A 25-year-old woman who recently moved to the UK presents to the TB Clinic. She has been experiencing a rash on her face for the past week, which seems to worsen when she is exposed to sunlight. On examination, there is redness and swelling over both cheeks, with the nasolabial folds being spared. A drug reaction is suspected and a decision is made to change her medication.
What is the best course of action for managing this patient’s condition?
A 28-year-old woman, who is 28 weeks pregnant, is admitted as an emergency from the Antenatal Clinic with severe headaches, blurred vision and bilateral leg swelling.
On examination, she has a blood pressure (BP) of 170/110 mmHg. There is bilateral papilloedema, peripheral oedema, increased tone, reflexes and bilateral extensor plantars. Ultrasound reveals that the fetus is growing adequately and there is no imminent need for delivery from the point of view of fetal health.
Investigations;
Haemoglobin (Hb) 120 g/l 115–155 g/l
White cell count (WCC) 6.2 × 109/l 4–11 × 109/l
Platelets (PLT) 170 × 109/l 150–400 × 109/l
Sodium (Na+) 138 mmol/l 135–145 mmol/l
Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
Creatinine (Cr) 100 µmol/l 50–120 µmol/l
What is the most appropriate next management step in controlling her BP?
A 55-year-old man is brought into the Emergency Department by the police. He appears drowsy and confused, and his unkempt appearance suggests neglect. Unfortunately, his confusion prevents him from providing a coherent history of his condition.
Upon examination, his pulse rate is 60 beats per minute, blood pressure is 90/60 mmHg, respiratory rate is 23 per minute, and his temperature is 35.2°C. There are no remarkable findings upon examination of his heart, lungs, and abdomen. However, there is no obvious head injury, and his eyes open to pain. His pupils are dilated, and light responses are absent. His speech is slurred and incoherent, and there is no evidence of a focal neurological deficit.
An arterial blood gas test is performed, which reveals a pH of 7.30 (7.36-7.44), pO2 of 10.1 kPa (11.3-12.6), pCO2 of 2.9 kPa (4.7-6.0), sodium of 142 mmol/L (137-144), chloride of 100 mmol/L (95-107), potassium of 4.2 mmol/L (3.5-4.9), bicarbonate of 12.9 mmol/L (20-28), urea of 9.2 mmol/L (2.5-7.5), and creatinine of 103 μmol/L (60-110). His glucose level is 8.4 mmol/L (3.0-6.0), and a urine dipstick test is positive for 1+ ketones and 1+ leukocytes but negative for nitrites.
Based on the likely diagnosis, what is the most appropriate initial treatment?
A 72-year-old man with known pancreatic carcinoma was experiencing severe pain despite an increase in oral morphine dosage. The latest oncology report on the hospital computer indicates multiple liver metastases and increasing signs of obstruction on his LFT monitoring, which did not respond to recent chemotherapy. His GP recently switched him to fentanyl patches after a review.
Regrettably, his family misinterpreted the advice of the palliative care nurse and applied a second patch after 24 hours. His family called an ambulance as he appeared to have rapidly deteriorated.
Upon examination in the Emergency Department, he is unresponsive with pinpoint pupils and a respiratory rate of 15 breaths/min. His blood pressure is 110/60 mmHg, pulse 66/min, and O2 saturation on air is 95%.
What is the most appropriate next step?
A 50-year-old woman with a family history of osteoporosis and a history of hysterectomy and oophorectomy at 35 years of age, presents to the Emergency department with sudden and severe back pain that radiates to the front of her chest.
Upon examination, she appears thin with a BMI of 23 kg/m2, has a pulse of 105 bpm, and a blood pressure of 166/72 mmHg. The patient is in significant pain, and there is noticeable tenderness over the mid thoracic vertebrae. Neurological examination reveals no abnormalities.
Her FBC and U+Es are normal, but her calcium levels are elevated at 2.78 mmol/L (2.2 – 2.6), and her alkaline phosphatase levels are also elevated at 145 IU/L (50-110). A plain radiograph of the thoracic spine confirms a crush fracture of the T5 vertebra.
What would be the most appropriate initial pain management for this patient?
