Clinical scenario and Handover 2

Question 1

You are the medical SHO on-call. You have been asked to see a 72 year old man in A+E resus. He has presented with chest pain and tachycardia. On arrival you are presented with the following ECG:

SVT - No ischaemic changes

The patient’s current observations: BP: 130/80 HR: 150 RR: 22 Sats: 96% on room air T: 36.8 degrees

Explain what the ECG shows

Answer 1

Go through working

Make sure theres activity
Look at rate
Is it regular
Look at P waves then PR interval
Look at QRS and is it wide
Look at ST - depression or long?
Look at QT - long?
Look at T wave - inversion or depressed?

Question 2

You are the medical SHO on-call. You have been asked to see a 72 year old man in A+E resus. He has presented with chest pain and tachycardia. On arrival you are presented with the following ECG:

ECG: SVT
The patient’s current observations: BP: 130/80 HR: 150 RR: 22 Sats: 96% on room air T: 36.8 degrees

What causes of SVT would you be thinking about before you approached the patient?

Answer 2

Dehydration, infection, caffeine, MI, PE, Thyroid issues, Hypo/hyperkalaemia, salbutamol, pain

Question 3

You are the medical SHO on-call. You have been asked to see a 72 year old man in A+E resus. He has presented with chest pain and tachycardia. On arrival you are presented with the following ECG:

ECG: SVT
The patient’s current observations: BP: 130/80 HR: 150 RR: 22 Sats: 96% on room air T: 36.8 degrees

How do you initially manage this patient

Answer 3

Reassured by obs that haemodynamically stable. If was unstable I would put out crash call.
Start with ABCDE

Will first try valsalva manouvures with legs up.

If unsuccessful, will refer to ALS guidelines so adenosine 6MG but discuss with med reg first, will ask nurses to prep.

Important to try and find cause and treat appropriately

Give 12 after 6mg of adenosine if not worked.

Other options are BB or diltiazem

Question 4

You are the medical SHO on-call. You have been asked to see a 72 year old man in A+E resus. He has presented with chest pain and tachycardia. On arrival you are presented with the following ECG:

ECG: SVT
The patient’s current observations: BP: 130/80 HR: 150 RR: 22 Sats: 96% on room air T: 36.8 degrees

What investigations would you want to do?

Answer 4

ECG, VBG, U+Es, Mg, CRP, LFTs, FBC, Ca, TFTs
CXR and MSU if concern about infection
ECHO and holter monitor once stable to look for structural heart disease and monitor if happens again

Question 5

Contraindications for adenosine

Answer 5

2nd or 3rd degree HB without pacemaker
Long QT syndrome
Decompensated HF
Asthma

Question 6

What should you explain to patient before giving adenosine for SVT

Answer 6

Sense of impending doom

Question 7

You are the medical SHO on-call. You have been asked to see a 72 year old man in A+E resus. He has presented with chest pain and tachycardia. On arrival you are presented with the following ECG:
ECG: SVT

The patient’s current observations: BP: 130/80 HR: 150 RR: 22 Sats: 96% on room air T: 36.8 degrees

The patient starts becoming hypotensive, with a BP of 80/50 mmHg, HR 170 bpm, and sats 88%. What would you now do?

Answer 7

Patient is now UNSTABLE

Put out 2222 and get senior support - Give IVT and oxygen

Consider DC cardioversion with senior input

Question 8

How do you differentiate SVTs?

Answer 8

SVTs can be broken down by site of origin and rhythm regularity. Is the SVT atrial in origin or atrioventricular? Is the rate regular or irregular?

Question 9

You are the medical SHO on-call. You have been asked to see a 72 year old man in A+E resus. He has presented with chest pain and tachycardia. On arrival you are presented with the following ECG:
ECG: SVT

The patient’s current observations: BP: 130/80 HR: 150 RR: 22 Sats: 96% on room air T: 36.8 degrees

The patient starts becoming hypotensive, with a BP of 80/50 mmHg, HR 170 bpm, and sats 88%.

give an sbar

Answer 9

Situation: This is a 72 year old man who is in SVT and has now become unstable with hypotension.

Background: The gentleman initially presented to A+E with chest pain and was tachycardic but initially maintaining his blood pressure. He has not received any other medications.

Assessment: A full ABCDE assessment has been carried out and investigations have been sent for common causes of SVT.

Recommendations: I have put out a 2222 cardiac arrest call. I need urgent medical assistance. As per the resuscitation guidelines this gentleman is likely to need DC cardioversion and I will need support from my senior colleagues to carry this out. Due to the hypotension this would now be the preferred management of the SVT rather than medical management.

Question 10

An 18 year old girl presents to A+E with a seizure. You have been asked to see her on the take by the medical registrar. She has a known history of epilepsy and is under the neurology team at the hospital. You have been told that she was last in hospital with seizures one month ago. On your way to A+E you are bleeped to tell you that she has started having seizures again and you are asked to see her urgently.

What do you understand by status epilepticus?

Answer 10

Status epilepticus is a single epileptic seizure lasting more than five minutes, or two or more seizures within a five minute period, without the person returning to normal in between them.

Status epilepticus can be divided into both convulsive and non-convulsive. Non-convulsive status can be difficult to diagnose.

Question 11

An 18 year old girl presents to A+E with a seizure. You have been asked to see her on the take by the medical registrar. She has a known history of epilepsy and is under the neurology team at the hospital. You have been told that she was last in hospital with seizures one month ago. On your way to A+E you are bleeped to tell you that she has started having seizures again and you are asked to see her urgently.

How should refractory status be managed and what is it?

Answer 11

Refractory status is where seizures continue beyond 60 minutes after initial therapy.

Refractory status should be treated by transferring the patient to ITU as they will require general anaesthesia (either propofol or thiopental). EEG monitoring should be commenced.

Question 12

What complications of status epilepticus are you aware of?

Answer 12

Hyperthermia
Acidosis (secondary to raised lactate)
Hypotension
Respiratory failure
Rhabdomyolysis
Aspiration

Question 13

What is important to tell a patient presenting with seizures for the first time?

Answer 13

Stop driving - minimum of 6 months from seizure date. For a year since last seizure if have further one. LGV drivers or passenger carrying vehicle drivers should not drive for five years after the date of the seizure.

Risks of bathing, stick to showers and dont swim alone

Avoid triggers.

Will need first fit clinic to discuss starting mediation and further investigations such as EEG

Question 14

Do you as the doctor need to inform the DVLA of this patient following a seizure?

Answer 14

The responsibility for informing the DVLA rests with the patient.

However if refuse to tell DVLA and continue to drive - must inform patient you will tell DVLA, if they still drive –> inform DVLA

Question 15

Should a patient be started on anti-epileptic drugs following a first seizure?

Answer 15

Treatment is usually not recommended until after a second epileptic seizure.

Indicated after a first seizure if the individual has a neurological deficit, brain imaging shows a structural abnormality or the electroencephalograph (EEG) shows unequivocal epileptic activity.

Question 16

A 72 year old woman has been referred to the medical team with worsening shortness of breath. It has been getting worse over the last two weeks and is associated with worsening lower limb oedema. Her past medical history includes hypertension, hypercholesterolaemia, previous myocardial infarction with three stents inserted, atrial fibrillation and a previous deep vein thrombosis. Her medication includes amlodipine 10mg OD, furosemide 40mg BD, ramipril 10mg OD, atorvastatin 80mg OD, bisoprolol 5mg OD. She is a known smoker. The nurse has called you to say she has arrived in the department and she is concerned that she is short of breath.

Blood Pressure: 164/97
Heart Rate: 117
Respiratory rate: 28
Saturations: 85% on room air
Temperature: 36.9 degrees

How would you approach this patient?

Answer 16

Start with A-E

A - Any signs of airway compromise? if so, seek ITU reg input

B - RR, sats, chest expansion, trachea central, auscultation and percussion, give O2, creps or wheeze?, ABG

C - ECG, CRT, HR, JVP, to determine if overloaded, degree of peripheral oedema, heart sounds

D - BM and GCS

E - Temp, review limbs

Question 17

A 72 year old woman has been referred to the medical team with worsening shortness of breath. It has been getting worse over the last two weeks and is associated with worsening lower limb oedema. Her past medical history includes hypertension, hypercholesterolaemia, previous myocardial infarction with three stents inserted, atrial fibrillation and a previous deep vein thrombosis. Her medication includes amlodipine 10mg OD, furosemide 40mg BD, ramipril 10mg OD, atorvastatin 80mg OD, bisoprolol 5mg OD. She is a known smoker. The nurse has called you to say she has arrived in the department and she is concerned that she is short of breath.

What is the likely diagnosis and what are your differential diagnoses?

Answer 17

Most likely is decompensated HF causing pulmonary oedema

Can also be CAP/COVID/Flu

Or PE

Question 18

A 72 year old woman has been referred to the medical team with worsening shortness of breath. It has been getting worse over the last two weeks and is associated with worsening lower limb oedema. Her past medical history includes hypertension, hypercholesterolaemia, previous myocardial infarction with three stents inserted, atrial fibrillation and a previous deep vein thrombosis. Her medication includes amlodipine 10mg OD, furosemide 40mg BD, ramipril 10mg OD, atorvastatin 80mg OD, bisoprolol 5mg OD. She is a known smoker. The nurse has called you to say she has arrived in the department and she is concerned that she is short of breath.

What initial investigations will you arrange?

Answer 18

Bloods - FBC, CRP, LFTs, U+Es, ABG, BNP

ECG

ECHO once stable

Question 19

What signs on CXR would suggest pulmonary oedema?

