A 23-year-old woman presents to the Emergency Department with a friend from work. Around 30 minutes ago she developed a ‘fluttering’ in her chest. She reports feeling ‘a bit faint’ but denies any chest pain or shortness of breath. An ECG shows a regular tachycardia of 166 bpm with a QRS duration of 110 ms. Blood pressure is 102/68 mmHg and oxygen saturations are 99% on room air.
What is the most appropriate initial management?
Intravenous magnesium sulphate
Direct current cardioversion
Intravenous adenosine 3mg
Intravenous adenosine 6mg
Vagal manoeuvres
The first-line management of supraventricular tachycardia is vagal manoeuvres. Only if these fail should adenosine be given. There are no indications for direct current cardioversion as per the ALS guidelines.
A 52-year-old man is seen in the hypertension clinic. He was diagnosed around three months ago and started on ramipril. This has been titrated up to 10mg od but his blood pressure remains around 156/92 mmHg.
What is the most appropriate next step in management?
Add amlodipine AND indapamide
Add amlodipine OR bisoprolol
Switch ramipril to losartan
Add amlodipine OR indapamide
Add losartan
Add amlodipine OR indapamide
You are clerking a 67-year-old man who has been admitted with chest pain. His past medical history includes hypertension, angina and he continues to smoke 20 cigarettes / day. Blood tests done in the Emergency Department show the following:
Na+ 133 mmol/l
K+ 3.3 mmol/l
Urea 4.5 mmol/l
Creatinine 90 µmol/l
Which one of the following factors is most likely to explain the abnormalities seen in the electrolytes?
Enalapril therapy
Felodipine therapy
Bendroflumethiazide therapy
His smoking history
Spironolactone therapy
Bendroflumethiazide therapy
Bendroflumethiazide causes both hyponatraemia and hypokalaemia. Spironolactone is associated with hyperkalaemia. His smoking would only be relevant if he had lung cancer cause syndrome of inappropriate ADH secretion - there is no indication of this from the question.
How do thiazide and thiazide like diuretics work?
Thiazide diuretics work by inhibiting sodium reabsorption at the beginning of the distal convoluted tubule (DCT) by blocking the thiazide-sensitive Na+-Clˆ’ symporter
Potassium is lost as a result of more sodium reaching the collecting ducts –> increased sodium reabsorption in exchange for potassium and hydrogen ions
Adverse effect of thiazide and thiazide like diuretics
Common adverse effects
- dehydration
- postural hypotension
- hypokalaemia
- hyponatraemia
- hypercalcaemia
the flip side of this is hypocalciuria, which may be useful in reducing the incidence of renal stones
- gout
- impaired glucose tolerance
- impotence
Rare adverse effects:
- thrombocytopaenia
- agranulocytosis
- photosensitivity rash
- pancreatitis
Thiazide diuretic examples
Whatever their name, they always have thiazide at the end
Chlorothiazide, hydrochlorothiazide, bendroflumethiazide
Thiazide diuretics vs loop diuretics in heart failure
Thiazide diuretics have a role in the treatment of mild heart failure although loop diuretics are better for reducing overload.
Examples of thiazide like diuretics
chlorthalidone, indapamide, and metolazone, quniethazone
A 76-year-old lady is brought in by ambulance to the emergency department. She presents with a right-sided limb weakness, a facial droop and slurred speech. A CT head was arranged which ruled out a haemorrhage, but did report a left-sided infarct. Her admission ECG shows that she has new atrial fibrillation (AF). She is treated with aspirin 300mg for the acute stroke and doing well on the ward.
Two weeks later she is reviewed. What medication should the patient be started on to reduce the risk of further stroke?
Warfarin or a direct thrombin or factor Xa inhibitor
Aspirin
Clopidogrel
Dipyridamole
Enoxaparin
Warfarin or a direct thrombin or factor Xa inhibitor
Aspirin/dipyridamole should only be given if needed for the treatment of other comorbidities. None are mentioned in the above scenario.
Aspirin/dipyridamole should only be given if needed for the treatment of other comorbidities. None are mentioned in the above scenario.
Enoxaparin would not be prescribed long term but can be used for bridging whilst a patient is started on warfarin, until their INR is within range
Warfarin or a new oral anticoagulant (NOAC) should be started for a patient with AF who has had a new TIA or stroke. This is because their risk of having a further cerebrovascular event is increased (2 points on the CHA‚‚DS‚‚-VASc score).
