pulsenotes

Quick fire anatomy 🔥 - The blood supply to the colon is primarily provided by the superior (SMA) and inferior mesenteric (IMA) arteries.

In addition to the mesenteric arteries, the final part of the hindgut is supplied by branches from the internal iliac artery.

There are many branches (detailed below) that supply the colon. The areas they supply cross-over and they have a tendency to anastomose allowing for a degree of collateral supply. The supply is most precarious at so called ‘watershed’ areas, where such collaterals are limited - namely the splenic flexure and rectosigmoid junction.

Want to learn more? Read our latest notes on Colonic Ischaemia - Available NOW for FREE!

💊 PSA practice question - A 68-year-old man presents to the ambulatory medical clinic with left calf swelling.

He has recently had a total knee joint replacement under the orthopaedic surgeons.

Write a prescription for ONE drug that is most appropriate to treat the DVT.

Answer - B ✅

A variety of anticoagulants may now be used to treat venous thromboembolisms (VTE) including direct-oral anticoagulants, low-molecular weight heparin and warfarin.

Direct-acting oral anticoagulants (DOACs) are now commonly used first line. It is important to choose the current dose as this differs depending on whether the indication is treatment or prophylaxis of VTE. In addition, it is important to consider the patients’ age, weight and renal function as these can also influence the dose prescribed. Some DOACs such as edoxaban require a period of parenteral anticoagulation (e.g. low-molecular-weight heparin) before initiation. Warfarin is a vitamin K antagonist that inhibits vitamin-K dependant clotting factors (II, VII, IX, X). However, it inhibits protein C and protein S (anticoagulation factors) activity faster meaning it is initially prothrombotic. Therefore, warfarin should be given alongside treatment dose low molecular weight heparin until the INR is therapeutic.

The dose of enoxaparin here is the prophylactic dose. It should be 120 mg subcutaneously once daily. The dose of apixaban is the prophylaxis reduced dose. In this patient, it should be 10 mg oral twice daily.
NOTE: In the exam the Prescribing Section is not in the single-best answer format. Instead you are asked to give a drug, the route, dose, and frequency. As such there can be more than one correct answer as well as partially correct answers. See the accompanying video for more details.

💊PSA practice question - A 37-year-old woman is admitted to a psychiatric unit with a manic episode.

PMH. Polycystic ovarian syndrome. DH. Medroxyprogesterone acetate 150 mg intramuscular every 12 weeks. She is placed under section 3 and a decision is made to start Quetiapine 50 mg orally twice a day for the first day and then increased by 50 mg every day until symptoms improve.

Select the most appropriate option to monitor for the adverse effects of Quetiapine during initiation of therapy.

A - ECG
B - Serum lipids
C - Serum creatiine
D - Thyroid function tests
E - Weight

Master the Prescribing Safety Assessment with Pulsenotes.

An intensive, on-demand crash course aimed at preparing you for the PSA examination.

- 9 on-demand tutorials
- 360+ minutes of premium HD content
- 130+ practice questions

Best of all? It’s COMPLETELY FREE FOR OUR MEMBERS!! 💪

https://www.pulsenotes.com/psa ✅

Acute onset headache... 🧠⁠
⁠
👨🏽‍⚕️ SAH should be suspected in any patient with a sudden or rapid onset severe headache, which is classical of SAH. These patients require urgent assessment and computed tomography (CT) of the head.⁠
⁠
📺️ A plain CT Head is required to check for the presence of acute blood in the subarachnoid space. If performed within six hours of onset of symptoms (ictus), it has a sensitivity of 98.7% and specificity of 99.9% for detecting a subarachnoid haemorrhage.⁠
⁠
💉 If a CT Head does not show any evidence of SAH then a lumbar puncture (LP) is required.⁠
⁠
A LP is used to collect and assess the cerebrospinal fluid (CSF) for evidence of SAH. This is particularly important for patients presenting > 6 hours from onset.⁠
⁠
Typically, haemoglobin and bilirubin are not found in CSF but after a SAH, red blood cells lyse and release oxyhaemoglobin which is converted to bilirubin. Oxyhaemoglobin on its own suggests a recent bleed or a traumatic lumbar puncture but the presence of both oxyhaemoglobin and bilirubin is suggestive of SAH. The LP should be delayed by 12 hours from symptom onset to improve the sensitivity of detecting red blood cell breakdown products (e.g. xanthochromia/bilirubin)⁠
⁠
❤️ We hope you like it.. check our more of our fantastic content @ app.pulsenotes.com⁠
⁠
⁠

