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After answering all questions in a chapter order oxcarbazepine 150 mg amex, as much time as necessary should be spent reviewing the explanations for each question at the end of the chapter trusted oxcarbazepine 300 mg. Atten- tion should be given to all explanations order 300 mg oxcarbazepine with mastercard, even if the examinee answered the question correctly. Those seeking more information on a subject should refer to the reference materials listed or to other standard texts in emergency medicine. He has a his- tory of hypertension, hypercholesterolemia, and a 20-pack-year smoking history. Give the patient two nitroglycerin tablets sublingually and observe if his chest pain resolves. She was able to fall asleep without difficulty but woke up in the morning with persistent pain that is worsened upon taking a deep breath. Two weeks ago, she took a 7-hour flight from Europe and since then has left-sided calf pain and swelling. He recalls feeling similar episodes of palpitations a few months ago but they resolved. Her daughter states that the patient has been increasingly tired and occasionally confused for the past 3 days and has not been eating her usual diet. A chest radiograph shows a small right-sided (less than 10% of the hemithorax) spontaneous pneumothorax. Perform needle decompression in the second intercostal space, midclavicular line c. He has a known history of alcohol abuse with multiple presentations for intoxication. Today, the patient complains of acute onset, persistent chest pain associated with dysphagia, and pain upon flexing his neck. Which of the following is the preferred study of choice to diagnose this patient’s condition? The patient states he never experienced chest pain in the past when using cocaine. The patient states that the only medication he takes is alprazolam to “calm his nerves. The patient states that she used to work as a convenience store clerk but was fired 2 weeks ago. Order a monospot test and recommend that the patient refrain from vigorous activities for 1 month. A 61-year-old woman was on her way to the grocery store when she started feeling chest pressure in the center of her chest. He describes a gradual onset of chest pain that is worse with activity and resolves when he is at rest. Administer ibuprofen and reassure the patient that he is not having a heart attack. While eating dinner, a 55-year-old man suddenly feels a piece of steak “get stuck” in his stomach. Which of the following is an absolute contraindication to receiving thrombolytic therapy? Her lung examination reveals bilateral crackles and she is beginning to have chest pain. Which of the following is the most appropriate immediate treatment for this patient? Which of the following is the most appropriate first-line medication to lower cardiac preload? The patient states that she started feel- ing short of breath approximately 12 hours ago and then noticed a tingling sensation in the middle of her chest and became diaphoretic. Which of the following cardiac markers begins to rise within 3 to 6 hours of chest pain onset, peaks at 12 to 24 hours, and returns to baseline in 7 to 10 days? A 27-year-old man complains of chest palpitations and lightheaded- ness for the past hour. Which of the following is the most appropriate med- ication to treat this dysrhythmia? He takes a β-blocker for hypertension, a proton-pump inhibitor for gastroesophageal reflux disease, and an antilipid agent for high cholesterol. The pain is worse when she is lying down on the stretcher and improves when she sits up. A 71-year-old man is playing cards with some friends when he starts to feel a pain in the left side of his chest. There are crackles midway up both lung fields and 2+ pitting edema midway up his legs.

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These cases are no substitute for clinical experience with real patients order oxcarbazepine 600mg on-line, but they provide a safe environment for students to explore clinical problems and their own approach to diagnosis and management generic 300mg oxcarbazepine with mastercard. Most are common problems that might present to a general practitioner’s surgery cheap 150mg oxcarbazepine fast delivery, a medical outpatients or a session on call in hospital. There are a few more unusual cases to illustrate specific points and to emphasize that rare things do present, even if they are uncommon. The cases are written to try to interest students in clinical problems and to enthuse them to find out more. They try to explore thinking about diagnosis and management of real clinical situations. The first 20 cases are arranged by systems, but the next 80 are in random order since, in medicine, symptoms such as breathlessness and pain may relate to many different clinical problems in various systems. We hope you enjoy working through the problems presented here and can put the lessons you learn into practice in your student and subsequent career. He was well until the last 6 months, since when he has had some falls, irregularly. On some occasions he lost consciousness and is unsure how long he has been unconscious. On a few occasions he has fallen, grazing his knees, and on others he has felt dizzy and has had to sit down but has not lost consciousness. These episodes usually happened on exertion, but once or twice they have occurred while sitting down. A diagnosis of benign prostatic hypertrophy has been made for which he is on no treatment. There is no leg oedema; the peripheral pulses are palpable except for the left dorsalis pedis. There may be an obvious flushing of the skin as cardiac output and blood flow return. There is complete dissociation of the atrial rate and the ventricular rate which is 33/min. The episodes of loss of consciousness are called Stokes–Adams attacks and are caused by self-limited rapid tachy- arrhythmias at the onset of heart block or transient asystole. Although these have been intermittent in the past he is now in stable complete heart block and, if this continues, the slow ventricular rate will be associated with reduced cardiac output which may cause fatigue, dizziness on exertion or heart failure. On examination, the occasional rises in the jugular venous pressure are intermittent ‘can- non’ a-waves as the right atrium contracts against a closed tricuspid valve. Differential diagnosis The differential diagnosis of transient loss of consciousness splits into neurological and vascular causes. Neurological causes are various forms of epilepsy, often with associated features. Local reduction may occur in transient ischaemic attacks or vertebrobasilar insufficiency. A more global reduction, often