Case # 1
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A patient came in E/R with C/O itching, redness and swelling of lips and gums giving the vague history of Insulin Allergy.He was known hypertensive and diabetic since years.
Vitals :
Pulse 100b/m
B.P 180/90 mmHg
Temp A/F RBS 335mg/dL
What should we do?
1. First lower the B.P by Inj Furosemide 40mg and Captopril 25mg S/L
2. Then lower the blood glucose with Insulin S/C 4U.
3. After that give Inj Pheniramine I/M or Inj Corticosteroid I/M for the allergic reaction.
An insulin allergy is an allergic response to an insulin medication. Insulin is a hormone normally produced by the pancreas that is taken via injection or other means by some people with diabetes. People whose bodies do not produce insulin or cannot use it properly may be prescribed insulin to regulate their glucose (blood sugar) levels.
Some people have an allergic response to insulin medication, although it occurs rarely.
An allergy occurs when the immune system identifies a harmless substance as being dangerous and produces antibodies to fight the substance. For some people with insulin allergies, the allergy goes undetected until they suffer an allergic reaction.
Insulin allergies occur because injectable insulin is not exactly the same as naturally produced human insulin. Insulin medication in the United States is almost exclusively a form that is genetically engineered to resemble natural human insulin. The chemical makeup of these human insulins is often modified slightly to change the duration of the insulin action. Rarely insulin from animal sources is used to treat diabetes. Allergic reactions are reactions to these differences, as well as the additives, bacteria and impurities that are present in synthetic human and animal-derived insulin. Insulin allergies are more common with insulin made from animals than with synthetic human insulin.
Allergic reactions associated with the use of insulin can be local (appearing around the injection site) or can affect two or more body systems (anaphylaxis). A local allergic reaction may cause itching, redness or swelling at the injection site. Anaphylaxis may cause breathing difficulty, rash and a drop in blood pressure. Without immediate emergency treatment, anaphylaxis can quickly progress to anaphylactic shock and become deadly.
Signs and symptoms of insulin allergy
Insulin allergies, although rare, are unpredictable and can occur at any time during treatment. Symptoms of an allergic reaction can be immediate or can appear after the patient has been taking the medication for longer than a week. Reactions can either be local or affect two or more body systems (anaphylaxis).
The signs and symptoms of a local allergic reaction to insulin include:
Dents under the skin at the injection site
Swelling at the injection site
Persistent or temporary redness at the injection site
Itching at the injection site
Clusters of small bumps that are similar to hives
Local reactions occur only in the area where the insulin was injected. These reactions usually appear within 30 to 60 minutes and usually disappear within a few days to a few weeks. Patients should contact their physician when they believe they are suffering a local allergic reaction to their insulin.
Early signs and symptoms include:
Severe itching of the eyes and face
Anxiety
Palpitations
Rapid or weak pulse
Swelling of the throat or tongue
Slurred speech
Difficulty swallowing
Coughing, choking, wheezing or difficulty breathing
Bluish tint to skin (cyanosis), including lips or nail beds
Nasal congestion
Red or swelling skin
Hives (including on the lips, eyelids, throat and tongue)
Abdominal cramps
Diarrhea
Nausea or vomiting
Drop in blood pressure
Without immediate emergency treatment, anaphylaxis can quickly progress to anaphylactic shock and become deadly. More advanced signs and symptoms include:
Collapse or loss of consciousness
Convulsions
Loss of bladder control
Shock
Stroke
Cardiac arrest
Respiratory arrest
Some of the typical approaches to an allergic reaction include administering an antihistamine, which may be given to relieve mild symptoms, such as itching and rash. Antihistamines are a group of drugs that block the effects of histamine, a chemical released during an allergic reaction.
Corticosteroid cream or tablets may be recommended when skin rashes fail to clear up. Corticosteroids are a group of anti-inflammatory and immunosuppressive drugs similar to hormones produced by the body. In patients with asthma-like symptoms, such as wheezing or cough, a bronchodilator may be prescribed. Bronchodilators are a group of drugs used to widen the lungs’ airways (bronchi).
