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2014-09-13 06:59:34
mcem B
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  1. A 46 year old business man develops diarrhoea 3 days into his trip to SE Asia. He has 3 very important meetings over the next three days and comes into the ED. What advice would you give him? General advice re traveller's diarrhoea including
    • -strict hand hygiene
    • -not eating washed salad
    • -not drinking the water.
    • Could prescribe antibiotics, good evidence for early treatment.
    • In SE Asia consider-> Campylobactor<- azithromycin rather than ciprofloxacin.
  2. What would you tell him about chemoprophylaxis for any further business trips/traveller's diarrhoea?
    -prophylactic antibiotics when the trip is vitally important or the consequences of diarrhoea would be difficult to manage.
  3. Why is chemoprophylaxis currently not recommended for most traveller's?
    • Potential complications e.g.
    • -predisposition to other conditions
    • -vaginal candidiasis
    • -C. difficle diarrhoea
    • -development of bacterial resistance
    • -cost
    • -lack of data and efficacy of antibiotics given for 2 or 3 weeks.
    • Are probiotics any good at preventing traveller's diarrhoea?
    • -Yes as much as 15% risk reduction
  5. When he returns he finds that the diarrhoea has persisted for 2 weeks he comes to the ED out of hours, as he couldn't get a GP appointment. What do you suggest?
    • -Stool sample ->for giardia, cryptosporidium and other parasities
    • -GP should follow up.
  6. 24 yo girl with chest pain who has been out clubbing- very talkative although the girl does indeed appear to be in severe pain. They admit to occasional substance misuse. The ECG seems to show widespread changes that look like an ST elevation M.I. What do you need to do?
    -Go through history very quickly-> risk factors for coronary disease. -Took illicit substances particularly cocaine, how much and when exactly she took it.
    • What important and potentially life threatening condition should be ruled out in this patient at this stage? Could the pain be related to aortic dissection?
    • -Unlikely given the nature of pain described but increased risk with cocaine use.
    • -CXR before treating anything else.
    • Yours suspicions were correct; she is having a myocardial infarction. How do you manage this patient?
    • -MONA.
    • -In addition IV GTN to be given at higher doses titrate but aim for high dose > 10mg/hr final level.
    • -Benzodiazepines to reduce anxiety
  9. You instigate initial measures as described above, what second line pharmacological agents could you use?
    • -Verapamil: in high doses reduces cardiac work load and hence restores oxygen supply and demand as well as reversing coronary vasoconstriction.
    • -Phentolamine: ?-adrenergic antagonist and reverses vasoconstriction.
    • -Labetalol: both ?& ?adrenergic effects it can be used after verapamil and phentolamine if patient remains hypertensive.
  10. The patient fails to improve what should happen next?
    • -PCI.
    • -Evidence for thrombolysis is weak and generally associated with poor outcome secondary to hypertensive induced haemorrhagic complications.
  11. A 35 yo man who has recently come to the UK from Liberia (West Africa) Presents with a 2 day history of worsening symptoms of joint pains, fever, chills, rigors and waking up drenched in sweat. On examination he is febrile at 40C and he is complaining of retrosternal pain. What initial investigations should you carry out?
    • -Blood cultures (all febrile patients)
    • -FBC,U&E
    • -Blood films-> malaria antigen dip stick testing
    • -LFTs
    • -Clotting
    • -Urinalysis
    • -CXR
  12. The malaria screen is negative what do you do?
    • -Contact an expert centre in infections/tropical diseases and arrange transfer.
    • -Consider the possibility of viral haemorrhagic fevers i.e. Lassa fever which is endemic to Liberia.
    • -malaria screen that is negative doesn't necessarily mean that malaria is not present.
  13. Name at least 2 subtypes of malaria and describe which one is potentially fatal?
    • -P. Falciparum (malignant) potentially fatal
    • -P. Ovale
    • -P. Vivax
    • -P. malariae
  14. Describe features that would make this a severe case of falciparum malaria?
    • -Renal failure
    • -Acidosis
    • -Coagulopathy
    • -Hypoglycaemia
    • -Coma
    • -WBC >12 Hb <7
    • -Pulmonary oedema
    • -Retinal haemorrhages
    • - More than 2% Schizonts on blood film
    • What is the first line treatment of falciparum malaria?
    • -Parenteral. If the patient is seriously ill or unable to take tablets-> QUININE IV infusion.
    • The adult dosage regimen for quinine by infusion is: loading dose(2) of 20 mg/kg(3) (up to maximum 1.4 g) of quinine salt(1) infused over 4 hours
    • then 8 hours after the start of the loading dose, maintenance dose of 10 mg/kg(4) (up to maximum 700 mg) of quinine salt(1) infused over 4 hours every 8 hours (until patient can swallow tablets to complete the 7-day course together with or followed by either doxycycline or clindamycin as above).
    • Specialist advice should be sought in difficult cases (e.g. very high parasite count, deterioration on optimal doses of quinine, infection acquired in quinine-resistant areas of south east Asia) because intravenous artesunate may be available for ?named-patient? use.
  16. A 69 yo smoker who lives alone is brought in acutely dyspnoeic by the crew. Initial observations show the she is drowsy GCS 13. RR 33, HR 146, BP 78/47. They let you know that according to her next door neighbour she only came home from hospital last week and hasn't left the house since. She has oxygen at home and is on lots of medication. Apparently she is awaiting placement in a nursing home as she can no longer manage with 3 calls a day. You diagnose a severe exacerbation of COPD and are not concerned about sepsis. Your initial impression is that the patient is peri-arrest. List 3 important things that you need to try to do in the next 5 minutes in order of priority.
    • 1. Treat what you can treat i.e. ABCDE assessment gain IV access, take blood off etc. Try to ascertain a diagnosis an ABG will be very helpful as will a chest x-ray (may be too unstable?)
    • 2. Get the arrest trolley out and organise your team.
    • 3. Try to speak with any family or the GP if possible, track down hospital notes; is there a plan in place for this patient if she should become very unwell
    • You notice that the oxygen is flowing at 15 litres from the wall supply via a non-rebreathe mask. Is this of relevance to the patient's condition? It might be?
    • -You need to access if the patient is adequately oxygenating and ventilating.
    • -The sats probe will help with the former but not the later.
    • -An ABG will guide you. It is possible that she has been over oxygenated on route to hospital and that the CO2 is raised causing the lowered GCS.
    • -Turning down the oxygen may improve the patient's condition.
  18. What amount of oxygen should you give this type of patient prior to obtaining an ABG?
    • -This is clearly not an exact science but it is much better to start low and titrate up when the history points towards COPD.
    • -If the patient is known to have had hypercapnic respiratory failure in the past then give an FiO2 of 24% via a venture mask.
    • -For all other patients and when the diagnosis is unclear give 40% FiO2 until an ABG has been obtained.
    • List 3 therapies that you gave the patient on admission.
    • -Salbutmaol nebs 2.5mg or 5 mg
    • -Ipratropium nebs 500mcg
    • -steroids, prednisolone 30mg if could swallow (unlikely) therefore 200mg of IV hydrocortisone.
    • -Stat dose of doxycycline also given 200mg.
  20. The medical registrar demands that this patient is put on NIV right now and sent straight to medical HDU. The patient's observations have now worsened. What is your response?
    • -No. The patient is clearly unstable is peri-arrest and would not tolerate NIV at present.
    • -Moving the patient would be catatrophic. ITU need to be involved with this patient.
    • -If a decision is made that invasive ventilation is not appropriate then a trial of NIV is an option although it may not be successful.
  21. 60 year old woman who has arrested. had chest pain but had arrested soon after the ambulance staff got to her home.The patient had received CPR and has IV access but has not received any medications thus far. What is the first step in the management if this patient is in VF?
    • -Give one shock.
    • -Resume CPR immediately after the shock.
  22. After this step how many cycles of CPR should be given before the next rhythm check?
    -Give five cycles of CPR and then check rhythm.
  23. After the cycles of CPR there is another rhythm check and the patient is still in VF. What are the three next management steps?
    • -Give 1 shock.
    • -Resume CPR.
    • -Give adrenaline 1mg IV/IO, repeat every 3-5 minutes.
  24. What anti-arrhythmic medication should be given during CPR?
    -Amiodarone 300mg IV/IO once, then consider additional 150mg IV/IO.
  25. If the patient is in torsades de pointes what medication should be given and at what dose?
    -Magnesium, loading dose 1 to 2g IV/IO.
  26. A 64 year old lady is brought in vomiting she has had haematemesis for the last 2 hours and has just passed a large volume of PR blood. What anatomical point differentiates an upper from a lower gastronintestinal bleed?
    -Ligament of Treitz it inserts as nonstriated muscle commonly into the third and fourth portions of the duodenum and frequently into the duodenojejunal flexure as well.
  27. Is it safe to assume that the above patient is having an upper or a lower gastrointestinal bleed (LGIB)?
    • -It is unclear. You need to know if the blood is classical malaena or fresh blood but be warned LGIB can present with fresh PR blood loss.
    • -15% of LGIB present as UGIB.
  28. List 5 potential causes of an upper GI bleed.
    • -Ulceration stomach or duodenum
    • -Inflammation: oesophagitis/gastritis/duodenitis
    • -Mallory Weiss tear
    • -Warfarin or clotting disorders
    • -Gastric or oesophageal malignancy
    • -Oesophageal varices
  29. Name a scoring system for risk stratifying upper GI bleeds and list 4 criteria that it focuses on.
    -The Rockall score 1 Variable Score 0 Score 1 Score 2 Score 3 Age <60 60- 79 >80 Shock No shock Pulse >100 SBP <100 Comorbidity Nil major CCF, IHD, major morbidity Renal failure, liver failure, metastatic cancer Diagnosis Mallory-weiss All other diagnoses GI malignancy Evidence of bleeding None Blood, adherent clot, spurting vessel
  30. What is the commonest type of LGIB?
    -UGIB followed by diverticular bleeds.
  31. The patients Hb comes back at 4.4 how many units of bloods will you give?
    • -Therefore the smallest volume of blood should be given aiming for a Hb> 7.
    • -3-4 units initially but if ongoing bleeding then more blood will be needed as will clotting factors and potentially platelets.
    • What methods can be used to control a variceal UGIB prior to endoscopy?
    • -Telipressin 2mg IV 4-6 hourly
    • -possible insertion of a Sengstaken/Minnesota tube.
  33. A 31 year old business man developed a sudden onset of sore throat, fever, diarrhoea and lethargy. He developed a rash over the next few days affecting the face/trunk/palms and soles. He had been in Singapore 2 months previously. OE he had cervical lymphadenopahy a widespread rash, temp 38.4 and an erythematous pharynx. He was also c/o a non-productive cough.List some differential diagnoses:
    • -HIV seroconversion
    • -EBV
    • -MV infection
    • -Acute hepatitis
    • -TB
  34. If he had glandular fever what would the most likely cause of the rash be?
    -Amoxicillin administration.
  35. What is common cause of diarrhoea in a patient infected with HIV?
    -Cryptosporidium (supportive treatment)
  36. A chest x-ray taken in the above patient showed bilateral diffuse interstitial shadowing. What is the likely diagnosis?
    -HIV/AIDS- pneumocystis jiroveci pneumonia (formerly PCP)
  37. What is the treatment?
    -IV co-trimoxazole
  38. An 18 yo male presented to the emergency department following a collapse at a local night club. O/E drowsy, T 40C sweating profusely. HR 120 bpm and regular. BP 170/100 mmHg. pupils dilated and reacted poorly to light. His blood investigations revealed a sodium of 124 mmol/l. What is the most likely cause of his presentation?
    -Ecstasy(MDMA) abuse.
  39. What are the possible complications of this presentation?(list four)
    • -Rhabdomyolysis
    • -ARF
    • -DIC
    • -acute hepatitis
    • -MI
    • -CVA.
  40. Give two therapeutic steps in the management of his temperature.
    • -Cooling/tepid sponging
    • -paracetamol and IV dantrolene.
  41. Give two explanations for the hyponatremia?
    • -SIADH
    • -excessive sodium loss from skin during profuse perspiration.
  42. Name some other causes of hyperpyrexia? (Name four)
    • -Septicaemia
    • -malaria
    • -viral infections
    • -neuroleptic malignant syndrome
    • -malignant hyperpyrexia
    • -cocaine abuse
    • -malignancy
    • -aspirin toxicity.
  43. A 41 yo man c/o feeling dizzy and having a headache, Lethargic and cannot concentrate on anything, not even watching the TV?. He tells you that he was knocked out a week ago at hid boxing gym but felt fine afterwards so didn't see a doctor. What points must you cover in the history?
    • -Questions about the drowsiness
    • -Intellectual function
    • -Neck pain
    • -Vomiting
    • -Photophobia
  44. What should you specifically look for on examination?
    • -Any focal neurology
    • -evidence of meningitis or intracranial haematoma
    • -papilloedema
  45. What 2 further questions are crucial?
    -patient is an alcoholic or if he has any bleeding tendencies as these patients are at high risk for chronic subdural haematomas.
  46. What is the likely diagnosis? )Your examination is unremarkable and the 2 questions you asked in part c) are negative).
    -Post-concussion syndrome.
  47. What advice do you give the patient?
    • -Write to GP explaining diagnosis
    • -To see GP for long term FU
    • -That symptoms may continue for a few months
    • -Reassure that symptoms should gradually resolve
    • -Advise not to return to contact sort until symptoms settle
  48. A 44 yo woman c/o headache and visual disturbance. She has essential hypertension. Her BP is 235/119. What is occurring?
    • -You don't know yet until full exam is performed.
    • -This is hypertensive urgency -Urgency is defined as severely elevated blood pressure (ie, systolic >220 mm Hg or diastolic >120 mm Hg) with no evidence of target organ damage.
    • -A hypertensive emergency is a condition in which elevated blood pressure results in target organ damage.
    • -For malignant hypertension to be diagnosed papiloedmea must be present.
  49. What examination is critical here?
    -Need to look at the fundi for papiloedema or other changes associated with vascular damage such as flame-shaped haemorrhages or soft exudates, but without papilloedema.
  50. How would you treat her?
    • -Depends if this turns out to be a hypertensive emergency or not, if not then aim to reduce the BP slowly if no contraindications for a beta blocker then this is a good option i.e. Atenolol 25mg
    • -Hypertensive emergencies require immediate therapy to decrease blood pressure within minutes to hours.
    • -In contrast, no evidence suggests a benefit from rapidly reducing blood pressure in patients with hypertensive urgency. In fact, such aggressive therapy may harm the patient, resulting in cardiac, renal, or cerebral hypoperfusion.
    • The fundoscopic picture reveals the following (see figure 1). What do you do?
    • -hypertensive emergency: IV drug is nitroprusside.
    • -An alternative for patients with renal insufficiency is IV fenoldopam. Labetalol is another common alternative, providing easy transition from IV to oral (PO) dosing.
    • -Beta-blockade can be accomplished intravenously with esmolol or metoprolol.
    • -Also available parenterally are diltiazem, verapamil, and enalapril.
    • -Hydralazine is reserved for use in pregnant patients
    • -while phentolamine is the drug of choice for a pheochromocytoma crisis.
    • -Pt should be managed with an arterial line on ITU.
  52. A 24 year old woman presented with left flank pain which had come on gradually and difficulty passing urine. On examination her temperature was 38.4 degrees. Urinalysis revealed nitrites, leukocytes and blood in her urine. What is the most likely diagnosis?
  53. How would you further investigate this patient?(Four steps)
    • -MSU to laboratory for microscopy, culture and sensitivity.
    • -FBC, UE,
    • -Blood cultures
    • -renal ultrasound.
  54. How would you manage this patient?(Three steps)
    • -Antibiotics
    • -IV fluids
    • -analgesia
    • -organise admission or follow up.
  55. What is the most common pathogen to cause this condition?Name another two pathogens to cause this condition?
    • -E.Coli.
    • -Others include klebsiella, enterococcus, and staph saprophyticus.
  56. Name three risk factors for this condition?
    • -Frequency (3 times per week) of sexual intercourse in the previous 30 days
    • -UTI within the previous 12 months (OR 4.4)
    • -diabetes (OR 4.1)
    • -stress incontinence within the previous 30 days (OR 3.9)
    • -a new sex partner in the previous year (OR 2.2)
    • -recent spermicide use (OR 1.7)
    • -UTI history in the participant's mother (OR 1.6).
  57. A 28 yo gentleman from Poland attends after falling over in the garden and cutting his finger on a piece or metal that was supporting a plant in his vegetable patch. The wound appears to be trivial. What important questions do you need to illicit in the history? (2 marks)
    • -tetanus prone wound? How old is the wound, was there any manure in the ground?
    • -Has he had immunisations against tetanus?
  58. What are the signs of tetanus infection and at what stage after sustaining a wound do they present? (2 marks)
    - 4-21 days (average 10) after infection, with agonising contraction superimposed on muscular rigidity.
  59. What features constitute a tetanus prone wound? List 5 things.
    • -significant degree of devitalised tissue
    • -puncture type wound
    • -contact with soil or manure
    • -clinical evidence of sepsis
    • -occurring more than 6 hours before presentation
  60. A 25 yo F + took 7 bottles of 650ml methadone and 2 bottles of vodka. The ED doctor who laid eyes on her wrote: looks dreadful in the notes. She has pinpoint pupils. What is your immediate management?
    • -ABCD with focused history if available Main priority will usually be A in such patients Ensure that airway is maintained (may require adjuncts or actually ventilating them, always have bag valve mask on hand)
    • -Can give IM naloxone if doesn't have IV access
  61. You cannot get IV access quickly in this lady what will you do?
    -Give IM naloxone likely better to start with a reasonable dose i.e. 600mcg. Can give 200mcg-2mg in repeated doses up to 10mg.
  62. What is the dose of naloxone in children?
    -10mcg/kg with subsequent doses 100mcg/kg (????)
  63. You get a response to your treatment. However it appears transient what will you do? (Please describe exactly showing the workings of any calculations)
    • - (600/100 x 60) = 360mcg to infuse over 1 hour.
    • - Make up a syringe containing 4mg of naloxone in 20mls (therefore 200mcg per ml) Therefore 1.8ml per hour needs IV infusion of naloxone.
    • - BNF says: By continuous intravenous infusion using an infusion pump, 4 mg diluted in 20 mL intravenous infusion solution [unlicensed concentration] at a rate adjusted according to response (initial rate may be set at 60% of initial intravenous injection dose (see above) and infused over 1 hour)
  64. You take an ABG and the results are shown below: pH 7.107 pCO2 8.93 pO2 36.05 HCO3 16.2 BE -10.6 HB 15.1 Glucose 13.2 Describe what it shows?
    • -Metabolic acidosis negative BE and low pH.
    • -Also comment on the glucose.
    • -Comment on the high CO2 Respiratory depression.
  65. A 21 yo F is brought in to the department looking desperately unwell, she has been at an all night rave and has taken 7 ecstasy tablets she is pale and hot but is lucid. She then becomes unresponsive, you fluid resuscitate her and check her BM which is normal. You send off a full set of investigations, which show the following: INR 3.4, WBC 18.3, Ur 14 Cr 312, temp 38.2, urine dip positive for blood, CK 1203. pH 6.31 What is going on?