with pallor, occurs with arrhythmias, postural hypotension and vasovagal faints. If the rhythm in complete heart block is stable then a permanent pacemaker should be inserted as soon as this can be arranged. If there is doubt about the ventricular escape rhythm then a temporary pacemaker should be inserted immediately. The current pain had come on 4 h earlier at 8 pm and has been persistent since then. Two paracetamol tablets taken earlier at 9 pm did not make any difference to the pain. The previous chest pain had been occasional, lasting a second or two at a time and with no particular precipitating factors. It has usually been on the left side of the chest although the position had varied. Two weeks previously he had an upper respiratory tract infection which lasted 4 days. His wife and two children were ill at the same time with similar symptoms but have been well since then. In the family history his father had a myocardial infarction at the age of 51 years and was found to have a marginally high cholesterol level. Cardiac pain, and virtually any other significant pain, lasts longer than this, and stabbing momentary left-sided chest pains are quite common. The positive family history increases the risk of ischaemic heart disease but there are no other risk factors evident from the history and examination. The relief from sitting up and leaning forward is typical of pain originating in the pericardium.

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In renal impairment cheap oxcarbazepine 150 mg mastercard, phenytoin protein bind- there is 50% elimination by renal excretion order oxcarbazepine 150 mg. The British ing is reduced by competition with accumulated molecules National Formulary tabulates drugs to be avoided or used normally cleared by the kidney and which bind to the same with caution in patients with renal failure purchase oxcarbazepine 600 mg with amex. The therapeutic range therefore has to be adjusted to lower values in patients with Clearance renal impairment, as otherwise doses will be selected that (ml/min) Weight cause toxicity. A reduced loading dose of 100 100 Serum digoxin is therefore appropriate in such patients, although the 90 90 creatinine effect of reduced glomerular filtration on digoxin clearance is 80 80 R (mg/100 ml) even more important, necessitating a reduced maintenance 70 70 5. Keep ruler at crossing point on R, then move the right-hand side of the Glomerular filtration and tubular secretion of drugs usually ruler to the appropriate serum creatinine value and read off fall in step with one another in patients with renal impair- clearance from the left-hand scale. Drug excretion is directly related to glomerular filtra- mol/L to mg/100mL, as is used on this scale, simply divide by 88. Low molecular weight heparin Metformin Creatinine would rise gradually over the next few days as it con- tinued to be produced in his body but was not cleared. The high albumin treatment under way but, although precise, such recommenda- concentration in tubular fluid contributes to the resistance to tions are inevitably based only on the effects of reduced renal diuretics that accompanies nephrotic syndrome. Therapy with these drugs is appropriately monitored by measuring ‘peak’ concentrations 1. Monitor therapeutic and adverse effects and, where the interval between doses is extended. The same is true of patients with heart failure, nephrotic These are useful approximations to get treatment under way, syndrome, cirrhosis or ascites. Such patients develop acute but their mathematical precision is illusory, and must not lull reversible renal impairment, often accompanied by salt and the inexperienced into a false sense of security – they do not water retention and hypertension if treated with non-steroidal permit a full ‘course’ of treatment to be prescribed safely. The British National Formulary has a vasodilator prostaglandins, notably prostaglandin I2 (prosta- useful appendix which is concise, simple and accessible. Sulindac is a partial exception because it inhibits cyclo-oxygenase less in kidneys than in other tissues, although this specificity is incomplete and dose dependent. This occurs predictably in patients with bilateral renal disease has major but unpredictable effects on drug handling. The explanation is that in such patients and distribution, as well as the metabolism of drugs. Prothrombin time also Plasma albumin in patients with nephrotic syndrome is low, shows a moderate correlation with drug clearance by the liver. Clearances of indocyanine green, antipyrine and lido- between microsomal enzyme activity from liver biopsy speci- caine have also been disappointing. Even Currently, therefore, cautious empiricism coupled with an in very severe disease, the metabolism of different drugs is not awareness of an increased likelihood of adverse drug effects affected to the same extent. It is therefore hazardous to extrapo- and close clinical monitoring is the best way for a prescriber to late from knowledge of the handling of one drug to effects on approach a patient with liver disease. Weigh risks against hoped for benefit, and minimize non- the liver should be employed. Monitor response, including adverse effects (and occasionally drug concentrations), and adjust therapy Absorption of drugs is altered in liver disease because of portal accordingly. Portal/systemic anastomoses allow the passage of common precipitants of hepatic coma. Drugs that are known to cause idiosyncratic liver disease ciclosporin, which must therefore be started in low doses in (e. Oral contraceptives are not advisable if there is active liver disease or a history of jaundice of pregnancy. Low plasma potassium provokes encephalopathy: avoid in cirrhosis, and that of phenytoin is increased by up to 40%. Potassium-sparing It is particularly important to appreciate this when plasma drugs, such as spironolactone, are useful. Avoid drugs that cause fluid overload or renal failure apy, as unless the therapeutic range is adjusted downward, (e. Increased Vd of several anticoagulants and fibrinolytics) whenever possible, drugs (e. Myxoedematous patients are extremely sensitive to digoxin, whereas unusually high doses are required in thyrotoxicosis. Patients with hypothyroidism are exceptionally sensitive to There is no significant difference in half-life between these opioid analgesics, which cause profound respiratory depres- groups, and a difference in Vd has been postulated to explain sion in this setting. This is probably due to reduced metab- the alteration of plasma concentration with thyroid activity. Changes in renal function, which occur with changes in thy- roid status, complicate this interpretation.

