A 64-year-old man is having a dual chamber pacemaker inserted. The ventricular lead is to be inserted via the coronary sinus.
Where does the coronary sinus drain into?
Correct Answer A:
Coronary circulation: Arterial supply of the heart:
Venous drainage of the heart:
A 57-year-old patient with acute pulmonary oedema is admitted to the ITU department. She has no past medical history of note. A Swan-Ganz catheter is inserted to enable measurement of the pulmonary capillary wedge pressure.
Which chamber of the heart does this pressure generally equate to?
Correct Answer C:
Pulmonary capillary wedge pressure:
Pulmonary capillary wedge pressure (PCWP) is measured using a balloon tipped Swan-Ganz catheter which is inserted into the pulmonary artery. The pressure measured is similar to that of the left atrium (normally 6-12 mmHg).
One of the main uses of measuring the PCWP is determining whether pulmonary oedema is caused by either heart failure or acute respiratory distress syndrome. In many modern ITU departments PCWP measurement has been replaced by non-invasive techniques.
Which one of the following is least recognized to cause a clubbed appearance of the fingers?
Correct Answer D:
Whether thyroid acropachy is a true cause of clubbing is a moot point. The question asks about a 'clubbed appearance of the fingers'
Clubbing:
The causes of clubbing may be divided into cardiac, respiratory and other.
Cardiac causes:
Respiratory causes:
Other causes:
A 14-year-old girl is admitted to hospital following a ruptured ectopic pregnancy. She comes from a family of Jehovah's Witnesses. Her haemoglobin on admission is 6.9 g/dl. She consents to a blood transfusion but her mother refuses.
What is the most appropriate course of action?
Correct Answer B:
The GMC gives the following guidance:
'You should encourage young people to involve their parents in making important decisions, but you should usually abide by any decision they have the capacity to make themselves'
With respect to Jehovah's witnesses:
'You should not make assumptions about the decisions that a Jehovah's Witness patient might make about treatment with blood or blood products. You should ask for and respect their views and answer their questions honestly and to the best of your ability. You may also wish to contact the hospital liaison committees established by the Watch Tower Society (the governing body of Jehovah's Witnesses) to support Jehovah's Witnesses faced with treatment decisions involving blood. These committees can advise on current Society policy regarding the acceptability or otherwise of particular blood products. They also keep details of hospitals and doctors who are experienced in 'bloodless' medical procedures.'
A blood transfusion is clearly in the patient's best interests and in the scenario described above may potentially be life-saving. Whilst a child cannot refuse treatment they are able to provide consent. Giving the blood transfusion is therefore both clinically and ethically the right course of action.
Not giving the blood transfusion not only fails to respect the patient's wishes but also causes potential harm.
The chance of a 45-year-old mother giving birth to a child with Down's syndrome is approximately:
Down's syndrome risk - 1/1,000 at 30 years then divide by 3 for every 5 years.
Down's syndrome: epidemiology and genetics:
Risk of Down's syndrome with increasing maternal age:
One way of remembering this is by starting at 1/1,000 at 30 years and then dividing the denominator by 3 (i.e. 3 times more common) for every extra 5 years of age.
Cytogenetics:
The chance of a further child with Down's syndrome is approximately 1 in 100 if the mother is less than 35 years old. If the trisomy 21 is a result of a translocation the risk is much higher.
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