    • -Rhabdodyloysis from raving all night and ecstasy.
    • -She has also developed DIC.
    • -Acute renal failure.
  66. Where should this patient go and what should be done?
    • -ITU
    • -Prompt correction of fluid deficits and acidosis are crucial.
    • -Will likely need renal support.
  67. What electrolytes can easily become deranged and need to be corrected in this condition?
    -K+ and Ca2+
  68. Give 3 other causes of the conditon:
    • -compartment syndrome direct injuries and severe burns exertional: raving
    • -fitting
    • -metabolic disorders: myxodema
    • -neuroleptic malignant syndrome
    • -myositis due to infection
  69. Eligibility criteria for the treatment of acute ischemic stroke with recombinant tissue plasminogen activator (rt-PA) include: Within how long a period of time can treatment be given after a clearly defined symptom onset?
    -Thrombolytic treatment should be initiated within 3 hours of a clearly defined symptom onset.
  70. Name three features of the HISTORY which may exclude the use of thrombolysis.
    • -stroke or head trauma within the prior 3 months
    • -any prior history of intracranial hemorrhage
    • -major surgery within 14 days
    • -gastrointestinal or gentitourinary bleeding within the previous 21 days
    • -myocardial infarction in the prior 3 months
    • -arterial puncture at a noncompressible site within 7 days
    • -lumbar puncture within 7 days.
  71. Name three CLINICAL features which exclude the use of thrombolysis.
    • -rapidly improving stroke symptoms
    • -only minor and isolated neurologic signs
    • -seizure at the onset of stroke is an exclusion if the residual impairments are due to postictal phenomenon (Seizure is not an exclusion if the clinician is convinced that residual impairments are due to stroke and not to postictal phenomenon)
    • -symptoms suggestive of subarachnoid hemorrhage, even if the CT is normal
    • -clinical presentation consistent with acute MI or post-MI pericarditis
    • -persistent systolic BP>185, diastolic BP>110 mmHg ->requiring aggressive therapy to control BP
    • -pregnancy or lactation
    • -active bleeding or acute trauma (fracture).
  72. Name three LABORATORY features which exclude the use of thrombolysis.
    • -platelets <100,000/mm3
    • -serum glucose <50 mg/dL (2.8 mmol/L) or >400 mg/dL (22.2 mmol/L)
    • -INR >1.7 if on warfarin and an elevated partial thromboplastin time if on heparin.
  73. Name two head CT scan features which exclude the use of thrombolysis.
    • -evidence of hemorrhage
    • -evidence major early infarct signs, such as diffuse swelling of the affected hemisphere, parenchymal hypodensity, and/or effacement of >33 percent of the middle cerebral artery territory.
  74. A 68 yo M presents with central chest pain. ECG shows an anterior STEMI. What is the best treatment?
    -Primary coronary angioplasty, lower mortality and lower re-infarction rates.
  75. What is the advantage of tenectaplase and reteplase as thrombolytic agents?
    -ease of administration as they are given as single bolus doses.
  76. What is the risk of major bleeding with thrombolysis?
    - 2-3%
  77. List 4 absolute contraindications to thrombolysis:
    • -Active internal bleeding
    • -suspected aortic dissection
    • -recent head trauma/intracranial tumour
    • -haemorrhagic stroke at any time
    • -ischaemic stroke within the last year
    • -previous allergic reaction to fibrinolytic agent
    • -trauma or surgery within the last 2 weeks at risk of bleeding.
  78. What drug is give along side thrombolytic agents?
    -IV heparin
  79. A man is brought in who has been involved in a fire in a factory, which makes mattresses. He looks drowsy but is rousable he is complaining of a headache and feeling dizzy. You do a blood gas, which reveals a CO level of 17%. You are concerned about CO poisoning. What do you do?
    • -severe poisoning
    • -Give high flow oxygen
    • -ECG check for arrhythmias and or MI
    • -If becomes unconscious the consider IPPV
    • -Consider hybebaric oxygen if there is a centre nearby.
  80. The ABG also showed a profound metabolic acidosis a nurse thinks that is breath smells sweet what do you consider?
    -Although the detection of almond smelling breath is not reliable 50% of people cannot smell it this may represent cyanide poisoning.
  81. What antidotes could you use if your suspicions above are correct?
    -Dicolbat edetate or sodium thiosulphate
  82. What level of CO can smokers have in normality?
    -Around 8% would be a normal level.
  83. What must you be careful of when treating this patient?
    -Avoid getting contaminated yourself. Ensure that Protective clothing is worn!
  84. A 68 yo M + feeling generally unwell and weak. His wife tells you that he collapsed earlier this morning but he is denying any such thing. He has lost 6kg in weight over the last 3 months. Abdominal examination reveals some left sided loin tenderness. Urinalysis reveals blood 4+, protein 2+. You do a chest x-ray as part of your collapse's Cause work up and find the following findings (see figure 1). What does the radiograph show? List a few differential diagnoses for this picture.
    • -Cannonball metastasis
    • -could be from renal, testicular, colon, osteosarcoma.
  85. The patient's haemoglobin is 19g/dL what could be the cause of this?
    -Renal cell carcinoma from the history given the relative polycythemia could be due to an increased amount of circulating rennin. Renal tumours often secrete rennin and ertythropoetin along with other peptide hormones.
  86. What lab tests are especially important in this case?
    • -Calcium level- could be raised and need treating.
    • -U&E- again could show decreased renal function.
    • -LFTs: any evidence of liver involvement.
  87. Given the likely diagnosis what is the management and prognosis for this patient?
    • -Very poor. If it has spread metastatically to other organs, the 5-year survival rate is less than 5 %.
    • -Management would still be surgical to remove the tumour from the left kidney if the patient was fit enough for surgery as removal of the primary tumour has been shown to improve survival and cause regression of the metastasis.
    • -Also likely to go on to have palliative chemo and radiotherapy.
  88. You see a 94 yo nursing home resident + confused. The nurse with her states that she is not normally confused. List 3 simple ED tests that are crucial in this case.
    • -Urinalysis
    • -Baseline observations
    • -Temperature BM
    • -AMMT
    • -Breath alcohol
  89. You take a very detailed history and perform a through examination. All base line observations are normal apart from a temp of 38.3C. The nurse tells you that she had been cold this morning and they had out on the gas fire in her room for the first time this year. Would you do any further tests in light of the above information?
    • -Need to perform an ABG for CO.
    • -Possible that she could have carbon monoxide poisoning.
  90. What other investigations would you like?
    • -CXR
    • -ECG
    • -FBC
    • -U&E
    • -blood glucose.
  91. The urinalysis is grossly positive and on repeat questioning the nurse had noticed that her urine had been rather pungent over the last 48 hours. What will you do now?
    • -Patient needs admission
    • -Bloods cultures
    • -Send MSU to the lab
    • -Empirically treat likely with oral antibiotics initially if patient can swallow them. Trimethoprim 200mg/BD
  92. Name 2 pathogens that commonly cause UTIs
    • -E coli spec
    • -Enterococcus faecalis
    • -Klebsiella pneumoniae
    • -Proteus mirabilis
    • -Bacteriodes
    • -Pseudomonas aeruginosa
  93. A 55 yo F + severe abdominal pain. She is an epileptic and takes Carbamazepine. Normally fit and well her only other medicines are the OCP. You examine her abdomen which is soft with no signs of peritonism. She is tachycardic but hypertensive. She also complains of loss of sensation in her lower limbs. She is also agitated. Her bloods reveal a sodium of 125mmmols/L. Her urine sample that was taken 30 minutes ago looks brown/red. What could be going on here? What would you do to confirm your suspicions?
    • -Although the differential is wide the history is suggestive of acute porphyria
    • -Other differentials include:
    • acute abdo pain (any cause of)
    • Guillain-Barre syndrome
    • Systemic lupus erythematosus
    • -Test the urine for porphobilinogen (PBG) (send a urine sample that is protected from light)
  94. Urinary porphobilinogen (PBG) is markedly elevated which confirms your suspicions about what is going on. What will you do?
    • -Manage pain! Normally requires opiod analgesia
    • -In severe attacks, a glucose 10% infusion is commenced, which may aid in recovery.
    • -Supportive treatment ensure that high carbohydrate feed is given.
    • -Haem arginate are the drugs of choice in acute porphyria
    • -Consider propanolol to treat hypertension
  95. What are the causes of the condition describe d?
    • -Abnormalities of haem-biosynthesis
    • -They are broadly classified as
    • hepatic porphyrias
    • erythropoietic porphyrias
    • based on the site of the overproduction and mainly accumulation of the porphyrins (or their chemical precursors).
    • They manifest with either skin problems or with neurological complications (or occasionally both).
  96. List things that can precipitate an attack of the condition described?
    • -ETOH
    • -lead poisoning
    • -iron deficiency
    • -drugs(carbamazipine, OCP, sulphonamides, methyldopa, barbiturates, danazol, chloramphenicol, tetracyclines, some antihistamines)
    • -smoking
    • -sudden dieting
    • -emotional and physical stress
    • -pregnancy
  97. A 77 yo F hx/o collapse. She had no preceeding or warning symptoms. She had no palpitations or seizure activity. On examination she appeared well and was in no distress. Her rhythm strip is shown. What is the diagnosis?
    -Complete heart block.
  98. What are the symptoms and clinical manifestations of this condition?
    • -Dizziness, presyncope and syncope (Stokes-Adams attacks), ventricular tachycardia, and ventricular fibrillation.
    • -The slow rate also can also worsen the symptoms of heart failure and angina pectoris.
  99. What are the most common causes of this condition?(Name)
    -fibrosis and sclerosis (sclerodegenerative changes) of the conduction system and ischemic heart disease.
  100. The QRS duration above is <120ms. What does this imply with regard to the level of the block?
    -If the escape rhythm has a normal QRS duration of less than 120 msec, the block occurs with almost equal frequency in the AV node and the bundle of His.
  101. How would you manage this patient in the emergency department?
    • -Monitored bed.
    • -Look for and correct reversible causes such as myocardial ischemia, increased vagal tone, and drugs that depress conduction.
    • -Urgent cardiology consultation with a view to insertion of a temporary pacing wire.
  102. What type of M.I. is shown in the ECG (fig 1), describe what is shown.
    -Lateral M.I. ST elevation in leads 1 and aVL can't see elevation in 2 and v6 but you don't always get a complete set. Also note the inferior reciprocal changes 2,3 and aVF.
  103. Which coronary vessel is likely to be occluded?
    • -Left circumflex.
    • -When the picture shows antero-lateral changes i.e. ST elevation in all the precordial and lateral leads the occlusion is higher up in the left coronary artery before it splits into the LAD and LCx.
  104. You consider thrombolysis for this patient, what 5 medications have you already given?
    • -Oxygen
    • -morphine
    • -Aspirin
    • -Clopidogrel
    • -LMWH.
  105. Name 2 agents that you could use for thrombolysis and describe how they are given. (STAR) Menomic
    • -Streptokinase give 1.5 mega units in a continuous infusion over 1 hour.
    • -Alteplase: 15mg bolus followed by 0.75mg/kg (max 50mg) IVI for 30 mins, then 0.5mg/kg (max 35mg) over 60 mins.
    • -Give heparin or s/c LMWH.
    • -Reteplase: 2 IV boluses of 10 units each 30 mins apart (give heparin as above).
    • -Tenecteplase: single IV bolus over 10 seconds, Dose according to weight (also give heparin as above)
  106. After you give thrombolysis the patient seems to still be in pain and after 30 minutes there is no resolution of the ST segments. What will you do?
    -transfer to an interventional centre for rescue PCI
  107. A 36 yo F + short history of breathlessness a rash and feeling wheezy and SOB that came on whilst out at a restaurant with friends. She is a known asthmatic and also has eczema. Name 4 common causes of anaphylaxis:
    • -Latex
    • -Food (nuts, shellfish, wheat, strawberries)
    • -Hymenoptera (bee stings)
    • -Drugs and vaccines (many including: NSAIDS, sux, Abx, Asprin, IV contrast etc
  108. What is your initial management (assume airway compromise and a severe reaction)?
    • -Assess ABC and treat accordingly
    • - 100% O2
    • - IM adrenaline if needed (0.5mg 1:1000 IM)
    • - Salbutmaol nebs
    • - 10mg IV chlorphemeramine
    • - Fluid if not responding to adrenaline
    • - Oral or IV steroid depending on if patient can swallow
  109. After assessing ABC the patient is stable. How long would you want to observe her for and why?
    -At least 4 hours looking for delayed hypersensitivity, also patient is asthmatic and they often have more severe reactions.
  110. Which medication is pertinent in the history of any patient presenting with angio-oedema?
    -ACE inhibitor i.e. Ramipril
  111. How do you treat Hereditary angio-oedema?
    -C1 esterase inhibitor
  112. A 56 yo F has taken 56 of her amitriptyline tablets. List features that would commonly be apparent in a patient who had done this?
    • -Dry mouth
    • -Tachycardia
    • -Dry skin
    • -Dilated pupils
    • -Ataxia
    • -Urinary retention
    • -Jerky limb movements
    • -Coma
  113. What dose is toxic?
    -When >10mg/kg is taken
  114. What ECG changes can be seen?
    • -Sinus tachycardia is common, with severe poisoning PR and ORS duration increase.
    • -The rhythm can look like VT as the P waves are superimposed on the preceding T wave and the QRS duration is prolonged.
    • -Any arrhythmia can occur and bradycardia normally indicates a per-arrest scenario.
  115. She becomes unconscious and requires mechanical ventilation, whilst being ventilated develops a bizarre tachyarrhythmia, what do you do?
    -Do not treat with antiarrhythmics, instead treat the acidosis and correct hypoxia, use sodium bicarbonate 8.4% (adult 50-100mL IV).
  116. Is there a role for activated charcoal in an amitriptyline overdose?
    -Yes it binds it but must ensure that the patient can protect their own airway and that it is given within an hour or so of presentation.
  117. A 59 yo F + hx/o IHD presents with tiredness and SOB. Her initial observations show a HR of 59 b.p.m. Bp of 140/84 and sats of 100%. What part of the history is key to making any diagnosis here?
    -Is she on beta-blockers? If yes then these may be normal observations, also if she was an especially fit 59 year old it is possible that this represents a normal heart rate.
  118. What is first degree AV block?
    • -Prolonged PR interval i.e. > than 0.2 seconds (5 small squares on standard ECG)
    • -it is benign but it may represent IHD, digoxin toxicity, electrolyte disturbances, acute rheumatic carditis
  119. Mobitz type 2, and mobitz type1 (Wenkebach type) are both types of secondary degree heart block. Which one is benign and which can lead to complete heart block?
    • -Wenchebach is normally benign.
    • -Mobitz 2 and 2:1 block can lead to third degree ->complete heart block.
  120. What does this ECG show (fig 1)?
    -Complete heart block (CHB)/third degree block
  121. How would you treat it in the emergency department if the patient were unstable?
    • -Atropine
    • -adrenaline
    • -then transcutaneous pacing. Temporary measures before transvenous pacing can be arranged.
  122. A 27 yo F + palpitations of sudden onset which she has had before. What does the ECG show (fig 1)?
    -Supraventricular tachycardia (SVT)
  123. In a young healthy individual with a normal resting ECG what is this type of rhythm likely due to?
    -It is likely to be an atrioventricular nodal re-entrant tachycardia (AVNRT) i.e. the most common cause of narrow complex tachycardia in patients with normal hearts.
  124. How do you treat it in the ED providing that she is stable with the rhythm? (Include exact drug doses and sequences)
    • -Attempt vagal manoeuvres, valsalva with 50 ml syringe, carotid sinus massage etc.
    • -If fails try IV adenosine 6mg, 12mg, 12mg
  125. Describe what you might need to explain to a patient prior to the interventions you gave in part c.
    -Warn of the side effects of adenosine feeling of sudden chest discomfort and flushing patients say that it feels terrible!
  126. What will the definitive management options?
    • -Radio frequency ablation (RFA) is the first line treatment for recurrent symptomatic episodes, which is curative.
    • -Or AV blocking drugs beta-blockers, diltiazem, or verapamil can be used as a ?pill in the pocket? type approach to terminate an event.
  127. A 71 yo M presents with central crushing chest pain. An ECG shows ST elevation in leads V1-V4. He receives thrombolysis. 3 hours later his ECG shows (see fig 1). What does the ECG show?
    -Second degree heart block- Mobitz type II.
  128. What size does the ST elevation need to be in the chest leads for thrombolysis?
    -: >2 mm. In 2 anatomically contiguous leads (>1mm in limb leads, >2mm in V leads)
  129. What has occurred with the above patient?
    -Pt has had an anterior MI which has led to Mobitz type II which could lead to complete heart block.
  130. With regard to the changes seen in figure 1 what does this patient need, please chose the best option 1. temporary venous pacing wire 2. Atropine 3. Angiography 4. No treatment 5. temporary transcutaneous pacing
    - 1tempory venous pacing wire - Mobitz type 2 in this setting is very dangerous; the rhythm could quickly turn into complete heart block.
  131. List the reasons that one would need to instigate urgent pacing after an M.I.
    • -Complete heart block
    • -Asystole
    • -Symptomatic bradycardia or Mobitz type 1 that is not responding to atropine
    • -New BBB with 1st degree heart block
    • -Old RBBB with 1st degree AV block and a new fasicular block
  132. An 88-yo F is brought in by ambulance. They were on route to the medical admissions unit but felt that the patient was too unwell. She is from a nursing home and has long standing dementia she was sent in by the GP due to a general deterioration and possible dehydration. The reason the crew became concerned was due to brief periods of unresponsiveness that seemed to be occurring quite frequently. She has a past history of CVA, IHD, HTN, NIDDM and dementia. She is on asprin, clopidogrel, simvastatin, ramipril, digoxin, bisoprolol and metformin. She is normally bed bound and fully dependant for all ADLs. List 4 investigations that are important in the initial care of this patient.
    • -BP, pulse, sats
    • -ECG
    • -CXR
    • -blood gases (for electrolytes and blood sugar) and to see if acidotic.
  133. What does the ECG in figure 1 show?
    -Complete heart block. The ventricular pacing rate has taken over as there is complete dissociation between the atria and the ventricles.
  134. What is occurring and how would you manage this patient initially?
    • -She is having syncopal episodes related to runs of asystole.
    • -She needs to be fully monitored using a defibrillator.
    • -Try atropine in 500mcg increments to a max of 3mg.
  135. What are the adverse signs according to the resus council UK that you need to treat when considering bradyarrhythmias?
    • -Systolic <90
    • -Heart rate <40
    • -Ventricular arrhythmias compromising BP
    • -Heart failure
  136. Thinking of possible causes of the picture described in this patient what potential reversible causes can be identified from the history given?
    • -Drugs! Digi-toxic or beta blocker overdose
    • -Consider addressing these 2 issues need to check to digoxin level also consider glucagon for reversing beta-blocker effect.
    • -Electrolyte abnormalities are also potential reversible causes to be considered ion complete heart block.
  137. The patient's heart rate appears to drop to around 20 b.p.m and she continues to have runs of asystole associated with no output. What will you do?
    • -the patient needs to be paced urgently- this could be done by transcutaneous pacing until trans-venous pacing can be established.
