PassMed: medicine Flashcards
A 45-year-old female patient with no risk factors other than well-controlled hypertension, obesity and varicose veins in the lower extremities presented to the emergency department. She reported sudden-onset chest tightness and fainting after slowly mobilising to the bathroom this morning. It was her third postoperative day following recent knee surgery.
Given the likely diagnosis, how long should she be treated for?
Life-long
1-month
2-months
3-months
6-months
‘Provoked’ pulmonary embolisms are typically treated for 3 months
1-month duration would be too short to treat a provoked pulmonary embolus (PE) and would potentially cause complications and increase her risk of mortality.
2-months duration would be insufficient to treat a provoked pulmonary embolus.
6-months duration is generally for people with active cancer and a confirmed proximal DVT or PE.
Life-long or indefinite anticoagulation is recommended in those patients with unprovoked PE or persistent risk factors such as antiphospholipid syndrome, active cancer or thrombophilia.
First line management of acute pericarditis
involves combination of NSAID and colchicine
Signs of pericarditis
Features
- chest pain: may be pleuritic. Is often relieved by sitting forwards
- other symptoms include non-productive cough, dyspnoea and flu-like symptoms
- pericardial rub
- tachypnoea
- tachycardia
- recent illness
ECG changes in pericarditis
- ECG changes
- global/widespread changes
- ‘saddle-shaped’ ST elevation
- PR depression: most specific ECG marker for pericarditis
when can a patient not be cardioverted during Atrial fibrillation
For cardioversion of AF: patients must either be anticoagulated or have had symptoms for < 48 hours to reduce the risk of stroke.
A 61-year-old man attends the emergency department with a one-hour history of palpitations and chest pain. His observations are as follows: heart rate 168 beats per minute, respiratory rate 22 per minute, oxygen saturations 98% on air, blood pressure 88/59 mmHg and temperature 37.1ºC. His ECG confirms the above heart rate and shows a regular broad complex tachycardia.
Which of the following would be the most appropriate treatment?
In the context of a tachyarrhythmia, a systolic BP < 90 mmHg → DC cardioversion
A 28-year-old man with no past medical history of note is admitted to the Emergency Department with palpitations. His blood pressure is 120/78 mmHg and his pulse is 165 bpm. An ECG is taken:
What is the treatment of choice?
Patients with SVT who are haemodynamically stable and who do not respond to vagal manoeuvres, the next step is treating with adenosine
You are asked to review an ECG of a 76-year-old who has been admitted for a left hemicolectomy:
What is the diagnosis?
The atrial flutter waves (‘sawtooth’) are clearly seen on this ECG. The rate suggests 4:1 block is present.
A 78-year-old man presents to the emergency department with severe, crushing chest pain and shortness of breath. He is seen immediately and, among other investigations, an ECG is performed. You are the F1 in the department, and your registrar says that the ECG shows tall R waves in the V1 and V2 leads.
What is this man suffering from?
Anterior myocardial infarction19%
Posterior MI typically present on ECG with tall R waves V1-2
This is a typical history of a posterior myocardial infarction (MI)- chest pain with tall R waves in V1+V2. This would be typical of a left coronary artery occlusion. An anterior MI would have ST elevation in leads V1-4, inferior would have ST elevation in II, III, and aVF. Pericarditis will cause widespread ST elevation, and cardiac tamponade will have a phenomenon called ‘electric alternans’- beat to beat variation in electrical amplitude.
A 78-year-old lady with known type 2 diabetes presents with a 1-week history of polydipsia, feeling generally unwell and drowsy. On examination, she looks very dehydrated and is difficult to rouse. She appears confused when she does talk to you.
Admission bloods show:
Na+149 mmol/lK+5.2 mmol/lUrea22.1 mmol/lCreatinine254 µmol/l
Her blood glucose is 36 mmol/L.
What’s the most important first management step?
This patient has hyperosmolar hyperglycaemic state (HHS). HHS is characterised by:
- 1.) Severe hyperglycaemia
- 2.) Dehydration and renal failure
- 3.) Mild/absent ketonuria
In this question the first priority should be fluid resuscitation. The commencement of a sliding scale would be a close second and in reality, would probably be prescribed at the same time although some schools of thought advise waiting 1 hour before starting insulin to avoid rapid changes and pontine myelinolysis. The fluid alone will lower the blood sugar and some argue that giving insulin straight away can lower the osmolality precipitously.
A 78-year-old lady with known type 2 diabetes presents with a 1-week history of polydipsia, feeling generally unwell and drowsy. On examination, she looks very dehydrated and is difficult to rouse. She appears confused when she does talk to you.
Admission bloods show:
Na+149 mmol/lK+5.2 mmol/lUrea22.1 mmol/lCreatinine254 µmol/l
Her blood glucose is 36 mmol/L.
What’s the most important first management step?
