YEAR 5 OSCE Flashcards

Question

Which patient profile requires breaking confidentiality and informing social services?

Answer 1

Children (<18) and Adult w/o capacity

Answer 2

Adults with capacity who have not given their consent

Answer 3

Children and adults w/o capacity - social services Adults with capacity - police / Local domestic abuse service/ counselling service/ social services

Answer 4

**Emergency protection order **

Answer 5

1. Type (physical/sexual/emotional) 2. Perpetrator (Who is it/ whats the relationship) 3. Pattern (when/are drugs and alcohol involved) 4. Timeframe (how long/has the abuse been escalating?) 5. Coping (how have they coped/have they tried anything to stop it or get away?) 6. Who else is involved (any children or vulnerable adults?) Social History * Who do they live with * Are there weapons in the house * Does the patient have an emergency safety plan? - if not construct one with patient and signpost police * Do they work RISK Assessment * To patient: Do they currently feel in danger? What would happen if they go home? * Has it affected their mood? have they considered harming themselves or taking their own life? * Any children or vulnerable adults involved?

Answer 6

**NSAIDS** **Benzodiazepines** **Anti-cholinergics** **Tricyclic Antidepressants** **Glibenclamide** (causes hypoglycaemia) **Doxasozin** (adrenergic antagonist - BPH)

Answer 7

**Bournemouth Criteria:** **\> 90 -** automatically frail **Age: 75-89 -** **_2_** of the following to be considered frail: **Immobility** **Incontinence** **Cognitive impairment** (i.e dementia/delirum - does not include learning disabilities) **Instability** (i.e falls) **Iatrogenesis** (i.e polypharmacy - \> 5 drugs) \*65-75 - need to be instituionalised (nursing/residential home)

Answer 8

**Patient/ Their care giver _and_** * Doctors • Nurses * Therapy (OT/PT/Nutrition/swallow etc) * Social services * Community services * Pharmacist \*CGA is not a form but a process of accumulating data on patient by all team members\* Includes: **- Physical Assessment** (illness/pain/incontinence/nutrition?ADL's etc) **- Psychological (**Sleeping/Mental Health/Alcohol) **- Social** **- Medication review** These domains all inform _care plan_ for patient.

Answer 9

**• Gold Standard: Comprehensive Geriatric Assessment**: MDT approach holistic assessment considering _physical issues, function_, _environment/ support_, _mobility and balanc_e, _psychological issues and medication_. Care plans can be put in place * **Exercise** interventions: core strength, flexibility, balance, endurance training * **Good nutrition**, considering total protein intake, **calcium and vitamin D** * Role for **BMI reduction**? Raised BMI associated with poor outcomes **• Medication reviews** **• Advance care planning**

Answer 10

•Previous osteoporotic fragility fracture. * Current or frequent recent use of oral corticosteroids. * Low body mass index (less than 18.5 kg/m2) * Smoker. * Alcohol intake \> 14 units per week. * A secondary cause of osteoporosis

Answer 11

* Calculate 10 year fragility fracture score (eg FRAX or Qfracture) * https://www.sheffield.ac.uk/FRAX/ - Fracture Risk Assessment Tool * DEXA if score \>10% or Straight to DEXA if PMH fragility fracture

Answer 12

T score: A measurement of bone mineral density as compared to that of a 30 year old adult (Z score: compares your BMD to what is normal in someone your age and body size) * **Osteopenia**: T score **-1 to -2.4** * **Osteoporosis** T-score **-2.5 and below** **Normal range** T-score -1 and above

Answer 13

**• Anticholinergics**: unsteadiness, blurred vision, dry mouth, urinary retention, confusion **• Benzodiazepines**: falls, regular use increases all-cause mortality, confusion **• Opioids**: constipation, falls, delirium **• NSAID**: AKI and gastric ulceration • **Antihypertensives**: AKI, falls

Answer 14

Patients should be approached in the DR ABCDE manner. **Airway protection** (in patients presenting with depressed consciousness) and **aspiration precautions** (in patients presenting with swallowing impairment) are very important. Subsequent stroke management depends on whether the stroke is ischaemic or haemorrhagic. **CT head should be performed on arrival to the emergency department to distinguish ischaemic from haemorrhagic stroke.** (The _most sensitive test_ for confirming ischaemic infarct is a _diffusion weighted MRI._ This is generally used if the diagnosis is unclear but is not normally possible in the emergency setting due to logistical challenges) **Alteplase** (_tissue plasminogen activator_) is indicated in patients presenting within **4.5 hours of symptom onset** _and_ with **no contraindications to thrombolysis** (e.g. recent head trauma, GI or intracranial haemorrhage, recent surgery, acceptable BP, platelet count, and INR). **Mechanical Thrombectomy** can be performed in patients with _anterior circulation strokes_ within _6 hours_ of symptom onset, provided that they have a good baseline functional status and lack of significant early infarction on initial CT scan. Mechanical Thrombectomy can also be performed in _posterior circulation_ strokes up to _12 hours_ after onset. If hyper-acute treatments are not offered, **patients should receive aspirin 300 mg orally once daily for two weeks**. If hyper-acute treatments are offered (i.e thrombolysis or Thrombectomy), aspirin is usually started _24 hours after the treatment_ **and** following a **repeat CT Head** that excludes any new haemorrhagic stroke.

Answer 15

In **ischaemic stroke**: **carotid ultrasound** (to identify critical carotid artery stenosis), **CT/MR angiography** (to identify intracranial and extracranial stenosis), and **echocardiogram** (if a cardio-embolic source is suspected). In _young patients_ further investigation e.g. **a vasculitis screen** or **thrombophilia** screen may be necessary. In **haemorrhagic stroke**: **serum toxicology** screen (sympathomimetic drugs e.g. cocaine are a strong risk factor for haemorrhagic stroke). Further investigations to quantify vascular risk factors include: **- serum glucose** (all patients with stroke should be screened for diabetes with a fasting plasma glucose or oral glucose tolerance test) **- serum lipids** (to check for raised total cholesterol/LDL cholesterol).