    • -However in the above patient the entire picture needs to be considered. She is very unlikely to do well in this scenario and there are significant risks involved with placing a transvenous pacing wire. It may be better to simply monitor the patient and aim to keep her comfortable.
  138. A 69 yo M + painful swollen right knee which had come on insidiously over the course of the previous 48 hours. He had no history of joint disease. There was no history of trauma. His backgound was of type II diabetes mellitus and was on warfarin for a prosthetic heart valve.On examination there was an effusion with restricted range of movement. Give a differential diagnosis of four conditions?
    • -Infective arthritis
    • -hemorrhagic effusions
    • -noninflammatory effusions (osteoarthritis)
    • -inflammatory effusions (RA, gout, pseudogout).
  139. Name three characteristics of normal synovial fluid?
    • -Highly viscous
    • -clear
    • -essentially acellular
    • -protein concentration approximately one-third that of plasma
    • -glucose concentration similar to that in plasma.
  140. Approximately what is the cell count in bacterial joint infections?
    -Bacterial joint infections typically are purulent with leukocyte counts (most of which are neutrophils) of 50,000 to 150,000 cells/mm3.
  141. What is seen in the synovial fluid in acute crystal-induced synovitis?
    • -Monosodium urate (MSU) crystals(Gout)
    • -calcium pyrophosphate dihydrate (CPPD) crystals(pseudogout).
  142. Name two conditions in which an eosinophilia may be prominent in the synovial fluid?
    • -suggests parasitic infection
    • -allergy
    • -neoplasm
    • -Lyme disease.
  143. A 30 yo F + overdose of amitriptyline. Name 8 possible clinical features?
    • -Tachycardia
    • -dry skin
    • -dry mouth
    • -dilated pupils
    • -urinary retention
    • -ataxia
    • -drowsiness
    • -delerium, hallucinations
    • -dysarthria
    • -jerky limb movements.
    • If the patient is unconscious they may have increased muscle tone, increased reflexes, myoclonus, an extensor plantar response,convulsions and a divergent squint.
  144. What blood investigations should also be considered?(Give two)
    • -Fingerstick glucose, to rule out hypoglycemia as the cause of any alteration in mental status
    • -paracetamol and salicylate levels to rule out these common co-ingestions
    • -serum beta-HCG.
  145. What ECG changes might be expected in this condition?
    • -Sinus tachycardia
    • -increased PR interval
    • -increased QRS complex
    • -ventricular arrhythmias.
  146. How would you manage this patient?
    • -ABCs
    • -monitoring
    • -activated charcoal if within one hour
    • -IV lorazepam for seizures
    • -consider treating acidosis with 8.4% sodium bicarbonate
    • -IV fluids and poisons information consultation.
  147. What are the possible complications of sodium bicarbonate infusion?(Give two)
    • -Anaphylaxis
    • -volume overload
    • -hypernatremia
    • -metabolic alkalosis may result from prolonged bicarbonate infusion.
    • Other listed adverse effects include
    • -cerebral hemorrhage
    • -CHF (aggravated)
    • -oedema, tetany
    • -gastric distension
    • -hypernatremia
    • -hyperosmolality
    • -hypocalcemia, hypokalemia
    • -intracranial acidosis
    • -pulmonary edema.
  148. It is marathon day in the city of the ED you work in and you are on shift. 2 patients come in at the same time both collapsed and both have been triaged as a cat 1. Who do you see first? Patient 1 is 29, pt 2 is 54. Patient 1: He is confused and his skin feels cold. His temp is 41C. Patient 2: He feels dizzy and hot, he is sweating profusely and is tachycardic at 169, His temp is 39C
    • -You should see patient 1 first he seems to be suffering from heat stroke
    • -whereas patient 2 is suffering form heat exhaustion. Think of it as a spectrum Heat cramps-heat exhaustion- Heat stroke.
  149. What would you do to reduce the temperature of patient 1?
    • -Rapid active cooling
    • -Remove all clothing
    • -Use fans Spray the naked patient with tepid tap water as evaporative coling is the best technique
    • -Don't use antipyretics
    • -Place ice packs in the groins, axilla, neck and scalp but avoid prolonged contact.
    • -Consider cold gastric or peritoneal lavage.
    • -Extreme cases cardiopulmonary bypass can be used.
  150. How would you treat the temperature of patient 2?
    • -More cautiously i.e. when the temp = <39C
    • -hypothermia can result quickly from active cooling.
  151. What conditions do you need to watch out for (3 things)?
    • -Fits
    • -Rhabdomyolysis
    • -Hypoglycaemia
    • -Coagulopathy
  152. What is the best way to measure core body temperature in these circumstances?
    -Oesophageal or intravascular probes are more sensitive.
  153. A 56 yo manager comes in after experiencing some palpitations. He tells you that he has experienced palpitations off and on for a number of years but has never worried about them. Today he felt as if they lasted longer than previous episodes. He is found to be in atrial fibrillation with a rate of 76 b.p.m What information is useful to know about this gentleman?
    • -Does he have any structural heart disease (ideally has he had an ECHO cardiogram)
    • -Is he on any medication that could precipitate AF ?
    • -Does he have a possible driving factor for AF i.e. infection/ETOH/thyroid disease etc ?
    • -Are there any old ECG tracings showing sinus rhythm? ?
  154. According to NICE guidance what will determine if the patient needs to be anti-coagulated prior to attempting rhythm control?
    • -The duration of the AF. If it is less than 48 hrs then no need for anticoagulation.
    • -Most parties would give LMWH to patients who they thought might be cardioverted acutely.
  155. What drug therapies are available in the above scenario?
    • -Flecanide would be a good option provided that he doesn't have any structural heart disease.
    • -If he does then amiodarone would be the preferred agent.
  156. Before you decide what you are going to do the patient becomes unresponsive and drops his BP to 76/43. The anaesthetist is unavailable for the next 30 minutes as there is a trauma in the next bay what do you do?
    • -Options here are variable of course- could give amiodarone IV to attempt to revert the arrhythmia.
    • -Ideally needs electrical cardioversion.?
  157. List 4 scenarios where rhythm control is felt to be superior to rate control when faced with a patient in AF.
    • -Age, less than 65 aim for rhythm control
    • -When the patient is very symptomatic
    • -1st presentation of lone AF
    • -When the AF is secondary to a treated or corrected precipitant
    • -With congestive cardiac failure ?
  158. An 80 yo M who has CKD 4 is sitting in the waiting area waiting to get a pre-tibial laceration dressed when he develops palpitations and feels unwell. A nurse kindly puts him in a bay and records an ECG (fig 1) What do the rhythm strips in figure 1 show?
    -Torsades de pointes
  159. Name 2 causes for this rhythm.
    • -Hypomagnesaemia
    • -hypokalaemia
    • -prolonged QT interval (congenital or drug related)
  160. Name to drugs that could have caused this rhythm?
    • -Sotalol
    • -antipsychotics
    • -antihistamines
    • -antidepressants
  161. Why is it a concerning pattern?
    -It may degenerate into VF
  162. How is it treated?
    -IV magnesium 2g IV over 10 mins
  163. It appears to be refractory what do you do?
    • -call cardiologist may require over-drive pacing
    • -can consider an isoprenaline infusion whilst awaiting pacing.
  164. You are alerted that a man (looks about 50) has collapsed outside the department after leaving the hospital from a renal out patient appointment. You rush outside with a portable defibrillator and some equipment. When you arrive at the scene there is a crowd and the patient appears to have arrested. You decide that it is too far to try to move him to the ED and you don't have a trolley so you shout for help and start the resuscitation. You have a good team and you quickly intubate the patient. The rhythm is VF and you deliver a shock. What size ET tube did you use? What is the ratio of ventilations to compressions now?
    • -8 or 9 normally for an adult male.
    • -7 or 8 for an adult female.
    • -When intubated the compressions are continuous as are the ventilations.
  165. You get a pulse back after the third shock with one dose of adrenaline given. You quickly transport the patient to the resus room. What do you do now?
    • -The patient is intubated so you need to assess for signs of life and check if he is making any respiratory effort
    • -it is likely that you will need to continue ventilating him. -Check an ABG and send off bloods, get an ECG
  166. The potassium is 7.2mmol/L. What do you do?
    • -Consider that this has caused the VF arrest, needs to be treated.
    • -Give 10mls of 10% calcium gluconate.
    • -Consider sodium bicarbonate particularly if there is severe acidosis/renal failure, which there clearly will be in this case.
    • -Give insulin and glucose
    • -Consider haemodyalysis on ITU
  167. What ECG changes are seen in hypokalaemia?
    -Prominent U waves and flattened T waves.
  168. What is the recommended maximum infusion rate for potassium? What is essential for giving IV potassium?
    • -20mmols/hr is the recommended maximum infusion rate but sometimes i.e. peri-arrest arrhythmias/cardiac arrest due to hypokalaemia can be given faster but ideally this should be through a central line.
    • -Must have cardiac monitoring to give IV replacement especially at the rates described.
  169. A 39 yo F + acutely SOB c/o of chest pain (worse on inspiration) She has a RR of 45 and her sats are 89% in air. She was completely well 30 minutes ago but collapsed suddenly at work. Give 3 differential diagnoses?
    • 1. Massive PE
    • 2. Pneumonia
    • 3. Cardiac collapse, M.I.; now with arrhythmia
    • 4. Sepsis
  170. Name 3 crucial tests that need to be done.
    • 1. ABG
    • 2. CXR
    • 3. ECG
    • 4. Bedside ECHO
  171. Are d-dimers useful (comment on specificity and sensitivity?
    • -It depends; they need to be interpreted within the realms of clinical probability.
    • -Current BTS guidelines are as follows:
    • If Pt has features consistent with PE namely a):Raised RR +/- haemoptysis +/- pleuritic chest pain Plus 2 other factors: 1. Absence of another reasonable clinical explanation. 2. Presence of a major risk factor.
    • If Pt has: a) plus 1&2: HIGH pre-test probability b) plus 1 or 2: INTERMEDIATE pre-test probability c) alone: LOW pre-test clinical probability There are 2 assays simpliRED and VIDAS. They vary in their sensitivity simpliRED 99% VIDAS 87%. Specificity is however poor 60-70% so both = high false positive rates.
    • -Basically a negative d-dimer in patients who were low (simpliRED) or intermediate (VIDAS) do not need further imaging.
    • -A negative test is not useful where the pre-test probability is high (so shouldn?t be done)->These pts will need imaging anyway!
    • -D-dimer becomes less reliable the longer a pt has been in hospital.
  172. The patient arrests in front of you. Rhythm is PEA. You start the resuscitate according to current ALS guidelines. What will you do?
    • -Need to consider thrombolysis in this young patient you has likely had a massive P.E.
    • -BTS guidelines would support thrombolysis where clinical probability suggests massive P.E. causing cardiovascular collapse.
  173. List the 4 H's of cardiac arrest
    • -Hypoxia
    • -Hypovolaemia
    • -Hypothermia
    • -Hyperkalaemia/Hypokalaemia, Hypomagnesaemia (metabolic etc)
  174. The nurse in charge takes a phone call from the ambulance staff who are en route to the ED with a 60 year old woman who has arrested. She had called the ambulance as she had chest pain but had arrested soon after the ambulance staff got to her home. They arrive in the ED. The patient had received CPR but does not have any IV access. What is the first step in the management if this patient is in asystole?
    -Resume CPR immediately for 5 cycles.
  175. What vasopressor medication should be given once IV/IO access is available?
    • -Adrenaline 1mg IV/IO.
    • -Repeat every 3-5 minutes.
  176. What other medication should be given for asystole or slow PEA? What is the dose?
    • -Atropine 1mg IV/IO.
    • -Repeat every 3-5 minutes up to 3 doses.
  177. After how many cycles of CPR should the rhythm be rechecked?
    -Give five cycles of CPR.
  178. Name eight possible contributing causes?(5H's and 5T's)
    • -Hypovolaemia, hypoxia, hydrogen ion(acidosis), hypokalaemia/hyperkalaemia, hypoglycaemia, hypothermia
    • -toxins, tamponade(cardiac), tension pneumothorax, thrombosis(coronary or pulmonary),and trauma.
  179. A 19 yo student presented to the Emergency department with a headache. He lived with 2 other students who found him after he failed to answer a wake up call. On exam he was flushed and drowsy.There was a cherry red discoloration to his lips. He was afebrile, he did not have a skin rash. His heart rate was 95 beats per minute and his blood pressure was 130/90 mmHg. His GCS was 11/15. There was no nuchal rigidity. The CNS and PNS examinations were normal. His investigations revealed a normal full blood count, renal profile and electrolyte profile. His ABG revealed a pH in the normal range, a low PaO2(7.8 kPa) and a low PaCO2 (3.6 kPa). His SpO2 was 98% on room air. What is the most likely diagnosis?
    -Carbon monoxide poisoning.
  180. Explain the arterial blood gas results?
    -Carbon monoxide displaces oxygen from Hb.
  181. Explain why the pulse oximeter reading is normal?
    • -Pulse oximeter analysers cannot differentiate between oxyHb and carboxyHb.
    • -PaO2 is low when there is significant carbon monoxide poisoning.
  182. Name some common sources of this condition?(Name two)
    • -Combustion engines
    • -faulty stoves
    • -paraffin heaters with poor ventilation facilities.
  183. What is the treatment for this condition?
    • -Administration of 100% oxygen.
    • -Patients with neurological signs and symptoms, ECG abnormalities, myocardial ischaemia, pulmonary oedema and shock require hyperbaric oxygen at a specialised centre.
  184. One of your staff nurses (aged 28) asks your advice because she has had loose bowel motions for two weeks since returning from India. She is worried she may have dysentry. She has 8 loose stools per day with abdominal cramps and for three days has noticed some blood in the stool. She is previously healthy. Give 3 possible differential diagnosis.
    • -Bacterial gastroenteritis
    • -Inflammatory bowel disease
    • -Viral gastroenteritis
    • -Parasitic disease
    • -Coeliac disease
    • -Tropical sprue
    • -Amoebic dysentry
  185. Give one indication for antibiotics in a patient who presents with diarrhoea.
    -Severe invasive disease blood / refractory, prolonged diarrhoea.
  186. Other than antibiotics, what two other medications might you consider and give the rationale for their use in patients with diarrhoea
    • -Simple analgesia e.g paracetamol for cramping pain
    • -Consider immodium to reduce motility
    • -Fluid and electrolyte replacement e.g diaralyte
  187. After discussion with microbiology, you decide to prescribe a course of antibiotics for her. What other 4 pieces of advice would you give her?
    • -Hydration
    • -Hand washing / hygiene
    • -Occupational health clearance prior to return to work
    • -Caution with local contacts ( family/friends/food preparation etc)
    • -Follow up stool culture
    • -Avoid lactose containing foods until diarrhoea stops
  188. A 26 yo samoan painter and decorator was admitted with acute colicky central abdominal pain associated with vomiting. The only past medical history was of a viral illness associated with a rash two weeks previously. On examination he was pale, his heart rate was 120 bpm and his blood pressure was 140/80 mmHg. The abdomen was generally tender but there was no guarding, and bowel sounds were present. Examination of the CNS revealed reduced power and tone in the lower limbs and absent ankle and knee reflexes. Investigations were unremarkable apart from a microcytic anaemia. A diagnosis of lead poisoning is being considered. What investigation would confirm the diagnosis?
    -Serum lead concentration.
  189. What is the treatment?
  190. Who is at risk for this condition?(Name four)
    • -Scrap-metal workers
    • -plumbers
    • -individuals ingesting water from lead pipes
    • -children ingesting old lead based paint in the house
    • -painters and decorators.
  191. What is the differential diagnosis for the above patient?(Give two)
    • -AIP
    • -arsenic poisoning
    • -guillain-barre syndrome
    • -PAN
    • -sarcoidosis
    • -alcohol abuse.
  192. A lead concentration above what value is considered toxic?
  193. You are asked to see a 44 yo immediately who has a GCS of 7/15. You clear ABC and move to assessing D. His pupils are equal, normal sized and reactive. What do you do? You have no history, he was found like this.
    • -Need to establish why GCS is 7, need to assess the need for airway protection
    • -Check BMG
    • -Look for evidence of opiate use
    • -Look for medi alert bracelet
    • -Look for signs of head injury
    • -Look for any focal neurological signs suggestive of CVA or SAH
    • -Evidence of ETOH?
    • -Evidence of any other overdose? Insulin?
  194. You decide to do a blood gas. It is normal apart form the glucose reads 1mmol/Litre. What is your management?
    • -Due to low GCS likely will not be able to give oral glucose therefore needs IV glucose, current recommendations are 50mls of 10% glucose (previously 50mls of 50%)
    • -Different in different hospitals, author advocates using 20% glucose.
    • -Glucagon 1mg IM/IV or SC Reassess BM after 5 minutes constantly reassess GCS.
  195. What risk factors are there giving IV glucose and how can they be minimised?
    • -Risk of thrombophlebitis
    • -extravasation can cause severe tissue necrosis-can result in loss of limb in extreme cases.
    • -Reduce the risk by using lower concentration of IV glucose.
  196. You find out from patient's wife that she thinks that he deliberately took an insulin overdose. What will you do?
    • -Needs to be managed on ITU/HDU
    • -May need to be on a sliding scale for 24 hours.
    • -Hypokalaemia can be problematic
    • -Block excision of the injection site has been used asbsuccessful treatment for insulin OD but there is no clear cut evidence that it works.
  197. You reassess but after 15 minutes the GCS is only 8/15. What do you need to consider now?
    • -Could there be another cause CVA etc
    • -Or might represent development of cerebral oedema due to hypoglycaemia, which has a high mortality.
    • -Will need urgent imaging of the brain.
  198. A 69 yo M + general malaise over the past 3 weeks. On further questioning he has had bony pains in his back and in his ribs for several weeks that he attributed to old age. A CXR is normal. His vision has been a bit blurry over the last few days. Bloods show: Hb 9.0, MCV 83 fL, MCH 29pg, MCHC 34g/dl WCC 8.4, Plts 334 Urea 35.6; Creat 587; Na 138; K 7.9 Ca 3.05; Alk P 220u/L Give two possible diagnoses
    • -Multiple myeloma: Hyperparathyroidism (and renal failure)
    • -Vit D excess (sarcoidosis and thyrotoxicosis)
    • -Hypercalcaemia of malignancy (expect elevated Alk P)
  199. Give 5 treatment options available (multiple treatments for the same abnormality not accepted)
    • -Re-hydraton is fairly crucial
    • -Rx hyperkalaemia: nebs, Insulin/Glc. Not Calcium (?)
    • -ARF: Dialysis, haemofiltration
    • -Hypercalcaemia: Fluids and steroids- hydrocortisone
    • -Pamidronate (malignancy) if the hypercalcaemia persists: For myeloma also consider prednislone 30-60mg Calcitonin
  200. How could you confirm the diagnosis?
    • -BJ protein
    • -serum/urine electrophoresis
    • -bone marrow
  201. A 55 yo M + 6 hour hx/o palpitations that woke him at 05:00am. His BMI is 29 but he is otherwise well and takes no medication. An ECG (fig 1) reveals the following rhythm: what is it?
