Crit-Care_Surg-Exam-2017 Flashcards
How much 0.75% Ropivocaine is in 20mL?
- 0.15gm
- 1.5gm
- 15gm
- 150gm
- 1500gm
= 0.15grams = 150mg
Ropivacaine hydrochloride (NAROPIN 0.75%) 150 mg/20 mL injection
Guy with severe GORD what’s the most effective method of managing?
- Sodium citrate on induction,
- Ranitidine IV
- PPI from the night before
- Metoclopramine
- Fasting for 6 hours
PPI from the night before.
PPIs are the most effective treatment for severe GORD because they significantly reduce gastric acid production. Starting a PPI from the night before allows for maximal acid suppression, which helps in managing and preventing severe reflux symptoms.
What is the MET equivalent of 4 METS?
- Ironing
- Golfing
- Vigorous sexual activity
- Mountain cycling
The MET (Metabolic Equivalent of Task) equivalent of 4 METs is generally:
- Golfing (typically 3-4 METs depending on whether it’s walking or using a cart).
- Ironing: 2-3 METs
- Golfing: Around 3-4 METs if walking and carrying clubs, and slightly lower if using a golf cart.
- Vigorous sexual activity: 5-6 METs.
- Mountain cycling: 6-12 METs depending on intensity and terrain.
Utilising the opioid risk tool but you had to actually know it - i.e. which patients is at most risk of abnormal opioid using practices post op after an uncomplicated knee surgery for fracture.
- 35 yr old male - depression - family history substance abuse
- 25 yr old female - bipolar - family history nil
- 75 yr old male - prescription drug abuse - family history of prescription drug abuse
- 30 yr old male - history alcoholism - family history illicit drug abuse
Based on the opioid risk tool, which assesses various factors to determine the risk of abnormal opioid use, the patient at the highest risk for abnormal opioid-using practices post-operatively would be:
75-year-old male - prescription drug abuse - family history of prescription drug abuse.
Which of the following patients do you need to bridge their anti-coagulation. Given option of 5 patients with various CHADS + operations with varying bleeding risk on either Warfarin, Rivaroxaban or Dabigatran.
Which causes hyperchloraemic metabolic acidosis (but you had to determine that from blood results):
- 0.9% NaCl
- 3% NaCl
- 5% dextrose
- Albumin
0.9% NaCl (Normal Saline)
Which of these are likely to be associated with desaturation and hypoxia at induction of anaesthesia in an older patient with a retropharyngeal abscess?
- Beard
- Mallampati score 3
- Thyromental distance 4cm
- OA of the neck
The strongest independent predictors of difficult intubation identified by meta-analysis of 35 studies were a combination of Mallampati and thyromental distance. However, this was still associated with low sensitivity 36% (14-59%). Therefore, the RCoA recommended the combination of Mallampati, thyromental distance and thorough patient history to improve sensitivity and predictive power.
Repeat question about which sequence is most appropriate in an RSI?
- Pre-oxygenation
- Induction with propofol
- Suxamethonium
- Intubation of trachea
= PISI
EMQ - Contraindications for pain management - the options were: Amitriptyline, Panadol, ketamine, tramadol, tapentadol, hydromorphone, clonidine, oxycodone, Celecoxib, Pregabalin, Codeine
a) Patient has epilepsy and is on Carbamazepine and Venlafaxine?
b) Alpha 2 agonist administered intra-thecally
c) What medication should a IVDU patient not be discharged on?
d) Patient with bowel resection taken back to surgery following anastamotic leak, which medication will decrease chronic pain?
e) Patient presenting with pyuria and has a history of chronic pelvic pain and is currently on a list of medications like buprenorphine patch, ACEi, amoxicillin and gentamicin?
EMQ - Contraindications for pain management - the options were: Amitriptyline, Panadol, ketamine, tramadol, tapentadol, hydromorphone, clonidine, oxycodone, Celecoxib, Pregabalin, Codeine
a) Patient has epilepsy and is on Carbamazepine and Venlafaxine = Amitriptyline
b) Alpha 2 agonist administered intra-thecally = Clonidine
c) What medication should a IVDU patient not be discharged on = Oxycodone
d) Patient with bowel resection taken back to surgery following anastamotic leak, which medication will decrease chronic pain = Ketamine
e) Patient presenting with pyuria and has a history of chronic pelvic pain and is currently on a list of medications like buprenorphine patch, ACEi, amoxicillin and gentamicin = Celecoxib : NSAID that can reduce blood flow to the kidneys and is associated with nephrotoxicity, especially in patients with existing kidney conditions or those who are dehydrated.
