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Flashcards in DPD 7 - Miscellaneous Deck (13)
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A 75y/o man presents w/ 3 days of worsening breathlessness, productive cough + reduced exercise tolerance w/ a 50 pack year Hx. Temp 38.5; PR 110 bpm; BP 140/87mmHg; RR 28 breaths per minute; O2 sat 87% on RA. Treated w/ O2, aiming for saturations of 88-92%. What is the next most appropriate step in management?
1. IV aminophylline
2. IV magnesium sulphate
3. IV steroids
4. Non-invasive ventilation
5. Salbutamol nebuliser

Salbutamol nebuliser
Aminophyllin is a competitive, non-selective phosphodiesterase inhibitor causeing increased cAMP which activates PKA which inhibits TNF-a thus decreasing inflammation. It is a non-selective adenosine receptor antagonist
Magnesium sulphate tends to work more in Asthmatics


What is the Tx for COPD?

1. Oxygen - via Venturi mask (24%) and aim for AsO2 88-92%; if high flow, there is a danger of CO2 retention and patients depend on hypoxic drive.
2. Acute management: Salbutamol nebuliser; ipratropium bromide
3. Steroids - reduces inflammation but not the first step
4. Aminophylline infusion if not responding
5. CPAP - if resp acidosis


A 66 y/o man w/ metastatic prostate cancer and ongoing bony pain. He is taking maximum doses of paracetamol, codeine, morphine but currently the pain is not well controlled. What is the next step in control of his pain?
1. Co-dydramold
2. Finasteride
3. Radiotherapy
4. Tamsulosin
5. Vitamin D

Radiotherapy - good palliative Tx of bone pain.
Co-dydramold = codeine + paracetamol so can't give more otherwise will overdose.
Finasteride is a Type 2 + 3 5a reductase inhibitor which treats benign prostatic hyperplasia.
Tamsulosin treats symptomatic benign prostatic hyperplasia + vit D can cause bony pain but in this case, bony pain is due to bony metastasis.


A 64 y/o woman presents w/ sudden onset central, crushing chest pain radiating to her left arm. Associated w/ breathlessness + sweating. Has a FHx of hypercholesterolaemia + O/E O2 sats is 98% on room air. Ix: ECG shows ST elevation in leads II, III and aVF. She is treated with morphine, nitrates, aspirin + clopidogrel. What is the next priority in her management?
1. Coronary artery bypass graft
2. High flow oxygen
4. Percutaneous coronary intervention
5. Ramipril

High flow O2 not required in this case as saturations are adequate. Ramipril is part of long term management (on discharge) but not part of immediate management


What is the Tx of NSTEMI?

1. Morphine (+ metaclopramide)
2. Nitrates (GTN)
3. LMWH/Fondaparinux


What is the Tx of STEMI?

1. Morphine (+metaclopramide = anti-emetic)
2. Oxygen
3. Nitrates (GTN) - keep an eye on BP, avoid hypotension: maintain SBP >100bpm
4. Aspirin/clopidogrel
5. PCI


A 66 y/o woman presents w/ increasing drowsiness + vomiting for 2 days. PMHx: HTN + osteoarthritis. DHx: perindopril, ibuprofen. Temp 37.5, PR 96, BP 110/67, RR 24, O2 sats 95% on room air. Ix shows hyperkalaemia, raised Cr + raised urea. What is the next most appropriate step in her management?
1. Calcium gluconate
2. IV fluids
3. Renal replacement Tx
4. Renal transplant
5. Slabutamol nebusiler

Calcium gluconate - hyperkalaemia where K+ > 6.5 or any ECG changes (peak T waves) require 10mg 10% calcium gluconate (NTK dose). Calcium gluconate stabilises the myocardium - prevents arrhythmias + saves lives.
Then, give insulin + 50ml 50% dextrose - insulin drives K+ and glucose into cells (dextrose given in combination to prevent hypoglycaemia).
Salbutamol is also part of the management for hyperkalaemia - beta agonist but is not first line.