    -Atrial fibrillation with rapid ventricular response
  202. What do you need to establish quickly?
    • -Whether this rhythm is compromising the patient or not i.e. are they stable?
    • -Reduced conscious level
    • -Systolic BP <90
    • -Chest pain
    • -Signs of heart failure 
  203. What questions need to be asked in the history to try to establish a cause?
    • -Any history of IHD or family Hx of structural (HOCM) or coronary disease
    • -HTN
    • -alcohol binge
    • -caffeine intake
    • -hyperthyroidism
    • -recent PE
    • -acute pericarditis
    • -acute pulmonary disease etc??.
  204. You consider this patient to be stable and he seems otherwise well. Would he be a candidate for pharmacologic cardioversion? What would contraindicate this?
    • -Probably yes, if there is any suspicion of cardiac failure LVF then it is contraindicated.
    • -Many drugs that could be used including sotalol, flecanide, quinidine, propafenone, disopyramide.
  205. Later on that day another patient comes in who is in what seems to be the same rhythm shown in the ECG in part a, she is 78 and has a history of palpitations on and off over the years. She takes digoxin and aspirin. She is haemodynamically stable. Where does your management focus lie?
    • -The cornerstones of AF management are controlling patients symptoms and preventing thromboembolic complications, not restoration of sinus rhythm.
    • -1st line treatment would be beta blockers or dihydrpyridine calcium channel blockers (verapamil or diltiazem) which are effective during exercise and at rest, digoxin is only effective at rest and should be considered a second line agent.
  206. A 66 year old woman presents after an overdose of propranolol. What are the clinical features of beta-blocker overdose?(Give six)
    • -Hypotension
    • -sinus bradycardia
    • -shock
    • -coma
    • -convulsions
    • -QRS prolongation, ST and T wave abnormalities
    • -hypoglycaemia in children
    • -bronchospasm in asthmatics.
  207. How would you investigate this patient?(Give four)
    • -ECG
    • -blood glucose
    • -UE
    • -calcium, paracetamol and salicylate levels.
  208. How would you manage this patient? (Give six)
    • -ABCs,
    • -IV fluids
    • -atropine
    • -glucagon 5mg
    • -activated charcoal
    • -Ca chloride or Ca gluconate
    • -vasopressors
    • -high dose insulin and glucose
    • -other potential treatments include: sodium bicarbonate (eg, prolonged QRS), magnesium (ventricular dysrhythmia), intraaortic balloon pump, temporary transvenous pacing, and hemodialysis.
  209. What is the role of activated charcoal?
    -Activated charcoal is given to all patients who present within 1 to 2 hours of a known or suspected beta blocker ingestion.
  210. What clinical feature is seen more often in a paediatric population than an adult population?
    -Hypoglycemia is seen more often in pediatric patients than adults.
  211. A 71 yo F + off legs + N/H for the last few months as she could no longer cope at home due to her metastatic breast malignancy. She appears dehydrated and a little confused. The nursing home staff state that she has mobile yesterday, they also tell you that she was doubly incontinent today which is unusual for her. If you could only perform 2 aspects of clinical examination in this case to ascertain the main problem which 2 would you chose? (e.g. cardiovascular exam and examination of the fundi)
    • -A PR (to check for anal tone and sensation)
    • -A complete lower limb neurological examination. Looking for evidence of spinal chord compression.
  212. What investigation do you try to organise?
    -MRI to image the spinal chord
  213. Which blood tests are you especially interested in?
    • -U&E and calcium are of particular interest
    • -hypercalcaemia is a very common cause of confusion in these patients.
  214. How will the primary problem described in a) be managed?
    -Normally radiotherapy but sometimes it may be appropriate for no treatment to occur and analgesia might be the mainstay of treatment.
  215. A 76 yo M + ECG above, his heart rate is as shown and he is symptomatic. What is the rate?
    -Accept 35-39 b.p.m. 300/8 = 37.5, 8-8.5 large squares.
  216. What is the rhythm called?
    -Its secondary degree heart block, mobitz type 2.
  217. What is your initial pharmacological management including dose?
    -Atropine 500 mcg or glycopyrolate 200-600 mcg.
  218. After the drug you gave there was no response. What do you do next?
    -Repeat atropine up to 3mg, rpt glycopyrolate as necessary.
  219. You have an external pacing device available, explain exactly what you would do and how it works to set it up including anything you would do to the patient. e) When do ventricular pauses become concerning?
    • -Consider sedative and analgesia as can be uncomfortable
    • -if clinical state will allow then give morphine and midazolam (cautious in elderly)
    • -Explain to the patient that will feel uncomfortable
    • -Apply sticky pads to the chest and to the back (AP paddles)
    • -Select external demand pacing mode on the defibrillator and set the rate to 70 b.p.m
    • -Then start to dial up the pacing current from zero until you see that a beat had been captured on the monitor.
    • -Clinically a capture beat results in a peripheral pulse and an improvement in the patients condition.
    • -Ensure that this occurs despite the monitor showing a captured beat.
    • -Answer; always of concern but generally if pauses are lasting > 3seconds then something needs to be done sooner rather than later.
  220. A 74 yo M + deliberately ingested 20 sulphonylurea tablets. What are the clinical features of sulphonylurea overdose?(Name four)
    • -Hypoglycaemia
    • -(confusion, difficulty speaking, dizziness, hemiparesis, seizures, or coma, anxiety, nausea, sweating, and palpitations)
    • -hypokalaemia.
  221. How would you investigate this patient?(Give four)
    • -UE
    • -Blood glucose
    • -check for paracetamol and salicylate level
    • -ECG.
  222. How would you manage this patient?(Give four)
    • -Observe for at least 24 hours
    • -oral or IV glucose as needed
    • -correct hypokalaemia
    • -consider octreotide
    • -expert advice in severe poisoning
    • -Mental health consultation.
  223. How would the management of this patient be different if he had renal failure?
    -Renal failure results in impaired drug clearance and this increases the risk of hypoglycaemia.
  224. Why may octreotide be indicated?
    -Octreotide blocks pancreatic insulin release.
  225. An 87 yo F from a N/H after having had a few episodes of collapse over the last week. She has clearly had a fall as she has a bruised face. She seems to be well on initial assessment. She is on a plethora of medications. List the 4 most important bits of history you want from this lady
    • 1.Medications- particularly warfarin/anticoagulants and any medications that cause bradycardia/hypotension etc
    • 2.Normal functional status i.e. is she independent etc
    • 3.What is her mental status today and what is normal for her.
    • 4.Any pre-syncopal features, i.e. is she aware that she is going to collapse ?
  226. What investigations do you want immediately in the ED?
    • 1. ECG
    • 2. Blood glucose
    • 3. Postural BP recordings
    • 4. routine blood tests, FBC,UE, calcium
  227. ECG revealed: see figure 1: What does it show?
    • -Mobitz type 2- this is mobitz 2 with 3:1 block.
    • -Mobitz Type 2 2nd degree Heart Block is considered an important warning signal of the potential progression to 3rd degree Heart Block, which requires prompt attention.
  228. What will you do about it?
    • -Depends if the pt is stable or unstable
    • -If stable then can prepare for a pacemaker at the next available opportunity
    • -If unstable then requires a temporary pacing wire to be inserted.
  229. Her heart rate drops to 38 b.p.m, what measures do you take?
    • -Measure the BP and re-assess the patient
    • -if unstable then may need to instigate immediate pacing- could use transcutaneous pacing
    • -If BP is relatively maintained could consider giving atropine (best titrated in this scenario)
  230. A 29 yo F + 38 weeks pregnant called an ambulance because she felt palpitations. The ambulance staff called in that the patient had a narrow complex tachycardia. What are the symptoms and signs that suggest that this patient may be unstable?(Give three)
    • -Altered mental status
    • -ongoing chest pain
    • -hypotension.
  231. If it is decided that the patient is stable give four basic steps prior to treatment?
    • -O2
    • -monitor
    • -IV access
    • -12 lead ECG.
  232. If the rhythm is regular and QRS complex is narrow how would you procede prior to administering any medication?
    -Vagal maneuvers.
  233. If this fails, with what medication would you treat the patient? What is the dose of the medication?
    • -Adenosine 6mg IV push.
    • -If no conversion give 12mg rapid IV push
    • -may repeat 12mg dose once.
  234. If the rhythm fails to convert after this medication what other diagnoses should be considered?(Give two)
    • -Atrial flutter
    • -ectopic atrial tachycardia or junctional tachycardia.
    • -The rate should be controlled with a calcium channel blocker or a beta blocker, treat the underlying cause and consider expert consultation.
  235. A 46 yo factory worker comes in with chest pain that started yesterday after some heavy lifting. His ECG shows T wave inversion in the lateral leads and his 12 hr troponin came back at 0.08. He is pain free when you see him. What does this represent?
    -troponin <0.1 is not an NSTEMI but > 0.03 may well represent unstable angina.
  236. What does this patient need?
    • -Needs to be admitted.
    • -He needs an aniogram.
    • -In patient exercise stress testing should be avoided in view of the abnormal troponin.
  237. List 3 causes of a raised troponin other than myocardial ischaemia?
    • -Renal failure
    • -infection- sepsis
    • -pulmonary embolism
    • -myocarditis/Pericarditis
    • -prolonged tachycardia
  238. The patient was sent home on asprin, clopidogrel and sivastatin. What other medication should the patient receive to improve his prognosis?
    • -ACEi/angiotensin receptor blocker.
    • -The HOPE study looked at the role of ACEi in high risk populations without any evidence of left ventricular dysfunction.
  239. How long does he effect of clopidogrel last for after it is discontinued?
    • -The life of the platelet as it irreversibly changes the platelets ability to aggregate- 10-14 days.
    • -It stops ADP from binding to its receptor on the platelet surface.
  240. A 35 yo M who has a known personality disorder says that he has taken 45 - 300mg asprin tablets. He is sweating profusely and is agitated, he has been vomiting and says that his ears will not stop ringing. Explain the results of the ABG: pH 7.36 paO2 12.3 paCO2 2.8 BE -16 HCO3- 17
    -Shows a mixed picture, shows a mixed metabolic acidosis with respiratory alkalosis which is typical in salicylate poisoning, the danger is that the acidosis will worsen.
  241. What does could be fatal?
    - >500mg/kg could cause fatal poisoning.
  242. Is there a role for activated charcoal with asprin od?
    -Yes, if 2 levels are taken and the second one increases you could consider giving another dose of 50g of activated charcoal.
  243. A CXR is taken (fig 1): What is shown and how would you manage this?
    -ARDS needs ITU for ventilation and supportive care, likely to need renal support.
  244. What is the definitive management in severe cases?
    • -ITU for haemodialysis
    • -Paralysis and ventilation often helpful IV glucose as brain levels can get very low.
  245. This ECG is from a 76 yo M who presented with central chest pain and nausea. What does the ECG in figure 1 show?
    -Infero-posterior M.I., would accept inferior M.I., with lateral reciprocal changes.
  246. The patient seems to deteriorate and a repeat ECG (fig 2) shows the following: Explain why this has occurred referring to the anatomy of the coronary arteries.
    • -When The patient has suffered an occlusion of the right coronary artery (RCA) the infero-posterior ischaemic changes in the first ECG demonstrate this.
    • -The RCA supplies the SA node, the AV node and the entire posterior surface of the heart.
    • -They can therefore lead to dangerous arrhythmias.
  247. When faced with the ECG in (figure 1) what additional investigations would you like to perform?
    • -Posterior leads. To do true posterior leads, here?s what you do: take all the chest lead wires off. Now stick on three more chest electrodes along the same line of V5 and V6, along the fifth intercostal space, using the same spacing that you used for the chest leads, ending up under the scapula: V7, V8, and V9.
    • -Now start reattaching the wires: put the V1 lead wire on the V4 electrode. See? The V2 lead goes on the V5 electrode. And so on around the chest. Now when you do your 12-lead, you ll get a clear picture of what the entire RV is doing: inferiorly and posteriorly.
  248. Name 3 acute complications of STEMI
    • -Continuing chest pain
    • -fever
    • -new systolic murmur (VSD, MR or Pericarditis)
    • -dysrrhythmia (VT, AV block ectopics and bradycardia)
    • -cardiogenic shock.
  249. A 46 yo F bipolar disorder presented as she had mistakenly taken to many of her lithium tablets. Her previous medication had been discontinued and she had been started on lithium the previous week. She was taking the lithium tablets according to her previous medication's dosing regime. This had resulted in her taking excess lithium tablets over the course of the week, a fact which she had only discovered on the day of presentation. What are the clinical features of lithium poisoning?
    • -Nausea, vomiting, diarrhoea
    • -tremor
    • -ataxia
    • -confusion
    • -increase in muscle tone
    • -clonus
    • -convulsions
    • -coma
    • -renal failure.
  250. What are the two most important blood investiagtions?
    • -UE
    • -lithium level.
  251. What is the normal range for therapeutic lithium levels?
    - <1.2mmol/L
  252. What is the role of activated charcoal in this patient's treatment?
    -Activated charcoal does not absorb lithium.
  253. How would you manage this patient?(Give four)
    • -Gastric lavage is indicated if within 1 hour of a single large overdose
    • -consider poisons consultation
    • -control convulsions with benzodiazepines
    • -haemodialysis for severe poisoning.
  254. An 84 yo F l+ lives alone at home who is acutely SOB. You suspect that she is in failure. The paramedics have surprisingly good notes on this lady as she was only discharged 2 days ago from a health care for the elderly ward following a UTI. She was found to be in AF and had an echo, which showed normal left ventricular function with a good EF. On clinical examination you here basal crepitations, she has a RR of 38 and sats of 92%. The chest x-ray has widespread air space shadowing with upper lobe diversion. What is going on?
    -2 main options: 1 either has non-cardiogenic pulmonary oedema or 2 has diastolic heart failure.
  255. Name 4 causes of acute pulmonary oedema other than heart failure?
    • -Increased pulmonary capillary pressure (hydrostatic): Increased left atrial pressure: Mitral valve disease, atrial myxoma, arrhythmias.
    • -Increased left ventricular end diastolic pressure: Ischaemia, aortic valve disease, cardiomyopathy, uncontrolled hypertension, fluid overload, high output states
    • -Neurogenic: Intracranial haemorrhage, cerebral oedema, post-ictal HAPE (rare obviously unless been up Everest recently)
    • -Increased pulmonary capillary permeability ARDS Hypoalbuminaemia
  256. Explain the pathophysiology of diastolic heart failure
    • -Essentially it occurs in the elderly who are hypertensive with LV hypertrophy, the ventricle has impaired relaxation in diastole this leads to pulmonary oedema.
    • -With tachycardia diastolic filling time shortens and as the ventricle is stiff in diastole left atrial pressure is increased and pulmonary oedema occurs.
  257. How would you manage a patient in pulmonary oedema who you new had a prosthetic mitral valve if they didn't respond to initial therapy?
    • -Need to involve cardiologist and cardiothoracic surgeon.
    • -Emergency thransthroacic or TOE to confirm diagnosis of presumed prosthetic valve failure.
  258. A 27 yo Turkish man presents to the ED at the weekend sent in from the walk in centre, he has painful legs and has noticed a rash. He lives in a poor area of the inner city. What is the rash shown in figure 1?
    -Erythema nodusom
  259. List 5 causes of this rash?
    • 1. Crohn's/colitis
    • 2. TB 3. HIV
    • 4. Drug induced
    • 5. Streptococcal infections (beta haemolytic)
    • 6. Sarcoidosis
    • 7. Leprosy and other infections( Yersina, toxoplasmosis, histomplasmosis, Chlamidya)
    • 8. SLE
    • 9. Behcet's disease ?
  260. What important questions do you ask in the history to try to help you with the diagnosis? Limit the answer to the 4 most important questions. (Remembering that common things are common)
    • -Ask about bowel habit/abdo pain and rectal bleeding/ features of IBD
    • -Ask about recent travel history and possible TB contact
    • -Take a complete drug history
    • -Ask about recent infection (anything to suggest strep sore throat etc) This probably covers the most common causes of erythema nodusum
  261. What base line investigations would be useful and why?
    • -CXR: look for evidence of TB and sarcoid
    • -FBC- looking for anaemia (IBD)
    • -ESR and CRP looking for inflammation (vadculitis/IBD)
    • -Antistreptolysin-O (ASO) titer
    • -Urinalysis
    • -Throat culture
    • -Intradermal tuberculin test
  262. He is smoker and tells you that he has a cough from time to time. From your screening questions that you chose above you decide that he doesn't seem to have any of the risk factors for common causes of this type of rash. You decide to investigate further. You find out that he has had some urthethritis but denies sexual intercourse in the last 6 months he has also noticed that he has intermittently painful joints. You notice some mouth ulcers on examination. What could the diagnosis be?
    -Behcet's disease?
  263. A 26 yo patient was admitted via ED with acute asthma for the 5th time in the last 2 years. The patient had recently had aminophyline added to her inhaled therapy, which consisted of seretide 500 and salbutamol. On admission she was unwell with sats of 88% in air and a RR of 44. CXR revealed consolidation at the right base. She was started on erythromycin as she had a penicillin allergy. She improved but 2 days later suffered 3 grand mal seizures and needed to be ventilated on ITU. What step is this patient on with regard to her asthma management according to BTS guidelines?
    - 4
  264. What is Seretide a combination of?
    -Salmeterol (LABA) and Fluticasone (steroid)
  265. What do you think might be the major problem with this patient?s asthma?
    -Poor compliance
  266. The patient had no previous history of fitting from the following options which do you think was the cause of the seizures and why? 1. Hypoxia 2. Meningitis 3. Benign intracranial hypertension 4. Reaction to erythromycin 5. Theophylline toxicity 6. Herpes encephalitis
    -Theophylline toxicity: the erythromycin inhibits the metabolism of theophylline therefore potentiating its effects.
  267. What is the cross over for penicillin allergic patients when considering giving cephalosporins?
    -Quoted as 10%
  268. A 72 yo M is phoned through presenting with chest pain, the crew have thrombolysed him as he had ST elevation.Name some different thrombolytics
    -Streptokinase, alteplase (rtPA), retaplase (modified rtPA), tenecteplase (mosified rtPA).
  269. Name a some side effects of the first thrombolytic agent
    • -Allergenic reaction to streptokinase.
    • -Causes hypotension.
    • -Also can?r be used again as antibodies are produced against it.
  270. What are the requirements for thrombolysis?
    - >1 mm ST elevation in the limb leads or >2mm in 2 contiguous chest leads or LBBB (with typical M.I. history NB DOES NOT HAVE TO BE NEW!)
  271. What are the anterior leads?
    • -V1-V3 = anteroseptal
    • -V2-V4 = anterior
    • -V5-V6 = anterolateral
  272. What is a right ventricular infarct? What type of M.I is it likely to occur with? 6. f) How do you diagnose it and what is it important to treat it with?
    • -When the right ventricle is taken out by an inferior M.I. ST elevation in V1 with inferior M.I. suggest it, especially if it is greater then in V2 and V3.
    • Answer to f) Answer: Perform ECG with V4R.
    • -Ensure that IV fluid is given to maintain adequate filling pressure in right ventricular failure.
