WPW, AD & ATAXIA

Q. DOC for a pateint with Wolf-Parkinson-White syndrome ...
a) Procainamide
b) Disopyramide
c) Quinidine
d) Amiodarone

Ans:  a) Procainamide

Treatment: Accessory Pathway-Mediated Tachycardias

 " In life-threatening situations, DC cardioversion should be used to terminate the AF. In nonlife-threatening situations, procainamide at a dose of 15 mg/kg administered IV over 20–30 min will slow the ventricular response and may organize and terminate AF. Ibutilide can also be used"

Ref: Harrison Internal Medicine 18 th ed.



Q. An 84 year old woman with Alzheimer's dementia has recently become incontinent and more confused than usual. What is the diagnosis?
a) Detrusor overactivity
b) Neuropathic bladder
c) Nocturnal enuresis
d) Urinary tract infection
e) Uterine prolapse

Ans:  d) Urinary tract infection

UTI is very common in Alzheimer disease that results in sudden deterioration of consciouslevel. Patient may beome profoundly confused.
Neuropathic bladder do not results in confusion.


Q. A 38 year old man with longstanding alcohol dependence has vertigo and a tremor every morning. What is the diagnosis?
a) Anxiety
b) Benign positional vertigo
c) Cerebellar degeneration
d) Optic neuritis
e) Temporal lobe epilepsy

Ans: cerebellar degeneration

In patients with alcohol-related ataxia, the symptoms affect gait and lower limbs more than arms and speech, often also with signs of peripheral neuropathy. The ataxia can stabilise or even improve with stopping alcohol, but worsen in those who continue. Brain imaging typically shows vermis atrophy.
Alcohol is directly toxic to the cerebellum, causing degeneration of the anterior superior vermis and hemispheres. 

ANTICONVULSANTS

ANTICONVULSANTS:

Q. A 35-year-old woman, recently diagnosed with simple partial seizures, started the prescribed therapy. Her past history was unremarkable, but her mother was known to suffer from acute intermit tent porphyria. Which of the following anticonvulsant drugs would be appropriate for this patient?
A. Diazepam
B. Ethosu ximide
C. Valproic acid
D. Carbamazepine
E. Phenytoin
F. Lamotrigine

Ans:  F.  Lamotrigine

Explanation:  Lamotrigine is effective in simple partial seizures, as well as in generalized tonic-clonic and absence seizures. It appears to have comparable effectiveness with more traditional anticonvulsant drugs, such as valproic acid, carbamazepine, and phenytoin. The primary mechanism of action of lamotrigine most likely includes a frequency-dependent blockade of voltage-gated Na+ channels. C−E Valproic acid, carbamazepine, and phenytoin are firstchoice drugs in partial seizures, but they are contraindicated when there is a risk of acute intermittent porphyria, because they can trigger an attack. Because acute intermittent porphyria is an autosomal disorder, it is bet ter to avoid these drugs in patients whose parents are known to suffer from the disease, as in this case. A, B Diazepam and ethosuximide are not effective in simple partial seizures.

Q. A 53-year-old man suffering from partial seizures had been receiving a high dose of carbamazepine for 6 months. Which of the following dose-related adverse effects most likely occurred during the therapy?
A. Gingival hyperplasia
B. Hallucinat ions
C. Ataxia
D. Stevens−Johnson syndrome
E. Heart failure
F. Dilut ional hyponatremia

Ans: C. Ataxia

Explanation: Some of the adverse e ects of carbamazepine are related to cerebellar-vestibular impairment. The most common  dose-related adverse effect of this kind is ataxia (up to 15%

of patients). A This would be an adverse e ect of phenytoin. It does not occur with carbamazepine. B, D−F All these are serious but quite rare adverse effects of carbamazepine.

 
Q. A 24-year-old woman with a long history of absence seizures had been successfully managed with valproic acid for the past 5 years. The patient had recently married, and during her last visit she expressed the desire to start a family. Which of the following drugs would be most appropriate for this patient to substitute for valproic acid therapy?
A. Carbamazepine
B. Clonazepam
C. Phenytoin
D. Ethosuximide
E. Phenobarbital
F. Tiagabine

Ans: D. Ethosuximide

Explanation: Valproic acid is classified by the U.S. Food and Drug Administration as pregnancy category D because it increases the 
 risk of neural tube defects (up to 20-fold) when given during pregnancy. Ethosuximide is instead classi ed as pregnancy category C and is a rst-line drug for absence seizures. A−C, E, F These drugs are not effective (and some of them can even be dangerous) in absence seizures.

PHENYTOIN LEVEL CHECK

Q. A 72-year-old man with known epilepsy and hypertension is admitted with pneumonia. His drug history includes aspirin, phenytoin, bendroflumethiazide and amlodipine. His heart rate is 67, blood pressure 170/93, sats 96 per cent on 2 L of oxygen. Neurological examination is normal. His doctor requests blood tests
including phenytoin level. What is the correct indication for this test?
A. Routine check
B. Ensure levels are not toxic
C. Confirm patient compliance
D. Ensure therapeutic level reached
E. Reassure the patient

Ans:  C

Explanation: 

 Routine measurement of phenytoin levels (A) is not good practice, they should be ordered with a question in mind. They can be helpful either for adjustment of phenytoin dose or looking for toxicity or patient compliance. Phenytoin levels are useful when adjusting the dose to avoid toxicity as phenytoin has zero-order kinetics (once elimination reaches saturation rates, it cannot be cleared any faster so a small change in the dose may result in high blood levels), but there is no reason to change this patient’s dose. There is no reason to suspect phenytoin toxicity either (B) as there are no signs or symptoms such as nystagmus, diplopia, dizziness, ataxia, confusion. However, his high blood pressure may be caused by noncompliance with his medication (C). Although target levels exist (D), they are imprecise and not applicable to all patients. Seizures may be well controlled with low levels, thus phenytoin should be adjusted according to the clinical picture and not levels. Levels are not helpful in reassuring the patient in this situation (E), although they often inappropriately reassure the doctor who requests them.

