Your Daily Meds

Good morning and welcome to your Friday dose of Your Daily Meds.

Bonus Review: What are the functions of the skin?

Answer: The skin does a few things -

* Protection (barrier)

* Thermoregulation (both sensory and effector)

* Environmental monitoring (sensory)

* Role in Vitamin D metabolism

* Psychosocial functions

* Immune functions

* Site for drug administration (patches), elimination (volatile anaesthetic agents) or metabolism.

Sweets:

Which of the following test results is not diagnostic of Diabetes?

* Fasting venous blood glucose of 6.5 mmol/L

* Random venous blood glucose of 11.5 mmol/L

* Two-hours post oral glucose tolerance test venous blood glucose of 11.8 mmol/L

* HbA1c of 7.2%

* HbA1c of 55 mmol/mol

Have a think.

Scroll for the chat.

Drugz:

Which of the following substances is least likely to exhibit a specific withdrawal syndrome?

* LSD

* Alcohol

* Benzodiazepines

* MDMA

* Cocaine

Have a think.

More scroll for more chat.

Diabeetus:

Diabetes can be diagnosed from fasting (> 7 mmol/L) or random (> 11.1 mmol/L) venous blood glucose concentrations; by formal measurement of venous blood glucose concentration two hours post oral glucose tolerance test (> 11.1 mmol/L); or from measurement of glycated haemoglobin.

The upper limits of normal for glycated haemoglobin, 48 mmol/mol and 6.5%, are equivalent. 

Of our options, a fasting venous blood glucose of 6.5 mmol/L is not indicative of Diabetes.

WithDrawaLS:

Substance-related and addictive disorders are characterised by compulsive drug-seeking and drug-taking, despite adverse consequences, with loss of control over the use of the drug. Dependence may take the form of behavioural use patterns, avoiding the physiological effects of withdrawal, or continued use of the substance to avoid dysphoria or attain the desired drug state. 

Intoxication with depressants such as alcohol and benzodiazepines tend to manifest with euphoria, slurred speech, disinhibition, confusion and poor coordination. Their withdrawal is characterised by anxiety, anhedonia, tremor, seizures, insomnia, delirium, psychosis and death at worst. 

Intoxication with stimulants such as MDMA and cocaine is characterised by euphoria, mania, psychosis with paranoia, insomnia and seizures. Their withdrawal may be manifested by a ‘crash’, cravings, dysphoria and suicidality. 

Intoxication with hallucinogens such as LSD (Lysergic Acid Diethylamide), a 5-HT2A agonist, tends to manifest as distortions of sensory stimuli, enhancement of feelings, psychosis with visual hallucinations, delirium, anxiety and poor coordination. Other signs include tachycardia, hypertension, mydriasis and tremor. Tolerance develops rapidly to most hallucinogens, often within hours or days, making physical dependence unlikely. Hallucinogen withdrawal is usually absent of significant symptoms.

So of our options, LSD is least likely to exhibit a specific withdrawal syndrome.

Bonus: How is the skin involved in Vitamin D metabolism?

Answer in Monday’s dose.

Closing:

Thank you for taking your Meds and we will see you Monday for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!

Luke.

Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.

Just credit us where credit is due.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com

Good morning and welcome to your Thursday dose of Your Daily Meds.

Bonus Review: With respect to the physiology of muscle contraction, what is a motor unit?

Answer: So the unit consists of a single anterior horn alpha-motor neurone, its axon and all the muscle fibres it innervates. This is considered the functional unit of contraction, as the stimulation of that motor neurone results in the contraction of all those muscle fibres.

Then of course the number of fibres in a single motor unit varies. Muscles involved in small movements with fine control have few fibres per motor axon, while large muscles controlling gross movements may have 150 fibres per motor axon.

Investigation:

Alright. So a 36-year-old male comes to the Emergency Department complaining of generalised weakness. His ECG is shown below:

Which of the following correctly describes the most likely diagnosis?

* Inferior infarction

* Hypokalaemia

* Hyperkalaemia

* Mobitz I heart block

* Atrial flutter

Have a think.

Scroll for the chat.

Quick Question:

When considering ankylosing spondylitis, which of the following features is most suggestive of poor prognosis?