    • -40% of patients with inferior wall infarctions have right ventricular and/or posterior wall involvement, which predisposes them to more complications and increased mortality.
  273. A 38 yo + samoan lady presented to the ED with an ulcer on the lateral aspect of her right small toe and a surrounding cellulitis. She had a one year history of NIDDM and was prescribed metformin but had not been taking this medication. How would you investigate this patient?(Four points)
    • -FBC
    • -UE
    • -blood cultures
    • -swab from lesion
    • -X Ray foot.
  274. How would you manage this patient?(Four points)
    • -IV antibiotics
    • -analgesia
    • -subcutaneous insulin sliding scale
    • -IV fluids
    • -endocrinology consultation.
  275. Name three categories of bacteria which may be causing infection in this patient?
    • -Aerobic gram-positive organisms
    • -gram-negative organisms
    • -anaerobic organisms.
  276. Name four factors which make patients with diabetes at high risk for foot infections?
    • -Sensory neuropathy(which causes a decreased appreciation of temperature and pain)
    • -motor neuropathy(which can cause foot deformities)
    • -autonomic neuropathy(which can cause decreased sweat and sebaceous gland secretion resulting in dry, cracked skin)
    • -peripheral arterial disease(which can reduce the blood supply needed for healing of ulcers and infections)
    • -hyperglycemia(which impairs neutrophil function and defects in host defenses).
  277. Name a complication of this condition?
    • -Osteomyelitis
    • -systemic infection.
  278. The following ECG was recorded on a 67 yo M in the ED. He was sweaty and clammy and felt SOB but said that he had no chest pain although he described discomfort in his mouth and neck. What changes are shown in yellow and blue, what is the diagnosis?
    • -Anterior M.I.
    • -yellow = ST segment elevation most pronounced in the anterior leads V1-V4.
    • -Blue = reciprocal changes in the inferior leads.
  279. Which coronary vessel is likely to have been occluded?
    -Likely left LAD to be exact.
  280. Name 3 conditions that could mimic the picture shown above.
    • -Pericarditis
    • -trauma to the myocardium
    • -WPW
    • -hyperkalaemia
    • -pneumothorax
    • -cardiac amyloid/sarcoid
    • -cardiac tumours
    • -cardiomyopathy
    • -LBBB
    • -LVH or RVH
    • -pancreatitis.
  281. When do troponin levels rise post M.I.? How long do they remain elevated for?
    • -They start to rise 3 hours post M.I.
    • -peak at 24-48 hours they can remain elevated for 7-14 days.
  282. Give 3 contraindications to thrombolysis, (appreciating that most are relative, choose ones where you would be very hesitant to administer thrombolytic agents).
    • -Arterial or major surgery within 4 weeks
    • -Previous haemorrhagic stroke
    • -Prolonged CPR
    • -Pregnancy
    • -Possible aortic dissection
    • -Severe hypertension
  283. A known alcoholic lady downs an entire bottle of antifreeze she wrote a suicide note and was found unconscious by her neighbour. Explain why it is toxic, what does it contain?
    -The substance is ethylene-glycol, it is toxic due to its metabolites.
  284. Give 2 antidotes and explain why they work?
    • -Alcohol and fomepizole.
    • -They work by inhibiting the metabolism of ethylene glycol and hence preventing the formation of metabolites.
  285. What are the presenting features assuming that you have no history of antifreeze ingestion?
    • -Pt appears drunk (but doesn't smell of ETOH)
    • -Ataxia
    • -Dysarthria
    • -Nausea/vomiting
    • -Haematemesis
  286. In severe poisoning like the lady described above what is going to be the likely course of management and where will she be managed?
    • -On ITU
    • -Haemodyalysis
    • -Correction of acidosis
  287. What metabolic disturbance must one be especially vigilant for? and how is it treated?
    -Hypocalcaemia, which can be severe, treated with calcium gluconate.
  288. A 54 yo F + bipolar affective disorder tells you that she took a months worth of her lithium tablets you have the boxes that she has brought in (they are slow release tablets) Would you consider using activated charcoal for this lady as she has presented within an hour of having taken the tablets?
    -No as it doesn't absorb lithium
  289. Could you perform gastric lavage?
    -No as the slow release tablets are too large to pass up the nasogastric tube.
  290. What do you do?
    -In contact with a poisons specialist could consider whole bowel irrigation when slow release tablets have been taken.
  291. What are the symptoms of lithium overdose?
    • -Nausea, vomiting, diarrhoea
    • -are followed by tremor, ataxia and confusion.
    • -In severe cases there may be renal failure, convulsions and coma.
  292. How would you control seizures if they occurred?
    -benzodiazepines: lorazepam, diazepam
  293. A 61 yo F is sitting in the cubicle area on a trolley, you go to see her and think that she looks unwell, she is sweaty clammy and tachycardic. You re-check her observations: she has a pulse of 105 sats of 96% in air and a BP 0f 145/70. She is with her partner who says that she fitted earlier and that's why they have come in. You find out that she is an alcoholic and hasn't drunk for 2 days now. What is going on?
    • -She appears to be withdrawing from alcohol.
    • -Although the differential diagnosis is wide and one needs to constantly assess and monitor this patient.
  294. How would you treat this situation?
    • -benzodiazepines normally chlordiazepoxide 20mg but higher doses may be required to control symptoms.
    • -Maximum does of 200mg in 24 hours.
    • -Also IV vitamin complexes (Pabrinex) will need vitamin B co-strong and thiamine.
  295. What is delirium tremens?
    • -It is a medical emergency occurring in alcohol withdrawal.
    • -The patient may have all the signs of withdrawal but in addition have hallucinations, sinister delusions, confusion and disorientation.
    • -Deaths occur from arrhythmias (secondary to acidosis, electrolyte disturbances or alcohol related cardiomyopathy).
  296. Explain the type of picture you might see on an ABG of a patient that you suspect has alcoholic ketoacidosis:
    • -It develops from an alcoholic withdrawing, not eating and vomiting repeatedly.
    • -A metabolic acidosis is normally seen with a high anion gap but the pH is actually variable as vomiting could lead to an alkalosis and they could have an element of respiratory alkalosis.
  297. The magnesium you sent earlier comes back at 0.017 what will you do?
    • -IV replacement but not too fast (likely chronically low) cannot do too much harm by giving high doses.
    • -good place to start is to give 8 mmol of magnesium sulphate over 20 minutes then to give another 8 mmols over 4-6 hours then re-checking the level.
    • -Ensure that all other electrolytes are checked carefully this patient should be managed on HDU.
  298. A 55 yo M is brought to the ED with haematemesis. His medical history is of alcohol abuse. Give a differential diagnosis?(give five)
    • -Peptic ulceration
    • -mucosal inflammation (oesophagitis, gastritis or duodenitis)
    • -oesophageal varices
    • -mallory-weiss tear
    • -gastric carcinoma
    • -coagulation disorders
    • -tumors.
  299. What is the most common cause?
  300. How would you investigate this patient?(Give five)
    • -FBC
    • -Coag screen
    • -UE
    • -blood glucose
    • -group and cross-match
    • -LFTs.
  301. How would you manage this patient?
    • -ABCs
    • -2 large IV cannulae
    • -IV fluids
    • -consider PPI
    • -keep fasted
    • -gastroenterology or surgical consultation.
  302. If the cause is thought to be oesophageal varices another medication which may be indicated?
    -Vasopressin/terlipressin and octreotide/somatostatin.
  303. A 60 yo F presented to the ED complaining of lethargy and weakness. Her husband reported that she seemed confused at times over the previous day. She self reported that she had a history of addisons disease. Her medical records were unavailable as she lived overseas and was visiting her daughter in the area. On examination she had a postural drop in her blood pressure and her heart rate was 110bpm. What is the most likely diagnosis?
    -Addisonian crises.
  304. What are the common causes of this condition?(Name two)
    • -Withdrawal of longterm steroid therapy
    • -intercurrent injury
    • -infection or stress.
  305. How would you investigate this patient?
    • -FBC
    • -UE
    • -blood glucose
    • -calcium
    • -blood cultures
    • -urine cultures
    • -sputum culture
    • -CXR.
  306. What findings would you expect from the electrolyte profile?(Name two)
    • -Hyponatremia
    • -hyperkalaemia
    • -uraemia
  307. How would you manage this patient?
    • -Hydrocortisone 100mg IV stat
    • -IV fluids
    • -treat hypoglycaemia if present
    • -treat with broad spectrum antibiotics if infection is believed to be the precipitant
    • -specialist consultation.
  308. A 21 yo university student comes in having ingested is Aunties complete supply of digoxin tablets. He is fully conscious but has a rate of 38 b.p.m. What is your initial management?
    • -ABCDE
    • -ECG
    • -IV access and atropine- in increments start with 0.5mg.
  309. Is digoxin positively or negatively ionotropic?
  310. Is there a role for charcoal in this patient?
    -Yes- give it down an NG tube
  311. Assuming your initial treatment works where should he be admitted?
  312. After 20 minutes he starts to feel dizzy and his HR drops to 36 b.p.m what is the next step in management?
    -Digoxin specific fab fragment (Digibind)
  313. The patient gets worse and the monitor shows VT, he has a pulse but his BP is 85/49. What will you do now?
    • -He is haemodynamically unstable and has a VT due to digoxon toxicity.
    • -DC cardioversion is relatively contraindicated here unless all other measures have been exhausted.
    • -The most useful drugs in this setting are lidociane and phenytoin.
    • -Amiodarone would increase digoxin levels and is CONTRAINDICATED.
  314. A 84 yo F has been getting chest pains on and off for the last week but they seemed a lot worse today so she came in to get checked over. She describes the pain as someone sitting on her chest and its not improved in the last hour she has also noticed that she has hiccups and feels sick. ECG (fig 1):What does it show? What is the diagnosis?
    -ST elevation in II, III and aVF with lateral reciprocal changes i.e. ST depression in I and aVL. Inferior myocardial infarction.
  315. Which coronary vessel is affected?
    • -RCA.
    • -It's worth mentioning that the inferior part of the heart is innervated partly by the same structures that innervate the stomach the wall of the one organ lying near the other and I understand that this is why people with inferior ischemia or infarct often have nausea or vomiting, or sometimes hiccups in place of anginal pain.
  316. With this picture would you be concerned about right ventricular involvement? What could you do to check?
    • -Yes.
    • -Although there is not ST elevation in V1 right ventricular infarcts are common when inferior infarction has occurred and non-standard leads to include V4R should be performed to look at the right ventricle.
  317. You notice that since you first assessed her blood pressure seems to have fallen and is now only 85/40. What do you do?
    • -Assume cardiogenic shock.
    • -Careful fluid balance is required to maintain right ventricular filling pressure.
  318. What provides better long term outcome; primary PCI or thrombolysis?
    • -Primary PCI
    • : Data from 10 large RCTs demonstrates a superior outcome in patients with STEMI who are treated with primary PCI in comparison to thrombolysis.
  319. A 65 yo M + 3 hour hx/o chest pain, palpitations and breathlessness. His past medical history was of hypertension and a myocardial infarct. His regular medications include aspirin 75mg , furosemide 40mg and atorvastatin 20mg. What is shown on the ECG?
    -Ventricular Tachycardia
  320. List the ECG features of this condition(List four)
    • -Broad complex QRS
    • -Extreme axis deviation
    • -positive or negative concordance in the precordial leads
    • -RSr pattern in V1
    • -Deep S-wave in V6
    • -Fusion and Capture beats
    • -Dissociated p-waves
  321. What drug may be used to treat this condition?
  322. Shortly after administering the drug the patient becomes clammy and cyanosed. His conscious level deteriorates and his blood pressure is low. What is the next step in management?
    -DC Cardioversion
  323. From which ventricle does the above rhythm usually arise?
    -Left ventricle.
  324. A 36 yo M was brought to the emergency department because his mother had found him that morning in his bedroom confused and drowsy. She had heard him vomiting during the night. She had found an empty packet of anti-histamines by his bedside. He had a medical history of alcoholism and IV drug abuse. On examination he was febrile at 38 degrees , his HR was 112, his SpO2 was 99% on RA and his BP was 140/90. His pupils were dilated and his skin was hot to touch. He was disorientated and answering questions inappropriately with incoherent speech. What is the most likely diagnosis? What other important diagnosis should be considered?
    • -Most likely diagnosis-Cholinergic toxicity.
    • -Other important diagnosis to consider is sepsis or meningitis or encephalitis given fever,tachycardia and disorientation.
  325. What other points may be found on examination of the patient?(Three points)
    • -Decreased or absent bowel sounds
    • -"Red as a beet" (cutaneous vasodilation)
    • -"Dry as a bone" (anhidrosis)
    • -"Hot as a hare" (anhydrotic hyperthermia)
    • -"Blind as a bat" (nonreactive mydriasis)
    • -"Mad as a hatter" (delirium; hallucinations)
    • -"Full as a flask" (urinary retention).
  326. How would you investigate this patient?(Give four points)
    • -FBC
    • -UE
    • -Blood glucose
    • -ECG
    • -Paracetamol level.
  327. How would you manage this patient?(Give five points)
    • -Stabilization of the airway, breathing, and circulation.
    • -Patients should have intravenous access, supplemental oxygen, cardiac monitoring, and continuous pulse oximetry.
    • -Consultation with a medical toxicologist or regional poison center.
    • -Agitation and seizures may be treated with benzodiazepines.
    • -Hyperthermia should be treated in typical fashion.
    • -Charcoal should be withheld in patients who are sedated.
    • A= Stabilization of the airway, supplemental oxygen.
    • B= Stabilization of the breathing, continious pulse oximetry.
    • C= IV access, cardiac monitoring
    • D= Agitation/Seizures may be treated with benzodiazepines.
    • E= Hyperthermia should be treated in typical fashion.
    • Consultation with a medical toxicologist or regional poison center.
  328. What is the anidote for this condition?
  329. Describe how the QT interval is measured.
    -From the start of the Q wave to the end of the T wave.
  330. What dangerous arrhythmias can be precipitated from long QT intervals?
    • -Torsades de Pointes
    • -VF and hence sudden cardiac death
  331. The QT interval gets shorter as the heart rate speeds up, and longer as it slows down. What is the QTc and why is it important?
    • -It is the corrected QT interval i.e. it takes the rate out of the equation.
    • -Normal range is <440 milliseconds.
  332. There are 2 types of LQTS congenital and acquired. Name 2 causes of acquired LQTS
    • Antiarrhythmics: Quninidine, procainamide, disopyramidine, flecanide, propafenone, sotalol, ibutilide, dofetilide, amaiodarone (rare)
    • Antimicrobials: Erythromycin, clarithromycin, trimethoprim, ketoconazole, itraconazole, choloroquine.
    • Antihistamines: terfenadine
    • Electrolyte imbalances
    • Severe bradycardia
  333. Name another cause of sudden cardiac death (SCD)?
    • -Hyperthrophic cardiomyopathy (HCM), risk of SCD is increased with early age of diagnosis, family hx of SCD, Non-sustained VT on 24hy tape, Abnormal BP in response to exercise, certain genetic mutations.
    • -Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) is probably the second most common cause of unexpected sudden death in the young.
    • -Dilated cardiomyopathy (DCM)
    • -Restrictive Cardiomyopathy is the rarest of the cardiomyopathies.
    • -Myocarditis
    • -Brugada Syndrome
    • -Progressive Cardiac Conduction Defect (Lev-Lenegre's Syndrome)
    • -Idiopathic Ventricular Fibrillation (without Brugada ECG changes)
    • -Catecholaminergic Polymorphic VT
  334. A 23 yo F is wheeled into the resus department complaining of chest pain and dizziness. She also says that she can't feel her fingers. The crew report that she has no medical history, she is a non-smoker and is normally very fit and well. Her observations in the ambulance show a respiratory rate of 45 but are otherwise unremarkable apart from her seeming very anxious. What is the most likely diagnosis from the history given above?
    • -Primary hyperventilation
    • -pyschongenic (panic attack)
  335. What tests must you do to confirm your initial thoughts?
    • -Need to rule out secondary causes for hyperventilation i.e. DKA Kussmal's breathing therefore to a BM
    • -Saturations: pneumothroax/PE
    • -ECG: cardiac cause
  336. What will you do with this patient?
    -Reassure her that there is nothing serious going on and encourage her to take control of her respirations perhaps counting breathe in through the nose, count for 6, breathe out through the mouth count for 6, hold for 3 etc.
  337. The RR doesn't come down and despite your efforts the patient isn't changing or improving. What tests would you do now?
    • -ABG
    • -CXR
    • -U&E
    • -blood glucose
    • -consider tox screen.
  338. Name a group of presentations common to the ED which could present in this way.
    -Overdose of: Aspirin/CO/ Methanol/ cyanide/ ethylene glycol
  339. A 62 yo M + acutely SOB. His vital signs are as follows: BP 78/49 pulse 110, he has a raised JVP, heart sounds are muffled and inspiratory crackles are heard throughout the chest. He has a metal mitral valve and he admits to having forgotten to take is warfarin the last week as he was on holiday in Spain. You perform a quick transthoracic ECHO which shows a mitral valve thrombus, what will you do?
    • -Thrombolysis.
    • -He has an acute valve thrombosis resulting in cardiogenic shock. If he was stable then surgery would be a better option.
  340. How do you measure the effect of your treatment?
    -Serial ECHO
  341. What is the best way to investigate/image a pt like this?
    -TOE gives much better views.
  342. List the differential diagnosis for the above patient if you didn't have access to ECHO
    • -CCF
    • -Cardiac tamponade
    • -Tension pneumothorax
    • -Cardiogenic shock post M.I.
  343. A 39 yo F + generalised macular erythematous rash. She had been feeling unwell for the previous two days but the rash had relatively quickly on the day of presentation.The week before presentation she had been started on a new medication for a chronic medical condition. She also complained of difficulty eating secondary to oral pain. On examination she was febrile and had a generalised erythematous macular rash. She had multiple oral ulcerated areas. A diagnosis of stevens-johnsons syndrome was made. What is the differential diagnosis of this condition?(Name three)
    • -Erythematous drug eruptions
    • -pustular drug eruptions
    • -phototoxic eruptions
    • -staphylococcal scalded skin syndrome (SSSS)
    • -toxic shock syndrome (TSS).
  344. Name two medications which commonly cause this condition?
    • -Anti-gout agents (especially allopurinol)
    • -antibiotics (sulfonamides >> penicillins > cephalosporins)
    • -antipsychotics and anti-epileptics (including carbamazepine, dilantin, lamotrigine, and phenobarbital)
    • -analgesics
    • -non-steroidal anti-inflammatory agents.
  345. How would you investigate this patient?(Name three appropriate investigations)
    • -FBC with differential cell count
    • -LFTs(Mild elevations in serum aminotransferase levels (two to three times normal) are present in about one-half of patients)
    • -skin biopsy
    • -CXR(condition may be caused by infection as well as medication).
  346. How would you manage this patient? (Five management steps)
    • -Prompt removal of offending agent.
    • -Supportive care includes wound care
    • -fluid and electrolyte management
    • -nutritional support
    • -ocular care
    • -oral care
    • -temperature management
    • -monitoring for and treatment of superinfections.
    • -Consider transfer to a burn unit as massive loss of the epidermis may occur.