A 29-year-old is seen by the GP with a two month history of increasing tiredness... 💤⁠
⁠
What do you think is the likely diagnosis? 👩🏿‍⚕️⁠
⁠
Macrocytic anaemia is the presence of a reduced Hb concentration and an increased MCV.⁠
⁠
Macrocytic anaemia is commonly due to vitamin B12 or folate deficiency and this should be excluded in the first instance. These are known as megaloblastic anaemias. Vitamin B12 (cobalamin) is found in meats and dairy products so patients who are vegans are at increased risk.⁠
⁠
Other causes should be screened for if these blood tests are normal.⁠
⁠
😍We hope you like it.. check out more of our fantastic content @ app.pulsenotes.com⁠
⁠
⁠

Memory loss... 🧠⁠
⁠
Dementia is a clinical syndrome characterised by significant deterioration in mental function. It is important to be able to distinguish between dementia subtypes.⁠
⁠
Dementia can be caused by several conditions, which all manifest with poor mental performance and impaired normal functioning. The clinical manifestations of dementia can reflect the underlying aetiology. Alzheimer’s disease is by far the most common cause of dementia. In some cases, there may be mixed dementia with different aetiologies contributing (e.g. vascular and Alzheimer’s).⁠
⁠
Causes of dementia: ⁠
- Alzheimer’s disease (AD): 50-75% ⁠
- Vascular dementia (VD): 20% ⁠
- Dementia with Lewy-body (DLB): 15-20% ⁠
- Frontotemporal dementia (FTD): 2% ⁠
- Rare causes: Parkinson’s disease dementia (PDD), Huntington’s disease (HD), Prion disease, others.⁠
⁠
All dementia is characterised by reduced mental performance and impaired normal functioning. However, certain clinical features may point towards a specific type of dementia. These are summarised in the table below.⁠
⁠
😍We hope you like it.. check out more of our fantastic content @ app.pulsenotes.com⁠
⁠
⁠

Chest pain... 💔

🤓 The ECG shows evidence of an anterolateral ST elevation myocardial infarction that requires urgent revascularization

Acute coronary syndrome (ACS) is an umbrella term for three conditions based on clinical features, ECG, & cardiac enzymes.

These are known as ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina (UA). ACS is usually triggered by the rupture of an atheromatous plaque in patients with underlying coronary artery disease. This leads to occlusion of a coronary vessel, ischaemia, and damage to the myocardium resulting in myocardial death and a rise in cardiac enzymes (e.g. troponin).

Patients with STEMI need urgent referral to cardiology for coronary angiography and percutaneous coronary intervention. Patients with NSTEMI/UA will usually require revascularisation, however, there is less urgency to immediately perform angiography and instead, they need optimisation with pharmacological therapy.

The management of ACS can be briefly summarised using the following mnemonics:

STEMI
The management of patients with STEMI can be remembered using the mnemonic 'TAAP':

-T - Transfer: Urgent transfer to a cardiac centre
-A - Antiplatelets (Aspirin 300 mg loading + Ticagrelor/Clopidogrel)
-A - Analgesia (morphine)
-P - Percutaneous coronary intervention (i.e. insertion of a stent to unblock the obstruction)

Emergency coronary angiography +/- primary percutaneous coronary intervention (PCI) should be offered within 120 minutes of a diagnosis of STEMI if patients present within 12 hours of chest pain.

