This drug is a vasoconstrictor which can be used as a nasal decongestant. It is also mydriatic when used as an eye drop.
Alpha 1 agonist. Alpha 1 agonists such as phenylephrine are vasoconstrictors and also have a use as a mydriatic. They are used as nasal decongestants as a result of their vasoconstrictor effect.
This drug lowers heart rate, cardiac output and mean arterial blood pressure during exercise. It can also be used for migraine prophylaxis and glaucoma. This drug also causes a decrease in endogenous renin release.
Beta blocker. Lower heart rate, CO and MABP during exercise. Reduce renin release and NA release. Use: migraine prophylaxis, anxiety, hypotension, post- MI, CCF. Also useful in arrhythmias as they act to increase the refractory period of the AVN.
Beta blocker contraindications
Absolute: - asthma - severe bradycardia - high AV block - sick sinus syndrome - severe unstable LVF Relative - peripheral vascular disease - depression
De compensated severe heart failure Bradycardia AV block Sick sinus syndrome
A 55 year old obese female complains of an occasional burning pain behind the sternum. The pain is worse after large meals and when drinking hot liquids.
GORD This patient has GORD characterised by heartburn and regurgitation of acid. It is more severe at night when the patient is lying flat and also when the patient is bending over. Risk factors include obesity and hiatus hernia. Diagnosis is generally clinical and cans also be achieved by a diagnostic trial of a PPI. Normally an upper GI endoscopy is reserved for complications such as strictures, Barrett's or cancer or for atypical features. An OGD may show oesophagitis, or Barrett's (red velvety). However it may be normal. Manometry or pH monitoring may also be performed but in this case this patient will probably just have a therapeutic and diagnostic trial of a PPI.
Mr L, an investment banker, who is as wide as he is tall, has been brought in to A&E at 2am on Sunday after collapsing at the kebab shop on Shepherds Bush Road. He is dressed in a schoolboy outfit, which only makes sense when a similarly dressed friend arrives to tell you that the office went clubbing in Po Na Na together. Apparently Mr L had been complaining of tight chest pain and anxiety earlier in the evening but a cigarette calmed him down.
Acute coronary syndrome. ACS refers to acute myocardial ischaemia and encompasses STEMI, NSTEMI and unstable angina. This man is clearly overweight and is seeming munching a kebab so there are clear cardiovascular risk factors. The right chest pain followed by a collapse make this sounds like an MI. Those with identified STEMI should be considered for immediate reperfusion therapy by thrombolytics or PCI. Those with NSTEMI or unstable angina do not benefit from this. Most complain of chest pain which is described as substernal pressure, heaviness, squeezing, burning or tightness. It may either localise or radiate to the arms, shoulders, back, neck or jaw and is usually reproduced by exertion, eating, cold or emotional stress. ECG and bio markers like troponin will be useful in confirming the diagnosis.
Miss A, a 52 year old attends a Rapid Diagnostic Clinic for Breast Cancer at CX. She is concerned over an area of tenderness on her left breast. O/E you find that the lower medial quadrant of the left breast feels sore when you palate deeply. There is no palpable lump and both mammography and US are normal.
Costochondritis. This is costochondritis or Tietze's syndrome (costochondritis & swelling), which presents with insidious onset of anterior chest wall pain which is made worse by certain movements of the chest and deep inspiration. The key sign is that there is pain when palpating the costochondral joints, particularly 2-5 and the diagnosis is clinical. Tests are done to exclude other diagnoses such as breast pathology. First line treatment is NSAIDs. Oral NSAIDs are preferred in the primary care setting and a beneficial response confirms the diagnosis. If NSAIDs or local corticosteroid injection fail to make the symptoms better then you should seek further investigations and consider a wider differential diagnosis including pleuritis, PE, rib fracture and GORD.
Pain on breathing in & out, dyspnoea, haemoptysis, stony dull to percuss.
PE Patients with a high clinical suspicion of PE should be anti coagulated while waiting a definitive diagnosis unless CI. PE can cause atelectasis which can result in a dull percussion note and a pleural effusion which is exudative in nature, causing a stony dull percussion note. SOB and chest pain are common symptoms and there may also be haemoptysis. Strong risk factors include DVT, obesity, surgery in the past 2 months, prolonged bed rest, malignancy, previous VTE, pregnancy and the thrombophilias such as factor V Leiden. ECG may be normal, or may show tachycardia, new RAD, new RBBB or the classical S wave in I, Q wave with TWI in III.