  347. What is the prognosis of this condition?
    -Mortality of 1 to 3%.
  348. A 70 yo M + feeling generally unwell. Blood investigations revealed a potassium level of 7.1 mmol/litre.His only medical history was of HTN for which he had recently been started on a medication. He had no known history of hyperkalaemia. Give a differential diagnosis for hyperkalaemia(Give four)?
    • -ARF, CRF
    • -potassium sparing diuretics
    • -crush injury
    • -burns
    • -tumor cell necrosis
    • -acidosis from any cause(potassium cellular shift)
    • -drugs such as suxamethonium and beta-blockers
    • -addisons disease
    • -haemolysis of the sample or a sample taken from a limb with a potassium infusion.
  349. What medication for his hypertension might this man have been started on which may exacerbate his hyperkalaemia.
    -Amiloride or spironolactone.
  350. What are the clinical features of this condition?(Name three)?
    • -Muscle weakness
    • -muscle cramps
    • -paraesthesiae
    • -hypotonia and may cause focal neurological deficits.
  351. What ECG features may be present?(Give four)
    • -Peaked T waves
    • -small broad or absent P waves
    • -widening QRS complex
    • -sine wave pattern QRST
    • -ventricular tachycardia/ventricular fibrillation.
  352. How would you manage this patient?
    • -Confirm result
    • -monitored ECG
    • -10ml 10% calcium chloride
    • -10units Actrapid with 50ml of 50% dextrose
    • -5mg nebulised salbutamol
    • -IV fluids
    • -treat underlying cause
    • -specialist consultation.
  353. A 50 yo M + extremely painful left ankle. There was no hx/o trauma and the pain had a gradual onset over the previous 24 hours. On examination there was minor redness and swelling. Besides acute gouty arthritis name two other possible diagnoses?
    • -Pseudogout
    • -septic arthritis.
  354. Name three predisposing factors to acute gouty arthritis?
    • -Trauma
    • -surgery
    • -starvation
    • -dietary overindulgence
    • -ingestion of drugs affecting serum urate concentrations (eg, allopurinol and uricosuric agents) may all promote gouty attacks.
    • -In men, increasing alcohol consumption (beer and spirits, but not wine) is associated with proportionately a greater risk of developing gout.
  355. What are the two most appropriate investigations to confirm acute gouty arthritis in this patient?
    • -Elevated serum urate (however an appreciable number of cases occur in patients with normal or even low serum urate concentrations)
    • -aspiration of synovial fluid from the affected joint and analysis of the fluid by Gram stain, culture and polarized light microscopy.
  356. Name one feature on a plain radiograph suggestive of gouty arthritis?
    • -Subcortical bone cysts.
    • -In chronic tophaceous gout bone erosions due to tophi may have delicate "overhanging" edges and punctate to diffuse soft tissue calcification.
  357. Name two factors that predispose to chronic tophaceous gout?
    • -Patients treated with cyclosporine (and often diuretics as well) are at increased risk for the accelerated development of chronic tophaceous gout.
    • -Other patients at increased risk for chronic tophaceous gout are those who have chronic kidney disease that precludes full dose antihyperuricemic drug therapy and those who are allergic to or otherwise intolerant of uricosuric agents and allopurinol.
  358. A 53 yo F presents with a vague history. She tells you that she was recently in hospital and that they treated her for a waterworks infection she also tells you that she had a catheter but had a successful TWOC prior to discharge and she was passing water as normal. She noticed in hospital that she had some vague sensory loss in her lower limbs and she felt that they were weak. She has had difficulty walking in a straight line and she feels that she needs to pass water now. She presents to the ED a week after hospital discharge. You go through her case notes and notice that she has a background of depression and a label of fibromyalgia. You also check the lab results for her last admission and see no significant growth from her urine culture. What are the important first steps in investigation?
    • -You need to do a full through neurological examination.
    • -Also a bladder scans to see if she genuinely is in retention
    • -urinalysis.
  359. What further history might be useful for working out what is causing the symptoms?
    • -Full history- the clues to the diagnosis are more often in the history
    • -does she have any features to suggest a UTI
    • -Does she have any alcohol/drug history
    • -Many drugs can cause peripheral neuropathies.
    • -Exposure to any chemicals/lead etc etc
  360. Neurological exam reveals the following positive features Lower limbs: up-going plantars, sensory loss with a patchy distribution worse on the right leg than the left, normal sensation above T4. Hyper-reflexia of ankle and knee jerks Upper limb: normal Cranial nerves: nystagmus at extreme lateral gaze Cerebellar: unable to heel toe walk, Romberg's positive, past pointing- normal speech Bladder scan shows 750mls residual. What is the differential diagnosis here and what is the investigation of choice?
    • -Cord compression needs to be ruled out urgently with an MRI of the spine
    • -due to the positive cerebellar features demyelination is a possibility and needs to be ruled out if the MRI spine is negative by ding an MRI brain.
    • -Other differentials are potentially wide and include- syringomyelia, haematomyelia, glioma/ependymoma, lymphoma, metastatic lesions, anterior spinal artery occlusion, meningomyelocele, TB of the cord/cerebellum, HIV, Syphilis.
  361. Why might it be relevant to look at the MCV in the full blood count of this lady?
    -She could have subacute combined degeneration of the chord due to vitamin B12 deficiency, which might be suspected with a raised MCV.
  362. What is transverse myelitis? List 3 causes
    • -It is inflammation of the spinal cord
    • -the exact aetiology is unknown
    • -can occur as a complication of syphilis, measles, Lyme disease, and some vaccinations, including those for chickenpox and rabies.
    • -Post viral is common and it has been described after mycoplasma infection.
  363. You see a 74 yo M with known HTN, he is c/o feeling sick, and has a headache, he also appears to be confused. His BP is 220/130. Is this mild, moderate or severe hypertension?
    -Severe: >125 diastolic = severe
  364. What is the diagnosis?
    -Hypertensive encephalophay.
  365. What must your physical examination look for? (What conditions need ruling out?)
    • -Exam retinal for changes (exudates, haemorrhages, papilodema)
    • -Any focal neurology, accurately record GCS and mental status.
    • -Rule out a stroke or subarachnoid haemorrhage. If suspected needs urgent CT head.
  366. When and who should start therapy? How should it be commenced?
    • -Not in the ED, medical team to start treatment may require ICU/HDU care.
    • -Aim is to reduce the BP slowly.
  367. A 60 yo M + diet controlled type II DM and HTN was found collapsed at the bottom of the stairs in his home by his son. He was on a thiazide diuretic. On exam he was drowsy, his HR was 40 bpm, his BP was 150/95mmHg. His temperature was 36.4 degrees and his JVP was not raised. The heart sounds were normal and his chest was clear. His right lower limb was externally rotated and painful to move, there was extensive bruising on his right buttock and thigh. How would you investigate this patient?(List 6)
    • -FBC
    • -UE
    • -LFTs
    • -Glucose
    • -CK
    • -urinalysis
    • -Hip X Ray
    • -ECG
    • -CXR
    • -CT Brain.
  368. His renal profile revealed that his urea was 15 mmol/l and his creatinine was 700 ummol/l.His CK was also grossly elevated. What is the diagnosis?
  369. What causes the renal failure in this condition?
    • -Skeletal muscle trauma
    • -inflammation or infarction causes raised myoglobin levels in the blood which is toxic to the renal tubules.
  370. Name four other causes of this condition?
    • -Electrocution
    • -hypothermia
    • -Status epilepticus
    • -ecstasy/amphetamine abuse
    • -burns
    • -septicaemia
    • -statins
    • -strenuous exercise
    • -neuroleptic malignant syndrome.
  371. How should this patient be treated?
    -Hydration with alkalinization of the urine.
  372. A 58 yo M + retrosternal chest pain for the last 2 hours. He appears unwell and is sweaty. He has smoked for the last 20 years but has no significant medical history of note. HR is 110 and his Bp is 82/45. His JVP is raised and he has an audible S3, he also has creps to the midzones of the lungs. ECG reveals St elevation in V1-V4 and depression in II,III and aVF. What 2 oral medications should he be given immediately?
    -Asprin and Clopidogrel 300mg each.
  373. What has occurred?
    -Large anterior M.I. complicated by cardiogenic shock
  374. What investigations would be very helpful in this case?
    • -CXR- To look for widening of the mediastinum to help rule out dissection (although NB that it doesn't rule it out)
    • -bedside ECHO to look for pericardial tamponade.
  375. How should this patient be managed?
    • -IV vasopressors to treat the shock and intra-aortic balloon pump (IABP)
    • -reperfusion of the coronary arteries via PCI.
    • -The SHOCK trial showed that emergently revascularisation was better than thrombolysis with regard to improving mortality!
  376. A 45 yo F who has recently started treatment for depression presents with confusion and agitation. On examination she is hypertensive,has muscle rigity and hyperreflexia. A diagnosis of serotonin syndrome is considered. How is the diagnosis made?
    -It is based entirely on clinical suspicion and exclusion of other psychiatric and medical conditions.
  377. What is the differential diagnosis?
    • -Drug intoxications(amphetamines, anticholinergics, cocaine, clonidine, LSD, MDMA)
    • -medical conditions (such as heat stroke, hypoglycaemia, hyperthyroidism, pheochromocytoma)
    • -adverse drug reactions (dystonic reactions, malignant hyperthermia)
    • -psychiatric conditions such as catatonia
    • -infectious diseases such as encephalitis.
  378. What immediate steps should be taken?
    -discontinuing all serotonergic drugs and providing appropriate supportive care.
  379. What drugs have potential to be effective antiserotonergic agents?
    • -Cyproheptadine
    • -methysergide
    • -propranolol.
  380. A 45 yo M has now been in the department for 2 hours he is profoundly unwell. He presented in what appeared to be septic shock and has been treated as such. He was febrile 39.2, tachycardic with a BP of 67/40. There is no history available about what happened. As yet no source for sepsis has been found. You do a tox screen which is also negative. List the differential diagnoses apart from sepsis.
    • -MDMA (ecstasy)
    • -Thyrotoxic storm
    • -Malignant hyperthermia
    • -Heat stroke (malignant hyperpyrexia)
    • -EBV
    • -Serotonin syndrome
  381. TSH is 8 and T4 is 20. What will you do now?
    • -Treat as a thyrotoxic crisis
    • -CVP and accurate fluid resuscitation
    • -Beta-blockers if no contraindications
    • -Active cooling techniques
    • -Treat any infection
    • -High dose antithyroid drugs Propylthiouricil is better than carbimazole
    • -Hydrocortisone inhibits the conversion of T4-T3
    • -Monitor glucose levels
  382. List 4 precipitants of a crisis such as this?
    • -Thyroid surgery
    • -Withdrawal of antithyroid drugs
    • -Iodinated contrast dyes
    • -Thyroid palpation
    • -Sepsis
    • -P.E.
    • -DKA
    • -Trauma or emotional stress
  383. What would giving salicylates do?
    -Make it worse by displacing the T4 from thyroid binding globulin (TBG)
  384. A 68 yo M presented with severe right sided eye pain which had come on over the course of two hours. He had no previous history of eye disease. A diagnosis of acute angle closure glaucoma has made. What are the risk factors for this condition?(Name four)
    • -Family history of angle closure
    • -age older than 40 to 50 years
    • -female
    • -history of symptoms suggesting angle-closure
    • -hyperopia (farsightedness)
    • -pseudoexfoliation (a condition in which abnormal flaky deposits on eye surfaces can weaken the zonules that support the lens and cause it to shift forward)
    • -race(the highest rates of angle closure are reported in Asian populations).
  385. Besides pain what are the other symptoms a patient may complain of?(Name four)
    • -Decreased vision
    • -halos around lights
    • -headache
    • -severe eye pain
    • -nausea and vomiting.
  386. What signs may be found on exam?(Name four)
    • -Conjunctival redness
    • -corneal edema or cloudiness
    • -shallow anterior chamber
    • -mid-dilated pupil (4 to 6 mm) that reacts poorly to light.
  387. What time of the day is this condition most likely to occur?
    -Signs and symptoms of acute glaucoma often occur in the evening, when lower light levels cause mydriasis, and folds of the peripheral iris block the narrow angle.
  388. What are the management steps in the emergency department? Name two eye drops which may be of benefit?
    • -Urgent opthalmology consultation
    • -prompt administration of pressure-lowering eye drops including 0.5% timolol maleate, 1% apraclonidine, and 2% pilocarpine
    • -Systemic medications (oral or IV acetazolamide, IV mannitol, or oral glycerol or isosorbide) to control the intraocular pressure are often given.
  389. An 80 yo M presented feeling generally unwell. On examination his heart rate was 30 bpm. Name three basic initial steps in the management of this man?
    -O2, ABCs, monitor ECG, monitor BP, SpO2, establish IV access.
  390. What are the signs and symptoms suggesting poor perfusion caused by bradcardia?(Name three)
    • -Acute altered mental status
    • -ongoing chest pain
    • -hypotension
    • -other signs of shock.
  391. If the patient has poor perfusion what medication should be considered?What is the dose?
    • -Atropine 0.5mg IV.
    • -May repeat to a total of 3mg.
  392. If this is ineffective and no specialist consultation is available what is the next step?
    -Transcutaneous pacing.
  393. If the therapeutic modality of step four is ineffective what medication may be added to try and increase its effectiveness?
    • -Adrenaline(2-10ug/min)
    • -dopamine(2-10 ug/kg per minute) infusion.
  394. A 45 yo F + pleuritic chest pain. What is the differential diagnosis of pleuritic chest pain?(Give four)
    • -PE
    • -pericarditis
    • -viral pleurisy
    • -Pneumonia
    • -Pneumothorax
    • -Collagen vascular diseases including systemic lupus erythematosus, mixed connective tissue disease, and rheumatoid arthritis
    • -drug-induced lupus, inflammatory bowel disease, familial Mediterranean fever, and radiation pneumonitis.
  395. How would you investigate this patient?(Give four)
    • -ECG
    • -Bloods: D-Dimer, FBC, ABG, Troponin, BNP
    • -Chest X Ray
    • -CTPA
    • -V/Q Scan.
  396. What percentage of patients with a PE have abnormal D-Dimer value?(not including sub-segmental PE)
    • -D-dimer levels are abnormal in 95% of patients with PE.
    • -They are abnormal in only 50% of patients with subsegmental PE.
  397. If PE is confirmed how would you manage this patient?(three steps)
    • -O2
    • -hemodynamic support
    • -analgesia
    • -anticoagulation.
  398. What is the prognosis of untreated PE?
    -PE is associated with a mortality rate of approximately 30 percent without treatment, primarily the result of recurrent embolism.
  399. A 72 yo M + low grade fever, weight loss, and fatigue. He complained of a severe new unilateral temporal headache and jaw claudication. Name three other symptoms associated with this condition?
    • -Temporal arteritis may cause visual complaints such as
    • amurosis fugax
    • polymyalgia rheumatica
    • upper respiratory tract symptoms
    • arm claudication
    • symptoms secondary to aotic aneurysms and aortic dissection may occur.
  400. Name three possible findings on physical exam?
    • -Pulses may be diminished in the setting of large vessel disease.
    • -Tender or thickened temporal or other cranial arteries can occur.
    • -Some patients have cotton wool spots in the retina, depending on the site of critical vascular lesions.
    • -Fundoscopic examination shows changes of ischemic optic neuropathy with a swollen pale disc and blurred margins.
    • -In patients with PMR, active range of motion of the shoulders, neck, and hips is limited due to pain.
    • -Bruits may be heard on auscultation of the carotid or supraclavicular areas.
  401. Name three likely laboratory findings?
    • -high erythrocyte sedimentation rate (ESR), which often reaches 100 mm/h or more.
    • -Serum CRP levels in GCA tend to parallel those of the ESR
    • -while the leukocyte count is usually normal, even in the setting of widespread systemic inflammation.
    • -Elevated serum concentrations of hepatic enzymes, such as aspartate aminotransferase and alkaline phosphatase, occur in 25 to 35 percent of patients.
    • -The serum albumin level is often moderately decreased at diagnosis and a normochromic anemia is generally present prior to therapy.
  402. What is the treatment for this condition?
    • -If temporal arteritis is not complicated by symptoms or signs of ischemic organ damage (eg, visual loss) an initial dose of glucocorticoid equivalent to 40 to 60 mg of prednisone in a single dose is appropriate.
    • -If potentially reversible symptoms persist or worsen, the dose may increased until symptomatic control is achieved.
  403. What is the prognosis for this condition?
    • -In most patients temporal arteritis tends to run a self-limited course over several months to several years.
    • -The glucocorticoid dose can eventually be reduced and discontinued in the majority of patients.
    • -A sizable minority have more chronic disease and require low doses of prednisone for a number of years to control symptoms.
  404. A 36 yo F + hx/o taking an overdose of tricyclic antidepressants. Outline her initial management
    • -ABCD
    • -IVI
    • -Monitoring ECG
    • -ABG
    • -baseline bloods
  405. She develops a broad complex tachycardia. How is this treated? (give dose where appropriate)
    • -Sodium bicarbonate 1ml/kg 8.4% IV
    • -Consider RSI and ventilation if inadequate tidal volume Elective intubation should be considered for symptomatic patients with poor cardiopulmonary reserve who may not be able to tolerate large fluid loads induced by fluid and sodium bicarbonate therapy.
    • -Early intubation with mild hyperventilation may be used to help alkalinize the serum in these patients.
    • -Monitor pH on ABG aim for alkalinisation pH 7.5
  406. How does this treatment work?
    • -Sodium bicarbonate therapy
    • -Serum alkalinization with sodium bicarbonate is the mainstay of therapy in TCA overdose.
    • -Alkalinization of the serum to a pH level of 7.45-7.55 increases protein binding and has been shown to decrease the QRS interval, stabilize arrhythmias, and increase blood pressure in patients with TCA poisoning.
    • -Sodium bicarbonate may also be beneficial in treating CA overdose because of the high sodium load.
    • -Animal studies and some human case reports of treatment with hypertonic saline (without serum alkalinization) have shown similar effects on myocardial conduction parameters. Blood gases should be monitored for the development of acidosis.
    • -Sodium bicarbonate should be administered if the patient has a pH level of less than 7.1, QRS interval of more than 100 milliseconds, arrhythmias, or hypotension.
    • -Bicarbonate should be administered as an initial bolus of 1-2 mEq/kg, followed by an infusion titrated to a QRS width of 100 milliseconds.
  407. How can you clinically confirm that the treatment is working?
    • -pH ABGs
    • -ECG
    • -BP
    • -GCS and other obs
  408. The toxic effects of CAs are related to the following 4 pharmacologic effects:
    • -Anticholinergic effects
    • -Direct alpha-adrenergic blockade
    • -Inhibition of norepinephrine and serotonin reuptake
    • -Blockade of fast sodium channels in myocardial cells, resulting in quinidinelike membrane-stabilizing effects
  409. The most serious adverse effects of CA toxicity are due to
    • CNS effects and cardiovascular instability.
    • Depressed mental status is generally caused by the antihistamine and anticholinergic properties of CAs, while seizures are thought to be due to increased CNS levels of biogenic amines.
