Medicine Miscellaneous Flashcards
A person has begun taking amlodipine as part of their management of HTN. What type of drug is it and what side effect should the patient look out for that will be present on exam?
It is a calcium channel blocker (dihydropyridine => not cardioselective => can be given with beta blockers). The main side effect to note is ankle oedema
A person has begun taking amiodarone as part of their management of Atrial Fibrillation.
What type of drug is it?
What should you advise the patient when taking amiodarone (4)?
Amiodarone is a Class III anti-arrhythmic drug => works by blocking K+ channels
Patient must be advised of 4 things:
Thyroid function (can cause both hypo and hyperthyroidism)
Pulmonary fibrosis of the lower bases (drugs typically affect lower bases)
!! Grey Man syndrome: Advise patient to use sunscreen or protective clothing when in sunlight due to irreversible skin changes when sunlight interacts with its metabolites in the skin. (bluish-gray discolouration)
Eye sight due to optic neuropathy
The angle of louis is an anatomical landmark that indicates the X rib. What is X?
2nd
A 76-year-old woman is brought into the emergency department by ambulance after collapsing suddenly at home. Initial assessment revealed a heart rate of 42 beats per minute and she is treated according to bradycardia resuscitation guidelines whereupon she stabilises.
Her past medical history includes stable angina for which she is prescribed verapamil, however, she has recently been suffering from bouts of anxiety following a car accident, leading her sister to lend her some of the tablets she takes to ‘calm her nerves’.
What is the most likely medication this patient has taken thus leading to her presentation?
Beta blocker e.g. propanolol
When a patient says chest tightness, what can they mean?
Chest pain
SOB
You have a routine telephone consultation booked with Mrs McGoldrick, a 53-year-old lady who has been seeing the health-care assistant for blood pressure (BP monitoring). The health care assistant booked the appointment as readings have been consistently around 150/90mmHg. You look at the records and see she was commenced on amlodipine as she is of Caribbean origin, and she is taking 10mg once a day. Her only other medication is atorvastatin 20mg. The health care assistant has commented in the record that the patient confirms she does take her medications as prescribed. What is the next step up in management?
Afro-carribean origin => ARBs over ACE inhibitors
Afro-carribean people have less renin and ACE inhibitors block Ang1 -> Ang 2 which involves renin. If it already low, blocking it further would have less of an effect than if there was raised Renin levels
ARBs target Ang II directly => blocking what is already made
What are the investigations for any arrhythmia?
As for any arrhythmia: except ECG
Bedside:
ECG/!Holter monitor: looking for patterns consistent with NSVT, VT, or VF (specific questions will come) + screen for previous MI, BBB, or LV hypertrophy
Urine dipstick (sepsis)
Urinalysis (evidence of CKD to guide management between DOAC and Warfarin) + Toxicology (sympathetomimetics)
Bloods:
FBC - Anaemia, infection, low platelets if DIC, infection, sepsis)
CRP - raised in infl. + inf.
U&E - Hypomagnesia + hyper/hypokalaemia + medications
TFTs - hyperthyroidism
Troponin + CKMB (ischaemia as a cause or result of arrhythmia)
BNP - HF in severe arrhythmia
HbA1c and Lipid profile (RFs)
Imaging:
CXR - sx of HF (ABCDE)
ECHO - TTE - atrial/ventricular size (LA enlargement/LV hypertrophy), RV systolic pressure, valvular involvement, pericardial disease - TOE - LA (appendage) thrombus, Rule out vegetations in IE
Procedure: Exercise stress test - helps identify ischaemia (not rly done so not required for 5/5)
We know that to restore K+, you need to restore Mg levels first. What is the hierarchy of these electrolytes?
Phosphate (PO4 2-) - Recall PTH
Mg 2+
K+ and Ca2+
Na+
You are about to administer prophylactic clexane as DVT prophylaxis.
How is it administered?
You come back the next day and on inspection of the site, you note 3 findings. Assuming no infection, what are they?