A 32 year old woman has a 2 day history of intermittent attacks of a sharp pain over the lower left side of her chest. The pain is exacerbated by movements of the rib cage and the patients tells you it becomes difficult to breathe. She has also felt feverish.
Bornholm disease. Bornholm disease is caused Coxsackie B virus and symptoms include the fever seen as well as the characteristic attacks of severe pain in the lower chest, which is exacerbated by small movements of the rib cage, which make it difficult for the patient to breathe.
A 25 year old basketball player, with very long arms, describes sudden onset chest pain over the left side of his chest. He is very short of breath. Choose the single most appropriate investigation.
CXR This patient has a primary pneumothorax. Marfan's syndrome is a risk factor and there are many reports of primary spontaneous pneumothoraces attributes to pulmonary tissue fragility due to defective fibrillin. Primary pneumothoraces occur in young people without known lung conditions. The main investigation is a CXR and are classified by the amount of visible rim: small 2cm. If the patient is clinically stable, they can be observed and given O2 - an invasive approach is not necessary and the O2 will increase the rate of pneumothorax reabsorption. A large pneumothorax may require per cutaneous needle aspiration. If this fails a chest drain should be inserted.
A 23 year old student comes into hospital as part of the regular treatment for his condition. He was first brought to see you at a young age after his GP noticed he was not gaining weight adequately. In addition he was noted to be an ill child and was always developing colds. The mother distinctly remembers that he had difficulty passing his first motions after he was born? What is the approximate carrier frequency of this disease? When 18 he presented with severe pneumonia productive of green sputum, which indicated the acquisition of a pathogen the doctors had been worried about for a number of years. What is the most likely pathogen? What is the most suitable antibiotic?
The features are consistent with a diagnosis of cystic fibrosis, a common AR genetic disorder. The gene affected is for the CFTR, which is a protein that functions as a Cl channel. Abnormalities in chloride secretion lead to viscous fluids and result in excess inflammation and infections due to impaired clearance of secretions. The carrier frequency in the white population is approximately 1/20-1/25. The actual incidence is 1/2500 live births. Pseudomonas aeruginosa is a common pathogen found in CF patients. It is an opportunistic organism, infection is usually occurring in immunocompromised and severely ill patients. The green sputum is highly characteristic and occurs due to a blue-green pigment produced by the bacteria. Ciprofloxaxin.
Which ONE of the following statements is true? A) paracetamol poisoning is the 2nd most commonly encountered drug overdose in the UK B) The hepatotoxic dose of paracetamol is taken as 150mg/kg for high risk patients. C) Paracetamol overdose leads to approx. 2000 deaths per year D) Activated charcoal is better than gastric lavage in certain situations. E) N-acetylcysteine is approx 75% useful in preventing significant hepatic impairment if given within 12 hours.
D) A) Paracetamol (acetaminophen) is the most common drug overdose. B) The hepatotoxic dose is 150mg/kg but those at high risk (2• to reduced glutathione reserves) can develop at much lower doses. C) 200 deaths per year E) N-acetylcysteine is 100% successful in preventing significant hepatic impairment if used within 8 hours.
Which 1 is true? A) High risk patients are those in whom hepatic glutathione reserves are increased. B) patients with anorexia nervosa should be treated using the low risk treatment line. C) 1% of patients develop an allergic reaction to N-acetylcysteine D) methionine is an alternative to N-acetylcysteine E) serum albumin is the best indicator for severity of liver damage.
D). A) High risk are those in whom glutathione reserves are diminished. B) High risk patients include those with anorexia C) 10% develop an allergic reaction E) PT time best indicator of severity of liver damage in paracetamol overdose.
A diabetic lady on metformin with suspected lung cancer is booked to have a CT scan of her chest. She has a microcytic anaemia with high urea and creatinine. Which 1 of the following should be undertaken? A) 0.9% saline for 12h prior to procedure B) increase metformin to optimise her blood sugar control. C) check for metal implants. D) ECG E) V/Q scan prior to procedure
A) This lady has pre-existing renal impairment as shown by the raised urea and creatinine and is also on metformin for her diabetes. She is therefore at great risk of developing contrast induced nephropathy. this is often not taken into consideration when people have CT scans with contrast. It presents as acute deterioration in renal function secondary to contrast medium used and can lead to significant morbidity and mortality. Good hydration prior to and following the procedure helps minimise the risk as does stopping metformin 48 hours before the scan. A number of agents are used in an attempt to prevent contrast induced nephropathy including N-acetylcysteine, aminophylline and statins. Contrast induced nephropathy is also of concern people undergoing interventional radiological procedures and coronary angiography. Renal function should be monitored in those people following the investigation.