* Enthesitis on plain x-ray

* Thoracic spine involvement

* Age <25 at onset of symptoms

* Presence of night pain

* Hip involvement

Have a think.

Google enthesitis. Stupid word.

More scroll for more chat.

The Squiggly Line Heart Thing:

This ECG shows sinus bradycardia at a rate of approximately 70 bpm. There are widespread ST-segment abnormalities, such as ST-segment depression and T wave inversion. There is also a biphasic appearance to the ST-segments and T waves, with U waves present, that appear to be merging into one another such that it is difficult to tell where one wave ends and the next begins. 

The combination of widespread ST-segment depression and T wave inversion, with prominent U waves and a long interval between the time of onset of the QRS complex to the end of the U wave, is suggestive of hypokalaemia. 

An inferior infarction may be noticed on the ECG with ST-segment elevation in the inferior leads of II, III and aVF. 

Hyperkalaemia is often characterised on ECG by a combination of bradycardia, flattening of P waves, QRS broadening and tenting of T waves. 

A Mobitz I heart block, or Wenckebach rhythm, is characterised by the progressive elongation of the PR interval eventually resulting in a non-conducted P wave. These rhythms are usually benign and asymptomatic patients do not require treatment.

Atrial flutter is characterised by a narrow complex tachycardia with regular atrial activity at approximately 300 bpm, often described as ‘sawtooth’ waves.

Spines and Stiffness:

Ankylosing spondylitis (AS) is predominantly a disorder of men and affects up to 0.5% of the general population. The inflammation in AS is focussed, initially, at the sacroiliac joints before moving to the lumbar, thoracic and cervical spine. Enthesitis, inflammation at an insertion point of tendon or ligament to bone, is a common feature of the disease. 

Ankylosing spondylitis is characterised by a gradual onset of symptoms before age 40, with a duration of symptoms longer than 3 months, prolonged morning stiffness and night pain. The symptom of pain tends to improve with physical activity and fails to improve with rest. Pain secondary to ankylosing spondylitis tends to respond to nonsteroidal anti-inflammatory drugs (NDAIDs). 

The features predictive of poor prognosis in ankylosing spondylitis include:

* Hip involvement

* Age <16 years at onset of symptoms

* Presence of 3 of the following factors within 2 years of onset of symptoms

* ESR >30mm/h or CRP >6mg/L

* Limitation of spinal movement

* Dactylitis

* Peripheral oligoarthritis 

* Inadequate symptom relief from NSAIDs

So of our options, hip involvement is most suggestive of poor prognosis when diagnosing ankylosing spondylitis.

Bonus: What are the functions of the skin?

Answer in tomorrow’s dose.

Closing:

Thank you for taking your Meds and we will see you tomorrow for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!

Luke.

Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.

Just credit us where credit is due.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com

Good morning and welcome to your Wednesday dose of Your Daily Meds.

Bonus Review: Why is it that the posterior pituitary has neural connections with the hypothalamus, but the anterior pituitary has vascular connections with the hypothalamus?

Answer: Well the posterior pituitary is part of the brain, so develops with the expected neural connections. The anterior pituitary develops from Rathke’s Pouch, an ectodermal outpouching from the roof of the oral cavity, and so develops vascular connections with the hypothalamus.

Some Obstetrics:

Which of the following is least likely to be responsible for uterine atony after birth?

* Chorioamnionitis 

* Prolonged labour

* High parity

* Multiple pregnancy

* Oligohydramnios

Have a think.

Scroll for the chat.

Case:

A 61-year-old male is seen on the wards 2-days after abdominal aortic aneurysm repair. He was noted to have an increase in serum creatinine by 55 µmol/L over the two days since surgery, and has been passing urine at a rate of 0.4 mL/kg/h for the last 8 hours up until the time of review. Which of the following investigation results is most strongly supportive of a diagnosis of prerenal acute kidney injury?

* Serum Urea : Serum Creatinine ratio of 5:1

* Serum Urea : Serum Creatinine ratio of 1:20

* Serum Urea : Serum Creatinine ratio of 1:30

* Serum Urea : Serum Creatinine ratio of 30:1

* Serum Urea : Serum Creatinine ratio of 10:1

Have a think.