Answer 16

Mnemonic **HALTSS:** + MDT!!! **Hypertension**: *No benefit in lowering the blood pressure acutely* (as this may impair cerebral perfusion) unless there is malignant hypertension (systolic blood pressure \>180 mmHg). _Anti-hypertensive_ therapy should, however, be initiated _2 weeks post-stroke_. **Antiplatelet therapy**: Patients should be administered **Clopidogrel 75 mg once daily** for long-term antiplatelet therapy. In patients with ischaemic stroke secondary to atrial fibrillation, however, **_warfarin_ (**target INR 2-3. **or** a **_direct oral anticoagulant_** (such as Rivaroxaban or Apixiban) is initiated _2 weeks post-stroke_. **Lipid-lowering therapy**: Patients should be prescribed high dose **atorvastatin 20-80 mg** _once nightly_ (irrespective of cholesterol level this lowers the risk of repeat stroke). **Tobacco**: Offer smoking cessation support. **Sugar**: Patients should be screened for diabetes and managed appropriately. **Surgery**: Patients with ipsilateral carotid artery stenosis more than 70% should be referred for carotid endarterectomy. **Rehabilitation and supportive management** will include an _MDT approach_ with involvement of _physiotherapy_, _occupational therapy_, _speech and language therapy_, and _neurorehabiliation._

Answer 17

**A history of falls is one of the strongest risk factors for a fall** - after a first fall, people have a 66% chance of having another fall within a year **Conditions that affects _balance,_ _mobility_ or _strength_**, such as arthritis, diabetes, incontinence, stroke, syncope, or Parkinson's disease. Other conditions, including _muscle weakness_, _poor balance_, _visual impairment_, _cognitive impairment_, _depression_, and _alcohol misuse_. **Polypharmacy**, or the use of psychoactive drugs (such as _benzodiazepines_) or drugs that can cause postural hypotension (such as _anti-hypertensive drugs_). **Environmental hazards**, such as loose rugs or mats, poor lighting, uneven surfaces, wet surfaces (especially in the bathroom), loose fittings (such as handrails), and poor footwear. The more risk factors a person has, the greater their risk of falling. Falls can also be a sign of underlying health issues, such as frailty

Answer 18

- **Analgesia** titration _to allow mobility_. - **Orthopaedic support,** but likely non-surgical (“_conservative_”) management. - **Delirium risk reduction** (Lighting/clock/continuation of staff). - **Medication review** - hold ACEi / beta-blocker / alpha blocker with low B.P. - **Multi-factorial falls assessment**, including _gait and balance_ / _lying and standing B.P_ / _medication review_ / _Alert technology whilst inpatient_, certainly patient activated “_call bell_” for assistance but with _dementia_ consider automated system such as a _falls alert mat_ / consider “_bay tag_” observation with cognitive impairment. - **Treat other co-morbidities** (for example, constipation,pneumonia) - **Patient education** with falls risk. - Further **cardiac monitor** (ECG) - **Further falls risk assessment as MDT** as part of discharge planning including: o **Medication review** when lying and standing B.P are known. o **Gait and balance specialist assessment** and balance and strengthening exercise programme and review walking aids. o **Environmental review** with interventions. o **Vitamin D supplementation** - check levels, fragility fracture / osteoporosis secondary prevention. o **Assistive technology** (falls sensor for possible future falls to alert and avoid “long lie”).

Answer 19

**When did you fall?** **Did anyone see you fall?** **Where did you fall?** **What happened before/during/and after?** **How many times have you fallen over the last few months?** **Bone health** - previous fractures / _family history of fracture_ / _smoking_, _alcohol_ / calcium intake **Previous Mobility**

Answer 20

_Non-specific_ **MOCA** **MMSE** **10/4 AMT** **6-CIT** _Delirum Specific_ **4AT**

Answer 21

Assume capacity unless patient gives you reason to doubt

Answer 22

65 Dipsticks become more unreliable with increasing age over 65 years. Up to half of older adults, and most with a urinary catheter, will have bacteria present in the bladder / urine without an infection. This “asymptomatic bacteriuria” is not harmful, and although it causes a positive urine dipstick, antibiotics are not beneficial and may cause harm.”

Answer 23

Recent surgery (14 days) Recent head trauma Intracranial or GI bleed (< 21 days) Low Platelets (<100,000/µl ) INR < 1.7 Hypertension (S: >185 or D: >110)

Answer 24

Bedside * Vital signs (BP/HR/RR/SpO2/Temperature - Sepsis/Bradycardia) * Lying and standing blood pressure (Orthostatic hypotension) * Urine dipstick (Infection/Rhabdomyolysis (+++ blood)) * ECG (Bradycardia/Arrhythmias) * Cognitive screening (e.g. AMT - Cognitive impairment) * Blood glucose (Hypoglycaemia secondary to poor oral intake) Bloods * Full blood count (Anaemia/Infection (raised white cells) * Urea and electrolytes (Dehydration/Electrolyte abnormalities/ Rhabdomyolysis) * Liver function tests (Chronic alcohol use) * Bone profile (Calcium abnormalities in malignancy/Over-supplementation of calcium) Imaging * Chest X-ray (Pneumonia) * CT head (Chronic or acute subdural/Stroke) * Echo (Valvular heart disease e.g aortic stenosis) Specialist * Tilt table test * Dix-Hallpike test (Benign paroxysmal positional vertigo) * Cardiac monitoring (e.g. 48hr tape) If no symptoms during monitoring episode in hospital.

