoxicillin aspirin prednisolone tramcinalone
prednisolone for Bell’s palsy
56 woman, bradykinesia, resting tremor, festinant gait. which drug could cause this aspirin cyclizine ramipril rispiridone sertraline
rispiridone - correct - antipsychotic (anti dopaminergic)
34 woman. mild confusion, unsteady gait and dysconjugate gaze. which of the following drugs is the most appropriate to treat her?
aciclovir chlordiazepoxide ceftriaxone multivitamins thiamine
thiamine
to avoid korsakoffs
? wernickes encephalopathy
34 yr old - double vision & feeling of fatigue. O/E complex opthalmoplegia and fatiguable proximal weakness in all muscle groups. otherwise well. Rx? azathioprine IvIG plasma exchange prednisolone pyridostigmine
azathioprine - a regular Rx for myasthenia gravis not for acute Rx
pyridostigmine - correct - increase ACh as is ACEI
if bulbar involvement - risk of respiratory failure
then Rx would be IvIG
58 memory impairment. MSE = alert and attentive with average vocab. Remembers 1 /5 objects after 2 mins and has marked difficulty with reasoning and abstraction delirium dementia korsakoffs major depression organic amnestic syndrome
Dementia
delirium - pnt semi-conscious
korsakoffs - STM deficit but intact reasoning
major depression - not attentive normally
organic amnestic syndrome - normal reasoning and abstraction, forget who they are
24 - morning headache, worse on coughing or bending down. odd sound in ears. Bilateral papilloedema. MRI - empty sella. Rx aspirin acetazolamide LP optic nerve fenestration surgical shunting
idiopathic intracranial hypertension
LP
measure opening and closing pressure
scan first to check for SOL as would cone if there was a structural abnormality
73 yr old - shuffling gait and tremor. Parkinsons. First line treatment apomorphine amantadine L-Dopa and carbidopa combination carbergoline procyclidine
L-Dopa and carbidopa
apomorphine - last line Rx
amantadine - anti-flu, does have small dopaminergic agonist
L-Dopa and carbidopa combination - correct - no evidence that it hastens the progression of the disease (or ropinirole - DA agonist)
carbergoline - no longer used as retroperitoneal fibrosis in small no of pnts
procyclidine - used to be used for tremor but not any more
79 loses vision in left eye. fluctuatung vision in that eye in last week. generally unwell for 4 wks. sore ear and weak shoulders. vision in left eye is reduced to hand movements. RAPD & pale swollen optic disc. ESR 112, WCC 11.6. RX?
GCA - giant cell arteritis
steroids
1 day hx of painful r eye. pain severe and vomited twice. R eye has acuity of hand movement only. L eye 6/12. R eye severely injected with a cloudy eye. pupil is fixed and semi-dilated. Diagnosis retinal detachment acute iritis optic neuritis acute closed angle glaucoma cataract
acute closed angle glaucoma
66 progressive loss of vision. has SLE and on immunosuppressive therapy for last 15 yrs Diagnosis retinal detachment acute iritis optic neuritis acute closed angle glaucoma cataract
steroid induced cataract
25 post partum. headache, altered mental state and mild weakness of LHS involving leg and arm. CT - infarction with subsequent venous phase MRI confirms a filling defect in the transverse venous sinus. small area of haemorrhage assoc with infarct. Rx
heparin
clopidogrel
warfarin
heparin
treat clot despite haemorrhage
then use warfarin
elderly man, fatigue, fine wrinkled skin, hairless in the armpits and pubic area and hypotensive. thyroxine 8, thyroid stimulating hormone low
alteplase beta interferon corticosteroids natalizumab no rx required
hypopituitarism
corticosteroids hastens recovery