What is the anticoagulation regimen of choice in a patient with AF has a cerebrovascular accident?
If a patient with AF has a stroke or TIA, the anticoagulant of choice should be warfarin or a direct thrombin or factor Xa inhibitor
Management of AF patient who just had a stroke or TIA
- Following a stroke or TIA it is obviously important to exclude a haemorrhage before starting any anticoagulation or antiplatelet therapy
- For longer-term stroke prevention, NICE recommend warfarin or a direct thrombin or factor Xa inhibitor
- The timing of when to start depends on whether it is a TIA or stroke:
* following a TIA, anticoagulation for AF should start immediately once imaging has excluded haemorrhage
* in acute stroke patients, in the absence of haemorrhage, anticoagulation therapy should be commenced after 2 weeks. Antiplatelet therapy should be given in the intervening period and stopped once anticoagulation started. If imaging shows a very large cerebral infarction then the initiation of anticoagulation should be delayed
A 35-year-old male presents his general practice with pain in his foot and lower limb which is worse at night. He describes that the pain improves when he hangs his leg over the edge of the bed. On further questioning, he also notes that he has been getting ‘pins and needles’ in his fingers and they feel very cold. He has no past medical history but smokes 25 cigarettes per day.
Based on the history, what is the most likely underlying diagnosis?
Buerger’s disease
Granulomatosis with polyangiitis
Peripheral vascular disease
Sickle cell anaemia
Vitamin B12 deficiency
Young male smoker with symptoms similar to limb ischaemia - think Buerger’s disease
Feature of Buerger’s disease
Common symptoms include paraesthesia/cold sensation in the fingers or limbs, rest pain and ulceration/gangrene may occur
Features
extremity ischaemia
intermittent claudication
ischaemic ulcers
superficial thrombophlebitis
Raynaud’s phenomenon
What is Buerger’s disease also known as?
thromboangiitis obliterans
A 42-year-old patient attends the emergency department complaining of feeling generally unwell. He states that he is aching all over and has been waking up at night in a cold sweat.
On examination, you note evidence of various injection marks on the antecubital fossa. His observations show a temperature of 38.1ºC, a heart rate of 122bpm, a blood pressure of 110/90mmHg, respiratory rate of 18/min and oxygen saturation of 98%.
You request urgent blood cultures and an echocardiogram.
What site is most likely affected given the diagnosis?
Aortic valve
Mitral valve
No vegetations visible
Pulmonary valve
Tricuspid valve
Tricuspid valve
Which valve is most commonly affected in infective endocarditis in IV drug users?
Infective endocarditis in intravenous drug users most commonly affects the tricuspid valve
Symptoms of IE
Can present either as an acute clinical deterioration or a subacute, more chronic development of the following non-specific symptoms;
- Fever (90%) - associated with chills, anorexia and weight loss.
- Other non-specific features include malaise, arthralgia, myalgia, night sweats, and abdominal pain.
Clinical signs of IE
most of these are not diagnostic (as they can also be present in healthy individuals) but their presence can help support clinical suspicion:
- Heart murmurs (85%)
- Cutaneous manifestations
*Petechiae on extremities or mucous membranes (30%)
* Splinter haemorrhages (reddish-brown linear lesion on the nail bed)
- Uncommon findings that are very specific for IE include;
*Janeway lesions
*Osler node
*Roth spots
- Clinical manifestations of complications (eg. Congestive heart failure) or systemic embolisation (eg. Embolic stroke) may be present at initial presentation.
In which subset of patients will a heart murmur be heard in IE
Usually only present in those with left sided IE.
What are Janeway lesions? Are thye more associated with subacute or acute cases?
Non-tender macules on palms and soles, more associated with acute onset
What are Osler node?
tender nodules on fingers and toes
What are Roth spots?
hemorrhagic retinal lesions with a pale centre seen on fundoscopy
What is most common presentation of isolated right sided IE?
Pulmonary septic emboli is the most common presentation (75%) of isolated right-sided IE. This can present clinically with a cough, dyspnoea, haemoptysis or pleuritic chest pain.
How common is isolated right sided IE
10% of all cases of IE