Answer 25

WHO Who has seen you fall? Ensure adequate collateral history including addressing the when, where, what and why. WHEN * When did you fall? * What time of day? * What were they doing at the time? Looking upwards (vertebrobasilar insufficiency) Getting up from bed (postural hypotension) WHERE *Where did you fall? *In the house, or outside? WHAT *What happened before/during and after the fall? Before * Was there any warning? * Was there any dizziness/chest pain or palpitations? During * Was there any incontinence or tongue biting? (indicating seizure activity) * Was there any loss of consciousness? * Was the patient pale/flushed? (may indicate vasovagal attack) * Did the patient injure themselves? * What part of the body had the first contact with the floor? After *What happened after the fall? *Was the patient able to get themselves up off the floor? *How long did it take them? *Was the patient able to resume normal activities afterwards? *Was there any confusion after the event? (head injury) *Was there any weakness or speech difficulty after the event? (e.g. stroke/TIA) WHY *Why do you think you fell? *May have tripped over a rug or started a new medication HOW *How many times have you fallen over the last 6 months? Allows you to gauge the severity of the problem **DO A FULL SYSTEMS REVIEW CARDIO/NEURO/RENAL etc**

Answer 26

Power of attorney Independent mental capacity advocate (IMCA) Deprivation Of Liberty Safeguard form (DOLS)

Answer 27

narrow 120

Answer 28

Dipyridamole (antiplatelet) Carbamazepine

Answer 29

Asthmatics Verapamil Adenosine is known to regulate myocardial and coronary circulatory functions. Adenosine not only dilates coronary vessels, but ***attenuates beta-adrenergic receptor***-mediated increases in myocardial contractility and depresses both sinoatrial and atrioventricular node activities.

Answer 30

Syncope Deep vein thrombosis Embolism Cardiac tamponade Congestive cardiac failure Myocardial infarction Death

Answer 31

**Neurological:** 1. Altered mental state 2. Tremor 3. Ataxia 4. Hyperreflexia. **Autonomic:** 1. Tachycardia 2. Hypertension 3. Diarrhoea 4. Hyperthermia NB - Distinct from *Neuroleptic malignant syndrome *which is caused by **anti-psychotics or sudden reduction in dopaminergics** (i.e parkinson's). Predominant neurological feature of NMS is also** rigidity **

Answer 32

**Investigations** Bedside observations Arterial blood gas ECG Troponin if concerned about a new cardiac event Serum BNP Chest X-ray **Management** - ***POUR SOD*** - Take an ABCDE approach - Sit the patient up - Administer oxygen - Ensure IV access - IV Furosemide (40mg stat) * Consider non-invasive ventilation such as **CPAP** if failed medical therapy (usually in an intensive care setting) * Consider further therapies in the intensive care setting such as **invasive ventilation and inotropic support** if the above fails https://www.nice.org.uk/guidance/cg187/chapter/1-Recommendations

Answer 33

If ingestion _less than 1 hour ago + dose \>150mg/kg:_ **Activated charcoal** If _ingestion \<4 hours ago:_ **Wait until 4 hours** to take a level and **treat with N-acetylcysteine based on level usin**_g_** *_nomogram_*** If _ingestion 4-15 hours ago_: **Take immediate level and treat based on level** If _staggered overdose ( which is defined as being an overdose taken over > 1 hour) or ingestion \>15 hours ago:_ **Start N-acetylcysteine** immediately Obtain following bloods: **FBC** **Urea and Electrolytes** **INR** **Venous gas** If a patient presents *after 16 hours,* there is *uncertainty about timing * or has a staggered overdose then NAC should be started regardless of the nomogram. NAC is associated with anaphylactoid reactions. These are not true anaphylactic reactions and can usually be managed by stopping the infusion temporarily and then restarting at a lower rate. Consider need for transfer to liver unit if blood tests are worsening Management Flow chart: https://emj.bmj.com/content/19/3/202

Answer 34

Treating DKA (**FIG-PICK**) Follow local protocols carefully. **F **– Fluids – IV fluid resuscitation with normal saline. If patient is alert, not significantly dehydrated and able to tolerate oral intake without vomiting --> encourage oral intake and give subcutaneous insulin injection. If patient is vomiting, confused, or significantly dehydrated --> **give IV fluids (initial bolus of 10ml/kg 0.9% NaCl then discuss with a senior)** and **insulin infusion at 0.1 units/kg/hour 1hr after starting IV fluids.** If there is **evidence of shock, the initial bolus should be 20ml/kg.** If patient is shocked or comatose --> ABCDE approach for emergency resuscitation Do not stop intravenous insulin infusion until 1 hour after subcutaneous insulin has been given. **I **– Insulin – Add an insulin infusion (e.g. Actrapid at 0.1 Unit/kg/hour) ***G** - Glucose – Closely monitor blood glucose and add a dextrose infusion if below a certain level (e.g. 14 mmol/l) **P** – Potassium – Closely monitor serum potassium (e.g. 4 hourly) and correct as required ** I ** - Infection – Treat underlying triggers such as infection ** C ** - Chart fluid balance **K** - Ketones – Monitor blood ketones (or bicarbonate if ketone monitoring is unavailable) Establish the patient on their normal subcutaneous insulin regime prior to stopping the insulin and fluid infusion. Remember as a general rule **potassium should not be infused at a rate of more than 10 mmol per hour. Aim for: (1) a reduction in blood ketones of 0.5 mmol/L/hour if unavailable (2) a reduction in blood glucose of 3mmol/L/hr or Increase in venous bicarbonate of 3mmol/L/hr

Answer 35

hyperglycaemia acidosis ketonaemia Specific values to make the diagnosis: * Ketonaemia: 3mmol/L and over * Blood glucose over 11mmol/L * Bicarbonate below 15mmol/L or venous pH less than 7.3 **NB: ** - Hyperglycaemia may not always be present.

Answer 36

Unstable: **Thrombolysis** - (Streptokinase/Alteplase - seek senior input) Stable: **LMWH or UFH infusion** (5 days - and INR >2 on 2 consecutive days) -** bridge with NOAC or Warfarin ** NB - **Provoked PE** - 3 months DOAC and check INR. - **Unprovoked PE** - 6 months DOAC and check INR (Side note: remember warfarin takes time to titrate INR but also can be reversed quickly with Vit.K) Recurrent or treatment resistant: **Inferior Vena Cava Filter** NICE visual summary: https://www.nice.org.uk/guidance/ng158/resources/visual-summary-pdf-11193380893

Answer 37

Tricyclic antidepressants are noradrenaline and serotonin re-uptake inhibitors, and can be fatal in overdose. They can cause drowsiness, coma, seizures and cardiac dysrhythmia. Clinical Features Signs of a TCA overdose include: Neurological and cardiovascular! Drowsiness Confusion Arrhythmias Seizures Vomiting Headache Flushing **Dilated pupils** (not pinpoint as in opiate toxicity) Investigations Bloods: FBC, UE, CRP, LFTs, Venous Blood gas (look for evidence of acidosis) **ECG **may show evidence of QT interval prolongation which can precipitate a cardiac arrhythmia. Management Overall management is supportive and dictated by the patient's symptoms (sodium bicarbonate can be used). Patients should be reviewed by intensive care if any concerns about their airway (particularly in drowsy patients) or severe metabolic acidosis that might require renal replacement therapy. **Activated charcoal** can be considered within *2-4 hours* of the overdose

Answer 38

Prothrombin time (INR) The King's College Criteria (of which INR is a component) can be used in patients with acute liver failure due to acetaminophen in order to assess their prognosis and facilitate assessment for consideration of a hepatic transplant.