Answer 19

Pulmonary venous diversion
Pleural effusions
Cardiomegaly
Kerly B lines

Question 20

A 72 year old woman has been referred to the medical team with worsening shortness of breath. It has been getting worse over the last two weeks and is associated with worsening lower limb oedema. Her past medical history includes hypertension, hypercholesterolaemia, previous myocardial infarction with three stents inserted, atrial fibrillation and a previous deep vein thrombosis. Her medication includes amlodipine 10mg OD, furosemide 40mg BD, ramipril 10mg OD, atorvastatin 80mg OD, bisoprolol 5mg OD. She is a known smoker. The nurse has called you to say she has arrived in the department and she is concerned that she is short of breath.

Your assessment and initial investigation suggests that this patient has pulmonary oedema secondary to decompensated heart failure. How will you manage this patient?

Answer 20

A-E as stated

Sit up, Oxygen, likely need IV furosemide and monitoring of U+Es and BP

Once stable - daily weights and ECHO

If high BP - would have to consider IV GTN and titrate dose

Monitor BP, sats and ABG, may need vasopressors or NIV

Question 21

A 72 year old woman has been referred to the medical team with worsening shortness of breath. It has been getting worse over the last two weeks and is associated with worsening lower limb oedema. Her past medical history includes hypertension, hypercholesterolaemia, previous myocardial infarction with three stents inserted, atrial fibrillation and a previous deep vein thrombosis. Her medication includes amlodipine 10mg OD, furosemide 40mg BD, ramipril 10mg OD, atorvastatin 80mg OD, bisoprolol 5mg OD. She is a known smoker. The nurse has called you to say she has arrived in the department and she is concerned that she is short of breath.

Your assessment and initial investigation suggests that this patient has pulmonary oedema secondary to decompensated heart failure.
What could be the cause for this patient’s decompensation?

Answer 21

As old woman, could be silent MI

Infection

AF

Uncontrolled HT

Poor compliance to medication or fluid restriction

Question 22

Do you know any classifications of heart failure?

Answer 22

NYHA Classification I-IV

Question 23

What medications improve morbidity and mortality in patients with heart failure?

Answer 23

Selective beta blockers, ACEI/ARBs and spironolactone

Question 24

A 72 year old woman has been referred to the medical team with worsening shortness of breath. It has been getting worse over the last two weeks and is associated with worsening lower limb oedema. Her past medical history includes hypertension, hypercholesterolaemia, previous myocardial infarction with three stents inserted, atrial fibrillation and a previous deep vein thrombosis. Her medication includes amlodipine 10mg OD, furosemide 40mg BD, ramipril 10mg OD, atorvastatin 80mg OD, bisoprolol 5mg OD. She is a known smoker. The nurse has called you to say she has arrived in the department and she is concerned that she is short of breath.

Your assessment and initial investigation suggests that this patient has pulmonary oedema secondary to decompensated heart failure.

This patient has AF. Would you start them on anticoagulation?

Answer 24

Would do CHADVASC and ORBIT

A score of two and above would indicate anticoagulation is appropriate. This would need discussion with the patient about the risks and benefits of anticoagulation.

Question 25

What counselling should a patient receive before starting a DOAC?

Answer 25

Important to explain why they need DOAC - to reduce stroke risk Explain that makes them at risk of bleeding. Explain they would need to seek medical input if significant bleeding or trauma. Explain would need to inform health professional if getting procedure.

Question 26

A 72 year old woman has been referred to the medical team with worsening shortness of breath. It has been getting worse over the last two weeks and is associated with worsening lower limb oedema. Her past medical history includes hypertension, hypercholesterolaemia, previous myocardial infarction with three stents inserted, atrial fibrillation and a previous deep vein thrombosis. Her medication includes amlodipine 10mg OD, furosemide 40mg BD, ramipril 10mg OD, atorvastatin 80mg OD, bisoprolol 5mg OD. She is a known smoker. The nurse has called you to say she has arrived in the department and she is concerned that she is short of breath. Your assessment and initial investigation suggests that this patient has pulmonary oedema secondary to decompensated heart failure. This patient has AF. You now have one minute to handover the patient in this scenario to your registrar/consultant as if you were at the Acute Medical Handover.

Answer 26

Situation: This is a 72 year old woman who has decompensated heart failure with significant pulmonary oedema causing saturations of 85% at presentation. Her breathing has been deteriorating over the last two weeks. There is no suggestion of infection based on her presentation. Background: She has an extensive cardiovascular history including a previous myocardial infarction. Assessment: Initial medical management has been with oxygen and IV diuretics. Investigations, including her chest x ray, would suggest that this is decompensated heart failure. Recommendations: If initial management is not helpful in relieving her symptoms, I would recommend initiating a vasodilator, such as a GTN infusion, if her BP remained elevated. If the BP is dropping or persistently low then the patient may need inotropic support and ITU should be involved early. Investigations will be needed to establish the cause of the decompensation.

Question 27

A 29-year-old woman is brought to resus having been found to be drowsy. Her partner is with her who has told staff that she is an insulin dependent diabetic. He has bought her insulin with her. He is unsure of her normal dose or when she takes it. He thinks she has been suffering from the flu for the last few days and has not been eating or drinking as much as she usually does. Today she has been very drowsy and confused. Her basic observations are as follows: Blood Pressure 87/52 Heart Rate: 114 Temperature: 38.2 degrees Celsius O2 Sats 96% on room air Respiratory Rate: 28 You have been given a Venous Blood Gas before seeing her: pH: 7.18 pCO2: 4.86 kPa HCO3: 15.3 mEq/L BE: -6.3 mEq/L Lac: 4.3 mmol/L Glu: 18.6 What is the likely diagnosis and what may have precipitated this?

Answer 27

DKA - infection is the likely cause as will cause her BMs to shoot up

Question 28

What clinical features might you expect to see with diabetic ketoacidosis?

Answer 28

Polyuria and polydipsia Weight loss; weakness Hyperventilation or breathlessness; the acidosis causes Kussmaul’s respiration Abdominal pain (DKA may present as an acute abdomen) Vomiting (exacerbates dehydration) Confusion

Question 29

A 29-year-old woman is brought to resus having been found to be drowsy. Her partner is with her who has told staff that she is an insulin dependent diabetic. He has bought her insulin with her. He is unsure of her normal dose or when she takes it. He thinks she has been suffering from the flu for the last few days and has not been eating or drinking as much as she usually does. Today she has been very drowsy and confused. Her basic observations are as follows: Blood Pressure 87/52 Heart Rate: 114 Temperature: 38.2 degrees Celsius O2 Sats 96% on room air Respiratory Rate: 28 You have been given a Venous Blood Gas before seeing her: pH: 7.18 pCO2: 4.86 kPa HCO3: 15.3 mEq/L BE: -6.3 mEq/L Lac: 4.3 mmol/L Glu: 18.6 How would you assess this patient?

Answer 29

Start with ABCDE A – If the patient is alert and communicative then it can be presumed that they are maintaining their airway. B - sats, RR, chest expansion, auscultation, percussion, trachea position, checking specifically for overload and infection, CXR C - CRT, HR, BP, JVP, ECG as tachycardic, Bloods - 2 large cannulas - FBC, CRP, LFTs, U+Es, VBG, blood glucose, BC for infection D - BMs and ketones, GCS (Will need monitored throughout admission) E - check for rashes or signs of infection

Question 30

A 29-year-old woman is brought to resus having been found to be drowsy. Her partner is with her who has told staff that she is an insulin dependent diabetic. He has bought her insulin with her. He is unsure of her normal dose or when she takes it. He thinks she has been suffering from the flu for the last few days and has not been eating or drinking as much as she usually does. Today she has been very drowsy and confused. Her basic observations are as follows: Blood Pressure 87/52 Heart Rate: 114 Temperature: 38.2 degrees Celsius O2 Sats 96% on room air Respiratory Rate: 28 You have been given a Venous Blood Gas before seeing her: pH: 7.18 pCO2: 4.86 kPa HCO3: 15.3 mEq/L BE: -6.3 mEq/L Lac: 4.3 mmol/L Glu: 18.6 What initial investigations will you do?

Answer 30

Bloods - 2 large cannulas - FBC, CRP, LFTs, U+Es, VBG, blood glucose, BC for infection COVID and flu swab CXR Urine dip BM and ketones

Question 31

A 29-year-old woman is brought to resus having been found to be drowsy. Her partner is with her who has told staff that she is an insulin dependent diabetic. He has bought her insulin with her. He is unsure of her normal dose or when she takes it. He thinks she has been suffering from the flu for the last few days and has not been eating or drinking as much as she usually does. Today she has been very drowsy and confused. Her basic observations are as follows: Blood Pressure 87/52 Heart Rate: 114 Temperature: 38.2 degrees Celsius O2 Sats 96% on room air Respiratory Rate: 28 You have been given a Venous Blood Gas before seeing her: pH: 7.18 pCO2: 4.86 kPa HCO3: 15.3 mEq/L BE: -6.3 mEq/L Lac: 4.3 mmol/L Glu: 18.6 What management would you initiate?

Answer 31

First line is IVT - 1litre stat, 1 litre over an hr, 1 litre over 2 hrs 1 litre over 4 hrs etc (NaCl) FIXED rate insulin infusion 0.1 unit/kg/hr K replacement - usually third bag Check for infection and monitor BMs VTE prophylaxis

Question 32

A 29-year-old woman is brought to resus having been found to be drowsy. Her partner is with her who has told staff that she is an insulin dependent diabetic. He has bought her insulin with her. He is unsure of her normal dose or when she takes it. He thinks she has been suffering from the flu for the last few days and has not been eating or drinking as much as she usually does. Today she has been very drowsy and confused. Her basic observations are as follows: Blood Pressure 87/52 Heart Rate: 114 Temperature: 38.2 degrees Celsius O2 Sats 96% on room air Respiratory Rate: 28 You have been given a Venous Blood Gas before seeing her: pH: 7.18 pCO2: 4.86 kPa HCO3: 15.3 mEq/L BE: -6.3 mEq/L Lac: 4.3 mmol/L Glu: 18.6 What features of the presentation would indicate early referral to ITU

Answer 32

GCS <12, Hypokalaemia, Systolic BP <90, Pregnant, pH <7.1, Severe DKA (Ketones >6 and bicarbonate less than 5)

Question 33

What are some of the complications of DKA?