In cases of anaphylaxis, treatment is frequently an injection of epinephrine. Epinephrine constricts the blood vessels, prevents fluid leakage, opens the airways and raises blood pressure. It also quickly relieves the itching and skin flushing that is part of most episodes of anaphylaxis.
Patients with a history of severe reactions may have a prescribed epinephrine injection kit to treat themselves in an emergency. These patients may be advised in advance by their physician to administer their shot while someone else calls for emergency help. Those who do not have access to epinephrine must seek emergency treatment immediately. Epinephrine may then be administered in an emergency room or by emergency personnel.
To diagnose an insulin allergy, a physician will ask patients about their medical history and perform a physical examination.
Symptoms and a history of allergies to medications are usually enough to diagnose an insulin allergy. A physician may order an allergy skin test to determine if any form of insulin can be tolerated. A variety of insulin types can be introduced to the skin. The test is positive if the skin shows a reaction.
When a patient reacts to all types of insulin, a physician may recommend desensitization. Desensitization is the process of reducing or eliminating a patient’s sensitivity to an allergen. This is accomplished over time by injecting the patient with small but increasing amounts of the allergen. Desensitization is a risky procedure and is considered only in cases when there are no alternative medications or therapies available.
The insulin type that triggered the smallest allergic reaction is usually used in the desensitization process. After the first dose is introduced, the patient is asked to wait a specific time period until the next dose. Increasing doses of insulin are given over a period of minutes or hours to days, until the usual therapeutic dose is tolerable. The patient is monitored for some time after each dose to ensure that a significant allergic reaction is not occurring. Allergic reactions can occur at any time, even when the previous doses did not trigger a reaction. Should allergy symptoms appear during the desensitization therapy, allergy medications (e.g., antihistamines, corticosteroids or epinephrine) may be administered to relieve the symptoms.
There is no known way to prevent the development of an insulin allergy. However, patients may be advised by their physician to avoid discontinuing insulin therapy because insulin allergies are more common in patients with a history of interrupted insulin therapy.
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1.Large ears -dysmorphophobia
2.AF 2 qs, one with heart failure- Rx digoxin (as basal crackles)
other without failure..-best Rx beta blocker (as given in onexam)
3.HUS– cells seen are howell jolly bodies (Howell-Jolly bodies are histopathological findings of basophilic nuclear remnants (clusters of DNA) in young erythrocytes during the
response to severe hemolytic anemia, megaloblastic anemia, splenectomy, or due to a damaged spleen. They can be present in conditions such as hyposplenism, hereditary
spherocytosis, sickle cell anemia and myelodysplastic syndrome(MDS). -wikipedia) mnemonic for HUS-FANTM- FEVER ARF NEURO MANIFESTATION,
MICROANGIOPATHIC HEMOLYTIC ANEMIA
4.HEP B -man was previously infected and had immunity due to tht (as hbsag neg and anti hbc positive)
5.SMALL MUSCLES OF HAND _ t1 lesion (onexam)
6.RTA -1 coz hypokalemia, loin pain(calculus) and severe acidosis (mnemonic hypo-ren-cal-sev-dis= hypokalemia, renal calculi, severe acido.sis)
7.V5,V6- lateral wall ischemia..signifies circumflex artery (emrcp)
8.CICLOSPORIN -nephrotoxic drug (1st complication in easterbrooke)
9.SLE MONITORING-think anti sm(most specific-kalra) am not sure
10.DUMPING SYNDROME- MODIFY THE DIET OF THE PATIENT…coz hes having symptoms of hypoglycemia after 30 mins…means he has to take a small meal of
carbohydrate and then after 30 mins tk more food.. (refer bailey)
11.ERECTILE DYSFUNCTION -56 yo m pt with hypogonadism, lh fsh decrease, prolactin increase slight….choices were asking for cause of er dys..vascular, hypogonadism,
hypopit, phychological, prolactin increase..ans: psychological…as erection is a parasympathetic process (ohcm) further discussion warranted
12.NATURAL SOURCE VIT D- FISH OILS-not milk as milk and mmilk products are fortified with vitd …
13.Q ON SSRI WITHDRAWAL ABRUPT
14.PT HAD SINGLE EPISODE AF- WARFARIN FOR—6 months…if repeated then life long- refer emrcp
15.SELEGELINE -MAO I INHIBITOR
16.T1 ROOT LESION-HORNERS
17.PARKINSONS PLUS CAN LOOK DOWN–supranuclear palsy(refer ohcm -steele olszewski syndrome)
18.HAEMOPHILUS INFLUENZAE-ACUTE epiglottitis
19.MARFANS CONNECTIVE TISSUE COMPONENT-fibrillin-1
20.70 years old female with MI 4 years ago with HIP OSTEOARTHRITIS FOR HIP REPLACEMENT in the pre-operative clinic,how to asses the myocardium dobutamine
challenge .SHE needs a stress test but her painfull hip is a contra-indication …
21.HEP C -CRYOGLOBULINEMIA
22.ORAL GENITAL ULCER – BEHCETS has dvt….