More scroll for more chat.

“I Don’t Like Your Tone”:

Uterine atony is the most common cause of postpartum haemorrhage due to failure of the contracting uterus to occlude the vessels supplying the placental bed. 

Uterine atony is less common with ‘active management’ of the third stage of labour, that stage between delivery of the baby and delivery of the placenta. The administration of oxytocic drugs and assisted delivery of the placenta halves the risk of postpartum haemorrhage due to uterine atony compared to those women choosing a ‘natural’ third stage of labour. 

Other causes of impaired uterine retraction after birth include chorioamnionitis, uterine ‘exhaustion’ after prolonged labour, high parity, and overdistension of the uterus during pregnancy. Overdistension of the uterus may be caused by a large baby, multiple pregnancy or polyhydramnios.

From the list, oligohydramnios is least likely to be responsible for uterine atony after birth.

Those (A)KIdneys:

Acute kidney injury (AKI) is defined as an abrupt (within 48 hours) decline in kidney function, as manifested by any of:

* Absolute increase in serum creatinine by 26.4 µmol/L or greater

* An increase in serum creatinine from baseline by 50% or greater

* Reduction in urine output, defined as less than 0.5 ml/kg/h for more than 6 hours.

AKI is commonly classified as prerenal, intrarenal or posterenal as a descriptor of aetiology and differential diagnoses. 

The ratio of Serum Urea : Serum Creatinine is an important finding and, when exceeds 20:1, suggests conditions of increased reabsorption of urea as in a prerenal AKI.

Bonus: With respect to the physiology of muscle contraction, what is a motor unit?

Answer in tomorrow’s dose.

Closing:

Thank you for taking your Meds and we will see you tomorrow for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!

Luke.

Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.

Just credit us where credit is due.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com

Good morning and welcome to your Tuesday dose of Your Daily Meds.

Bonus Review: What are some functions of the Hypothalamus.

Answer: It does a few things -

* Control of water balance

* Temperature regulation

* Control of anterior pituitary hormones (neuroendocrine function)

* Production of posterior pituitary hormones (more neuroendocrine function)

* Appetite and satiety

* Role in behaviour and emotions

Quick Question:

In the physical examination of the neonate, which of the following describes a common newborn rash, manifesting as pustules with an erythematous base, often with a widespread distribution?

* Erythema toxicum

* Milia

* Pustules

* Lanugo

* Naevus simplex

Have a think.

Scroll for the chat.

Ethics Case:

You are a motivated little Emergency Department Doctor.

You have just met a 15-year-old female who attempted suicide last night by swallowing button batteries.

The girl was brought to the Emergency Department under the Mental Health Act’s Emergency Examination Authority, so if she had tried to leave during the morning, she would have been detained. But she had not tried to leave, she was calm and cooperative.

Her parents are completely uncontactable.

You know that these button batteries are very corrosive so you erect x-ray the abdomen.

The batteries are still in the region of the stomach. They are potentially retrievable endoscopically before they can cause harm.

You discuss all this with your ED Consultant, then you call the Gastroenterologist on call.

“Sure!” she says, “If you could consent her for the Endoscopy, I’ll do it on my morning list within the next couple of hours.”

You discuss the risks of Endoscopy and Sedation with the young girl versus the risks of leaving the batteries in situ and watching and waiting.

The girl is receptive to your explanation, she seems to be able to understand, retain, consider, use and communicate her wishes and consents for Endoscopy.

You take the signed consent forms to the Day Procedure Unit.

“No”, says the Nurse in charge. “She is under sixteen - you will need to contact the Child Guardian.”

Now, I ask you. What are your thoughts here?

Do you punch on with this Nurse, or do you go and jump into the pre-recorded telephone cue of another government bureaucracy?

Or do you do something else?

Scroll for the chat.

Bumpy Babies:

Erythema toxicum is a common newborn rash manifesting with pustules with an erythematous base. The rash can have a widespread distribution that may change over a period of several hours. Differentiating infected lesions can be accomplished by microscopic examination of the vesicle contents which contain eosinophils in cases of erythema toxicum. 

Milia occur particularly over the neonatal nose and are small sebaceous cysts that disappear by several months of age.