Answer 33

DVT/PE Cerebral oedema Hypokaelaemia Tissue hypoperfusion

Question 34

How will you manage this DKA patient prior to discharge?

Answer 34

Review insulin management - adherence and education on riggers also With diabetic specialist nurse follow-up

Question 35

What is Hyperosmolar Hyperglycaemic State (HHS)?

Answer 35

hyperglycaemia, hyperosmolarity and dehydration, without significant ketoacidosis. Most patient’s present with severe dehydration. Commonly in frail type 2 diabetics with poor cognition leading to poor insulin control.

Question 36

How does the management of HHS differ from DKA?

Answer 36

The most important aspect of management in HHS is fluid resuscitation. This is to avoid cardiovascular collapse and to perfuse vital organs. Insulin is usually not required as will fall with IVT alone

Question 37

A 29-year-old woman is brought to resus having been found to be drowsy. Her partner is with her who has told staff that she is an insulin dependent diabetic. He has bought her insulin with her. He is unsure of her normal dose or when she takes it. He thinks she has been suffering from the flu for the last few days and has not been eating or drinking as much as she usually does. Today she has been very drowsy and confused. Her basic observations are as follows: Blood Pressure 87/52 Heart Rate: 114 Temperature: 38.2 degrees Celsius O2 Sats 96% on room air Respiratory Rate: 28 You have been given a Venous Blood Gas before seeing her: pH: 7.18 pCO2: 4.86 kPa HCO3: 15.3 mEq/L BE: -6.3 mEq/L Lac: 4.3 mmol/L Glu: 18.6 You have started fluid management, a fixed rate insulin infusion and broad spectrum antibiotics. You now have one minute to handover the patient in this scenario to your registrar/consultant as if you were at the Acute Medical Handover.

Answer 37

Situation: I am handing over a 29 year old woman who has presented in diabetic ketoacidosis. Her clinical observations suggest that she may be septic. . Background: She is an insulin dependent diabetic, and has been unwell for several days with a reduced oral intake. It is not clear when she last took insulin. Assessment: I have started aggressive fluid management, a fixed rate insulin infusion and broad spectrum antibiotics. Recommendations: This patient needs a referral to ITU because they are hypotensive and meet the criteria for ITU intervention. Glucose and ketone monitoring will be required once the insulin infusion has started. They will need regular bloods to monitor their potassium which could drop with initiation of treatment.

Question 38

You have been asked to see an 89-year-old lady in A&E. She has been admitted with confusion from a nursing home. She has a background of hypertension, previous myocardial infarction, chronic obstructive pulmonary disease and chronic kidney disease. The nursing staff at the home are concerned that she has become increasingly confused over the last week. She is not drinking or eating properly and has not been able to mobilise out of bed for the last two days. She was seen by her GP 2 days ago who started her on antibiotics for a possible urine infection. Her current observations are as follows: Blood pressure: 109/67 Heart Rate: 104 bpm Respiratory rate: 22 Saturations: 94% on room air Temperature: 37.8 degrees How would you approach this patient?

Answer 38

A – Is the patient talking? Are they able to maintain their own airway? B - RR, sats, chest expansion and auscultation, fluid/infection, CXR if any concerns C - HR, CRT, BP, Heart sounds, IVT if required, urine output D - GCS and BMs E - temp, signs of infection or rashes

Question 39

You have been asked to see an 89-year-old lady in A&E. She has been admitted with confusion from a nursing home. She has a background of hypertension, previous myocardial infarction, chronic obstructive pulmonary disease and chronic kidney disease. The nursing staff at the home are concerned that she has become increasingly confused over the last week. She is not drinking or eating properly and has not been able to mobilise out of bed for the last two days. She was seen by her GP 2 days ago who started her on antibiotics for a possible urine infection. Her current observations are as follows: Blood pressure: 109/67 Heart Rate: 104 bpm Respiratory rate: 22 Saturations: 94% on room air Temperature: 37.8 degrees What are your differential diagnoses?

Answer 39

Extensive number of causes for acute confusion but would look at Pain Infection Nutrition Constipation Hydration Medications Environment - change Intracranial bleed?

Question 40

You have been asked to see an 89-year-old lady in A&E. She has been admitted with confusion from a nursing home. She has a background of hypertension, previous myocardial infarction, chronic obstructive pulmonary disease and chronic kidney disease. The nursing staff at the home are concerned that she has become increasingly confused over the last week. She is not drinking or eating properly and has not been able to mobilise out of bed for the last two days. She was seen by her GP 2 days ago who started her on antibiotics for a possible urine infection. Her current observations are as follows: Blood pressure: 109/67 Heart Rate: 104 bpm Respiratory rate: 22 Saturations: 94% on room air Temperature: 37.8 degrees What investigations will you initiate?

Answer 40

Bloods - fbc, crp, u+es, lfts, BC, Calcium, glucose (B12, Folate, Thiamine and Thyroid function if persistent) CXR and MSU May consider CT head if concern /trauma

Question 41

How will you assess acute confusion on admission?

Answer 41

Cognitive function can be assessed quickly using the abbreviated mental test score (AMTS).

Question 42

What is the difference between Delirium and Dementia?

Answer 42

Delirium is a sudden onset and fluctuating impairment in cognitive function and consciousness. It is transient and reversible. Dementia is the progressive and irreversible decline in global function from a premorbid level, without any impairment in consciousness.

Question 43

What factors predispose a patient to delirium?

Answer 43

Age >65 Dementia Multiple co-morbidities Visual and hearing impairment Recent surgery Polypharmacy Drugs and alcohol dependence

Question 44

What are the causes of dementia?

Answer 44

Vascular dementia - stepwise drop Alzhiemers disease Frontotemporal dementia Wernickes encephalopathy Normal pressure hydrocephalus Syphilis/HIV Low B12 or thyroid

Question 45

How would you investigate a possible diagnosis of dementia?

Answer 45

Not good to diagnose in hospital when unwell - aim to diagnose in memory clinic. Do Ix to R/O reversible causes - b12, folate, TFTs CT head to R/O any structural reversible causes The discharge summary should include instructions to the GP to refer the patient to the memory clinic. I would discuss the possible diagnosis with the patient if appropriate, or with the patient’s family so they understand why the memory clinic will be contacting them.

Question 46

What pharmacological treatment is available for the treatment of Alzheimer’s disease?

Answer 46

Acetylcholinesterase inhibitors such as Donepezil may be considered in patients with mild to moderate Alzheimer’s disease. Treatment should be initiated by a specialist in dementia. Memantine (an NMDA receptor antagonist) is licensed for use in severe Alzheimer’s disease (MMSE 3-14).

Question 47

You have been asked to see an 89-year-old lady in A&E. She has been admitted with confusion from a nursing home. She has a background of hypertension, previous myocardial infarction, chronic obstructive pulmonary disease and chronic kidney disease. The nursing staff at the home are concerned that she has become increasingly confused over the last week. She is not drinking or eating properly and has not been able to mobilise out of bed for the last two days. She was seen by her GP 2 days ago who started her on antibiotics for a possible urine infection. Her current observations are as follows: Blood pressure: 109/67 Heart Rate: 104 bpm Respiratory rate: 22 Saturations: 94% on room air Temperature: 37.8 degrees You have sent investigations to rule out common reversible causes and an AMT is done Give an SBAR

Answer 47

Situation: This is an 89 year old lady who presents with delirium likely secondary to a urine infection. Staff report she is increasingly confused with reduced oral intake. She is tachycardic and has a mild pyrexia. Background: She has multiple comorbidities including coronary vascular disease and CKD, but no known history of cognitive impairment. Assessment: Investigations have been sent to rule out common causes of delirium and an AMTs has been done. Recommendations: She needs to be admitted to an acute medical ward. I would recommend further investigations, including a CT head, and consideration of reversible causes of cognitive impairment. She will need a senior review and discussion with her next of kin about escalation of treatment and resuscitation.

Question 48

You are the IMT1 on call covering the wards at night. You are called by the Senior Nurse on the Acute Medical Unit about Mrs Khan, a 68 year old lady who has been admitted with an infective exacerbation of her COPD. In addition to her COPD, Mrs Khan has a past medical history that includes type 2 diabetes, coronary artery disease and has suffered two myocardial infarctions in the past. She has hypothyroidism and was previously treated for breast cancer. Since her admission two hours ago she has been started on nebulisers, IV fluids and IV antibiotics. The nurse has contacted you as the patient has acutely desaturated and is struggling to breathe. The nurse sounds concerned on the phone. You are on the phone with the AMU Nurse. What information would you want to know over the phone?

Answer 48

Ask for obs and a basic A-E A - Can they speak? B - RR and sats C - Chest pain and BP with HR How they presented on admission and treatment so far? Any other symptoms? If continuing to deteriorate - get crash team

Question 49

You are the IMT1 on call covering the wards at night. You are called by the Senior Nurse on the Acute Medical Unit about Mrs Khan, a 68 year old lady who has been admitted with an infective exacerbation of her COPD. In addition to her COPD, Mrs Khan has a past medical history that includes type 2 diabetes, coronary artery disease and has suffered two myocardial infarctions in the past. She has hypothyroidism and was previously treated for breast cancer. Since her admission two hours ago she has been started on nebulisers, IV fluids and IV antibiotics. The nurse has contacted you as the patient has acutely desaturated and is struggling to breathe. The nurse sounds concerned on the phone. The Nurse informs you that just before the desaturation the patient was given a penicillin based antibiotic. They have also developed a rash. She has checked the notes and the patient is allergic to that particular antibiotic. What advice would you give them over the phone and what would you do?