    • Life-threatening cardiovascular complications are due to impaired conduction from fast sodium channel blockade. This decreases the slope of phase zero depolarization, widens the QRS complex, and prolongs the PR and QT intervals. Impaired cardiac conduction may lead to heart block and unstable ventricular arrhythmias or asystole.
    • CAs have also been shown to directly depress myocardial contractility. However, the profound hypotension seen in serious TCA poisoning is primarily due to vasodilatation from direct alpha-adrenergic blockade.
  410. A 26 yo M + stiff jaw and being unable to open his mouth. Three days previously he was immunized with tetanus toxin after lacerating his finger. On examination he had evidence of 'lock jaw'. His injured finger was swollen , painful and exuding pus. What is the most likely diagnosis?
  411. What is the organism?
    -Clostridium tetani.
  412. Where is the organism commonly found?
    • -Soil
    • -faeces of domestic animals.
  413. What are the features of this condition?(Name four)
    • -Rigidity
    • -stiffness
    • -reflex spasms
    • -tachycardia
    • -blood pressure instability
    • -dysphagia
    • -laryngeal spasm
    • -opisthotonus.
  414. What is the immediate management?
    • -Intramuscular human tetanus immunoglobulin
    • -cleaning and if necessary surgical debridement of the wound
  415. A 29 yo Nepalese man presented with haemoptysis. He had moved to the UK 2 months previously to train in hotel management.There was no hx/o trauma. How could you confirm with that the blood is from the lungs and not the stomach?(Give two methods)
    • -Alkaline pH
    • -foaminess
    • -or the presence of pus may sometimes suggest the lungs as the primary source of bleeding rather than the stomach.
  416. What is the differential diagnosis?(Give eight)
    • -Infection(URTI,pneumonia,TB,lung abscess)
    • -carcinoma
    • -bronchiectasis
    • -pulmonary oedema
    • -PE
    • -inherited or acquired coagulation disorder
    • -wegener's granulomatosis
    • -goodpastures syndrome.
  417. How would you investigate this patient?(Give eight)
    • -FBC
    • -Coag screen
    • -UE
    • -LFTs
    • -Blood group and crossmatch
    • -ABG
    • -SpO2
    • -CXR
    • -ECG
    • -Sputum M/C/S
    • -dipstick urine.
  418. How would you manage this patient?(Give four)
    • -ABCs
    • -O2
    • -suction
    • -face mask
    • -2 large bore IV cannulae, IV fluids
    • -blood transfusion if indicated
    • -correct coagulopathy
    • -respiratory consultation.
  419. How would you define massive haemoptysis and what is its significance?
    • -Massive hemoptysis is variably defined as expectoration of blood exceeding 100 to 600 mL over a 24-hour period.
    • -Although only 5% of haemoptysis is massive some studies report a mortality rate of up to 80% in this group.
  420. A 65 yo M + classic sounding history for cardiac chest pain which came on suddenly across his chest 32 hours ago. Describe the 2 important changes shown by the ECG (fig 1) ECG and hence locate anatomically the pathology.
    • -ST elevation in II,III and aVF
    • -Reciprocal changes in leads V1 and V2
    • -This is therefore an acute inferior myocardial infarction
  421. What is it important to be vigilant for when a patient presents with this type of picture (specific to the above ECG changes) and what additional test could you do to access for this?
    • -Right ventricular infarct
    • -Do right ventricular leads (V4R)
  422. The patient responds very quickly to GTN spray and the chest pain settles, also you notice that the repeat ECG taken 5 minutes after the GTN now looks normal. What is a possible explanation for such quick resolution?
    -ECG changes resolving so quickly are more in keeping with Prinzmetal's angina or variant angina
  423. List 4 of the most important contraindications to thrombolysis
    • -Severe hypertension systolic >200 mmHg, diastolic >120mmHg
    • -Head injury, CVA or resent TIA
    • -Previous neurosurgery or cerebral tumour
    • -Recent GI or GU bleed
    • -Warfarin
    • -Pregnancy
    • -Recent major surgery
    • -Puncture of non-compressible vessel
  424. List 4 things that can cause a rise in Troponin levels
    • a. Acute myocardial infarction
    • b. Sepsis
    • c. Acute renal failure
    • d. Pulmonary embolus
  425. A 50 yo truck driver presented with dysuria and painful wrists, shoulders, knees and ankles. He also complained of purulent eye discharge. O/E he was febrile (38.5 degrees) and had a small joint effusion in his right knee. His dipstick urine test revealed nitrites, leukocytes and blood. What is the diagnosis?
    -Reiters syndrome.
  426. Name five investigations which should be carried out?
    • -FBC
    • -UE
    • -MSU
    • -blood cultures
    • -knee synovial fluid aspiration
    • -stool culture (as enteric infections can cause a reactive arthritis)
    • -CRP, ESR
    • -plain radiographs to exclude other diagnoses.
  427. Name three pathogens which can cause a reactive arthritis?
    • -Chlamydia trachomatis
    • -Yersinia
    • -Salmonella
    • -Shigella
    • -Campylobacter
    • -and perhaps Clostridium difficile and Chlamydia pneumoniae.
  428. Name three management steps in the emergency department?
    • -NSAIDS
    • -Rheumatology consultation
    • -Infectious diseases consultation to discuss appropriate additional tests and medications for symptomatic relief or microbiologic cure and to ensure follow-up treatment.
  429. What is the prognosis of this condition?
    • -Most patients remit completely or have little active disease six months after presentation.
    • -Chronic persistent arthritis, lasting more than six months, occurs in only a small proportion of patients.
  430. A 55 yo M is on the observation ward/ CDU after a minor head injury. You are urgently called to see him as the nurses feel he is acutely withdrawing from alcohol. List 6 features that would support this diagnosis
    • -Tremor
    • -anxiety
    • -hallucinations
    • -sweaty
    • -agitation
    • -confusion
  431. What are the risk factors for severe withdrawal to occur?
    • -Fitting
    • -electrolyte disturbances
    • -arrythmias
    • -infection
    • -cardiovascular collapse
    • -hpoglycaemia
    • -alcoholic ketoacisosis,
  432. What are the diagnostic features of Wernicke-Korsakoff syndrome and how might it be precipitated?
    • -Ophthalmoplegia
    • -Ataxia
    • -Mental status changes
    • -nystagmus
    • -Mental status changes Apathy, indifference, paucity of speech
    • -Hallucination
    • -agitation
    • -Confabulation: Patient fills in gaps of memory with data that can be recalled at that moment.
    • -Debate remains as to whether this action represents a deliberate attempt by the patient to hide his memory deficits or if it is an unconscious mechanism.
  433. A 18 yo girl was brought to the ED after overdosing on her mothers iron tablets.What are the clinical features of iron toxicity?
    • -Nausea, vomiting, diarrhoea
    • -abdominal pain
    • -black stools
    • -hyperglycaemia
    • -shock
    • -hypoglycaemia
    • -jaundice
    • -metabolic acidosis
    • -hepatic encephalopathy
    • -renal failure
    • -coma.
  434. How would you investigate this patient?(Give four)
    • -Check serum iron
    • -FBC
    • -UE
    • -glucose
    • -ABG.
  435. How would you manage this patient?
    • -Charcoal does NOT absorb iron
    • -gastric lavage if within 1 hour
    • -expert advice
    • -supportive measures
    • -desferrioxamine.
  436. What are the complications of desferrioxamine?(Give four)
    • -Iron-desferrioxamine complex makes the urine orange or red
    • -desferrioxamine causes hypotension if infused too rapidly, rashes, anaphylaxis, pulmonary oedema, ARDS.
  437. What gastrointestinal sequelae may survivors exhibit? (Give one)
    -Gastric strictures and pyloric obstruction.
  438. You perform a CXR on a 59 yo M + SOB. Describe what it shows: (fig 1)
    -Large right sided pleural effusion.
  439. He doesn't have heart failure, you decide to do a pleural tap for diagnostic purposes, what do you need to send samples for?
    • -Check pH (can use blood gas syringe)
    • -Send to micro in culture bottles and plain tube for gram stain MC+S also for AFB cultures.
    • -Send plain sample pot to biochemistry for LDH and protein.
    • -Send as much as you can in a sterile pot for cytology
  440. The protein is 29g/L, how do you work out if it is a transudate or an exudate?
    • -Using Light's criteria
    • effusion is an exudates if it meets one of the following criteria:
    • -If the fluid protein/serum protein ratio >0.5
    • -Pleural fluid LDH/serum LDH ratio >0.6
    • -Pleural fluid LDH> two-thirds the upper limit of normal serum LDH
  441. List the 4 most common causes for a pleural effusion in the Uk
    • -Cardiac failure
    • -pneumonia
    • -malignancy
    • -pulmonary embolus
  442. The pH comes back at 7.16 what will you do?
    • -Needs an intercostal drain
    • -empyema unlikely to resolve without drainage.
  443. A 46 yo M was came into his house after being in the garden playing with his dog. Over the course of an hour he developed facial swelling and shortness of breath resulting in his wife calling the ambulance. Name three common causes of anaphylaxis?
    • -Drugs
    • -vaccines
    • -bee/wasp stings
    • -nuts
    • -shellfish
    • -strawberries
    • -wheat
    • -latex.
  444. Patients taking what medication may have particularly severe symptoms?
  445. What are the basic initial management steps with this man?
    • -Cardiac monitoring
    • -SpO2
    • -monitoring
    • -IV access
    • -supplemental O2
    • -monitor BP.
  446. What dose of adrenaline should be given if there is shock, airway swelling or respiratory difficulty?
    • -0.5mg (0.5ml of 1:1000) IM.
    • -Repeat in five minutes if there is no improvement.
  447. Caution should be observed in administering adrenaline if the patient is taking what medications?(Name two)
    • -TCAs
    • -MAOIs
    • -B-Blockers
  448. A 68 yo M is brought in by ambulance after being found collapsed at his home. He is covered in faeces and appears very thin and unkempt. He has had some malaena. The paramedics do not know what happened today and had to break into his house. The patient's daughter called them, as she hadn't heard from him in 2 days. He is an alcoholic who drinks a litre of vodka a day. On examination he had following observations: A- own B- Clear sats 98% in air C- pulse 120 BP 81/40 D- GCS 13 E- abdomen soft- maleana present on the sheets. You discover from the notes that he has had 2 previous GI bleeds and on the last attendance he refused an OGD and was treated as a presumed bleed. You instigate initial resuscitation- list 8 things that you do?
    • 1- IV fluids
    • 2- IV pabrinex
    • 3- Check blood glucose
    • 4- ECG
    • 5- Chest x-ray
    • 6- Blood test including cultures
    • 7- Blood gas
    • 8- Speak to any family, try to gain as much pre morbid functional status as possible
  449. He stabilises a little and his blood pressure improves. His GCS remains 13. Pending blood test results you speak to the on-call enoscopist. What is the next most important investigation/intervention? Blood glucose is 6.1
    • -Need to work out why GCS is 13.
    • -Look for signs of trauma will likely need a CT head if hasn't improved after initial resuscitation in the ED. ->has had a subdural etc
  450. Blood tests come back as follows ALT- 112 GGT- 980 Bili- 73 ALKP- 442 Alb- 38 Lactate- 10.3 Na+ 149 K+ 4.8 Ur 3.2 Cr 172 Hb 12.6 Plts 263 WBC 12.3 Clotting normal Lipase- 5479 Amylase 332 How does this affect the differential diagnosis? What could be going on? Which tests results are most concerning?
    • -Pt is clearly unwell with a lactate of 10.3, liver function is grossly deranged but renal function is not too far abnormal
    • -the urea is normal and the haemoglobin is also normal meaning that any GI blood loss is likely not to be the most significant thing occurring here.
    • -The lactate is the most concerning blood test.
    • -Differential- diagnosis: pancreatitis? Ischaemic gut? Alcoholic ketoacidosis? GI bleed with perforation?
  451. His chest x-ray is normal as is the ECG. There is no sign of ascites and he is not septic, abdominal examination is unremarkable. Urinalysis reveals 4+ ketones. What is the diagnosis?
    -This case is alcoholic ketoacidosis
  452. A 62 yo obese lady attends complaining of difficulty in getting her breath- she has inspiratory stridor and a grossly swollen tongue.She is on some medication for hypertension, angina and asthma. Which of the following medications most likely caused this presentation?: Nicorandil, asprin, ramipril, simvastatin, monteleukast
    • -Ramirpil- well described angioedematous reaction can occur years after stating an ACEi.
    • -Also can occur with angiotensin 2 receptor blockers.
  453. How would you treat the patient?
    • -Ensure that the airway is protected
    • -consider ENT and anaesthetic input if required
    • -nurse in an area where pt is monitored closely, be alert to any changes in pt condition.
    • -Oxygen
    • -consider IM adrenaline
    • -chlorpenamine
    • -hydrocortisone. (treat as for anaphylaxis) These patients need 24 hours in hospital as there have been reported cases of airway obstruction after early discharge.
  454. The patient doesn't appear to improve and also complains of some abdominal pain. On examination you notice that she has prominent cervical lyphadenopathy. What could explain her lack of improvement?
    • -This could be acquired C1 esterase deficiency- seen in lymphoma.
    • -C1 estersae deficiency can be congenital or acquired
    • -It can be treated with synthetic preparations of C1 esterase.
  455. When you look through her blood tests you note that the GP did a recent fasting glucose which came back as 8.4. What does this mean and which of the following should be instigated?: Rosiglitazone, metformin, insulin, diet modification, gliclazide, pioglitazone.
    • -She is diabetic and obese- likely to need drug therapy but start with diet modification and then first option would be metformin as obese.
    • -Can't have glitazones as has IHD.?
  456. A 44-yo M + sudden onset SOB. He denies chest pain or cough. He is tachycardic at 105 bpm but has an otherwise normal CVS exam. On chest auscultation he has normal breath sounds but his oxygen saturations are 91% in air. He is afebrile. List 4 risk factors for a pulmonary embolus in this patient.
    • -Recent immobilisation/recent prolonged travel
    • -Recent lower limb trauma/surgery
    • -Clinical DVT
    • -Previous proven DVT or PE
    • -Major medical illness/cancer
    • -IVDU
    • -Family history of clotting disorder
  457. Apart from a D-Dimer give 3 investigations that are useful at this stage to exclude other causes for his symptoms according to the British thoracic Society guidelines:
    • -WBC
    • -Chest x-ray
    • -ABG
    • -ECG
    • -Peak flow
  458. Why is a D- Dimer a limited investigation?
    • -It is not sensitive or specific.
    • -Lots of other things cause a raised D-Dimer.
    • -However it has a reasonable negative predictive value i.e. if it normal a P.E. is unlikely but not impossible.
  459. His D-Dimer result comes back at 300ng/ml (normal <224ng/ml) give 2 management steps you would now take in the ED:
    • -Start LMWH 1.5mg/kg
    • -Organise a CTPA
  460. The patient deteriorates in the department and becomes hypotensive. His GCS is now 12/15. His ABG shows that he has a pure type 1 respiratory failure with a metabolic acidosis. Other than oxygen what single step will you consider now?
    • -Organise an urgent ECHO if possible to look for right heart strain and consider thrombolysis.
    • -Also consider IVC filter and cardiothoracic surgical opinion.
  461. A 65 yo F + chest pain. Her ECG is shown in figure 1.What are the 4 criteria according to the UK Resuscitation Council 2005 guidelines that constitute an unstable tachyarrhythmia?
    • 1. Presence of chest pain
    • 2. Systolic BP <90
    • 3. Evidence of heart failure
    • 4. Decrease in conscious level
  462. What is the treatment of choice? What is it crucial to appreciate from an anaesthetic viewpoint?
    • -DC cardioversion is the treatment of choice.
    • -Must be done in synchronised mode so that the shock is delivered on the R wave to avoid precipitating VF.
    • -Need to appreciate that the circulation time and cardiac output are obviously markedly reduced therefore a gentle anaesthetic is required, also high risk of aspiration as not starved.
  463. How many joules would you select for the above rhythm?
    • -200 monophasic
    • -120-150 biphasic for starters
  464. How many shocks would you deliver if your first were not successful?
    - 3
  465. What would you do after the number of shocks you stated in part d?
    -Give 300mg of amiodarone over 10-20 mins and rpt the shock.
  466. A 60 yo M + SOB. He complained that he was waking at night with SOB and could not lie flat. His previous history was of MI. O/E pulmonary rales and mild lower extremity edema. What is the diagnosis?
    -Symptomatic left ventricular systolic dysfunction.
  467. Name two other possible findings on examination in this condition?
    • -S3 gallop
    • -a decrease in tissue perfusion
    • -pulsus alternans
    • -elevated jugular venous pressure
  468. How would you investigate this patient?(Name six)
    • -SpO2
    • -FBC
    • -UE
    • -LFTs
    • -blood glucose
    • -thyroid function tests
    • -iron studies
    • -plasma BNP
    • -chest X Ray
    • -echocardiography
    • -ECG.
  469. How would you manage this patient in the ED?(Name four)
    • -O2 +/- assisted ventilation
    • -IV loop diuretic
    • -vasodilator therapy(nitroglycerin)
    • -morphine sulfate
    • -positive inotropic agents.
  470. What are the four most common cause of this condition?
    • -coronary (ischemic) heart disease
    • -idiopathic dilated cardiomyopathy (DCM)
    • -hypertension
    • -valvular disease.
  471. 35 yo presents with tingling of the hands and feet, she has been feeling very weak over the last 2/7. Knee reflexes are absent. There is blurring of the vision and diplopia on lateral gaze. She admits to a recent URTI. Give the nerve roots for the reflexes:
    • -Jaw: trigeminal V
    • -Biceps: The biceps and brachioradialis reflexes are mediated by the C5 and C6 nerve roots
    • -Triceps The triceps reflex is mediated by the C6 and C7 nerve roots, predominantly by C7.
    • -Supinator C5-6
    • -Knee: The knee jerk reflex is mediated by the L3 and L4 nerve roots, mainly L4.
    • -Ankle: The ankle jerk reflex is mediated by the S1 nerve root.
  472. What is the most likely diagnosis
    • -Guillain Barre Syndrome
    • -Antecedent illness Up to two thirds of patients with GBS report an antecedent illness or event 1-3 weeks prior to the onset of weakness.
    • -Upper respiratory and gastrointestinal illnesses are the most commonly reported conditions.
    • -Symptoms generally have resolved by the time of medical presentation for the neurologic condition.
    • -Ophthalmoparesis may be observed in up to 25% of patients with GBS.
    • -The most common limitation of eye movement is from a symmetric palsy associated with cranial nerve VI
    • -Lower extremity weakness usually begins first and ascends symmetrically and progressively over the first several days.
    • -Upper extremity, trunk, facial, and oropharyngeal weakness is observed to a variable extent.
    • -Marked asymmetric weakness calls the diagnosis of GBS into question.
    • -Despite frequent complaints of paresthesias, objective sensory changes are minimal.
