past paper questions 5 Flashcards
most likely mechanism underlying the interaction between warfarin and erythromycin is:
cytochrome P450 enzyme inhibition caused by erythromycin
48 y/o
pmh: Rheumatoid arthritis for which she is on methotrexate
pc: UTI, given antibiotic.4 days later becomes unwell with high fever.
diagnosis of neutropenic sepsis made.
what therapy was commenced that has caused this drug interaction
trimethoprim
other drugs given for UTI?
Either:
- trimethoprim
- nitrofurantoin
management of UTI
antibiotics
- trimethoprim
- nitrofurantoin
alternatives
- amoxicillin
- cefalexin
management of pyelonephritis
the following are first line NICE:
- cefalexin
- co-amoxiclav
- trimethoprim
- ciprofloxacin
UTI in pregnancy increases risk of:
3
- pyelonephtitis
- premature rupture of membranes
- preterm labour
management of UTI in pregnancy?
Management in pregnancy:
7 days of antibiotics (even with asymptomatic bacteruria)
Urine for culture and sensitivities
First line: nitrofurantoin
Second line: cefalexin or amoxicillin
Nitrofurantoin is generally avoided in the third trimester as it is linked with haemolytic anaemia in the newborn.
Trimethoprim is generally considered safe in pregnancy but avoided in the first trimester or if they are on another medication that affects folic acid (such as anti-epileptics) due to the anti-folate effects.
main bacteria causing UTI
E.coli
Most common cause is Escherichia coli (E. coli). This is a gram-negative, anaerobic, rod-shaped bacteria that is part of the normal lower intestinal microbiome. It is found in faeces and can easily spread to the bladder.
Other causes:
- Klebsiella pneumoniae (gram-negative anaerobic rod)
- Enterococcus
- Pseudomonas aeruginosa
- Staphylococcus
- saprophyticus
- Candida albicans (fungal)
72 y/o
pc: ED with palpitation
ECG: ventricular tachycardia
OE: BP normal, no evidence of Heart failure. no chest pain or tightness.
most appropriate therapy:
amiodarone
A 32 year old man in admitted with a supraventricular tachycardia. Name one contra-indication to administering adenosine.
asthma
metformin is a type of:
biguanide
18 y/o male normally fit and well.
pc: ED with lethargy and thirst
BG: 32mmol/L (4-6)
ABG: 7.11 (7.35-7.45)
Low CO2
low bicarb
once patient is managed, he is started on long term medication. what would be the most appropriate long term treatment?
DKA
- common way patients with new diagnosis of T1DM present
Managing DKA
- correct dehydration
- give fixed rate insulin infusion
long term insulin therapy!
what certain viruses may trigger T1DM?
- coxsackie
- enterovirus
remember:
T1DM, pancreas stops being able to produce insulin
treating DKA
Treating DKA (FIG-PICK) Follow local protocols carefully.
F – Fluids – IV fluid resuscitation with normal saline (e.g. 1 litre stat, then 4 litres with added potassium over the next 12 hours)
I – Insulin – Add an insulin infusion (e.g. Actrapid at 0.1 Unit/kg/hour)
G – Glucose – Closely monitor blood glucose and add a dextrose infusion if below a certain level (e.g. 14 mmol/l)
P – Potassium – Closely monitor serum potassium (e.g. 4 hourly) and correct as required
I – Infection – Treat underlying triggers such as infection
C – Chart fluid balance
K – Ketones – Monitor blood ketones (or bicarbonate if ketone monitoring is unavailable)
68 y/o male
pmh: heart failure
given medications.
which of the following drug may have caused him to develop a cough.
a) furosemide
b) metoprolol
c) losartain
d) ramipril
e) digoxin
Rampiril
- ACE inhibitor
Describe the first-line medical treatment for heart failure:
ABAL
ACE inhibitor (e.g. rampiril)
Beta blocker (bisoprolol)
Aldosterone antagonist (spironolactone) when symptoms not controlled with A+B
Loop diruetics
A 62 year woman presents with an area of worsening erythema on the dorsum of her left hand having recently scratched herself on a rose thorn.