Answer 49

Prep adrenaline and put out 2222 call Stop the abx! 0.5 mg adrenaline via the intramuscular route.

Question 50

You are the IMT1 on call covering the wards at night. You are called by the Senior Nurse on the Acute Medical Unit about Mrs Khan, a 68 year old lady who has been admitted with an infective exacerbation of her COPD. In addition to her COPD, Mrs Khan has a past medical history that includes type 2 diabetes, coronary artery disease and has suffered two myocardial infarctions in the past. She has hypothyroidism and was previously treated for breast cancer. Since her admission two hours ago she has been started on nebulisers, IV fluids and IV antibiotics. The nurse has contacted you as the patient has acutely desaturated and is struggling to breathe. The nurse sounds concerned on the phone. The Nurse informs you that just before the desaturation the patient was given a penicillin based antibiotic. They have also developed a rash. She has checked the notes and the patient is allergic to that particular antibiotic. What other potential causes are there for this presentation that you should also be thinking about?

Answer 50

Anaphylaxis PE Fluid overload especially with cardic hx Sepsis

Question 51

You are the IMT1 on call covering the wards at night. You are called by the Senior Nurse on the Acute Medical Unit about Mrs Khan, a 68 year old lady who has been admitted with an infective exacerbation of her COPD. In addition to her COPD, Mrs Khan has a past medical history that includes type 2 diabetes, coronary artery disease and has suffered two myocardial infarctions in the past. She has hypothyroidism and was previously treated for breast cancer. Since her admission two hours ago she has been started on nebulisers, IV fluids and IV antibiotics. The nurse has contacted you as the patient has acutely desaturated and is struggling to breathe. The nurse sounds concerned on the phone. The Nurse informs you that just before the desaturation the patient was given a penicillin based antibiotic. They have also developed a rash. She has checked the notes and the patient is allergic to that particular antibiotic. What bedside tests could you do to help you with your differential list?

Answer 51

Bloods - CRP, LFTs, U+Es, lactate, serum tryptase ABG CXR

Question 52

You review the patient quickly and decide that she is having an anaphylactic reaction. What would you do?

Answer 52

I would call for help and make sure the nurses have contacted my seniors and 2222. I would check for life threatening features of anaphylactic reaction. These include: Airway: swelling, hoarseness, stridor Breathing: rapid breathing, wheeze, fatigue, cyanosis, SpO2 < 92%, confusion Circulation: pale, clammy, low blood pressure, faintness, drowsy/coma If ANY of above present - Give IM adrenaline and IV stat with legs up. Get airway control and then give another IM of adrenaline stat if required.

Question 53

You are the IMT1 on call covering the wards at night. You are called by the Senior Nurse on the Acute Medical Unit about Mrs Khan, a 68 year old lady who has been admitted with an infective exacerbation of her COPD. In addition to her COPD, Mrs Khan has a past medical history that includes type 2 diabetes, coronary artery disease and has suffered two myocardial infarctions in the past. She has hypothyroidism and was previously treated for breast cancer. Since her admission two hours ago she has been started on nebulisers, IV fluids and IV antibiotics. The nurse has contacted you as the patient has acutely desaturated and is struggling to breathe. The nurse sounds concerned on the phone. The Nurse informs you that just before the desaturation the patient was given a penicillin based antibiotic. They have also developed a rash. She has checked the notes and the patient is allergic to that particular antibiotic. You initiate the treatment with IM Adrenaline. Unfortunately, Mrs Khan continues to deteriorate and collapses. You assess for a pulse and cannot find one. What would you do?

Answer 53

Shout for help and start CPR Ask someone to get defib and call 2222 if not already done so

Question 54

You are the IMT1 on call covering the wards at night. You are called by the Senior Nurse on the Acute Medical Unit about Mrs Khan, a 68 year old lady who has been admitted with an infective exacerbation of her COPD. In addition to her COPD, Mrs Khan has a past medical history that includes type 2 diabetes, coronary artery disease and has suffered two myocardial infarctions in the past. She has hypothyroidism and was previously treated for breast cancer. Since her admission two hours ago she has been started on nebulisers, IV fluids and IV antibiotics. The nurse has contacted you as the patient has acutely desaturated and is struggling to breathe. The nurse sounds concerned on the phone. The Nurse informs you that just before the desaturation the patient was given a penicillin based antibiotic. They have also developed a rash. She has checked the notes and the patient is allergic to that particular antibiotic. You initiate the treatment with IM Adrenaline. Unfortunately, Mrs Khan continues to deteriorate and collapses. You assess for a pulse and cannot find one. Mrs Khan is intubated and taken to ITU having been stabilised. Mrs Khan’s husband has now come into the hospital and would like to know what is happening.

Answer 54

SPIKES model During this discussion it is important to discuss with the husband that his wife may have reacted to an antibiotic given incorrectly. Tell the husband that if he would like to speak to your registrar or consultant you can arrange this.

Question 55

What is duty of candour?

Answer 55

Tell the patient (or, where appropriate, the patient’s advocate, carer or family) when something has gone wrong Apologise to the patient (or, where appropriate, the patient’s advocate, carer or family) Offer an appropriate remedy or support to put matters right (if possible) Explain fully to the patient (or, where appropriate, the patient’s advocate, carer or family) the short and long term effects of what has happened.

Question 56

You are the IMT1 on call covering the wards at night. You are called by the Senior Nurse on the Acute Medical Unit about Mrs Khan, a 68 year old lady who has been admitted with an infective exacerbation of her COPD. In addition to her COPD, Mrs Khan has a past medical history that includes type 2 diabetes, coronary artery disease and has suffered two myocardial infarctions in the past. She has hypothyroidism and was previously treated for breast cancer. Since her admission two hours ago she has been started on nebulisers, IV fluids and IV antibiotics. The nurse has contacted you as the patient has acutely desaturated and is struggling to breathe. The nurse sounds concerned on the phone. The Nurse informs you that just before the desaturation the patient was given a penicillin based antibiotic. They have also developed a rash. She has checked the notes and the patient is allergic to that particular antibiotic. You initiate the treatment with IM Adrenaline. Unfortunately, Mrs Khan continues to deteriorate and collapses. You assess for a pulse and cannot find one. Mrs Khan is intubated and taken to ITU having been stabilised. Mrs Khan’s husband has now come into the hospital and would like to know what is happening. You now have one minute to handover the patient in this scenario to your registrar/consultant as if you were at the Acute Medical Handover.

Answer 56

Situation: This 68-year-old lady has had an anaphylactic reaction to penicillin and subsequent cardiac arrest. Background: She was initially admitted today because of an infective exacerbation of her COPD. She was started on an IV penicillin-based drug which she is known to be allergic to. Assessment: She was initially given IM adrenaline but continued to deteriorate. She was urgently seen by the cardiac arrest team and has had a return of spontaneous circulation. She has been intubated and taken to ITU. Recommendations: Her husband has come into hospital and I have spoken with him already about what has happened, but he would benefit from speaking with a senior clinician to further explain the situation. An incident report will need to be completed given her history of penicillin allergy was known prior to receiving it.

Question 57

A 32 year old man presents to A&E with vomiting, abdominal pain and confusion. You have been asked to see him on the medical take. The nurse calls you as she is concerned about his observations. She tells you that the patient’s girlfriend has indicated he has been feeling increasingly weak and lethargic over the last week. He started vomiting today so she called the doctor who sent them to A&E. She is concerned, as the patient has been losing weight over the last 4 months without any known cause. He has also been having dizzy spells and fainted two weeks ago. His observations are as follows: Blood Pressure: 87/54 Heart Rate: 120 (regular) Respiratory rate: 24 Saturations: 100% (on room air) Temperature 37.8 degrees Celsius On arrival the nurse shows you his VBG: pH 7.29 pCO2 4.7 HCO3- 28 Na+ 115 K+ 5.3 Glu 3.9 Lac 3.7 How would you initially approach and manage this patient?

Answer 57

ABCDE A - make sure its patent B - RR, sats, Chest expansion and percussion, auscultation, CXR if concerned C - In shock so would want BP, HR, CRT, Heart sounds, ECG, IV access with formal bloods (usual, lactate, BC as temp), Give IVT D - GCS and BMs E - Temp, rashes, etc

Question 58

A 32 year old man presents to A&E with vomiting, abdominal pain and confusion. You have been asked to see him on the medical take. The nurse calls you as she is concerned about his observations. She tells you that the patient’s girlfriend has indicated he has been feeling increasingly weak and lethargic over the last week. He started vomiting today so she called the doctor who sent them to A&E. She is concerned, as the patient has been losing weight over the last 4 months without any known cause. He has also been having dizzy spells and fainted two weeks ago. His observations are as follows: Blood Pressure: 87/54 Heart Rate: 120 (regular) Respiratory rate: 24 Saturations: 100% (on room air) Temperature 37.8 degrees Celsius On arrival the nurse shows you his VBG: pH 7.29 pCO2 4.7 HCO3- 28 Na+ 115 K+ 5.3 Glu 3.9 Lac 3.7 What investigations would you do?

Answer 58

Bloods - FBC, U+Es, CRP, LFTs (Abdominal pain), Thyroid function, Calcium, BC, Magnesium and Amylase. I would also send a random cortisol An ECG will be important, as the patient is tachycardic chest XR and urine dip will be important to complete my septic screen. CT head - increasingly confused and vomiting so would need a CT head May need CT abdo due to raised lactate and pain but would discuss with senior first.

