Day 8 A&E Flashcards
Which intravenous induction agents is the preferred agent for day case anaesthesia?
Propofol has an elimination half life of four hours hence it has a short duration of action.
It is suitable for day case procedures and ITU sedation.
Etomidate is no longer used because it causes significant postoperative nausea and vomiting, has been associated with venous thrombosis and interferes with glucocorticoid production.
A 26-year-old man presents with a red and painful right eye. He also gives a history of episodic back pain and stiffness, particularly when he wakes up in the mornings.
What is the diagnosis?
Ankylosing Spondylitis
Gout vs Psuedo-gout (pyrophosphate arthropathy)
A 35-year-old businessman presents with a two week history of a swollen right knee. On further questioning, he admits that he has recently had unprotected intercourse during a business trip, and has developed a discharge from his penis.
What is the diagnosis?
reactive-arthritis
Reactive arthritis is a sterile synovitis which occurs following an infection. In this patient, the infection is likely to be sexually transmitted.
A 45-year-old woman has a fungating metastatic breast cancer and is increasingly distressed by the malodorous discharge from the affected breast, which is causing considerable social embarrassment.
How should she be treated?
Metronidazole may improve smells emanating from anaerobic organisms that infect fungating tumours.
INTRA VS EXTRACELLULAR FLUID
Which has a higher protein concentration
Which has a higher phosphate concentration
Which has a higher potassium concentration
Which has a higher osmolarity
Which has a higher pH
Which has a higher protein concentration
- extracellular
Which has a higher phosphate concentration
- extracellular
Which has a higher potassium concentration
- extracellular
Which has a higher osmolarity
- extracellular
Which has a higher pH
- intracellular
An 80-year old woman reports severe paroxysms of knife-like or electric shock-like pain, lasting seconds, in the lower part of the right side of her face.
What is the diagnosis?
How should she be treated?
Carbamazepine provides effective relief for this brief and intense stabbing pain within the distribution of the trigeminal nerve, known as trigeminal neuralgia. The usual dose is 100-400 mg, 8 hourly.
How is brain stem death confirmed?
Brain stem death (BSD) is confirmed by demonstrating the absence of brain stem reflexes, and is characterised by profound coma. Before the tests can be performed, several preconditions must be met unequivocally:
- the presence of apnoeic coma
- a defined cause of severe and irreversible brain damage and
- the exclusion of potentially reversible conditions which can mimic BSD (hypothermia can mimic BSD, so the core temperature must be above 34°C).
The tests must be performed by two doctors and then repeated following an interval determined by the clinical condition of the patient (not 24 hours apart).
The confirmatory tests include:
- fixed unresponsive pupils with absence of both the direct and consensual light reflexes (the pupils do not have to be dilated and pupil size is not a factor)
- absent corneal reflexes
- absent vestibulo-ocular reflexes
- absent motor activity after painful stimulation
- absent gag reflex
- absence of spontaneous respiration.
Name the drug
Discontinue 1 week before surgery.
Discontinue and replace with subcutaneous/intravenous equivalent 48-72 hours before surgery.
Inform anaesthetist and continue therapy up to and after surgery if appropriate.
Discontinue oral administration but replace with intravenous equivalent at induction.
Discontinue 1 week before surgery.
- Clopidogrel
Discontinue and replace with subcutaneous/intravenous equivalent 48-72 hours before surgery.
- Oral anti-coagulants
Inform anaesthetist and continue therapy up to and after surgery if appropriate.
- antihypertensives
Discontinue oral administration but replace with intravenous equivalent at induction.
- oral corticosteroids
Which ECG findings are associated with:
Hyperkalaemia
Wolff-Parkinson-White disease
Pericarditis
Hyperkalaemia
- widened QRS complex (>120 msec) when the potassium is >6.5
Wolff-Parkinson-White disease
- delta wave (notch) preceding the QRS complex
Pericarditis
- Pericarditis is associated with concave upward ST segment elevation on the ECG, versus convex upward ST segment elevation in MI.