54 yr old female with a history of gout secondary to rx for her RA develops a swollen, tender right knee. O/E she has an antalgic gait with reduced ROM. What is the most appropriate initial management? ANA CT knee aspirate MCS serum urate start ibuprofen
knee aspirate MCS - correct (as must rule out septic joint)
Septic joint Rx benpen fluclox fluclox & sodium fusidate clarithromycin clindamycin
fluclox + sodium fusidate
clindamycin if penicillin allergic
Prosthetic joints are most often infected with staph epidermidis -Treat with vancomycin & beta lactam & rifampicin
Newborn in heart block. Blood test from mother : FBC anaemia, RF +, ANA +, dsDNA -, CCP - What is the mothers diagnosis? RA stills systemic sclerosis SLE sjogren's
sjogrens
Newborn in heart block. Blood test from mother : FBC anaemia, RF +, ANA +, dsDNA -, CCP -
Which antibody is responsible for causing the neonatal heart block
anti-jo
anti-ro
anti-la
RF
anti-nucleolar
anti-Ro
anti-Ro +ve in pnts with sjogrens - can cross placenta and enter fetus and block SA node
neonates need support until antibodies have cleared
anti-jo - dermatomyositis (heliotrope rash) & polymyositis anti-ro - correct anti-la - in sjogrens RF - sjogrens anti-nucleolar
27 yr old recurrent episodes of acute abdo pain - presents with acute airway obstruction. intubation difficult due to laryngeal oedema. known to have hereditary angiooedema. pathology? Wiskott-Aldrich syndrome c1q deficiency c1 esterase inhibitor deficiency C3/c4 deficiency kallikrenin deficiency
c1 esterase inhibitor deficiency
Wiskott-Aldrich syndrome - thrombocytopenia, immune deficiency and eczema
c1q deficiency - proposed hypothesis for cause of SLE - uncontrolled immune response to challenges
c1 esterase inhibitor deficiency - correct - prevents build up of kallikrenin which causes airway obstruction
C3/c4 deficiency - fatal probably (can reduce during flares of SLE)
kallikrenin deficiency
27 yr old recurrent episodes of acute abdo pain - presents with acute airway obstruction. intubation difficult due to laryngeal oedema. known to have hereditary angiooedema.what is the most appropriate Rx
IM adrenalin (1ml of 1:1000) (or 10ml 1:10000 IV)
IV hydrocortisone
chlorpeniamine
fresh frozen plasma
IV dopamine
FFP - as enzyme in FFP
8 yr old to A&E with chest pain. Her mother reports that over the past 2 wks she has been quite unwell with fevers and rashes. She is afebrile, fissuring of lips and peeling of soles of her feet. 2cm swelling in neck. painful joints. ECG - myocardial ischaemia. Diagnosis? Stills disease Takayasu's arteritis Kawasaki disease polyarteritis nodosa acute lymphoblastic leukaemia
KAWASAKI
Stills disease - juvenile RA
Takayasu’s arteritis - large cell arteritis
Kawasaki disease - strawberry red tongue, fissuring of the lips, cervical lyphadenopathys - correct
polyarteritis nodosa - in teens earliest, kawaaki in an adult
acute lymphoblastic leukaemia
8 yr old to A&E with chest pain. Her mother reports that over the past 2 wks she has been quite unwell with fevers and rashes. She is afebrile, fissuring of lips and peeling of soles of her feet. 2cm swelling in neck. painful joints. ECG - myocardial ischaemia. Rx? prednisolone IvIG haemodialysis adrenaline FFP
Kawasaki disease
Rx IvIG, plasmaphoresis
34 yr old female, on rx for pulmonary TB. malar rash and 2 wk hx of myalgia, malaise and arthralgia. GP wants to investigate for suspected drug induced lupus. most specifc test? anti nuclear antibody anti dsDNA antibody anti histone antibody anti smith antibody anti Ro antibody
anti histone antibody - correct - as most specific for drug induced
34 yr old female, on rx for pulmonary TB. malar rash and 2 wk hx of myalgia, malaise and arthralgia. GP wants to investigate for suspected drug induced lupus. Which drug? rifampicin ethambutol isoniazid pyrazinamide pyridoxine
