Tuesday 17th

Question 1

Following a stroke all patients should be offered

Answer 1

an antiplatelet drug unless the person has an indication for an anticoagulant

Question 2

Immediately after an ischaemic stroke is confirmed by brain imaging

Answer 2

Aspirin 300 mg daily for 2 weeks should be given immediately

• Following this, clopidogrel 75 mg daily should be given long-term
• OR modified-release dipyridamole alongside low dose aspirin

Question 3

Antiplatelet: Acute coronary syndrome (medically treated)

Answer 3

1st: Aspirin (lifelong) & ticagrelor (12 months)
2nd: If aspirin contraindicated, clopidogrel (lifelong)

Question 4

Antiplatelet: Percutaneous coronary intervention

Answer 4

1st: Aspirin (lifelong) & prasurgrel or ticagrelor (12 months)
2nd: If aspirin contraindicated, clopidogrel (lifelong)

Question 5

Antiplatelet: TIA

Answer 5

1st: Clopidogrel (lifelong)
2nd: Aspirin (lifelong) & dipyridamole (lifelong)

Question 6

Antiplatelet: Ischaemic stroke

Answer 6

1st: Clopidogrel (lifelong)
2nd: Aspirin (lifelong) & dipyridamole (lifelong)

Question 7

Antiplatelet: Peripheral arterial disease

Answer 7

1st: Clopidogrel (lifelong)
2nd: Asprin (lifelong)

Question 8

Cyclizine

Answer 8

H1-receptor antagonist that acts by blocking histamine receptors in the CTZ
- safe to use in pregnancy

• CI: cause a drop in cardiac output and an increase in heart rate. For this reason, caution should be employed in patients with severe heart failure

Question 9

metoclopramide

Answer 9

Dopamine antagonists

• pro-kinetics and should therefore be avoided in intestinal obstruction
• used with caution in patients with Parkinson’s disease

Question 10

Motion sickness

Answer 10

1st: hyoscine (e.g. transdermal patch) as being the most effective treatment. Use is limited due to side-effects
2nd: non-sedating antihistamines such as cyclizine or cinnarizine are recommended in preference to sedating preparation such as promethazine

Question 11

Raised superior vena cava pressure

Answer 11

(e.g. secondary to a bad cough) may cause petechiae in the upper body but would not cause purpura

Question 12

sumatriptan

Answer 12

5-HT1D receptor agonist

- acute treatment of migraine

Question 13

ergotamine

Answer 13

partial agonist of 5-HT1 receptors

Question 14

pizotifen

Answer 14

5-HT2 receptor antagonist

- prophylaxis of migraine attacks

Question 15

Methysergide

Answer 15

5-HT2 receptor antagonist

- rarely used due to the risk of retroperitoneal fibrosis

Question 16

cyproheptadine

Answer 16

5-HT2 receptor antagonist

- control diarrhoea in patients with carcinoid syndrome

Question 17

ondansetron

Answer 17

5-HT3 receptor antagonist

- antiemetic

Question 18

Factors which reduce BNP levels

Answer 18

• aldosterone antagonists
• ACE inhibitors
• angiotensin-II receptor antagonists
• beta-blockers
• diuretics
• obesity

Question 19

Increased BNP levels (>400)

Answer 19

• left ventricular hypertrophy
• MI
• AF
• pulmonary hypertension
• hypoxia
• pulmonary embolism
• right ventricular strain
• COPD
• liver failure
• sepsis
• diabetes
• renal impairment
• women
• older than 70

Question 20

B-type natriuretic peptide (BNP)

Answer 20

• left ventricular myocardium in response to strain
• increase renal excretion of water and sodium
• relax vascular smooth muscle causing vasodilation
• suppresses both sympathetic tone and the renin-angiotensin-aldosterone system

Question 21

Acute ischaemic stroke

Answer 21

thrombolysis within 4.5 hours of symptom onset

Question 22

Confirmed proximal anterior circulation occlusion

Answer 22

thrombectomy within 6 hours

Question 23

Confirmed occlusion of the proximal anterior or posterior circulation

Answer 23

• demonstrated by CTA or MRA and if there is the potential to salvage brain tissue
  > shown by imaging such as CT perfusion or
  diffusion-weighted MRI sequences showing limited
  infarct core volume
• Thrombectomy can be offered up to 24 hours after symptom onset

