EMQs in Clinical Medicine.pdf - Peshawar Medical College

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Cardiovascular emergencies – answers 21 10 Cardiovascular emergencies Answers: K B C H E K B C H E A 57-year-old businessman presents with a 4-h history of crushing chest pain. The ECG changes include ST elevation in II, III and aVF. This is the presentation of an inferior myocardial infarction and thrombolysis is indicated. Streptokinase is effective in reducing mortality when it is given early, ideally within a few hours of the onset of the chest pain. Contraindications for thrombolysis include any form of internal bleeding, pregnancy, recent head trauma, cerebral malignancy, acute pancreatitis, recent haemorrhagic stroke and oesophageal varices. In these cases urgent primary angioplasty may be deemed a viable alternative. A 65-year-old man presenting with chest pain becomes unresponsive. His ECG shows ventricular fibrillation. DC shock is indicated according to current ACLS (Advanced Cardiac Life Support) guidelines, which emphasize the importance of early defibrillation. Defibrillation should not be delayed to give adrenaline, which should be administered if three shocks (200 J, 200 J, 360 J) have been unsuccessful/contraindicated. A 40-year-old woman collapses after a flight with breathlessness and right-sided pleuritic chest pain. This is a presentation of pulmonary embolus (PE). Streptokinase has also been used successfully following a major embolism. Open embolectomy is indicated following a massive PE if thrombolysis is unsuccessful/ contraindicated. A 45-year-old man with chronic glomerulonephritis presents with a severe headache. On examination he has papilloedema and bilateral retinal haemorrhages. His BP is 240/132 mmHg. This is the presentation of malignant hypertension. The therapeutic aim should be rapid, but gradual and controllable reduction in blood pressure is the ideal. Both oral and parenteral therapy may be used depending on the clinician’s preference. Sublingual nifedipine is contraindicated because it may produce a profound uncontrollable reduction in the patient which may compromise cerebral perfusion. A 55-year-old man requires immediate pharmacological management for severe symptomatic sinus bradycardia. Atropine is the drug of choice. It is a muscarinic acetylcholine receptor antagonist and thus increases the heart rate by inhibiting vagal tone of the heart. If the patient does not respond to atropinization, cardiac pacing should be instituted.
22 Cardiovascular medicine REVISION BOXES Cardiovascular medicine These descriptions of pulses in an extended matching question (EMQ) are highly suggestive of the conditions described (Box 1). Box 1 Conditions indicated by pulses [2] Pulse Condition Irregularly irregular Atrial fibrillation Slow-rising pulse Aortic stenosis Collapsing pulse Aortic regurgitation Bounding pulse Acute CO 2 retention, hepatic failure, sepsis Radiofemoral delay Coarctation of aorta Jerky pulse Hypertrophic obstructive cardiomyopathy Mitral regurgitation Pulsus bisferiens Mixed aortic valve disease Hypertrophic obstructive cardiomyopathy Pulsus paradoxus Constrictive pericarditis Cardiac tamponade The descriptions of the jugular venous pressure (JVP) in Box 2, often given in an EMQ, are highly suggestive of the conditions described. Box 2 Conditions indicated by jugular venous pressure [4] JVP Condition Raised, fixed JVP Superior vena cava obstruction JVP rising on inspiration Cardiac tamponade Constrictive pericarditis Large ‘v’ waves Tricuspid regurgitation Absent ‘a’ waves Atrial fibrillation Cannon ‘a’ waves Complete heart block Atrioventricular (AV) dissociation Ventricular arrhythmias Descriptions of a murmur that require you to detect a valvular defect or other cardiac anomaly are common in EMQs (Box 3).
Page 2 and 3: EMQs in CLINICAL MEDICINE
Page 4 and 5: EMQs in CLINICAL MEDICINE Irfan Sye
Page 6 and 7: Dedication To Mum, Dad, Reshma and
Page 8 and 9: Contents vii SECTION 4: NEUROLOGY 7
Page 10 and 11: Preface Extended matching questions
Page 12 and 13: INTRODUCTION: EMQ REVISION The most
Page 14 and 15: SECTION 1: CARDIOVASCULAR MEDICINE
Page 16 and 17: Pulses 3 2 Pulses A B C D E F mitra
Page 18 and 19: Jugular venous pressure 5 4 Jugular
Page 20 and 21: ECG abnormalities 7 6 ECG abnormali
Page 22 and 23: Treatment of heart failure 9 8 Trea
Page 24 and 25: Cardiovascular emergencies 11 10 Ca
Page 26 and 27: Pulses - answers 13 D A 23-year-old
Page 28 and 29: Jugular venous pressure - answers 1
Page 30 and 31: Hypertension - answers 17 activity.