isoniazid
rifampicin = p450 inducer ethambutol = colour blindness
27 yr old male. Rx for chlamydia infection. presents conjunctivitis and unusual rash on feet. wrist and ankle pain for last 5 days. diagnosis? reactive arthritis ank spond behcets disease psoriatic arthritis enteropathic arthritis
reactive arthritis
keratoderma blemorrhagica is the rash
45 yr old previous hx of pulmonary TB is started on treatment of her RA develops cough with haemoptysis, assoc with fevers and night sweats. Agent? abciximab infliximab rituximab ciclosporin tacrolimus
infliximab - TNF alpha receptor blocker
role in Rx of RA
54 yr old man. taking long term immunosuppressan for IBD. He also takes spironolactone, furosemide, perindopril. started on allopurinol following a flare of gout. FBC yesterday reveals a pancytopenia and on exam he has gingivitis and evidence of bruising. Causative agent? azathioprine cyclophosphamide infliximab etanercept methotrexate
azathioprine
31 yr old female - SLE. Diagnostic value of ANA sensitive and specific sensitive but not specific specific but not sensitive high positive predictive value low positive predictive value
sensitive but not specific
anti-sm is most specific for SLE
anti-scl70 most specific for systemic sclerosis
anti-TopoI - limited sclerosis
Azathioprine. MOA? anti CD20 antibody dihydrofolate reductase inhibitor methotrexate purine analogue pyrimidine analogue alkylating agent
purine analogue
anti CD20 antibody - Rituximab assoc with severe immunosuppression
dihydrofolate reductase inhibitor - methotrexate - megaloblastic anaemia
purine analogue - correct - myelosuppression
pyrimidine analogue - flourouracil
alkylating agent - cyclophosphamide - cancer risk increases
genetic polymorphisms in which enzymes can predispose pnts taking azathioprine to increased risk of severe myelosuppresssion?
p450 dependent mixed function oxidase catalase glutathione synthase thiopurine-S-methyltransferase thiol oxidase
thiopurine-S-methyltransferase
45 yr old woman with severe SLE required a renal transplant. She was started on immunosuppressive therapy. which drug "reduces purine synthesis via reversible inhibition of inosine monophosphate dehydrogenase"? azathioprine cyclophosphamide mycophenolate mofetil ciclosporin tacrolimus
azathioprine - purine analogue and stops DNA forming (myelosuppression, potentiated by allopurinol)
cyclophosphamide - alkylating agent (cross-link DNA stopping replication) (haemorrhagic cystitis)
mycophenolate mofetil - correct
ciclosporin - calcineurin inhibitor so inhibit T cells (hypertensive, hirsuitism, hyperglycaemia, gingivitis)
tacrolimus - calcineurin inhibitor so inhibit T cells (SE: hyperglycaemic)
severe RA. started on a new med. 4 months later - hypertensive. Exam reveals gingivitis. ciclosporin cyclophosphamide hydroxychloroquine mycophenolate mofetil methotrexate
ciclosporin - correct - hirsuit, coarse tremor, hypertension (also for phenytoin)
cyclophosphamide
hydroxychloroquine - aplastic anaemia - idiosyncratic reaction
mycophenolate mofetil
methotrexate
23 male - 3 month hx of progressive lower back pain, worse in the morning , attends optician with this red eye diagnosis scleritis epscleritis ant uveitis lens dislocation keratitis
ant uveitis - correct (assoc with HLA-B27 spondyloarthritides)
which agent reduces disease progression in ank spond NSAIDS azathioprine methotrexate infliximab cyclophosphamide
infliximab
54 yr old male presents to A&E with 3 days of dark urine assoc with joint pains and ankle swelling . On exam - hypertensive (180/90) and he has evidence of recent epistaxis. Pattern of glomerular injury?
