Day 5 A&E

Question 1

A 35-year-old man presents with paraesthesia in the central area of the dorsum of his foot and proximal toes except the fifth.

Sensation is normal in the first dorsal web space.

He is also found to have some weakness of eversion of the foot.

Which of the following nerves is most likely to be involved?

Answer 1

The superficial peroneal nerve

The superficial peroneal nerve also supplies peroneus longus and brevis, tested by everting the foot against resistance.

The only sensory loss from damage to the deep peroneal nerve is in the first interdigital cleft.

The sural nerve supplies the dorsum of the lateral one and a half toes.

The deep peroneal nerve innervates the anterior compartment of the leg.

The common peroneal nerve provides senosry innervation to the posteriolateral aspect of the thigh and knee

The tibial nerve supplies the tibialis posterior, flexor digitorum longus, flexor hallucis longus, and deep part of soleus muscle.

Question 2

A 62-year-old male complains of increasing tiredness and generally feeling unwell.

He recently commenced enalapril for hypertension and has a history of peripheral vascular disease.

How will this be reflected in his

• sodium
• potassium
• urea

Answer 2

• Sodium normal
• Potassium normal
• Urea up

The introduction of an ACE inhibitor in a patient with renal artery stenosis may produce deteriorating ischaemic nephropathy with elevations of both urea and creatinine.

RAS is more common in patients with underlying peripheral vascular disease.

With a history of PVD and recent commencement of ACEi, then the reduced renal perfusion will result primarily in an elevation of the urea.

Question 3

A 33-year-old male is noted to be hypertensive at an employment medical examination. He also describes occasional episodes of muscle cramps.

He has a BMI of 25 kg/m2 and has a sustained blood pressure of 180/106 mmHg.

How would this be reflected in his

• sodium
• potassium
• urea

What is the diagnosis?

Answer 3

How would this be reflected in his

• sodium - normal
• potassium - lowered
• urea - normal

What is the diagnosis?

Secondary hypertension should always be considered in a younger hypertensive.

In this case he is not obese and the suggested muscle cramps would point to a diagnosis of Conn’s syndrome (primary hyperaldosteronism).

This condition is typified by a hypokalaemia.

Question 4

Which epithelium is presnt in the oesaphgus?

Answer 4

It is lined by stratified squamous epithelium in its upper two thirds and stratified columnar epithelium in its lower third.

Question 5

What is Carbenoxolone?

Answer 5

Carbenoxolone is used for the treatment of peptic, esophageal and oral ulceration and inflammation.

Question 6

Euvolemic Hypotonic Hyponatremia

Answer 6

• drugs
• pain
• CNS disorders
• malignancies
• pulmonary disorders
• postoperative state
• Hereditary (V2 receptor, hypothalamus)

Question 7

Causes of Hypervolemic Hypotonic Hyponatremia

(3)

Answer 7

heart failure

liver cirrhosis

nephrotic syndrome

Question 8

Nephrotic syndrome triad

(3)

Answer 8

Triad of:

1. Proteinuria (> 3g/24hr) causing
2. Hypoalbuminaemia (< 30g/L) and
3. Oedema

Question 9

Minimal change disease Pathophysiology

(2)

Answer 9

T-cell and cytokine-mediated damage to the glomerular basement membrane → polyanion loss

the resultant reduction of electrostatic charge → increased glomerular permeability to serum albumin

Question 10

nephritic syndrome features

(4)

Answer 10

haematuria with red cell casts

proteinuria

hypertension

oliguria

Question 11

A 72-year-old male presents with a week’s history of confusion. He has otherwise been well but takes atenolol for hypertension and is a smoker of 10 cigarettes per day.

Examination reveals a pulse of 88 beats per minute, a blood pressure of 126/88 mmHg and a temperature of 37.1°C.

He is disorientated in time and place.

What is the diagnosis?

Answer 11

The diagnosis of SIADH requires the patient to be euvolaemic with a low serum sodium or osmolality (<134 mmol/L or <280 mosmol/kg respectively) with an inappropriately high urine sodium and osmolality (>40 mmol/L; >100 mosmol/kg), with exclusion of other causes such as glucocorticoid deficiency, hypothyroidism and diuretic therapy

Question 12

Where else might you expect to find abnormalities in this 42-year-old patient who presents with exertional chest pain?

What is the diagnosis?

Answer 12

This patient has a corneal arcus at a young age.

In this scenario the history of chest pain suggests ischaemic heart disease due to familial hypercholesterolaemia.

Other sites where cholesterol may deposit include the tendons, in particular elbows and Achilles tendon.

Eruptive xanthomatosis on the buttocks usually occurs with hypertriglyceridaemia and palmar xanthomatosis is typical of a type III (remnant) hyperlipidaemia.

Hypercholesterolaemia is associated with premature cardiovascular disease and should be treated with statin therapy.

Question 13

A 40-year-old alcoholic man presents with polyneuropathy, confusion, vomiting, nystagmus and ophthalmoplegia.

Which vitamin deficiency does he have?

Answer 13

Vitamin B12

Question 14

An 80-year-old Asian immigrant woman presents with waddling gait and proximal myopathy.

Which vitamin deficiency does he have?

Answer 14

Vitamin D

Question 15

What is pellagra?

What are the symptoms?

Answer 15

What is pellagra?

a deficiency disease caused by a lack of nicotinic acid or its precursor tryptophan in the diet.

What are the symptoms?

It is characterized by dermatitis, diarrhoea, and mental disturbance,

Question 16

Which of the following hormones are elevated in the post-prandial state?

Answer 16

Insulin and GLP-1 (glucagon-like-peptide 1)

Question 17

A 55-year-old lady presents with generalised aches and pains. She has not presented to the surgery before.

What is the diagnosis?

Answer 17

Osteomalacia due to vitamin D deficiency

Question 18

A 32-year-old doctor with a family history of polycystic disease of the kidney collapsed suddenly after a sudden persistent occipital headache.

A sample of cerebrospinal fluid obtained 12 hours later was reported as xanthochromic.

What is the likely diagnosis?

Answer 18

Subarachnoid haemorrhage

Question 19

An 18-year-old student presents with headache, neck stiffness and photophobia.

The cerebrospinal fluid examination shows 100 lymphocytes, CSF glucose is more than 2/3 blood glucose value and CSF protein is 0.60g/L.

Gram stain was negative.

What is the most likely diagnosis?

Answer 19

Viral meningitis

Question 20

A 28-year-old woman presents with urinary incontinence and pain on movement of right eye with rapid deterioration in central vision.

On examination she has impaired co-ordination on heel-shin test.

She has nystagmus and an internuclear ophthalmoplegia.

The cerebrospinal fluid shows a slight increase in lymphocyte count, raised total proteins and raised immunoglobulins.