This patient has hyperosmolar hyperglycaemic state (HHS). HHS is characterised by:
- 1.) Severe hyperglycaemia
- 2.) Dehydration and renal failure
- 3.) Mild/absent ketonuria
In this question the first priority should be fluid resuscitation. The commencement of a sliding scale would be a close second and in reality, would probably be prescribed at the same time although some schools of thought advise waiting 1 hour before starting insulin to avoid rapid changes and pontine myelinolysis. The fluid alone will lower the blood sugar and some argue that giving insulin straight away can lower the osmolality precipitously.
A 78-year-old lady with known type 2 diabetes presents with a 1-week history of polydipsia, feeling generally unwell and drowsy. On examination, she looks very dehydrated and is difficult to rouse. She appears confused when she does talk to you.
Admission bloods show:
Na+149 mmol/lK+5.2 mmol/lUrea22.1 mmol/lCreatinine254 µmol/l
Her blood glucose is 36 mmol/L.
What’s the most important first management step?
This patient has hyperosmolar hyperglycaemic state (HHS). HHS is characterised by:
- 1.) Severe hyperglycaemia
- 2.) Dehydration and renal failure
- 3.) Mild/absent ketonuria
In this question the first priority should be fluid resuscitation. The commencement of a sliding scale would be a close second and in reality, would probably be prescribed at the same time although some schools of thought advise waiting 1 hour before starting insulin to avoid rapid changes and pontine myelinolysis. The fluid alone will lower the blood sugar and some argue that giving insulin straight away can lower the osmolality precipitously.
Over-replacement with thyroxine increases the risk for
osteoporosis
A 62-year-old woman visits her GP for her annual diabetic review. She was diagnosed with type 2 diabetes mellitus 3 years ago and has been taking metformin and glibenclamide to manage her condition. She has a history of bladder cancer and her BMI is 29kg/m².
Her most recent HbA1c comes back at 62mmol/mol.
Which of the following would be most appropriate with regards to her medication?
TD2M already on 2 drugs - if HbA1c > 58 mmol/mol then triple therapy with one of the following combinations should be offered:
- metformin + gliptin + sulfonylurea
- metformin + pioglitazone + sulfonylurea
- metformin + sulfonylurea + SGLT-2 inhibitor
- metformin + pioglitazone + SGLT-2 inhibitor
- OR insulin therapy should be considered
You are working in general practice. Your next patient is a 54-year-old lady with a long history of alcohol dependence, multiple drug misuse and depression. Approximately 3 months ago, she moved in to a local women’s refuge and last week has registered at your practice. She has presented today for her annual review of thyroid function tests, taken earlier in the week.
Her repeat medications include the following:
- Levothyroxine 75 micrograms OD
- Amlodipine 5mg OD
- Thiamine 100mg BD
- Sertraline 50mg OD
Her blood results are as follows:
TSH 11.2 mU/L(0.4 - 4.0)
T4 20 pmol/L(9 - 25)
What is the most likely explanation for this patient’s thyroid function results?
A patient with increased TSH levels and normal T4 may be poorly compliant with thyroxine medication
This patient most likely has had a period of poor compliance with her thyroxine medication, possibly due to her chaotic lifestyle and having only recently registered at the practice. The normal T4 indicates that she has been taking her thyroxine on the days prior to the blood test, however the TSH remaining raised indicates that the T4 level has been low for some time prior to this period - therefore indicating that compliance has overall been poor.
A 25-year-old female presents to her general practitioner with a 2-month history of polyuria, nocturia and chronic thirst. She suffered a concussion in a car crash, one month prior to the onset of her urinary symptoms. Amongst other investigations, she is referred for a water deprivation test.
Give the likely diagnosis, what is this patient’s water deprivation test likely to show?
Water deprivation test: cranial DI
- urine osmolality after fluid deprivation: low
- urine osmolality after desmopressin: high
A 32-year-old woman presents to her GP with a 2-month history of lethargy and cough. She reports chest pain associated with her dry cough and has occasionally noted feeling feverish at home. She has no past medical history and no regular medications. On examination, she has a mild bibasal wheeze. When examining her calves, she has bilateral erythematous bruising on her shins which is painful when palpated. When questioned about this, she assumes she must have knocked her legs while running around after her young twins.
Considering her presentation, which diagnosis should be considered out of those listed below?
Painful shin rash + cough → ?sarcoidosis
A 60-year-old woman who has recently been diagnosed with chronic obstructive pulmonary disease (COPD) presents for review. She is still occasionally breathless despite using a short-acting muscarinic antagonist (SAMA) as required. Her FEV1 is 45% of predicted and she has managed to stop smoking. Looking at her past medical history, you see that she also has been diagnosed as being asthmatic in the past, but only required salbutamol as required when she was exercising. She last had a prescription for salbutamol 10 years ago.
Of the following options, which one is the most appropriate next step in management?
COPD - still breathless despite using SABA/SAMA and asthma/steroid responsive features → add a LABA + ICS
name a SAMA used in initial treatment of COPD
Ipratropium bromide
name a LAMA used as a second line treatment for COPD
Tiotropium is a long-acting muscarinic antagonist and is used as a second-line treatment for COPD (alongside a LABA) in patients with no features of asthma/steroid responsiveness.