Which one of the following statements is true about pancreatitis? A) serum amylase is preferred over lipase the diagnosis of the above condition B) the Glasgow School is valid six hours after presentation C) enteral nutrition is of benefit to patients with the above condition D) patients with persisting organ failure and severe disease will require serial abdominal x-rays to aid and management E) if gallstones are suspected ERCP should be delayed until clinical improvement because.
C) Patients with pancreatitis are usually very ill and will require nutritional support to aid the recovery. This is most needed in those with severe disease with the enteral route being preferred you to lower costs and side-effects If pancreatitis is thought to be secondary to gallstones then urgent ERCP should be performed ideally less than 72 hours after presentation.
Which one of the following statements is false? A) subdural haematoma is are more common in alcoholics B) delirium tremens occurs after 2 to 3 days of alcohol abstinence C) Wernicke syndrome is the triad of ophthalmoplegia, nystagmus and amnesia. D) Acamprosate works by binding to NMDA receptors to increase abstinence to alcohol E) mortality of untreated delirium tremens is in the order of 30%
C) Wernicke Syndrome is actually the triad of ophthalmoplegia and nystagmus, ataxia and encephalopathy. Amnesia would be more in keeping with Korsakoff syndrome - a progression of Wernicke encephalopathy
Which one of the following is most useful in a patient with constipation secondary to sigmoid volvulus? A) laparotomy B) phosphate enema C) gastrgrafin meal D) flatus tube insertion E) conservative management
D) Conservative management of flatus tube insertion or flexible sigmoidoscopy can be all that is required to relieve the obstruction and untwist the bowel. Occasionally more aggressive surgical treatment is required.
Which 1 of the following is true? A) DKA only occurs in patients with T1DM. B) The mortality rate of DKA is greater than that of HHS. C) DKA typically has an onset of less than 24 hours. D) A raised WCC in a patient with DKA implies co-existent infection. E) Under-dosing insulin is the commonest factor precipitating DKA.
C) A) Occurs in both but more common in T1DM. B) DKA mortality ~5%; HHS mortality 15-25% D) Raised WCC can be independent of infection in DKA. E) infection is the most common precipitating factor.
A 3 year old girl is febrile and has been unwell for 12 hours. She complains of a headache and is drowsy but otherwise neurologically intact. What is the most discriminating investigation in the acute management?
Lumbar Puncture Meningitis commonly affect the extremes of age (60) due to impaired immunity. An LP to obtain CSF is the most important investigation when this diagnosis is considered. This should not however delay the starting of empirical anti microbial therapy. When the specific organism is identified, treatment can be modified accordingly. Fever, headache and drowsiness should make you suspicious here of this diagnosis. Atypical presentations can also occur, particularly in the very young, old or immunocompromised. In older patients, frequently, the only presenting sign of meningitis is confusion or an altered mental state. In infants, S&S can be very non-specific and may include lethargy, poor feeding, irritability and fever. A rash is noted in 80-90%, commonly 4-18h after initial symptoms and is associated with meningococcal aetiology. In bacterial meningitis, the CSF pressure is usually raised and the WBC count is elevated. Glucose level is decreased compared to the serum value and the protein level is increased. In those who are untreated, Gram stain and culture of CSF are usually positive for the causative organism. If an LP is delayed or regarded as clinically unsafe (in raised ICP) then blood samples should be obtained for culture. Of course, a heat CT should be considered before LP if there is focal neurology, new onset seizures, papilloedema, altered consciousness or any sign that May indicate raised ICP.
2 weeks after a holiday on the Far East, a 30 year old lady presented with anorexia, fever and joint pains. Jaundice appeared a week later and on examination her liver and spleen were both enlarged and tender. What is the most likely pathogen?