A 52-year-old male in the post-operative ICU with a central line catheter develops spikes of fever.
Which of the following is the likely causative organism?
Coagulase-negative Staphylococci
Coagulase-negative Staphylococci are among the most commonly isolated bacteria in clinical microbiology laboratories.
Such coagulase-negative, novobiocin-susceptible Staphylococci as Staphylococcus epidermidis have emerged as a major cause of infection, particularly in hospitalised patients with indwelling foreign bodies and in immunocompromised patients.
What is the aetiology of carcinoid syndrome?
(3)
- usually occurs when metastases are present in the liver and release serotonin into the systemic circulation
- may also occur with lung carcinoid as mediators are not ‘cleared’ by the liver
- arise from enterochromaffin cells
What is pellagra
a deficiency disease caused by a lack of nicotinic acid or its precursor tryptophan in the diet.
Investigations for carcinoid syndrome (2)
urinary 5-HIAA
plasma chromogranin A y
A 60-year-old woman has developed bowel obstruction secondary to inoperable ovarian cancer. She is complaining of colicky abdominal pain which is not controlled by high doses of morphine.
How should she be treated?
Hyoscine butylbromide (more commonly known by its trade name, Buscopan) is an antimuscarinic which can be used to treat pain associated with smooth muscle spasm.
An 80-year-old man with spinal metastases from prostate cancer complains of increasingly severe back pain, despite being on a high dose of oral morphine, regular NSAIDs, and alendronic acid. Spinal cord compression is ruled out by MRI scanning.
What is the best next treatment step?
Radiotherapy is often helpful in bone pain from metastatic cancer.
A 91-year-old woman with multiple myeloma complains of severe abdominal pain, vomiting and constipation.
Her serum calcium is 3.6 mmol/L.
How should she be treated?
Abdominal pain, vomiting and constipation are symptoms of hypercalcaemia.
The first line treatment is intravenous rehydration.
Bisphosphonates (for example, intravenous pamidromate) are also used, but take longer to act.
To visualise the vocal cords, the tip of a Macintosh laryngoscope should be inserted into what?
The Macintosh laryngoscope blade has a small bulbous tip, which is designed to sit in the vallecula.
Actions of metoclapromide
(5)
Stimulates upper gastrointestinal motility
increases gastroesophageal sphincter tone
decreases gastric acid secretion
Acts on central dopaminergic receptors
Increases gastric fluid pH
How do the following drugs relieve pain in cancer?
Pinaverium
Carbamazepine
Clodronate
Corticosteroids
Nifedipine
Oxybutynin
Pinaverium is used to reduce the pain duration in irritable bowel syndrome (IBS).
Carbamazepine is in use for the treatment of neuropathic pain of malignancy, diabetes and other disorders.
Clodronate inhibits osteoclastic bone resorption and is used to treat malignant bone pain and the associated hypercalcaemia.
corticosteroids are used to treat pain from central nervous system tumours. Reducing the inflammation and oedema relieves the pain caused by neural compression.
Nifedipine helps relieve painful oesophageal spasm and tenesmus associated with gastrointestinal tumours.
Painful bladder spasm may be relieved by oxybutynin.
Which one of the listed diagnoses is typically associated with the following conditions?
Eisenmenger’s syndrome
Ankylosing spondylitis
Syphilitic aortitis
Which one of the listed diagnoses is typically associated with the following conditions?
Eisenmenger’s syndrome
- Ventricular septal defect
Ankylosing spondylitis
- Aortic regurgitation
Syphilitic aortitis
- Aortic regurgitation
A 65-year-old man presents with a six month history of deteriorating breathlessness.
He is found to have aortic stenosis.
Which physical sign provides the best clinical marker of the severity of the valvular disease?
Length of the murmur
In cases of aortic stenosis, the murmur tends to become longer as the disease is more severe because of the longer ejection time needed.