On examination this is localised, well demarcated and tender. There is no tracking and she is not systemically unwell.
Which of the following treatments is most suitable?
a) amoxicillin
b) doxycycline
c) erythromycin
d) flucloxacillin
e) gentamicin
- flucloxacillin
- presumed skin infection
A 52 year old man presents with an atrial arrhythmia. He is a known asthmatic. He is successfully treated with a drug which is a class IV anti-arrhythmic drug usually used as a second line agent for atrial arrhythmias. It is contraindicated in heart failure due to its negative inotropic effect.
diltiazem
- calcium channel blocker
Tachycardia treatment summary: UNSTABLE patient
- consider 3 synchronised shocks
- consider an amiodarone infusion
Tachycardia treatment summary: STABLE patient
NARROW COMPLEX
Narrow complex
Atrial fibrillation - rate control with Beta blocker or diltiazem (calcium channel blocker)
Atrial flutter - control rate with beta blocker
Superventricular tachycardia - vasovagal manouever and adenosine
Tachycardia treatment summary: STABLE patient
BROAD COMPLEX
QRS more than 0.12s
Ventricular tachycardia or unclear - amiodarone
If known SVT with bundle branch block treat as normal SVT
If irregular may be AF variation – seek expert help
What four possible rhythms might you see in a pulseless unresponsive patient.
Categorise these into shockable and non-shockable.
Shockable- defib may be effective
Shockable
- Ventricular tachycardia
- ventricular fibrillation
Non-shockable
- pulseless electrical activity
- asystole
What is an atrial flutter?
appearance on ECG
- caused by an re-entrant rhythm in either atrium
- sawtooth appearance of ECG
treatment for atrial flutter (3)
similar to AF
- rate rhythmn control - beta blockers or cardioversion
- radiofrequency ablation of re-entrant rhytm
- anticoagulation based on CHADVASC score
Describe supraventricular tachycardia?
- electrical signal re-entering the atria from ventricles
- self-perpetuating electrical loop without end point
- results in fast narrow complex tachycardia
acute management of stable patients with SVT (5)
- valsalva manoevere
- carotid sinus massage
- adenosine
- alternative to adenosine is verapamil (calcium channel blocker)
- direct current cardioversion
This is caused by an extra electrical pathway connecting the atria and ventricles. Normally there is only one pathway connecting the atria and ventricles called the atrio-ventricular node.
Wolff-parkinson white syndrome
The definitive treatment for Wolff-Parkinson White syndrome is radiofrequency ablation of the accessory pathway.
what is 1st degree heart block?
- delayed atrioventricular conduction through the AV node
- every p wave results in a QRS complex
- PR interval greater than 0.2s
What is 2nd degree heart block?
- some atrial impulses do not make it through AV node
- instances where p waves do not lead to QRS complexes
- 2 types
Mobitz type 1
2nd degree heart block (Wenckebach’s phenomenon)
- atrial impulse becomes gradually weaker until it does not pass through AV node
- after failing to stimulate ventricular contraction, atrial impulse returns to being strong again
- so ECG will show increasing PR interval until P wave no longer conducts to ventricles so absence of QRS complex
- PR interval then returns to normal until another QRS complex is missed
Mobitz type 2
2nd degree heart block
- intermitted failure of interruption of AV conduction
- results in missing QRS complexes
- usually a set ratio of P waves to QRS complexes
- such as 2:1 block, 2 P waves for each QRS complex
treatment for bradycardia
stable: observe
unstable: 1st line = atropine
if no improvement
- atropine IV repeated
- noradrenalin
- transcutaneous cardiac pacing with defib
Atropine side effects
Atropine is an antimuscarinic medication and works by inhibiting the parasympathetic nervous system.
