pt 31 quiz for intl tutorial

A 75 year old Māori man presents to the Emergency Department with central chest pain. It has been present for the past 40 minutes and came on while he was resting. He feels terrible.

Which areas of the heart does the left coronary artery normally supply?  The left coronary artery:

• Normally supplies the anterior 2/3 of the interventricular septum, gives the circumflex artery and supplies the sino-atrial node

• Normally supplies the anterior 2/3 of the interventricular septum, gives the circumflex artery and mostly supplies the left atrium and ventricle.

• Normally supplies the anterior 2/3 of the interventricular septum, gives the right marginal artery and mostly supplies the left atrium and ventricle.

• Normally supplies the posterior 1/3 of the interventricular septum, gives the left anterior descending artery and supplies the sino-atrial node.

Answer explanation

LCA = circumflex a. + LAD

LAD supply the anterior 2/3 of the interventricular septum of the heart + the left ventricle.

circumflex artery supplying the left atrium and ventricle

On further examination you note a bruise and contusion on the right occiput, she also has evidence of older bruising over her forearms and pre-tibial areas. Examination reveals an irregular heart rhythm with a pan-systolic murmur heard loudest at her apex. Her ECG is below, what rhythm does this show?

• Atrial flutter

• Ventricular tachycardia

• Atrial fibrillation

• First degree AV block

You are on your surgical placement when a 40 year old NZ European woman presents to the Emergency Department with sudden onset abdominal pain. She finds the pain severe and she has been vomiting. She has no relevant medical history. You go to see her with the surgical registrar.

She has been previously well and has never had abdominal surgery. On examination she is curled up in bed and looks pale, restless and sweaty. Her heart rate is 110, blood pressure 110/80, Temperature 37.2 C. The abdomen is distended and tender without rebound. Loud runs of bowel sounds are heard. Which is the most likely diagnosis?

• Acute appendicitis

• Acute pancreatitis

• Impacted cystic duct stone

• Small bowel obstruction

Answer explanation

An impacted cystic duct stone would cause biliary colic which would be associated with vomiting but is likely to have radiation of the pain to the right upper back and not have abdominal distension and runs of bowel sounds.

Acute appendicitis may begin with central abdominal pain but is not usually associated with pallor and distension. Bowel sounds would usually not be active.

Acute pancreatitis usually has pain radiating to the back with the patient lying still and decreased bowel sounds.

Acute gastritis is not likely to have associated increased bowel sounds and restlessness.

Colicky abdominal pain associated with distension and increased bowel sounds is likely to be a bowel obstruction.

A 17 year old NZ European man presents to the Emergency department complaining of abdominal pain and passing lots of urine. He has vomited twice and is breathing rapidly with deep sighing breaths. The blood glucose is 27 mmol/L and serum ketones are strongly positive.Which of the following arterial blood gas results would be most consistent with his presentation?

(normal pH: 7.35 - 7.45)

• pH 7.47, pCO₂ 38 [35-45], HCO₃^- 36 [21-30], Na⁺ 138 [135-145], Cl^- 112 [95-105]

• pH 7.38, pCO₂ 38 [35-45], HCO₃^- 23 [21-30], Na⁺ 136 [135-145], Cl^- 96 [95-105]

• pH 7.22, pCO₂ 35 [35-45], HCO₃^- 16 [21-30], Na⁺ 142 [135-145], Cl^- 96 [95-105]

• pH 7.24, pCO₂ 50 [35-45], HCO₃^- 28 [21-30], Na⁺ 142 [135-145], Cl^- 98 [95-105]

• pH 7.20, pCO₂ 38 [35-45], HCO₃^- 18 [21-30], Na⁺ 140 [135-145], Cl^- 112 [95-105]

Answer explanation

Diabetic ketoacidosis is a form of acute metabolic acidosis with an increased anion gap, which can be approximated by [Na⁺]-[HCO₃^-+Cl^-].

This is distinct from Option E which shows a normal anion gap (or hyperchloraemic) metabolic acidosis.

Option D shows a respiratory rather than metabolic acidosis

the first two options show an alkalosis rather than acidosis.

A 25 year old NZ European man presents to his GP with low back pain. The pain has been present for more than 18 months but increased in intensity over the last 3 months. There is pronounced early morning stiffness lasting over 2 hours and nocturnal pain such that he is awake most nights. Ibuprofen relieves his symptoms. He has a past medical history of a painful red eye on two separate occasions and bilateral Achilles tendonitis. There is no family history of arthritis, but his sister has Crohn's disease. He smokes 20 cigarettes per day and works as a forklift driver in a warehouse.

You recognize that he is describing inflammatory back pain and decide to arrange some imaging. Which of these investigations is the most appropriate initial test?

• CT sacroiliac joints

• Isotope bone scan

• MRI spine and sacroiliac joints

• Plain x-rays of his pelvis and lumbar spine

• Ultrasound of his sacroiliac joints

A 19-year-old male is referred to you for physical examination. Upon physical examination, you note that he has sensory loss at his right fifth digit and the medial aspect of his right forearm. You also note that his right hand appears to be 'claw-shaped'. His right forearm is also supinated. He tells you that a couple of weeks ago he fell off his ladder at work and was saved by hanging onto a nearby ledge with his right hand. Given the likely diagnosis, which nerve root(s) is involved?

• C4

• C5/6

• C7

• C8-T1

• T2

Answer explanation

Since he was hanging on the ledge, it is likely that he hyperabducted his arm. This action is likely to injure the lower brachial plexus i.e. C8, T1 root lesion. The claw-shaped hand is also characteristic of a lower brachial plexus injury (Klumpke-Dejerine palsy). The sensory loss on the medial aspect of his forearm and fifth digit referred to the C8 and T1 dermatomes.

A 68 year old NZ European man presents complaining of trembling in his right hand progressing over the last 2 years. His wife has noticed that his writing has got worse and that he is 'slowing down', especially when getting up from his chair. Past medical history includes gastro-oesophageal reflux disease and hypertension, for which he takes omeprazole, metoclopramide and bendrofluazide.

What is the next most important step?

• Physiotherapy

• Start dopaminergic therapy

• Stop bendrofluazide

• Stop omeprazole

• Stop metoclopramide

A 48-year-old lady presented to ED with eight days history of worsening headache and with persistent vomiting >5 times. She did not report any triggering and relieving factors and rated the pain 8/10 on the day of admission.

She has uncontrolled hypertension taking losartan, amlodipine, carvedilol, doxazosin, and bendroflumethiazide.

On examination, her GCS is 11/15. Blood pressure is 148/75 mmHg, and heart rate is 89bpm. Temp 39 C.

Both pupils are equal and reactive to light. Cranial nerves are intact, and no focal neurological deficits

What is the next best course of action?

• reassure and discharge with paracetamol 1 g

• discharge with outpatient neurology follow-up in 2 weeks

• Right pterional craniotomy and clipping of the right MCA bifurcation aneurysm

• urgent plain CT brain

• digital subtraction angiography

A 54 year old Tongan man with known nut allergy presents with difficulty breathing. His throat feels swollen and he is very distressed. It all started when he ate at a restaurant.

Given the likely diagnosis, what is the most appropriate medication to administer to this patient at the first instance?

• Loratadine orally 10mg

• Intramuscular adrenaline 0.5mg

• reassurance and observation until symptoms settle

• 600 micrograms (6 inhalations) of Salbutamol at 10- 20 minute intervals, up to 3 times in the first hour until symptoms resolve.

• Oxygen therapy at 10L/min via nasal prongs