Ankylosing spondylitis features - the ‘A’s
- Apical fibrosis
- Anterior uveitis
- Aortic regurgitation
- Achilles tendonitis
- AV node block
- Amyloidosis
A 72-year-old female presents to her general practitioner with a one-month history of bilateral shoulder and hip girdle pain. A diagnosis of polymyalgia rheumatica is made and a daily dose of 15mg oral prednisolone is prescribed.
As the patient will most likely be taking prednisolone for over 3 months, what is the most appropriate action regarding her increased risk of developing osteoporosis?
immediate co-prescription with alendronate
Bone protection for patients who are going to take long-term steroids should start immediately
You are called to see a 75-year-old man with a history of Parkinson’s disease who has just come back from surgery. He has been complaining of nausea and appears to be suffering from post-operative delirium.
Which of the following drugs would be contraindicated?
Haloperidol is a dopamine antagonist that can worsen symptoms in those with Parkinson’s disease and should be avoided.
Despite being a dopamine antagonist, domperidone does not easily cross the blood-brain barrier and is actually considered safe for treating gastrointestinal symptoms in patients with Parkinson’s disease (PD) because the risk of developing extrapyramidal adverse effects is considered minimal.
An elderly, frail woman is admitted to the ward following a fall at home. What is the most appropriate way to assess her risk of developing a pressure sore?
waterlow score
A 88-year-old woman is referred to the memory clinic for assessment after her family report that she has become gradually more forgetful over the past few months. Her Mini Mental State Examination (MMSE) score is 15/30.
The consultant asks you to start her on an acetylcholinesterase inhibitor.
Which of the following medications would you start?
Donepezil
Donepezil is an acetylcholinesterase inhibitor, which along with with galantamine and rivastigmine, are first line for management of mild to moderate Alzheimer’s dementia.
A 79-year-old man is seen in memory clinic with his wife. He has an 18-month history of memory problems. His wife reports she first noticed him struggling to make decisions around that time. This was stable until about 6 months ago, when he became suddenly worse at finding the right words for things. Starting about a month or so, his memory became notably worse. His past medical history includes hypertension and diabetes. An MMSE performed in clinic scored 19/30.
What is the most likely cause of this patient’s cognitive issues?
Stepwise progression of symptoms in dementia - think vascular dementia
A 16-year-old female presents to the emergency department after having ingested 2 packs of paracetamol. She is admitted and given acetylcysteine. The following day she starts showing signs of acute liver failure including hepatic encephalopathy. The doctor decides to order some blood tests that show the following:
Which one of the following blood tests is more likely to monitor the function of the affected organ?
prothrombin time or albumin
Liver enzymes (ALT) are a poor way to look at liver function - they are usually low in end-stage cirrhosis whereas coagulation and albumin are better measures
hypersensitivity reaction overview
after influenza infection which bacteria is most likely to cause pneumonia
Preceding influenza predisposes to Staphylococcus aureus pneumonia
how is AKI classified
AKI is staged according to the serum creatinine changes, and/or the production of urine.
This chest x-ray was taken from a 30-year-old woman who presented with a productive cough.
ALWAYS CHECK THE SIDE OF THE CHEST THE HEART IS ON SILLLLY
Kartageners syndrome
- This patient has x-ray findings consistent with dextrocardia and bronchiectasis (tram-track opacities). Hyperinflation is also seen in this film.
A 25-year-old man presents to the Emergency Department with a two-day history of dyspnoea. His pulse is 84/min, respiratory rate is 18/min and oxygen saturations are 97% on room air. The trachea is central on examination. You review his chest x-ray:
Left-sided pneumothorax (no tension)75%
A pneumothorax is seen on the left side but there is no significant mediastinal shift indicating that there is no underlying tension. The two-day history and unremarkable observations also point away from it being a tension pneumothorax- non-haemodynamic instability
- if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered
- otherwise, aspiration should be attempted
- if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
A 30-year-old unkempt female of no fixed abode presents to the emergency department with severe right upper quadrant pain, decreased consciousness levels and vomiting. She is confused and combative, so a further history is difficult to obtain. On examination she appears thin, jaundiced and has large bruises on her arms and legs. Needle track marks are noted in her anterior cubital fossa. Abdominal exam reveals tenderness in the right upper quadrant but nil else of note.
Observations: respiratory rate = 22 breaths/min, oxygen saturations = 98% on air, heart rate = 112 bpm, blood pressure = 103/98 mmHg, temperature = 37.8ºC, Glasgow Coma Scale score = 12 (E3 V4 M5).
The AST/ALT ratio in alcoholic hepatitis is 2:1
A 76-year-old man presents to his GP with fatigue and abdominal discomfort. He appears pale and has lost about 5kg of weight in the last three weeks. He has also noticed episodes of dark, foul-smelling stool. Blood tests are taken and the results are as shown.
Gastric carcinoma is the correct answer.
The fatigue and weight loss, alongside the anaemia and elevated urea levels, make this the most likely answer.
Gastric cancer can present with an upper gastrointestinal (GI) bleed which would result in raised urea due to digestion of blood. The patient’s dark, foul-smelling stools are indicative of digested blood being passed in the stool.