RSI sequence – same as formative but they change thiopentone to propofol
- Preoxygenate
- Induce
- Sedate
- Intubate
Tetanus prophylaxis in a girl who steps on a rusty nail but remembers having a tetanus shot 10 years ago
- Give tetanus (ADT) IM?
- Give ADT and Tetanus IVIG
- Give clindamycin to stop Clostridium tetanii infection
In the case of a girl who stepped on a rusty nail and had a tetanus shot 10 years ago, the appropriate tetanus prophylaxis would be to: Give tetanus (ADT) IM.
- Tetanus boosters (tetanus toxoid-containing vaccine, ADT) are generally recommended if the last dose was given more than 5 years ago and the wound is considered high risk (e.g., puncture wound with potential for contamination, like stepping on a rusty nail).
- Tetanus IVIG is not necessary unless the patient has incomplete vaccination or immunocompromise.
- Antibiotics like clindamycin are not routinely given solely to prevent tetanus but may be considered if there are signs of infection.
- Since she received her last tetanus shot 10 years ago, a booster dose of tetanus (ADT) IM is recommended.
Preamble about a girl at a ‘teen pharm party’ who ingested random things. Which would suggest TCA overdose toxicity?
- Miosis
- Urinary incontinence
- QRS of 0.13
- Bronchorrhoea
= QRS of 0.13
The normal QRS complex duration on an ECG is: 0.06 to 0.10 seconds (or 60 to 100 milliseconds).
A QRS duration greater than 0.12 seconds (120 milliseconds) is considered prolonged and can indicate conduction abnormalities, such as a bundle branch block or ventricular arrhythmia.
Clinical features of pericardial effusion?
- Augmented heart sounds
- Reduced CVP
- Pulses paradoxus
- >30mmg
Clinical features of pericardial effusion?
- Augmented heart sounds
- Reduced CVP - no typically, central venous pressure is increased in pericardial effusion due to impaired venous return to the heart, especially in tamponade situations.
- Pulses paradoxus = This is an exaggerated decrease in systolic blood pressure (>10 mmHg) during inspiration. It’s commonly seen in larger effusions or cardiac tamponade.
- >30mmg SBP = tamponade
When can you not use lignocaine + adrenaline?
digit block (end artery)
‘Sexually active’ 28 year old presents to ED with dysuria, frequency and pyuria. what bacteria would you target for treatment?
E.coli
Young guy with past history of bronchiectasis presenting with pleuritic chest pain 2 weeks after a knee surgery. History of unilateral leg swelling was present after surgery. What do you do next?- D-Dimer?
- PERC?
- CTPA?
- VQ scan?
CTPA
Old lady who has IHD, bipolar disease, is recently started on diuretics. She presents with visual disturbances and has green/yellow halos around objects?
- Lithium toxicity
- Digoxin toxicity
- Glaucoma
Digoxin
What is the most common presentation of a AAA to ED?
- Abdo pain with hypotension
- Incidental finding on abdo exam
- Severe pain in loin radiating through to the groin
- Localised rupture with back pain
= Incidental finding on abdo exam
The majority of AAAs are asymptomatic and are detected as an incidental finding on ultrasonography, abdominal computed tomography or magnetic resonance imaging performed for other purposes. It can also present with abdominal pain or complications such as thrombosis, embolization and rupture. Approximately 30% of asymptomatic AAAs are discovered as a pulsatile abdominal mass on routine physical examination.
The most appropriate management of an aggressive patient in the ED is:
a. Interview them alone, away from security and police
b. If sedatives are being used, best given orally
c. Establish empathic verbal rapport early
d. Establish an authoritative and controlling demeanour
e. Another one about seeing them on your own behind closed doors
c. Establish empathic verbal rapport early.
- Establishing a connection and demonstrating understanding can help de-escalate aggression and build trust. This approach often leads to better cooperation and reduces the likelihood of violence.