Pustules may be present from birth in congenital candida infection or may appear later with Staphylococcus aureus skin infections. Erythema toxicum is a more common differential diagnosis. 

Lanugo is the fine downy hair covering the skin of the shoulders, upper arms and thighs of the neonate. It may be more evident in premature babies.

Naevus simplex, birth marks, are superficial vascular naevi commonly found on the occiput, over the eyelids or between the eyebrows of the neonate. They tend to fade over several months, often disappearing in the second year of life.

What To Do…?:

Well, you could calmly explain the concept of Gillick Competence to the Nurse.

But that did not go down so well.

You could tell on that Nurse to your boss.

That works better.

But the best result was to have the Gastroenterologist, the actual proceduralist doing the procedure, to consent the patient again in Endoscopy suite, just to be sure.

Remember, just because you happen to be a medico-legal-ethics nerd, doesn’t mean that other people are. And when you are having a busy day in the ED, you can’t be having stand up arguments citing decisions from the House of Lords when you have other jobs piling up.

Remember more that people who have tried to kill themselves can still have capacity to make the decision for life saving or condition-altering treatment. Like it or not.

Because capacity is context-dependent. And someone with “…sufficient understanding and intelligence to understand fully what is proposed” has capacity to make their decision, wether you agree with that decision or not; regardless of arbitrary age cutoffs.

(Also, just quietly, a 103-year old fellow with an acute delirium on top of his dementia very likely does not have capacity to consent for an Endoscopy……..even though he is over the age of sixteen…but I didn’t drop that bomb…)

Anyway this was a real case. So there.

Bottom line: People that have done silly things are still autonomous individuals (once particular conditions that would actively hinder their autonomy have been excluded) so are free to make their own decisions, in so far as they have the capacity to do so.

Bonus: Why is it that the posterior pituitary has neural connections with the hypothalamus, but the anterior pituitary has vascular connections with the hypothalamus?

Answer in tomorrow’s dose.

Closing:

Thank you for taking your Meds and we will see you tomorrow for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!

Luke.

Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.

Just credit us where credit is due.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com

Good morning and welcome to your Monday dose of Your Daily Meds.

Bonus Review: What is the difference between the blood-CSF barrier and the blood-brain barrier?

Answer: Whereas in the blood-CSF barrier, the barrier is due to the tight junctions between the epithelial cells (ependyma) of the choroid plexus; the blood-brain barrier involves a barrier of tight junctions between the capillary endothelial cells.

= BBB - tight junctions between capillary endothelial cells

= BCSFB - tight junctions between choroid plexus epithelial cells

Psych Question:

Marked fear or anxiety about which of the following is NOT consistent with a diagnosis of agoraphobia?

* Using public transportation

* Being in open spaces

* Being in enclosed spaces

* Standing in line or being in a crowd

* Allowing others into one’s home

Have a think.

Scroll for the chat.

Somewhat Anatomical:

The Eustachian tube is an osseocartilaginous passage connecting the nasopharynx and middle ear. Which of the following cranial nerves supplies general sensory innervation to the Eustachian tube?

* CN VII

* CN VIII

* CN IX

* CN X

* CN XI

Have a think.

Remember some rude mnemonics.

Scroll for the chat.

The Phobia:

Agoraphobia is essentially a disorder of excessive anxiety about being unable to escape a particular situation or place. Anxiety is a fearful response in the absence of a specific danger or threat, or in their anticipation. Anxiety is distinct from fear, which is a response to a realistic and immediate danger. Fear is adaptive in situations of stress or danger with priming of the physiological ‘fight or flight’ mechanism.

Agoraphobia is characterised by more than six months of excessive anxiety about being unable to escape a particular situation or place, in the context of at least two of the following:

* Using public transportation

* Being in open spaces

* Being in enclosed spaces

* Standing in line or being in a crowd

* Being outside of the home alone

The management of agoraphobia includes education around the symptoms of the patient’s anxiety and on how avoidance behaviours may be self-perpetuating. Relaxation techniques and graded exposure to a hierarchy of the patient’s feared situations may also be employed. 

So marked fear or anxiety about allowing others into one’s home is not consistent with a diagnosis of agoraphobia.