What is the likely diagnosis?

Answer 20

Multiple sclerosis

Question 21

A 24-year-old student has a 24 hour history of an ear infection, with photophobia, neck stiffness and a headache.

Cerebrospinal fluid shows a white cell count of 500/mm3, almost all of which are polymorphs.

Answer 21

bacterial meningitis

Question 22

Pathologen causes of GBS

(3)

Answer 22

Campylobacter

Cytomegalovirus (HSV5) cytomegalovirus

Epstein Barr Virus

Question 23

A 72-year-old patient with type 2 diabetes and stable ischaemic heart disease is admitted with palpitations of 5 days duration.

He is taking metformin 500 mg tds, aspirin 75 mg daily, ramipril 2.5 mg daily and simvastatin 40 mg daily.

On examination his pulse rate is 140 /minute, blood pressure is 128/98 mmHg. He has no chest pain.

There is no evidence of acute heart failure, and his ECG confirms atrial fibrillation.

Which of the following would be the most appropriate treatment for management of his atrial fibrillation?

Answer 23

In this patient with acute onset symptomatic, fast atrial fibrillation (AF), the most appropriate chemical agent for rate control would be beta blockers.

This man has ischaemic heart disease and is likely to be managed by rate control initially.

In those where beta blockers are contraindicated, rate-limiting calcium channel blockers can be used.

If he were hypotensive then he would be rate-controlled with IV digoxin.

If he could not have a beta blocker, calcium channel blocker, or digoxin, then amiodarone would be given.

Question 24

Characteristics of healthy CSF

(5)

Answer 24

CSF has a pH of 7.31, therefore lower than plasma.

It has a lower concentration of potassium, calcium, and protein than plasma. It has a higher concentration of sodium, chloride, bicarbonate and magnesium.

The CSF typically has no cells present but white cells should be less than 4/ml.

The pressure of CSF is typically less than 20 cm of water.

It has approximately two-thirds the glucose concentration of plasma with a concentration of approximately 3.3-4 mmol/L.

Question 25

A 56-year-old woman is brought to the Emergency department with increasing lethargy. She drinks a bottle of vodka a day and has had problems with persistent vomiting for one week.

On examination, her pulse is 96/min and blood pressure is 109/70 mmHg.

The following blood results are obtained:

What management should she be given?

Answer 25

IV thiamine followed by 5% dextrose plus 40 mmoles potassium chloride

This lady with an alcoholic abuse problem has starvation ketosis, as evidenced by the ;

• low pH
• low bicarbonate
• low base excess
• compensatory low PaCO2

The appropriate treatment for this is intravenous (IV) dextrose.

The glucose can, however, precipitate Wernicke’s encephalopathy, therefore what she needs initially is IV Pabrinex.

Question 26

“A blood-borne flavovirus with a single stranded RNA genome that has a 3% vertical transmission rate.”

Which virus is this referring to?

Answer 26

Hep C

Question 27

A 62-year-old man presents to the Emergency department after collapsing at home. He has had several episodes of syncope and severe shortness of breath over the past three months, which usually occur on exertion.

In his drug history he is being treated for chronic stable angina.

On examination he has a pulse of 80 beats per minute, a blood pressure of 112/92 mmHg and a systolic murmur over the praecordium.

Based on his history and examination what is the most likely diagnosis?

List two causes of this condition.

List two appropriate investigations you would request for this patient.

Answer 27

Based on his history and examination what is the most likely diagnosis?

• Aortic stenosis

List two causes of this condition.

• Rheumatic heart disease
• Calcification of a congenital bicuspid valve
• Calcification of a normal valve

List two appropriate investigations you would request for this patient.

• Echocardiography
• ECG
• Chest x ray

Question 28

You are called to the assessment unit to review a 67-year-old man with a three day history of fevers and purulent green sputum. He has no medical history of note and is on no regular medications. He is keen to go home as he is the main carer for his infirm father.

Examination reveals an orientated patient with bronchial breathing at the right base and a respiratory rate of 32 breaths per minute.

His observations are: HR 115 regular, BP 88/58 mmHg, O2 92% room air.

Initial blood results reveal a WCC of 13.2 ×109/L (4-11) and urea of 8.5 mmol/L (2.5-7.5).

Which criteria should be used to assess their need for hospitalisation?

What is the most appropriate management?

Answer 28

The assessment of patients for pneumonia is a regular occurrence for clinicians. The ‘CURB-65 criteria’ has now become a good stratification tool to decide upon whether patients need hospitalisation.

The criteria are:

Confusion - Abbreviated mental test score (AMTS) less than 8 or new disorientation in time, place or person

Urea greater than 7

Respiratory rate greater than 30

Blood pressure less than 90 systolic or less than 60 diastolic

Age greater than 65.

Patients that score 0-1 are suitable for home treatment.

Patients with scores of 2-3 should be considered for admission on a general ward.

Patients with scores of 4-5 are likely to require HDU level interventions.

Question 29

A late middle-aged homeless man is brought to the emergency department with a six hour history of profuse vomiting. He complains of nausea and headache.

The history available is sketchy. He is of no fixed abode and denies having any previous medical problems. He appears unkempt and is confused - oriented to person but not time or place. He is afebrile. His breath smells of ketones.

Twelve hours after admission his condition deteriorates. He complains of blurred vision and his pupils are fixed and dilated; his respiratory rate increases sharply over the next few minutes and he becomes unconscious.

What is his anion gap?

What is the likely diagnosis?

What is the treatment?

Answer 29

What is his anion gap?

• 23

What is the likely diagnosis?

• methanol poisoning

What is the treatment?

• Eliminating formic acid (alkaline diuresis or haemodialysis).
• Correcting acidosis with IV bicarbonate.
• Preventing metabolism of methanol to formic acid by administering IV ethanol.

Question 30

A 66-year-old man presents to A&E with a 24 hour history of epigastric pain radiating to the back and vomiting.

His serum amylase is 2000 and a diagnosis of pancreatitis is made.

Further selected blood tests are:

What is his modified glasgow score​?

Answer 30

Question 31

This patient presents with sudden onset of breathlessness.

Examination reveals him to be dyspnoeic at rest with saturations of 80% on air and a pulse of 100 beats per minute.

His trachea is not deviated and his blood pressure is 117/82.

After administering oxygen, what is the definitive management?

Answer 31

Pleural aspiration or chest drain

This patient has a large pnuemothorax with an obvious lung edge visible through the left hemithorax and radiolucency signifying air to the right of this. There is no mediastinal shift and he is not hypotensive so there is no evidence of a tension pneumothrax at this time; however an attempt at needle decompression may still be appropriate.

Question 32

A 56-year-old male with a five year history of hypertension attends the Emergency department complaining of severe chest pain which radiates to the back.

