The Complete SAQ Study Guide

Medicine, Surgery and the Clinical Specialties

Schofield Andrew

• Publisher: CRC Press
• Year: 2019
• ISBN:
  9781846198656
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This detailed guide is a must for medical students preparing for clinical attachment and final exams. Its wide-ranging approach is also ideal for those sitting GP entrance exams. Presenting short answer questions encompassing the entire current curriculum, this informative revision aid covers all bases.

Answers

Cardiology

A¹

1.Smoking, diabetes, hypertension, hypercholesterolaemia, +ve family history, male, increasing age, obesity, sedentary lifestyle. (½ a mark for each, max 2 marks)

2.Left anterior descending artery. (1)

3.Assess ABC, morphine, oxygen, GTN spray, 300mg aspirin, contact cardiology/CCU/cath lab, LMWH. (1 mark for each, max 3 marks)

4.Primary PCI, thrombolysis. (1 mark for each, max 2 marks)

5.Aspirin, ACE inhibitor, β-blocker, statin, PRN GTN spray. (½ a mark for each, max 2 marks)

The major risk factors for ischaemic heart disease are smoking, hypertension, diabetes and hypercholesterolaemia. For the diagnosis of myocardial infarction, two of the following are required: cardiac-sounding chest pain, positive ECG changes and raised biochemical markers. If the ECG shows ST elevation, the diagnosis is an ST-segment elevation myocardial infarction (STEMI). If the cardiac enzymes are raised and the chest pain sounds cardiac, the diagnosis is a non-ST-segment elevation myocardial infarction (NSTEMI). Both are encompassed by the term acute coronary syndrome (ACS), as is unstable angina. This is angina of new onset, angina that is increasing in severity or frequency or angina that comes on with minimal exertion or at rest. Cardiac chest pain is often described as a crushing or heavy central pain and may radiate to the neck/jaw or arms. Many centres now offer 24-hour PCI, and this is the treatment of choice for the majority of patients. Following a myocardial infarction, patients should be taking aspirin, an ACE inhibitor, a β-blocker and a statin as long as there are no contraindications. In addition to these, clopidogrel should be taken for 1 year if PCI has been performed. Nonpharmacological measures also play a significant role, including cardiac rehabilitation programmes, smoking cessation, encouraging weight loss and dietary changes.

A²

1.Leads I, aVL, V5 and V6. (1)

2.Left circumflex artery. (1)

3.Troponin (I/T), CK-MB, CK, AST, LDH. (1 mark for each, max 2 marks)

4.Inverted T waves, pathological Q waves. (1 mark for each, max 2 marks)

5.Not allowed to drive for 4 weeks, can drive from then on so long as not otherwise disqualified, DVLA do not need to be informed. (1 mark for any of above points)

6.Bleeding/haemorrhage, infection, MI, stroke, allergy to contrast, damage to coronary vessels requiring intervention, death. (1 mark for each, max 3 marks)

ECG changes tend to be seen in the leads that represent that territory of the myocardium, and each territory is supplied by a major coronary artery. The anterior leads are supplied by the left anterior descending artery and are represented by leads V1-V4. The lateral leads are supplied by the left circumflex artery and are represented by leads I, aVL, V5 and V6. The right coronary artery supplies the inferior myocardium, and this territory is represented by leads II, III and aVF. Immediate changes seen on an ECG following a STEMI are hyperacute T waves and then ST elevation (or new-onset left-bundle branch block). T-wave inversion and pathological Q waves develop over the next few days. Complications following an AH include cardiac arrest, arrhythmias, heart failure, DVT/ PE and pericarditis, among others.

A³

1.Cold/windy weather, emotion (anger/excitement), lying down (decubitus angina), vivid dreams (nocturnal angina). (1 mark for each, max 2 marks)

2.Shortness of breath, sweating, feeling faint/light-headed. (½ a mark for each, max 1 mark)

3.FBC for anaemia, TFTs for thyrotoxicosis, lipid profile for hypercholesterolaemia, glucose (random/fasting/OGTT) for diabetes, U&Es for renal vessel disease/if considering ACEi (½ a mark for each test, ½ a mark for each reason, max 2 named investigations, max 2 marks)

4.ECG, exercise tolerance test (ETT)/exercise ECG, myocardial perfusion scintigraphy (MPS), echocardiography, coronary angiography. (1 mark for each, max 3 marks)

5.Irreversibly inhibits cyclooxygenase, which prevents further production of TxA₂ (thromboxine) from platelets as they do not have a nucleus, shifting the balance of PGI₂ : TxA₂ towards inhibiting platelet aggregation (1 mark for each of above points, max 2 marks)

Angina is central chest pain brought on by exercise and relieved by rest, and indicates coronary artery disease. Diagnosis is often made following the history, and there may be no obvious signs to find on examination, but you should look for signs of aortic stenosis, thyrotoxicosis and anaemia that would suggest the coronary arteries are not the problem. An ECG at rest is most likely to be normal, but signs of previous ischaemia, such as Q waves or left-bundle branch block, may be seen. Other investigations, such as exercise ECGs and myocardial perfusion scintigraphy, attempt to identify myocardial ischaemia following stress. Angiography may also be used to determine the coronary artery anatomy, and also if the diagnosis is unclear. Management should include identifying and managing risk factors for cardiovascular disease. A glyceryl trinitrate (GTN) spray may be used when the patient experiences chest pain. This is administered sublingually by the patient and causes coronary vasodilatation, hence improving blood flow through the arteries. Those with significant coronary artery disease often require percutaneous coronary intervention (PCI) or a coronary artery bypass graft (CABG), depending on the severity of their condition and the number of vessels involved.

A⁴

1.Tachypnoea, tachycardia, raised JVP, fine lung crepitations, wheeze, additional heart sounds/gallop rhythm, dull percussion of bases, cyanosis, decreased tactile/vocal fremitus. (1 mark for each, max 3 marks)

2.FBC, U&Es, lipids, glucose, cardiac enzymes (troponin, CK-MB, LDH), ECG, chest X-ray, ABG, echocardiogram. (½ a mark for each, max 2 marks)

3.Furosemide, GTN/nitrates, morphine/diamorphine, oxygen. (1 mark for each, max 2 marks)

4.Furosemide. (1)

5.Orally (e.g. sando-K), IV (add KC1 to IV fluids). (2)

Acute pulmonary oedema is a medical emergency. The patient should be sat up, as fluid accumulates at the lung bases, and given high-flow oxygen. IV furosemide is commonly given first-line to offload excess fluid. Morphine and nitrates are also used and act by reducing the preload. If these measures do not improve symptoms or if the patient remains hypotensive, inotropic support may be required, but an alternative diagnosis should also be considered. Many patients are treated for failure and infection simultaneously until a definitive diagnosis has been made. The causes of acute pulmonary oedema include post-MI, valvular disease and arrhythmias such as complete heart block. Non-cardiac causes include fluid overload (e.g. secondary to renal failure or a patient being given too much fluid intravenously), post-head injury and ARDS.

A⁵

1.Inferior. (1)

2.Right coronary artery. (1)

3.Call for help/the crash team, start chest compressions. (1 mark for each, max 2 marks)

4.< 0.12 s (< 3 small squares). (1)

5.Normal QRS complex between VT complexes. (1)

6.Ventricular tachycardia. (1)

7.Yes - as no pulse palpable. (1)

8.Oxygen, adrenaline, amiodarone, lignocaine/lidocaine. (1 mark f...