Answer 39

Details - patient/time/previous ECG's Rate - Rhythm strip X 6 Rhythm - count boxes between each QRS wave (use ruler and dots if neccessary) P wave - Present before every QRS? Yes - sinus NO? - AF etc. PR interval - <200ms or 5 boxes (each box 40ms or 0.04 secs). NO? - heart block. Primary secondary etc. QRS wave - < 3 boxes or 120ms/0.12 seconds. NO? - Bundle Branch BLock (BBB). - William Marrow (V1 and V6) ST segments - Compare with isoelectric line after the complex. (ST elevation is caused by a lack of blood supply to the muscle. The potassium channels responsible for depolarization are ATP dependent and thus cannot open when there is a lack of blood) T waves - inverted or flattened more than twice in each segment? Axis - look at leads 1 and 3 If lead 3 is greater in amplitude than lead 1 - consider axis deviation If leads arriving - right axis deviation If leads leaving - left axis deviation Everything else is normal. Other stuff - QT/QTc Interval / P wave morphology / Ventricular hypertrophy / Strain (amplitude of QRS - can be nromal in a skinny person)

Answer 40

Benzodiazepine (diazepam) Labetalol (beta and alpha blocker)

Answer 41

Flumazenil (a selective GABAA receptor antagonist) Only given in rare life-threatening circumstances

Answer 42

ABCDE - treat as appropriate Remember **POUR SOD MAN ** Pour away IV fluids Oxygen (high flow) Diuretic (IV furosemide 40mg) Morphine (venous system dilatory effect and reduces preload) Anti-emetic (Metaclopramide 10mg IV) Nitrates in severe pulmonary oedema (IV if systolic bp >110 2 sprays if systolic BP > 90) Step up therapy if this is refractory: Treat any other underlying cause (arrythmia/MIValvular dysfunction etc) CPAP Inotropes and Intra-aortic balloon therapy (ICU)

Answer 43

Treat underlying cause if appropriate *Pharmacological therapy:* **ABAL** ACEi/ARB Beta-blocker Diuretic if fluid overloaded If this fails to control symptoms: Aldosterone antagonist or Ivabradine *Non-Pharmacological:* Cardiac resynchronisation therapy if ORS > 0.12s/ 3 squares ICD if risk of Ventricular arrythmia *Ivabradine is a heart-rate-lowering agent that acts by selectively and specifically inhibiting the cardiac pacemaker current (If), a mixed sodium-potassium inward current that controls the spontaneous diastolic depolarization in the sinoatrial (SA) node and hence regulates the heart rate. This is based on NICE guidelines 2018. See the full guidelines before implementing treatment. Refer to specialist (NT-proBNP > 2,000 ng/litre warrants urgent referral) Careful discussion and explanation of the condition Medical management (see below) Surgical treatment in severe aortic stenosis or mitral regurgitation Heart failure specialist nurse input for advice and support Additional management: Yearly flu and pneumococcal vaccine Stop smoking Optimise treatment of co-morbidities Exercise at tolerated

Answer 44

3 causes: 1. Reduced excretion from kidneys 2. Release from cells 3. Acidosis 1. Reduced excretion from kidneys: **AKI** and **Addison's** DRUGs that reduce K+ excretion from the kidneys : **KBANK **: K+ containing laxatives (movicol/fybogel) Beta Blockers ACE inhibitors NSAIDs Potassium Sparing Diuretics (i.e aldosterone antagonists - spironolactone/eplerenone etc.) but also diuretics in general Heparin (which inhibits aldosterone release) and Ciclosporin 2. Cellular Release: **Rhabdomyolysis** **Digoxin Toxicity** (NB - Can be precipitated by hypokalemaia) - "*_Reverse tick sign_*" on ECG **Tumour Lysis Syndrome** **Massive Haemolysis** 3. Acidosis: DKA or any other metabolic acidosis

Answer 45

Hyperkalaemia is a potentially life threatening electrolyte abnormality. Treat K+ **\>6.5mmol/L** _or_ any with **ECG changes** with the following; Give **10ml of 10% calcium gluconate** (or chloride) **over 10 mins** - this is cardioprotective **Intravenous insulin** (10u soluble insulin) in **25g glucose** (50mL of 50% or 125ml of 20% glucose) - *insulin causes intracellular K+ shift* and *glucose to required to prevent hypoglycaemia* **Nebulised salbutamol** - also causes intracellular K+ shift Treatment with sodium bicarbonate is controversial Other aspects of management: Check contributing **drugs** (e.g. ACE inhibitors, spironolactone) Once initial measures completed, **recheck urea** and **electrolytes** and **ECG** and **glucose** **Urinary potassium**

Answer 46

Remember to classify into: **Hypovolaemic** (In the elderly _dehydration is a very common_ cause especially in patients with _dementia_) **Euvolaemic** (SIADH / Hypothyroidism) **Hypervolaemic** and **drugs:** **Thiazide diuretics** \> **Loop Diuretics** \> **K+ sparing diuretics**

Answer 47

A few days (around 3) 10 or more days Tunour lysis syndrome is a condition which typically presents a few days after chemotherapy and is common for haematological malignancies, particularly **non-Hodgkin lymphomas**. The administration of chemotherapy can cause **significant cell death** in mitotically active tumours, resulting in the **extravasation** of intracellular contents such as **nucleic acids into the circulation.** These are then broken down into **uric acid and phosphate**. Uric acid can precipitate in renal tubules leading to an **acute kidney injury**, which may cause the anuria as reported by this patient. **Raised phosphate levels sequester free Ca2+ ions in the bloodstream, leading to hypocalcaemia and its characteristic symptoms, such as tetany (cramps) and vomiting**. This man has significant risk factors for tumour lysis syndrome and combined with anuria means that he may have an acute kidney injury. The most appropriate management for this should be fluid resuscitation in the first instance, particularly given his hypotension.