He describes it as tearing in nature.

He is tachycardic and hypertensive with blood pressure of 185/95 mmHg and a soft early diastolic murmur is noted.

The ECG shows ST elevation of 2 mm in the inferior leads and there is a small left sided pleural effusion on chest x ray.

Given the clinical history what is the likley diagnosis which needs to be ruled out first?

Answer 32

This patient has an aortic dissection.

He is hypertensive, the pain is typical in nature and the radiation through to the back is a cardinal feature.

Examination findings of hypertension, aortic regurgitation and pleural effusion are consistent.

The inferior lead ECG changes are likely due to aortic dissection compromising the right coronary artery.

This patient needs a thorough evaluation of peripheral pulses and urgent imaging of the aorta.

Question 33

A 2-year-old boy presents with a barking cough and stridor.

What treatment does he need?

Answer 33

The second case has croup as characterised by the barking cough. Humidified oxygen can help for mild cases but more severe cases require dexamethasone.

Question 34

A 30-year-old male is admitted to the MAU with a 72 hour history of significant lethargy, fever and a sore throat.

The nurse is concerned that his breathing is ‘noisy’ and describes it to you over the phone as harsh and high pitched. His current observations demonstrate a temperature of 39.4°C and a raised respiratory and heart rate.

What is the most likely diagnosis?

Answer 34

Bacterial tracheitis

Question 35

This is the ECG of a 72-year-old man who presents with light headedness and dyspnoea.

He has a past history of ischaemic heart disease for which he takes atenolol, amlopidine and ramipril.

What is the diagnosis?

Answer 35

Complete heart block

Question 36

What is Pralidoxime used to treat?

Answer 36

organophosphate poisoning

Question 37

What is Penicillamine used to treat?

Answer 37

Wilson’s disease

Question 38

What is Dimercaprol used to treat?

(4)

Answer 38

Dimercaprol, also called British anti-Lewisite, is a medication used to treat acute poisoning by

• arsenic
• mercury
• gold
• lead

Question 39

Which drug is used to treat heavy metal poisoning?

Answer 39

Dimercaprol, also called British anti-Lewisite, is a medication used to treat acute poisoning by

• arsenic
• mercury
• gold
• lead

Question 40

Which drug is used to treat Wilson’s disease?

Answer 40

Penicillamine

Question 41

A 38-year-old man has been complaining of headaches, dizziness and poor concentration for some time.

He is brought into hospital with weakness on the left side.

His haemoglobin is 200 g/L.

What is the most likely diagnosis?

(3)

Answer 41

Cerebral thrombosis

Polycythaemia vera causes focal neurological signs as a result of thrombosis from increased viscosity.

There is a paradoxical risk of haemorrhage.

Polycythaemia vera (a type of blood cancer)

Question 42

A 62-year-old male is found drunk outside a pub in the early hours of the morning.

He is conscious but unable to move the right side of his body.

He starts to have partial seizures in hospital.

What is the most likely diagnosis?

(3)

Answer 42

subdural hamotoma

• Chronic subdural haematomas sometimes present as strokes.
• A history of previous trauma to the head or alcoholic abuse is useful.
• Alcoholics sometimes have suffered trauma in the past of which they have no recollection.

Question 43

Extradural vs subdural haematoma on x-ray

(2)

Answer 43

• subdural looks like a banana/crecent
• extradural looks like a lemon

Question 44

A 26-year-old woman with a history of epilepsy presents with numerous episodes of tonic-clonic seizures over the last four hours.

She has not regained consciousness at any point during this time according to an observer.

What is the diagnosis?

List two urgent investigations that you would perform.

List two intravenous therapies you would consider for this patient.

Answer 44

What is the diagnosis?

Status epilepticus

List two urgent investigations that you would perform.

• Electroencephalogram (EEG)
• Calcium

List two intravenous therapies you would consider for this patient.

• Lorazepam
• Diazepam
• Phenytoin
• Dexamethasone
• Magnesium

Question 45

This 74-year-old man presented following a collapse at home. There was no history of chest pain or shortness of breath.

He was noted to be in first degree heart block on admission to the Emergency department.

What is the diagnosis?

Answer 45

Myotonic dystrophy is the commonest adult muscular dysrophy.

• Frontal baldness in men, and
• Atrophy of temporalis, masseters and facial muscle.

Neck muscles (including sternocleidomastoid) are involved early in the course of disease.

Cardiac abnormalities are common, and include first degree heart block and complete heart block.

Question 46

Features of Myotonic dystrophy

(3)

Answer 46

Myotonic dystrophy is the commonest adult muscular dysrophy.

• Frontal baldness in men, and
• Atrophy of temporalis, masseters and facial muscle.

Neck muscles (including sternocleidomastoid) are involved early in the course of disease.

Cardiac abnormalities are common, and include first degree heart block and complete heart block.

Question 47

A 26-year-old female presents to the Emergency department in distress. She is agitated and has had a haematemesis. Examination reveals a temperature of 40°C, a pulse of 120 beats per minute and a blood pressure of 110/80 mmHg. She has a respiratory rate of 38/minute and has saturations of 100%. Her pupils are normal in size.

What has most likely poisoned her?

What would her ABG show?

How should she be treated?

Answer 47

Aspirin

• This case has hyperventilation, a pyrexia and has had a haematemesis suggestive of a gastric irritant - aspirin.
• This causes a metabolic acidosis with hyperpyrexia in overdose.
• Haematemesis due to gastric irritation is a feature and coagulation may be deranged.

Treatment

• general (ABC, charcoal)
• urinary alkalinization with intravenous sodium bicarbonate - enhances elimination of aspirin in the urine
• haemodialysis

Question 48

A 42-year-old female presents unconscious. She has a Glasgow coma scale of 7, a temperature of 37.5°C, a pulse of 134 beats per minute, a blood pressure of 130/60 mmHg and a respiratory rate of 22 with saturations of 95%.

Examination of the pupils reveals dilated pupils.

A bladder is palpable on examination of the abdomen.

What has she been poisoned with?

How should she be treated?

Answer 48

This case has reduced conscious level, a tachycardia, urinary retention and dilated pupils.

These features suggest an anticholinergic toxicity and from the above list, tricyclic antidepressants fit.

Fits and ventricular arrhythmias are other features.

Question 49

A 17-year-old girl with an approximate body weight of 70 kg and in cardiac arrest is brought by the ambulance service to the Emergency department. She was found collapsed at home 30 minutes previously with a weak pulse and no respiratory effort surrounded by empty packets of amitriptyline 25 mg.

She has been intubated and is being ventilated by bag-valve mask. The presenting rhythm is a sinusoidal supraventricular tachycardia with wide QRS complexes. Blood pressure is barely recordable but a weak carotid and femoral pulse are palpable. Immediate arterial bloods gases are obtained and reveal:

What does her blood gas show?