focal global glomerulonephritis
focal segmental glomerulonephritis
focal segmental glomerulonephritis with crescent formation
diffuse global glomerulonephritis with crescent formation
diffuse global glomerulonephritis
diffuse global glomerulonephritis with crescent formation - correct
crescents increase risk of rapidly progresssive glomerulonephritis
patient with severe rheumatoid arthritis is started on a drug. 4 months later she is hypertensive. exam reveals severe gingivitis. which is the likely causative agent? methotrexate ciclosporin hydroxychloroquine mycophenolate mofetil
methotrexate - dihydrofolate reductase inhibitor (enzyme involved in purine synthesis)
ciclosporin - correct
hydroxychloroquine
mycophenolate mofetil
34 yr old presents with a migratory arthritis, progressed to the left knee and now involves the right wrist. he reports a urethral discharge. on exam he has a single mouth ulcer and arthralgia. HLA-B27 is negative. what is the most likely diagnosis? Behçet's disease Crohn's disease reactive arthritis (Reiters) gonorrhoea rheumatoid arthritis
Gonorrhoea - mouth ulcers, intracellular diplococcus, urethral discharge, pharyngitis, migratory arthralgia
Behçet’s disease (mouth ulcers,genital ulcers and uveitis)
Crohn’s disease (crampy abdo pain, mucus in stool, change in bowel habit, night pain, weight loss, anorexia, fevers)
reactive arthritis (Reiters) - is HLA-B27 positive
gonorrhoea (intracellular diplococcus)- correct
rheumatoid arthritis -
man from syria, 35yrs old. 3yr fluctuating malaise feveres, weight loss, odynophagia, persistent arthralgia of knees, wrists and ankles. 8 episodes of bloody diarrhoea over last 2 days. biopsies - non-specific colitis. pain during sex. intermittent dysuria. 2 ulcers in oropharynx and one genital ulcer. Painful nodules on shins and evidence of thrombophlebitis. Abdomen was tender but not peritonitic and PR exam unremarkable. Ocular exam - uveitis and optic atrophy. Initial investigations showed he was pyrexial with a tachycardia and a CRP 150 and Hb 96 . Management?
arrange CT colonoscopy
arrange colonoscopy
start oral prednisolone and review in 1 wk
perform inpatient work up including AXR
start azathioprine
perform inpatient work up including AXR - correct as anaemia, high inflammatory markers and pyrexial therefore admit
Truelove & witts criteria for admitting patients with colitis is the person passing 6 stools per day is temp >37.5 is pulse >90 is Hb 30 -- ADMIT
man from syria, 35yrs old. 3yr fluctuating malaise feveres, weight loss, odynophagia, persistent arthralgia of knees, wrists and ankles. 8 episodes of bloody diarrhoea over last 2 days. biopsies - non-specific colitis. pain during sex. intermittent dysuria. 2 ulcers in oropharynx and one genital ulcer. Painful nodules on shins and evidence of thrombophlebitis. Abdomen was tender but not peritonitic and PR exam unremarkable. Ocular exam - uveitis and optic atrophy. Initial investigations showed he was pyrexial with a tachycardia and a CRP 150 and Hb 96 . RF -ve ANA -ve dsDNA -ve plts 500 WCC 15 pathergy test +ve radiology of joints - nothing abnormal detected colonoscopy - pending
UC Crohns Sjogrens Reiters Behcets SLE
Behcets - correct - pathergy test , if from syria/Turkey think behcets
25 yr old 6 month hx of wrosening fatigue, night sweats arthralgia and recurrent fevers. she is hypertensive, and 2 months hx of raynauds (bilateral). blood tests reveal anaemia assoc with raised ESR and hyperaldosteronism. absent pulses in left arm. most likely cause of her symptoms? polyarteritis nodosa giant cell arteritis kawasaki disease takayasus arteritis microscopic polyangitis
takayasus arteritis - correct - as absent pulses , hyperaldosteronism due to renal artery stenosis, large artery vasculitis cause hypertension due to kidney disturbance.
54 year old male with chest pain and SOB. He is on warfarin with a target INR of 2.5 for a DVT 2 months ago. He has fatigue and is itchy. FBC: Hb 18.6 Plts normal. WCC 5.
a. Essential thrombocythaenia
b. Gaistocks syndrome
c. multiple myeloma
d. myelofibrosis
e. polycythaemia rubra vera
e. polycythaemia rubra vera.
erythrocyte monoclonal expansion -> myelofibrosis
can be premalignant (essential throbocythaenia is also premalignant) -> AML
If plts were near 1000 - essential thrombocythaenia more likely
Gaistocks syndrome = thrombovythaenia & hypertension
Multiple myeloma = bone pain, raised ESR, monoclonal bands in urine
myelofibrosis- giant splenomegaly, tear drop cells, dry bone marrow tap
Hb low, WCC normal, Plts normal. Reticulocytes low MCV mildly low RDR normal K+ high, urea and creat high Ca low DAT -ve low serum iron TIBC low Transferrin high
What is the diagnosis
Anaemia of chronic disease secondary to CKD
Urea and creatinine high indicating renal failure. MCV is only milady low so picture is more one of a normocytic anaemia than microcytic. (if iron deficient would expect TIBC to be high). Low reticulocytes is also a clue. This is due to the lack of erythropoietin synthesis.