Critical care drugs EMQ: Amiodarone, Suxamethonium, Diazepam, Insulin, Midazolam, Phenytoin, Magnesium chloride, Glucagon, 5% glucose, Calcium chloride, Calcium gluconate
a. Causes oesophageal relaxation, used in hypoglycaemia?
b. Would raise serum potassium from 0.2-0.4mmol/L in a normal person?
c. Can be given IM to terminate seizure activity?
d. Needs to be cardiac monitored during IV infusion for seizure management?
e. What drug used to treat hyperkalaemia is irritant to small peripheral veins?
Patient is in septic shock and on noradrenaline, but his MAP is still inadequate, what do you do?
- Add metaraminol infusion
- Add dopamine infusion
- Stop noradrenaline and give adrenaline
- Stop noradrenaline and give something else unhelpful
- Start vasopressin
Start vasopressin
What do you treat pseudomonas with?
Ciprofloxacin
35 yr old lady with history of atypical pneumonia (coryza, bilateral interstitial infiltrates on CXR) what do you treat with?
Azithromycin
Patient with COPD on CPAP and what should you change her to? Given an ABG and she is oxygenated well and comfortable but the CO2 is 75 & pH 7.15?
- BiPAP with 15mmHg inspiratory pressure and 5mmhg expiratory pressure
- O2 with higher FiO2, intubate and ventilate
- Keep same settings
- Increase CPAP to 10mmHg
In the context of a patient with COPD on CPAP who has a high CO2 level (75 mmHg) and a low pH (7.15), the most appropriate change would be to switch to BiPAP (Bilevel Positive Airway Pressure) with with 15mmHg inspiratory pressure and 5mmhg expiratory pressure.
- BiPAP provides different pressures for inhalation and exhalation, which can help improve ventilation and reduce CO2 levels more effectively than CPAP alone.
- This is particularly useful in patients with hypercapnia and acidosis.
Patient with cardiogenic shock who is shut down peripherally and struggling. What drug do you give them?
- Dopamine
- Dobutamine
- Isoprenaline
- Noradrenaline
In the case of cardiogenic shock with peripheral shutdown and significant struggling, dobutamine is often the most appropriate drug to administer.
Patient admitted for exacerbation of COPD and begins to decline after a central line is put in. CXR shown (complication of central line insertion) and asked about management?
Pneumothorax = Air in the pleural space, which can occur if the lung is punctured during central line insertion.
- Small Pneumothorax: May be managed conservatively with observation and supplemental oxygen.
- Large Pneumothorax: Requires chest tube insertion to remove the air and re-expand the lung.
E coli urosepsis, which one wouldn’t help?
- Meropenem
- Vancomycin
- Ciprofloxacin
- Ceftriaxone
For E. coli urosepsis, vancomycin would not be helpful.
Chronic smoker with OSA (refuses to use CPAP), woken up with a headache & is drowsy. ABG;
- pH 7.35
- PaCO2 65
- PO2 65
- HCO3 32
Chronic Respiratory Acidosis with Metabolic Compensation
Picture of tonsils with exudate + lymphadenopathy. What’s the diagnosis?
EBV tonsillitis
Tympanic membrane of 5 year old aboriginal kid with language difficulty but mum says no history of ear pain or discharge. Was chronic otitis media with effusion – what management is most appropriate?
- Trial antibiotics for 3 months
- Grommets
- Audiometry
What does Lachman’s Draw Test assess?
- ACL
- PCL
- Meniscal injury
= ACL. -The Lachman test is a passive accessory movement test of the knee performed to identify the integrity of the anterior cruciate ligament (ACL). The test is designed to assess single and sagittal plane instability.
Patient with a history of shoulder girdle pain that is worse in the morning and improves with activity and now he is experiencing hip pain. Most relevant investigation?
- RF
- Anti-CCP
- ESR
- ANA
- CK
= ESR - suspected polymyalgia rheumatica
Patient with 10kg weight gain, notices paraesthesia on outer part of left thigh, no distal loss of reflexes. No pain. Diagnosis?
- Meralgia paraesthetica (aka lateral cutaenous nerve of thigh)
- Lumbar radiculoapthy
- Spinal stenosis
- Osteoarthritis
The patient’s presentation of 10 kg weight gain, paraesthesia on the outer part of the left thigh, no distal loss of reflexes, and no pain is most consistent with meralgia paraesthetica (also known as lateral cutaneous nerve of the thigh entrapment).