This leads to side effects of:
- pupil dilatation
- urinary retention
- dry eyes
- constipation.
what must be performed before starting a biological agent such as infliximab (UC)
- interferon gamma release assay
management of Crohns
Inducing remission
- 1st line = steroids (prednisolone or IV hydrocortisone)
Adding immunosuppresant
- azathioprine
- methotrexate
- infliximab
how to maintain remission of crohns
first line
- azathioprine
- mercaptopurine
alternatives
- methotrexate
- infliximab
management of ulcerative colitis: inducing remission
mild to moderate
severe disease
mild to moderate
1st line: aminosalicylate (mesalazine oral or rectal)
2nd line: corticosteroids (pred)
severe
1st line: IV corticosteroids
2nd line: IV ciclosporin
maintaining remission of ulcerative colitis
- aminosalicylate (mesalazine oral or rectal)
- azathioprine
- mercaptopurine
what role does histamine play in anapylaxis?
- capillary vasodilation
- smooth muscle constriciton
53 y/o female
pc: severe cough, pain on inspiration, productive cough green sputum tinged with blood.
OE: reduced air entry, bronchial breathing at left base , overlying pleural rub.
indicative of:
Pneumonia: LOBAR
Lobar pneumonia
- usually unilateral whereas broncho pneumonia usually bilateral
- consolidation of entire lobe common
Bronchopneumonia
- patchy inflammation
- involves alveoli of more than 1 lobe
- usually in basilar parts
27 y/o female with asthma.
pc: to GP , acuteexacerbation of asthma not improved with usual SABA + inhaled corticosteroid
RR- 25
Pulse - 90bpm
peak flow - 70% predicted
next appropriate drug treatment?
- prednisolone
- not a severe exacerbation
68 y/o male
pc: difficulty breathing, dry cough and wheeze on reg basis.
pmh: breathlessness which has worsened over the year.s
sh: worked as a coal miner since 18, no pets.
OE: 37.1, 88bpm, bibasal fine crackles
Pulmonary fibrosis
important to note:
- mesothelioma, lung malignant
- strongly associated with asbestos inhalation
- huge latent period
- prognosis very poor
75 y/o male
pc: to GP w/ long term moderate wheeze.
pmh: COPD
dx: salbutamol
peak flow: 65% of predicted
next appropriate drug treatmnet:
salmeterol
Long-acting β2 adrenergic receptor agonist (LABA)
A 60 year old man with rheumatoid arthritis has a 3 week history of dry cough and breathlessness. He has never smoked. His temperature is 36.0°C and there is dullness to percussion and reduced breath sounds at the right lung base.
pleural effusion
- Pleural involvement is a common pulmonary manifestation of rheumatoid arthritis, with small pleural effusions noted in up to 70% on autopsy studies
type 1 vs type 2 respiratory failure
type 1
- damage to lung tissue
- but remaining lung still sufficient to excrete carbon dioxide
- low oxygen, normal to low co2
type 2
- alveolar ventilation insufficient to secrete CO2
- increased resistance to ventilation
- CO2 accumulates
A 67 year old with COPD attends the emergency department with cough and shortness of breath.
ABGs shows:
pH 7.30 (7.35 – 7.45)
PCO2 8.8 kPa (4.5 – 6)
PO2 7.0 kPa (10-14)
BE 9 (-2 - +2)
HCO3 32 mmol/L (22-26)
what is the clinical picture:
- type 2 respiratory failure (increased CO2)
- respiratory acidosis
- with partial compensation
- should aim for sats of 88-92%
which result would be consistent with alcohol excess?
haem: 76 (130-175)
MCV: 100Fl (80-96)
Platelets: 500 (150 - 400)
vitamin b12: >2000 (160-925)
hx of alcohol abuse - cause of raised mean cell volume
- toxic effect on bone marrow
- causing macrocytosis
medical management of pre-eclampsia
- labetolol 1st line antihypertensive
- nifedipine 2nd line (or in asthmatics)
Methyldopa is used third-line (needs to be stopped within two days of birth)
Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia
IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures
Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload
HELLP syndrome is a combination of features that occurs as a complication of pre-eclampsia and eclampsia. It is an acronym for the key characteristics:
Haemolysis
Elevated Liver enzymes
Low Platelets
can cause epigastric pain.