Page 32 and 33: Treatment of arrhythmias - answers
Page 36 and 37: Cardiovascular medicine - revision
Page 38 and 39: Cardiovascular medicine - revision
Page 40 and 41: SECTION 2: RESPIRATORY MEDICINE 11
Page 42 and 43: Causes of pneumonia 29 12 Causes of
Page 44 and 45: Chest radiograph pathology 31 14 Ch
Page 46 and 47: Treatment of asthma and COPD 33 16
Page 48 and 49: Management of COPD 35 18 Management
Page 50 and 51: Shortness of breath - answers 37 AN
Page 52 and 53: Haemoptysis - answers 39 and Mycopl
Page 54 and 55: Chest radiograph pathology - answer
Page 56 and 57: Treatment of asthma and COPD - answ
Page 58 and 59: Emergency management: respiratory d
Page 60 and 61: Treatment of respiratory infections
Page 62 and 63: Respiratory medicine - revision box
Page 64 and 65: SECTION 3: HAEMATOLOGY AND ONCOLOGY
Page 66 and 67: Anaemia 53 21 Anaemia A B C D E F s
Page 68 and 69: Haematological diseases 55 23 Haema
Page 70 and 71: Tumour markers 57 25 Tumour markers
Page 72 and 73: Adverse effects of chemotherapy 59
Page 74 and 75: Anaemia - answers 61 It is importan
Page 76 and 77: The peripheral blood film - answers
Page 78 and 79: Cancer care - answers 65 In Ham’s
Page 80 and 81: Adverse effects of chemotherapy - a
Page 82 and 83: Haematology and oncology - revision
Page 84 and 85:
Haematology and oncology - revision
Page 86 and 87:
SECTION 4: NEUROLOGY 28 Dizziness a
Page 88 and 89:
Headache 75 29 Headache A B C D E F
Page 90 and 91:
Weakness in the legs 77 31 Weakness
Page 92 and 93:
Cranial nerve lesions 79 33 Cranial
Page 94 and 95:
Neurological problems 81 35 Neurolo
Page 96 and 97:
Falls and loss of consciousness 83
Page 98 and 99:
Antiepileptic drug therapy 85 39 An
Page 100 and 101:
Treatment of Parkinson’s disease
Page 102 and 103:
Headache - answers 89 B I A 50-year
Page 104 and 105:
Headache - answers 91 The clusters
Page 106 and 107:
Weakness in the legs - answers 93 D
Page 108 and 109:
Abnormal movements - answers 95 33
Page 110 and 111:
Neurological problems - answers 97
Page 112 and 113:
Falls and loss of consciousness - a
Page 114 and 115:
Antiepileptic drug therapy - answer
Page 116 and 117:
Treatment of headache - answers 103
Page 118 and 119:
Neurology - revision boxes 105 REVI
Page 120 and 121:
Neurology - revision boxes 107 Box
Page 122 and 123:
Neurology - revision boxes 109 Box
Page 124 and 125:
SECTION 5: ORTHOPAEDICS AND RHEUMAT
Page 126 and 127:
Joint pain 113 43 Joint pain A B C
Page 128 and 129:
Back pain 115 45 Back pain A B C D
Page 130 and 131:
Complications of fractures 117 47 C
Page 132 and 133:
Fall on the outstretched hand 119 4
Page 134 and 135:
Knee problems 121 51 Knee problems
Page 136 and 137:
Disease-modifying anti-rheumatic dr
Page 138 and 139:
Joint pain - answers 125 triggered
Page 140 and 141:
Back pain - answers 127 males. The
Page 142 and 143:
Rheumatological conditions - answer
Page 144 and 145:
Fall on the outstretched hand - ans
Page 146 and 147:
Shoulder problems - answers 133 50
Page 148 and 149:
Disease-modifying anti-rheumatic dr
Page 150 and 151:
Orthopaedics and rheumatology - rev
Page 152 and 153:
Orthopaedics and rheumatology - rev
Page 154 and 155:
SECTION 6: THE ABDOMEN AND SURGERY
