Your Daily Meds

Good morning and welcome to your Friday dose of Your Daily Meds.

Bonus Review: What is erythropoietin? Where is it produced?

Answer: It is a glycoprotein hormone and is the main factor controlling red cell production.

Regulation of erythropoietin (EPO) production controls red cell mass and then blood oxygen carrying capacity.

In adults, EPO is produced mostly in the kidneys. In the foetus, the liver.

(Us adults only have 10-15% of our EPO being produced in our livers)

Case:

A 45-year-old male presents with a 5-day history of malaise, productive cough and right-sided chest pain with fevers.

He has a 20 pack-year history of smoking.

On examination, his temperature is 38.1, HR 112, BP 115/78, RR 23/min, SpO2 93% on room air.

Which of the following is the most likely diagnosis?

* Bronchial carcinoma

* Community acquired pneumonia

* Sarcoidosis

* Tuberculosis

* Wegener’s granulomatosis

Have a think.

Scroll for the chat.

Query:

During preoperative airway assessment, a clinician asks a patient to open his mouth and protrude his tongue as far as possible. During this process, the clinician visualises the following:

Which of the following scores correctly describes this result?

* Mallampati 1

* Mallampati 2

* Mallampati 3

* ASA 1

* ASA 2

Have a think.

Open your mouth in front of a mirror.

More scroll for more chat.

Cough-y:

Note that this man has symptoms of an acute infection. These include the history of fevers, and malaise with a likely chest focus. His smoking history also puts him at risk of community-acquired pneumonia, most commonly Streptococcus pneumoniae. Note that he has no signs of confusion nor any severe prognostic signs such as systolic BP < 90 or RR >30/min. Given these signs and this man’s age, it is likely that he will be able to be managed without admission. 

This man has a significant smoking history, however he is relatively young to be developing lung cancer. Further, the history is that of an acute illness not that of gradual decline. Sarcoidosis is unlikely as it rarely presents with an acute infective picture. Tuberculosis may be a reasonable diagnosis given the systemic symptoms and productive cough. Further travel and contact history would need to be taken. Further investigation of sputum, such as testing for acid-fast bacilli would be required. The short time course of the illness, however, makes a pneumonia more likely. Wegener’s granulomatosis is a vasculitis that can present with cough and haemoptysis on a chronic background, rather than acute onset.

Wide Open:

This question asks for assessment of the Mallampati score for preoperative assessment of an airway in the context of predicting difficult intubation. The Mallampati classification has four levels illustrated by the following:

When asked to open the mouth and protrude the tongue as far as possible, the clinician judges the Mallampati score based of visualisation of features in the oral cavity and oropharynx as follows:

* Class 1 – Soft palate, uvula, fauces, pillars visible

* Class 2 – Soft palate, uvula, fauces visible

* Class 3 – Soft palate, base of uvula visible

* Class 4 – Only hard palate visible

The ASA score references the American Society of Anaesthesiologists physical status classification. It is a subjective assessment of a patient’s overall health:

* ASA I – patient is completely fit and healthy

* ASA II – patient has mild systemic disease

* ASA III – patient has severe systemic disease that is not incapacitating

* ASA IV – patient has incapacitating disease that is a constant threat to life

* ASA V – a moribund patient who is not expected to live 24 hours without surgery

* ASA VI – a declared brain-dead patient whose organs are being removed for donor purposes

* (E – emergency surgery, an ‘E’ is placed after the Roman numeral)

So this was Mallampati 2.

Bonus: What are the actions of erythropoietin?

Answer in Monday’s dose.

Closing:

Thank you for taking your Meds and we will see you Monday for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!

Luke.

Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.

Just credit us where credit is due.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com

Good morning and welcome to your Thursday dose of Your Daily Meds.

Bonus Review: Why are newborn infants susceptible to Vitamin K deficiency?

Answer: Firstly, Vitamin K deficiency in the newborn can result in haemorrhagic disease of the newborn, resulting in neonates bleeding to death…

Not good.

