A 35-year-old patient with a kidney infection is being treated with gentamicin 60 mg (tds). The nursing staff requests your review of the gentamicin regimen. The patient’s symptoms are improving, but they are concerned about potential side effects.
Gentamicin levels are taken:
Peak level 4 µg/ml 3–4 µg/ml
Trough level 1.8 µg/ml 2 µg/ml
What is the appropriate action to take in this situation?
A 35-year-old former teacher is seen in the Allergy Clinic. She has a history of peanut allergy, with two episodes of anaphylaxis over the past year, and she carries an adrenaline auto-injector with her at all times for this reason. Her primary care physician is asking about appropriate medications to manage her high blood pressure. She has no other significant medical history. During her visit, her blood pressure is 160/95 mmHg, and her pulse is 80 bpm and regular. Her BMI is 23 kg/m2.
Which antihypertensive medication should be avoided due to its potential to worsen anaphylactic reactions?
A 50-year-old man presents to the emergency department with drowsiness. He was found unconscious in a park. He is not able to provide a meaningful history. His observations are as follows: heart rate 110 beats per minute, blood pressure 130/85 mmHg, respiratory rate 22 breaths per minute, temperature 37.5ºC, and SpO2 95% on air. On examination of his fundus, you note optic disc swelling.
Blood results are as follows:
Hb 120 g/L Male: (135-180)
Female: (115 – 160)
Platelets 165 * 109/L (150 – 400)
WBC 14.8 * 109/L (4.0 – 11.0)
Na+ 135 mmol/L (135 – 145)
K+ 4.2 mmol/L (3.5 – 5.0)
Urea 2.8 mmol/L (2.0 – 7.0)
Creatinine 68 µmol/L (55 – 120)
CRP 22 mg/L (< 5)
Glucose 4.2 mmol/L (3.9 – 5.6)
Serum osmolarity 305 mOsm/kg (275 – 295)
What is the treatment of choice for this patient?
A 67-year-old retired teacher visits the diabetic clinic after her GP discovered a random blood glucose level of 25 mmol/L during a routine check-up. She has been living with diabetes for 25 years and was previously well-controlled on glibenclamide 5 mg bd and metformin 800 mg TDS. She is currently asymptomatic and has no other medical conditions, except for a BMI of 32. On examination, she has symmetrical stocking distribution sensory neuropathy, scattered hard exudates, and dot blot haemorrhages on fundoscopy. Her fasting blood glucose on the day of the clinic is 20 mmol/L (3.0-6.0).
What is the most appropriate approach to managing this patient?
A 25-year-old female is brought to the Emergency Department from a beach day in Cornwall. While wading through the water, she suddenly felt a sharp pain in her left foot. She immediately stopped and noticed a small puncture wound on her foot. The pain became unbearable, and she was unable to walk.
On examination, the patient was anxious and had difficulty breathing. Blood pressure was 100/70 mmHg, pulse rate was 110/min, respiratory rate was 24/min, and she had swelling and discoloration around the site. During the evaluation, she complained of blurred vision and dizziness.
Which of the following is an important initial management step?
A 44-year-old male was rushed to the Intensive Care Unit (ICU) as an emergency admission after experiencing complications during an elective open cholecystectomy under general anaesthetic. He had been successfully intubated and ventilated, but shortly after the operation began, his heart rate skyrocketed from a resting rate of 72 bpm to 142 bpm. His oxygen saturation levels dropped to 92% on 15 litres of oxygen per minute, and his blood pressure rose from his baseline of 114/78 mmHg to 162/98 mmHg. Despite several checks to ensure that the tracheal tube was correctly sited, his end tidal CO2 concentration continued to rise. The patient’s medical history was unremarkable except for an appendicectomy under general anaesthetic at the age of 26.
The surgery was immediately halted, and the patient was intubated and ventilated upon arrival at the ICU. He maintained an oxygen saturation level of 96% on 15 litres per minute of oxygen, but appeared flushed and had significant muscle rigidity. His blood pressure had risen to 174/102 mmHg, and his heart rate was 136 bpm. His temperature was 38.2 C. Upon examination, the cardiovascular system revealed vasodilated peripheries with a bounding pulse and normal heart sounds. Auscultation of the lungs revealed good air entry in all zones and a correctly cited tracheal tube. Examination of the abdomen was unremarkable. The neurological system examination confirmed the presence of equal and reactive pupils, with generalised muscle hypertonicity and masseter muscle spasm. A central venous catheter and arterial line were inserted, and the central venous pressure was 9 cm.
An arterial blood gas sample was taken on 15 litres of oxygen, revealing the following results:
pH 7.26
HCO3 18 mmol/l
Pa02 17 kPa
PaC02 7.6 kPa
Na+ 139 mmol/l
K+ 7.1 mmol/l
What is the most appropriate immediate management step?
A 72-year-old woman returns to the Emergency Ward with confusion some two weeks after discharge post-hip replacement surgery. She made a relatively good recovery and was started on a range of medications, including an antidepressant, as she said she was feeling really very low after the surgery. She did have depression which required medication a few years earlier, and felt that her old symptoms were returning. Her daughter tells you that she has become increasingly forgetful over the past three to four days.
On examination, her blood pressure (BP) is 130/80 mmHg, her pulse is 72/min and regular. She is euvolaemic.
Investigations:
Haemoglobin 138 g/l 135–175 g/l
White cell count (WCC) 5.8 × 109/l 4–11 × 109/l
Platelets 195 × 109/l 150–400 × 109/l
Sodium (Na+) 129 mmol/l 135–145 mmol/l
Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
Creatinine 95 µmol/l 50–120 µmol/l
Which of the following medications is most likely to be responsible for her low sodium?
A 32-year-old woman presents to the clinic for follow-up of her rheumatoid arthritis. She is currently on weekly methotrexate but is still experiencing active tenosynovitis in her wrists and small finger joints. She has expressed her desire to start a family soon but understands the importance of stabilizing her joint disease before becoming pregnant. Her routine blood work is normal.
What is the most suitable treatment plan during pregnancy?
A 49-year-old man is admitted to the Medical Assessment Unit with a pneumonia. He has had a persistent cough for the past week despite taking amoxicillin prescribed by his GP.
His medical history includes alcoholic liver disease and a hepatic transplant 8 months ago, hypertension, and type II diabetes controlled by diet. He has been sober for the past 2 years and has never smoked. He is currently taking ramipril, simvastatin, and tacrolimus.
Upon admission, he has a temperature of 38.1 ºC and oxygen saturation of 94% on air. His heart rate is 110 beats per minute and blood pressure is 105/65 mmHg. Left basal crepitations are heard on auscultation, and a chest x-ray confirms a left lower lobe pneumonia.
The patient is started on intravenous fluids, 2 liters of oxygen via nasal cannulae, co-amoxiclav, and clarithromycin. His statin is withheld.
Two days later, the ward team is called to review the patient as he has developed limb twitching. During the assessment, he experiences a generalized tonic-clonic seizure that requires lorazepam to terminate it.
Which investigation is most likely to reveal the cause of his seizures?
A 42-year-old construction worker is discovered in a distressed state after collapsing while handling chemicals on a job site. Upon arrival at the Emergency department, the patient is confused, experiencing excessive salivation, and has had an episode of urinary and fecal incontinence. The patient is also exhibiting noisy breathing, with a blood pressure of 90/60 mmHg and a pulse rate of 48 beats per minute.
What is the most suitable course of action in this situation?