SBAs, SEs & interactions Flashcards
A patient presents with severe stomach pain. He has a history of sweats and new onset diabetes. Evidence of prognathism and depression.
The past medical history is remarkable for OGD for peptic ulcer disease.
What is the most likely cause?
Addison's disease Wermer's syndrome Sipple's syndrome Acromegaly Gastrinoma
A = Wermer’s (MEN type 1)
High calcium - severe thirst, depression, general confusion
(Low -> neuromuscular spasms; Chvostek’s and Trousseau’s signs)
- Addison’s disease
- Wermer’s syndrome = MEN type 1. Most frequent tumours: parathyroid gland (so high calcium), pituitary gland (acromegaly; later sexual hormone dysfunction etc), and pancreas (hence diabetes). Can also cause gastrinomas - > hence peptic ulcer disease
- Sipple’s syndrome = MEN2. Phaeochromocytomas only happen in type 2. Tumours generally occur in endocrine organs (e.g. medullary thyroid carcinoma, parathyroid, and adrenals). Medullary thyroid carcinomas drop calcium; can balance out effects of parathyroid tumour - so can be difficult to catch. Tachy cardic, massive sweat response, pounding heart rate. Tend to have dopamine as main catecholamine in urine. 24hr urinary catecholamine = gold standard test. Can do a spot test though.
- Acromegaly
- Gastrinoma - can increase gastrin in the stomach.
Type 2b or 3 = Marfanoid and mucosal neuromas
23 year old primary school teacher presents with central chest pain, feeling generally unwell. A&E requests a medical review. ECG is normal (always do on admission if chest pain). Many coryzal children in her class. Pain reproducible on pressing the sternum.
MI Pericarditis Tietze's syndrome Aortic dissection Pulmonary embolus
A: Tietze’s syndrome
MI - too young, no other suggestive symptoms
Pericarditis - shouldn’t be reproduced by pressing sternum. Produces *PR depression( on ECG. Widespread saddle shaped ST elevation
Tietze’s syndrome - benign inflammation of one or more of the costal cartilages, plus swelling. Used to be thought to be associated with viral infection, now not considered to be.
Aortic dissection - lost or decreased pulse in left arm. Radial-radial or radial-femoral delay. Described as a ‘tearing’ or ‘ripping’ sign. Mediastinal widening on CXR.
Pulmonary embolus - can cause chest wall tenderness (but rarely). No pleuritic chest pain which there would be with this.
Bornholm’s (epidemic myalgia) - muscle tenderness due to Coxsackie B (and echovirus)
Causes of pericarditis
viral/bacterial infection, high urea, above 25 (renal failure), TB, autoimmune conditions, RF, trauma, radiation, hydralazine.
A patient presents with bradycardia. ECG machine is unfortunately missing or broken. On examination there is a regularly regular pulse at a rate of 40bpm. There is a history of a recent inferior MI and the last ECG shows evidence of trifascicular block. Cannon waves are visible at the bedside.
Constrictive pericarditis Mobitz type I HB AF Complete heart block Sinus bradycardia
Not pericarditis - doesn’t cause bradycardia
AF - no, as pulse would be irregularly irregular
Mobitz type 1 - PR interval gets longer and longer until you drop a beat. Also no since pulse is regular.
So must be complete heart block or sinus bradycardia.
Inferior MI -> complete heart block.
If HR
Absent JVP (can’t see pulse wave form) is pathognomonic for
Some kind of superior vena caval obstruction (eg. SCC of lung)
Tapping apex beat is pathognomonic for
Mitral stenosis
Cannon A waves (on JVP) is pathognomonic for
complete heart block
Dominant V waves (or C-V waves) implies: huge JVP and is pathognomonic for:
Tricuspid regurgitation (Secondary venous upstroke due to filling of RA during systole) Fluid overload
Dominant A wave is pathognomonic for:
tricuspid stenosis (or pulmonary HTN)
How to tell constrictive pericarditis apart from cardiac tamponnade from JVP?
cardiac tamponnade: prominent x descent and absent y descent - very worrying
constrictive pericarditis - prominent x descent and prominent y descent. Can happen in renal failure; repeated inflammation leads to fibrosis and the pericardial sac becomes tighter.
What is Beck’s triad (in cardiac tamponnade). Other signs apart from low ouse volume, pulsus paradoxus (weaker on inspiration
Raised neck veins (raised JVP)
Muffled heart sounds (as fluid around the heart, preventing sounds from transmitting)
Hypotension
-> seen only in 50% of people with cardiac tamponnade. Need an echo to make a diagnosis of cardiac tamponnade
How to treat cardiac tamponnade?
pericardiocentesis (emergency)
Kussmaul’s sign
JVP rises on inspiration. (in normal physiology it should disappear into the chest cavity sue to negative intrathoracic pressure). Can also be seen in severe asthma.
A patient with a hisotry of rheumatic heart disease presents unwell and feverish. Spots under her fingernails (splinter haemorrhages) and a low grade temperature. Her fingertips have a couple of black petechiae (embolic) and nailfold infarcts are seen in the feet. There is a new systolic murmur at the apex and the spleen is palpable. The urine dipstick is positive for blood. A blood culture may classically isolate which bacteria?
Strep viridans
Splinter haemorrhages and nailfold infarcts are particularly common.