Question 59

A 32 year old man presents to A&E with vomiting, abdominal pain and confusion. You have been asked to see him on the medical take. The nurse calls you as she is concerned about his observations. She tells you that the patient’s girlfriend has indicated he has been feeling increasingly weak and lethargic over the last week. He started vomiting today so she called the doctor who sent them to A&E. She is concerned, as the patient has been losing weight over the last 4 months without any known cause. He has also been having dizzy spells and fainted two weeks ago. His observations are as follows: Blood Pressure: 87/54 Heart Rate: 120 (regular) Respiratory rate: 24 Saturations: 100% (on room air) Temperature 37.8 degrees Celsius On arrival the nurse shows you his VBG: pH 7.29 pCO2 4.7 HCO3- 28 Na+ 115 K+ 5.3 Glu 3.9 Lac 3.7 What is your differential diagnosis?

Answer 59

Septic shock Acute pancreatitis Liver failure However - note the low Na, low BM and weight loss and fatigue - ?adrenal crisis exacerbated by infection

Question 60

What do you understand by Adrenal Crisis?

Answer 60

Medical emergency - Insufficient levels of the hormone cortisol symptoms including dizziness, vomiting and in life threatening cases, altered consciousness.

Question 61

What may precipitate Adrenal Crisis?

Answer 61

Infection Stopping steroids abruptly Stress Surgery

Question 62

A 32 year old man presents to A+E with vomiting, abdominal pain and confusion. You have been asked to see him on the medical take. The nurse calls you as she is concerned about his observations. She tells you that the patient’s girlfriend has indicated he has been feeling increasingly weak and lethargic over the last week. He started vomiting today so she called the doctor who sent them to A+E. She is concerned, as the patient has been losing weight over the last 4 months without any known cause. He has also been having dizzy spells and fainted two weeks ago. His observations are as follows: Blood Pressure: 87/54 Heart Rate: 120. Regular Respiratory rate: 24 Saturations: 100% room air Temperature 37.8 degrees On arrival the nurse shows you his VBG: pH 7.29 pCO2 4.7 HCO3- 28 Na+ 115 K+ 5.3 Glu 3.9 Lac 3.7 How would you treat this patient if the diagnosis were Adrenal Crisis?

Answer 62

Fluid and steroid replacement is key - IV hydrocortisone then oral switch in 72hrs. Then start fludrocortisone once stable.

Question 63

A 32 year old man presents to A+E with vomiting, abdominal pain and confusion. You have been asked to see him on the medical take. The nurse calls you as she is concerned about his observations. She tells you that the patient’s girlfriend has indicated he has been feeling increasingly weak and lethargic over the last week. He started vomiting today so she called the doctor who sent them to A+E. She is concerned, as the patient has been losing weight over the last 4 months without any known cause. He has also been having dizzy spells and fainted two weeks ago. His observations are as follows: Blood Pressure: 87/54 Heart Rate: 120. Regular Respiratory rate: 24 Saturations: 100% room air Temperature 37.8 degrees On arrival the nurse shows you his VBG: pH 7.29 pCO2 4.7 HCO3- 28 Na+ 115 K+ 5.3 Glu 3.9 Lac 3.7 The presentation is consistent with an adrenal crisis. What symptoms and signs would support an underlying diagnosis of Addison’s disease?

Answer 63

General signs of adrenal crisis - weakness, low Na, confusion, low BMs Addisons specifically - hyperpigmentation

Question 64

What other diseases is Addison’s disease typically associated with?

Answer 64

Addison’s disease is typically associated with other autoimmune disorders such as autoimmune thyroid disease, premature ovarian failure, type 1 diabetes mellitus, vitiligo, alopecia and coeliac disease.

Question 65

What information would you give to someone with Addison’s disease?

Answer 65

Patients should be told to wear a medical alert bracelet. During times of stress (e.g. minor surgery, infections) patients should be instructed to double or triple their usual maintenance dose of steroid. Patients should know to contact their GP or seek medical help in times of severe stress when oral uptake of steroids may be compromised – for example in severe vomiting or diarrhoea. Patients should also be given instruction on how to administer IM injections in these scenarios.

Question 66

How would you investigate someone for primary adrenal insufficiency?

Answer 66

Once stable - Short synacthen test and serum cortisol If still unstable - random cortisol

Question 67

What complications are you aware of with rapid correction of hyponatraemia?

Answer 67

central pontine myelinolysis - no more than 10mmol/l in first 24 hrs

Question 68

A 32 year old man presents to A+E with vomiting, abdominal pain and confusion. You have been asked to see him on the medical take. The nurse calls you as she is concerned about his observations. She tells you that the patient’s girlfriend has indicated he has been feeling increasingly weak and lethargic over the last week. He started vomiting today so she called the doctor who sent them to A+E. She is concerned, as the patient has been losing weight over the last 4 months without any known cause. He has also been having dizzy spells and fainted two weeks ago. His observations are as follows: Blood Pressure: 87/54 Heart Rate: 120. Regular Respiratory rate: 24 Saturations: 100% room air Temperature 37.8 degrees On arrival the nurse shows you his VBG: pH 7.29 pCO2 4.7 HCO3- 28 Na+ 115 K+ 5.3 Glu 3.9 Lac 3.7 The presentation is consistent with an adrenal crisis. You have given IVT steroids, IV and infection screen is sent with cortisol You now have one minute to handover the patient in this scenario to your registrar/consultant as if you were at the Acute Medical Handover.

Answer 68

S – This is a 32 year old man who has presented with hypovolaemic shock and hyponatraemia consistent with a suspected diagnosis of adrenal crisis. B – He has deteriorated over the last week with increasing lethargy and weakness, but has been losing weight for the past 4 months. There is no known medical history. A – I have completed an A-E assessment and started aggressive fluid resuscitation in addition to broad spectrum antibiotics to cover any potential precipitating infection. Given my differential I have sent a cortisol level and have given hydrocortisone. R – This patient needs to be urgently admitted. I feel he would benefit from a review with the ITU team given the hypovolaemic shock and hyponatraemia as currently he warrants HDU level care. He will need continuous fluid balance monitoring, regular sodium, potassium, and glucose monitoring as we commence fluid resuscitation. I would recommend contacting the on-call endocrine team to discuss this patient and his further management.

Question 69

What features suggest acute life threatening anaphylaxis?

Answer 69

Airway: swelling, hoarse voice, stridor Breathing: wheeze, shortness of breath, respiratory arrest Circulation: pale, clammy, tachycardia, cardiac arrest, shock

Question 70

What are some common causes of anaphylaxis?

Answer 70

Drugs and IV infusions – this can include antibiotics, IV infusions (blood products, IV immunoglobulins, contrast mediums) Insect bites Food – e.g. nuts, sea food Other common causes: latex, hair dye

Question 71

How could this patient’s airway be maintained in an emergency situation when intubation is not immediately possible?

Answer 71

An emergency cricothyroidotomy can be performed in an emergency setting where intubation fails or cannot be undertaken. A 14G needle and insufflation with 100% oxygen can be used as a temporary measure until a definitive airway can be achieved. WOULD NEED ITU INPUT FOR THIS

Question 72

The patient is intubated and taken to ITU. Fortunately the patient makes a good recovery. The patient’s penicillin allergy had been documented on the admission documents but not on the drug chart. How should this be managed?

Answer 72

In the first instance there is duty of candour towards the patient. The patient should be made aware of the error and apologised to. The most appropriate team member to do this may be the lead or accountable physician, but in some instances you may be the appropriate person to deliver this. In addition, the error should be highlighted to the team. A clinical incident form should be logged as serious harm came to the patient. This should then be fed back to the members of the disciplinary team involved in the incident.

Question 73

How would you class anaphylaxis as a hypersensitivity reaction?

Answer 73

Type 1 - IgE mediates it which causes histamine release and vasodiltation and bronchal constriction

Question 74

A 61-year-old gentleman has presented to A&E with severe chest pain. He has been sent by his GP who has also provided a past medical history. The gentleman has type 2 diabetes, hypertension, hypercholesterolaemia and five years ago was treated for colon cancer, for which he underwent a partial colectomy. You have been asked by the medical registrar to go and assess the patient in the resus department. The reg has asked for an ECG and this will be available to view once you have seen the patient. What are your differential diagnoses for this patient?

Answer 74

Cardio - ACS Resp - PE, pleurisy/CAP, Pneumothorax MSK - Costochondiritis, Rib fracture GI - GORD, pancreatitis Vascular - Dissection

Question 75

A 61-year-old gentleman has presented to A&E with severe chest pain. He has been sent by his GP who has also provided a past medical history. The gentleman has type 2 diabetes, hypertension, hypercholesterolaemia and five years ago was treated for colon cancer, for which he underwent a partial colectomy. You have been asked by the medical registrar to go and assess the patient in the resus department. The reg has asked for an ECG and this will be available to view once you have seen the patient. What questions will help you to narrow down your differential diagnosis?

Answer 75

Start with open question of what has brought them into hospital Then SOCRATES Ask about associated symptoms - fever, bowels, vomiting, palpitations, coughs, colds, PE risk factors

Question 76

A 61-year-old gentleman has presented to A&E with severe chest pain. He has been sent by his GP who has also provided a past medical history. The gentleman has type 2 diabetes, hypertension, hypercholesterolaemia and five years ago was treated for colon cancer, for which he underwent a partial colectomy. You have been asked by the medical registrar to go and assess the patient in the resus department. The reg has asked for an ECG and this will be available to view once you have seen the patient. What investigations are you going to do for this patient?

