Aims and objectives Recap some of the most challenging questions from - PowerPoint PPT Presentation

Aims and objectives Recap some of the most challenging questions from yesterday’s quiz • Not every question will be addressed for the purpose of time • All answers and explanations are in the slides • Duration: 60 mins • Slides and recordings: app.bitemedicine.com • 2

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Explanations A young lady presents with stridor after eating a peanut. You have given IM adrenaline and started 500ml IV fluids. What is your next step? IV chlorphenamine In anaphylaxis, antihistamine should be given after adrenaline and fluids Oral prednisolone IV steroids are given in anaphylaxis IV hydrocortisone Given after antihistamine as steroids take time to work Salbutamol nebuliser May be given as an adjunct for bronchodilation IV noradrenaline Not involved in anaphylaxis management app.bitemedicine.com 7

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Explanations A patient with known CKD has a potassium of 6.9mmol/L. The ECG is shown. What is your next step? Monitor The potassium is raised and so action must be taken Calcium gluconate Only given in the presence of ECG changes (UK renal association) Calcium resonium Reduces potassium absorption in the gut but takes time to work Nebulised salbutamol Causes intracellular shift of potassium Haemodialysis Only used in refractory cases app.bitemedicine.com 11

Explanations Adapted from the UK renal association guidelines app.bitemedicine.com 12

Explanations (2) app.bitemedicine.com 13

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Explanations A 67-year-old female is admitted with a UTI. She weighs 60kg. Which of the following suggests she has an AKI? Rise in creatinine 1.25x baseline AKI: 1.5x baseline Cr in the past 7 days Urine output < 40ml/hour AKI: fall in urine output to less than 0.5ml/kg/h for more than 6 hours Urine output < 35ml/hour AKI: fall in urine output to less than 0.5ml/kg/h for more than 6 hours Rise in creatinine of 30umol/L AKI: rise in Cr of 26 umol/L in 48h eGFR 45 A stand- alone measurement is not useful. We need to know the patient’s baseline app.bitemedicine.com 15

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Explanations A patient presents with haematemesis and is diagnosed with a bleeding peptic ulcer on endoscopy. What is the most appropriate management option? Adrenaline therapy alone Never used alone, only as an adjunct, as per NICE Fibrin sclerotherapy Sclerotherapy and thermal coagulation require adrenaline as well Thrombin sclerotherapy Sclerotherapy and thermal coagulation require adrenaline as well Thermal coagulation Sclerotherapy and thermal coagulation require adrenaline as well Clipping Can be done with or without adrenaline app.bitemedicine.com 17

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Explanations A 60-year-old male with a UTI presents with a HR 110 and BP 85/60. You have not started treatment. Which option suggests septic shock in this patient? Lactate 3 mmol/L Treatment has not yet started so septic shock cannot be diagnosed Systolic BP 85 mmHg Treatment has not yet started so septic shock cannot be diagnosed Diastolic BP 60 mmHg Treatment has not yet started so septic shock cannot be diagnosed HR 110 Treatment has not yet started so septic shock cannot be diagnosed None of the above Septic shock is defined as fluid refractory hypotension with a raised lactate. This patient has not yet commenced treatment so shock cannot be diagnosed app.bitemedicine.com 19

Explanations After fluid resuscitation app.bitemedicine.com 20

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Explanations Which of the following is the most common cause of meningitis? Coxsackie Viruses are the most common cause of meningitis, of which enteroviruses (e.g. Coxsackie) are the commonest Mumps Rare cause S.pneumoniae (pneumococcus) Most common bacterial cause in the US N.meningitides (meningococcal) Most common bacterial cause in the UK (NICE) E.coli A rare cause and typically affects neonates app.bitemedicine.com 22

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Explanations A patient on Dalteparin (LMWH) develops thrombocytopaenia. Which of the following antigens is involved? Platelet factor 4 Heparin induced thrombocytopaenia involves antibodies against heparin-PF4 complex ADAMTS 13 Enzyme responsible for cleaving vWF. Reduced activity in TTP Factor VIII Incorrect GpIIb/IIIa Involved in platelet adhesion. Deficiency results in Glanzmann disease IgG Incorrect app.bitemedicine.com 24

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Explanations A 70-year-old male presents with fatigue. His spleen is palpable at his umbilicus and he has cervical lymphadenopathy. What is the likely diagnosis? CML Lymphadenopathy not common CLL Most common adult leukaemia. Suspect in elderly with massive splenomegaly and lymphadenopathy AML May also present similarly but less common and median age of presentation is younger ALL Typically seen in children Marginal zone lymphoma Rare and associated with underlying condition such as H.pylori gastritis app.bitemedicine.com 26

