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 35-year-old software developer visits his primary care physician complaining of symptoms indicative of a mixed anxiety and depression disorder. The doctor prescribes him fluoxetine 20 mg daily and alprazolam 0.25 mg per day. The next day, the patient arrives at the hospital with his wife, who reports that he has become excessively elated and hyperactive.
During the examination, the patient appears disoriented and experiences frequent sudden, brief muscle spasms in different parts of his body. When asked about his medication history, he admits to self-medicating with St. John’s wort in addition to his prescribed medications. He provides a urine sample at the hospital, which tests positive for blood.
What is the most probable diagnosis?
You review an 80-year-old man with moderate cognitive impairment who appears to have Alzheimer’s dementia. There is a past medical history of ischaemic heart disease and hypertension, and medication includes ramipril, furosemide, isosorbide mononitrate, aspirin and atorvastatin.
During examination, his blood pressure is 110/72 mmHg, his pulse is 80 bpm and regular. His chest is clear and there is no peripheral ankle oedema. He is selected for a trial of donepezil therapy as he fulfils the NICE criteria for receiving it.
What would you caution him is the most likely outcome?
A 72-year-old woman, feeling lethargic and disoriented, is brought to the hospital in the middle of the night by her caregiver. She accidentally took an overdose of her medication from her pill organizer about 5 hours ago. She has a medical history of Parkinson’s disease, high blood pressure, and osteoporosis. Her medication list includes levodopa, lisinopril, and alendronate. Her pulse is 40 bpm, blood pressure is 90/50 mmHg, respiratory rate is 16/min, and oxygen saturation is 97%. There is no response to 2 mg of atropine.
Initial investigations:
Blood gases on air:
pH 7.38 7.35–7.45
pa(O2) 10.2 kPa 10.5–13.5 kPa
pa(CO2) 5.0 kPa 4.6–6.0 kPa
Sodium (Na+) 138 mmol/l 135–145 mmol/l
Potassium (K+) 4.2 mmol/l 3.5–5.0 mmol/l
Urea 6.2 mmol/l 2.5–6.5 mmol/l
Creatinine 70 µmol/l 50–120 µmol/l
Bicarbonate (HCO3-) 24 mmol/l 24–30 mmol/l
Glucose 2.5 mmol/l 3.5–5.5 mmol/l
Electrocardiogram Sinus bradycardia 40 bpm
She is given intravenous glucose; what is the appropriate next step in management?
A 68-year-old woman has a history of atrial fibrillation and is taking rivaroxaban for anticoagulation. She is brought to the Emergency Department after a suspected overdose. What is the best method to determine if she is at risk of bleeding due to rivaroxaban?
There are a few ways to assess the risk of bleeding in patients taking rivaroxaban. One method is to measure the drug’s concentration in the blood, but this is not routinely available in most hospitals. Another option is to perform a coagulation test, such as a prothrombin time (PT) or activated partial thromboplastin time (aPTT), which can indicate if the blood is clotting properly. However, these tests may not accurately reflect the anticoagulant effect of rivaroxaban.
The most reliable way to assess the risk of bleeding in this patient is to evaluate her clinical status, including any signs or symptoms of bleeding, such as bruising, petechiae, or hematomas. Additionally, her medical history, including any recent surgeries or injuries, should be taken into account. It is important to note that the risk of bleeding may be increased in patients who have renal impairment or are taking other medications that affect blood clotting. Close monitoring and appropriate management of any bleeding complications are essential in this patient population.
A 35-year-old man visits his primary care physician (PCP) complaining of fatigue, weakness, headaches, and tremors. He underwent a liver transplant six months ago and is currently on an immunosuppressive regimen that includes tacrolimus. He recently started taking a prolonged course of fluconazole for a persistent fungal infection. Laboratory tests show the following results:
– Hemoglobin (Hb): 95 g/L (normal range: 130-170 g/L)
– White blood cell count (WBC): 2.5 x 10^9/L (normal range: 4-11 x 10^9/L)
– Platelet count (PLT): 85 x 10^9/L (normal range: 150-400 x 10^9/L)
– Sodium (Na+): 138 mmol/L (normal range: 135-145 mmol/L)
– Potassium (K+): 4.2 mmol/L (normal range: 3.5-5.0 mmol/L)
– Creatinine (Cr): 220 µmol/L (normal range: 60-110 µmol/L)
What is the most likely cause of this patient’s symptoms and abnormal laboratory results?
A 22-year-old woman is brought to the hospital after intentionally overdosing on paracetamol following a fight with her partner. She ingested 30 × 500 mg tablets of paracetamol along with a few glasses of wine. The next day, she confessed to her family about her actions. What factor would most likely lead to a referral to a specialized liver unit for this patient?