You are asked to see a 55-year-old patient two days after undergoing a left total knee replacement. He complains of weakness of movement of his right foot since surgery.
He had a spinal anaesthetic and wonders if this was the cause although no complications were reported at the time.
He is otherwise well and clinical examination confirms suspected foot drop as there is weaked dorsiflexion of his right foot.
What is the likely cause?
Poor intra-operative positioning and padding
- Prolonged pressure on the common peroneal nerve during anaesthesia is a well documented cause of post-operative foot drop.
- One must ensure adequate padding on the fibula head when positioning patients under general or regional anaesthesia for long periods of time.
An elderly woman with severe ischaemic heart disease complains of stiff, painful hands, neck, knees and feet.
Examination of the hands reveals Heberden’s nodes.
What is the diagnosis?
What is the treatment?
osteoarthritis
paracetamol
Acute management of gout
(6)
NSAIDs or colchicine are first-line (not in asthmatics)
colchicine* has a slower onset of action. The main side-effect is diarrhoea
oral steroids may be considered if NSAIDs and colchicine are contraindicated. A dose of prednisolone 15mg/day is usually used
another option is intra-articular steroid injection
if the patient is already taking allopurinol it should be continued
Causes of AF
(8)
- Thyrotoxicosis
- Mitral valve disease
- Congenital heart disease
- Previous cardiac surgery
- Pericarditis
- Ischaemic heart disease
- Pulmonary embolism
- Pneumonia
Which monoamine oxidase inhibitors need to be stopped before general anaesthesia? (4)
How long prior to the surgery must they be stopped?
- Isocarboxazid
- Phenelzine
- Selegiline
- Tranylcypromine
should be stopped at least two weeks prior to elective surgery.
At what age can children consent to treatment in the United Kingdom independent of parents’ influence?
Some children below this age are able to give fully informed consent independent of their parents. What term is used to describe such children?
The patient is worried about being confused after the operation. List common causes of post-operative confusion.
At what age can children consent to treatment in the United Kingdom independent of parents’ influence?
16 years old (2)
Gillick competence can occur at any age (1)
Some children below this age are able to give fully informed consent independent of their parents. What term is used to describe such children?
Gillick competence/competent (2)
The patient is worried about being confused after the operation. List common causes of post-operative confusion.
- Hypoxia (2)
- Pneumonia (2)
- Atelectasis (2)
- Left ventricular failure (1)
- Pulmonary embolism (2)
- Drugs (2)(opiates, sedatives, etc.)
- Urinary retention (2)
How do the following anti-emetics work?
Cyclizine
Dexamethasone
Granisetron
Droperidol
Prochlorperazine
metoclapromide
Prochlorperazine and droperidol are both dopamine antagonists.
Cyclizine is an anticholinergic drug.
Granisetron is a 5HT3 receptor antagonist, is of the same class of drug as ondansetron and metoclapromide.
Both granisetron and dexamethasone are useful antiemetics in the management of nausea and vomiting secondary to cytotoxic chemotherapy.
What are “confabulations”?
Confabulation is the creation of false memories in the absence of intentions of deception
You are asked to see a 60-year-old man on the high dependency unit who has just returned from theatre.
He has undergone a left hemicolectomy for colon carcinoma. You are asked to prescribe his intravenous fluids.
How can you best judge the rate at which the fluids should be infused?
Measure his urine output and adjust accordingly
How does THC act to block pain?
(4)
Cannabinoids are derived from the resin of cannabis sativa, and 9-tetrahydrocannabinol (9-THC) is its most important pharmacologically active constituent.
Oral bioavailability of THC, whether given in the pure form or as THC in marijuana, is low and extremely variable, ranging between 5% and 20%, with effects occurring 0.5-3 hours later. Bioavailability of THC in a marijuana cigarette or pipe also rarely exceeds 10-20%.