Answer 76

Will depend on Hx taking ECG Bloods - FBC, CRP, LFTs, U+Es, lactate, D-dimer, troponin CXR

Question 77

A 61-year-old gentleman has presented to A&E with severe chest pain. He has been sent by his GP who has also provided a past medical history. The gentleman has type 2 diabetes, hypertension, hypercholesterolaemia and five years ago was treated for colon cancer, for which he underwent a partial colectomy. You have been asked by the medical registrar to go and assess the patient in the resus department. The reg has asked for an ECG and this will be available to view once you have seen the patient. ECG shows - widespread ST segment depression most obvious in the anterolateral leads. What does it show and how would you manage this patient?

Answer 77

Would initate NSTEMI management after A-E Aspirin 300mg, morphine, GTN, O2 if low sats Discuss with reg before starting Clopi/ticagrelor and foundiparinaux Secondary - lifestyle measures, ACEI, BB, Statin, aspirin

Question 78

A 61-year-old gentleman has presented to A&E with severe chest pain. He has been sent by his GP who has also provided a past medical history. The gentleman has type 2 diabetes, hypertension, hypercholesterolaemia and five years ago was treated for colon cancer, for which he underwent a partial colectomy. You have been asked by the medical registrar to go and assess the patient in the resus department. The reg has asked for an ECG and this will be available to view once you have seen the patient. ECG shows - widespread ST segment depression most obvious in the anterolateral leads. Once the patient is stable what is the next phase of management?

Answer 78

GRACE score and consider angiography and angioplasty ECHO and possible cardiac MRI for extent of infarction.

Question 79

What would you do if the patient had an ST elevation myocardial infarction, as demonstrated by an ECG?

Answer 79

All patients with chest pain and ST elevation or new left bundle branch block (LBBB) fulfil primary percutaneous coronary intervention (PC) criteria. Would have to be discussed with cardiology PCI centre - at hospital or elsewhere ASAP as needs PCI within 2 hrs of CP onset)

Question 80

Can you list some common complications post MI?

Answer 80

Death, rupture, arrhythmias, oedema, dresslers syndrome

Question 81

What do you know about Dressler’s Syndrome?

Answer 81

autoimmune pericarditis, it occurs 2-10 weeks post MI. diffuse saddle-shaped ST elevation across multiple leads. An echocardiogram may show pericardial effusion. The management of this condition is with non-steroidal anti-inflammatory medication.

Question 82

A 61-year-old gentleman has presented to A&E with severe chest pain. He has been sent by his GP who has also provided a past medical history. The gentleman has type 2 diabetes, hypertension, hypercholesterolaemia and five years ago was treated for colon cancer, for which he underwent a partial colectomy. You have been asked by the medical registrar to go and assess the patient in the resus department. The reg has asked for an ECG and this will be available to view once you have seen the patient. ECG shows - widespread ST segment depression most obvious in the anterolateral leads. Give an SBAR

Answer 82

S – This is a 61 year old man who has presented with acute chest pain, with an ECG demonstrating widespread ST depression, consistent with an NSTEMI. B – He has risk factors for ischaemic heart disease including type 2 diabetes, hypertension and raised cholesterol. A – Following assessment I have started initial management with morphine, aspirin, high flow oxygen, beta blockers and an ACE inhibitor. R – I would recommend that this patient is urgently discussed with the Cardiology team, as further interventional management is likely to be required, given he has other co-morbidities and is therefore considered high risk.

Question 83

A 24 year old lady has been referred by her local GP with persistent diarrhoea. She has been having diarrhoea for the last 10 days. Over the last 5 days she has noticed that she has been passing mucous with her stool. She has no known past medical history and is usually fit and well. Blood pressure 110/65 Heart Rate 96 bpm Saturations 96% on room air Temperature: 37.4 degrees Respiratory rate 22 How will you assess this patient?

Answer 83

How will you assess this patient? ABCDE A – Is the patient talking? Are they able to maintain their own airway? B – I would continue to monitor the patient’s saturations and respiratory rate. If there are signs of hypoxia I would start high flow oxygen. I would listen to the chest for signs of infection or fluid. Chest expansion, percussion, trachea position C - CRT, BP, HR, MM, ECG, IV access - fbc, crp, lfts, u+es, lactate, IVT D - BMs and GCS E - temp and rash

Question 84

A 24 year old lady has been referred by her local GP with persistent diarrhoea. She has been having diarrhoea for the last 10 days. Over the last 5 days she has noticed that she has been passing mucous with her stool. She has no known past medical history and is usually fit and well. Blood pressure 110/65 Heart Rate 96 bpm Saturations 96% on room air Temperature: 37.4 degrees Respiratory rate 22 What further information would you like to know from this patient in her history?

Answer 84

Unwell contacts? Foreign travel? Ate anything unusual/dodgy? Any previous episodes like this? Any FH of IBD?

Question 85

A 24 year old lady has been referred by her local GP with persistent diarrhoea. She has been having diarrhoea for the last 10 days. Over the last 5 days she has noticed that she has been passing mucous with her stool. She has no known past medical history and is usually fit and well. Blood pressure 110/65 Heart Rate 96 bpm Saturations 96% on room air Temperature: 37.4 degrees Respiratory rate 22 The patient has not travelled anywhere recently. She does remember having persistent bouts of loose stool over the last 5 days but tended to put it down to her diet. She has in the past noticed blood when opening her bowels as well as mucous. Her mother has inflammatory bowel disease, but she doesn’t know which type. None of her close contacts have been ill with diarrhoea recently. She is currently a student in her last year of university. What is your differential diagnosis?

Answer 85

Could be IBD or simple gastroenteritis Coeliac disease IBS

Question 86

A 24 year old lady has been referred by her local GP with persistent diarrhoea. She has been having diarrhoea for the last 10 days. Over the last 5 days she has noticed that she has been passing mucous with her stool. She has no known past medical history and is usually fit and well. Blood pressure 110/65 Heart Rate 96 bpm Saturations 96% on room air Temperature: 37.4 degrees Respiratory rate 22 The patient has not travelled anywhere recently. She does remember having persistent bouts of loose stool over the last 5 days but tended to put it down to her diet. She has in the past noticed blood when opening her bowels as well as mucous. Her mother has inflammatory bowel disease, but she doesn’t know which type. None of her close contacts have been ill with diarrhoea recently. She is currently a student in her last year of university. How will you investigate this patient?

Answer 86

ECG IV access - fbc, crp, lfts, u+es, lactate, IVT Stool culture, faecal calprotectin, TGAA antibodies If becomes acutely unwell/deteriorates - may need CT abdo

Question 87

A 24 year old lady has been referred by her local GP with persistent diarrhoea. She has been having diarrhoea for the last 10 days. Over the last 5 days she has noticed that she has been passing mucous with her stool. She has no known past medical history and is usually fit and well. Blood pressure 110/65 Heart Rate 96 bpm Saturations 96% on room air Temperature: 37.4 degrees Respiratory rate 22 The patient has not travelled anywhere recently. She does remember having persistent bouts of loose stool over the last 5 days but tended to put it down to her diet. She has in the past noticed blood when opening her bowels as well as mucous. Her mother has inflammatory bowel disease, but she doesn’t know which type. None of her close contacts have been ill with diarrhoea recently. She is currently a student in her last year of university. How will you manage this patient?

Answer 87

Fluid management - monitor electrolytes and kidney function

Question 88

What clinical signs on examination may suggest at an underlying diagnosis of IBD?

Answer 88

Joint pains Anterior uveitis Fistulas/perianal abscesses/tracts Pyoderma gangeronosum Oral ulcers Erythema nodosum

Question 89

What markers would suggest a severe attack of IBD?

Answer 89

>6 bloody stools a day Systemically unwell: pyrexia and tachycardia Hb <100 Albumin <30g/L Toxic dilatation

Question 90

How would you manage an acute flare of IBD?

Answer 90

A-E Fluid resus and fix electrolyte derangements. IV hydrocortisone - discuss with reg first

Question 91

What findings on sigmoidoscopy/colonoscopy would differentiate Crohn’s disease from Ulcerative Colitis?

Answer 91

UC - large bowel, no crypts or goblet cells and no granulomas, superficial Crohns - full thickness, cobblestone appearance and throughout bowel

Question 92

Does surgery have a role in the management of IBD?

Answer 92

Yes if not improved in 3 days of medical management - surgery is often considered. Only curative for UC though Do surgery in crohns if - perforation, obstruction, abscess formation and fistulae.

Question 93

A 24 year old lady has been referred by her local GP with persistent diarrhoea. She has been having diarrhoea for the last 10 days. Over the last 5 days she has noticed that she has been passing mucous with her stool. She has no known past medical history and is usually fit and well. Blood pressure 110/65 Heart Rate 96 bpm Saturations 96% on room air Temperature: 37.4 degrees Respiratory rate 22 The patient has not travelled anywhere recently. She does remember having persistent bouts of loose stool over the last 5 days but tended to put it down to her diet. She has in the past noticed blood when opening her bowels as well as mucous. Her mother has inflammatory bowel disease, but she doesn’t know which type. None of her close contacts have been ill with diarrhoea recently. She is currently a student in her last year of university. You have started IVT and sent cultures and bloods and think this is IBD Give an SBAR

Answer 93

S – I am handing over a 24 year old woman with a likely first presentation of inflammatory bowel disease. B – She has a history of 5 days of bloody diarrhoea with no other features of infection and a family history of inflammatory bowel disease. A – I have sent investigations to check for electrolyte imbalance and dehydration. I have started fluid resuscitation. I have sent stool cultures to rule out infection but have not started antibiotics pending the results of this. R – I would recommend admitting this patient and an urgent referral to the gastroenterology team to give advice on further management and investigations which may include starting steroids and arranging a sigmoidoscopy.