Viral hepatitis. This is likely HAV, which is primarily transmitted via the faeco-oral route. After the virus is consumed absorbed, it replicates in the liver and is excreted in the bile (to be re-transmitted). Transmission usually precedes symptoms by about 2 weeks and patients are non-infectious 1 week after the onset of jaundice. The history can reveal risk factors such as living in an endemic area, contact with an infected person, MSM or a known food borne outbreak. (Classically associated with shellfish harvesters from sewage contaminated water) The clinical course of HAV consists of a pre-icteric phase, lasting 5-7 days, consisting characteristically of N&V, abdo pain, fever, malaise and headache. Rarer symptoms may be present such as arthralgias and even severe thrombocytopenia and signs that maybe found include splenomegaly, RUQ pain and tender hepatomegaly as well as bradycardia. The icteric phase is characterised by dark urine, pale stools, jaundice and pruritis. Jaundice peaks at 2 weeks. A fulminant course in 10.000 units although this doesn't correlate with severity. ALT is normally > than AST.
A 12 year old boy presents with a flu-like illness, fever, headache, vomiting, tremor on the left side if his body and weakness of his left leg. What is the most likely pathogen?
Polio Poliovirus infection is usually asymptomatic and when symptomatic the most common presentation is with a minor GI illness. There is no cure for poliovirus infection and treatment is primarily supportive. This patient had acute flaccid paralysis or paralytic poliomyelitis, which is the hallmark of major illness. This can rarely progress to bulbar paralysis and respiratory compromise. Paralytic poliomyelitis presents with decreased tone and motor function as well as reduced tendon reflexes and muscle atrophy of the affected limb. Lack of vaccination is a strong risk factor. Remember that there are 2 main types of polio vaccine- Sabin (oral weakened strain used in endemic regions) & Salk (inactivated poliovirus used in the rest of the world).
These organisms are an increasing problem as nosocomial infections. They are commensalism of the GIT. Many are vancomycin resistant. What is the organism?
Enterococcus faecium Vancomycin resistance enterococci (VRE) - most are Enterococcus faecium. Enterococcus faecalis are mostly not VRE but are more prevalent than Enterococcus faecium. These are one of the big causes of nosocomial infections in the UK. Enterococcus faecium is a Gram positive bacteria and is a GIT commensal. It is commonly implicated in hospital acquired line and UTI. The UK top 5 hospital-acquired infections are: MRSA, VRE, ESBL (E.coli & Klebsiella), Pseudomonas & Acinetobacter.
What is the Tensilon test?
The Tensilon test is used to distinguish between myasthenia gravis and lambert eaton syndrome. Edrophonium (aka Tensilon) is an AChEi that is given. It improves MG muscle weakness but has no effect to Lambert-Eaton.
A 62-year-old man presents to the emergency department with acute onset shortness of breath and haemoptysis. He had a hip replacement operation two weeks ago has been finding the exercises to get back on its feet very difficult. On examination his tachypnoeic at rest tachycardic with the pulse of 130 minute has a pyrexia of 37.4°C and oxygen saturation of 92% on room air. Which one of the following is the most appropriate investigation in this patient? A) bronchoscopy B) DD diner C) ECG D) lateral chest x-ray E) blood cultures
ECG The patient has a diagnosis of a pulmonary embolism given the sudden onset of shortness of breath haemoptysis and hypoxia caused by a recent hip operation and prolonged inability. Given the height pre-test probability of a pulmonary embolism a d dimer test should not be performed because regardless of the result you investigate with a CT pulmonary angiogram or a V/Q scan to confirm your clinical suspicion. The place of the d dimer testing is in those patients with a pre-test probability of a PE and to help in its exclusion. D dimers should not be used for diagnostic reasons because although the sensitivity of the test is high the specificity is low A bronchoscopy is not useful as the haemoptysis does not reflect underlying suspicion of malignancy or infection. A low-grade pyrexia is a common finding in patience with a PE and blood cultures are therefore not the most appropriate investigation. In the acute setting a PA or AP chest x-ray is vital in the acute assessment of a patient short of breath but a lateral x-ray would not be required. The most appropriate investigation is therefore an ECG
A 24 year old university student presents to her GP with a worsening tiredness and bruising. On examination she is extremely pale and has multiple bruises over her body. She is referred urgently to the local hospital where a blood count shows: Hb: 7.2g/dl WCC: 2.08x10(9)/l PMN: 0.74x10(9)/l Platelets: 48x10(9)/l She has no past medical history of note, takes no regular medications and there is no significant family history apart from a distant aunt who has sickle-cell disease. She does drink a few glasses of wine a week and smoke cigarettes occasionally but denies recreational drug use. She is reviewed by the haematologists who perform a bone marrow biopsy which reveals a hypoplastic marrow Which one of the following is the most likely diagnosis? A) myelodysplastic syndrome B) aplastic anaemia C) Evans syndrome D) myelofibrosis E) TTP
B) Aplastic anaemia The patient presented severe anaemia, leucopenia and thrombocytopenia with a hypoplastic marrow. The most likely diagnosis is aplastic anaemia. Myelodysplastic syndrome is a disease of the elderly with decreasing production and quality of press conference. Evans syndrome is the presence of autoimmune haemolysis and autoimmune thrombocytopenia together in the same patient.