Neonates are Vitamin K deficient as -

* Vitamin K does not cross the placenta in sufficient amounts = neonatal hepatic stores are low as are their stores of clotting factors 2, 7, 9 and 10

* The neonatal bowel is initially sterile, so they don’t even get that little bit of bacterial production of Vitamin K

* Breast milk is low in Vitamin K

Happily, bacteria colonise the neonatal colon in the first week and start to produce some Vitamin K.

Case:

A 16-year-old female presents to the Emergency Department complaining of diffuse abdominal pain, anorexia and vomiting. On examination, she was febrile to 38°C and the abdomen was tender, especially over the right iliac fossa. The which of the following would not be considered a sign of peritonism in this patient?

* Rigidity

* Involuntary guarding

* Murphy’s sign

* Rebound tenderness

* Percussion tenderness

Have a think.

Scroll for the chat.

Something Obstetric:

A 32-year-old female presents to the Emergency Department complaining of vaginal bleeding. She is in the third trimester of her second pregnancy. She reports no pain with the bleeding and no other discharge. She reports a large volume of bright red blood in an episode of bleeding prior to presentation to the ED. On examination, she is afebrile, hypotensive and tachycardic. In which of the following differential diagnoses for this complaint would a digital examination be contraindicated?

* Vasa praevia

* Abruptio placentae

* Spontaneous abortion

* Atrophic vaginitis

* Placenta previa

Have a think.

Remember some Latin (or Greek…I dunno).

More scroll for more chat.

McMurphy:

Key to answering this question is recognising the likelihood diagnosis of appendicitis and the risk of peritonitis with inflammation and rupture.

The classical history of diffuse abdominal pain that eventually localises to the right iliac fossa describes the process of inflammation spreading from visceral peritoneum to parietal peritoneum. The sensory input from the visceral peritoneum is vague, while the sensation associated with parietal peritoneum inflammation is well-localised and distinct. 

Peritonism describes the painful sensation resulting from when inflamed peritoneal surfaces are moved relative to each other. Rigidity, a tendency for the patient to remain very still, and involuntary guarding, an inability to relax the abdominal wall even with distraction, are associated with peritonitis. Rebound tenderness, tenderness felt on the quick release after firm palpation, and percussion tenderness also suggest peritonism.

Murphy’s sign describes the cessation of inhalation during palpation of the right upper quadrant and is sensitive for acute cholecystitis.

The Preview:

Placenta praevia is an obstetric complication of placental implantation into the uterine wall such that it is near or covering the internal cervical os. Complete praevia is a complete covering of the os by the placenta. A marginal praevia is when the placenta is less than 2cm from the internal os, but not covering it. Placenta praevia has an inherent risk for haemorrhage.

Because of the risk of uncontrolled bleeding, digital examination of the vagina is contraindicated until placenta praevia is excluded. Any pregnant woman beyond the first trimester presenting with vaginal bleeding should have a speculum examination and diagnostic ultrasonography. If ultrasonography is unavailable and a digital examination is necessary, it should be performed in a theatre prepared for emergent caesarean delivery if at a suitable gestation.

Vasa praevia is a condition in which the blood vessels supplying the foetus run adjacent or over the internal cervical os. Vasa previa may be associated with a low-lying placenta. There is a risk of foetal exsanguination due to vessel damage when the membranes rupture. The vessels can also be compressed by the foetus during labour.

Abruptio placentae is the premature separation of the placenta from the uterus. Patients present with bleeding, uterine contractions and foetal distress.

Spontaneous abortion, a process of early pregnancy loss, is associated with a history of vaginal bleeding, abdominal pain and passage of tissue. The vaginal bleeding and abdominal pain tends to subside when the tissue has passed.

Atrophic vaginitis is characterised by vaginal soreness, postcoital burning, dyspareunia, burning leukorrhoea and occasional spotting.

Bonus: What is erythropoietin? Where is it produced?

Answer in tomorrow’s dose.

Closing:

Thank you for taking your Meds and we will see you tomorrow for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!

Luke.

Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.

Just credit us where credit is due.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com

Good morning and welcome to your Wednesday dose of Your Daily Meds.

Bonus Review: Where does Vitamin K come from? Where is it absorbed? Why is it called Vitamin K?

Answer: We need dietary Vitamin K. We get most of our dietary Vitamin K from leafy green vegetables and meats.