Question 94

A 56 year old man has been referred to the Ambulatory Care Unit by his GP with worsening jaundice. It has been present and getting worse for the last year and a half, and he only recently saw his GP about it. On examination the patient is icteric, with cachexia and abdominal distention. You have been asked to assess him by the consultant running the clinic and to arrange some suitable investigations. What information would you like to know from the gentleman’s history?

Answer 94

Duration of time Pain Associated symptoms - weight loss, abdo pain, N+V, Bowel function PMH - hepatitis, gallstones SH - Alcohol, IVDU, other medication, foreign travel

Question 95

A 56 year old man has been referred to the Ambulatory Care Unit by his GP with worsening jaundice. It has been present and getting worse for the last year and a half, and he only recently saw his GP about it. On examination the patient is icteric, with cachexia and abdominal distention. You have been asked to assess him by the consultant running the clinic and to arrange some suitable investigations. What signs of chronic liver disease might you find on examination?

Answer 95

Cahectic, flapping tremor, spider naevi, gynaecomastia, ascites, hepatomegaly

Question 96

A 56 year old man has been referred to the Ambulatory Care Unit by his GP with worsening jaundice. It has been present and getting worse for the last year and a half, and he only recently saw his GP about it. On examination the patient is icteric, with cachexia and abdominal distention. You have been asked to assess him by the consultant running the clinic and to arrange some suitable investigations. What causes of liver cirrhosis do you know?

Answer 96

Alcohol, NAFLD, Hep B and C, Autoimmunehepatitis, Wilsons and haemochromatosis

Question 97

A 56 year old man has been referred to the Ambulatory Care Unit by his GP with worsening jaundice. It has been present and getting worse for the last year and a half, and he only recently saw his GP about it. On examination the patient is icteric, with cachexia and abdominal distention. You have been asked to assess him by the consultant running the clinic and to arrange some suitable investigations. What investigations will you arrange?

Answer 97

FBC, CRP, LFTs, U+Es, AST, Amylase, clotting US abdo Hep B, C serology Ceroplasmin, transferrin and ferritin Ascitic tap

Question 98

A 56 year old man has been referred to the Ambulatory Care Unit by his GP with worsening jaundice. It has been present and getting worse for the last year and a half, and he only recently saw his GP about it. On examination the patient is icteric, with cachexia and abdominal distention. You have been asked to assess him by the consultant running the clinic and to arrange some suitable investigations. The patient presents to hospital three weeks later and is seen in A+E. He is now confused and disorientated and was bought in after his family became concerned that he was becoming more drowsy. He is tachycardic and hypotensive. What could be the cause of this?

Answer 98

Decompensated chronic liver disease causing hepatic encephalopathy

Question 99

A 56 year old man has been referred to the Ambulatory Care Unit by his GP with worsening jaundice. It has been present and getting worse for the last year and a half, and he only recently saw his GP about it. On examination the patient is icteric, with cachexia and abdominal distention. You have been asked to assess him by the consultant running the clinic and to arrange some suitable investigations. The patient presents to hospital three weeks later and is seen in A+E. He is now confused and disorientated and was bought in after his family became concerned that he was becoming more drowsy. He is tachycardic and hypotensive. Name some causes of acute decompensation of chronic liver disease

Answer 99

Infection - spontaneous bacterial peritonitis, big GI bleed, constipation, alcohol, medication, electrolyte disturbance

Question 100

What is hepatic encephalopathy?

Answer 100

disturbance of cognitive function in a patient with acute on chronic liver disease. Clinically there is altered conscious level, asterixis, abnormal EEG, impaired psychometric tests, and an elevated arterial ammonia concentration.

Question 101

How is hepatic encephalopathy graded?

Answer 101

Westhaven score

Question 102

How would you manage hepatic encephalopathy?

Answer 102

Exclude other causes of confusion Identify cause Give lactulose and possibly rifampicin Phosphate enema

Question 103

How would you manage liver cirrhosis in the long term?

Answer 103

Treat cause - antivirals/alcohol abstinence etc 6 monthly - US abdo and AFP Annual - endoscopies for varices Prophylactic abx if spontaneous bacterial peritonitis

Question 104

When would a patient be recommended for liver transplantation?

Answer 104

A transplant centre should take this decision. The selection for transplantation is taken based on the severity of the underlying liver disease against the presence of any co-morbidities. Some conditions should be considered for transplant irrespective of disease severity such as PBC or recurrent cholangitis in PSC.

Question 104

A 56 year old man has been referred to the Ambulatory Care Unit by his GP with worsening jaundice. It has been present and getting worse for the last year and a half, and he only recently saw his GP about it. On examination the patient is icteric, with cachexia and abdominal distention. You have been asked to assess him by the consultant running the clinic and to arrange some suitable investigations. The patient presents to hospital three weeks later and is seen in A+E. He is now confused and disorientated and was bought in after his family became concerned that he was becoming more drowsy. He is tachycardic and hypotensive. You have sent blood tests to rule out infection and acute viral hepatitis, electrolyte imbalance and hypoglycaemia. I have initiated treatment with lactulose and prescribed phosphate enemas to help the patient open their bowels. You now have one minute to handover the patient in this scenario to your registrar/consultant as if you were at the Acute Medical Handover.

Answer 104

S – I am handing over a 56 year old man with decompensated chronic liver disease and grade two hepatic encephalopathy. B – He has previously presented with jaundice and signs consistent with chronic liver disease. The cause of this decompensation is not currently known. A – I have sent blood tests to rule out infection and acute viral hepatitis, electrolyte imbalance and hypoglycaemia. I have initiated treatment with lactulose and prescribed phosphate enemas to help the patient open their bowels. R – I would recommend that this patient is admitted and urgently discussed with the gastroenterology team as hepatic encephalopathy carries a high risk of mortality. Treatment with rifaximin may be indicated if there is no response to initial treatment, but this should be discussed with the gastroenterology team.

Question 105

Chronic asthma management

Answer 105

Now changed - Low dose MART PRN --> Low dose MART Regular --> Medium dose MART Patient education for asthma Smoking cessation GP follow-up within 48hrs if possibke

Question 106

A 64 year old gentleman has been sent to the AMU by his GP with a two day history of passing black stool. He has been feeling increasingly unwell but has not had any other symptoms. His past medical history includes hypertension, hypercholesterolemia, angina and osteoarthritis. The medical SpR has asked you to go and see the gentleman on the medical take. The nurse gives you his basic observations: Blood Pressure: 110/67 Heart Rate: 110 bpm Saturations: 94% on room air Respiratory rate: 20 Temperature: 36.9 What further information would be helpful to you when taking a history from this gentleman?

Answer 106

Amount of stool, how many times it has started, if the stool had an unusual smell (not always true malaena), associated symptoms - dizziness, pain, vomiting/haematemesis PMH - stomach ulcers, GORD Drugs - NSAIDs, alcohol, SSRIs

Question 107

A 64 year old gentleman has been sent to the AMU by his GP with a two day history of passing black stool. He has been feeling increasingly unwell but has not had any other symptoms. His past medical history includes hypertension, hypercholesterolemia, angina and osteoarthritis. The medical SpR has asked you to go and see the gentleman on the medical take. The nurse gives you his basic observations: Blood Pressure: 110/67 Heart Rate: 110 bpm Saturations: 94% on room air Respiratory rate: 20 Temperature: 36.9 What could be the cause of this gentleman’s black stool?

Answer 107

Gastritis Peptic ulcer Iron sulfate/fumerate oesophagitis Gastric cancer

Question 108

A 64 year old gentleman has been sent to the AMU by his GP with a two day history of passing black stool. He has been feeling increasingly unwell but has not had any other symptoms. His past medical history includes hypertension, hypercholesterolemia, angina and osteoarthritis. The medical SpR has asked you to go and see the gentleman on the medical take. The nurse gives you his basic observations: Blood Pressure: 110/67 Heart Rate: 110 bpm Saturations: 94% on room air Respiratory rate: 20 Temperature: 36.9 What investigations will you arrange?

Answer 108

FBC, CRP, LFTs, U+Es, G+S, coag PR exam Scope - urgency depends on severity of bleed

Question 109

Do you know of any measures of severity when assessing a patient with a suspected UGIB?

Answer 109

The Glasgow-Blatchford bleeding score (GBS) - 0 - OP scope <7 - admit and scope >7 - severe bleed and discuss urgently with scope team

Question 110

A 64 year old gentleman has been sent to the AMU by his GP with a two day history of passing black stool. He has been feeling increasingly unwell but has not had any other symptoms. His past medical history includes hypertension, hypercholesterolemia, angina and osteoarthritis. The medical SpR has asked you to go and see the gentleman on the medical take. The nurse gives you his basic observations: Blood Pressure: 110/67 Heart Rate: 110 bpm Saturations: 94% on room air Respiratory rate: 20 Temperature: 36.9 During your assessment the patient passes a large amount of black stool. His blood pressure drops further to 87/49 and his heart rate is 142. The VBG shows that the patient’s Hb is 69 g/L. What do you do now?