What is the treatment?

Answer 49

Early treatment with IV 8.4% bicarbonate in patients with acidosis or ECG changes following tricyclic antidepressant overdose saves lives.

Question 50

You are asked to review urgently a 24-year-old male who has presented to the Emergency department after admitting to drinking 15 units of alcohol and taking 2 ecstasy tablets tonight.

He is alert and orientated however is complaining of palpitations.

He denies any chest pain or shortness of breath.

His observations are: HR 180 regular, BP 115/80 mmHg, RR 18 & O2 99% room air.

An ECG is performed and demonstrates an atrioventricular nodal re-entry tachycardia (SVT).

What treatment option would you first initiate?

Answer 50

• Vasovagal manoeuvres should be tried first in SVT.
• Then, adenosine is the drug of choice with an initial dose of 6 mg

Question 51

An 18-year-old cystic fibrosis sufferer has persistent cough, which is productive of purulent sputum.

He has finger clubbing and low-pitched inspiratory and expiratory crackles on auscultation.

What is the likely diagnosis?

What is the likely exacerbatative organism?

Answer 51

What is the likely diagnosis?

• Bronchiectasis

What is the likely exacerbatative organism?

• Haemophilus influenzae (most common)

Question 52

A 48-year-old woman of Caribbean origin complains of progressive shortness of breath and painful lesions on her shins.

She has a history of hypertension and of joint pain.

A blood test shows hypercalcaemia.

What is the likely diagnosis?

Answer 52

Sarcoidosis is of unknown cause characterised by non-caseating granuloma.

It is commoner in Afro-Caribbean people and it may affect any organ or age group.

Question 53

Wernicke-Korsakoff syndrome

• Dementia
• Nystagmus
• Paralysis of extraocular muscles
• Ataxia
• Retrograde amnesia particularly in alcoholism.

Which vitamin should be used in the treatment?

Answer 53

Thiamine

Question 54

A 22-year-old homosexual male is positive for IgM anti-HBc antibody and hepatitis B surface antigens.

Which of the following best describes his disease state?

Answer 54

Acutely infected with Hep B

Question 55

A 68-year-old white man has been unwell for three months and develops pain over the thoracic spine.

On examination there is evidence of recent weight loss; there is tenderness over T10.

Serum corrected calcium is 3.3 mmol/L, creatinine is 350 µmol/L, and ESR is 110 mm in the first hour.

What is the most likely diagnosis?

Answer 55

Multiple myeloma presents commonly in this age group and slightly more commonly in males.

Tenderness over T10 indicates vertebral collapse secondary to lytic bone lesions.

Renal failure may be secondary to hypercalcaemia, hyperuricaemia or dehydration.

A markedly elevated ESR is common due to the presence of paraprotein in the serum.

Question 56

A 30-year-old Asian woman complains of poorly localised pain in the shoulders and pelvis.

Examination reveals no localising signs.

Serum corrected calcium is 2.1 mmol/L, the alkaline phosphatase is raised, and ESR is 10 mm in the first hour.

What is the likely diagnosis?

Answer 56

Osteomalacia is relatively common in Asian females.

The alkaline phosphatase is raised, the calcium low or normal, with a low serum phosphate.

Bone pain can be due to subclinical fractures.

Question 57

A 30-year old white man complains of chronic pain in the lumbosacral region.

Examination reveals tenderness over the sacro-iliac joints and restricted range of spinal movements.

• Serum corrected calcium is 2.3 mmol/L,
• alkaline phosphatase is normal,
• and ESR is 30 mm in the first hour.

What is the likely diagnosis?

Answer 57

Serum calcium and alkaline phosphatase are normal in ankylosing spondylitis.

The ESR is often elevated.

Restricted range of lumbar lateral flexion is often an early feature and ankylosing spondylitis usually presents below the age of 40.

Question 58

A 22-year-old man is admitted with 40% burns following an industrial accident. It has taken two hours to extricate him from the scene of the accident and the paramedics were unable to get intravenous access.

On examination he has pale cold peripheries, his pulse is 110 and BP 95/65 mmHg.

Which type of shock is he in?

Answer 58

hypovolaemic shock

Hypovolaemic shock results from a decreased volume of blood plasma. It results from haemorrhage or dehydration.

Major burns result in loss of body water, as the protective nature of the skin has been lost.

Question 59

An anxious 22-year-old woman with a high respiratory rate has the following arterial blood gas results:

What do they show?

Answer 59

Metabolic acidosis with some compensatory respiratory alkalosis

Question 60

A 26-year-old female presents in a confused and drowsy state.

A friend found her this morning after she had been out drinking the previous night but also states that she had been upset after her boyfriend had ‘dumped her’.

Examination reveals that she is drowsy with a Glasgow coma scale rating of 10/15. She has a blood pressure of 138/90 mmHg, a temperature of 37.5°C, large pupils which react slowly to light, a pulse of 120 beats per minute, a respiratory rate of 32/min and has exaggerated reflexes with down-going plantar responses. Examination of the abdomen reveals a palpable bladder.

Which of the following substances is she most likely to have taken?

How should he be treated?

Answer 60

Tricyclic antidepressants

Iv sodium bicarbonate

Question 61

A 32-year-old farm labourer with sore mouth, pulmonary oedema and renal failure.

What is the most likely causative agent?

Answer 61

Paraquat is found in weed killers.

This causes:

• diarrhoea and vomiting
• painful oral ulcers
• alveolitis (pulmonary oedema)
• and renal failure.

Question 62

A 20-year-old student is found in her bedroom by friends drowsy, confused and sweating. She is unable to give a clear history.

On examination she has a fever of 38.3°C, pulse 110 bpm, BP 110/60 mmHg and she appears short of breath with a respiratory rate of 30. there is no neck stiffness. Her chest sounds clear to auscultation.

Arterial blood gas result taken on 15 l/min oxygen shows:

What is the likely diagnosis?

Answer 62

There are a number of clues here that point to aspirin toxicity:

• fever
• sweating
• tachypnoea, and
• acidosis.