- Meralgia paraesthetica: This condition occurs due to compression of the lateral femoral cutaneous nerve (a purely sensory nerve), typically in the inguinal region. It often results in paraesthesia or numbness in the outer thigh without motor symptoms or reflex changes. Weight gain is a common contributing factor, as it can increase pressure on the nerve.
EMQ - pseudogout, viral arthritis, psoriatic arthritis, reactive arthritis, polyarticular osteoarthritis, gout, ankylosing spondylitis, rheumatoid arthritis, dermatomyositis, polymyositis
- Patient presenting with multiple joint that are painful and mentions a brief rash he had 2 weeks prior on his torso?
- Post surgical, wrist swelling, Positively birifringent?
- Lady can’t reach above her head, elevated CK with papules over her eyes and face?
- Lady with 7 year history of stiffness in her hands, particularly DIPs and PIPs. Has fixed flexion deformity, particularly in DIPs. Has hard swellings?
Young patient with history of diarrhoea with obvious blood and mucus over the past few months presents with abdominal pain and distension. Doesn’t resolve and she has a total colectomy. On histology there was mucosal involvement, crypt abscesses with neutrophils and lymphocytes, broken mucosa with pseudopolyps. What is the diagnosis?
- Crohn’s
- Pseudomembranous colitis
- UC
The histological and clinical findings in this case are most consistent with ulcerative colitis (UC).
42 year old lady who is married with 3 kids presents with bloody nipple discharge. Otherwise well, no family history of breast cancer. Only breast issue was mastitis when breast feeding. What is the most likely cause?
- Ductal ectasia
- Ductal papilloma
- Ductal carcinoma,
- Lobular carcinoma
Ductal papilloma
Where will a patient with a melanoma primary in the thigh have a recurrence?
- Around the excision border
- Inguinal lymph nodes
- Subcutaneous fat
Inguinal lymph nodes
What is the most common bone cancer?
- Multiple myeloma
- Metastatic cancer
- Ewing’s
The most common “bone cancer” is metastatic cancer.
Lady experiences dysphagia feels nauseous until she vomits and then is hungry again. Has lost a lot of weight?
- Gastric cancer
- Oesophageal cancer
- Pancreatic cancer
Patient with medial malleous ulcer that is irregular and beefy and you’re concerned about osteomyelitis of the bone underneath. Before you treat it with compression stockings and bandage, what should you do?
- Biopsy of the edge
- Doppler venous ultrasound
- Arteriogram
Patient presents with RUQ pain and gallstones with thickened GB seen on ultrasound. Why is the pain felt here?
- Irritation of parietal peritoneum
- Referred pain via parasympathetic afferents
- Referred pain via sympathetic afferents
- Foregut pain
Old male falls and hits the front of his head on the ground and was immediately too weak to lift himself up. Had weakness of wrist extension, loss of triceps reflex bilaterally. After 1 day became hyperreflexic with some leg weakness. Where is the lesion likely?
- Cervical cord
- Cervical nerve root
- Frontal lobe
- Brachial plexus
25 yr old girl who has a slow growing lump on the dorsum of her hand. Not painful but wants it removed because she thinks it’s ugly. Moves with hand movement
- Ganglion
- Epidermoid cyst
- Sebaceous cyst
= Ganglion
Post op complications EMQ - a repeat of previous years - Primary haemorrhage, Secondary haemorrhage, Anastomotic leak, Post op MI, Line Sepsis, Others
a) 60 year old male day 4 post bowel resection has new onset AF and diffuse abdominal pain?
b) 30 yr old guy presents with low BP after haemorrhoidectomy
a) 60 year old male day 4 post bowel resection has new onset AF and diffuse abdominal pain - anastomotic leak
b) 30 yr old guy presents with low BP after haemorrhoidectomy -?primary haemorrhage
Patient comes to see you with a neck mass, take a targeted history.
Differentials for a neck mass:
What are your differentials for a neck lump?
Differentials:
1. To rule out tumours (benign vs malignant)
2. Goitre (swollen thyroid gland) or thyroid nodules
3. Skin abscess / sebaceous cyst / branchial cysts/ thyroglossal cysts
4. Lymphadenopathy /lymphoma
5. Lipoma
6. Carotid body tumour
7. Sarcoidosis (non-caseating granuloma)
Patient comes to see you with a neck mass, you take a targeted history. In the history there’s no smoking, only really some skin lesions burnt off I think? No dysphagia, fevers, weight loss, pain. Perform an examination.