Answer 110

A-E and activate major haemorrhage protocol. Large bore IV access x2 – this is essential as you will be aggressively fluid resuscitating this patient. I will send bloods for G+S and cross match 4-8 units. 0.9% saline to maintain SBP > 110 mmHg (100 mmHg if variceal) Correct coagulopathy using vitamin K +/- FFP if required Transfuse platelets if < 50 If worry of variceal bleed - can give terlepressin and abx NBM and call endoscopist on-call

Question 111

A 64 year old gentleman has been sent to the AMU by his GP with a two day history of passing black stool. He has been feeling increasingly unwell but has not had any other symptoms. His past medical history includes hypertension, hypercholesterolemia, angina and osteoarthritis. The medical SpR has asked you to go and see the gentleman on the medical take. The nurse gives you his basic observations: Blood Pressure: 110/67 Heart Rate: 110 bpm Saturations: 94% on room air Respiratory rate: 20 Temperature: 36.9 During your assessment the patient passes a large amount of black stool. His blood pressure drops further to 87/49 and his heart rate is 142. The VBG shows that the patient’s Hb is 69 g/L. An endoscopy result shows a bleeding peptic ulcer which is injected and the patient is stabilised. How could you investigate this gentleman for Helicobacter pylori (H. pylori) infection?

Answer 111

Urea breath test

Question 112

What treatment would you initiate for H. pylori?

Answer 112

Triple therapy, using a PPI and two antibiotics (often amoxicillin and clarithromycin) Metronidazole of pen allergic

Question 113

A 64 year old gentleman has been sent to the AMU by his GP with a two day history of passing black stool. He has been feeling increasingly unwell but has not had any other symptoms. His past medical history includes hypertension, hypercholesterolemia, angina and osteoarthritis. The medical SpR has asked you to go and see the gentleman on the medical take. The nurse gives you his basic observations: Blood Pressure: 110/67 Heart Rate: 110 bpm Saturations: 94% on room air Respiratory rate: 20 Temperature: 36.9 During your assessment the patient passes a large amount of black stool. His blood pressure drops further to 87/49 and his heart rate is 142. The VBG shows that the patient’s Hb is 69 g/L. An endoscopy result shows a bleeding peptic ulcer which is injected and the patient is stabilised. What advice should this man be given regarding his long term management and discharge?

Answer 113

Avoid alcohol, smoking, NSAIDs, SSRIs PPI for 6 weeks then repeat OGD Safety net patient

Question 114

A 64 year old gentleman has been sent to the AMU by his GP with a two day history of passing black stool. He has been feeling increasingly unwell but has not had any other symptoms. His past medical history includes hypertension, hypercholesterolemia, angina and osteoarthritis. The medical SpR has asked you to go and see the gentleman on the medical take. The nurse gives you his basic observations: Blood Pressure: 110/67 Heart Rate: 110 bpm Saturations: 94% on room air Respiratory rate: 20 Temperature: 36.9 During your assessment the patient passes a large amount of black stool. His blood pressure drops further to 87/49 and his heart rate is 142. The VBG shows that the patient’s Hb is 69 g/L. Now handover to reg/consultant on-call

Answer 114

S – I am handing over a 64 year old male patient with an acute upper GI bleed who is showing signs of hypovolaemic shock. I think he is having a life threatening upper GI bleed. B – He presented with a two day history of melaena, before passing a further large amount of black stool in A+E. A – I have obtained IV access and started aggressive fluid management. R – This gentleman will need an urgent transfusion. I have sent an urgent cross match but have asked the team to have Group O negative blood ready for immediate transfusion if there is further deterioration. He needs to be urgently discussed with the on-call gastroenterology team as he needs an urgent endoscopy to identify the site of bleeding.

Question 115

You are the IMT on the acute take. You are asked by A+E to see a 56 year old woman who has presented with a 3 day history of feeling increasingly unwell. She presented with a temperature of 39.2 degrees, HR of 131, blood pressure of 105/70, saturations of 93% on room air, and a respiratory rate of 24. Her past medical history is notable for rheumatoid arthritis. What factors or results might prompt you to ask for an urgent senior review?

Answer 115

Raised lactate High NEWS Oliguria Reduced conciousness

Question 116

You are the IMT on the acute take. You are asked by A+E to see a 56 year old woman who has presented with a 3 day history of feeling increasingly unwell. She presented with a temperature of 39.2 degrees, HR of 131, blood pressure of 105/70, saturations of 93% on room air, and a respiratory rate of 24. Her past medical history is notable for rheumatoid arthritis. Your patient has been started on treatment. What would be essential for you to find out when taking your history?

Answer 116

When the symptoms started Any pain Associated infective symptoms - sore joints, cough, cold, dysuria, skin rashes, headaches etc Anyone else unwell What immunosuppression she is on

Question 117

You are the IMT on the acute take. You are asked by A+E to see a 56 year old woman who has presented with a 3 day history of feeling increasingly unwell. She presented with a temperature of 39.2 degrees, HR of 131, blood pressure of 105/70, saturations of 93% on room air, and a respiratory rate of 24. Her past medical history is notable for rheumatoid arthritis. You find out that the patient has been taking methotrexate. What would you include in your differential and what investigations would be important to send or request at your first assessment?

Answer 117

Methotrexate can cause bone marrow suppression which can lead to a drop in circulating white cells. This is a rare complication of the medication, but in a person presenting with an unspecified fever, I would be worried about neutropenic sepsis and would manage this according to local trust antimicrobial guidelines. Also send septic screen and LFTs to ensure no hepatotoxicity from methotrexate

Question 118

You are the IMT on the acute take. You are asked by A+E to see a 56 year old woman who has presented with a 3 day history of feeling increasingly unwell. She presented with a temperature of 39.2 degrees, HR of 131, blood pressure of 105/70, saturations of 93% on room air, and a respiratory rate of 24. Her past medical history is notable for rheumatoid arthritis. You find out that the patient has been taking methotrexate. Your blood tests come back and confirm a low neutrophil count consistent with your diagnosis of neutropenic sepsis. The patient also has a Stage 1 AKI. The patient has been taking methotrexate for several years and is generally stable. Can you think of any factors that may have resulted in her developing myelosuppression?

Answer 118

New AKI as methotrexate renally excreted Stopped taking folic acid?

Question 119

You are the IMT on the acute take. You are asked by A+E to see a 56 year old woman who has presented with a 3 day history of feeling increasingly unwell. She presented with a temperature of 39.2 degrees, HR of 131, blood pressure of 105/70, saturations of 93% on room air, and a respiratory rate of 24. Her past medical history is notable for rheumatoid arthritis. You find out that the patient has been taking methotrexate. Your blood tests come back and confirm a low neutrophil count consistent with your diagnosis of neutropenic sepsis. The patient also has a Stage 1 AKI. The patient has been taking methotrexate for several years and is generally stable. What would you do with the methotrexate after admission?

Answer 119

I would liaise with the patient's Rheumatology team to advise them of the admission and that methotrexate has been stopped. They may want to consider whether restarting the methotrexate is the correct decision or whether another agent would be safer.

Question 120

You are the IMT on the acute take. You are asked by A+E to see a 56 year old woman who has presented with a 3 day history of feeling increasingly unwell. She presented with a temperature of 39.2 degrees, HR of 131, blood pressure of 105/70, saturations of 93% on room air, and a respiratory rate of 24. Her past medical history is notable for rheumatoid arthritis. You find out that the patient has been taking methotrexate. Your blood tests come back and confirm a low neutrophil count consistent with your diagnosis of neutropenic sepsis. The patient also has a Stage 1 AKI. The patient has been taking methotrexate for several years and is generally stable. You now have one minute to hand this patient over to the medical registrar on call. Having seen this patient on the acute take, what would you advise with regard to her admission?

Answer 120

I have just seen a 56 years old woman with a diagnosis of neutropenic sepsis and AKI. She has presented with a three day history of fever and general malaise without specific symptoms. She is known to have rheumatoid arthritis and takes methotrexate. I suspect that her methotrexate use has resulted in her neutropenia. I have commenced broad spectrum antibiotics in line with the trust guidelines, pending further investigations including blood cultures, urine cultures and a chest x-ray. I have stopped her methotrexate. This patient needs to be admitted to monitor her response to treatment. She will need a repeat lactate level and clinical review to assess her response to fluid resuscitation. If she does not respond to the initial treatment I would recommend an urgent review by the ITU team. She would benefit from a review with the rheumatology team to assess her ongoing treatment with methotrexate following this admission.

Question 121

You are an IMT 1 in a Rheumatology Clinic. You have been asked to assess Mr Pine, a 72-year-old gentleman who has been referred in by his GP with a history of joint pain in the hands and knees. He has a past medical history of hypertension. He used to work as a plumber but retired 4 years ago. What key questions would you want to answer when taking a history from this patient?

Answer 121

What joints are sore What makes them worse or better Does he get morning stiffness Any fevers Any time they are hot red or swollen Any other sore joints/jaw pain/eye pain Any FH of rheum conditions How it affects ADLs

Question 122

You are an IMT 1 in a Rheumatology Clinic. You have been asked to assess Mr Pine, a 72-year-old gentleman who has been referred in by his GP with a history of joint pain in the hands and knees. He has a past medical history of hypertension. He used to work as a plumber but retired 4 years ago. Picture of OA - Heberdens and buchard nodes What investigations would you consider for this gentleman?

Answer 122

ESR, CRP, x-ray of hands Anti-CCP, urate and ANA.

Question 123

You are an IMT 1 in a Rheumatology Clinic. You have been asked to assess Mr Pine, a 72-year-old gentleman who has been referred in by his GP with a history of joint pain in the hands and knees. He has a past medical history of hypertension. He used to work as a plumber but retired 4 years ago. Picture of OA - Heberdens and buchard nodes Your investigations come back which have not found any inflammatory cause of the arthritis. The case has been discussed at an MDT and it is felt that there are no identifying inflammatory features on the x ray which are felt to be more consistent with osteoarthritis. You are due to see the patient again in clinic. How would you manage this patient's pain at your clinic appointment?

Answer 123

Physio, heat packs, rest, topical NSAIDs and paracetamol Would use WHO pain ladder but would want to avoid oral NSAIDs and codeine due to peptic ulcer disease/CKD and also codeine due to dependence.