Question 63

Hyperkalaemia management

(3)

Answer 63

All patients with severe hyperkalaemia (≥ 6.5 mmol/L) or with ECG changes should have emergency treatment

• IV calcium gluconate: to stabilise the myocardium
• insulin/dextrose infusion: short-term shift in potassium from ECF to ICF
• other treatments such as nebulised salbutamol may be given to temporarily lower the serum potassium

Question 64

Main principles of management of DKA

(4)

Answer 64

fluid replacement

• most patients with DKA are deplete around 5-8 litres
• isotonic saline is used initially, even if the patient is severely acidotic
• please see an example fluid regime below.

insulin

• an intravenous infusion should be started at 0.1 unit/kg/hour
• once blood glucose is < 15 mmol/l an infusion of 5% dextrose should be started

correction of electrolyte disturbance

• serum potassium is often high on admission despite total body potassium being low
• this often falls quickly following treatment with insulin resulting in hypokalaemia
• potassium may therefore need to be added to the replacement fluids
• if the rate of potassium infusion is greater than 20 mmol/hour then cardiac monitoring may be required

long-acting insulin should be continued, short-acting insulin should be stopped

Question 65

A 23-year-old female presents with headache, pains in her arms and legs, and feeling weak. She feels that she is getting worse. She has no past medical history apart from a miscarriage two years ago.

She has a normal neurological and musculoskeletal examination. There are no ‘red flags’ in the history of the headache. Her GP performs a full set of bloods, which are all normal.

Which of the following is the most likely diagnosis?

Answer 65

Somatoform disorder involves the dysfuntion (without organic cause) of one or more bodily system.

In hypochondriasis the patient worries they have a specific disorder

Question 66

You are asked to see a 20-year-old man who has earlier had an incision and drainage of pilonidal abscess.

The nursing staff are concerned that he is behaving strangely. He has previously admitted smoking cannabis socially.

When you arrive he is forcibly protruding his tongue and forcibly flexing his neck to the left and then the right. His eyes are deviated upwards and his pupils are dilated. His blood glucose is 5 mmol/L and routine observations are all within normal limits. He has been given paracetamol and an anti-emetic in the last 10 minutes.

What is the most appropriate treatment?

Answer 66

This is a case of oculogyric crisis, an acute dystonic reaction mainly seen with neuroleptics and also with the anti-emetic metoclopramide.

The clinical spectrum is poorly understood frequently leading to a mislabel of a psychogenic disorder.

The onset of a crisis may be paroxysmal over several hours or acute. Initial symptoms include restlessness, agitation, malaise, or a fixed stare followed by the more characteristically described maximal upward deviation of the eyes in the sustained fashion. The eyes may also converge, deviate upward and laterally, or deviate downward.

The most frequently reported associated findings are backwards and lateral flexion of the neck, widely opened mouth, tongue protrusion, and ocular pain.

The abrupt termination of the symptoms with procyclidine at the conclusion of the crisis is striking.

Question 67

organophosphate poisoning treatment

Answer 67

The definitive treatment for organophosphate poisoning is atropine

Question 68

A 67-year-old indigent male is admitted to hospital for osteomyelitis secondary to a diabetic foot ulcer. While in hospital it becomes apparent that he has significant memory impairment. When asked about the events that occurred this morning he reports a plausible story that is completely different from what actually occurred. He appears to have no conscious intent to deceive the medical staff. He has no insight into his memory impairment and completely denies any difficulties with memory. When his family is questioned they report that this memory impairment has been present for at least the last 4-5 months. He has a 40-year history of excessive alcohol consumption.

What is the most likely cause of his memory deficits?

Answer 68

The combination of anterograde amnesia, confabulation, lack of insight and chronic alcoholism support the diagnosis of Korsakoff’s syndrome.

Question 69

What is the mechanism of Disulfiram?

Answer 69

Disulfiram works by inhibiting the enzyme acetaldehyde dehydrogenase, causing many of the effects of a hangover to be felt immediately following alcohol consumption

Question 70

You are a core trainee on call in England when an informally admitted 40-year-old patient who is suicidal and may be suffering from psychosis threatens to leave the hospital.

Under which section of the Mental Health Act can you detain this patient?

Answer 70

Section 5(2) leads to patients being detained for up to 72 hours pending a Mental Health Act assessment

Question 71

Which blood test results would be altered in anorexia nervosa

(4)

Answer 71

Hypokalaemia

Hypochloraemic alkalosis (both due to vomiting and/or diuretic/laxative abuse)

Hypercholesterolaemia (mechanism unknown)

Low white cell count

Question 72

A 79-year-old man has a six month history of rapidly progressive memory impairment. He has also had bradykinesia and rigidity, which was not responsive to co-beneldopa (Madopar) and has recently become very aggressive to his wife.

What is the diagnosis?

Answer 72

This patient has Lewy body dementia hallmarked by the presence of Lewy bodies within the brain stem and neocortex.

There are features of parkinsonism which fail to respond to therapy and fluctuating cognitive loss.

Question 73

A 79-year-old man has a six month history of rapidly progressive memory impairment. He has also had bradykinesia and rigidity, which was not responsive to co-beneldopa (Madopar) and has recently become very aggressive to his wife.

What is the most likely diagnosis?

Answer 73

Lewy body dementia

This patient has Lewy body dementia hallmarked by the presence of Lewy bodies within the brain stem and neocortex.

There are features of parkinsonism which fail to respond to therapy and fluctuating cognitive loss.

Question 74

An 82-year-old lady with dementia presents from a nursing home with vaginal discharge.

High vaginal swabs have confirmed gonorrheal infection and she has been commenced on appropriate treatment.

What else would you like to do for this patient?

Answer 74

Discuss with the family

• This appears to be a case of elder sexual abuse.
• For those who are legally competent, voluntary referrals to social services, victims’ services, the criminal justice system, or any other appropriate resource agency are encouraged. Doctors should not report the incidence without the patient’s permission.
• Here this demented lady is not legally competent. In this case one should discuss this case with the next of kin first to establish if there truly is sexual abuse, or whether in fact this patient has been having a relationship with a third party.
• The facts should be established first before involving the police.
• If in any doubt, contact your medical defence organisation.

Question 75

A 30-year-old schizophrenic female attacks her mother believing that aliens have replaced her with an exact double.

What is the diagnosis?

Answer 75

This lady displays the classical features of Capgras syndrome.

Question 76

A 43-year-old male is scheduled to have an elective laparoscopic cholecystectomy the next day, held in the afternoon. The patient is diabetic, for which he usually takes gliclazide twice a day. The patient asks the doctor if he can still take his medication, as usual, leading up to the operation.

What should the doctor advise?

Answer 76

Take medication on the day prior to surgery and omit both doses on day of surgery

Surgery / sulfonylureas on day of surgery:

• omit on the day of surgery
• exception is morning surgery in patients who take BD - they can have the afternoon dose

Question 77

What is Pseudocholinesterase deficiency?

Answer 77

Pseudocholinesterase deficiency (also known as suxamethonium apnoea) is a rare abnormality in the production of plasma cholinesterases. This leads to an increased duration of action of muscle relaxants used in anaesthesia, such as suxamethonium. Respiratory arrest is inevitable unless the patient can be mechanically ventilated safely while waiting for the circulating muscle relaxants to degrade.

