Questions I got wrong-surgery

Question 1

You are an FY2 in the ED. A 20-year-old chef comes in with a cut on his hand from a broken glass. After assessing the patient and stabilising the bleeding, you discuss the patient with your registrar and decide to suture the wound in the department.
Your assessment of the patient should include:

Answer 1

Remember X-ray is open wound and radioopaque object used, but if not radioopaque and wound is closed then can use ultrasound

Question 2

You have cleaned the wound, set up your sterile field, and you are ready to inject local anaesthetic into the patient. Which 3 of the following will reduce the pain on injection and provide the most effective analgesia?

Answer 2

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Question 3

Which 2 of the following agents are the most suitable to provide initial pain relief for this patient prior to suturing?

Answer 3

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Question 4

Which 2 of the following are true regarding local anaesthetic agents?

Answer 4

Pain pathway: thermal, mechanical, or chemical stimuli → nociceptor stimulation → conversion of stimulus to an electric signal (action potential) → neural conduction of electric signal to the CNS → perception of pain
LAs bind to the inner portion of voltage-gated sodium channels of the nerve fibers; → reversible blockage of sodium channels → inhibition of nerve excitation and impulse conduction (pain signals) → local anesthesia in the area supplied by the nerve
LAs with 3° amine structure infiltrate membranes in their uncharged form, then bind to ion channels in their charged form.
The susceptibility of nerve fibers to LA depends on their firing rate, size, and myelination.
Rapidly firing neurons are blocked more effectively than slow-firing neurons.
Small diameter nerves are the first to be anesthetized.
Myelinated nerves are blocked faster than unmyelinated nerves.
Because size is thought to outweigh myelination, nerve fibers are blocked in the following order:
Small myelinated fibers
Small unmyelinated fibers
Large myelinated fibers
Large unmyelinated fibers

Loss of sensation occurs in the following order:
Pain
Temperature
Touch
Pressure

Factors that affect the efficacy of LA
Use of vasoconstrictors (e.g., adrenaline) reduces bleeding and systemic absorption of LAs, leading to a prolonged anesthetic effect.
Inflamed/infected tissue: decreased efficacy of LAs
LAs are composed of a lipophilic group and a hydrophilic group, and permeability depends on which group is predominant.
Because inflamed tissue has an acidic environment, alkaline anesthetics are charged; and the hydrophilic group predominates → ↓ ability to penetrate the nerve cell membranes → ↓ efficacy

Question 5

Which of the following are possible side effects of local anaesthetics?

Answer 5

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Question 6

Question 1

A drug chart is shown below (Figure 1). Identify two prescribing errors on the chart.

Answer 6

See next question for full stem of question for this one!

Question 7

Which one of the following regimens would have been most appropriate for re-starting this patient on warfarin?

Answer 7

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Question 8

Question 3

You are concerned that his Hb has dropped and are unhappy to re-prescribe warfarin without knowing the INR. You check his INR and it is now 5.5.
What 3 reasons explain why the patient is now over anti-coagulated on 3mg daily of warfarin when he was previously OK on this dose?

Answer 8

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Question 9

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Answer 9

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Question 10

Initial diagnosis=

Answer 10

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Question 11

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Answer 11

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Question 12

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Answer 12

When transfusing an anaemic patient Packed Red Cells should be requested. Packed red blood cells are red blood cells that have been separated from whole blood by a centrifuge. The red blood cells are denser and settle to the bottom, and the majority of the liquid blood plasma remains on the top. The plasma is separated and the red blood cells are kept in a preservative solution. The solution can consist of saline, adenine, glucose and mannitol (SAGM) although there are others.

In the UK all blood undergoes leukodepletion, where the donor blood is filtered to remove white cells to minimise risk of transmission of vCJD. Blood may also be irradiated, which destroys the DNA in the white cells and prevents graft versus host disease. With additive solutions, RBCs are typically kept at refrigerated temperatures for up to 42 days. Whole blood is no longer available.

Cryoprecipitate is a blood component rich in fibrinogen and used specifically when a patient has low levels, which can occur in massive haemorrhage or Disseminated Intravascular Coagulation (DIC). Fresh frozen plasma is used to replace clotting factors. Using any blood product other than Packed Red Cells will involve a discussion with the haematology department.

Question 13

A 74-year-old woman who lives in a residential home falls and fractures her right wrist. You see her in your dedicated falls and bone health clinic.

Answer 13

According to guidelines published by NICE, Denosumab is an alternative treatment for ‘who are unable to comply with the special instructions for administering alendronate and either risedronate or etidronate, or have an intolerance of, or a contraindication to, those treatments’ and satisfy various other clinical risk factors.

The spinal column and the hips are the most exposed bones and joints to the impact of weight of the body and vulnerable to fragility fractures.

Question 14

The clinical diagnosis can be confirmed by Tinel’s sign and Phalen’s test. A nerve conduction test can be used to confirm the diagnosis.

Answer 14

The usual treatment is rest, splintage, anti-inflammatory medication and steroid injection, but the majority of the people require release of the carpal tunnel, which is a very successful operation and can be done under local, regional or general anaesthetic.