Naloxone and other opioid receptor antagonists block the analgesic actions of cannabinoids.
Synthetic cannabinoids reduce arachidonic acid-induced inflammation by inhibiting eicosanoid production.
Hypothermia facts
Hypothermia is defined as a core temperature of less than 35°C.
Children have a relatively large body surface area to weight ratio and even though they have a higher basal metabolic rate they are very susceptible to hypothermia.
Alcohol and anaesthetic gases cause vasodilatation, thus increase heat loss.
As the core temperature continues to fall the cardiac rhythm becomes increasingly unstable, sinus bradycardia tends to give way to atrial fibrillation followed by ventricular fibrillation and finally asystole.
In hypothermic patients, J waves are frequently seen on the ECG.
A 24-year-old previously well male gives a history of right iliac fossa pain associated with anorexia and vomiting.
Acute appendicitis is suspected and he is booked for an appendicectomy.
Please select the most appropriate choice of anaesthetic
Rapid sequence induction with cricoid pressure
This patient has an acute abdomen and he needs an urgent operation.
We do not know when he last had food but gastric emptying will be delayed even if there is no ileus.
Therefore, the risk of regurgitation and subsequent aspiration is high.
To protect his airway a cuffed endotracheal tube must be secured following a rapid sequence induction.
Cricoid pressure is applied in attempt to occlude the oesophagus and thus reduce the risk of gastric contents being aspirated.
A regional technique is contraindicated in the presence of a raised white cell count.
A 28-year-old female is scheduled to have a knee arthroscopy and possible anterior cruciate ligament (ACL) reconstruction. She smokes 20 cigarettes per day and has asthma.
She admits to never using the prescribed inhalers.
What is the most appropriate method of anaesthesia?
The main issues for this patient is is that she is a heavy smoker, has asthma and is non-compliant with her medication.
A spontaneously ventilating technique using an LMA is the method of choice.
As an LMA does not enter the trachea, the risk of coughing and bronchospasm is reduced.
Unless an LMA is contraindicated, avoiding intubation would be the sensible choice.
A knee arthroscopy is a short procedure but if an ACL reconstruction is required it can increase the duration of surgery by several hours.
A regional technique avoids any stimulation of the airway but the anticipated duration of surgery cannot be clearly defined.
A spinal would be acceptable, but should the procedure be prolonged then conversion to a general anaesthetic may be necessary.
The block provided by an epidural takes time to become established but would be preferable to a spinal as the block can be supplemented if the surgery is extended.
A 59-year-old female has fallen and presents with a displaced fracture to the distal radius. Her past medical history includes an inferior myocardial infarct four months ago and anticoagulation for atrial fibrillation. She has been nil by mouth for six hours and is booked for a manipulation under anaesthesia (MUA).
What is the most appropriate method of anaesthesia?
This is a high risk patient and alternatives to general anaesthesia should be considered.
A Bier’s block (intravenous regional anaesthesia) can provide anaesthesia for minor surgery to the distal ends of both upper and lower limbs.
A tourniquet is applied and a suitable local anaesthetic injected intravenously.
Using a double cuff can reduce discomfort.
A subclavian perivascular block is contraindicated in day case surgery due to the risk of pneumothorax and in anticoagulated patients.
Macrocytic anaemia may be caused by
(3)
Normocytic, normochromic anaemia may be caused by
(4)
Macrocytic anaemia may be caused by:
- Folate deficiency
- B12 deficiency, and
- Alcoholism.
Normocytic, normochromic anaemia may be caused by:
- Acute blood loss
- Haemolytic anaemia
- Chronic disorders, and
- Leucoerythroblastic anaemias.
Respiratory alkalosis
side effects of volatile anaesthetics agents
(2)
Severe hyperkalaemia and myoglobinuria may occur following prolonged exposure to volatile anaesthetic agents, therefore regional techniques are preferred.
What is Entonox?