Tubes and Supply:

The Eustachian tube receives general sensory innervation from cranial nerve IX, the glossopharyngeal nerve. The glossopharyngeal nerve exits the skull through the jugular foramen and has motor innervation to the stylopharyngeus muscle and sensory innervation for taste and general sensation to the posterior 1/3 of the tongue.

Cranial nerve VII, the facial nerve, supplies taste sensation to the anterior 2/3 of the tongue; supplies motor innervation to the muscles of facial expression and the stapedius muscle; and supplies parasympathetic innervation to the salivary and lacrimal glands.

Cranial nerve VIII, the vestibulocochlear nerve, supplies sensory innervation to the cochlea and vestibular apparatus.

Cranial nerve X, the vagus nerve, supplies sensory innervation to many structures including the pharynx and larynx; supplies motor function to the soft palate, larynx, pharynx and upper oesophagus; and parasympathetic innervation to the cardiovascular, respiratory and gastrointestinal symptoms.

Cranial nerve XI, the accessory nerve, supplies motor innervation to the sternocleidomastoid and trapezius muscles.

Bonus: Tell me some functions of the Hypothalamus.

Answer in tomorrow’s dose.

Closing:

Thank you for taking your Meds and we will see you tomorrow for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!

Luke.

Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.

Just credit us where credit is due.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com

Good morning and welcome to your Friday dose of Your Daily Meds.

Bonus Review: Can substances pass freely from blood into the CSF?

Answer: Nah. There is a barrier to diffusion of most polar molecules. Naturally, this is called the blood-CSF barrier. In this case, the barrier is due to the tight junctions between the epithelial cells (ependyma) of the choroid plexus. The endothelial cells in the capillaries of the choroid plexus have gaps allowing small molecules to pass between and cross the capillary wall.

Paeds Question:

Which of the following is NOT one of the primary mechanisms by which foetal lung fluid is cleared at the time of birth?

* Reduction of fluid secretion in the lungs

* Expulsion of lung fluid as the foetal chest is compressed during labour

* Lymphatic resorption of lung fluid 

* Resorption of lung fluid via capillaries

* Reduced foetal urine output prior to labour

Have a think.

Scroll for the chat.

Case:

A 34-year-old woman, currently at 37 weeks’ gestation in her second pregnancy is reviewed in clinic.

She reports headache, some visual disturbances and epigastric pain, although there has been no vomiting.

On examination, she is hypertensive to 165/115 mmHg, has a tender abdomen worst over the right upper quadrant and is seen to have brisk reflexes.

Which of the following is most suitable to administer given this woman’s clinical presentation?

* Phenytoin

* Sodium valproate

* Magnesium sulphate

* Calcium gluconate

* Cephazolin

Have a think.

Scroll for the chat.

He’s Got Fluid:

The foetal lung acts as a secretory organ prior to birth, with approximately 100-150 mL/kg body weight of fluid being produced in the lungs of the normal foetus. This foetal lung fluid, along with foetal urine, are the primary contributors to amniotic fluid volume. Lung fluid is cleared during the time of birth by several mechanisms, including:

* Reduction of fluid secretion in the lungs

* Expulsion of lung fluid as the foetal chest is compressed during labour

* Resorption of lung fluid via lung interstitium into pulmonary lymphatics and capillaries

Of these, resorption is the main mechanism by which lung fluid is cleared and a failure of this mechanism can lead to transient tachypnoea of the newborn. 

So a reduction of foetal urine output prior to labour is not one of the primary mechanisms by which foetal lung fluid is cleared at the time of birth.

Pre-Nasty:

Key to answering this question is recognising the pregnant woman with signs of preeclampsia with severe features.

This is evidenced by headache and visual changes, symptoms of central nervous system dysfunction, epigastric pain and right upper quadrant tenderness, potential signs of hepatic abnormality of HELLP (Haemolysis, Elevated Liver enzymes, Low Platelets) syndrome of severe preeclampsia, and brisk reflexes, potentially foreshadowing the seizures of eclampsia. 

Nasty.

Given the features of severe disease in this woman, delivery must occur to minimise the risks of maternal and foetal complications, such as cerebral haemorrhage, hepatic rupture, renal failure, pulmonary oedema, seizure, bleeding of thrombocytopaenia, placental abruption or intra-uterine growth restriction. 