Small, subcutaneous Hematoma (may mimic rash/telangiectasia)
Lipodystrophy from repeat injections (also insulin)
Quick bacteria vs viral infection on CSF findings?
Bacterial: Low glucose, high protein, raised PMN
Viral: High glucose, Low protein, raised lymphocytes
Patient with meningitis suspected. What antibiotics/antivirals will you give?
Ceftriaxone to cover meningococcal and pneumococcl
Vancomycin to cover penumococcus
Amoxicillin to cover listeria
Aciclovir to cover viral (given anyways just incase)
What 2 signs is indicative of meningococcal meningitis compared to other types?
What are these signs also used for?
Kernig’s and Brudzinski’s sign also used for SAH
Kernig
Patient lying supine, flex patients hip and knees to 90 degrees. then extend knee fully. Positive if patient experiences pain or resistance in the hamstrings or lower back
Brudzinski’s sign
Patient also lying supine, examiner gently flexes the patient’s neck, bringing the chin down toward the chest. If the patient’s knees/hips flex involuntarily, then it is positive.
Why? These basically irritate the meninges => the flexion relieves tension to ease the pain
What antibiotics are you going to use for an ENT infection?
G+ve
Amoxicillin/Co-amoxiclav
if penicillin allergy, Clarithromycin or azithromycin
A nursing home patient on their first day after moving gets sick. is this CAP or HAP?
What organisms are you looking for in each case anyways?
CAP. although a nursing home is consideref HAP, it still has not been 48 hours
CAP: Staph/strep
HAP: Klebiella, pseudomonas, MRSA
A patient with a chest infection, night sweats and weight loss. What is the most likely organism?
Tb
Give 3 medications that may cause C.Diff
Co-amoxiclav (beta lactam ab)
Clarithromycin (Macrolides)
Ciprofloxacin (fluoroquinolones)
What empiric antibiotics will you give for a GI infection (if you had to)
G-ve => Tazocin, Flagyl (Metronidazole)
Empiric antibiotic for skin infections
If this was complicated with Nec Fasciitis, what is the ideal antibiotic to start with?
Flucloxacillin (might also be able to say benzylpenicillin) -> Vancomycin for MRSA later
Nec Fasciitis -> Clindamicin
UTI top 3 antibiotics
Which one for pregnancy?
Nitrofurantoin
Trimethoprim
Cephalexin (pregnancy)
When someone says CPE, what bacteria are they referring to?
Also what does CPE stand for?
Carbapenemase-producing Enterobacterales
E.coli
Klebsiella
Enterobacter
NOT Enterococci (faecalis, faecium)
Enterobacterales (E.coli, klebsiella, enterobacter) may be carbapenemase-producing (CPE). What about for Enterococci (faecalis, faecium)?
VRE - Vancomycin-resistant Enterococci
What medications would you use for
CPE:
VRE:
CPE: Colistin (polymyxin) or Meropenem
VRE: Linezolid
when taking a history, a patient tells you they have an allergy to penicillin. You ask them to tell you what happens when they take penicillin. For the following, state if it is an allergy or sensitivity
Diarrhoea:
Stomach pain:
Rash:
Angioedema:
Hives:
Trouble breathing
You already know the answers to all
The point is that a rash is a sensitivity not an allergy
Youre in the ED someone comes in with sepsis. You have no clue whats going on and no one likes you. What empiric antibiotics is the best to prescribe in this scenario?
Piptaz + STAT gentamicin (not just prescribed because of nephrotoxicity)
Is orthostatic hypotension a type of vasovagal syncope?