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Explanations A 65-year-old lady presents to the GP with fatigue. She is noted to have an iron deficient anaemia. She is otherwise well. What is your next step? Urgent colonoscopy Fe deficient anaemia in the elderly is colon cancer until proven otherwise Urgent OGD OGD may also be done if colonoscopy does not reveal bleeding point Urgent OGD and colonoscopy OGD may also be done if colonoscopy does not reveal bleeding point Faecal occult blood OGD may also be done if colonoscopy does not reveal bleeding point Commence IV iron The patient should be started on oral iron app.bitemedicine.com 28

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Explanations A 50-year-old male with a history of COPD presents with pleuritic chest pain. He is diagnosed with a 3cm pneumothorax. What is your management? Aspirate with a 16G cannula Aspiration suitable for a primary pneumothorax (>2cm) or a secondary pneumothorax (1-2cm) Aspirate with an 18G cannula Sclerotherapy and thermal coagulation require adrenaline as well Insert 8-14Fr chest drain Secondary pneumothorax (as COPD history) and over 2cm requires 8-14Fr chest drain as per BTS Insert 20-28Fr chest drain Too big Discharge and review in outpatient clinic Not appropriate app.bitemedicine.com 30

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Explanations A 20-year-old male presents with loin-to-groin pain. He is apyrexial and passing urine. CT KUB: 22mm renal pelvis stone. What is your management? Percutaneous nephrolithotomy Renal stone larger than 20 mm in adult, including staghorn stones, offer PCNL Shockwave lithotripsy Used for small renal and ureteric stones Tamsulosin expulsive therapy Only suitable for small ureteric stones Watchful waiting Too big Ureteroscopy Can be used second-line app.bitemedicine.com 33

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Explanations An elderly female has a fall and AP pelvis and lateral hip x-rays demonstrate no clear fracture. A hip fracture is strongly suspected. What do you do? CT of hip/pelvis Only if MRI is unavailable within 24 hours or contraindicated MRI of hip/pelvis Offer MRI if hip fracture is suspected despite negative X-rays. If MRI is not available within 24 hours or is contraindicated, consider CT Ultrasound of hip/pelvis Not sensitive Discharge with analgesia and reassurance Clinical suspicion warrants further imaging Prepare the patient for theatre Imaging required before theatre app.bitemedicine.com 36

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Explanations A 60-year-old is 2 days post-op following an open cholecystectomy. He develops breathlessness, vomiting and abdominal distension. What is the cause? Adhesional small bowel obstruction Adhesional SBO will not present so soon post-op Large bowel obstruction Vomiting is a late feature of LBO and more suggest SBO Hospital acquired pneumonia The patient is breathless due to abdominal splinting. There are no other features of pneumonia Paralytic ileus Features of SBO post abdominal surgery = ileus. The patient is breathless due to abdominal splinting Community acquired pneumonia The patient is breathless due to abdominal splinting. There are no other features of pneumonia app.bitemedicine.com 38

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Explanations A 60-year-old Caucasian needs optimisation of his hypertension. He is on ramipril, amlodipine, indapamide. Which agent should be added? Na 140, K 4.9. Spironolactone Only start if K < 4.5 Bisoprolol Quadruple therapy with K > 4.5 requires an alpha or beta blocker Verapamil Not used in HTN Finasteride Not used in HTN Losartan Already on an ACEi. ARB may be used instead of an ACEi but not in addition app.bitemedicine.com 40

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Explanations A type 2 diabetic is on 1g BD metformin and her HbA1c is 59 mmol/mol. She has a BMI of 33 and an eGFR of 62 ml/min. What is your next step? Increase the dose of metformin 1g BD is max dose Commence gliclazide Causes weight gain Commence liraglutide Only indicated if BMI 35 or over and the patient has failed triple therapy Commence pioglitazone Causes weight gain Commence dapaglifozin Does not cause weight gain app.bitemedicine.com 42

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Explanations Drug class Side effects GI upset Biguanides AKI Sulfonylureas Hypoglycaemia Weight gain SGLT-2 inhibitor UTI Thiazolidinediones Weight gain Fluid retention DPP-4 inhibitor GI upset GLP-1 inhibitor GI upset Loss of appetite app.bitemedicine.com 44

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