• DOACS

• opiate addiction

• Thrombocytopenia

• COPD, O2 suppl.

• viral prodromes

• ACS

• C difficile

• pulmonary embolism

• sepsis

• pneumonia

A 78yr old woman presents with

dizziness. ECG shows AF however it

reverts to SR in ED.

Background hypertension, diabetes and

renal impairment, with eGFR 20 ml/min.

She is stable for d/c.

What is the optimal approach approach

regarding the AF ?

• Nothing, she is in SR and stable

• enoxaparin 1 mg/kg bd until INR therapeutic on warfarin

• apixaban 5mg bd x7 days then 2.5mg bd

• dabigatran 110mg bd

• rivaroxaban 15mg bd x3wk then 20mg daily

• Nothing, she is in SR and stable

• enoxaparin 1 mg/kg bd until INR therapeutic on warfarin

• apixaban 5mg bd x7 days then 2.5mg bd

• dabigatran 110mg bd

• rivaroxaban 15mg bd x3wk then 20mg daily

She has done well, with paroxysmal AF

that is controlled.

2 years later she is diagnosed with PE

and found to have breast cancer

eGFR is now 40 ml/min

What is the optimal anticoagulation now?

• enoxaparin until INR therapeutic on warfarin

• enoxaparin

• apixaban 10mg bd x7 days then 5mg bd

• dabigatran 110mg bd

• rivaroxaban 15mg bd x3wk then 20mg daily

• enoxaparin until INR therapeutic on warfarin

• enoxaparin

• apixaban 10mg bd x7 days then 5mg bd

• dabigatran 110mg bd

• rivaroxaban 15mg bd x3wk then 20mg daily

A 36yr man is brought in by police because of concern for his

agitated behaviour. He has abdominal cramping and is

agitated.

It is clear he is in opiate withdrawal.

What is the best approach?

• Let him suffer, he deserves it and it will teach him a lesson

• Load him with endone and give a script for discharge as

well as a fentanyl patch if he runs out of tablets

• symptomatic management including benzodiazepines,

antiemetic, clonidine; then admit for supervised detox.

• symptomatic management as above, then commence

buprenorphine

• Let him suffer, he deserves it and it will teach him a lesson

• Load him with endone and give a script for discharge as

well as a fentanyl patch if he runs out of tablets

• symptomatic management including benzodiazepines,

antiemetic, clonidine; then admit for supervised detox.

• symptomatic management as above, then commence

buprenorphine

A 35 yr woman with no medical history of note presents with

a petechial rash following a mild viral RTI.

She is otherwise stable, exam is normal

Platelet count 2; no other abnormality

You diagnose ITP

What is the initial treatment?

• prednisone 50mg daily with haematology follow up

• dexamethasone 40mg daily x4 days

• plasmapheresis

• platelet transfusion

• prednisone 50mg daily with haematology follow up

• dexamethasone 40mg daily x4 days

• plasmapheresis

• platelet transfusion

ie mucosal involvement

Increased risk ICH

Her friend also mentions that she has a similar rash, and feels

unwell. She also has no medical history of note

You say “can’t you see we’re busy”

Triage wonders why she can’t see her GP for a rash, and sends

her to the waiting room

Further history reveals she has been intermittently confused

Temp 38.4, vital signs stable, exam shows petechial rash

The lab phones her results:

• Hb 86

• platelets 35

• bilirubin 46

• LDH 640

• creatinine 325

• INR/APTT normal

Next step

• dexamethasone 40mg/day x4 days

• urgent referral for plasmapheresis; insert vas cath

• admit medicine and refer haematology for bone marrow

biopsy

• treat for sepsis

Next step

• dexamethasone 40mg/day x4 days

• urgent referral for plasmapheresis; insert vas cath

• admit medicine and refer haematology for bone marrow

biopsy

• treat for sepsis

?? exertion symptoms with acceptable O2 sats

Anything more ?

Most false +ve if

testing low risk groups

What is best way to monitor

response of HIV to ART?

• viral load

• CD4 count

• both

What is best way to monitor

response of HIV to ART?

• viral load

• CD4 count

• both

What is best way to monitor

response of HIV to ART?

• viral load

• CD4 count

• effective treatment prevents low CD4

• can drop transiently <200 in acute illness

• both

A 64yr- man develops C difficile diarrhoea after antibiotics

given for pneumonia. He is clinically stable with eGFR 55

What is the preferred treatment?

• oral metronidazole 500mg tds

• IV metronidazole 500mg tds

• oral vancomycin 125mg QID

• IV vancomycin 1g bd

A 64yr- man develops C difficile diarrhoea after antibiotics

given for pneumonia. He is clinically stable with eGFR 55

What is the preferred treatment?

• oral metronidazole 500mg tds

• IV metronidazole 500mg tds

• oral vancomycin 125mg QID

• IV vancomycin 1g bd

Low risk

Well’s score 0-4.0

Moderate risk

Well’s score 4.5-6.0

Safely reduced imaging from 52 to 34 %

Case: 68yr-F presents with cough, productive sputum and

fever. HR is 95 bpm, BP 115/80, RR 22, O2 sats on air 93%,

lactate 2.4. There is patchy inflammatory changes on CXR,

and she is admitted for IV benzylpenicillin and oral

doxycycline.

The respiratory physician contacts the ED Director to

express concern that antibiotics were not given until 5 hours

after arrival.

• How would you respond?

Time to clinical stability