- If you were asked to perform head and neck examination, in general don’t forget to go over the followings:
1. Oral cavity and oropharynx - Trismus, ulcers, leukoplakia, asymmetry of the tonsils, fallen or lost teeth, examine the floor of mouth and the gingiva buccal
sulcus, bimanual palpation is a must
2. Nasal cavity - Notice any bleeding, ulcers or masses, nasal blockage, nasal deformity, involvement of the eyes
3. Ear - Masses or lesions in the pinna or the canal, middle ear effusion- may suggest nasopharyngeal
carcinoma
4. Scalp - Don’t forget to examine the scalp for any lesions – look for BCC, or SCCA and chronic infections
5. Cranial nerves - Facial paraesthesia or numbness and any facial
weakness
Patient comes to see you with a neck mass. In the history there’s no smoking, only really some skin lesions burnt off I think? No dysphagia, fevers, weight loss, pain…Examination reveals a lump not connected to skin 2cm below the angle of the right jaw. Give your three top differentials to the examiner in order of most to least likely. How would you investigate?
- Lymphadenopathy - reactive (previous URTI?)
- Lymphadenopathy - malignant mets (previous URTI?)
- Salivary gland tumour or inflammation from Sialadenitis
Patient comes to see you with a neck mass. In the history there’s no smoking, only really some skin lesions burnt off I think? No dysphagia, fevers, weight loss, pain…Examination reveals a lump not connected to skin 2cm below the angle of the right jaw. Give your three top differentials to the examiner in order of most to least likely. How would you investigate - FNA & ultrasound. The findings come back as mets to a lymph node of SCC. Where is the most likely site that the primary SCC is located?
Investigations to Identify the Primary Site:
1. Thorough head and neck examination: Detailed examination of the oral cavity, pharynx, larynx, and nasopharynx using direct visualization techniques (e.g., laryngoscopy, nasoendoscopy).
2. Panendoscopy (Triple endoscopy: laryngoscopy, esophagoscopy, and bronchoscopy): To examine mucosal surfaces of the upper aerodigestive tract for potential primary tumors.
3. HPV testing (if the oropharynx is suspected): As HPV-related SCC is more common in non-smokers and can present as metastatic lymphadenopathy with an occult primary.
4. CT or MRI of the head and neck: Cross-sectional imaging to help identify the primary tumor in deeper structures or less accessible areas.
5. PET-CT scan: If no obvious primary is found, a PET-CT can be used to detect occult primary sites by highlighting areas of increased metabolic activity.
37-year-old male accountant comes to ED from the pub with severe abdominal pain. Take a history, do an exam and answer questions from the examiner. HISTORY?
- 8 Differentials?
SOCRATES & Associated features:
Initial Differentials to Consider:
1. Acute pancreatitis (especially with recent alcohol intake)
2. Peptic ulcer disease (potential perforation if sudden pain)
3. Biliary colic or acute cholecystitis
4. Gastroenteritis
5. Appendicitis
6. Gastroesophageal reflux disease (GERD) or gastritis
7. Acute alcoholic gastritis
8. Abdominal aortic aneurysm rupture (less likely given age but important to rule out)
37-year-old male accountant comes to ED from the pub with severe abdominal pain. The patient describes sudden onset pain over minutes while he was drinking at the pub, epigastric region, nothing made it better or worse, had a small vomit - no blood. Was able to walk to the hospital but now did not want to move just lie still. No recent weight loss, fever, melaena, haematemesis. No history of reflux, cancer, previous abdominal surgery. No family history of cancer. Drinks a six pack of beer a day. What is your working diagnosis. How would you investigate this? (one test only) and what would you look for on examination?
If a patient presents with pancreatitis, what 10 labs would you do to assess the severity of it & why?
Acute Pancreatitis
- Aetiology: 3 most common causes? Other? I GET SMASHED?
- Pathophysiology: Sequence of events? Sequelae?