Entonox is a mixture of 50% nitrous oxide and 50% oxygen that is stored in cylinders as a gas. The cylinders have a French blue body and blue and white quarters at the top.
If the gaseous mixture were to cool below its pseudocritical temperature of −6°C the oxygen and nitrous oxide might separate out by a process called lamination. Thus a potentially hypoxic and dangerous gas may be administered.
Although Entonox represents a flammable mixture, and both nitrous oxide and oxygen support combustion, the mixture is not considered explosive.
It is effective in short term analgesia, is safe to infant and mother with an onset after inhalation of 30 s and a duration of action after analgesia of approximately one minute.
Nitrous oxide (N2O) is not to be confused with nitric oxide (NO).
What is the difference between incidence and prevalence?
The incidence of the condition is the number of newly diagnosed cases of the condition over a specific period.
The prevalence is the proportion of people in the entire population who are found to be with disease at a certain point in time.
What is Hyoscine butylbromide used for?
Hyoscine butylbromide (commonly known by its tradename Buscopan) is used for symptomatic relief of pain associated with gastrointestinal or genito-urinary smooth muscle spasm.
Mebeverine is a simple antispasmodic and has no antimuscarinic action.
Hypokalaemia shows which phenomenom on ECG?
Delta waves
Hypocalcaemia shows which phenomenom on ECG?
prolonged QT interval
Hypothermia shows which phenomenom on ECG?
J waves
Pulmonary embolism shows which phenomenon on ecg?
right axis deviation
A 21-year-old female with Turner’s syndrome is reviewed prior to dental surgery.
On examination her blood pressure is 118/80 mmHg and she has a soft systolic murmur at the second right intercostal space.
What is the heart defect
Why?
Atrial septal defect
In the second case of a woman with Turner’s, a systolic murmur at the second right intercostal space would suggest aortic stenosis due to a bicuspid aortic valve rather than co-arctation where hypertension would be expected. Both coarctation and bicuspid aortic valves are found in Turner’s syndrome, with the latter commoner.
A 25-year-old male attends for eye surgery for anterior dislocation of the lens.
On examination, he is tall, has a blood pressure of 134/84 mmHg and has a mid systolic click with murmur at the apex.
What is the heart defect?
What is his underlying condition?
Mitral valve prolapse
Explanation
The final case of a young man with tall stature, anterior lens dislocation and a harsh mid systolic murmur at the apex suggests a diagnosis of Marfan’s syndrome which is associated with mitral valve prolapse.
In particular the harsh mid systolic murmur with click is typical.
A 73-year-old male is admitted for inguinal herniorrhaphy.
On examination, his blood pressure is 110/90 mmHg and auscultation reveals a harsh systolic murmur at the second right intercostal space.
What is the likely underlying heart defect?
Aortic stenosis
This patient has a harsh systolic murmur at the right second intercostal space and a narrow pulse pressure, suggesting aortic stenosis.
This is most likely to be due to calcific aortic sclerosis and echo would be required to assess the severity of this prior to surgery.
What are the contents of Hartman’s solution?
(5)
- Sodium
- chloride
- potassium
- calcium
- lactate
The features of Horner’s include: (5)
The features of Horner’s include:
- Partial ptosis
- Miosis (contraction)
- Apparent enophthalmos
- Lack of sweating, and
- Nasal stuffiness on the affected side.
An 83-year-old lady had an emergency laparotomy for a bleeding duodenal ulcer 18 hours ago. She has become pyrexial and pulse oximetry shows saturation of 90% on 2 litres of oxygen. Her blood pressure is normal but her pulse rate is 110/minute. Her respiratory rate is 20/minute and she has decreased breath sounds at the right base.
What is the likely diagnosis?
Atelectasis
This patient has had emergency upper abdominal surgery.
She is probably not breathing satisfactorily because of postoperative pain. She therefore has a reduced oxygen saturation.
At this stage, that is, less than 24 hours postoperatively the alveoli have collapsed because of inadequate ventilation.
