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Phase 4 > F1 cases > Flashcards

F1 cases Flashcards

1
Q

What are the common causes of bowel obstruction in a surgical patient

A
  1. Ileus (recent post op period)

2. Adhesions

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2
Q

Best fluids for ?bowel obstruction

A

NaCl - because been when vomit a lot a) get metabolic alkalosis and b) lose a lot of chlorine from HCL being thrown up. NaCl is therefore good choice of fluid with potassium added in.

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3
Q

Why should you get a CXR in ?bowel obstruction

A

To check for perforation

To check for lower lobe pneumonia

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4
Q

What is an ileus

A

Functional bowel obstruction - reduced bowel motility - nothing blocking it

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5
Q

What does coffee bean sign show on abdominal XR

A

Sigmoid volvulus

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6
Q

What follow up tests should you say you will do after a abdominal exam

A 
DRE
External genitalia 
Pelvic exam - females 
Hernial orifices 
Stool sample 
Urinalysis
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7
Q

How do you elicit murphy’s sign

A

Palpate liver edge as patient breaths in

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8
Q

What are the 3 possible causes of abdominal colic

A

Renal (stone, stricture, clot, tumour), biliary (gallstones), bowel (obstruction, hernia)

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9
Q

Indications for urgent surgery bowel obstruction

A

peritonitis
strangulation (severe pain)
complete small bowel obstruction
collapsing patient

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10
Q

What bloods need to be requested for a bleeding patient

Explain purpose of each one

A

Clotting - if they are going to need to go to theatre will need to know if they are coagulopathic
Group & save - will check blood group of patient and screens for atypical antibodies (NO BLOOD ISSUED)
Cross match - will mix patients blood with donor blood to check no reaction

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11
Q

What does a group and save do

A

A G&S determines the patient’s blood group (ABO and RhD) and screens the blood for any atypical antibodies; the process takes around 40 minutes and no blood is issued
A G&S is recommended if blood loss is not anticipated, but blood may be required should there be greater blood loss than expected

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12
Q

What does cross match do

A

A cross-match involves physically mixing the patient’s blood with the donor’s blood, in order to see if any immune reaction takes places; if it does not, the donor blood is issued and can be transfused in to the patient, otherwise alternative blood is trialled
This process also takes ~40 minutes (in addition to the 40 minutes required to G&S the blood, which must be done first), and should be done if blood loss is anticipated

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13
Q

What can you use for reversal of heparin and LMWH overdose

A

Protamine sulphate
Heparin antagonist
Works better for unfractioned heparin (Heparin) than LMWH
Does not work for fondaparinux

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14
Q

How can you distinguish chronic co2 retention in blood gas

A

Bicarb level
Assessing the HCO3 in conjunction with the CO2 can help differentiate if the CO2 retention is acute or chronic. This is known as the 1 for 10 rule. 1 for 10 rule. ACUTE: For every rise of 10 of the PaCO2 above 40 mmHg, the bicarbonate will rise by 1; CHRONIC: For every rise of 10 of the PaCO2 above 40mmHg, the bicarbonate will rise by 4

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15
Q

What can the anion gap be used for

A

Confirming metabolic acidosis

Narrowing down list of causes of metabolic acidosis

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16
Q

Why does hypoalbuminaemia cause metabolic acidosis

A

Because albumin carries ions and so the unmeasured ions carried by albumin creates the ‘gap’. If you have less albumin, you have more free ions and the gap balances out = low anion gap.

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17
Q

What process should you use for interpreting an ABG

A
  1. Ph - acidaemia, alkalaemia
  2. Respiratory or metabolic. CO2 (High or low) (T1 or T2 resp failure?). HCO3 and BE.
  3. Compensated - are there any changes in the other system that suggest compensation? Resp acute or chronic?
    Raised bicarb with COPD - chronic
  4. Anion gap - will narrow causes of metabolic acidosis
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18
Q

How do you check for compensation on an ABG

A

Identify if respiratory or metabolic
Then look if there is some counter-response from opposing system.
Can be partial (ph still abnormal)
Or full (ph pushed back to normal)

