A 24 year old was brought to the ER with a heart rate of 212 His batchmates carried him in from the hostel. Palpitations. Breathlessness. Panic Couldn’t sit still, kept grabbing the bed rail HR 212 on the monitor. Narrow complex tachycardia No prior cardiac history. No previous episodes. Completely healthy till tonight History revealed they’d been drinking. Smoking cigarettes. Normal hostel night Then someone brought a joint. Single joint. Passed around between five of them Four of them were fine Only he ended up here Same alcohol. Same cigarettes. Same joint. Same room So what was different about him? We tried a Valsalva The rhythm broke. He converted back to sinus. Once he settled down, we took the history again. Properly this time Specifically, anything in the last 48 hours. Anything at all. Even something you don’t think counts. He thought for a moment Then he said He had taken one tablet the previous day. Something small. Something he bought over the counter. Something he didn’t mention because it didn’t feel important Fluconazole 150 mg One tablet. Taken for a minor fungal issue. Available without prescription. Forgotten about completely Fluconazole is a potent CYP inhibitor. That’s one of the pathways responsible for clearing THC from the body Block that pathway and THC doesn’t metabolize normally Instead it accumulates as 11-OH-THC, its active metabolite which crosses the blood brain barrier more efficiently than THC itself and produces stronger sympathetic stimulation Fluconazole has a half life of about 30 hours It was still fully active when that joint came around His friends cleared the THC normally His liver couldn’t The same joint effectively became a much larger dose His sympathetic system fired His heart rate hit 212 Same alcohol. Same cigarettes. Same joint But one over the counter tablet had quietly changed the evening Drug interactions don’t care why you took the drug They don’t care that it was just ONE tablet Sometimes the critical detail is the one patients leave out The small thing they thought wasn’t worth mentioning.

Imaging tells you what it sees. Clinical exam tells you what’s happening!

Name this OBSOLETE technique ______ ❓

Type of gait? Most likely diagnosis ?

Heavy SMOKER presenting with this what’s the cause❓

What is the most likely diagnosis ??

Painless, soft, compressible forehead mass Diagnosis ?

What’s your immediate NEXT move ??

What’s the name of this procedure? When is it done ?

Critical OB decision Your Move: ______?

First line treatment ______ ❓

Bradycardia B/L pitting pedal edema Raised JVP Dyspnoea What’s the diagnosis ??

Which disorder gives this ‘edematous malnutrition’ picture ??

No fever. No pus Just brutal neuropathic pain and this rash Diagnosis ??

These PAINLESS bumps appeared after using a common towel Diagnosis ??

Diabetic man This isn’t trauma. It’s something far worse What is it ?