Answer 48

**_G-CSF_** - **Granulocyte Colony Stimulating Factor**

Answer 49

38 degrees 0.5 ×10⁹/L

Answer 50

**MASCC** (Multinational Association for Supportive Care in Cancer) **\> 21** \***YOU WANT A HIGH SCORE**\* ## Footnote https://www.mdcalc.com/calc/3913/mascc-risk-index-febrile-neutropenia

Answer 51

1) Thorough **history and examination** (including neurological and PR exam) to identify neurological deficits. 2) Referral for **imaging**: **whole spine MRI** scan is the _gold standard_ for suspected metastatic spinal cord compression. 3) If spinal cord compression is suspected - **commence high dose Dexamethasone 16 mg stat then 8 mg BD** _until_ imaging complete. Follow local policy for urgent investigation and a **protein pump inhibitor** (e.g. Omeprazole or Lansoprazole) if needed. 4) If _pain is not controlled_ by step 2 of analgesics, we would **escalate to step 3 (strong opioids + non opioids).** This means commencing the patient on an opioid preparation (preferably on M/R (modified release) opiate, given he was taking step 2 analgesia) and stopping codeine PRN. **Consider co-prescription of a laxative and / or an antiemetic.** Additional Screen: - FBC (rule out infection and neutropenia) - U+E's and LFT's before opiate - Bone Scan - Myeloma Screen (Discussion points: timescale for requesting urgent imaging, within a week vs within 24 hours - depending on clinical scenario i.e Bladder/Bowel dysfunction)

Answer 52

Appendix abscess / Mass (omentum envelopes inflammed appendix giving a mass like feeling on palpation) Hepatomegaly Crohn's Caecal carcinoma Meckels diverticulum (paeds) Ileo-ceacal stricture (Yersinia and TB - 2 rare but important differentials to be excluded with CXR)

Answer 53

I GET SMASHED ``` Iatrogenic Gall stones Ethanol (alcohol) Trauma Steroids Mumps Autoimmune Scorpion bite Hyperlipidaemia ERCP Drugs (Azothioprine/ Anticonvulsants (ex. sodium valproate) / Antimicrobials (metronidazole) / Diuretics (ex. Thiazides and Furosemide) ```

Answer 54

``` Infection (Suture site/from laporotomy/UTI/ Hospital acquired pneumonia) DVT/PE Haemorrhage Obstruction Paralytic ileus (bowel goes to sleep) Anastomotic leak ```

Answer 55

Fever (usually with rigors) Jaundice RUQ pain Ascending Cholangitis (infection of the biliary tree)

Answer 56

``` 5F's Female Forty Fat Fertile Family History ``` Pregnancy / oral contraceptives (oestrogen causes more bile to be secreted into bile duct) / any condition that causes haemolysis (sickle cell disease etc) / Malabsorption (ileal resection / crohns)

Answer 57

3-6-9 rule Small bowel <3cm Large bowel <6cm Appendix <6mm Caecum <9cm

Answer 58

Apply pressure to RUQ and ask patient to inhale. Cessation of inspiratory effort due to pain in RUQ is indicative of Gall bladder Inflammation (i.e cholecystitis and not biliary colic).

Answer 59

Acute Pancreatitis Gall bladder mucocoele (mucous filled overdistended gall bladder - can become infected and lead to empyema) Porcelain gall bladder (calcified gall bladder wall) Small bowel obstruction (lodge at ileo-coecal valve) Ascending cholangitis (infection of biliary tree)

Answer 60

Remember Mnemonic PANCREAS (1 point for each) ``` PaO2 (<60 mmHg / < 8kPa ) Age (> **55** y/o) Neutrophilia (>15) Calcium (<2) uRea (>16) Enzymes (LDH > 600 AST/ALT > 200) Albumin (<32) Sugar (glucose >10) ``` If 3 or greater - Severe pancreatitis is likely ## Footnote https://www.mdcalc.com/calc/3287/glasgow-imrie-criteria-severity-acute-pancreatitis

Answer 61

Painless jaundice and palpable RUQ mass is indicative that pathology is not caused by gall stones and thus an obstructing pancreatic or biliary neoplasm until proven other wise. Could also be a gall bladder stricture.

Answer 62

E.Coli (27%) / Klebsiella (16%) / Enterococcus (15%)