Large amounts of menaquinone (Vitamin K2) is produced by bacterial action in the colon - unfortunately Vitamin K absorption does not occur in the colon. Some of the bacterially-produced Vitamin K is absorbed in the terminal ileum where there are some bile salts present. But, again, we need dietary Vitamin K.

The absorption of dietary Vitamin K is from the small intestine. Remember that Vitamin K is fat soluble and so needs bile salts so that it can initially be solubilised into micelles which facilitates absorption into the circulation (via chylomicron form in the lymphatics).

So, in patients with obstructive jaundice and an absence of bile salts in the small intestine, Vitamin K absorption will be impaired. They might even need some intravenous Vitamin K.

Or what about the intubated malnourished patient with terminal ileitis from Crohn’s Disease. He has normal small bowel bile salts but no dietary Vitamin K? And naturally that little bit of bacterially produced Vitamin K are not going to be absorbed in the terminal ileum…let’s watch his INR go up…

Also the ‘K’ in Vitamin K comes from the German ‘Koagulation’…

Case:

Consider the following ECG:

What is the correct rate, axis and interpretation, respectively?

* 100/min; normal axis; left bundle branch block

* 120/min; normal axis; atrial flutter

* 120/min; left axis deviation; atrial flutter with ectopic beats

* 120/min; normal axis; atrial fibrillation with rapid ventricular rate

* 100/min; right axis deviation; sinus rhythm

Have a think.

Count some little squares and look at the squiggles.

Scroll for the chat.

Investigation:

A 25-year-old male is being worked up for an obstructive respiratory condition. Which of the following respiratory function test results would be most indicative of asthma.

(FEV1 = forced expiratory volume in 1 second; VC = vital capacity; TLCO = carbon monoxide transfer factor; KCO = carbon monoxide transfer factor per unit lung volume; TLC = total lung capacity; RV = residual volume) 

* FEV1 ↓↓; VC ↓; FEV1/VC ↓; TLCO →; KCO →/↑; TLC →/↑; RV →/↑ 

* FEV1 ↓↓; VC ↓; FEV1/VC ↓; TLCO →; KCO →; TLC ↑; RV ↑

* FEV1 →; VC →; FEV1/VC →; TLCO →; KCO →; TLC →; RV →

* FEV1 ↓↓; VC ↓; FEV1/VC ↓; TLCO ↓↓; KCO ↓; TLC ↑↑; RV ↑↑

* FEV1↓; VC ↓↓; FEV1/VC →/↑; TLCO↓↓; KCO→/↓; TLC ↓; RV ↓

(And where down arrow means decreased, sideways arrow means normal/stable etc…)

Have a think.

Remember those flow-volume curve/loop things.

More scroll for more chat.

Rapidamente:

This ECG shows atrial fibrillation with rapid ventricular rate. 

The rate is approximately 120/min and with clear atrial fibrillation as P waves are not seen. The QRS complex is narrow at approximately 80ms. The axis is normal. Note there is mild horizontal ST depression in V4, V5 and V6 which is likely rate-related, not due to ischaemia.

Vitality:

Answer a) is most suggestive of asthma. The greatly reduced FEV1 is suggestive of airflow obstruction, as in asthma and COPD. To differentiate asthma from chronic bronchitis and emphysema, it is important to note the carbon monoxide transfer capacity, greatly reduced in emphysema, and the TLC and RV, which is not necessarily increased in asthma, unlike chronic bronchitis.

Thus, answer a) is most suggestive of asthma;answer b) most suggestive of chronic bronchitis, answer c) is most likely a normal respiratory function test result; answer d) is suggestive of emphysema; and answer e) is suggestive of pulmonary fibrosis.

In the case of asthma, lung function tests should be repeated after administration of a short-acting beta-2-adrenoreceptor agonist, such as salbutamol, to observe for any reversibility, such as a large improvement in FEV1 (eg 400mL). 

Bonus: Why are newborn infants susceptible to Vitamin K deficiency?

Answer in tomorrow’s dose.

Closing:

Thank you for taking your Meds and we will see you tomorrow for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!

Luke.

Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.