A 22-year-old patient has a history of a regular menstrual cycles over the past few years. She is well known to you and has seen you regularly with regard to her weight problem, oily skin and acne. She presents to you on this occasion with a five-month history of amenorrhoea and weight gain. Which one of the following is the most appropriate initial investigation in the above scenario? A) pelvic US B) sex hormone binding globulin free androgen levels. C) LH:FSH levels D) OGTT E) BhCG estimation
E) BhCG estimation Although the history for this patient is suggestive of PCOS, it is extremely important to exclude pregnancy in any patient presenting with amenorrhea before considering alternative diagnoses.
Which 1 of the following statements is true? A) haemolytic disease of the newborn is caused by IgM Abs. B) Goodpasture's disease is an example of a type III HS reaction. C) Anaphylactic reactions are due to IgA D) RBCs sensitised in vivo to autoAb can be detected using the direct Coombs reaction. E) HIV uses CXCR4 and CCR5 co-receptors to gain entry into CD8 T cells.
D) A) This occurs in Rhesus disease. Maternal IgG crosses the placenta leading to haemolysis. B) Goodpasture's is a type II HS reaction where Ab cause damage by binding to Ag in tissues. Type III is caused by IC deposition. C) anaphylaxis involves IgE E) HIV targets CD4 cells.
A 34-year-old man has attacks of sudden severe pain waking up the last fortnight. The pain is on the right side of his face and makes eyes water. What is the diagnosis?
Cluster headache Cluster headache is characterised by attacks of severe pain localised the unilateral orbital, supraorbital and or temporal areas which lasts from 15 minutes to 3 hours, and occurs with a frequency ranging from once every other day to 8 times a day. These attacks can occur at the same time period of many weeks (known as the cluster period) accompanied by ipsilateral autonomic signs. The cause is hypothalamic activation with secondary trigeminal autonomic activation (for instance lacrimation, rhinorrhoea, nasal congestion conjunctival infection and partial Horner's i.e. ptosis and miosis). Cluster period attacks can be triggered by things like alcohol. Greater occipital nerve blockade often provide immediate relief until preventative medication take effect.
A 40 year-old man presents with an instantaneous onset of a severe headache but by drowsiness and vomiting. What is the diagnosis?
Subarachnoid haemorrhage SAH (bleeding into subarachnoid space) presents with sudden severe headache patients often described as the worst headache of their life, and can often be so bad that they feel like they have been kicked in the back of the head. Half of all patients lose consciousness and eye pain with exposure to light can also be seen. Altered mental status is common. SAH occurs most commonly in the 50 to 55 age group and affects women and black people more than men and white people. The most common cause of the non-traumatic SAH is an aneurysm which ruptures. Conditions which predisposed to aneurysm formation and SAH include adult PKD, Marfan's, NF1 and Ehlers-Danlos. Cerebral aneurysms arise around the circle of Willis. A CT scan is indicated, and if unrevealing, this should be followed by an LP. Cerebral angiography can confirm the presence of aneurysms. The patient should be stabilised and is followed by surgical clipping or endovascular coil embolisation, the choice is subject to much current controversy sparked by relatively recent research. Complications can commonly occur and include rebleeding, hydrocephalus and vasospasm.
830-year-old woman experienced a strange feeling in the stomach, followed by stiffness and jerking in the left arm. Afterwards, she felt drowsy but remembers everything. What is the diagnosis?
Partial seizure. The feeling this woman felt in her stomach before (Aura), the description of the arm, incontinence and feeling "worn out" afterwards make this a seizure. Seizures can happen in anyone but epilepsy is the tendency to have repeated, unprovoked seizures. Epileptic seizures can be split into focal (partial or localised) and generalised (involving both hemispheres). Generalised seizures can be further divided into absence (typical or atypical), myoclonic, chronic, tonic, tonic-clonic and atonic types. Be sure to exclude other causes, such as a space occupying lesion with a CT or MRI scan. There may also be tongue biting. Always think of "before, during and after" when taking history. History taking is the most important aspect of diagnosis. Antiepileptic monotherapy is the preferred treatment.