Answer 63

``` RUQ pain Fever Jaundice Hypotension Confusion ``` Cholangitis (patients may also present with tachycardia)

Answer 64

Usually due to obstruction of the biliary tree Gall stones ERCP Cholangiocarcinoma More rarely Primary sclerosing cholangitis Ischaemic cholangiopathy (damage/stricturing of biliary tree due to lack of blood flow). Parasitic infection

Answer 65

IV Fluids Broad spec Antibiotics (do not delay and wait for culture results as these patients can become septic very quickly) Analgesia Other investigaitons LFTs Bloods (FBC) Culture Imaging: Ultrasound for stones and duct dilatation MRCP if dilatation but no stone identified on ultrasound ERCP for biliary decompression sphincterotomy/stenting if stone identified. Patient may need laparoscopic cholecystectomy in the long term. If patient too unwell for ERCP then a percutaneous transhepatic cholangiography (PTC) can be performed.

Answer 66

Refer 2 ww >40 - Unexplained weight loss and abdominal pain >50 - Unexplained rectal bleeding (haematochezia) >60 - Iron deficient anaemia or change in bowel habit Or Positive FIT test

Answer 67

Surgery (orthopaedic) Severe illness (cardiac ischaemia) Trauma Electrolyte imbalance (Hypercalcaemia/Hypomagnesaemia/Hypothyroidism/Hypokalaemia) Neurological (Parkinsons/MS/Hirschsprung's disease) Medications (Opiates/Calcium channel blockers/Anti-depressants)

Answer 68

Conservative (i.e Nil by mouth/ IV fluids/ NG tube if vomiting) If this fails to resolve within 48hrs Endoscopic decompression with flatus tube Failing this IV Neostigmine (anticholinesterase) - should be avoided if possible due to complications. Surgery required if all this fails or evidence of perforation

Answer 69

******PMH **(including anesthesia history - previus rxns or FH/ Sickle Cell disease) **ASA grade** **Consent ** **Fasting ** **Bloods** (FBC/U+Es/LFTs/HbA1C/ABG/Clotting/Group + save/Crossmatch) **Investigations** (ECG/Echo/Lung function tests (if resp disease) **MRSA Screening** **Medication changes - ** Stop: ***Anticoagulants** - Bleeding *** COCP or HRT** - VTE risk *** Corticosteroids** - adrenal suppression ***Diabetes**** **- Sulfonylureas (gliclazide - hypoglycaemia)/ Metformin (metabolic acidosis) /SGLT2 (DKA) ** VTE prophylaxis **

Answer 70

Anticoagulants COCP/HRT (4 weeks beforehand) Steroids (adrenal suppression) Diabetes (sulfonylureas/SGLT2 inhibitors/Metformin)

Answer 71

Prokinetic antiemetics such as **metoclopramide** should be avoided in a bowel obstruction secondary to a mechanical obstruction, as they stimulate peristalsis. **Cyclizine **would be an appropriate choice of antiemetic.

Answer 72

Conservatively 72 hrs gastrografin contrast ## Footnote file:///Users/cianohalloran/Downloads/Emergency%20General%20Surgery%20%20Commissioning%20Guide.pdf

Answer 73

3-6-6-9 rule !

Answer 74

Pre-op assessment Consent Bloods (including group+save/Crossmatch) Fasting Medication Changes VTE risk assessment Surgery school (expectations in recovery/associated risks and side effects)

Answer 75

Pre-op history - PMH PSH Medications Allergies Adverse response to anaesthesia or FH of response to anaesthesia Smoking Alcohol **Pregnancy / Sickle Cell FH / Cardio and Resp exam** **ASA grade** according to the patients health

Answer 76

The American Society of Anesthesiologists (ASA) grading system classifies the physical status of the patient for anaesthesia. Patients are given a grade to describe their current fitness prior to undergoing anaesthesia/surgery: ASA I – normal healthy patient ASA II – mild systemic disease ASA III – severe systemic disease ASA IV – severe systemic disease that constantly threatens life ASA V – “moribund” and expected to die without the operation ASA VI – declared brain-dead and undergoing an organ donation operation E – this is used for emergency operations

Answer 77

Bloods: - FBC/U+E's/LFTs/Clotting or INR - Group and Save / Crossmatch - HbA1C - ABG Imaging: - ECG - ECHO - Lung function tests (ex.spriometry etc) **MRSA screening**

Answer 78

6 hrs no food 2hrs no fluids

Answer 79

Anticoagulants (warfarin can be continued due to rapid reversal with vit.k / DOACs stopped 24-72 hrs before surgery) Diabetic medications - Sulfonylureas (glicazide - hypoglycaemia) - Metformin (lactic acidosis) - SGLT2 inhibitors (dapaglifozin - DKA) start **variable rate insulin infusion ** plus **sliding scale ** of glucose / sodium/ potassium for optimal control of electrolytes Steroids - can cause adrenal suppression COCP/HRT (stopped 4 weeks previously if oestrogen containing due to increased risk of VTE)

Answer 80

Every patient admitted to hospital should be assessed for their risk of venous thromboembolism (VTE). Surgery, particularly where the patient is likely to be immobilised (e.g., orthopaedic surgery), significantly increases the risk of venous thromboembolism. There are local and national policies on reducing the risk that involve: Low molecular weight heparin (LMWH) such as enoxaparin DOACs (e.g., apixaban or rivaroxaban) may be used as an alternative to LMWH **Intermittent pneumatic compression** (inflating cuffs around the legs) Anti-embolic compression stockings

Answer 81

Understand Info Retain it Weigh up the pros and cons Communicate their decision

Answer 82

Enhanced recovery aims to get patients back to their pre-operative condition as quickly as possible, by encouraging *independence, early mobility and appropriate diet.* There are increased nutritional requirements after the physiological stress of surgery, so *sufficient calories are very important*. The aim is to discharge as soon as possible. This leads to better outcomes for the patient. The principles of enhanced recovery are: ***Good preparation for surgery *(e.g., healthy diet and exercise) ***Minimally invasive surgery* **(keyhole or local anaesthetic where possible) **Adequate analgesia** **Good nutritional support ** around surgery **Early return to oral diet and fluid intake** **Early mobilisation** **Avoiding drains and NG tubes where possible, early catheter removal ** **Early discharge**

Answer 83

Examination: DRABCDE Systems-based examinations ENT Fundoscopy DO NOT perform DRE until antibiotics given) Investigations: Blood tests from complete * 2 sets of blood cultures * FBC blood cell count, WCC, inflammatory markers * U+E's * LFTs * Clotting screen — if abnormal may indicate coagulopathy/DIC. Imaging * CXR * Serology and PCR for viruses e.g. CMV * Sputum, urine, stool samples, CT scans etc. where clinically indicated. *** Swabs from any indwelling lines** Patients at high risk: * Have sustained, significant neutropenia that is expected to last more than 7 days. * Are clinically unstable * Have an underlying malignancy and are being treated with high-intensity chemo * Have significant co-morbidities