19
Q

How does a mixed ABG look

A

When the respiratory and metabolic components both show a pattern consistent with the direction on the ph, rather than just one, or just one plus compensatory pattern

20
Q

List a method for considering the possible differential diagnosis for an ABG result

A 
1. Resp - is it type 1 or type 2 RESP failure. 
Type 1 - V/Q mistmatch causes mainly 
Type 2 - ventilatory failure causes 
2. Metabolic
Anion gap - high, normal or low 
High - CAT MUDPILES
Normal - Na (hyponatramia), Bicarb (diarrhoea), Cl (?)
Low - hypoalbuminaemia
21
Q

When should you not give a 500ml fluid challenge

A

Heart failure/ ?valve disease

Trauma

22
Q

Whats the difference between pitting and non-pitting odema, how do you assess and grade it

A

Pitting - sign of poor circulation or blood pooling
causes are CCF, Renal disease (poor circulation), cirrhosis, cancer (low albumin), and venous insufficiency (pooling). Lymph normal.
Non-pitting - sign of lymph block, or myxedma (thyroid - mucopolysaccarides pass into tissues and so pull water back after being pushed so not pitting)

23
Q

What volume of fluid should you give as a fluid bolus and why

A

500 ml

250 ml elderly/ dodgy heart/ trauma

24
Q

what’s the max fluid you can give

A

2L

Unless have HF etc dont give this much

25
Q

what vital is the best indicator of when someone needs fluids

A

HR

if someone has a low BP and hr is low and urine output is ok, they dont need fluids

26
Q

what determines what fluid you pick

A

the u&e’s

27
Q

what determines how fast you give fluids

A

maintenance - 8 hourly (young-50/60)
older 10 hourly, 12 hourly
eg 80 year old - 12 hours

28
Q

if someone is at risk of overload how much fluid should you prescribe

A

only do 1 L as will need a fluid assessment after this

29
Q

how would you assess someone with new back pain

A 
weakness
numbness/ sensory loss - find a sensory level
bladder - retention 
bowels 
reflexes
bone / joint tenderness
range of movement
rectal exam
30
Q

what questions should you ask in patients with hx of malignancy and new back pain

A

worse when laying down
worse at night
worse on straining

31
Q

causes of hypoglycaemia

A

Too much insulin or sulphonylurea (eg gliclazide or tolbutamide)
Sulphonylureas cause the pancreas to release insulin

2) Not enough food at a meal, especially carbohydrate
3) Delayed or missed meal or snack

4) Other illness especially impaired renal function
action of both insulin and sulphonylurea (gliclazide) is prolonged in renal impairment
5) Exercise, for example during physiotherapy
exercise increases the body’s need for glucose as a source of energy

32
Q

At what blood glucose level do neuroglycopenic symptoms develop

A

<3.5

33
Q

when should you treat a hypo even if no clinical symptoms

A

glucose <4

34
Q

if someone has a gliclazide induced hypo, what needs to be prescribed afterwards

A

continuous glucose infusion 10%

35
Q

If a T1DM has a hypo how should you amend their insulin

A

NEVER STOP INSULIN

Can reduce next dose but never stop

36
Q

Causes of a hypo

A

diet (missed meals, what in the meal)
treatment (sulphonlyureas)
activity
physiology (sick/ illness etc)

37
Q

When is mixed insulin NEVER given

A

at bedtime

mixed always have to be given with a meal

38
Q

how many units of insulin are there in 1 ml

A

100 units

39
Q

what should you always write up with insulin

A

fluids - nacl if over >14 mmol or glucose 10% if <14 mmol

40
Q

How do you describe respiratory findings

A
  1. Breath sounds - present / absent
  2. Air entry - equal / reduced
  3. Bronchial breathing - density
  4. Crackles
  5. Wheeze - fine, coarse
  6. Rub - creaking
41
Q

what presentation for cord compression is most common

A 
bowel incontinence (weakness of pudendal nerve to contract EAS)
urinary retention (weakness of pudendal nerve to relax EUS)
42
Q

What bisphosphonate is given for hypercalcaemia in cancer

A

Zolendronic acid

43
Q

what bisphosphonates are used for hypercalcaemia

A

zolendronic acid

pamidronate

Phase 4 (1 decks)

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