Of the options listed, magnesium sulphate is the most appropriate medication to administer as it has been shown to reduce the risk of eclampsia, and may be administered intravenously.

Phenytoin and sodium valproate are other medications used for seizure prophylaxis, but are inferior to magnesium sulphate in this particular obstetric context. 

Calcium gluconate may be used to treat magnesium toxicity in the context of seizure prophylaxis with magnesium sulphate. 

Cephazolin is used as intrapartum antibiotic therapy in those mothers positive for commensal group B streptococcus infection and hypersensitive to penicillins to prevent neonatal streptococcus disease.

Bonus: What is the difference between the blood-CSF barrier and the blood-brain barrier?

Answer in Monday’s dose.

Closing:

Thank you for taking your Meds and we will see you Monday for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!

Luke.

Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.

Just credit us where credit is due.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com

Good morning and welcome to your Thursday dose of Your Daily Meds.

Bonus Review: How is CSF different from Plasma?

Answer: CSF is identical to brain ECF in composition. But the differences to plasma include -

* pCO2 is higher in CSF (about 50mmHg) resulting in lower pH (about 7.33)

* Very low protein content - so CSF has low acid-base buffering ability

* Lower glucose concentration

* [Cl-] is higher by about 10% and [K+] is lower by about 40%

* Very low cholesterol content

Psych Question:

Which of the following does NOT contribute to the classification of anxiety as pathological?

* Fear greatly out of proportion to severity of risk or threat

* Response continues until removal of the threat

* Response becomes generalised to other similar or dissimilar situations

* Social or occupational function is impaired

* Comorbid with substance use and depression

Have a think.

Scroll for the chat.

Surgery Question:

A 49-year-old man underwent a complete thyroidectomy in the setting of papillary thyroid cancer. Which of the following would be the least likely complication of this surgery?

* Peri-oral paraesthesia

* Hoarseness

* Dysphagia

* Seroma formation

* Ptosis

Have a think.

Scroll for the chat.

The Threat:

Anxiety is a fearful response in the absence of a specific danger or threat, or in their anticipation. Anxiety is distinct from fear, which is a response to a realistic and immediate danger. Fear is adaptive in situations of stress or danger with priming of the physiological ‘fight or flight’ mechanism.

Anxiety is more likely to diminish performance and is considered pathological when:

* Fear greatly out of proportion to severity of risk or threat

* Response continues beyond existence of threat

* Response becomes generalised to other similar or dissimilar situations

* Social or occupational function is impaired

* Comorbid with substance use and depression

So a response that continues until removal of the threat is least likely to contribute to the classification of anxiety as pathological, rather a response continuing beyond the existence of the threat would be indicative.

Complications:

Perioral paraesthesia is a symptom of hypocalcaemia. Hypocalcaemia as a result of hypoparathyroidism (parathyroid damage or removal in surgery) is the most common complication of thyroidectomy. This would be very bad.

Hoarseness after thyroid surgery is common and can be due to a range of problems ranging from oedema to nerve injury, such as to the recurrent laryngeal nerve.

Dysphagia, difficulty swallowing, post-thyroid surgery is common and may be due to adhesions, trauma, inflammation or nerve damage.

Wound seromas post-operatively tend to resolve without intervention.

Ptosis (as in part of Horner syndrome) is a very rare complication of thyroidectomy and results from disruption of the sympathetic supply to the head, eye and neck. Horner syndrome is most often associated with lateral neck dissection. (Or an apical lung cancer affecting the sympathetic trunk…)

Bonus: Can substances pass freely from blood into the CSF?

Answer in tomorrow’s dose.

Closing:

Thank you for taking your Meds and we will see you tomorrow for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!

Luke.

Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.

Just credit us where credit is due.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com

Good morning and welcome to your Wednesday dose of Your Daily Meds.

Bonus Review: What are the functions of the CSF?