Just credit us where credit is due.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com

Good morning and welcome to your Tuesday dose of Your Daily Meds.

Bonus Review: Ok so what is the difference between a Hormone and a Vitamin?

Answer: A few things -

A Hormone = endogenous chemical messenger which…

* Is secreted into the blood by a ductless gland

* Combines with a specific receptor on a distant cell and;

* Produces a change in the metabolism of that distant cell

While a Vitamin = an organic substance which…

* The body cannot produce

* Must come from an exogenous source (yes, usually diet)

* Is only required in small amounts

* Is usually essential for survival

* Affects specific biochemical reactions

* Is not a caloric source

Case:

You meet a 45-year-old male in the Emergency Department.

He has a long history of peptic ulcer disease.

He tells you of severe, sudden onset epigastric pain.

And on examination, there is involuntary rigidity and percussion tenderness over the upper abdomen.

His erect chest/abdominal x-ray is shown below:

Given this man’s history and examination, what is the key finding in this x-ray?

* Omental fat between liver and diaphragm

* Pneumothorax

* Enlarged gastric bubble

* Subdiaphragmatic free gas

* Subdiaphragmatic abscess

Ward Call:

A nurse calls you quite concerned from the medical ward:

Doctor, could you please come and review Mr Smith urgently. I think he has haematuria. I just looked in his indwelling catheter drainage bag and his urine is dark red. So I am quite worried.

While you ponder this, otherwise calmly watching a soap opera in the on-call room, what are some questions you could ask over the phone to decide if you should go and review this chap, or wait until the next ad break?

Have a think.

More scroll for more chat.

That X-Ray

This man has a history of peptic ulcer disease and signs of peritonitis

The main concern should be an acutely perforated ulcer.

This would allow a communication between the stomach or duodenum with the peritoneal space, irritating the peritoneum and causing peritonitis.

The x-ray shows free gas under both domes of the diaphragm.

This is Pneumoperitoneum.

Also note a nasogastric tube in situ.

On Haematuria:

Some questions you could ask include:

* When did this ‘haematuria’ start and has it happened before?

* Are there any associated symptoms?

* eg colicky flank pain suggesting a renal tract stone. Dysuria and frequency of a UTI.

* We have been told there is a urinary catheter in place, but was this recently inserted?

* Traumatic or inexperienced IDC insertions may lead to bleeding.

* Has the patient had recent surgery?

* Procedures on the bladder and kidneys are associated with transient bleeding.

* Low gastrointestinal surgeries sometimes place the bladder at risk of injury, so an IDC may be left in situ for the actual purpose of checking for haematuria as a surrogate of bladder injury. A conversation with your surgical registrar may ensue.

* Same for women post-caesarean section - ongoing haematuria may signify damage to the at-risk bladder in surgery.

* Is the patient anti-coagulated?

* Anticoagulants may require reversal in the actively bleeding patient.

* Or withholding of those anticoagulants that cannot be reversed.

* Or, combine a couple of ideas, has this patient recently had surgery and now has ‘haematuria’ after restarting their anticoagulants (that had been withheld over the preoperative period)?

* What are the vital signs?

* Hypotension and tachycardia of significant blood loss.

* Fever of urosepsis.

* What was the reason for admission?

Ok so I have written ‘haematuria’ with the squiggles (‘‘) a couple of times above. Haematuria probably gets used a bit too often to describe dark urine.

Because there is a difference between the concentrated urine of dehydration (or the anti-diuretic state), the coca-cola urine of bilirubinuria, microscopic haematuria from laboratory microscopy (the urine looks normal to the eye), macroscopic haematuria (the urine looks dark and there is blood on the dipstick and microscopy) and frank haematuria (the patient is literally bleeding fresh blood from their urethra).

Again, dark red cordial urine is still not necessarily frank haematuria - a tiny bit of bleeding will stain a bladder full of urine to a concerning colour.

Naturally, an apparent connection between the left ventricle and urethra resulting in haemodynamic instability secondary to haemorrhage of fresh blood should warrant more concern than trace blood from a recently inserted indwelling catheter.

So those simple questions of - when was IDC inserted, reason for admission, vital signs, how does patient look - will probably give you most bang for your buck.