Yes
I need all your differentials for Syncope
15 for 5/5
Cardiovascular:
Vasovagal Syncope incl. Orthostatic hypotension
Acute Coronary syndrome (STEMI, NSTEMI, Unstable angina)
Aortic dissection
Cardiomyopathy
Shock (septic/distributive, anaphylactic, cardiogenic, autonomic, hypovolemic…)
Arrhythmias (SVT, Brady/block)
Infective endocarditis
Resp:
PE, pneumothorax, Acute exacerbation of COPD, asthma, CF, bronchiectasis
Neuro: Stroke, ICH, Sezure (absence, focal, focal progressive, generalised)
GI: Severe Upper/lower GI bleed
Metabolic: DKA, Myxoedema coma, Thyrotoxic storm, Addisonian crisis
Psychogenic: Malingering
Trauma
Medication-induced
Malignancy
When you say vasovagal syncope what is the cause?
Cerebral hypoperfusion after a trigger
A patient comes to you with a history of a syncopal episode. On examination, there is evidence of deep cut/bite on the upper 1/3 of the tongue. What is the most likely cause of this presentation?
Upper 1/3 of tongue/ front of tongue => most likely caused by trauma from the fall
A patient comes to you with a history of a syncopal episode. On examination, there is evidence of deep lateral cut/bite on the tongue. What is the most likely cause of this presentation?
This one is seizure. Lateral bite
Define vasovagal syncope
Transient loss of consciousness (syncope) resulting from a sudden drop in BP and HR, leading to a sudden drop in cerebral perfusion caused by excessive stimulation of the vagus nerve
What are the causes of vasovagal (Just 10 enough) syncope?
Physical Triggers:
Dehydration
Standing for long periods
Heat exposure
Exhaustion/hunger
Intense physical activity
Situational Triggers:
Medical procedures
Micturition syncope
Defecation syncope
Swallow syncope
Post-prandial syncope (elderly)
Coughing/Sneezing
Emotional Triggers:
Anxiety/fear
Pain
Distress
How would you assess for orthostatic hypotension? What are you looking for?
What 2 medications can be given to those with orthostatic hypotension given that there are no reversible causes?
Lying down and seated+/-standing pressures at 0,1,3,5 minutes. Looking for >20 drop in SBP
Midodrine - alpha agonist
Fludrocortisone - Mineralocorticoid (used in addison’s for the same reason)
Why do the elderly experience orthostatic hypotension
Baroreceptors become less sensitive so they are more prone
e.g. Post-prandial syncope
When performing an abdominal exam. How should your hand be oriented? Why?
Horizontal in order to feel for the splenic notch
What is Waldeyer’s ring? Go through it
It is the ring of lymphoid tissue in the naso and oropharynx
Pharyngeal tonsil (Adenoid)
Tubal tonsils (next to ET tube)
Palatine tonsils (main ones)
Lingual tonsil
What treatments should you offer sperm banking before starting?
Chemotherapy (esp alkylating agents). Alkylating agents such as cyclophosphamide are also used in BM transplants and autoimmune conditions
Radiotherapy to sensitive areas
Surgical: Procedures that may directly (obv) or indirectly affect reproductive organs such as bladder or colorectal surgeries
Androgen-deprivation therapy (prostate Ca, male breast Ca)
State Virchow’s Triad
Stasis/turbulent flow
Endothelial injury
Hypercoagulability
What 3 genetic/inherited abnormalities lead to hypercoagulability
Antiphospholipid syndrome
Anti-thrombin 3 deficiency (also acquired via nephrotic syndrome)
Protein S/Protein C
When asked about why youre performing an ECHO, what will you say?
TTE ECHO looking for a
1) Atrial/ventricular size (LA enlargement, LV hypertrophy),
2) RV systolic pressure (RHF)
3) presence of valvular disease e.g. papillary rupture causing acute mitral regurgitation (rule out),
4) Atrial and ventricular filling,
5) Pericardial disease (dressler)
TOE needed for identifying left atrial thrombus. (also rule out vegetations in IE)
What surgeries should be asked about when taking a history with a renal component?
Fistulas, Permcath, urostomy
CABG
Parathyroid
Renal transplant
How is an EPO injection administered?
SC
If a patient when taking a family history tells you ADPKD. What diseases should you ask questions about?