23.GUY COMES FROM SOME COUNTRY AND HAS PAINFUL PENILE ULCERS-( Chancroid is a sexually transmitted infection characterized by painful sores on the genitalia.
Chancroid is known to be spread from one to another individual through sexual contact.—WIKIPEDIA)
24. VZV IG in unimmunized pregnant woman.
25.FACTOR V LEIDEN-defect seen is activated protien c resistance
26.HAS MILD SYSTOLIC DYSFUNCTION-RAMIPRIL-decreases afterload as dilates arterioles due to angiotensin 2 antagonism ( onexam)
27.DEMYELINATION-decreased motor conduction velocity
28.CONNS SYNDROME_ diag by hypokalemia, difficult to treat htn…test is ARR ratio
29.CLOPIDOGREL -MECH IS ADP ANTAGONIST (EASTERBROOK- MNEMONIC CaT CLOPIDOGREL AND TICLOPIDINE HAVE ADP ACTION)
30.VARICEAL PROPHYLAXIS AFTER 2-3 EPISODES BLEED -PROPRANOLOL (actually propranolol is used when theres no episodes of bleeding and u want to prevent , but
this patient had already undergone banding and other options were spironolactone…which didnt suit)
31.WHO GIVES ORDER TO STOP RESUSCITATION IN 18 YR OLD GUY -fiance, parents, consultant on call, cheif of emergency (or smth)–think consultant and parents both r
correct
32.ASKED WHICH DECREASES PULM VASC RESISTANCE- NATURALLY- ADENOSINE–PGSMAY ALSO BE RIGHT( DISCUSSION WARRANTED)
33.BLOODY DIARRHOEA- shigella (emrcp) salmonella doesnt cause bloody diarrhoea
34.ECSTASY -HYPERTHERMIA
35.AFTER 3 DAYS REINFARCTION CHECK CKMB (ONEXAM)
36.FAMILY WITH PC KD….check usg of all as all relatives were greater than 20 yrs of age (if less than 20 then genetic studies) -refer onexam
37.GUY WITH HEARING LOSS RINNE POSITIVE AND SEVERE HEADACHE IMM INV- here do skull xray as pt is haveing pagets
38.guy with motor aphasia- lesion –brocas area posterior frontal (anterior frontal was also given)
39.SCOTOMA CENTRAL- optic neuritis
40.ALPORTS PT- (Alport syndrome is a genetic disorder characterized by glomerulonephritis, endstage kidney disease, and hearing loss. Alport syndrome can also affect the
eyes. The presence of blood in the urine (hematuria) is almost always found in this condition.- WIKIPEDIA)
41.CARBAMAZEPINE AUTOINDUCTION
42.SPECIFICITY Q
43.NNT Q
44.PURPOSE OF CALCULATING POWER OF A STUDY-(to know which test is the best to use- minimum 80 percent power required–easterbrook)
45.LITHIUM -HYDROCHLOROTHIAZIDE INTERACTION
46.TORTICOLLIS – METOCLOPROMIDE
47.GUYS FLECAINADE IS GIVEN ONLY on hospital set up as its dangerous drug and never the first choice
48.q on obsessive c d
49.gas used for calculating transfer factor–carbon monoxide
50.THYROXINE-increases insulin sensitivity
51.INSULIN RECEPTOR LOCATION-(-In molecular biology, the insulin receptor is a transmembrane receptor that is activated by insulin. It belongs to the large class of
tyrosine kinase receptors.Two alpha subunits and two beta subunits make up the insulin receptor. The beta subunits pass through the cellular membrane and are linked by
disulfide bonds.-WIKIPEDIA)
52.CONFUSED FEMALE-old lady with confusion ,was thirsty for a couple of weeks with signs of hepercalcemia low hb ,xray lytic lesions ,what the next immediate action