ANKYLOSING SPONDYLITIS

Q. A 22 year old man has had an acute, painful, red right eye with blurring of vision for one day. He had a similar episode one year ago and has had episodic back pain and stiffness relieved by exercise and diclofenac for four years. What is the most likely cause of his red eye?
a) Chorioretinitis
b) Conjunctivitis
c) Episcleritis
d) Iritis
e) Keratitis

Ans: d) Iritis


Explanation: 

Ankylosing spondylitis (AS):  is a chronic inflammatory disease of the spine and sacroiliac joints, of unknown aetiology. 
Prevalence: 0.25–1%. 

 Men present earlier:  M:F≈ 6:1 at 16yrs old, and ~2:1 at 30yrs old. ~90% are HLA B27 +ve
 
Symptoms and signs: The typical patient is a man <30yrs old with gradual onset of low back pain, worse at night, with spinal morning stiff ness relieved by exercise. Pain radiates from sacroiliac joints to hips/buttocks, and usually improves towards the end of the day. There is progressive loss of spinal movement (all directions)—hence thoracic expansion. . The disease course is variable; a few progress to kyphosis, neck hyperextension, and spino-cranial ankylosis. Other features include enthesitis , especially Achilles tendonitis, plantar fasciitis, at the tibial and ischial tuberosities, and at the iliac crests. Anterior mechanical chest pain due to costochondritis and fatigue may feature. 
 Acute iritis occurs in~⅓ of patients and may lead to blindness if untreated (but may also have occurred many years before, so enquire directly). AS is also associated with osteoporosis (up
to 60%), aortic valve incompetence (<3%) and pulmonary apical fibrosis. 

Tests: Diagnosis is clinical, supported by imaging (MRI is most sensitive and better at detecting early disease). Sacroiliitis is the earliest X-ray feature, but may appear late: look for irregularities, erosions, or sclerosis aff ecting the lower half of the sacroiliac joints, especially the iliac side. Vertebral syndesmophytes are characteristic: bony proliferations due to enthesitis between ligaments and vertebrae. These fuse with the vertebral body above, causing ankylosis. In later stages, calcification of ligaments with ankylosis lead to a ‘bamboo spine’ appearance.
Also: FBC (normocytic anaemia), increased ESR, CRP, HLA B27+ve (not diagnostic).
 
Management:  Exercise, not rest, for backache, including intense exercise regimens to maintain posture and mobility—ideally with a physiotherapist specializing in AS. NSAIDS  usually relieve symptoms within 48h, and they may slow radiographic progression. 41 TNF alfa blockers etanercept, adalimumab and golimumab are indicated in severe active AS if NSAIDS fail . Local
steroid injections provide temporary relief. Surgery includes hip replacement to improve pain and mobility if the hips are involved, and rarely spinal osteotomy. There is increased risk of osteoporotic spinal fractures (consider bisphosphonates). Prognosis: There is not always a clear relationship between the activity of arthritis and severity of underlying infl ammation (as for all the spondyloarthritides). Prognosis is worse if ESR >30; onset <16yrs; early hip involvement or poor response to NSAIDS.



Source: Oxford Book Of Clinical Medicne 

CHEMOTHERAPY SKIN REACTION

Q. A 57-year-old man with metastatic adenocarcinoma of the lung is attending for cycle three of his palliative pemetrexed/cisplatin chemotherapy. During his cisplatin infusion, he noticed his arm becoming painful, swollen and red at the cannula site. The most likely cause of this is:

A. Cellulitis

B. Venous thrombosis

C. Extravasation of chemotherapy

D. Adverse drug reaction

E. Normal chemotherapy reaction

Ans: C

 Extravasation of chemotherapy (C) is describing the inadvertent administration of drugs into the surrounding tissues rather than into a vein. This may be caused by a displaced cannula. Depending on the agent being administered, the degree of injury may range from a mild skin reaction to skin necrosis and thus, it requires urgent attention. The chemotherapy infusion should be stopped, the arm elevated and the affected area marked. A senior doctor should be informed and the guidelines on extravasation for that particular agent should be checked. Cisplatin is classified as an exfoliant, which can cause inflammation and shedding of the skin. A cold pack should be applied and advice of a plastic surgeon sought. Saline washout of the extravasation site may be necessary in this case. Acute onset of cellulitis (A) after administration of chemotherapy is an unlikely answer. Cancer patients are at higher risk of venous thrombosis (B) and all patients attending hospital should have a venous thromboembolism risk assessment and prescription of a low-molecular weight heparin if required.

In this situation though, it is more likely that extravasation has caused the pain and swelling, particularly in light of the skin reaction. Since this is his third cycle of chemotherapy, an adverse drug reaction (D) is unlikely. You are not expected to know the details of managing extravasation of chemotherapy. However, it is important to know that such a reaction after administration of chemotherapy is not normal (E) and senior attention should be sought.

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