A 30-year-old woman presents to the Emergency Department with a suspected overdose of aspirin. She has been experiencing vomiting and tinnitus. Upon examination, she appears dehydrated, restless, and is sweating profusely. Her vital signs are as follows: temperature 38.5°C, pulse 120 regular, blood pressure 140/85 mmHg, respiratory rate 25 breaths per minute, Glasgow coma score of 12, and oxygen saturation 95% on air. It is believed that the aspirin was ingested eight hours ago and that the plasma levels have already peaked. The biochemistry results show a pH of 7.25 (7.35-7.45), PaCO2 of 20 mmHg (38-42), PaO2 of 102 mmHg (75-100), BE of +8 (-3 to +3), Bicarbonate of 22 mEq/L (22-28), SpO2 of 96%, glucose of 13 mmol/L (3.5-5.5), and salicylate levels of 601 mg/L. What is the most appropriate initial clinical intervention in this case?
A 49-year-old woman comes to the hospital after experiencing a self-limited tonic-clonic seizure. She confesses to regularly misusing benzodiazepines and opioids. She recently switched her primary care physician (PCP) because her previous one refused to prescribe her the 70 mg lorazepam and 200 mg of oxycodone she takes daily. She does not consume alcohol and has not been known to misuse other prescription drugs.
Upon examination in the Emergency Department, no abnormalities are found.
What is the most appropriate course of action?
A 28-year-old man is brought to the Emergency Department following a suspected deliberate overdose. On arrival, he is drowsy with a GCS of 13/15 (E3V4M6) and confused. His airway is currently patent. The respiratory rate is 30 breaths per minute although oxygen saturations are 98% on 2L/min oxygen. The chest is clear to auscultation. Heart rate is 108 bpm and blood pressure is 96/48 mmHg. The ECG shows sinus tachycardia only. He complains of severe abdominal pain and is groaning on examination. There is significant tenderness in the right upper quadrant. Bowel sounds are hyperactive. Neurological examination is difficult but discloses downgoing plantars and reactive, mid-size pupils.
Blood tests show:
Haemoglobin 112g/L Sodium 131 mmol/L Glucose 17.8 mmol
MCV 96 fL Potassium Haemolysed Lactate 5.3mmol/L
White cells 15.7×109/L Urea 15.6 mmol/L pH 7.14
Neutrophils 13.7×109/L Creatinine 207 mol/L pCO2 2.9kPa
Platelets 278×109/L ALP 234U/L pO2 19.2kPa
INR 1.2 ALT 2453U/L Bicarbonate 9.4mmol/L
PT 14 secs AST 3109U/L Base excess -15.4mEq/L
APTT 49.2secs Bilirubin 36mol/L Anion gap 30.8
The laboratory comments there is significant haemolysis of the samples.
He has a massive vomit whilst being assessed, of black liquid and fresh blood.
Which of the following drugs is this patient most likely to have overdosed upon?
A 45-year-old man is admitted to the hospital after ingesting an unknown substance. His medical history includes alcoholism and ongoing treatment for tuberculosis. Upon arrival, he had already experienced one tonic-clonic seizure at home, which was treated with 5 mg of diazepam intravenously. During transport to the hospital, he had two more seizures, for which he received an additional 5 mg of diazepam. Upon examination, he was unresponsive except to painful stimuli, with a Glasgow coma scale of 8/15 and a temperature of 38.5°C. He had two more seizures during his hospital stay. The following laboratory results were obtained: sodium 131 mmol/L, potassium 3.9 mmol/L, pH 7.21, PCO2 4.0 kPa / 30 mmHg, PO2 15.3 kPa / 115 mmHg, bicarbonate 8 mmol/L, and chloride 105 mmol/L. What is the most likely cause of his intractable seizures?
A 47-year-old woman presents to the Emergency department with worsening nausea and lethargy over the past few days. She had a renal transplant for end stage renal failure due to chronic reflux nephropathy 2 months ago. It is suspected that her GP prescribed an antibiotic for a respiratory tract infection without considering potential interactions with her ciclosporin based immunosuppressive therapy. Her creatinine levels have significantly increased and her ciclosporin levels are above the recommended range.
Investigations:
Na+ 142 mmol/l
K+ 5.1 mmol/l
Urea 8.2 mmol/l
Creatinine (2 months ago) 161 µmol/l
Creatinine (today) 225 µmol/l
Which antibiotic is most likely to have been prescribed to the patient?