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The low plasma sodium purchase oxcarbazepine 300mg mastercard, potassium and urea in this patient are consistent with water excess purchase oxcarbazepine 300 mg. The clinical and biochemical picture in this woman is consistent with diuretic-induced hyponatraemia buy oxcarbazepine 150 mg free shipping. She had woken that morning to notice that her calf was swollen and found it painful to put her foot to the ground. She has had no previous medical illnesses other than some cartilage problems in the knees. In her obstetric history she has had two first-trimester miscarriages and has not had any successful pregnancies. Her left leg is clearly swollen, with a 4 cm difference in circum- ference around the left calf measured 10 cm below the tibial tuberosity. There is some pitting oedema in the left ankle and there are superficial veins evident in the left leg. The main differential diagnoses of an acutely swollen leg are a ruptured Baker’s cyst, trauma and acute cellulitis. The knee cartilage problems raise the possibility of ruptured Baker’s cyst, and the active lifestyle is compatible with muscle trauma such as a ruptured plantaris but there is no story of an acute onset. The history of miscarriage and the raised activated partial thrombopastin time suggest the presence of antiphospho- lipid syndrome (lupus anticoagulant) which should be investigated together with serological tests for systemic lupus erythematosus. This patient should be immediately anticoagulated either with intravenous heparin or sub- cutaneous low-molecular-weight heparin to prevent proximal propagation of the thrombus and pulmonary emboli. Patients with antiphos- pholipid antibodies require lifelong anticoagulation and consultation with a haematologist to prevent further thrombotic events. On that occasion he took some indigestion mixture obtained from a retail pharmacy, and the symptoms resolved after 10 weeks. It often occurs at night, when it can wake him up, and seems to improve after meals. Some foods such as curries and other spicy foods seem to bring on the pain on occasions. He has smoked 10–15 cigarettes per day for 25 years and drinks around 30 units of alco- hol each week. He has been feeling more tired recently and had put this down to pressure of work. Examination There is mild tenderness in the epigastrium, but no other abnormalities. The high red cell count with low haemoglobin shows that the haemoglobin content of the cells is reduced. The blood film confirms that the cells are microcytic and low in haemoglobin (hypochromasia). The commonest cause of iron-deficiency anaemia in a man is gastrointestinal blood loss. The abdominal pains would be consistent with those from a peptic ulcer, especially a duodenal ulcer when there is more often some relief from food. The diagnosis should be established by endoscopy because alternative diagnoses such as carcinoma of the stomach cannot be ruled out from the history. In this case, an endoscopy confirmed an active duodenal ulcer and samples were positive for Helicobacter pylori. He was given strong recommendations to stop smoking and to address his excessive alcohol consumption. The iron deficiency was corrected by additional oral iron which was continued for 3 months to replenish the iron stores in the bone marrow. Repeat endoscopy to show healing con- firms the original diagnosis of benign ulceration. She struggles to get out of bed by herself and she has difficulty lifting her hand to comb her hair. She has lost 4 kg in weight, and has noticed some sweats which seem to occur at night. Patients may pres- ent primarily with polymyalgia-type symptoms (proximal muscle pain and stiffness most marked in the mornings) or temporal arteritis symptoms (severe headaches with tenderness over the arteries involved). Patients may have systemic symptoms such as general malaise, weight loss and night sweats. In polymyalgia, the main symptoms are muscle stiffness and pain which may simulate muscle weakness. When there are headaches and giant cell arteritis is suspected, a temporal artery biopsy should be performed. However, the histology may be normal because the vessel involve- ment with inflammation is patchy. Nevertheless, a positive result provides reassurance about the diagnosis and the need for long-term steroids. This patient has clear evidence of giant cell arteritis (also known as temporal arteritis although other vessels are involved), and is at risk of irreversible visual loss either due to ischaemic damage to the ciliary arteries causing optic neuritis, or central retinal artery occlusion.

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