A 72 y/o man presents w/ sudden onset, left-sided weakness of 2 hours duration. PMHx: hyperlipidaemia, HTN, T2DM. 40 pack year smoking Hx. O/E temp 36.5, PR 93, BP 144/89, RR 18, O2 sats 96% on room air. What is the next step in management of his hemiparesis?
1. Aspirin
2. Carotid artery Doppler
3. CT scan of the head
4. ECG
5. Tranthoracic echo

CT head - a stroke is suspected but you don't know if the stroke is ischaemic/haemorrhagic.
Carotid artery doppler is done later to look for source of embolus.


A 16 y/o girl with T1DM presents w/ severe abdominal pain, nausea + vomiting. O/E: Temp 36.9, PR 110, BP 114/74, RR 28, O2 sats 99% on RA. VBG on 28% O2 shows: decreased pH, decreased pO2, decreased pCO2, decreased bicarbonate, increased glucose. What is the next step in management?
1. Abdo X ray
2. ABG
3. Capillary ketone
4. CXR
5. ECG

Capillary ketone - DKA is suspected and cannot look at pCO2 as this is a VBG not an ABG.
VBGs are done first as ABGs are painful and with minimal added value - only done if indicated. VBG will give you the pH, bicarb + pCO2. If hypoxic, you want to do an ABG.


A 74 y/o man presents w/ a 2 month Hx of weight loss. Change in bowel habit + intermittent rectal bleeding. Blood is fresh and mixed with stool. O/E: Temp 36.4, PR 74, BP 132/87, RR 21, O2 sats 97% on room air. Ix: decreased Hb, decreased MCV, increased Pt. What is the next step in management?
1. Abdo X ray
2. Barium meal and follow through
3. Colonoscopy +/- biopsy
4. CT abdo + pelvis
5. MRI abdo +pelvis

Colonoscopy +/- biopsy
AXR indicated to investigate obstruction (dilated bowel) or colitis (toxic megacolon)


A 78 y/o man has 3 month of worsening hesitancy, nocturia + terminal dribbling when passing urine. He has a smooth firm prostate. O/E: 36.9, PR 84, BP 132/88, RR 18, O2 sats 98% on RA. Urinalysis: negative. What is the next step in management?
1. Advise to increase oral fluid intake
2. Oxybutynin
3. Radical prostatectomy
4. Tamsulosin
5. Transurethral resection of prostate

Tamsulosin - alpha blocker relaxes smooth muscle which improves lower urinary tract (obstructive) symptoms. Treat symptomatic benign prostatic hyperplasia + help passage of kidney stones. Relaxes bladder neck muscles + muscle fibres in prostate which makes it easier to urinate.
Oxybutynin helps with detrussor instability by decreasing muscle spasms of the bladder. Muscarinic ACh antagonist - to relieve urinary and bladder difficulties. TURP considered if pharmacological Tx insufficient.


A 52 y/o woman presented w/ right knee swelling and severe pain. No Hx of trauma. O/E: Temp 38.9; HR 84; BP 124/68, RR 20, O2 sats 100% on RA. What is the next step in management in this patient?
1. Broad spectrum Abx
2. Intra-articular steroid injection
3. Knee aspiration
4. Knee X ray
5. Physiotherapy

Knee aspiration - look for crystals under polarised light to exclude gout (negatively needle shaped berifengent crystals). Gram stain
Not broad spectrum Abs because it may not be sepsis - need to rule out other DDx e.g. gout. If systemically unwell (hypotensive, tachycardic) then treat sepsis
The DDx: septic/infective arthritis; gout; seronegative arthritis; CTD


A 75 y/o man presents w/ sudden onset painful right leg. It is cold and pale, dorsalis pedis pulse is not palpable. Hx of hypercholesterolaemia + HTN. ECG shows irregular rhythm with no clear P waves. What is the next step in his management?
1. Aspirin
2. Below knee amputation
3. Decompressive fasciotomy
4. IV Heparin
5. Warfarin

IV heparin then refer to vascular surgeon
The pain, pallor + coldness suggest acute ischaemic limb