1st Years Pre-AMK lecture - Benjamin Smeeton (ExeSS)
AMK hints & tips Benjamin Smeeton
Question 1.A 44 year old male presents to ED with a 6 hour Hx of painand tenderness which started centrally and then progressedto the right iliac fossa (RIF). He is pyrexic (38.5°C) andincreasingly nauseous; he has vomited a number of times.What is the most likely diagnosis?a) Gastroenteritisb) Ruptured abdominal aortic aneurysm (AAA)c) Acute appendicitisd) Myocardial infarctione) Don’t know
Acute appendicitis.• Appendicitis is an acute inflammation of the appendix.• The appendix is a blind-ended tube connected to the caecum (the junction between the small and large bowel).• It is an embryological remnant that has lost its original function through the process of evolution.• 2-20 cm in length!
Acute appendicitis.• Lumen becomes obstructed (e.g. faeces, enlarged lymph nodes etc)• Bacteria proliferate and invade the appendix wall.• Pain – typically epigastric, before localising to the RIF• Nausea + vomiting, anorexia• Fever (pyrexia)• Appendectomy – don’t be afraid to treat quickly!• Delaying treatment increases mortality.
Question 2.You are a F1 doctor and you are called to see your patient, Mrs Smith, a 79year old lady, who is receiving broad spectrum IV antibiotics for a recentcomplex UTI. She has been on treatment for about 5 days, and nowcomplains of watery diarrhoea and abdominal discomfort. What is themost likely cause?a) Allergic reaction to antibioticsb) Ischaemic bowelc) E.coli infectiond) Clostridium difficile infectione) Don’t know
Clostridium difficile infection.• Clostridium difficile is a bacterium• Carried in the normal gut flora of the large intestine• Generally, becomes problematic after taking broad- spectrum antibiotics and is a very common hospital- acquired infection.
Clostridium difficile infection.• Antibiotics destroy the natural ‘anaerobic wallpaper’ of the gut• Clostridium difficile proliferate and produce TOXINS• Usually 5-10 post BS-antibiotic use• Diarrhoea +/- blood• Abdominal pain / discomfort• Oral metronidazole (v. cheap, but horrible SEs)• Vancomycin (much ‘nicer’ but more expensive)
Question 3.A 59 year old male is admitted to ED having collapsed at work. Hecomplains of a tearing sensation with pain radiating to his back betweenhis scapulae. He looks pale and sweaty and his BP is recorded as 88/54. Heis a chronic smoker (20/day) with a longstanding Hx of hypertension. Youperform an ECG but no ST changes are noted. What is the most likelydiagnosis?a) Myocardial infarction (MI)b) Aortic dissectionc) Pulmonary embolism (PE)d) Infective endocarditise) Don’t know
Aortic dissection• Arteries are made up for three layers: • Intima (inner most) • Media • Adventia• Aortic dissection is a tear in the intimal lining, which enables blood to flow between the intimal and media layers of the aorta.
Question 4.You are the F1 doctor on-call, its night and your less-than responsible reghas decided he just can’t miss the latest series of Come Dine with Me sohas gone home. You are called to the orthopaedic ward to see MrsWilliams, a 82 year old lady who has just undergone a total kneereplacement. For the last 2 hours she has been acutely breathless, andcomplains of chest pain. She is apyrexial. You perform an ECG but it isnormal. What is the most likely diagnosis?a) Myocardial infarction (MI)b) Pulmonary embolism (PE)c) Pneumoniad) Exacerbation of COPDe) Don’t know
Pulmonary embolism (PE)• PEs result when thrombi (blood clots) embolise via the right heart into the pulmonary arteries.• Predisposing factors include: • Recent surgery • Immobilisation (e.g. long haul flights) • Malignancy • Pregnancy • Family Hx
Pulmonary embolism (PE)• Three main factors contribute to thrombus formation (blood stagnation, endothelial damage, derangements of coagulability)• Dyspnoea – difficulty breathing• ↑HR, ↑RR• Chest pain (pleuritic in nature – sharp pain on inspiration)• CT pulmonary angiogram (GOLD STANDARD)• Thrombolysis, warfarin