Question 78

Sodium Thiopentone contra-indications

Answer 78

Thiopental should be used with caution in cases of;

• liver disease
• Addison’s disease
• myxedema (advanced hypothyroidism)
• severe heart disease
• severe hypotension

Question 79

What is the main caution with Halothane?

Answer 79

Halothane is hepatotoxic. Despite this it remains in mainstream use. It should be avoided in patients with hepatic dysfunction, and scavengers should be used in theatres as accumulation of the drug may be injurious to theatre staff.

Question 80

You are called to see a 21-year-old man in the Emergency Department. He had cut his arm, and one of the junior doctors had been attempting to suture the wound. When injecting lidocaine, she had forgotten to draw back on the syringe to ensure she was not in a vessel. He initially started complaining of tongue numbness and a metallic taste in his mouth and has now developed generalised convulsions.

What is the most appropriate treatment?

Answer 80

Local anesthetic toxicity can be treated with IV 20% lipid emulsion

20% lipid emulsion (IV) can be used to treat local anaesthetic toxicity. This patient has had lidocaine, a local anaesthetic, injected intravenously and has subsequently developed local anaesthetic toxicity.

This is a medical emergency. Initial features may be agitation, confusion, dizziness, drowsiness, dysphoria, auditory changes, tinnitus, perioral numbness, metallic taste, and dysarthria. If not promptly recognised and treated, these signs and symptoms can progress to seizures, respiratory arrest, and/or coma.

Question 81

What is Sodium bicarbonate used to treat?

Answer 81

Aspirin overdose

Lithium toxicity

Question 82

The anaesthetist present decides that the patient should be intubated following rapid sequence induction, as there is concern over the patient’s airway. The anaesthetist delivers the sedation, then follows by delivering the muscle relaxant to allow for intubation.

Shortly after this, you notice a number of fine muscle twitches across John’s body for a few seconds, before profound paralysis occurs.

Which of the following medications has the anaesthetist most likely used to result in these symptoms?

Answer 82

Depolarising muscles relaxants like suxamethonium can cause fasciculations and are not reversible due to their mechanism of non-competitive agonism

Question 83

A 53-year-old woman is diagnosed with acute cholecystitis. She is scheduled for a cholecystectomy in 4 days. She currently takes 20 units of long acting insulin in the morning to control her type 1 diabetes.

What should her once-daily dose of insulin be on the day before surgery?

Answer 83

16 units

Surgery / diabetes: once-daily insulin dose should generally be reduced by 20% on the day before and the day of surgery

Question 84

A 56-year-old male patient is admitted to a surgical ward the day before a routine cholecystectomy. He has a background of type 2 diabetes mellitus and hypertension. Their drug history includes metformin 500mg BD, gliclazide 120mg BD, ramipril 5mg and atorvastatin 20mg.

On the morning of the surgery, the nurse on the drug round asks the doctor on the ward whether they should administer the morning dose of gliclazide written up. His surgery is scheduled for 9 am.

What should the doctor inform the nurse?

Answer 84

The morning dose of gliclazide should be held but the afternoon dose can be given

Surgery / sulfonylureas on day of surgery:

• omit on the day of surgery
• exception is morning surgery in patients who take BD - they can have the afternoon dose

Question 85

A 26-year-old man involved in a road traffic collision is assessed by the pre-hospital trauma team. It is determined that he required intubation with rapid sequence induction to manage his condition.

Etomidate is used as the induction agent for the procedure.

What severe side effect is important to be aware of when using this anaesthetic agent?

Answer 85

Adrenal suppression

Etomidate may result in adrenal suppression

Question 86

A 36-year-old man is attending fracture clinic with a fracture of his radius. Which of the following medications may slow the rate of healing of his fracture?

Answer 86

Use of NSAIDS will slow bone healing

Question 87

An 18-year-old woman is brought into the emergency department after being involved in a traffic collision.

She is minimally responsive, visibly pale, and groaning in pain.

You make several attempts at siting a cannula but fail.

What is the most appropriate next step in the management of this patient’s hypotension?

Answer 87

If intravenous access is difficult or impossible, consider the intraosseous (IO) route during a cardiac arrest

Question 88

A 65-year-old female is admitted for an elective total hip replacement of the right hip. On admission she is given thigh-length anti-embolism stockings to wear before surgery and until she regains mobility. It is hospital policy to also use a low molecular weight heparin for postoperative thromboprophylaxis.

According to NICE guidelines, when should this be initiated?

Answer 88

For elective total hip replacement surgery NICE recommend commencing a low molecular weight heparin 6-12 hours after surgery.

Question 89

The registrar requests an abdominal CT which demonstrates an anastomotic leak.

What is the most appropriate initial management of this patient?

Answer 89

An anastomotic leak is a surgical emergency and patients must be taken back to theatre as soon as possible

Question 90

DEPOLARISING ANESTHETIC AGENTS

Mechanism of action

Examples

Adverse effects (2)

Notes (2)

Contraindications

Answer 90

DEPOLARISING ANAESTHETICS

Mechanism of action

• Binds to nicotinic acetylcholine receptors resulting in persistent depolarization of the motor end plate

Examples

• Suxamethonium

Adverse effects (2)

• hyperkalaemia
• malignant hyperthermia

Notes (2)

• The muscle relaxant of choice for rapid sequence induction for intubation
• May cause fasciculations

Contraindications

• patients with penetrating eye injuries
• acute narrow angle glaucoma, as suxamethonium increases intra-ocular pressure

Question 91

NON-DEPOLARISING ANESTHETIC AGENTS

Mechanism of action

Examples (4)

Adverse effects

Reversal

Answer 91

NON-DEPOLARISING ANESTHETIC AGENTS

Mechanism of action

• Competitive antagonist of nicotinic acetylcholine receptors

Examples

• Tubcurarine
• atracurium
• vecuronium
• pancuronium

Adverse effects

• Hypotension

Reversal

• Acetylcholinesterase inhibitors (e.g. neostigmine)

Question 92

Four days after undergoing a right hemicolectomy for colon cancer, a 67-year-old woman develops vomiting. On examination she has a distended abdomen and no bowel sounds. Her temperature is 36.8 ºC, her blood results show the following:

CRP 124 mg/l

WBC 5.2 * 109/l

The nursing notes indicate she has not opened her bowels since undergoing surgery.

What is the most likely cause of all her symptoms and signs?

Answer 92

Paralytic ileus

In this patient:

• The vomiting and absent bowel sounds makes simple constipation less likely than paralytic ileus, especially this soon after surgery. Constipation would not account for all of her symptoms and signs.
• The caecum will have been removed as part of the right hemicolectomy so it could not be a caecal volvulus.
• The raised CRP is a normal response after surgery.
• Peritonitis would more commonly be associated with severe abdominal pain, tenderness and guarding as well as more severely raised inflammatory markers and fever.
• Hirschsprung’s disease is a congenital condition and would be very unlikely to present for the first time in a 67-year-old lady.

