2019

Question 1

58F PC: 6/12 PR bleeding (mixed) + dull abdo pain No FLAWS FH: brother Colorectal Ca What will you include in your assessment i.e. history and exam (not Ix)?

Answer 1

1) Nature of bleeding - duration, frequency, colour of the bleeding, relation to stool and defecation 2) Associated symptoms - pain (especially association with defaecation), haematemesis, PR mucus, or previous episodes 3) Family history of bowel cancer or inflammatory bowel disease 4) PR examination is essential for every patient presenting with haemotochezia, allowing assessment for any rectal masses or anal fissures

Question 2

58F PC: 6/12 PR bleeding (mixed) + dull abdo pain No FLAWS FH: brother Colorectal Ca Differentials?

Answer 2

DDx for painless lower GI bleed: Malignant - colorectal malignancy Benign/structural- Haemorrhoids, Diverticulosis (painless), angiodysplasis Other DDx for lower GI bleeds: Infective - shigella, entamoeba histolytica Inflammatory - IBD, Diverticulitis (painful) Vascular - ischaemic colitis, Iatrogenic - radiation proctitis Upper V Lower Upper: Lower:

Question 3

58F 6/12 PR bleeding (mixed) + dull abdo pain No FLAWS FHx brother Colorectal Ca Investigations?

Answer 3

1) Bloods - incl FBC/U&E/LFT/Coag/G&D 2) Stool sample - infective 3) Flexi sigmoidoscopy, if inconclusive -> Full colonoscopy +/- OGD +/- MRI small bowel +/- Biopsy! 3b) If HD unstable -> Urgent CT angiogram +/- embolisation

Question 4

58F 6/12 PR bleeding (mixed) + dull abdo pain No FLAWS FHx brother Colorectal Ca Management?

Answer 4

Acute large rectal bleeding = upper GI bleed until proven otherwise! Lower GI 1) A-E Resuscitation 95% settle spontaneously 2) Ix as outpatient OR if old/co-morbid Ix as inpatient 5% non-resolving/HD unstable 1) Endoscopic haemostasis Inj (Adrenaline injection), thermal ( bipolar electrocoagulation/argon plasma co-agulation), mechanical (clips/band) 2) Angiography +/- arterial embolisation 3) Surgical intervention

Question 5

Day 5 post Left colectomy PC: Peritonitic abdo pain How will you assess this patient?

Answer 5

A-E incl abdo exam and wound assessment Review of notes + Op note + results (whilst awaiting results from A-E Ix)

Question 6

Day 5 post Left colectomy PC: Peritonitic abdo pain Vitals/Bloods suggestive of sepsis Immediate management?

Answer 6

A-E Incl sepsis 6: lactate, culture, catheter, fluid, ABx, O2 (if required) Imaging: CT Abdo pelvis

Question 7

Day 5 post Left colectomy PC: Peritonitic abdo pain Differential diagnosis for high NEWS/post op abdo pain

Answer 7

Specific post op complication: Anastomotic leak, internal bleeding, General post op complication: hospital acquired infection e.g. pneumonia/UTI, PE/DVT, wound infection, constipation

Question 8

Management of anastomotic leak

Answer 8

-

Question 9

Management of post operative intra-abdominal collection

Answer 9

-

Question 10

Management of post operative abdominal pain

Answer 10

-

Question 11

Management of colorectal Ca

Answer 11

-

Question 12

Aortic Valve

Patients with this congentital abnormaltiy are at risk of ___ . What is the pathogenesis?

Answer 12

At risk of: Aortic Stenosis + Aortic dilation (and infective endocarditis)

Pathogenesis: Higher pressure outflow causes haemodynamic stress + turbulence = continuous trauma -> chronic inflammation

-> fibrosis & calcification = rigidity & stiffening of the aortic valve with stenosis of aortic orifice
(Calcified aortic valve = surface for bacterial -> IE)

-> aortic medical degeneration -> aortic dilation

Question 13

Cause of sudden death in a patient with bicuspid valve?