You will probably have to go and look at that urine at some point, however, and nursing concern should not be ignored.

But maybe it can wait until the next ad break…

Bonus: Where does Vitamin K come from? Where is it absorbed? Why is it called Vitamin K?

Answer in tomorrow’s dose.

Closing:

Thank you for taking your Meds and we will see you tomorrow for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!

Luke.

Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.

Just credit us where credit is due.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com

Good morning and welcome to your Monday dose of Your Daily Meds.

Bonus Review: Consider a Rhesus (Rh) positive foetus being carried by a Rh negative mother in her first pregnancy. Would that foetus be affected by the mother’s antibodies against foetal red blood cells?

Answer: In short, probably not.

Given this is her first pregnancy, the mother will probably not have any Rhesus antibodies (Anti-D antibodies).

She could have developed these antibodies if she had been exposed to Rh positive blood in the past, such as in a previous pregnancy with an Rh positive foetus or an Rh positive blood transfusion.

So, by considering the use of Anti-D passive immunisation in the event of a sensitising event in a pregnant woman of this status; and avoiding Rh positive transfusions in women of child-bearing age, we can reduce the risk of blowing up foetal red blood cells…

Case:

A 34-year-old male is brought into the Emergency Department via ambulance after a high-speed motor vehicle accident.

On assessment:

* There is no eye opening

* Incomprehensible sounds are noted

* He pulls his hand away when you firmly squeeze his nailbed with a pen.

Which of the following correctly describes this man’s GCS score?

* GCS 7 – E 1; V 2; M 4

* GCS 7 – E 1; V 2; M 4

* GCS 7 – E 1; V 2; M 4

* GCS 7 – E 1; V 2; M 4

* GCS 7 – E 1; V 2; M 4

Have a think.

Scroll for the chat.

Paediatrics:

Which of the following is not considered in the calculation of an Apgar Score for a neonate?

* Heart rate

* Respiratory effort

* Muscle tone

* Temperature

* Reflex response

Have a think.

More scroll for more chat.

What the GCS?:

The Glasgow Coma Scale is used as a neurological scoring system and assesses the patient’s best eye response, best vocal response and best motor response.

It is scored out of 15, with the eye component scored out of 4, the verbal component out of 5 and the motor component out of 6.

In this case, there is no eye opening (E 1), there are incomprehensible sounds verbalised (V 2), and the patient withdraws from painful stimulus (M 4). This results in a total GCS of 7.

A GCS of 8 or less is often used as a marker for the need for intubation in the setting of an unprotected airway.

Remember, the minimum GCS is 3, not 0.

Toasters have a GCS of 3. As do logs.

The GCS marking criteria are shown below for reference:

APGARing:

The Apgar Score comprises the assessment of neonatal heart rate, respiratory effort, muscle tone, colour and reflex response; with each criterion scored from 0-2 with a maximum score of 10. 

Not Temperature.

Consider the table below:

The score is based on the degree of cardiorespiratory and neurological depression present in the neonate and is measured at 1 and 5 (and sometimes 10) minutes after birth. 

A normal Apgar score is between 7 to 10. Apgar score of 4 to 6 indicate moderate depression; and 0 to 3 indicates severe depression. 

Bonus: Ok so what is the difference between a Hormone and a Vitamin?

Answer in tomorrow’s dose.

Closing:

Thank you for taking your Meds and we will see you tomorrow for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!

Luke.

Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.

Just credit us where credit is due.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com

Good morning and welcome to your Friday dose of Your Daily Meds.

Bonus Review: What are the major blood groups? How are they determined and why are they important?

Answer: ‘Blood groups’ is a term that is used to refer to the genetically determined antigens that are present in the membranes of red blood cells.

The importance of these ‘groups’ then, is related to the degree of antigenicity of these antigens in the membrane.

The ABO grouping system are the most important because they are the most antigenic. The Rhesus (Rh) grouping system also has significant antigenicity.

Then there are many other descriptors and systems of blood grouping which describe antigens of much lower clinical importance.

Case:

Which of the following patterns of serological test results indicates vaccination against hepatitis B virus infection?

