A 62-year-old woman had sudden chest pain and sob 2 hrs ago.

 ECG shows ST elevation in leads I, II, III.

 Oxygen has been started and she was given GTN which has improved her chest pain.

 Her heart rate is 70 bpm and rr is 18/min.

 What is the SINGLE most appropriate next step in management?  

A. Low molecular weight heparin  

B. Streptokinase 

 C. Warfarin  

D. Proton pump inhibitors  

E. Continue current management 

 Percutaneous intervention (PCI) would be the best management for myocardial infarction. As PCI not given in the options. Thrombolysis would be the next best step. In terms of thrombolysis, Alteplase is preferred over streptokinase in the NHS. However, alteplase is not given in the options thus the best option would be option B. (streptokinase).

Thirty yrs old female presented with itchy scaly rash on both wrists with fine white streaks overlying the lesion. 

Her nails have ridges and her buccal mucosa is lined with a lacy white pattern. What is the SINGLE most likely diagnosis? A. Psoriasis  

B.Dermatitis herpetiformi

C. Candida Infection

D. Scabies E. Lichen Planus

key- Lichen planus Lichen planus is a skin disorder with the following Features - Purple, pruritic, papular, polygonal rash on flexor surfaces - Lacy white pattern on buccal mucosa Mnemonic: 4P  

A 25 yr-old female presents with an itcy demarcated bright red elevated lesions over the extensor surface of her body. she also complain of dry itchy scalp. Her mother and 2 older sisters also have similar rash that often comes and goes. What is the SINGLE most likely diagnosis?
A. Eczema
B. Psoriasis
C. Impetigo
D. Lichen planus
E. Seborrheic dermatitis

Dry itchy scaly scalp are presentation of scalp psoriasis. Her family hx of similar rash is suggestive of psoriasis. 

Key- Itchy, well-demarcated circular-to-oval bright red/pink elevated lesions (plaques) with overlying white or silvery scale, distributed symmetrically over extensor body surfaces and the scalp - Check Nails- about 80% of patients with psoriasis have nail changes: pitting( small depressions on the nail surface, onycholysis( distal nail seperation from nailbed), subungual hyperkeratosis, oil spots. Don't forget to ask about joints - Relapses - May have a family history

Always ask your patient for precipitating factors.

Psoriasis has no cure - it is a relapsing-remitting disease that often improves with warmer weather and relapsing during stressful events or infections. 

Treatments include- Topical- steroids, vitamin D3, combination products, salicytic acid, coal tar, emolients etc, Systemic treatment- agents like metotrexate, sulfasalazine, cyclosporine

Biologics Treatment- anti-TNF agents. and Photo-therapy

to read more about psoriasis- (Information for clinicians)-psoriasis area severity index www.pasi.corti.li/

www.psoriasis.org/psa-screening/providers

www.bad.org.uk/shared/get-file.ashx?id=178&itemtype=document

www.sign.ac.uk/assests/sign121.pdf

A 20 year old male presents with pruritus especially around the wrists and palms of his hands. On examination, his skin is dry and red. His mother is asthmatic and older brother has hay fever. What is the SINGLE most likely diagnosis? A. Dermatitis herpetiformis B. Scabies C. Eczema D. Hand foot disease E. Systemic lupus erythematosus 

 The findings are consistent with eczema. Having atopic disease in a first-degree relative favours the diagnosis of eczema.

NOTE- In people with skin of color, eczema often appears “ashen”, brown, or grayish in color and not red

 A 62-year-old woman presents with sob and palpitations, ongoing for few hours. 1 year hx of feet and ankle swelling. Other symptom include DIB while lying down. She is a known alcoholic. 

A chest radiograph shows evidence of cardiac enlargement. What is the SINGLE most likely cause of her worsening condition? A. Ventricular tachycardia B. Paroxysmal supraventricular tachycardia C. Ventricular fibrillation D. Atrial fibrillation E. Ventricular ectopic  

Simplified/ Key word/Clinical pearl- Ankle swelling and orthopnoea are features of heart failure. These features in combination with the history of alcoholism gives us the hints of an alcoholic cardiomyopathy which is a type of dilated cardiomyopathy.  

Atrial fibrillation is the most common arrhythmia that develops in patients with dilated cardiomyopathy.  

AF is a supraventricular tachyarrhythmia (BMJ 2019)

Note- Irregular supra ventricular tachycardia is usually AF.