Answer 13

MI (secondary to AS)

Aortic Dissection (secondary to ADilation)

Question 14

Causes of Aortic Stenosis

Answer 14

Senile calcification e.g. aging (commonest), Congenital e.g. bicuspid valve, williams syndrome, Rheumatic

Question 15

Symptoms of Aortic Stenosis

Answer 15

Triad: Angina, dyspnoea, syncope ON EXERTION

Arrhythmias

If LVF: PND, orthopnoea

If IE: Systemic emboli

Question 16

Signs of AS

Answer 16

Slow rising pulse

Narrow pulse pressure

Aortic thrill

Apex: Forceful, non-displaced (pressure)

HS: Quiet A2, S4 (forceful contraction vs hypertrophied ventricle), paradoxical split S2

ESM with click is pliable young valve - accentuated by sitting forward in end expiration, radiates to carotids

Displaced apex beat

Question 17

Aortic Stenosis V Aortic Slerosis

Answer 17

Question 18

In a patient with aortic stenosis, what might an ECG show

Answer 18

1) LVH
2) LV strain: Tall R, ST depression, T inversion in V4-6
3) LBBB or complete AV block (due to septal calcification)
4) AF

Question 19

Complications of Aortic Stenosis

Answer 19

Angina, Syncope, Heart Failure, Pulmonary oedema, Arrythmia, Cardiac arrest, Infective endocarditis, Pulmonary hypertension, Atrial fibrillation

Question 20

Management of aortic stenosis

Answer 20

Medical management:

• Optimise RF; statins, anti-HTN, DM
• Monitor with Echo
• Angina; beta blockers
• HF: ACEi, diuretics
• Avoid nitrates

Surgical AVR: If severe symptomatic AS, severe asymptomatic with reduced EF, sever AD undergoing CABG/orther valve op

• Mechanical - requires AC (young)
• Bioprosthetic - does not require AC (old)

Transcatheter Aortic Valve Implanation: high peri-op risk of stroke!

Question 21

What oganism commonly causes IE?

Answer 21

Cardiac valves develop vegetations composed of bacteria and platelet-fibrin thrombus.

Strep. Viridans

Staph. Aureus

(S.bovid, S Epidermidis, Enterococci, Pseudomonas / Haemophilus, actinobacillus, Cardiobacterium, Eikenella, Kingella, Coxiella, Chlamydia/ SLE, marantic)

Question 22

What type of anticoagulation is used post valve replacement?

Answer 22

Warfarin -

prevents reduction of Vit K Epoxide to active Vit K

inhibitting Vit K’s co-factor role in the activation of 2, 7, 9, 10 + Protein S/C/Z

delaying thrombin generation

i.e. prevents activation of extrinsic and common pathway via vit K

Question 23

How is warfarin reversed?

Answer 23

No bleeding and…

• INR<8 = Hold wararin until INR therapeutic
• INR>8 give PO Vit K and repeat INR @24hrs

Bleeding:

• Major = V Vit K (phytomenadione) + Prothrombin complex (II, VII, IX, X) or FFP (all clotting factors, fibrinogen, protein C&S, AT III)
• INR>5 and minor bleeding = IV Vit K and repeat INR @24hrs

Note Cryoprecipitate contains - Factor VIII, XIII, Fibrinogen, vWF

Question 24

Answer 24

Question 25

Answer 25

Question 26

What is the nerve supply of Gluteus Medius?
What is the primary function of gluteus medius?

Answer 26

• Superior gluteal nerve (L4/5/1) -> Glut medius, Glut Minimus, Tensor Fascia latae
• Inferior gluteal nerve (L5/1/2) -> Glut maximus
• Nerve to obturator internus (L5/1/2) -> Obturator internus, superior gemellus
• Nerve to quadratus femoris (L4/5/1) -> Quadratus femoris, inferior gemellus

Glut Medius - Abduction, medial/internal rotation of femus/depression of pelvis i.e. hold opposite side of pelvis at a horizonal when foot is off the ground

Answer 27