* HBsAg negative; Anti-HBc positive; Anti-HBs positive

* HBsAg negative; Anti-HBc negative; Anti-HBs negative

* HBsAg negative; Anti-HBc negative; Anti-HBs positive

* HBsAg positive; Anti-HBc positive; Anti-HBs negative

* HBsAg positive; Anti-HBc negative; Anti-HBs positive

(Where: HBsAg = hepatitis B surface antigen; Anti-HBc = antibodies to hepatitis B core antigen; Anti-HBs = antibodies to hepatitis B surface antigen)

Pause for a moment.

Sift through this pile of acronyms.

And scroll for the chat.

Ward Call:

You have just arrived to start your evening shift when you receive a call from the maternity ward about a patient who is receiving a blood transfusion.

Hi Doctor, could you please come and review Mrs Smith in the maternity ward? We started a blood transfusion for her approximately 15 minutes ago and now she is a bit unsettled. She is a little bit warm at 37.9 degrees and looks a bit flushed across her chest. I am worried she is having a transfusion reaction.

While you have this nurse on the phone, what further questions could you ask to triage this concern?

Have a think.

More scroll for more chat.

The Big B:

The pattern of serological investigations in the patient vaccinated against hepatitis B virus infection is characterised by the patient testing negative for hepatitis B surface antigen (HBsAg), negative to antibodies to hepatitis B core antigen (anti-HBc) and positive for antibodies to hepatitis B surface antigen (anti-HBs). 

The patterns of serological test results for hepatitis B infection are given in the following table:

Hot and Bothered:

Alright. Some questions you could ask over the phone to triage your concern regarding a transfusion reaction include:

* What symptoms does the patient have?

* Fevers, chills, chest pain, back pain, diaphoresis and dyspnoea can all be manifestations of a transfusion reaction.

* What are the vital signs?

* Need to know as anaphylaxis will look very different to fever alone.

* Which blood product is being transfused?

* How long ago was it started?

* Instant anaphylaxis reaction versus effects of fluid overload etc.

* What was the reason for admission?

* Symptomatic anaemia post caesarean section versus ongoing haemorrhage etc

Most transfusion reactions are non-haemolytic febrile reactions, especially if this is a multi-transfused or multiparous patient, and are due to WBC antigen-antibody reactions or cytokines. The transfusion does not need to be stopped and she may just need some paracetamol and promethazine.

BUT

The reason you are asking some questions over the phone is because the major threats to life with transfusions include:

* Anaphylaxis = deadness

* Acute Haemolytic Reaction - can cause Disseminated Intravascular Coagulation (DIC) = deadness

* Transfusion-Related Acute Lung Injury (TRALI) - respiratory failure = deadness

* Transfusion-Associated Circulatory Overload (TACO) - circulatory failure = deadness

* Bacterial contamination - septic shock = deadness

Bonus: Consider a Rhesus (Rh) positive foetus being carried by a Rh negative mother in her first pregnancy. Would that foetus be affected by the mother’s antibodies against foetal red blood cells?

Answer in Monday’s dose.

Closing:

Thank you for taking your Meds and we will see you Monday for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!

Luke.

Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.

Just credit us where credit is due.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com

Good morning and welcome to your Thursday dose of Your Daily Meds.

Bonus Review: How is iron carried (or transferred) in the blood?

Answer: Fe2+ is converted into Fe3+ Which is then carried on transferrin. Transferrin is a plasma protein, of the B-1 globulin class and is produced in the liver.

Quick Question:

In approximately what proportion of pregnancies does a single loop of umbilical cord around the foetal neck occur?

* 0.5%

* 2%

* 12%

* 15%

* 25%

Have a think.

Have a guess.

Scroll for the chat.

Psyche:

When considering schizoid personality disorder, which of the following correctly describes the expected thought form, thought content and relationships that patients may express?

(I shall be trying to confuse you between schizoid and schizotypal personality disorders; and schizophrenia with these answer options…)

* Thought form organised; thought content without psychosis; no desire for social relationships

* Thought form vague and circumstantial; thoughts of odd beliefs and magical thinking; socially inept

* Thought form disorganised; psychotic thought content; socially marginalised, not by choice

* Thought form disorganised; thought content without psychosis; socially marginalised, not by choice

* Thought form organised; psychotic thought content; socially inept

Have a think.