DAT -ve indicates no autoimmune haemolysis
Ca is low due to lack of action of 1alpha hydroxylase in making activated calcidiol
If urea had been elevated and not creatinine - this would be more indicative of a bleed / haemolysis
If creatinine high alone - ?renal failure ? afro caribbean
55 male with lethargy and night sweats. Weight has recently increased and he has abdominal distension. O/E giant splenomegaly. PMH includes RA, takes cyclophosphamide. What is the cellular abnormality? p53 mutation RAS mutation Mutated mismatch repair tumour chromosomal translocation DNA crosslinking
chromosomal translocation - this is the t(9,22) philadelphia chromosome translocation that is present in CML
p53 mutations inherited in Li Fraumeni
RAS mutation - part of chain for colorectal cancer
Mutated mismatch repair tumour - Lynch syndrome (also causes HNPCC, ovarian and endometrial cancers)
DNA crosslinking = mech pf action of cyclophosphamide
55 male with lethargy and night sweats. Weight has recently increased and he has abdominal distension. O/E giant splenomegaly. PMH includes RA, takes cyclophosphamide. What is the chromosomal translocation? t(14,18) t(9,22) t(15,17) t(11,22) t(8,14)
t(9,22) - this is the philadelphia chromosome in CML
t(14,18) = follicular lymphoma- bcl-2
t(15,17) = APML (retinoid acid suppressor -> give retinoic acid - vit a)
t(11,22) = Ewings sarcoma - bone cancer children - noon skin appearance
t(8,14) - burkitts lymphoma - EBV - c-myc
EBV is also assoc with nasopharyngeal and liver cancers
55 male with lethargy and night sweats. Weight has recently increased and he has abdominal distension. O/E giant splenomegaly. PMH includes RA, takes cyclophosphamide. Pnt given red cell and plt transfusion and imatinib. MOA of imatinib? monoclonal antibody vs bcr-abl fusion toxin vs bcr-abl fusion protein nucleoside analogue tyrosine kinase inhibitor alkylating agent
tyrosine kinase inhibitor
60 year old male on an anti platelet following an acute MI. He has a macrocytic anaemia & unconjugated hyperbilirubinaemia & schistocytes. Neurologically he has fluctuating mood, odd behaviour. He has a high urea and creatinine. Giant cell arteritis Haemolytic uraemic syndrome Idiopathic thrombocytopaenic purport Thrombotic thrombocytopaenic purpura frontal lobe dementia
Thrombotic thrombocytopaenic purpura
If has recently eaten a dodgy burger it may have contained campylobacter jejuni (gram -, spiral rod) -> can trigger HUS. Also caused dark urine and schistocytes.
TTP - often triggered by drugs.
Both are MAHA
ITP is platelet type bleeding - petechiae, eccymosis. plts
45 year old male on warfarin for metallic heart valve. Has an upper GI bleed. Tachycardic, tachyopnoeic & postural drop in BP. Haematemesis. Optimal management to reverse the anticoagulation? cryopecipitate frozen fresh plasma prothrombin complex concentrate stop warfarin and restart when INR
Prothrombin complex concentrate
Vit K would completely reverse anticoag and pnt would require LMWH after because of valve
FFP - would take too long
cyroprecipitate - used in DIC patients (as they use up fibrinogen and this is packed with fibrinogen)
45 yr old male on warfarin for a metallic heart valve and is going to undergo surgery. What anticoagulation during surgery?
LMWH
unfractionated heparin
stop warfarin and restart after surgery
reverse anticoag with Vit K
administer prothrombin complex concentrate
Unfractionated heparin & monitor APTT (intrinsic pathway)
Use as has short half life and can give IV
15 year old male in ITU for meningococcal sepsis. Diagnosed with Waterhouse-Friederichson syndrome following adrenal failure. Clotting screen results consistent with cause of adrenal failure?