At the present time she has not developed secondary infection but if she receives good pain relief and physiotherapy one should be able to avoid secondary infection of the collapsed alveoli.
Which of the volatile agents was associated with fulminant hepatitis following secondary exposure?
Halothane hepatitis may result in damage ranging from minor derangement in liver function tests to fulminant hepatic failure.
It has been described as the appearance of liver damage within 28 days of halothane exposure when other known causes of liver disease have been excluded.
Seventy five per cent of patients with halothane hepatitis have antibodies reacting to halothane-altered antigens.
Halothane should be avoided if:
- A previous exposure has occurred within three months
- There is a known adverse reaction to halothane
- There is a family history of adverse reaction
- Pre-existing liver disease.
Which agents cause Malignant hyperthermia?
Which agent is used to treat it?
Which agents cause Malignant hyperthermia?
Halothane
Suxamethonium
Which agent is used to treat it?
dantrolene
A healthy female is scheduled for a laparoscopic sterilisation.
Suitable muscle relaxation will be provided by which drug?
Muscle relaxation is required during the creation of a pneumoperitoneum, which provides a clear view and access to the fallopian tubes.
The anticipated duration of surgery is 20 to 30 minutes, thus atracurium is the best choice.
Suxamethonium is too short acting and pancuronium lasts too long.
A young male is due to have a large lipoma excised from his forearm.
Which agent would be a suitable intravenous induction agent to allow placement of an LMA?
Propofol is the best induction agent when planning to use an LMA.
It inhibits the pharyngeal and laryngeal reflexes faster than thiopentone or etomidate, providing optimal conditions for inserting the device.
A 52-year-old lady presents with nine days of heavy, continuous vaginal bleeding. Her periods have been irregular for the past year and the last period was six months ago. She is also complaining of frequent disabling hot flushes. She had a bilateral mastectomy four years ago for breast cancer and is taking tamoxifen.
What is the likely diagnosis?
There should be a strong suspicion of endometrial cancer in this perimenopausal lady with prolonged heavy vaginal bleeding.
Tamoxifen is a risk factor.
A 19-year-old medical student is admitted as an emergency case to a university hospital, as he was found semi-conscious at home.
On examination he has a Glasgow coma scale of 12, is febrile at 39.5°C, has a pulse of 120/min, has a blood pressure of 105/60 mmHg, is photophobic and has meningism.
The patient has been cannulated and blood cultures have been sent.
What is the most appropriate next step?
IV antibiotics followed by CT head and subsequent lumbar puncture
Causes of microcytic hypochromic anaemia
(2)
iron deficiency
thalassaemia
A 75-year-old Japanese lady who presents with haematemesis is noted to have bilateral ovarian swellings.
Which ovarian tumour is she likely to have?
Krukenberg tumour refers to secondary tumour in the ovary from a gastro-intestinal primary particularly stomach. The haematomas in Japanese women were meant to give a clue to the primary source and the fact that this was most likely to be the primary source and the ovarian swellings were likely to be secondary.
A 45-year-old lady complaining of breathlessness is noted to have pleural effusions and bilateral ovarian masses.
What is the likely ovarian tumour?
The syndrome described is Meigs’ syndrome and this is commonly associated with ovarian fibromas be they benign or malignant.
In this case benign pathology is probably sequestration of fluid to the ovary secondary to hypoproteinaemia in general leading to third spacing, other ascites and/or pleural effusions but the syndrome refers particularly to pleural effusions and ovarian masses.
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 likely diagnosis?
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.
A previously healthy 75-year-old white woman presents with acute onset of severe pain over the mid-thoracic spine. Examination reveals localised tenderness over T5. Serum calcium and alkaline phosphatase are normal, and ESR is 20 mm in the first hour.
What is the most likely diagnosis?
The most likely diagnosis is an osteoporotic vertebral collapse in a female of this age with a normal calcium and alkaline phosphatase, with only a mildly raised ESR, which may be normal for this age group.
