Week 2 questions Flashcards
What’s the most likely diagnosis?
Small bowel ileus secondary to surgical anastomosis
Small vs large bowel obstruction
What initial investigations would you choose?
Question 4
The abdominal x-ray demonstrates multiple dilated loops of small bowel – the appearances would be in keeping with an ileus when combined with the clinical findings. Pelvic ultrasound shows a pelvic fluid collection suspicious of an abscess.
Which three of the following would you do next?
It is important at this stage to establish that the surgical anastomosis is intact and there is no evidence of leakage. Which one investigation would be must appropriate?
Which three of the following will help identify normal small bowel on an abdominal radiograph and allow differentiation from large bowel?
When talking to this woman, what would it be important to bear in mind?
Which procedure or action would be appropriate at this patient’s visit to the clinic?
Surgery - Perioperative Care 323
A 56-year-old man is seen in the preoperative assessment clinic. He is scheduled to undergo inguinal hernia repair in 2 weeks’ time. He is on treatment for hypertension, which was diagnosed 2 years ago. His medications are Amlodipine 5 mg daily and Aspirin 75mg daily. He smokes 10 cigarettes per day.
The aims of a preoperative assessment clinic include:
A haemoglobin concentration of 115 g/l in the blood taken at the clinic should lead to the following course of action:
Surgery - Perioperative Care 326
A 79-year-old woman slipped on the pavement and fractured her left hip. She had to undergo a hemiarthroplasty. On the first postoperative day, although clinically well, the patient was noted to have a haemoglobin (Hb) concentration of 70 g/L (120-155 g/L).
Concerning your evaluation of this patient:
Perioperative transfusion of donated blood may be decreased in surgical patients by:
Which one of the following should be requested for this patient?
18 hours after an elective total knee replacement, a 71-year-old patient was found to have a temperature of 38.2oC measured by a tympanic thermometer.
If the pyrexia did not resolve after a further 24 hours, what four further interventions should you perform on the ward?
The most common presentation of postoperative urinary tract infection is fever, lower abdominal pain and dysuria
A 58-year-old female who underwent an uneventful laparascopic cholecystectomy was admitted into the postoperative recovery unit at 11.00 am. She was expected to go home later that afternoon. Initial observations were within normal limits, but fours hours after surgery, the following were recorded: BP 70/40 mmHg, heart rate 65bpm. The patient was sitting up in bed, conscious, orientated and had only mild discomfort in the abdomen.
Which 2 of the following assessments are correct?
To assess whether the patient is hypovolaemic, a reasonable clinical test would be:
What is this patient’s mean arterial blood pressure (MAP)?
What three immediate interventions would be appropriate in the management of this patient?
Mr Chandler is 69-year-old man and undergoes elective total hip replacement (THR). On returning to the ward, he complains of some chest pain. The nurses find him to be tachycardic, with a BP of 115/78 mmHg. The nurses would like you to review him.
Question 1
On further questioning he does NOT have chest pain but feels ‘aware of my heart beating’. On examination, he looks well, radial pulse is irregularly irregular at a rate of 120, there are no added heart sounds. What is the most likely diagnosis?
What diagnostic tool will confirm this?
Which four of the following management options are appropriate?
Note-fluid level would be a flat line
Feedback
Manage the patient in the ABCDE approach.
Oxygenation would come first out of the options provided using this approach. Myocardial muscle needs Oxygen so it is important to put 15L via non-rebreathe mask first and continual cardiac monitoring is also recommended.
Nitrates administration is ordinarily second, because it will dilate the coronary arteries however in this case nitrates may be contraindicated in an inferior MI as they can cause severe hypotension. Then clopidogrel 300mg and aspirin 300mg.
Ultimately the coronary vessel needs to be re-opened via angioplasty, therefore involve cardiology ASAP so that arrangements can be made. Whilst the nurses are giving the aspirin and clopidogrel you can get on the phone to the cardiologist.
Tell them concisely the patient’s ECG findings, the nature of their chest pain and their risk factors (including that they are post-op). Also tell them what you have done so far. Whilst the cardiologist is coming you can ensure the patient has IV access and take the bloods. Do a VBG as that will give an instant Hb (anaemia worsens ischaemia).
They will need to take the patient for PCI so tell the nurses in case they need to do any paperwork/ transfer documentation. Your senior should also be keep up to date.
Long term the patient will need statins and cardiology can decide upon giving beta-blockers and ACE inhibitors.
New heart murmur and fever -infective endocarditis
Peripheral oedema, basal crackles and SOB - acute heart failure
SOB and pain on deep inspiration - pulmonary embolism
Febrile, tachycardic and productive cough -pneumonia
Central chest pain, non-radiating worse at night and relieved by eating -oesophagitis/gastritis
SOB, heavy smoker and occasional wheeze, productive cough -COPD
Lung bases are dull to percuss and poor air entry bilaterally -pleural effusion
Syncope: Sudden collapse (transient loss of consciousness) immediately waking on reaching the floor -aortic stenosis
This is a simplified list of ‘typical’ presentations and causes of SOB +/- chest pain. They are well worth excluding when assessing an unwell patient. Many complications could occur post-operatively and it is important to familiarise yourself with these.
Feedback
This description is in keeping with a diagnosis of acute heart failure. There are many causes including:
Decompensation of pre-existing chronic heart disease/failure
Myocardial ischaemic event (often silent MI)
Acute arrythmia
Fluid overload
Anaemia
Post surgery
ECG changes showing LV hypertrophy include:
Prolonged QRS (broad) Tall R wave (>5 squares) Left axis deviation Inverted T waves in V5/ V6 (if severe). The drug chart should be checked to ensure that all regular medications have been written up. The drug chart should be reviewed everyday on the ward round.
The patient should be catheterised and fluid balance chart started. This is imperative. If the urine output is low, then the patient requires IV fluids. IV access should be obtained (and bloods sent), to enable IV furosemide administration. The U&Es are needed to help consider which IV fluids and treatment options are appropriate. Gather the information, observations and refer to the Medical Registrar for help and advice if needed. The severity of heart failure will determine how quickly you contact them. Some hospitals also have a heart failure team/nurse who are a source of help when the patient is more stable. A CXR is required, but the patient should be stable if leaving the ward. If not, ask for a mobile X-ray.
- Antagonist of vitamin K
- Prothrombin inhibitor
- Intrinsic, extrinsic, and common pathway
- Common pathway
- Extrinsic pathway
Prior to a blood transfusion does Mr Globe needs to give verbal consent
Mr Globe has his colonscopy and a bleeding, benign polyp is removed. Due to his AF he needs to be put back onto some form of anti-coagulant / platelet for prophylaxis of thrombosis / emboli. This is not your decision as an FY, and may require a referral to on call cardiology team. What score can be used to ascertain whether warfarin or aspirin is indicated?
Mr Globe is recovering and has re-started warfarin. As he is getting ready to leave, he tells you he is on the waiting list for an elective operation: bunion correction, under the orthopaedic team. He wants to know what will happen to his warfarin and the operation. What advice would you expect pre-assessment to give him?
The principal difference between “general” anaesthesia and “regional” anaesthesia is:
Which of these drugs are considered local anaesthetics?