More scroll for more chat.

Looping Back:

One loop of umbilical cord around the foetal neck occurs in approximately 25% of pregnancies. The rates for second and third loops are much lower, at 2.5% and 0.5% respectively. Furthermore, a loop of umbilical cord around the foetal body occurs in 4% of pregnancies.

It is important to note that true knots of the umbilical cord occur in 1% of pregnancies but are overrepresented in stillbirths, where they occur at an incidence of 4%.

On the Clusters:

Schizoid personality disorder is a Cluster A personality disorder, characterised by a lack of desire or enjoyment in close relationships and lifelong pattern of social withdrawal. They often have a detached or flat affect and may be described as emotionally cold. They rarely have close friends and take pleasure in few, if any, activities.

In contrast to schizotypal personality disorder, another Cluster A disorder, and schizophrenia (not a personality disorder, a distinct disorder of reality testing), people with schizoid personality disorder have organised thoughts, no psychosis and have no desire for close relationships.

Check out my hastily created reference table:

Bonus: What are the major blood groups? How are they determined and why are they important?

Answer in tomorrow’s dose.

Closing:

Thank you for taking your Meds and we will see you tomorrow for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!

Luke.

Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.

Just credit us where credit is due.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com

Good morning and welcome to your Wednesday dose of Your Daily Meds.

Bonus Review: At what level in the body does control of iron stores occur?

Answer: Control of iron in the body occurs at the level of the small bowel mucosal cells. These enterocytes are responsible for the control of iron absorption.

* When body iron stores are low - plasma transferrin is high, its iron saturation is low, more iron passes from ferritin in the eneterocytes to transferrin in blood

* When body iron stores are adequate - transferin saturation is higher, the iron remains in the enterocyte and the unwanted iron is lost from the available absorption pool when the enterocyte is shed

* Remember that iron is readily absorbed by these enterocytes, but the absorption across the enterocyte basal membrane is regulated by levels of ferritin and transferrin and transferrin saturation.

* If we overload this mucosal block with excessive iron supplementation, we will absorb excess iron

* Or if the function of the control mechanism is defective, such as in haemochromatosis, we will be overloaded with iron, resulting in iron deposition in the tissues

Case:

A 45-year-old male is brought to the Emergency Department by ambulance.

On examination, he has a temperature of 38.2°C and is agitated.

There is tremor, muscle rigidity and a marked deep tendon hyperreflexia of the lower limbs more so than the upper limbs.

His pupils are dilated and mucus membranes dry.

Relatives at his home informed the paramedics that he has a history of depression for which he is known to a Psychiatrist.

Which of the following is the most likely diagnosis?

* Serotonin syndrome

* Neuroleptic malignant syndrome

* Malignant hyperthermia

* Sympathomimetic toxicity

* Seizure

Have a think.

Scroll for the chat.

Procedure:

Alright then.

As if in an OSCE situation, tell me how you would approach, prepare for and conduct the ‘procedure’ of local anaesthetic infiltration.

Have a think.

Jot some things down.

Scroll for the chat.

The Syndrome:

This man has signs suggestive of serotonin syndrome.

Serotonin syndrome can be a life-threatening condition with increased serotonergic activity in the central nervous system. It can be caused by therapeutic medication use, interactions between medications and intentional overdose. Classically, serotonin syndrome is a clinical diagnosis of mental status changes, autonomic hyperactivity and neuromuscular abnormalities. In this case, serotonin syndrome is manifested by hyperthermia, agitation, muscular rigidity and hyperreflexia, along with the history of antidepressant use. Common antidepressants like Sertraline are Selective Serotonin Reuptake Inhibitors (SSRIs), which increase the extracellular levels of serotonin and serotonergic neurotransmission in the brain. 

Neuroleptic malignant syndrome is a life-threatening neurological emergency associated with the use of neuroleptic medication. It is characterised by mental status change, rigidity, fever and dysautonomia. In this case, the physical signs more prominent in the lower limbs and the associated SSRI usage are more suggestive of serotonin syndrome. 