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 most likely diagnosis?
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.
A healthy female is scheduled for a laparoscopic sterilisation. Suitable muscle relaxation will be provided by which drug?
Muscle relaxation is required during the creation of a pneumoperitoneum, which provides a clear view and access to the fallopian tubes.
The anticipated duration of surgery is 20 to 30 minutes, thus atracurium is the best choice.
Suxamethonium is too short acting and pancuronium lasts too long.
A young male is due to have a large lipoma excised from his forearm. Which agent would be a suitable intravenous induction agent to allow placement of an LMA?
Propofol is the best induction agent when planning to use an LMA. It inhibits the pharyngeal and laryngeal reflexes faster than thiopentone or etomidate, providing optimal conditions for inserting the device.
How does clopidgrel work?
How does warfarin work?
How do DOACs work?
How does Heparin work?
How does LWMH work?
How does clopidgrel work?
- The active metabolite of clopidogrel selectively inhibits the binding of adenosine diphosphate (ADP) to its platelet P2Y12 receptor and the subsequent ADP- mediated activation of the glycoprotein GPIIb/IIIa complex, thereby inhibiting platelet aggregation.
How does warfarin work?
- Warfarin blocks one of the enzymes (proteins) that uses vitamin K to produce clotting factors. 1972
How do DOACs work?
- Direct factor Xa inhibitors
How does Heparin work?
- Activates antithrombin III.
- Forms a complex that inhibits thrombin, factors Xa, IXa, Xia and XIIa
How does LWMH work?
- Activates antithrombin III.
- Forms a complex that inhibits factor Xa
A 73-year-old woman is admitted for left hip replacement. On examination, both cheeks appear rather ruddy, she has a blood pressure of 122/82 mmHg, a faint mid- diastolic murmur with no other sounds.
What is the likely cardiac abnormality?
Mitral stenosis
The elderly woman with a mid-diastolic murmur associated with a malar flush suggests mitral stenosis. The absence of a pre-systolic click or loud first heart sound would suggest that the valve may be calcified.
A 4-year-old boy presents with oedema of the ankles, face and abdomen.
Urine specimens reveal a heavy proteinuria and blood tests show that he is hypoalbuminaemic.
What is name of this syndrome?
What is its most likely cause in this case?
List two treatments you would consider in this patient.
List one complication of this condition.
What is name of this syndrome?
- Nephrotic syndrome
What is its most likely cause in this case?
- Minimal change glomerulonephropathy
List two treatments you would consider in this patient.
- Diuretics (2)
- Salt restriction (2)
- Steroids/ prednisolone (2)
List one complication of this condition.
- Venous thrombosis (2)
- Sepsis (2)
- Acute renal failure (2)
A 72-year-old man presents to his GP with a three month history of rectal bleeding and a change in bowel habit. He has also lost a stone in weight during this time.
The picture shows the appearance of this man’s fingers and nails.
What is the name given to the appearance of this man’s nails?
List a cause of this nail appearance.
What TWO abnormalities would you expect to see on this man’s full blood count?
What is the most likely diagnosis?
What is the name given to the appearance of this man’s nails?
- Koilonychia (2 marks), spoon-shaped (1)
List a cause of this nail appearance.
- Iron deficiency anaemia (2), anaemia (1)
What TWO abnormalities would you expect to see on this man’s full blood count?
- (Max 4) Low haemoglobin/anaemia (2), low MCV (2), iron deficiency anaemia (2)
What is the most likely diagnosis?
- Colon/rectal/colorectal carcinoma/cancer (2), diverticulosis, colitis (1)
Causes of cyanotic congenital heart disease (3)
tetralogy of Fallot (TOF)
transposition of the great arteries (TGA)
tricuspid atresia
Hereditary Spherocytosis vs G6PD
Gender
Ethnicity
Typical history
Blood film
Diagnostic test