Question 24

Management of acute stroke

Answer 24

• blood glucose, hydration, oxygen saturation and temperature should be maintained within normal limits
• blood pressure should not be lowered in the acute phase unless there are complications e.g. Hypertensive encephalopathy*
• aspirin 300mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded
• with regards to atrial fibrillation, the RCP state: ‘anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days have passed from the onset of an ischaemic stroke’
• if the cholesterol is > 3.5 mmol/l patients should be commenced on a statin. Many physicians will delay treatment until after at least 48 hours due to the risk of haemorrhagic transformation

Question 25

Thrombolysis for acute ischaemic stroke

Answer 25

Alteplase should only be given if: - it is administered within 4.5 hours of onset of stroke symptoms (unless as part of a clinical trial) - haemorrhage has been definitively excluded (i.e. Imaging has been performed)

Question 26

Contraindications to thrombolysis: ABSOLUTE

Answer 26

- Previous intracranial haemorrhage - Seizure at onset of stroke - Intracranial neoplasm - Suspected subarachnoid haemorrhage - Stroke or traumatic brain injury in preceding 3 months - Lumbar puncture in preceding 7 days - Gastrointestinal haemorrhage in preceding 3 weeks - Active bleeding - Pregnancy - Oesophageal varices - Uncontrolled hypertension >200/120mmHg

Question 27

Contraindications to thrombolysis: RELATIVE

Answer 27

- Concurrent anticoagulation (INR >1.7) - Haemorrhagic diathesis - Active diabetic haemorrhagic retinopathy - Suspected intracardiac thrombus - Major surgery / trauma in the preceding 2 weeks

Question 28

Carotid artery endarterectomy

Answer 28

- if patient has suffered stroke or TIA in the carotid territory and are not severely disabled - should only be considered if carotid stenosis > 70% according ECST** criteria or > 50% according to NASCET*** criteria

Question 29

splenic flexure

Answer 29

most likely area to be affected by ischaemic colitis - splenic flexure marks the point where the majority of blood supplied changes from the superior mesenteric artery (SMA) to the inferior mesenteric artery (IMA)

Question 30

Ischaemia to the lower gastrointestinal tract

Answer 30

- acute mesenteric ischaemia - chronic mesenteric ischaemia - ischaemic colitis

Question 31

Common features in bowel ischaemia

Answer 31

- abdominal pain - in acute mesenteric ischaemia this is often of sudden onset, severe and out-of-keeping with physical exam findings - rectal bleeding - diarrhoea - fever - bloods typically show an elevated white blood cell count associated with a lactic acidosis 1st: CT

Question 32

Bowel ischaemia: Common predisposing factors

Answer 32

- increasing age - atrial fibrillation - particularly for mesenteric ischaemia - other causes of emboli: endocarditis, malignancy - cardiovascular disease risk factors: smoking, hypertension, diabetes - cocaine: ischaemic colitis is sometimes seen in young patients following cocaine use

Question 33

Acute mesenteric ischaemia

Answer 33

- typically embolism > occlusion > e.g. superior mesenteric artery - Classically, history of atrial fibrillation - Abdominal pain is typically severe, of sudden onset and out-of-keeping with physical exam findings - Management: urgent surgery is usually required > poor prognosis, especially if surgery delayed

Question 34

Chronic mesenteric ischaemia

Answer 34

- Relatively rare clinical diagnosis due to it's non-specific features and may be thought of as 'intestinal angina' - Colickly, intermittent abdominal pain occurs

Question 35

Ischaemiac colitis

Answer 35

- acute but transient compromise in the blood flow to the large bowel - may lead to inflammation, ulceration and haemorrhage - Investigations: 'thumbprinting' may be seen on abdominal x-ray due to mucosal oedema/haemorrhage - Management > usually supportive > surgery may be required in a minority of cases if conservative measures fail > Indications: generalised peritonitis, perforation or ongoing haemorrhage