N Griffin

(H Wallis)

· The following are indications for thrombolysis in a patient presenting within 12 hours of an episode of chest pain compatible with a myocardial infarct:
1. ST elevation >1mm in 2 contiguous chest leads
2. Left bundle branch block
3. ST elevation 1mm in one limb lead
4. ST segment depression combined with raised troponin
5. Raised CK-MB with normal ECG

· Which of the following statements concerning treatments for STEMI are true?
6. Streptokinase causes a higher incidence of intracranial haemorrhage than tPA
7. Clopidogrel combined with aspirin is more effective than either drug used alone
8. Primary percutaneous coronary intervention is less effective that thrombolysis
9. Unless contraindicated all patients should be treated with intravenous beta blockade
10. Perindopril confers long-term benefit even in the absence of heart failure

(T S Leary)

· Concerning the initial management of coma
11. Intravenous glucose should only be administered if hypoglycaemia is confirmed by rapid reagent testing
12. Flumazenil may precipitate seizures
13. Absence of conjugate eye movements suggests brainstem disease
14. Bilateral dilated, reactive pupils usually indicate 3rd nerve compression
15. Glasgow coma score

· Which of the following statements is/ are true
16. A raised anion gap commonly results from lithium poisoning
17. Absence of localising motor response and roving eye movements 72 hours after cardiac arrest predicts <10% chance of functional recovery 18. Hyperthermia may accelerate neuronal damage following head injury 19. Following traumatic brain injury PaCO2 should be maintained in the range 4-4.5kPa 20. Propofol should be avoided following head injury because of its tendency to cause systemic hypotension and hence reduce cerebral perfusion pressure (N Griffin) · Which of the following reliably distinguish SAH from benign thunderclap headache? 21. Focal neurological signs? 22. Headache lasting for more than 1 hour? 23. Absence of haemorrhage on a CT performed 3 days after headache onset? 24. Absence of bilirubin in the CSF 6 hours after headache onset? 25. Absence of bilirubin in the CSF 3 days after headache onset? · Which of the statements about SAH are true? 26. 15% of SAH are not due to ruptured aneurysms. 27. Perimesencephalic haemorrhages have a better prognosis than aneurysmal SAH. 28. Most aneurysms present with sentinel headaches before they rupture. 29. The headache of SAH may develop over a few minutes. 30. Patients with SAH should be fluid restricted. (M T Bacon) · In the Patient with ‘Funny Turns’ 31. There is always a prodrome before Faintin 32. Cardiac Causes have a greater morbidity/mortality 33. There may be amnesia for any loss of consciousness 34. Falls and Syncope can overlap · Key Preliminary Investigations Include 35. Holter Monitor (24 Hour Tape) 36. Random blood sugar 37. 12 Lead ECG 38. Lying and Standing Blood Pressure · Syncope 39. Is a well recognised event after meals 40. Only occurs in the upright position 41. Does not cause incontinence 42. Has psychological sequelae · Contraindications to Syncope Testing include 43. Carotid Bruits 44. Recent Stroke 45. Previous tachyarrhthmias 46. Unable to stand for 30 minutes · Carotid Sinus Hypersensitivty exists if: 47. Massage produces sinus pause >3 seconds
48. Massage produces a BP drop of >50 mmHg
49. Massage produces symptoms without BP/HR change

· The Classical Drop Attack
50. Is preceded by Light headedness
51. Causes bewilderment in the patient
52. Is usually a result of vertebrobasilar insufficiency
53. May be due to Vasovagal syncope

(Y C Gary Lee & J O Davies)

· Regarding thoracentesis in the investigation of a pleural effusion
54. A closed pleural biopsy should always be performed at the same time
55. Atropine should be routinely administered as a premedication, unless there are contraindications.
56. Removal of a large amount of pleural f luid (eg 2 litres) can lead to re-expansion pulmonary oedema.
57. A pneumothorax on the post-thoracentesis radiograph may represent a trapped lung that fails to re-expand, rather than an airleak from puncture of the lung.
58. Ultrasound is more sensitive and accurate than clinical examination in locating the site of fluid accumulation.

· In the analysis of pleural fluid
59. Differentiating between a transudate and an exudates effusion is the important first question.
60. Pleural fluid albumin level can be useful in differentiating between an exudate and a transudate in patients receiving diuretic therapy.
61. Amylase level should be measured routinely.
62. A haemothorax is diagnosed when the effusion appeared heavily blood stained.
63. Effusions secondary to pulmonary emboli are excluded if the pleural f luid is a transudate.

· Empyema
64. Requires prompt drainage.
65. Is usually lymphocytic.
66. Is characterised by low pleural fluid pH and glucose levels.
67. Should be suspected in all patients with infective symptoms and a pleural effusion.
68. Requires surgical drainage and decortication in most cases.