immediate thing is iv saline as pt had hypercalcemia which is an emergency later look for ur dear multiple myeloma
53.YOUNG LADY WAS CENTRALLY CYANOSED + BREATHLESS-40 yr old lady..presents ansr is asd with eisenmenger…pulm htn cant b as thers no cyanosis in pulm htn and
cant b vsd either as it presents early( refer op ghai book of paediatrics)
54.complication of angio-ansrs were arrhythmia, coronary artery dissection, mi…..think its arrhythmia….(discuss)
55.thalidomide mech of action- acts on cd8 lymphocytes
56.guy with symmetric rash on nose chin and cheeks with papules and pustules was rosacea(not simple acne)
57.aberrant fusion of 2 genes in aml promyelocytic leukemia
58.GUY ON IMMUNOSUPRESSION DEVELOPS PAINFUL SWALLOWING- candidiasis
59.pcod PT ALREADY DID CLOMIPHENECITRATE. IS OBESE AND FASTING GLUCOSE IS INCREASED–DOC METFORMIN
60.HAEMOPHILIA–PTS NONE OF SONS WILL HAVE AS daddy contribute only the y chromosome
61.immunophenotyping in CLL
62.GUY WITH TREMORS ONLY IN CERTAIN HAND POSTURES BILATERAL….BENIGN ESS TREMOR( DISCUSS)
63CIPRO CAUSE DECREASED SEIZURE THRESHOLD (SEE PHILIPPA EASTERBRROKE)
64.MAN THIS WAS COOL—2 SAME QS I GOT BOTH RIGHT…..STEROIDS DECREASE THE NUMBER OF EXACERBATION IN COPD AND DONT HAVE AFFECT ON
MORTALITY
65.Dexamethasone in pt. with liver mets suffering from anorexia & wt.loss (HERE Q WAS HOW DO U IMPROVE THE SYMPTOMS)
66.IDIOPATHIC URTICARIA -first treatment would b to try oral antihistamines as CETRIZINE…(ONEXAM)-
67.two drugs op1 and op2 ,op1 binds with 10 times more affinity to the same receptor then means tht op1 has more POTENCY
68.THT GIRL WAS TAKING EXOGENOUS INSULIN
69.GUY WITH ACUTE GOUT (ALCOHOLIC) TOOK ALLOPURINOL-acute exacerbation due to allopurinol therapy (not alcohol binge-refer onexam)
70.mean is for taking average income
71.guy with absent knee jerk and sensory loss on anterior thigh with absent knee jerk(action of quadriceps)-think was femoral nerve lesion discuss)
72.C1 ESTERASE DEFICIENCY
73FLUOXETINE DEPRESSION NOT CONTROLLED – 2 ANSRS DOUBTFUL CITALOPRAM AND LOFEPRAMINE-(DISCUSS)
74.SPLENECTOMY PATIENT –HERE pt came 2 wks after getting splenectomy –guidelines acc to onexam suggest immediate vaccination for pneumococcus–there no need for
penicillin as pt is havin no active infection
75.ADH WORKS ON COLLECTING DUCT
76.UNILATERAL MASTECTOMY FOR MALE PT…NOW PRESNTS WITH THE OTHER BREAST ENLARGED—LH , FSH NORMAL…..OR INCR…KLINEFELTERS (NOT
KALLMANS AS NO ANOSMIA , and also kallmans is hypogonadotropic hypogonadism and lh fsh will be decreased along with testosterone)
77.Boy with one kidney absent & nephrotic proteinuria give steroid trial( BP 126/66)
78.hypomg due to thiazide diuretic (mnemonic remember this thoroughly- hyper GLUC fr thiazide (glucose, uric acid, calcium–rest all DECREASED) –U WILL B AMAZED HOW
MANY QS U CAN ANSR IF U REMEMBER THIS
79.HYPERINFLATED CHEST WITH REDUCED TLCO AND FEV1/FVC RATIO 55% IS EMPHYSEMA
80.MS pt with 20 ml post void bladder vol. give anti-cholinergic( or intermittent catheterization) –HERE Q SAID HOW DO U CONTROL THE PAT. SYMPTOMS OF
INCONTINENCE AND NOT HOW TO PREVENT INFECTION–FOR FORMER ITS OXYBUTININ i.e antichol..but for latter its intermittent cath..