In Acute AF under 48hrs, try to control rate and rhythm-

chronic AF- after 48hrs- control the rate

• Rate control drugs- Beta blocker, Calcium channel antagonist (diltiazem/verapamil) and digoxin
• The main stay of treatment in AF is rate control and not cardioversion.
• AF needs anticoagulants- Warfarin to prevent embolism, Aspirin if pt younger than 65yrs and no htn, no dm, no lv dysfunction, no valvular heart disease and no MI/TIA
• PEARL- Use the CHAD2 SCORE to decide whether pateint needs to be on aspirin or warfarin

For paroxysmal AF- flecanaide (pill in the pocket), sotalol, anticoagulation . Sotalol is usually initiated and titrated up to an appropriate dose in secondary care. However, a primary care practitioner may be expected to continue prescribing sotalol

The appropriate investigation for Paroxysmal AF is 24 hour ECG/amubulatory ECG

Acute AF- less than or equal to 48hrs duration

if patient is very ill or heamodynamically unstable do electrical cardioversion

A 52 year old male was admitted to hospital few days ago for myocardial infarction. Patient is now ready to be discharged. His medical history remains insignificant other than the myocardial infarction he had. He has no drug allergies. He has already been put on aspirin and clopidogrel. 

What is the SINGLE most appropriate medication(s) to be given to him on discharge? A. Statin and Warfarin 

  B. Statin only

 C. Statin and ACE inhibitor

D. . Warfarin only

 E. Heparin only

All patients with MI on discharge: Dual antiplatelet therapy: Aspirin + Clopidogrel

Aspirin is continued life long Clopidogrel for 12 months, 

 Beta Blockers- Offer BB to people who present acutely with MI as soon as they are hemodynamically stable Continue a beta-blocker for at least 12 months after an MI in people without heart failure. 

Continue a beta-blocker indefinitely in people with HF .

ACEi -Offer ACEi to people who present acutely with MI as soon as they are hemodynamically stable

If intolerant to ACEi → use ARB 

STATINS

Mnemonic: Once the patient is discharged, he can take the CAB or BAS (BUS) home.

 C - Clopidogrel

 A - Aspirin 

B - Beta Blockers

 A - ACEi S – Statin

A 28-year-old man complains of heart racing. He is completely conscious throughout. He has a pulse of 132 beats/minute, a blood pressure of 120/80 mmHg and a respiratory rate of 20 breaths/minute. An ECG was taken which shows supraventricular tachycardia. What is the SINGLE most appropriate initial management? A. Amiodarone B. Adenosine C. Radio-frequency ablation D. Carotid massage E. Metoprolol

Carotid massage first before giving IV adenosine.

Supraventricular tachycardia Paroxysmal supraventricular tachycardia is manifested as an absolutely regular rhythm at a rate between 130 and 220 beats/min. Acute management should be done in the following sequence.   

 1st. Valsalva manoeuvre, carotid massage  

2nd Adenosine IV  

3rd. Electrical Cardioversion    

Prevention of episodes: - beta-blockers - radio-frequency ablation

10 years old girl with medical history of t1dm presents with drowsiness and deep breathing. Her blood glucose is 18 mmol/L. She has a blood pressure of 120/80 mmHg and her mucous membranes are dry. What is the SINGLE most appropriate next step? 

 A. Serum urea B. Blood culture C. Computed tomography D. HbA1c  

E. Arterial blood gas  

This child is likely suffering from diabetic ketoacidosis. An arterial blood gas at this time would be a good investigation of choice to determine the severity.

DKA mostly occurs in type 1 diabetes

presentation- abdopain, vomiting, kussmaul breathing (deep hyperventilation), dehydration, glucose greater than 11

management- IV FLUIDS followed by IV infusion of insulin and do ABG

Diabetic patient suddenly collapsed and fell unconscious → Random Blood Glucose.

If blood sugar is below 4 → hypoglycemia (tachycardia, sweating, confusion,altered mentation)

Management:

• If conscious patient and can swallow: give 200 ml fruit juice.

If cannot swallow: administer 200 ml of 10% glucose IV OR 1 mg glucagon IM or

SC.

• If unconscious → IV 75 ml of 20% Glucose.

Causes of hypoglycemia: alcohol and liver failure (impaired gluconeogenesis),

Excess paracetamol, aspirin, sulphonylureas (e.g. glibenclamide).

Congenital Hypothyroidism Complication → Jaundice

It is rarely seen nowadays as there are screening test.

If not corrected early, complications:

Prolonged Physiological Jaundice (starts after 24 hrs and lasts for long time)

FFT (failure to thrive), Short stature, impaired mental development

Broad Flat nose, widely set eyes, protruding tongue.