Page 156 and 157:
Abdominal pain 143 55 Abdominal pai
Page 158 and 159:
Liver diseases 145 57 Liver disease
Page 160 and 161:
Jaundice 147 59 Jaundice A B C D E
Page 162 and 163:
Presentation with a lump 149 61 Pre
Page 164 and 165:
Lumps in the groin 151 63 Lumps in
Page 166 and 167:
Anorectal conditions 153 65 Anorect
Page 168 and 169:
Treatment of peripheral vascular di
Page 170 and 171:
Haematuria 157 69 Haematuria A B C
Page 172 and 173:
Dysphagia 159 71 Dysphagia A B C D
Page 174 and 175:
Haematemesis 161 73 Haematemesis A
Page 176 and 177:
Constipation 163 75 Constipation A
Page 178 and 179:
Treatment of gastrointestinal condi
Page 180 and 181:
Abdominal pain - answers 167 Helico
Page 182 and 183:
Liver diseases - answers 169 E F A
Page 184 and 185:
Causes of splenomegaly - answers 17
Page 186 and 187:
Jaundice - answers 173 C A J L M He
Page 188 and 189:
Presentation with a lump - answers
Page 190 and 191:
Lumps in the groin - answers 177 G
Page 192 and 193:
Anorectal conditions - answers 179
Page 194 and 195:
Treatment of peripheral vascular di
Page 196 and 197:
Haematuria - answers 183 G A 46-yea
Page 198 and 199:
Dysphagia - answers 185 G K A 10-ye
Page 200 and 201:
Haematemesis - answers 187 Common b
Page 202 and 203:
Constipation - answers 189 L J A 17
Page 204 and 205:
Treatment of gastrointestinal condi
Page 206 and 207:
The abdomen and surgery - revision
Page 208 and 209:
SECTION 7: METABOLIC AND ENDOCRINE
Page 210 and 211:
Nutritional deficiencies 197 79 Nut
Page 212 and 213:
Disorders of sodium balance 199 81
Page 214 and 215:
Diabetic complications 201 83 Diabe
Page 216 and 217:
Endocrine problems - answers 203 AN
Page 218 and 219:
Electrolyte and metabolic disturban
Page 220 and 221:
Hypercalcaemia - answers 207 The wa
Page 222 and 223:
Treatment of diabetes - answers 209
Page 224 and 225:
Metabolic and endocrine disturbance
Page 226 and 227:
SECTION 8: MISCELLANEOUS 85 Antibio
Page 228 and 229:
Antibiotics 215 86 Antibiotics A B
Page 230 and 231:
Antiviral therapies 217 88 Antivira
Page 232 and 233:
Treatment of poisioning and overdos
Page 234 and 235:
Adverse drug reactions 221 92 Adver
Page 236 and 237:
Adverse drug reactions 223 94 Adver
Page 238 and 239:
Infections 225 96 Infections A B C
Page 240 and 241:
Medical emergencies 227 98 Medical
Page 242 and 243:
Drugs and immunity 229 100 Drugs an
Page 244 and 245:
Treatment of infection - answers 23
Page 246 and 247:
Poisoning and overdose - answers 23
Page 248 and 249:
Treatment of poisoning and overdose
Page 250 and 251:
Adverse drug reactions - answers 23
Page 252 and 253:
Adverse drug reactions - answers 23
Page 254 and 255:
Infections - answers 241 D H N A 72
Page 256 and 257:
Infections - answers 243 I G A This
Page 258 and 259:
The confused patient - answers 245
Page 260 and 261:
Drugs and immunity - answers 247 J
Page 262 and 263:
Index 249 antibiotics 85, 86 antibo
Page 264 and 265:
Index 251 compartment syndrome 47 c
Page 266 and 267:
Index 253 gastric carcinoma 26, 56,
Page 268 and 269:
Index 255 laparotomy 77 lateral med
Page 270 and 271:
Index 257 penicillamine 53, 57, 81,
Page 272 and 273:
Index 259 spinal stenosis 45 spiron
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