Question 93

A 77-year-old man is scheduled for an elective hip replacement on the next day. He has type 2 diabetes mellitus and is first on tomorrow’s list for surgery. He has been advised that he can continue taking a once-daily dose of metformin and his new anti-diabetic medication on the day of his operation. His general practitioner had recently changed the tablet he takes for his diabetes after he suffered from hypoglycaemic episodes with the previous medication.

Which medication is most likely to be his new anti-diabetic medication?

Answer 93

Surgery / diabetes: DPP IV inhibitors (-gliptins) and GLP-1 analogues (-tides) can be continued on the day of surgery

Question 94

A patient who underwent abdominal surgery 8 hours ago now has a temperature of 38.1ºC. Their blood pressure is 120/80 mmHg, heart rate 65 beats per minute and respiratory rate 15 breaths/minute. The patient states that they are experiencing pain around the incisional wound. On examination, the wound looks red and their chest is clear.

What is the most likely cause of pyrexia in this case?

Answer 94

Isolated fever in well patient in first 24 hours following surgery?

Think physiological reaction to operation

Question 95

There is feculent matter in a patient’s abdominal wound drain.

Which of the following imaging modalities is the most appropriate investigation?

Answer 95

An anastomotic leak can be diagnosed with an abdominal CT

Question 96

A 34-year-old woman presents with a lengthy post-operative ileus after extensive small bowel resection for Crohn’s disease. The surgical consultant suspects total intestinal failure after a prolonged postoperative period in which her remaining gut has failed to absorb.

Which route of administration is most appropriate for the delivery of nutrition in this patient?

Answer 96

• Subclavian line
• Total parenteral nutrition should be administered via a central vein as it is strongly phlebitic

Question 97

WHO (World Health Organisation) Surgical Safety Checklist

(7)

Answer 97

Before the induction of anaesthesia, the following must have been checked:

• Patient has confirmed: Site, identity, procedure, consent
• Site is marked
• Anaesthesia safety check completed
• Pulse oximeter is on patient and functioning
• Does the patient have a known allergy?
• Is there a difficult airway/aspiration risk?
• Is there a risk of > 500ml blood loss (7ml/kg in children)?

Answer 98

Question 99

You are working in the emergency department. On approaching the bedside of an elderly obese man, you find him quite drowsy. When you call out his name, you hear a grunting noise. You can see that the patient has periorbital ecchymosis and clear fluid leaking from one nostril. The patient’s oxygen saturations are 82% on air.

Which airway adjunct should you not use in this patient?

Answer 99

Nasopharyngeal airways are contraindicated in suspected are known base of skull fractures

Question 100

A 68-year-old woman presents to the orthopaedic surgery ward one day prior to an elective knee replacement. She has osteoarthritis and hypertension and is currently being treated for an episode of giant cell arteritis that occurred three months ago with 20mg prednisolone daily. She has never had surgery before and is anxious about the anaesthetic.

What is the most important drug to prescribe prior to surgery?

Answer 100

Hydrocortisone supplementation is required prior to surgery for patients taking prednisolone

Question 101

5W’s of Post-op Pyrexia:

Answer 101

• *5W’s of Post-op Pyrexia:**
• Wind (1day): atelectasis
• Water(3days): UTI
• Wound(5days): surgical site infection/abscess
• Walking(7days): DVT/PE
• Wonder-drugs(Anytime): adverse drug reaction

Question 102

A 6-year-old boy is found unconscious in the bath. He is brought into the emergency department as a paediatric cardiac arrest. They attempt to get peripheral IV access but cannot get a line in.

The registrar decides to put in an intraosseous line.

Which of the following is the most common insertion site for this type of line?

Answer 102

Intraosseous access is most commonly obtained at the proximal tibia

Question 103

For each of the following procedures select the most appropriate preparation with respect to ordering blood products:

Cystectomy

Appendicectomy

Elective abdominal aortic aneurysm (AAA) repair

Answer 103

Cystectomy

• Cross-match 4-6 units depending on local protocols

Appendicectomy

• Group and save

Elective abdominal aortic aneurysm (AAA) repair

• Cross-match 4-6 units depending on local protocols

Question 104

A 75-year-old man attends the surgical assessment unit prior to an elective Hartmann’s procedure in 7 days due to bowel cancer. He has a past medical history of atrial fibrillation, hypertension and previous cerebrovascular accident. Your registrar asks you to review him prior to his procedure next week. You notice that he is currently taking warfarin and his INR today is 2.6. His remaining blood tests are normal.

What is the most appropriate management for his anticoagulation peri-operatively?

Answer 104

Stop his warfarin and commence treatment dose low molecular weight heparin

Question 105

A 28-year-old female with no underlying comorbidities develops a sudden rise in temperature up to 40°C during a tonsil removal surgery. Her pulse rate rises to 160 beats per minute and systolic blood pressure is recorded as 180 mmHg. The patient also shows features of muscle rigidity in the limbs.

Her pre-anaesthetic evaluation before the surgery has been normal.

There is no known family history of neuromuscular disease or complications during surgery or anaesthesia.

It is noted that anaesthesia for this patient is induced on propofol and suxamethonium.

Which of the following is the definitive treatment for this patient in this scenario?

Answer 105

Malignant hyperthermia is a recognised serious side effect of suxamethonium among those who are susceptible and requires IV dantrolene therapy

Question 106

You are called to see a pyrexic 29-year-old female patient in the surgical recovery room after her appendectomy.

The patient doesn’t report any symptoms beyond malaise from the fever.

The nurse informs you that her temperature is 39.1ºC and confirms that she had an indwelling catheter placed for her operation.

Operation notes reveal that the appendectomy was performed 20 hours ago.

What is the most likely cause of the patient’s fever?

Answer 106

Isolated fever in well patient in first 24 hours following surgery?

Think physiological reaction to operation

Question 107

Which anaesthetic is used in haemodynamically unstable patients?

Answer 107

Ketamine is a good anaesthetic agent for haemodynamically unstable patients

Question 108

A 17-year-old man undergoes an elective right hemicolectomy. Post operatively he receives a total of 6 litres of 0.9% sodium chloride solution, over 24 hours.

Which complication may ensue?

Answer 108

Hyperchloraemiac acidosis

Excessive infusions of any intravenous fluid carry the risk of development of tissue oedema and potentially cardiac failure.

Excessive administration of sodium chloride is a recognised cause of hyperchloraemic acidosis and therefore Hartmans solution may be preferred where large volumes of fluid are to be administered.