- PT high, APTT high, plts low, bleeding time high, fibrin degradation products low
- PT high, APTT high, plts low, bleeding time high, fibrin degradation products normal
- PT high, APTT high, plts low, bleeding time high, fibrin degradation products high
- PT high, APTT high, plts normal, bleeding time high
- PT high, APTT normal, plts normal, bleeding time high
Waterhouse–Friderichsen syndrome is defined as adrenal gland failure due to bleeding into the adrenal glands, caused by severe bacterial infection.
PT high, APTT high, plts low, bleeding time high, fibrin degradation products high
as has DIC and fibrin is being used to degradation products are high
Causes of DIC?
sepsis pre-eclampsia HELLP (high liver enzymes, low platelets) amniotic fluid embolus (causes PE too) malignancy trauma leukaemia transfusion reactions fat embolus (also cause PE)
22 year old female. abdo pain 8/10. opened bowels. pretechial rash on buttocks. bloods Hb 12, WCC high, plts normal, CRP high, LFTs normal
aspirin overdose henoch-schonlein purpura immune thrombocytopaenic purpura leukaemia osler-weber rendu syndrome
henoch-schonlein purpura
the abdo pain is due to mesenteric ichaemia
the purpura is due to a problem of the vessel wall rather than plt number (Immune thrombocytopaenic purpura ) or function (aspirin overdose).
34 year old male. Penicillamine for wilsons disease. A&E - facial swelling and dross bipedal oedema. Urine dip +++ protein but -ve for blood, nitrites and leucocytes. 2 days later develops renal vein thrombosis. Def of which protein led to this? antithrombin III factor II plasminogen protein C protein S
antithrombin III protein lost in nephrotic syndrome
which is a complication of warfarin
clots
skin necrosis
dementia
skin necrosis
- lose protein C first (is one of the vit K clotting factors) and is prothrombotic
-> gangrene of toes
therefore start warfarin with heparin cover
warfarin requires loading as has zero order kinetics like amiodarone and digoxin and ehtanol
20 yr old male 3 DVTs. Clotting reveals decreased APTT which didn't correct upon rx with activated protein C. Diagnosis? antithrombin III deficiency factor V leiden protein C deficiency protein S deficiency prothrombin mutant
factor V leiden
most common clotting abnormality
also protein C works on factor V therefore is factor V a mutant no matter how much protein C patient is still susceptible to clots
32 female. Lethargy. Itchy bullous rash on extensor surfaces. Blood film - howell jolly bodies.
atrophic gastritis and pernicious anaemia
coeliacs
crohns
steven-johnson disease
hashimotos thyroiditis
coeliacs
the rash is dermatitis herpatiformis
also coeliacs is a cause of hyposplenism and this explains the howell jolly bodies.
SJS - assoc with erythema multiform involving mucosal membranes.
atrophic gsatritis and coeliacs are assoc with increased risk of GALT lymphoma
40 female cough 6 months. weight loss and decreased exercise. <1 yr smoking hx. on Xray - 1 well circumscribed lesion
adenocarcinoma aspergilloma large cell carcinoma small squamous
adenocarcinoma
- no smoking hx required
aspergilloma - expect more systemic features e.g. fever
small - normally metastasised on presentation
squamous - assoc highly with smoking
bronchoalveolar carcinoma is a subtype of adenocarcinoma and is the most common in non-smoking females
drug causes of immune mediated haemolysis
cephalosporins dapsone levodopa levofloxacin methyldopa nitrofurantoin NSAIDs
Half life of naloxone 5mins 15mins 60mins 180mins 360mins
60mins
give 400-1200mcg IV for opioid overdose
clinical effects in 1-2mins and lasts 45mins
naloxone doesn’t work as well after buprenorphine overdose
Benzo overdose?
flumazenil should always be used
may be associated with ataxia and dysarthria
dicobalt edetate is an effective antidote
effect NMDA receptor
not exacerbated by alcohol
may be assoc with ataxia and dysarthria `(and decreased gcs )
usually managed with supportive care. if severe then flumazenil used - only on expert advice