81.pretibial myxedema –graves
82. ret protooncogene -med carcinoma–mnemonic( pipapa for men1 : para.pheo.med for men2a: muco.pheo.med for men2b)
83. ecstasy hyperthermia …omg rcp loves to repeat qs and i love rcp
84.Lasix-enalapril in LVf ?? here pt didnt have edema (they said no edema in the q) and mild lvf ..options were digoxin, ramipril, and lasix—digoxin try to avoid in mild lvf..and
as no edema why give a diuretic….ramipril decreases afterload therefore preferred (discuss)
85. CI TO LUNG CA SURGERY (SVC OBSTRUCTION)
86. TOXOPLASMOSIS – SULFADOXINE AND PYREMETHAMINE
87. Pulsus paradoxus Physiology ( dec. Lt. atrial filling)
88. Walder. Macroglobinemia –IGM PARAPROTIEN INCREASED AND …THROMBOTIC COMPLICATIONS
89. Check prolactin in asymptomatic MEN-1
90. PT WITH VWF AND WAS ASKED WHT ABNORMALITY WILL U SEE…ITS THT THE PLATELETS CANT ADHERE TO EACH OTHER DUE TO SOME PROBLEM WITH
GP 1
91. VZV IG in unimmunized pregnant woman.
92. PT WITH RECURRENT CHEST INFECTIONS HAD CLL WAS ON PREDNISOLONE AND ONE CYTOTOXIC I THINK CHLORAMBUCIL……HERE IMMUNOGLOBULIN
DEFICIENCY…..(REFER ONEXAM)
93.erytematous MACULE –FLAT RED LESION
94.pt on dialysis for 5 years with back pain=b2 microglobinemia
95.granulomas in rectal biopsy ——-crohns
96. hypopigmented..scaly lesion in a tanned young man—- scraping for mycology ,TAENIA versicolor
97.Question with absent corneal reflex i selected acoustic neuroma
98.DONEPEZIL-DRUG IN ALZHEIMERS
99. LEGIONELLA TEST WAS URINARY ANTIGEN
100. RA PAINLESS EYE -EPISCLERITIS……
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Case # 2
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A 60 year old man presents with worsening breathlesness, confusion and headache. Since 3 months ago he began to have progressive exertional dyspnea, aching in the legs and pain in the left arm (without chest discomfort) after 50 yards :
IgA 2.8 (0.5 - 4.0) g/l
IgG 7 (5 - 13) g/l
IgM 24 (0.3 - 2.2) g/l
ESR 90mm/hr
A. Monoclonal gammopathy of unknown significance
B. B cell lymphoma
C. Antiphospholipid syndrome
D. Multiple myeloma
E. Waldenstrom’s macroglobulinaemia
Answer: e) Waldenstrom’s macroglobulinaemia.
The diagnosis is likely to be Waldenstrom’s macroglobulinemia due to the high IgM levels. Waldenström’s macroglobulinemia is a malignant tumor of lymphocytic and plasmacytic cells that secrete IgM. Patients often present with hepatosplenomegaly and lymphadenopathy. Most of the clinical manifestations are due to the hyperviscosity syndrome. Common presentations are: fatigue (related to anaemia), serum hyperviscosity – causing mucosal and gastrointestinal bleeding, and retinal haemorrhage(not thrombosis); due to engorged vessels and platelet dysfunction , purpura , hepatosplenomegaly and lymphadenopathy (rare in multiple myeloma), bone involvement is rare, neurologic symptoms – alterations in consciousness, peripheral neuropathy, visual disturbance, nausea and vertigo.
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1.The young man with hypersalivation and problem with studies, brother has liver problem…
Ans wilson’s disease, give penicillamine.
2. Lack of libido in women…lack d/t to testosterone def.
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