Answer: Couple of roles -

* Protective role - water bath effect

* The CSF is contained in the meninges - acts as a cushion to protect brain from injury

* The water bath effect gives a 1400g brain an effective mass of 50g

* Buffers rises in ICP

* CSF translocation to the extra cranial subarachnoid space

* An acute space occupying lesion won’t cause a large rise in ICP until this buffer is exhausted

* Remember, CSF is incompressible but mobile

* Return of interstitial protein to the circulation

* Brain has no lymph vessels

* Interstitial protein is absorbed with CSF across the arachnoid villi

* Other functions

* Probably returns some waste from brain ECF to the circulation

* May have a nutritive role (although is low glucose)

* Some suggestion that neuropeptides may be transported between brain regions via CSF

Quick Question:

Which of the following is a contraindication to induction of labour?

* Prolonged pregnancy

* Preeclampsia

* Prelabour rupture of the membranes

* Gestational diabetes mellitus

* Placenta praevia

Have a think.

Scroll for the chat.

Case:

An 80-year-old male comes to the Emergency Department.

The problem: shortness of breath.

He has a history of atrial fibrillation and has a permanent pacemaker in situ.

On examination, he is afebrile and hypertensive to a systolic blood pressure of 200. He has a raised JVP and mild ankle swelling.

A postero-anterior chest x-ray is taken and is shown below:

Which of the following is least likely to be included in the emergency management of this man?

* Supplemental oxygen

* Intravenous frusemide

* Intravenous nitrates

* Continuous positive airway pressure (CPAP)

* Oral high-dose metoprolol

Have a think.

More scroll for more chat.

No Go:

Induction of labour takes place in approximately 25% of pregnancies. The indications for induction of labour are any circumstances or conditions in which there is a likely benefit from delivery prior to spontaneous labour. These may include:

* Prolonged pregnancy

* Hypertensive disorders (such as preeclampsia)

* Diabetes mellitus

* Other systemic medical conditions

* Likely or suspected placental insufficiency

* Prelabour rupture of the membranes

* Multiple pregnancy

* Antepartum haemorrhage

* Psychological or mental health conditions

* Social circumstances

So placenta praevia is a contraindication to the induction of labour as it is a contraindication to vaginal birth. Placenta praevia describes an abnormal placentation near or covering the internal cervical os. It classically presents as painless, vaginal bleeding in the third trimester.

A Wee Bit Wet:

Key to answering this question is recognising the radiological signs of acute interstitial oedema in the setting of heart failure. The chest x-ray shows an enlarged heart with marked prominence of the interstitial markings. The prominent interstitial markings are called Kerley lines and represent expansion of the interstitial space by fluid.

Beta-blocker initiation, such as metoprolol, is not recommended in the acute, decompensated phase of heart failure.

It is used in the management of heart failure with reduced ejection fraction and is initiated slowly.

If this man had already been taking a beta-blocker when he had presented with shortness of breath, there would likely be no benefit in ceasing it. The risk comes from initiating beta-blocker therapy while decompensated. The other options in this question all form the mainstay of acute decompensated heart failure management. Nitrates are especially useful when there is high systolic blood pressure.

Bonus: How is CSF different from Plasma?

Answer in tomorrow’s dose.

Closing:

Thank you for taking your Meds and we will see you tomorrow for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!

Luke.

Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.

Just credit us where credit is due.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com

Good morning and welcome to your Tuesday dose of Your Daily Meds.

Bonus Review: What is CSF?

Answer: Cerebrospinal Fluid is the stuff that bathes the brain and spinal cord. It is contained in the ventricles and subarachnoid space and is part of the body’s trans cellular fluids.

Babies and Stuff:

Which of the following correctly describes the third stage of labour?

* From delivery of the baby until delivery of the placenta

* From full dilatation of the cervix until delivery of the baby

* From first ‘show’ of blood and mucous until delivery of the baby

* From rupture of membranes until delivery of the placenta

* From visualisation of the baby’s head until delivery of the baby

Have a think.

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A Relevant-To-Ward-Call Question:

Which of the following medications, used in cases of hypertensive urgency, is most likely to cause a delayed precipitous fall in blood pressure?

* Nifedipine immediate-release 10 mg orally

* Captopril 12.5 mg orally

* Clonidine 100 micrograms orally

* Prazosin 2 mg orally

* Amlodipine 5 mg orally

Have a think.

Have a guess.

More scroll for more chat.