    • -Reflexes are absent or hyporeflexic early in the disease course and represent a major clinical finding on examination of the patient with GBS
  473. Give two differential diagnoses
    • -Poliomyelitis
    • -Nutritional neuropathies
    • -Toxic neuropathies (eg, arsenic, thallium, organophosphates, lead)
    • -Multifocal motor neuropathy
    • -Mononeuritis multiplex
    • -Critical illness polyneuropathy
    • -Botulism
    • -Vasculitic neuropathies
    • -Diphtheritic polyneuritis
    • -Acute myasthenia gravis
  474. Name three things to do in the ED to get the diagnosis
    • -Speak to neurologist
    • -Spirometry Frequent evaluations of these parameters should be performed at bedside to monitor respiratory status and the need for ventilatory assistance
    • -LP The increase in CSF protein is thought to reflect the widespread inflammatory disease of the nerve roots MRI brain
    • -Imaging studies such as MRI or computed tomography (CT) scan of the spine may be more helpful in excluding other diagnoses, such as mechanical causes of myelopathy, than in assisting in the diagnosis of GBS Nerve conduction studies: Electromyography (EMG) studies can be very helpful in the diagnostic workup of patients with suspected GBS.
    • -Abnormalities in the NCS consistent with demyelination are sensitive and represent specific findings for classic GBS Basic laboratory studies, such as complete blood counts and metabolic panels, are of limited value in the diagnosis of GBS.
    • -They often are ordered, although, to exclude other infectious or metabolic causes of the weakness
  475. What needs to be monitored whet the patient is admitted?
    -FVC to see any deterioration in respiratory function.
  476. A 39 yo F + generalised macular erythematous rash. She had been feeling unwell for the previous two days but the rash had relatively quickly on the day of presentation.The week before presentation she had been started on a new medication for a chronic medical condition. She also complained of difficulty eating secondary to oral pain. On examination she was febrile and had a generalised erythematous macular rash. She had multiple oral ulcerated areas. A diagnosis of stevens-johnsons syndrome was made. What is the differential diagnosis of this condition?(Name three)
    • -Erythematous drug eruptions
    • -pustular drug eruptions
    • -phototoxic eruptions
    • -staphylococcal scalded skin syndrome (SSSS)
    • -toxic shock syndrome (TSS).
  477. Name two medications which commonly cause this condition?
    • -Anti-gout agents (especially allopurinol)
    • -antibiotics (sulfonamides >> penicillins > cephalosporins)
    • -antipsychotics and anti-epileptics (including carbamazepine, dilantin, lamotrigine, and phenobarbital)
    • -analgesics and non-steroidal anti-inflammatory agents.
  478. How would you investigate this patient?(Name three appropriate investigations)
    • -FBC with differential cell count
    • -LFTs(Mild elevations in serum aminotransferase levels (two to three times normal) are present in about one-half of patients)
    • -skin biopsy
    • -CXR(condition may be caused by infection as well as medication).
  479. How would you manage this patient? (Five management steps)
    • -Prompt removal of offending agent.
    • -Supportive care includes wound care, fluid and electrolyte management, nutritional support, ocular care,oral care, temperature management, and monitoring for and treatment of superinfections.
    • -Consider transfer to a burn unit as massive loss of the epidermis may occur.
  480. What is the prognosis of this condition?
    -Mortality of 1 to 3%.
  481. A 45 yo M + cough, and shortness of breath. On examination he was febrile and had bronchial breathing in the right lower zone. What is the condition shown in the radiograph?
  482. Name three common microbes which cause this condition?
    • -Strep. pneumoniae
    • -respiratory viruses
    • -mycoplasma pneumoniae
    • -chlamydia pneumoniae
    • -haemophilus influenzae.
  483. Name four risk factors?
    • -Alcoholism
    • -COPD
    • -smoking
    • -structural lung disease aspiration
    • -lung abscess
    • -HIV infection
    • -age
    • -exposure to birds droppings.
  484. What is an initial appropriate anti-biotic regime for a patient not admitted to ICU?
    • -Combination therapy with ceftriaxone (1 to 2 g IV daily) or cefotaxime (1 to 2 g IV every 8 hours) plus azithromycin (500 mg IV or orally daily).
    • -Alternatively monotherapy with a respiratory fluoroquinolone given either IV or orally except as noted (levofloxacin 750 mg daily or moxifloxacin 400 mg daily or gemifloxacin 320 mg daily [only available in oral formulation]).
  485. How long after discharge should the radiographic abnormalities be resolved?
    -Chest x-ray at 7 to 12 weeks after treatment is recommended for selected patients who are over age 40 years or are smokers to document resolution of the pneumonia and exclude underlying diseases, such as malignancy.
  486. A 66 yo F + 3 week hx/o progressive SOB and purulent cough. She had tuberculosis treated in East Timor 24 years previously. O/E SatO2A 92%. Describe the main finding in the the chest radiograph shown? Name two other findings which are seen in radiographs of patient with TB?
    • -There is a right upper zone opacity with cavitation.
    • -Other findings include hilar adenopathy, sometimes associated with right middle lobe collapse, infiltrates or cavities in the middle or lower lung zones, pleural effusions, solitary nodules.
  487. Besides tuberculosis give a differential diagnosis of two other conditions?
    • -Neoplasm
    • -pneumonia.
  488. What further investigations should be carried out in the ED?(Name three)
    • -Full blood count
    • -U/E
    • -random sample sputum staining for acid-fast bacilli
    • -Blood cultures.
  489. How should this lady be managed in the emergency department?(three steps)
    • -Isolation with barrier nursing
    • -negative pressure room if available
    • -supplemental oxygen therapy
    • -respiratory consultation.
  490. Name two complications of this condition?
    • -Haemoptysis
    • -pneumothorax
    • -bronchiectasis
    • -extensive pulmonary destruction.
  491. A 73 yo M + acutely SOB, in fast AF 153bpm. He suffered 3 M.I.s last year and has a 10 yr hx/o HTN. BP 100/53 and auscultation of his chest revealed inspiratory crackles and expiratory wheeze with a raised JVP. What should happen to this patient according to resus council guidelines?
    • -Attempt synchronised shocks up to 3 attempts.
    • -According to tachyarrhythmia guidelines the patient is unstable and requires electrical cardioversion.
  492. Which of the following drugs would be the best for restoring sinus rhythm? 1. IV digoxin 2. IV amiodarone 3. IV flecanide 4. IVesmolol 5. IVdofetolide
    • -IV amiodarone. -
    • -digoxin and esmolol wouldn't restore sinus ryhtm
    • -flecanide is contraindicated in heart failure
    • -amiodarone is the least negatively ionotropic
    • -Dofetolide = good option but amiodarone = better.
  493. What type of patient should one avoid digoxin in?
    -Renal patients/ patients with known renal failure.
  494. List the investigations that you would want to help you work out why the patient was in fast AF.
    • -CXR
    • -MSU
    • -Blood cultures
    • -ECHO
  495. A 34 yo M + sudden onset of left sided chest pain worse on inspiration. SatO2A 94%. You consider the diagnosis of a spontaneous pneumothorax. What element of the social history that you do not have would support the likelihood of a spontaneous pneumothorax?
    -Smoking the lifetime risk of developing a pneumothorax in healthy smoking men may be as much as 12% compared with 0.1% in non-smoking men.
  496. What is a primary pneumothrax compared to a secondary one?
    • -Primary pneumothoraces arise in otherwise healthy people without any lung disease.
    • -Secondary pneumothoraces arise in subjects with underlying lung disease.
  497. You perform a chest radiograph which confirms your diagnosis, which 2 features would lead you to considering aspiration according to current BTS guidelines?
    • -If the rim was >2cm from the chest wall
    • -or if the patient was breathless as a result of it. 
  498. You attempt aspiration but it is unsuccessful, what would you do next?
    -Could consider repeat aspiration or if that fails again insert an intercostal drain.
  499. Explain why it is crucial to obtain an erect chest x-ray in patients with a suspected pneumothorax.
    • -On supine x-rays lung markings will extend to the chest wall as air in the pleural cavity moves anteriorly.
    • -A lateral chest or lateral decubitus radiograph should be performed if the clinical suspicion of pneumothorax is high, but a PA radiograph is normal.
  500. What type of x-ray may be of benefit in these cases?
    -lateral decubitus film.
  501. In an older patient with underlying COPD who develops a spontaneous pneumothorax that is 4 cm in size what condition must you be wary of post aspiration?
    -re expansion pulmonary oedema, this is especially important if the patient has waited a few days before seeking medical attention as the incidence is higher the longer the lung has been collapsed.
  502. A 56 yo male + episode of syncope. It occurred whilst he was out walking his dogs. He smokes 15c/d; HTN,Hyperchol. O/E ESM and a soft second heart sound. He feels completely fine now and wants to go home, what do you need to do in the ED?
    -The patient likely has cardiac syncope related to severe AS->needs admission for urgent echocardiogram to assess the aortic valve. He will likely need to have it replaced and will therefore also need angiography prior to this to guide the cardiac surgeons.
  503. You perform an ECG (figure 1). Describe what it shows:
    • -ECG showing gross left ventricular hypertrophy (LVH) with strain in case with severe aortic stenosis.
    • -The R waves in V5 and V6 are so tall that they are overlapping with the tracing in the channel above.
    • -ST segment depression and T wave inversion are seen in inferior and lateral leads. This is a pressure overload pattern which can be seen also in severe systemic hypertension and hypertrophic obstructive cardiomyopathy.
  504. What is the next step in this patients? management? 1. Start an ACE inh 2. Tredmill test 3. Percutaneous aortic balloon valvulotomy 4. Give flecanide 5. Amiodarone 300mg IV over 30 minutes 6. All of the above 7. None of the above
    - 7. This patient if shown to have what you believe clinically to be severe aortic stenosis will need his valve replacing, valvulotomy is only really used as a bridge to surgery in unstable patients.
  505. What is the current guidance regarding antibiotic prophylaxis for patient undergoing dental procedures who have valvular heart disease?
    • -That it is NOT REQUIRED. New guidance in 2006 from British Society for Antimicrobial Chemotherapy (BSAC) states that it is no longer required as there is no evidence that it leads to BE.
    • -HOWEVER THIS IS CONTROVERSIAL and a lot of cardiologists do not agree- we await NICE guidance on this.
  506. A 75 yo man was found collapsed at home. There was no available PMH. He was living independently and had last been seen 2 days previously by his son. On examination his GCS was 7/15. There was no nuchal rigidity, pupil reflexes were sluggish but fundi examination was noraml. Tone was slightly increased in all four limbs. The peripheral reflexes were present and plantars were downgoing. HR39 bpm, BP 76/42 mmHg. Heart sounds were normal and the chest was clear. Hypothermia was suspected. How is hypothermia defined?
    -A fall in core temperature below 35 degrees.
  507. How should the temperature be measured?
    -Rectal (core) temperature with a low reading thermometer.
  508. List some clinical features of this condition?(four)
    • -Impaired consciousness
    • -cardiac embarrassment
    • -bradycardia
    • -hypotension
    • -hypopnoea
    • -sluggish pupillary and peripheral reflexes
    • -muscle rigidity
    • -coma
    • -ventricular fibrillation
    • -asystole.
  509. List some ECG features of this condition?(list four)
    • -Bradycardia
    • -tremor artefact
    • -J-waves
    • -prolonged QT interval
    • -prolonged PR.
  510. How would you treat this man if the diagnosis is confirmed?
    • -Gradual rewarming using space blankets.
    • -If the patient is unconsciousness or the temperature is less than 32 warm IV fluids may be given.
    • -The aim is to increase the temperature by one degree/hour.
  511. A 65 yo man presents with a week long history of palpitations. PMH stroke 2 years ago, HTN, DM2, on ramipril, metformin and aspirin. NKDA, non-smoker. HR 130 bpm (irregular), BP 145/90, T36.9°C. What is the diagnosis? (1)
    -Atrial fibrillation
  512. List 4 potential causes of this condition: (2)
    • -Hypertension
    • -Pulmonary embolism
    • -Coronary artery disease
    • -Other primary heart disease e.g. HOCM, congenital, etc.
    • -Hyperthyroidism
    • -Alcohol
    • -Drug abuse e.g. cocaine
    • -Sepsis / infection
  513. Name an oral medication that could be used as first line treatment for rate-control in this gentleman: (1)
    • -Beta-blocker e.g. bisoprolol or;
    • Calcium channel blocker e.g. diltiazem
  514. List 3 factors that would make a rate-control strategy preferable in his long-term management: (3)
    • -Age over 65
    • -Presence of coronary artery disease
    • -Contraindications to anti-arrhythmic drugs
    • -Unsuitable for cardioversion e.g. contraindications to anticoagulation or structural heart disease
    • -Long duration of AF (> 12 months)
    • -Absence of congestive heart failure
  515. Name a scoring system and 5 risk factors within it that could help you decide whether anti-coagulation is a suitable management option in this patient: (3)
    • CHA2DS2-VASc score
    • C – Congestive heart failure (1 point)
    • H – Hypertension (1 point)
    • A2 – Age > 75 years (2 points)
    • D – Diabetes mellitus (1 point)
    • S2 – Prior stroke or TIA (2 points)
    • V – Vascular disease (1 point)
    • A – Age 65-74 years (1 point)
    • Sc – Sex category (female gender) (1 point)
    • 0 – low risk, 1 – moderate risk (aspirin or warfarin), > 2 – high risk (warfarin)
  516. A 24 yo rugby player has suffered a left sided ankle injury during a game. He is complaining of pain and swelling and has been unable to weight bear in the department. His X-ray is shown below: Describe the X-ray changes. (1)
    -There is a fracture of the fibula at the level of the syndesmosis. This is a Weber B fracture.
  517. Describe a classification system that can be used to assess these types of fractures: (3)
    • -Type A – fracture below the level of the syndesmosis
    • -Type B – fracture at the level of the syndesmosis
    • -Type C – fracture above the level of the syndesmosis
  518. Which additional radiograph, other than a lateral, would be useful in assessing this particular injury and why? (2)
    • -
    • A gravity stress radiograph.
    • Gravity stress radiographs assess the integrity of the deltoid ligament in lateral malleolar ankle fractures without talar shift and are particularly helpful in assessing undisplaced Weber B fractures.
  519. Outline the Ottawa rules for foot and ankle radiographs: (3)
  520. Ankle radiographs are only required if there is pain in the malleolar area and any one of the following:
    • -Bone tenderness over the distal 6cm of the posterior edge or tip of the lateral malleolus
    • -Bone tenderness over the distal 6cm of the posterior edge or tip of the medial malleolus
    • -Inability to weight bear immediately and in the Emergency Department
    • Foot radiographs are only required if there is pain in the midfoot area and any one of the following:
    • -Bone tenderness at the base of the fifth metatarsal
    • -Bone tenderness at the navicular bone
    • -Inability to weight bear immediately and in the Emergency Department
  521. Name two groups of patients that are excluded from the Ottawa rules: (1)
    • -Pregnant women
    • -Head injury patients with diminished ability to follow test
    • -Intoxicated patients with diminished ability to follow test
    • -Children under 6
  522. A 3 yo boy presents accompanied by his Dad. He suffers with asthma for which he takes a salbutamol inhaler as required. He has been coryzal for the past few days and has become wheezy this evening. His best peak flow is 250 L/min and his peak flow this evening is 180 L/min. His observations are as follows: HR 100, RR 26, SaO2 97% on air, Temperature 37.4°C. How would you classify his asthma at this presentation? (1)
    -Moderate asthma exacerbation
  523. Outline your initial management in the ED: (3)
    • -10 puffs salbutamol via spacer
    • -Oral prednisolone (soluble) 20 mg
    • -Re-assess after 15 minutes
  524. What are the normal ranges for heart rate and respiratory rate in a child this age? (2)
    • -
    • In 2-5 year olds:
    • Heart rate = 95-140 bpm
    • Respiratory rate = 25-30 breaths per minute
  525. He responds to your initial treatment. Outline your discharge plan: (2)
    • -Discharge with 4 hourly salbutamol
    • -Oral prednisolone 20mg for 3 days
    • -Arrange GP follow up
    • -Check inhaler technique
    • -Give a written asthma management plan
  526. List 4 features of acute severe asthma in this age group: (2)
    • -O2 saturations less than 92%
    • -Too breathless to talk or feed
    • -HR > 130/min
    • -RR > 50/min
    • -Use of accessory muscles
  527. A 32 yo man + overdose of 60 paracetamol tablets (30 g) 6 hours earlier. He is a known alcoholic and appears poorly nourished weighing 50 kg. He is currently vomiting but has no abdominal pain. He has no other medical history of note and takes no medications. His paracetamol level at 6 hours is 90 mg/L. The new treatment line for paracetamol overdose, introduced in September 2012, is shown below: Outline 4 initial management points for this patient. (include any drug doses): (4)
    • -Take bloods for U&Es, LFTs and clotting profile
    • -Take arterial blood gas
    • -Seek advice from NPIS / Toxbase
    • -Give anti-emetic e.g Cyclizine 50 mg IV
    • -Note that the patient is over the treatment line for a high risk patientn Commence N-acetylcysteine – initial dose 150 mg/kg in 200 mL of 5% dextrose over 1 hour
    • -Refer to medical team for admission
  528. He refuses to take intravenous medications. Name an oral alternative and give the dose: (1)
    • -
    • Methionine 2.5 g every 4 hours to a maximum dose of 10 g
  529. Outline 4 'high risk' groups for suicide attempts: (4)
    • -Male gender
    • -Elderly patients
    • -Living alone / isolated
    • -Separated, divorced or widowed
    • -Unemployed or retired
    • -Chronic physical illness or disability
    • -Psychiatric illness (especially depression and schizophrenia)
    • -Alcoholism
  530. Which blood test is the most sensitive indicator of liver damage? (1)
    -The INR or prothrombin ratio
  531. A 36 yo lady is brought to the resuscitation area of your Emergency Department by ambulance having a tonic-clonic seizure. She is 34 weeks pregnant and has been treated for pre-eclampsia antenatally with labetolol 100 mg bd. Her airway is patent and her observations are as follows: HR 100, BP 162/94, SaO2 100% on high flow oxygen. What is the diagnosis and the underlying pathophysiology of her seizure? (2)
    • -Eclampsia.
    • The seizure is a result of brain hypoxia due to ischaemia secondary to cerebral oedema and vasospasm.
  532. What is the drug of choice for management of her seizure (please include the dose and route of administration)? (2)
    -IV Magnesium sulphate 4 g
  533. What is the definitive treatment for this condition? (1)
    -Delivery of the baby
  534. List 2 neurological features of severe pre-eclampsia: (2)
    • -Headache
    • -Visual disturbance
    • -Confusion
    • -Papilloedema
    • -Clonus
  535. List 3 abnormalities found on blood tests that are indicative of severe pre-eclampsia: (3)
    • -Raised creatinine
    • -Low platelet count (<100 x 109 /L)
    • -Elevated liver enzymes (AST and ALT)
  536. Give two causes of acute exacerbation of COPD
    • -Lower respiratory tract infection
    • -Pneumothorax
  537. Give 4 initial treatments you would give this patient
    • -Oxygen via fixed delivery device aiming for saturations 88-92%
    • -Salbutamol nebulisers 5mg repeated as required
    • -Ipratropium nebulisers 500mcg
    • -Oral Prednisolone 30-40mg
  538. Indication for empirical antibiotics in acute exacerbation of COPD
    • -Increased sputum production
    • -Consolidation on the CXR
    • -Clinical signs of pneumonia