Question 109

Doris, a 53-year-old woman with COPD and a 50-pack-year history, recently had a hysterectomy due to uterine fibroids. She had standard induction of anaesthesia with propofol and rocuronium, and maintenance with sevoflurane.

Her post-operative recovery period was complicated by apnoea on extubation and a prolonged stay in the intensive care unit (ICU) until she was weaned from the ventilator.

When she is better, the ICU doctor takes a complete history from her to try and ascertain why this has happened. She says she hadn’t thought it was relevant at the time but over the last few months she has been experiencing some double vision, worse at the end of the day, and weakness in movements of her hands and fingers, which again worsens throughout the day. She had put this down to tiredness.

What is most likely to have caused her prolonged reliance on the ventilator?

Answer 109

Patients with myasthenia gravis are very sensitive to non-depolarising agents

Non-depolarising agents, such as rocuronium, work by antagonism of nicotinic acetylcholine receptors in the motor end plate, producing paralysis by their blockade. This is in contrast with suxamethonium, which produces paralysis by acting on these receptors. The myasthenic patient has fewer available nicotinic receptors due to autoimmune-mediated destruction, meaning that they are more sensitive to non-depolarising blockade.

Question 110

A 24-year-old woman is airlifted to hospital with dyspnoea and severe chest pain after being thrown from a horse and trampled during an event.

On examination, there are reduced breath sounds on the left side of the chest associated with hyper resonant percussion, with the apex beat being shifted to the right. The patient’s right arm appears grossly deformed, consistent with a closed humeral fracture.

Given the examination findings, what drug should only be used with caution?

Answer 110

Nitrous oxide should be used with caution in patients with a pneumothorax

Question 111

You are working as a junior doctor on a surgical ward when you are asked to clerk in a 60-year-old woman who has been admitted with cholecystitis. Emergency surgery to remove her gallbladder has been scheduled for the following morning. The patient is first on the list.

The patient has a background of type 2 diabetes mellitus for which she takes metformin 1g twice daily. A recent HbA1c has come back very elevated at 95 mmol/mol but the patient has not yet seen her GP to discuss this. Admission bloods show normal renal function.

The ward nurse asks how this patient’s diabetes mellitus should be managed in the perioperative period.

Which is likely the most appropriate management?

Answer 111

A variable rate insulin infusion should be started

Surgery / diabetes: patients on insulin who are either undergoing major procedures (surgery requiring a long fasting period of more than one missed meal) or whose diabetes is poorly controlled, will usually require a variable rate intravenous insulin infusion (VRIII)

Question 112

You have been asked to see a 42-year-old man who just underwent a cholecystectomy under general anaesthesia yesterday. The procedure was uncomplicated but now has started vomiting, and complaining of headache, and flank pain.

On examination his capillary refill time is 6s, blood pressure is 98/43mmHg and weakness of his limbs.

8am cortisol 1.5µg/dL (10-20µg/dL)

ACTH 140ng/dL (>100ng/dL)

Which agent is the most likely cause of his symptoms?

Which patients is it preferred in?

Answer 112

Etomidate potentiates GABAa receptors.

It is preferred in patients with cardiac pathology as it causes less hypotension compared to propofol and thiopental.

Etomidate can however cause adrenal suppression so should be avoided in hypocortisolism.

Question 113

A 23-year-old female is due to undergo implantation of a middle ear prosthesis for sensorineural hearing loss. Her previous surgical history includes an appendectomy, for which she developed severe post-op nausea and vomiting.

Which of the following anaesthetic agents would be most appropriate to use?

Answer 113

Propofol is an antiemetic and is therefore particularly useful for patients with a high risk of post-operative vomiting

Question 114

What are the consequences of long term mechanical ventilation?

Answer 114

Long term mechanical ventilation in trauma patients can result in tracheo-oesophageal fistula formation

Question 115

A 65-year-old male undergoes a Hartmann’s procedure for a sigmoid cancer. On day 2 post-op, nurses are concerned as his colostomy has not passed any wind or stool yet and he is complaining of increasing bloatedness. You review the patient and witness him vomit profusely.

• *What is the diagnosis?**
• *How would you manage this common post-operative complication?**

Answer 115

Place the patient nil by mouth and insert a nasogastric tube

Post-operative ileus is a common complication in colorectal surgery due to intra-operative bowel handling.

Management is conservative with nasogastric tube insertion for stomach decompression for symptom control and placing the patient nil by mouth to allow bowel rest.

The recommencement of fluids/light diet should be in stages and guided by the clinical state of the patient.

Question 116

A 25-year-old male with no significant past medical history is taken to the operating theatre for an emergency appendicectomy.

He is induced with sevoflurane and maintained on sevoflurane and propofol.

A warning on the anaesthetic machine appears, due to elevated end-tidal CO2.

The patient appears unwell, with skin mottling and diaphoresis.

What is most likely responsible for this change in his presentation?

Answer 116

Volatile liquid anaesthetics
(isoflurane, desflurane, sevoflurane) may cause malignant hyperthermia

Question 117

A 23-year-old male comes in after crashing his motorbike into a bus stop. He is orientated to person place and time denies head trauma but is in extreme pain in many places.

Physical examination reveals pain and tenderness in the right leg, significant abdominal bruising, and tenderness diffusely over the ribcage.

His vitals are;

• Heart rate; 105 beats/min
• Blood pressure; 105/62 mmHg
• Respiratory rate; 20 breaths/min
• SpO2; 98% on room air

Imaging reveals a fractured right femur, multiple fractured ribs, and a fractured left tibia. He is consented and sent for emergency theatre.

Which of the following is most preferable as an induction agent for anaesthesia?

Answer 117

This patient has borderline low blood pressure, and therefore, in the context of his trauma, is at risk of low blood pressure intra-operatively.

Ketamine is an NMDA receptor antagonist that increases blood pressure and is, therefore, useful for general anaesthetic in patients with trauma.

Question 118

A 22-year-old fit and well male undergoes an emergency appendicectomy.

He is given suxamethonium.

An inflamed appendix is removed and the patient is returned to recovery.

One hour post operatively the patient develops a tachycardia of 120 bpm and a temperature of 40 ºC. He has generalised muscular rigidity.

What is the most likely diagnosis?

Answer 118

Anaesthetic agents, such as suxamethonium, can cause malignant hyperthermia in patients with a genetic defect.

Question 119

A 24-year-old female is due to undergo urgent surgery after sustaining traumatic injuries to her left leg in a car crash. She has a family history of malignant hyperpyrexia and last ate solid food 90 minutes ago.

Which of the following would be unsafe to use in this patient?

• Endotracheal tube
• Ketamine
• Laryngeal mask
• Non-depolarising muscle relaxants
• Sodium thiopentone

Answer 119

Laryngeal mask airway provides poor control against reflux of gastric contents therefore is unsuitable in non fasted patients