Most common causes
1. Biliary pancreatitis (∼ 40% of cases; mostly caused by gallstones)
2. Alcohol-induced (∼ 20% of cases)
3. Idiopathic (∼ 25% of cases)
I GET SMASHED: Idiopathic, Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion venom, Hypercalcemia and hypertriglyceridemia, ERCP, and Drugs are causes of acute pancreatitis.
Acute Pancreatitis
- 7 Symptoms?
- Clinical features on exam?
Symptoms
1. Constant, severe epigastric pain
2. Classically radiating towards the back
3. Worse after meals and when supine
4. Improves on leaning forwards
5. Nausea, vomiting
6. Fever
7. If pulmonary complications are present: chest pain, dyspnea
Acute Pancreatitis - Diagnosis
- Diagnostic crieria? (3)
- Approach?
- Lab studies - 7 tests and their findings?
Diagnostic criteria for acute pancreatitis - Two of the three following criteria should be met for a diagnosis of acute pancreatitis to be made:
1. Characteristic abdominal pain
2. ↑ Serum pancreatic enzymes: lipase or amylase ≥ 3× ULN
3. Characteristic findings of acute pancreatitis on cross-sectional imaging (e.g., abdominal ultrasound, contrast-enhanced CT abdomen)
Acute Pancreatitis - Diagnosis
- What does the level of lipase/amylase tell us about severity?
- When should you measure triglycerides?
- Why is measuring calcium so important?
- Initial imaging? Findings?
- 2nd line imaging? Findings?
- The degree of lipase and/or amylase elevation does not necessarily correlate with the severity of or prognosis for acute pancreatitis.
- Measure serum triglycerides promptly after symptom onset, as levels decrease rapidly with fasting.
- Determining calcium values is very important: Hypercalcemia may cause pancreatitis, which may then, in turn, cause hypocalcemia!
Acute Pancreatitis - Diagnosis
- When would you do a CXR/AXR for suspected acute pancreatitis? Supportive findings?
- When would you do an MRI? Supportive findings?
- MRCP vs. ERCP?
Endoscopic retrograde cholangiopancreatography
Indications
1. Suspected choledocholithiasis (if MRCP or MRI are not feasible)
2. To evaluate for sphincter of Oddi dysfunction in patients with recurrent pancreatitis and normal or inconclusive EUS and MRCP
Acute Pancreatitis
- Severity scoring: revised Atlanta?
Treatment
- Which fluids?
- 3 supportive therapies?
- Prophylactic antibiotics?
- Nutrition?
- Management of the underlying cause?
Revised Atlanta grades of severity - mild, moderately severe, or severe, depending on the presence of organ failure.
- Mild acute pancreatitis: no organ failure and no local or systemic complications
- Moderately severe acute pancreatitis: transient organ failure (< 48 hours) and/or local or systemic complications
- Severe acute pancreatitis: persistent organ failure (> 48 hours)
Patients with organ failure at presentation or within the first 24 hours of admission should be classified as having severe pancreatitis. If organ failure resolves within 48hrs, patients can be reclassified as having moderately severe acute pancreatitis.
Acute Pancreatitis
- 7 complications?
- Necrotizing pancreatitis
- Infected necrotizing pancreatitis
- Walled-off necrosis
- Pancreatic pseudocyst
- Abdominal compartment syndrome
- Pancreatic hemorrhage (blood vessel erosion with bleeding)
- Systemic complications - Shock, sepsis, DIC
Pneumonia, respiratory failure, ARDS, Pleural effusion, Prerenal failure due to volume depletion, Hypocalcemia, Paralytic ileus, Pancreatic ascites
Compare Acute vs. Chronic Pancreatitis:
- Characteristics?
- Aetiology?
- Pathophysiology?
Compare Acute vs. Chronic Pancreatitis:
- Course?
- Clinical features: main sxs? further?
- Diagnostics: lab studies? imaging?
Compare Acute vs. Chronic Pancreatitis:
- Treatment?
- Complications?
- Prognosis?
Surgery CBE - Melanoma
- History?
Examination - ABCDE approach: Asymmetry, Border, Colour, Diameter, and Evolution) and potentially an excisional or punch biopsy if melanoma is suspected.
Melanoma
- Summary?
- Epidemiology?
- List 7 Risk factors?
Epidemiology
- Most common cause of skin cancer-related death
- Incidence is higher among individuals who are:
- Non-Hispanic White
- Male
- ≥ 75 years of age