Rheumatic heart disease typically affects the mitral valve, and typically stenosis.
75 y/o on warfarin. INR rises suddenly, presents with epistaxis Which drug is responsible?
Bendrofluazide Doxazosin (scroll down!) Erythromycin Ramipril Rifampicin
Erythromycin
Rifampicin induces P450 so INR drops
I70 year old woman w/ HF and renal impairment is taking enalapril, co-amilofruse (combination diuretic - amiloride increases K+) and aspirin. A new drug is started, and she presents with a high K+. Which drug is responsible?
Bisoprolol Digoxin Metolazone Spironolactone Verapamil (strongly negatively inotropic so would never give in CCF).
Spironolactone (K+ sparing so can cause K+ to rise)
80 y/o man with HTN and F. Normally on atenolol, digoxin, (cardiac glycoside) bendrofluazide and aspirin
New drug started and he develops complete heart block. Which drug most likely responsible?
Clopi
Enalapril
Simvastatin
Verapamil
Warfarin
Verapamil (enormously negatively inotropic since process is calcium antagonist - 1st generation). NEVER combine with a beta-blocker.
Can get away with 2 drugs slowing transmission through the AV node, 3 is too many.
Diet controlled T2DM develops uncontrolled hyperglycaemia.
Which drug is most likely to be responsible?
Atenolol
Bendrofluazide
Cholestyramine - bile salt sequestrant so not reabsorbed.
Prednisolone -
Ramipril - renoprotective, often used in DM
Prednisolone (by increased insulin resistance and mechanisms within the liver to promote gluconeogenesis
Can cause major increases -> 15-20mmol.
Bendrofluazide - impairs glucose tolerance but doesn’t cause uncontrolled hyperglycaemia.
Atenolol also upsets glucose tolerance
Both by ~1mmol/l
55 y/o woman taking inh. salbulamol for asthma and paracetamol for osteoarthritis is started on timolol eye drops for glaucoma
Most likely complication? confusion constipation dyspnoea and wheeze hyperkalaemia hypocalcaemia
dyspnoea and wheeze
as salbutamol antagonised by timolol (even though topical -some gets swallowed)
Can also cause bradycardia and collapse, eg. in older patients.
50 y/o woman on oxybutynin (antimuscarinic, non-specific) for bladder overactivity and verapamil for HTN is started on dihydrocodeine for OA pain. What is the most likely complication?
Confusion Constipation Diarrhoea Postural hypotension Urinary obstruction
In a 90 year old could be confusion, constipation or postural hypotension
In a 50 year old, constipation is the most likely.
73 year old man on fluoxetine for depression and orlistat (lipase inhibitor - steatorrhea and fat malabsorption) for obesity is given misoprostol (PGE2 analogue; also used for termination and induction of labour, protects from stomach ulcers but diarrhoea is a common side effect) with diclofenac for pain from osteoarthritis. Most likely complication?
Confusion Constipation Diarrhoea Dyspnoea and wheeze weight gain
diarrhoea - caused by fluoxetine, orlistat and misoprostol.
Drugs causes of gynaecomastia: which one doesn't? DA agonists eg. methyldopa Digoxin – similar structure to steroids Spironolactone Enalapril Cyproterone
Enalapril
55 y/o man fails to recommence spontaneous ventilation after a GA. Ventilated overnight in ITU. Which of the following is responsible?
Amiodarone (anti-arrhythmic)
Dantrolene (muscle relaxant used to treat malignant hyperthermia and neuroleptic malignant syndrome)
Noradrenaline
Propafol
Suxamethonium - muscle relaxant, derived from curare. Used in electroconvulsant therapy
Suxamethonium apnoea - in a small proportion of patients lacking enzymes to break down.
Check family history before surgery; genetically linked.
Dantrolene - for malignant hyperthermia. Quickly out of the system once infusion stopped.
65 y/o with paroxysmal ventricular tachycardia develops a photosensitive rash 2m after being prescribed a new medication. Which of the following is responsible?\
Amiodarone Atenolol Digoxin Diltiazem (Ca-channel blocker) Verapamil (Ca-channel blocker)
Amiodarone - contains iodine
Only drug given for a ventricular tachycardia!
& also causes a photosensitive rash.
Think of iodine on photographic paper (!) tell patients on amiodarone to avoid excessive sunlight exposure. Affects all patients, very unpleasant
Unlikely to be diltiazem or verapamil since they are cousins.
Biopsy of a patient complaining of palpitations , sweats and weight loss. Current medications include digoxin, bendrofluazide, ramipril, amlodipine and amiodarane. What is the diagnosis?
From symptoms: thyrotoxicosis
Amiodarone-induced thyrotoxicosis
An 18 year old man develops a diffuse maculopapular rash following the treatment of a sore throat. Which drug is responsible?
Amoxicillin Erythromycin Ibuprofen Paracetamol Penicillin V
Amoxicillin
Likely to be due to EBV with a bacterial superinfection - streptococcal sore throat.
O/E: enlarged tonsils with exudate (bacterial)
GP prescribes amoxicillin for strep. throat. On amoxicillin or ampicillin, 50% or more with EBV/Strep co-infection will get a nasty pruritic rash.
Safe alternative choice: erythromycin, penicillin V - go for this unless the patient is allergic.
