Past papers 6 Flashcards
One minute to consider the case before examination, 10 minutes of verbal
communication, 4 minutes to move to the next question
Verbal Question 1:
A 46 year- old woman with systemic lupus erythematosus presented to her GP
with features compatible with ophthalmic shingles.
She was on prednisolone
and azathioprine and her creatinine clearance was 35 ml/min. Normal range >100ml/min
GP started oral aciclovir 800mg five times per day. Three days later, she presented to
Emergency Department [ED] with confusion and was admitted. The ED registrar called you to discuss.
Encephalitis - likely due to VZV
swab rash
Lumber puncture
CT head
Bloods - ALT hepatitis
Bloods - UE renal toxicity
CXR - pneumonitis
Alternative diagnosis is aciclovir drug neuro-toxicitiy.
Send pre-dose and post-dose bloods to Bristol for aciclovir/CMMG level.
Can also test levels in CSF
clarify history of aciclovir use, and whether drug resistance is possible
infection control - rash cant be covered - side room with droplet precautions
opthalmology care - eye drops
consider other causes of encephalitis - need travel/ exposure history
Why does neurotoxicity occur sometimes with aciclovir use?
elevated 9-CMMG levels - product of aciclovir metabolism
What is treatment of neurotoxicity following aciclovir use?
stop aciclovir
haemodialysis
new antiviral - famciclovir less associated with neurotoxicity. Could use another drug such as ganciclovir/foscarnet, but no data and not without their own risks
One minute to consider the case before examination, 10 minutes of verbal
communication, 4 minutes to move to the next question
An orthopaedic surgeon sustained a penetrative injury from a sharp piece of
bone when operating on a patient with multiple fractures following a road
traffic accident. The source patient was thought to be an intravenous drug
user. He remained unconscious after the operation and not expected to regain
consciousness anytime soon. The injured surgeon called you for advice
surgeon should contact occupational health to liaise with everyone
check first aid applied
check wearing gloves
Check records of source - any history of infection
take recipient bloods storage
check had HBV vaccine in past year
If not going to regain ocnsciousness, if no documentation that they would not want testing, can test source bloods for BBV, on basis that a human would want to help someone else. BHIVA guidelines. Document in notes. Must be an independent third party
HIV PEP - if not testing source, or results not in 72 hours, if high risk injury, and high risk patient, in city centre with HIV rate >0.2% - give HIV PEP
What is HIV PEP drugs?
disoproxil 245mg/emtricitabine 200mg fixed dose combination plus
raltegravir 1200mg once daily for 28 days
HIV PEP
about to start patient on PEP
What baseline tests are required?
All exposures:
1. Creatinine (and eGFR)
2. Alanine transaminase
3. HIV-1 Ag/Ab
4. If not known to be vaccinated with documented HepBsAb >10 IU: Hepatitis B serology
(HepBsAg, HepBsAb, HepBcAb)
5. pregnancy test
Sexual exposure: as for ‘all exposures’, plus chlamydia, gonorrhoea and syphilis testing.
One minute to consider the case before examination, 10 minutes of verbal
communication, 4 minutes to move to the next question
A 32 year -old male sewerage engineer presents with a 1-day history of fever,
abdominal pain, headache, myalgia and drowsiness. He had just completed a
3-month assignment in rural Nigeria and returned to UK two days prior to his
onset of illness.
The Emergency Department registrar has called you to
discuss.
What further history do you want to know?
History
where travel e.g rural/ urban
flight layovers
anti-malarials
pre-travel vaccines
occupational exposure
unwell contacts
funerals/ caves/ rat exposure
tick bites/ mosquito bites
water drank - disinfected?
housing stayed in
sexual history
PMHx
DHx
year
-
old female
with jaundice, dark urine,
encephalopathy
and multi
-
organ failure
.
The only
unusual history is a new sexual partner. Discuss
Possibly HSV disseminated - with no lesion
One minute to consider the case before examination, 10 minutes of verbal
communication, 4 minutes to move to the next question
A 32 year -old male sewerage engineer presents with a 1-day history of fever,
abdominal pain, headache, myalgia and drowsiness. He had just completed a
3-month assignment in rural Nigeria and returned to UK two days prior to his
onset of illness.
The Emergency Department registrar has called you to discuss.
What is your initial management?
VHF assessment - check map. Nigeria endemic Lassa. Check ProMed for outbreak information - including other outbreaks
if answers yes to any questions on VHF fever chart, then manage as VHF - side room, full PPE. Contact imported fever service. Possibly transfer to Royal Free
FBC - check platelets
UE -
LFTs
CRP
Coag
Blood film - malaria
Blood culture
Legionalla urinary antigen
Blood/ urine - Leptospira
Blood geographic - Chikungunya/ Rickettsia
CT head
Lumbar puncture
HIV test
HBV
HCV
You have been asked to write a business case for setting up rapid near-patient testing
[NPT] by molecular methods for respiratory viral infections in the Emergency Department
and its associated Clinical Decision unit (for patients considering possible admission) in
your hospital Trust.
What is point of care testing?
diagnostic testing performed in laboratory near patient (not the main laboratory), by medical staff who may not be trained laboratory staff
You have been asked to write a business case for setting up rapid near-patient testing
[NPT] by molecular methods for respiratory viral infections in the Emergency Department
and its associated Clinical Decision unit (for patients considering possible admission) in
your hospital Trust.
Which ISO regulation will Near Patient Testing fall under (since Dec 2022)
ISO 15189:2022 - Medical laboratories — Requirements for quality and competence.
You have been asked to write a business case for setting up rapid near-patient testing
[NPT] by molecular methods for respiratory viral infections in the Emergency Department
and its associated Clinical Decision unit (for patients considering possible admission) in
your hospital Trust.
Name 4 precise viral RNA/ DNA targets that could be in a NPT limited molecular viral panel?
SARS-CoV-2 RNA
Influenza A RNA
Influenza B RNA
RSV
You have been asked to write a business case for setting up rapid near-patient testing
[NPT] by molecular methods for respiratory viral infections in the Emergency Department
and its associated Clinical Decision unit (for patients considering possible admission) in
your hospital Trust.
name two commercial companies that manufacture these limited RNA panels?
Limited e.g Flu/RSV/ covid
DRW - Samba
Roche - Cobas Liat
Expanded
Qiagen - Qiastat
Biofire -Biomerieux
You have been asked to write a business case for setting up rapid near-patient testing
[NPT] by molecular methods for respiratory viral infections in the Emergency Department
and its associated Clinical Decision unit (for patients considering possible admission) in
your hospital Trust
Name 4 advantages of limited panels in an Emergency Department?
Faster turnaround - faster decision making
24/7 access to testing
Discharge faster
Start treatment faster
Antimicrobial stewardship
Better infection control
You have been asked to write a business case for setting up rapid near-patient testing
[NPT] by molecular methods for respiratory viral infections in the Emergency Department
and its associated Clinical Decision unit (for patients considering possible admission) in
your hospital Trust
Name three disadvantages of limited panels in an Emergency Department?
Cost of machines, consumables
Maintenance of equipment/ quality control
Training - results can be heavily user dependent
Lower sensitivity/ specificity - higher chance of false results, which could influence decision making