The Labour Diaries:

Traditionally, labour is described in three stages:

* First – from onset of regular contractions until full dilatation of the cervix

* Second – from full dilatation of the cervix until delivery of the baby

* Third – from delivery of the baby until delivery of the placenta

Treating the Numbers:

Hypertensive urgency describes severely elevated blood pressure, with pressures at 180/110 mmHg or higher, with symptoms of moderate non-acute damage or dysfunction to end organs.

The initial management goals of hypertensive urgency include relief of symptoms and reduction of BP to below 180 mmHg systolic over several hours. 

Amlodipine has a delayed onset of action compared to the other medications listed, and so is most likely to cause a delayed precipitous fall in blood pressure due to repeated doses over a short time (as a consequence of perceived lack of effect).

PS. -

Amlodipine and Nifedipine = Calcium Channel Blockers

Captopril = ACE-Inhibitor

Prazosin = Alpha-1 Antagonist

Clonidine = Central Alpha-2 Agonist

Bonus: What are the functions of the CSF?

Answer in tomorrow’s dose.

Closing:

Thank you for taking your Meds and we will see you tomorrow for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!

Luke.

Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.

Just credit us where credit is due.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com

Good morning and welcome to your Monday dose of Your Daily Meds.

Bonus Review: What happens during a cough?

Answer: The cough reflex is a protective mechanism of the airway, used to expel irritating material with a high velocity turbulent gas stream.

A rough guide would involve -

* Inspiration

* Epiglottis and cords close very tightly

* Abdominal muscles contract forcefully

* Pressure within the chest can rise to 100mmHg

* Cords and epiglottis suddenly open

* Rapid exit of high pressure gas from the lungs occurs

Anatomy-ish Case:

A middle-aged fellow comes to the Emergency Department after being stabbed in the back during a mugging.

On examination, there is upper motor neuron weakness, loss of vibration and proprioception sense in the left lower limb; and a loss of pain and temperature sensation in the right lower limb. Where is the most likely location of the pathology?

* Posterior spinal cord

* Left spinal cord

* Right spinal cord

* Anterior spinal cord

* Central canal of spinal cord

Have a think.

Remember all the silly multicoloured spinal cord tracts from the textbooks.

Have a think.

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Quick Question:

In a community acquired pneumonia (CAP), which of the following patient characteristics is least suggestive of severe disease that will require inpatient management?

* Respiratory rate > 30 breaths per minute

* Systolic blood pressure < 90 mmHg

* Heart rate > 100 beats per minute

* Subjective dyspnoea at rest

* Multilobar involvement on chest x-ray

Have a think.

More scroll for more chat.

Stabbing Back Pain:

This scenario describes Brown-Séquard syndrome, due to pathology to one half of the spinal cord; in this case, most likely a stab wound affecting the left half of the spinal cord.

Pain and temperature sensation are carried in the spinothalamic tract, the fibres of which decussate at the level of the spinal cord. In this case, an injury to the left half of the spinal cord would explain the loss of these sensations on the right.

Fibres carrying light touch, vibration and proprioception sense are carried in the dorsal column-medial lemniscus pathway, which decussates at the level of the medulla. In this case, an injury to the left half of the spinal cord would explain the loss of these sensations in the left lower limb.

Furthermore, in Brown-Séquard syndrome, a region of complete sensory loss can be detected on the same side as the lesion at the level of the lesion.

See the pretty pictures:

A Bit Chesty:

The features of community acquired pneumonia (CAP), that are viewed as ‘red flags’ and are suggestive of the need for inpatient management include:

* Respiratory rate > 30 breaths per minute

* Systolic blood pressure < 90 mmHg

* Oxygen saturation < 92%

* Acute onset confusion

* Heart rate > 100 beats per minute

* Multilobar involvement on chest x-ray

These features are suggestive of more severe disease.

Patients with these features, in the context of CAP, require close clinical review.

Of the options listed, subjective dyspnoea at rest is least suggestive of severe CAP requiring inpatient management.

Bonus: What is CSF?

Answer in tomorrow’s dose.

Closing:

Thank you for taking your Meds and we will see you tomorrow for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!

Luke.

Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.

Just credit us where credit is due.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com