Malignant hyperthermia is characterised by hypermetabolic crisis when a susceptible individual is exposed to a volatile anaesthetic agent, which is unlikely given the history in this case.

Sympathomimetic toxicity is manifested by stimulation of alpha- and beta-adrenergic receptors and characterised by typical adrenergic signs and symptoms, including hyperthermia, tachycardia, diaphoresis, hypertension and cardiac arrhythmias. Sympathomimetic toxicity can be caused by prescribed and non-prescribed substances, such as ecstasy.

Seizure is unlikely given the autonomic changes and neuromuscular abnormalities in this patient.

Infiltration:

Ok, so lets start with Indications:

* Local anaesthesia (LA) for painful procedures eg

* Suturing

* Debridement of wound

* Foreign body removal

* Reduction of disclocated small joint

* Arterial puncture

Then some Contraindications:

* Local anaesthetic allergy - rare

* Avoid lignocaine with adrenaline in areas of end-arterial supply eg:

* Fingers

* Toes

* Penis

* Pinna

* Nose

* (Even though amputated digits can be reattached (after a period of literally zero blood supply) and adrenaline is used in local anaesthetics for digital blocks of fingers and toes… best stick to the safe answer in the test…)

Equipment:

* Alcohol swab

* Skin cleansing solution eg some chlorhexidine

* Local Anaesthetic agent of choice

* Syringe: 5mL or 10mL

* Needle: 25G and 21G

Choice:

* Small volumes of concentrated anaesthetic for small areas or joints

* Large volumes of less concentrated anaesthetic for large areas or joints

* Select adrenaline-containing anaesthetic for vascular sites - causes vasoconstriction

* Likely help reduce bleeding

* Reduce systemic absorption of lignocaine

* Maintain higher anaesthetic concentration near nerve fibres

* Prolong local anaesthetic conduction blockade

* Lignocaine is most commonly used

* Bupivacaine and Ropivacaine are longer acting, usually used for nerve blocks or epidurals

Calculate:

Maximum safe dose of your chosen agent:

* Lignocaine - Max dose 3mg/kg - Duration 0.5-1 hour

* Lignocaine with adrenaline - Max dose 7mg/kg - Duration 2-5 hours

This means you will need to do some maths to work out how many mL of a particular % concentration lignocaine +/- adrenaline you can safely inject.

Just make sure you calculate your maximum mg for the particular patient FIRST, then work out the mL from the bottle SECOND.

Procedure:

* Consent, explain procedure blah blah blah

* Clean the site

* Recheck dose, safe maximum, dilution, allergies etc

* Draw LA into syringe with 25G needle

* Enter dermis of skin at 45deg, aspirate to ensure needle not in blood vessel

* Infiltrate 1-2mL of LA to make a bleb

* Exchange 25G for 21G needle

* Enter skin through previously anaesthetised bleb site

* Advance subcutaneously, aspirate and inject

* Repeat: Advance, aspirate, inject

* If you aspirate blood, withdraw a bit, aspirate then inject and continue

* Repeat such that the desired area is infiltrated with LA

* Wait at least two minutes to take effect

Then get on to cutting or suturing or realigning or whatever.

Bonus: How is iron carried (or transferred) in the blood?

Answer in tomorrow’s dose.

Closing:

Thank you for taking your Meds and we will see you tomorrow for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!

Luke.

Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.

Just credit us where credit is due.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com

Good morning and welcome to Your Daily Meds for Tuesday the 2nd of November, 2021.

I am planning on releasing an audio companion version of the daily newsletter that can be taken together or consumed on its own and will effectively be a transcript of the text.

I want you all to have the option of being able to listen to the audio version of the content while doing other things rather than having to carve out time to sit and read.

Allegedly these recordings will show up in podcast players, but you will all receive them in an email form along with the text version.

Now I have never recorded anything before so this will likely be a little clunky until I figure out how it all works.

So, forgive me in advance for the cheesy royalty free musical interludes and poor scripting.

Today should be the only day that you receive two separate emails. I should be able to include the audio and text in a single email from here on out.

Luke.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit yourdailymeds.substack.com