pace your MRCP-PACES

*🩺 Management Essential 11 – Acute Severe Asthma* *(by pace your MRCP – Dr Tanzeel Bukhari)* *Initial priorities* • ABCDE approach; treat first, do not delay for investigations • Sit patient upright, continuous monitoring (SpO₂, HR, RR) *Immediate treatment* • High-flow oxygen to maintain SpO₂ 94–98% • Back-to-back nebulised salbutamol (oxygen-driven) • Add ipratropium bromide in severe/life-threatening attacks • IV hydrocortisone (or oral prednisolone if able) *Escalation* • IV magnesium sulfate if poor response to nebulisers • Consider IV salbutamol or aminophylline in ICU setting • Early senior/ICU involvement if: o Silent chest, exhaustion, rising PaCO₂, or reduced GCS *Key safety pearls* • Normal or rising PaCO₂ = impending respiratory failure • Avoid sedatives • Early intubation only by experienced team

🩺 Symptom Snapshot 15 – Chronic Headache (by pace your MRCP – Dr Tanzeel Bukhari) 1️⃣ Tension-Type Headache Chronic, bilateral, pressing or tight pain No nausea or focal neurological symptoms Often related to stress, anxiety, or poor posture 2️⃣ Medication Overuse Headache Daily or near-daily headache History of frequent analgesic or triptan use Improves only after withdrawal of overused drugs 3️⃣ Raised Intracranial Pressure (ICP) Morning headache, worse on coughing or straining May be associated with vomiting or visual disturbance Requires urgent neuroimaging

🩺 Symptom Snapshot 14 – Sudden Severe Headache (by pace your MRCP – Dr Tanzeel Bukhari) 1️⃣ Subarachnoid Haemorrhage (SAH) Sudden “thunderclap” headache, maximal at onset May be associated with neck stiffness, vomiting, collapse Medical emergency → urgent CT head ± lumbar puncture 2️⃣ Intracerebral Haemorrhage Acute severe headache with focal neurological deficit Often associated with uncontrolled hypertension Reduced level of consciousness may be present 3️⃣ Cerebral Venous Thrombosis (CVT) Severe headache ± seizures or focal deficits Risk factors: pregnancy, OCP use, thrombophilia Requires MR venography for diagnosis

🩺 Symptom Snapshot 13 – Headache (by pace your MRCP – Dr Tanzeel Bukhari) 1️⃣ Tension-Type Headache Bilateral, tight or band-like pain No nausea or neurological deficit Often related to stress or poor posture 2️⃣ Migraine Unilateral, throbbing headache Associated with nausea, photophobia, phonophobia May be preceded by aura 3️⃣ Secondary Headache (Red Flags) New or worsening headache, especially >50 years Associated with fever, focal neurology, or raised BP Consider causes like intracranial bleed, meningitis, or GCA

Investigation Pearl 14 – Hyperkalaemia: ECG > Number (by pace your MRCP – Dr Tanzeel Bukhari) Key Principle: ECG changes define urgency more than serum K⁺. Progression: peaked T → PR prolongation/P loss → QRS widening → sine wave → arrest. Exam tip: Treat immediately if ECG changes are present.

Investigation Pearl 13 – Normocytic Anaemia Can Be Serious (by pace your MRCP – Dr Tanzeel Bukhari) Key Principle: Normal MCV does not exclude significant pathology. Consider acute blood loss, anaemia of chronic disease, CKD, haemolysis, mixed deficiencies. Exam tip: Use reticulocytes, ferritin/iron, CRP and renal profile.

Investigation Pearl 12 – Hyponatraemia: Volume Status First (by pace your MRCP – Dr Tanzeel Bukhari) Key Principle: Management depends on volume status (hypo/eu/hypervolaemic). Treating sodium without assessing volume can worsen the condition (e.g., fluids in SIADH). Exam tip: Clinical assessment comes first.

Dear colleagues due to sour throat we have to cancel our tomorrow's session, as i need to get some voice rest.I regret any inconvenience,

*🩺 Symptom Snapshot 10 – Wheeze* *(by pace your MRCP – Dr Tanzeel Bukhari)* *1️⃣ Asthma* Episodic wheeze with chest tightness and breathlessness Often worse at night or early morning Triggers include allergens, exercise, cold air *2️⃣ COPD* Persistent wheeze with chronic cough and sputum Usually in smokers or ex-smokers Progressive and less reversible than asthma *3️⃣ Cardiac Asthma (Left Ventricular Failure)* Wheeze due to pulmonary oedema Associated with orthopnoea and PND Improves with diuretics, not bronchodilators

*🩺 Symptom Snapshot 11 – Stridor* *(by pace your MRCP – Dr Tanzeel Bukhari)* *1️⃣ Upper Airway Obstruction (Tumour / Foreign Body)* High-pitched inspiratory noise Often associated with voice change or dysphagia Red flag → urgent ENT assessment *2️⃣ Anaphylaxis / Laryngeal Oedema* Acute onset stridor with facial or lip swelling May have hypotension, urticaria Medical emergency → adrenaline immediately *3️⃣ Post-intubation or Tracheal Stenosis* Progressive exertional stridor History of prolonged intubation or tracheostomy Fixed upper airway narrowing

*🩺 Symptom Snapshot 12 – Exercise Intolerance* *(by pace your MRCP – Dr Tanzeel Bukhari)* *1️⃣ Heart Failure* Reduced ability to perform physical activity Associated with breathlessness, fatigue, ankle swelling Progressive decline over time *2️⃣ Chronic Lung Disease (COPD / ILD)* Early fatigue and breathlessness on exertion May have chronic cough or crackles Oxygen desaturation on exertion *3️⃣ Anaemia* Generalised fatigue and reduced exercise capacity May have pallor, tachycardia Confirmed on full blood count

Investigation Pearl 8 – ABG Red Flag: Normal PaCO₂ in Acute Breathlessness Key Principle: Acute breathlessness usually causes hyperventilation → low PaCO₂. Normal PaCO₂ suggests fatigue and impending ventilatory failure; raised PaCO₂ suggests established failure. Exam tip: Low CO₂ = compensation; normal CO₂ = danger; high CO₂ = failure.

Investigation Pearl 7 – ESR vs CRP Key Principle: CRP changes quickly; ESR rises slowly and stays elevated longer. CRP is better for acute inflammation/infection and response to treatment; ESR useful in chronic inflammatory burden (e.g., PMR/GCA). Pitfalls: ESR affected by age, anaemia, pregnancy, malignancy. Exam tip: Don’t treat ESR and CRP as interchangeable.

*Investigation Pearl 6 – Troponin: Interpret with Dynamics and Context* *Key Principle* : Troponin indicates myocardial injury, not MI alone. Diagnose ACS using rise/fall pattern + symptoms + ECG changes. *Non‑ACS causes* : CKD, HF, sepsis, PE, myocarditis, tachyarrhythmias. *Exam tip* : A single raised troponin ≠ ACS.

Dear colleagues due to sour throat we have to cancel our tomorrow's session. I regret any inconvenience,

dear colleagues do to some inevitable circumstances I am unable to share daily info in the group. I am sorry for this inconvenience, hopefully we wiill start again soon, regards

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Photo from Dr Tanzeel Bukhari