A 70 year old man is admitted with haematemesis over the past 4 hours. He has been resuscitated appropriately in the emergency department. Bloods taken by his GP were normal 6 weeks ago. Bloods on admission show;
Hb 61g/L (130 – 175)
Plt 455 x 109/L (150 - 400)
WCC 7.4 x 109/L (3 – 10)
Creatinine 80µmol/L (60 – 120)
Urea 12.2mmol/L (2.5 – 7.8)
Blood have been taken for group and save and cross-match.
What is next most important step in this man’s management?
OGD
Gastroscopy (OGD - Oesophago-gastro-duodenoscopy)
For the patient with a bowel complaint please select the most appropriate investigation.
A 20 year old man returned from holiday two weeks ago. Whilst abroad he developed diarrhoea which has persisted. Clinical examination is unremarkable.
investigation:
stool culture
A 38 year old man is referred by his General Practitioner because there is a family history of bowel cancer with both, father and brother developing the disease bowel cancer in their 40’s. The patient is asymptomatic
investigation:
colonoscopy
A 65 year old man with sudden onset of absolute constipation, vomiting and colicky abdominal pain. Examination reveals a distended abdomen and an empty rectum on rectal examination. Bloods are normal.
investigation
plain abdo x-ray
A 60 year old man had just returned from a holiday in the Caribbean when he developed colicky abdominal pain radiating from the loin to the groin. The general practitioner dipsticked his urine and there was blood +++ present. This patient was pale, restless and sweaty.
a) acute nephritis
b) hypovolemia
c) renal stones
d) rhabdomyolysis
e) UTI
loin to groin –> renal
restless
renal stones!
peritonitis: very still
the following point to what clinical picture:
may result from the incomplete metabolism of fats and ketoacids
occurs as a consequence of renal failure
metabolic acidosis
results from an excessive loss of H+ ions due to prolonged vomiting
results in:
metabolic alkalosis
results from the excessive excretion of CO2, commonly seen in hyperventilation due to anxiety states
respiratory alkalosis
59 y/o female
pc: ED w/ 30 min hx central chest pain radiating to left arm.
ECG: ST elevation in leads II, III, aVF.
which coronary artery is likely to be affected?
right coronary
rI,III,ght coronary
inferior MI
ECG changes in anteroseptal MI ?
which coronary artery affected?
V1-V4
left anterior descending
ECG changes in inferior MI?
which coronary artery is affected?
II, III, aVF
right coronary artery
ECG changes in anterolateral MI?
which coronary artery is affected?
V4-V6 , I, aVL
left anterior descending or left circumflex
ECG changes in lateral MI?
which coronary artery is affected?
I, aVL +/- V5-V6
left circumflex
ECG changes in posterior MI?
which coronary artery is affected?
Tall R waves V1-V2
usually left circumflex, also right coronary
The following ECG changes may be seen in hypothermia?
- brady cardia
- J wave (huge hump at end of QRS complex)
- 1st degree heart block
- long QT interval
- atrial and ventricular arrhytmias
the following features represent what:
ECG features
- down-sloping ST depression (‘reverse tick’, ‘scooped out’)
- flattened/inverted T waves
- short QT interval
- arrhythmias e.g. AV block, bradycardia
indicative of digoxin toxicity
most common finding in hyperkalaemia:
a) increased PR interval
b) prominent U waves
c) narrow QRS complexes
d) peaked T waves
e) low ST segment
peaked t waves
ECG with right bundle branch block and left axis deviation indicates:
bifasicular block
to determine axis deviation look at leads I, II, III
If two leads positive then RIGHT BBB
if two leads negative then left BBB
65 y/o male
pc: central crushing chest pain, radiates to his left arm and jaw
Obs: 50/min
ECG: ST elevation, bradycardia with 1st degree heart block.
given the history, which leads are most likely to show ST elevation?
1st degree heart block
- MI most likely to affect inferior leads
- RCA provides BS to AV node
Inferior
- II, III, aVF
- Right coronary