Answer 84

Management DRABCDE approach And then sepsis 6! - BUFALO and blood gas * Give oxygen therapy to people with reduced oxygen saturation or with an increase in oxygen requirement over baseline, to maintain oxygen saturation above 94% unless contraindicated. *Take blood tests and microbiology samples including: - Blood gas including glucose and lactate measurement — hypoglycaemia may result from depleted glycogen stores; hyperglycaemia may result from the stress response to sepsis; hyperlactataemia is a non-specific indicator of cellular or metabolic stress and is a marker of illness severity, with a higher level predictive of higher mortality rates. - Blood culture — ideally done before antibiotic administration. - Full blood count — white cell count may be high or low; thrombocytopenia may indicate disseminated intravascular coagulation (DIC), but may also be chemotherapy- or tumour-related. - C-reactive protein (CRP) — may indicate infection and/or inflammation. - Creatinine, urea and electrolytes — may indicate dehydration and/or acute kidney injury. - Liver function tests — increased bilirubin or alanine aminotransferase (ALT) levels may indicate cholestasis or other liver dysfunction, and may be chemotherapy-induced. - Clotting screen — if abnormal may indicate coagulopathy/DIC. - Urine analysis and culture, sputum microscopy and culture, chest X-ray, and additional investigations such as chest CT or bronchoalveolar lavage may be indicated if there is severe or prolonged neutropenia. This may allow identification of the source of infection, pathogen(s) and sensitivities, and subsequent tailoring and/or de-escalation of antibiotic therapy if appropriate. Source control to eliminate a focus of infection may be possible, such as abscess drainage, debridement of infected tissue, removal of infected devices or foreign bodies, or surgery. - Give an intravenous broad-spectrum antibiotic at the maximum recommended dose. - The choice of antibiotic will depend on the person's age, clinical presentation, most likely source of infection, recent antibiotic use, and local antibiotic prescribing guidelines. Antibiotic treatment should not be delayed until neutropenia is confirmed. Anti-pseudomonal cover is important for people with suspected neutropenic sepsis, so a first-line choice may be monotherapy with piperacillin/tazobactam, depending on local protocols. Prolonged antibiotic therapy may be needed. - Prolonged fever or failure to improve clinically may suggest fungal or atypical infection requiring additional specialist assessment and treatment. - Give an intravenous fluid bolus to restore tissue perfusion. - Check serial lactate measurement. - Check urine output, monitor fluid balance hourly and monitor the person's clinical condition. This may include **risk stratification using a clinical prediction rule such as the Multinational Association of Supportive Care in Cancer (MASCC) **prognostic index to identify people at low risk of complications. If low risk can give oral antibiotics (quinolone + co-amoxiclav) Features suggesting low risk: * Hemodynamically stable * Doesn't have acute leukaemia * No organ failure * No soft tissue infection * No indwelling lines * For most patients, they need **empirical IV treatment with piperacillin and tazobactam (tazocin - pseudomonas cover**), with added coverage for MRSA or gram-negatives if thought at risk. * **A macrolide should also be added if diagnosed with pneumonia** (to cover atypical organisms) Daily measures of fever and baseline bloods until the patient is apyrexial and neutrophil count above 0.5x10^9^ When the neutrophil count is normal, has been afebrile for 48 hours and blood tests have normalized, antibiotics can be stopped. * Prophylaxis with a **fluoroquinolone **can be offered

Answer 85

History: * Type and timing of chemo regimen and any other immunosuppressive medication being taken. * Localizing symptoms e.g right lower-quadrant pain associated with neutropenic enterocolitis * Recent infections and antibiotics used * Latent infections are known to reactivate (e.g. TB), sick contacts, blood transfusions * Co-morbidities * Any intravascular device

Answer 86

The mnemonic “SNOOP”, without the “D-O-double G”, summarizes some of the red flags. “S” is for systemic symptoms like fever or weight loss. “N” is for neurological symptoms, like weakness, sensory deficits, or vision loss. The first “O” is for a new or sudden onset headache. The second “O” is for other associated conditions, like trauma. The “P” stands for progression or pattern, such as a headache that is worsening in severity or frequency. **\*\*Remember COCP can also cause headache**\*\*

Answer 87

Vascular - Extradural or Subdural Hematoma/ Subarachnoid/ Cerebral venous sinus thrombosis/ cerebellar infarct. Infection - Encephalitis/Meningitis Vision threatening - Giant cell arteritis/ Glaucoma/ Cavernous sinus thrombosis/ Pituitary apoplexy (tumour outgrows blood supply and bleeds) Intracranial pressure: SOLs: Neoplasm/ Brain abscess/ Cyst/ Cerebral oedema (trauma/altitude), hydrocephalus, malignant hypertension/ IIH/ Viagra or GTN Dissection - Aortic/ Carotid/ Vertebral

Answer 88

**Abortive** Mild : * NSAIDs/Acetaminophen Moderate/Severe: * Triptans (Serotonin/5-HT agonist. ex Sumatriptan) * Metaclopramide/Prochlorperazine (Dopamine antagonists) - for nausea and vomiting * Aspirin **Prophylactic:** (only useful if migraines are very frequent such as 2 weeks, and only effective 50% of the time) 1st line: * Beta Blocker/ Candesartan (good side effect profile)/ Amitryptilline 2nd line: * Anti-epileptics (ex. topiramate - teratogenic can cause cleft lip and palate and valproate) - not to be used in female of child bearing age. ``` Acupuncture Vitamin B2 (Riboflavin) supplementation ```

Answer 89

Abortive: Oxygen (at least 12L/min) and/or Triptans (Ex sumatriptan 6mg subcutaneously or intranasally) Prophylactic: 1st line: Verapamil (Ca Channel Blocker) 2nd line: Lithium Prednisolone

Answer 90

Acetaminophen/NSAIDs

Answer 91

Stress Bright lights Strong smells Foods (ex. Chocolate/cheese/caffeine) Abnormal sleep patterns Menstruation (NSAIDS - mefanamic acid and triptans most suitable therapy) Dehydration Trauma Physical overexertion

Answer 92

Aim for: (1) a reduction in blood ketones of 0.5 mmol/L/hour if unavailable (2) a reduction in blood glucose of 3mmol/L/hr or Increase in venous bicarbonate of 3mmol/L/hr

Answer 93