Aneurysms
AAA (abdo pain, examination)
SAH (headache, brain bleeds…)
Popliteal etc.. Any aneurysm
What are the 3 main SC injections most commonly used in the population?
What are the top 2 examination findings associated with all of them.
1) LMWH (+small subcutaneous haematomas)
2) Insulin
3) EPO
What is the difference between dizziness and vertigo?
Dizziness = Unsteadiness
Vertigo = sensation of person or environment spinning
What is the most important immediate question you should ask when facing a patient with syncope
Position!! and activity the person is doing at the time of syncope
Is parkinson’s onset unilateral or bilateral? How about parkinson +?
Parkinson’s Unilateral
Ddx of Parkinson’s Bilateral
What are the 3 components necessary for balance?
What gait is typically demonstrated in patients with poor balance?
What diseases should you be thinking about when a patient walks into your clinic with that gait?
Wide-based gait
Vestibular system 70% (Think stroke/ENT)
Proprioception 20% (think dorsal columns)
Vision 10% (think demyelination/diabetes)
Others: Alcohol, tumour, vascular, encephalitis, Brucella
Epilepsy drug if you have no idea whats going on
Kepra, Leviteracetam
Whatre the most common causes of delirium?
PINCH ME
Pain
Infection
Nutrition
Constipation
(de)Hydration
Medication
Environment (being in hospital)
Mesothelioma is cancer of the _____?
Pleura (not lung)
Someone says they have occasional palpitations. What is the most important investigation?
Holter monitor 48 hours-2 weeks
What is the format of any set of investigations you want to give?
5+1 things:
Bedside
Bloods
Micro/stool
Radiology
Procedures
+ MDT (allied professionals)
How is heparin monitored? If you have to reverse it what will you do?
Unfractionated is completely reversed with Protamine sulfate but LMWH is only 60-70% reversed with it
What is the main complicated associated with heparin (not present with other anti-coagulants)? Is it more common in LMWH or Unfractionated heparin?
Heparin-induced thrombocytopenia
What is Heparin-induced thrombocytopenia
When does it typically occur after heparin intitiation?
An immune-mediated pro-thrombotic state leading to reduction in platelets. It is a combination of increased platelet activation used up in thrombus formation and increased platelet destruction by the spleen (so another DIC mimic)
This typically occurs 5-10 days after initiation
What is the difference between LMWH and Heparin with regards to the following:
Molecularly
MOA
Administration and Pharmacokinetics
Monitoring and Reversal
Unfractionated heparin is “untouched” large polysaccharides and has an effect on Thrombin (IIa => preventing fibrinogen to fibrin) and Factor Xa in a 1:1 ratio
LMWH are smaller polysaccharide fragments that primarily inhibits Xa with little effect on thrombin
Unfractionated (IV) has a very short half life whereas LMWH (SC) has a long one
Unfractionated requires APTT monitoring whereas LMWH does not. Unfractionated is also completely reversed with Protamine sulfate but LMWH is only 60-70% reversed with it
Look at the image attached. Notice how Xa affects both Prothrombin -> thrombin but also Plasminogen -> Plasmin and hence why it is associated with Heparin-induced thrombocytopenia
Warfarin affects what clotting factors exactly?
You need to perform emergency surgery on a patient with PUD and on Warfarin with an INR of 5.5. You decide to give the patient Octaplex (Prothrombin complex concentrate). What exactly is in the octaplex?
Vitamin K-dependent clotting factors =>2+7=9,10 (dont let it confuse you, it still mainly affects the extrinsic pathway)
Octaplex contains factors 2+7=9, 10 + Protein S and C!
What generation of immigrants will have the same risk of developing idiopathic diseases as those who are residents?
2nd generation, which suggests the environmental aspect of triggering disease
When performing a cardio exam what is a quick way you should use to determine if it is AS or AR?
If pulse of carotid in sync with murmur => stenosis (AS)
If not in sync (AR)
Define Palliative care
It is the management of patients with a chronic progressive life-limiting illness where curative treatment is no longer the goal
