Monday [08/08/22]

Question 1

Steps to performing death confirmation [8]

Answer 1

1. Confirm identity of patient by checking wrist band
2. Speak to patient: “can you hear me”
3. Inspect for signs of life including respiratory effort and chest movement
4. assess response to pain: either fingernail/traps/supraorbital pressure
5. assess pupillary reflexes using pen torch
6. carotid pulse
7. auscultate to identify heart/resp sounds [heart 2m, resp for 3m]
8. Document each step of the process

Question 2

Causes of AKI [3]

Answer 2

Prerenal = hypovolaemia, renal artery stenosis
Intrinsic = toxins, sepsis, medications, ATN, glomuerlonephritis, rhabdomyolysis
Postrenal = kidney stones, BPH, external compression

Question 3

Define AKI with current NICE guidelines [3]

Answer 3

• A rise in serum creatinine of 26 micromol/litre or greater within 48 hours
• A 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days
• A fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours in adults and more than

Question 4

Stages of AKI [3]

Answer 4

1. x2 baseline serum creatinine
2. x2-3 baseline creatinine
3. x3 baseline creatinine. Or eGFR <35ml/min. Or anuria.
   Also urine output 6->12->24 hours [<0.3ml] less than 0.5ml/kg/hr

Question 5

Safe to continue drugs AKI [5]

Answer 5

Aspirin, warfarin, statins, clopidogrel, beta blockers

Question 6

Should stop AKI as may worsen renal function [5]

Answer 6

NSAIDs
• Aminoglycosides
• ACE inhibitors
• Angiotensin II receptor antagonists
• Diuretics

Question 7

May have to be stopped in AKI as increased risk toxicity [3]

Answer 7

• Metformin
• Lithium
• Digoxin

Question 8

When is renal replacement therapy used in AKI? [1]

Answer 8

Renal replacement therapy (e.g. haemodialysis) is used when a patient is not responding to medical treatment of complications, for example hyperkalaemia, acidosis or uraemia

Question 9

Elements of the CIWA score for alcohol withdrawal [10]

Answer 9

• N+V
• tremor
• paroxysmal sweats
• anxiety
• agitation
• tactile disturbances
• auditory disturbances
• visual disturbances
• headache/fullness in head
• orientation/clouding of sensorium

Question 10

Conditions that predispose you to refeeding syndrome [4]

Answer 10

• anorexia
• alcohol use disorder
• cancer
• difficulty swallowing

Question 11

Electrolyte disturbances in refeeding syndrome [5]

Answer 11

• abnormal sodium and fluid levels
• changes in fat, glucose or protein metabolism [go from breaking down carbohydrates->fats]
• thiamine deficiency
• hypomagnesaemia
• hypokalaemia
• hypophosphotaemiav

Question 12

Sx of refeeding syndrome [6]

Answer 12

• fatigue
• weakness
• confusion
• inability to breathe
• HBP
• seizures
• heart arrhtymias
• HF
• coma
• death
• Sx typically start within 4d of the refeeding process, some people not at risk but can’t tell which ones they are.

Question 13

Tx of refeeding syndrome [4]

Answer 13

The repletion of calories should be slow and is typically at about 20 calories per kilogram of body weight on average, or around 1,000 calories per day initially.

Electrolyte levels are monitored with frequent blood tests. Intravenous (IV) infusions based on body weight are often used to replace electrolytes. But this treatment may not be suitable for people with:

impaired kidney function
hypocalcemia (low calcium)
hypercalcemia (high calcium)
In addition, fluids are reintroduced at a slower rate. Sodium (salt) replacement may also be carefully monitored. People who are at risk of heart-related complications may require heart monitorin

Question 14

Features of alcohol withdrawal [3]

Answer 14

• symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
• peak incidence of seizures at 36 hours
• peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

Question 15

Mx of alcohol withdrawal [4]

Answer 15

patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised
first-line: benzodiazepines e.g. chlordiazepoxide. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol
carbamazepine also effective in treatment of alcohol withdrawal
phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures

Question 16

Ix for UC [3]

Answer 16

• faecal calprotectin: screening tool for IBD. Adults it has sensitivity of 93% and specificity of 96%, in children 75%
• imaging
• bloods: raised inflammatory markers, anaemia

Question 17

Severity of UC [3]

Answer 17

mild: < 4 stools/day, only a small amount of blood
moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)

Question 18

Tx mild-moderate UC flare [3]

Answer 18

topical aminosalicylate -> oral aminosalicylate [like mesalazine] -> oral/topical COC

Question 19

Tx severe colitis flare [3]

Answer 19

should be treated in hospital
intravenous steroids are usually given first-line
intravenous ciclosporin may be used if steroid are contraindicated
if after 72 hours there has been no improvement, consider adding intravenous ciclosporin to intravenous corticosteroids or consider surgery

Question 20

Maintaining remission for mild-to-moderate UC [1]

Answer 20

• topical/oral aminosalicylate

Question 21

Maintaining remission for severe relapse or >=2 execrations per year UC [1]

Answer 21

Oral azathioprine or oral mercaptopurine