Age Sex (males higher mortality) Cancer Heart Failure Chronic Lung Disease Hypotension (<100 systolic) Tachycardia Raised RR Temperature (<36) Sats <90 Altered Mental state ## Footnote https://www.mdcalc.com/calc/1304/pulmonary-embolism-severity-index-pesi

Answer 94

* Bowel obstruction * early appendicitis * acute gastritis * acute pancreatitis * ruptured abdominal aortic aneurysm. Less common but extremely important causes include ** ischaemic bowel disease.** It is important to consider non-gastrointestinal causes such as: * Pneumonia * Acute coronary syndrome * Diabetic ketoacidosis.

Answer 95

1. Colonic tumour 2. Strictures – secondary to diverticular disease, or other conditions such as inflammatory bowel disease or post-surgical anastomosis 3. Volvulus – sigmoid or caecal 4. Hernias 5. Adhesions (In order of most common^)

Answer 96

Initial Investigations In a patient presenting with potential intestinal obstruction, peritonitis is a worrying sign and the consideration to transfer to theatre must be considered. Some basic investigations that should be done include: Bloods: *FBC (Looking for leukocytosis or anaemia) *U+Es (Organ dysfunction or signs of hypovolaemia) *Lactate (An important examination to establish if there is bowel ischaemia or necrosis) It can be falsely low – the liver can break down lactate quickly so may not increase until late in the presentation *Amylase (Always important in all cases of acute abdomen) *Group and Save * VBG (can be useful to evaluate for end-organ and for the immediate assessment of any metabolic derangement secondary to dehydration or excessive vomiting - metabolic acidosis) Imaging: *Abdominal and chest X-ray *Assess in upright position to look for pneumoperitoneum *Absence of air in the rectum can indicate complete obstruction * Abdominal X ray – helps to establish diagnosis of large bowel obstruction * CT Abdomen with contrast can be useful to establish cause (e.g. malignancy), as well as provide other useful information such as transition point and distinguishing between caecal and sigmoid volvulus. Further Investigations once patients are stabilised - If no peritonitis is present and the patient is stable, the following investigations may further help: * CT abdomen and pelvis with contrast: best diagnostic test -Establishes underlying cause -Establishes site of obstruction -Establishes partial vs. complete obstruction * Small bowel contrast study using **gastrograffin** - Can be used as a therapeutic measurement in partial SBO, as presence of contrast in rectum 24 hours after ingestion of substance establishes resolving partial SBO – hence reducing need for surgery - MRI abdomen (No better than CT scan but can be useful in young patients to avoid doses of ionising radiation) - US abdomen Not as good as CT but can be used in children to avoid ionising radiation exposure * Diagnostic laparotomy/laparoscopy Used to distinguish between partial and complete obstruction if no clear evidence on imaging

Answer 97

Management * Supportive care – analgesia, IV fluids, anti-emetics * Decompression of sigmoid volvulus – using flexible sigmoidoscope * The majority of patients (70%) with large bowel obstruction require surgical intervention – laparoscopic or open colonic resection. This can involve a primary anastomosis or stoma formation. * Palliative care – a proportion of patients who present with malignant large bowel obstruction are not candidates for surgery. Palliative stenting of the obstruction can be performed to help relieve symptoms.

Answer 98

Causes of small bowel obstruction Factors outside of the bowel: * Adhesions Most common cause in the Western World Previous intra-abdominal operations are the main risk factor for development of adhesions. The larger the operation, the more likely the development of adhesions * Intra-abdominal hernia * Incarcerated hernias cause acute obstruction Factors relating to the bowel wall: *Crohn's disease *Appendicitis Factors relating to inside the bowel: *Malignancy *Foreign body ingestion *Gallstone ileus Diseases causing small bowel obstruction in children include: *Intussusception *Volvulus *Intestinal atresia *Appendicitis

Answer 99

Small bowel obstruction most commonly presents with the following features: * Abdominal pain with distension (Initially colicky pain that becomes continuous) * Bloating and vomiting (often bilious) * Failure to pass flatus or stool * History of abdominal/gynaecological surgery or hernia *Tympanic, high-pitched bowel sounds on examination *Empty rectum on examination in complete bowel obstruction *They may have a fever and can be significantly fluid-depleted. Peritonitis indicates severe bowel obstruction, with complications developing. This requires urgent surgical intervention. Simple or partial SBO will generally continue to pass some flatus/stool with a mild temperature. If untreated, SBO can lead to ischaemic or necrotic bowel as well as perforation.

Answer 100

Management of small bowel obstruction * Initially, manage according to resuscitation protocols (ABCDE) * Correction of fluid and electrolytes reduce operative risk before surgery for obstruction * Fluid resuscitation and NG tube to aspirate content for decompression ('Drip and suck') - 80% effective in adhesion caused SBO * Surgery if conservative measures fail. The exact surgery depends on the cause but might include: * Adhesionolysis * Bowel resection * Closure of hernias * Tumour resection

Answer 101

The differential diagnoses for a patient presenting with suspected bowel obstruction include * pseudo-obstruction * paralytic ileus * toxic megacolon * constipation Pseudo-obstruction vs Ileus: Pseudo-obstruction is clearly limited to the colon alone, whereas ileus involves both the small bowel and colon.

Answer 102

ABCDE approach Recovery position Jaw thrust Nasopharyngeal airway (trismus aka jaw clenching prevents OPA) Oxygen 15L NRM IV Access NEWS2 Score Blood glucose FBC including calcium and clotting and antiepileptic drug levels ECG MRI/CT (focal lesions or bleed) EEG Lumbar if Meningitis/encephalitis Pharmacological: IV Lorazepam 4mg or PR Diazepam 10mg 10 mins Repeat 10 mins IV phenytoin 18mg/kg (maz 2g at 50mg/min and cardiac monitoring) 30 mins General anasthesia ICU *also consider IV pabrinex and IV glucose*

Answer 103

Remember \*VITAMINS\* Vascular (Ischaemic/Haemorrhagic Stroke) Infection (Meningitis/Encephalitis/Brain Abscess) Trauma / Toxins (Amphetamine overdose/Alcohol withdrawal/ Isoniazid (TB drug) Autoimmune (CNS vasculitis or SLE) Metabolic (Hyponatraemia/Hypocalcaemia/Hypo or Hyper glycaemia/ Hyperthyroidism/ Uraemic Hepatic and Wernickes Encephalopathy) Idiopathic (epilepsy) Neoplasm Syncope