NSTEMI/UA
The management of patients with NSTEMI or UA can be remembered using the mnemonic 'BATMAN':

-B - Beta-blockers (unless contraindicated)
-A - Aspirin (300 mg loading, then 75 mg once daily)
-T - Ticagrelor (180 mg loading, then 90 mg twice daily), alternatively clopidogrel if high bleeding risk
-M - Morphine (titrate for analgesia)
-A - Antithrombotic agent (Fondaparinux 2.5 mg subcutaneous unless contraindicated)
-N - Nitrates (sublingual nitrates to relieve pain - consider infusion if ongoing pain)

Status epilepticus... 🧠⁠
⁠
refers to continuous seizure activity, which has failed to self-terminate. It is traditionally defined as:⁠
⁠
- A single epileptic seizure lasting > 30 minutes ⁠
- A run of epileptic seizures (≥2) without regaining consciousness between episodes⁠
⁠
⭐️ The majority of seizures will spontaneously terminate within 3 minutes and do not require emergency treatment. ⁠
⁠
However, those with sustained seizures are at risk of long-term neurological damage. The highest risk is with generalised tonic-clonic seizures. In clinical practice, there is an urgency to treat status to prevent irreversible neurological damage. This means the traditional definitions may not be practical. Instead, patients should be treated as status if they have the following: ⁠
- A convulsive seizure lasting > 5 minutes ⁠
- Recurring seizures without recovery⁠
⁠
Convulsive status is used to describe the typical, sustained generalised tonic-clonic seizure, which presents with generalised muscle stiffening and rhythmic muscle jerking. Other types can present. The emergency treatment follows a step-wise algorithm. After two doses of benzodiazepines, patients should be started on an anti-epileptic medication. This is traditionally phenytoin, but in modern guidelines, newer agents may be used (e.g. levetiracetam).⁠
⁠
🎁 For more fantastic medical content check out app.pulsenotes.com⁠
⁠

Haematology... 🩸⁠
⁠
👩‍🏫 Aplastic anaemia refers to immune-mediated destruction of hematopoietic cells within the bone marrow. This leads to pancytopaenia with a reduction in white cells, red cells and platelets. The condition may be non-severe, severe or very severe and potentially lead to life-threatening bleeding or neutropenic sepsis. It is broadly defined as pancytopaenia with hypocellular bone marrow (i.e. lack of replicating cells) in the absence of abnormal infiltrates (e.g. malignant cells) or marrow fibrosis. Some insults to the marrow (e.g. viral infection, drugs) may cause a transient fall in counts that subsequently recover. Therefore, monitoring patients for reversibility is important.⁠
⁠
✅ Here, the presence of pancytopaenia in the absence of another identifiable cause and hypocellular bone marrow is consistent with aplastic anaemia.⁠
⁠

How well do you know your EYELID ANATOMY!?

The eye lids protect the eyes, distribute tears & regulate light exposure.

In addition, they are involved in facial expressions and non-verbal communication.

The eyelids are divided into two anatomical lamellae:

- Anterior lamella - skin & orbicularis oculi muscle.
- Posterior lamella - tarsal plate & conjunctiva.

We hope you like it.. check our more of our fantastic content @ app.pulsenotes.com

How well do you know your HAND ANATOMY!? 👋

PART ONE!

There are 27 bones in the human hand:
- 8 carpal bones
- 5 metacarpals
- 14 phalanges

The 8 carpal bones are arranged in TWO TRANSVERSE ROWS.

You can use the mnemonic: SO LONG TO PINKY, HERE COMES THE THUMB to remember them and their order!

SO - Scaphoid
LONG - Lunate
TO - Triquetrum
PINKY - Pisiform

HERE - Hamate
COMES - Capitate
THE - Trapezoid
THUMB - Trapezium (Sits underneath the thumb!)

We hope you like it.. check our more of our fantastic content @ app.pulsenotes.com

A 30-year old surgical trainee presents to her GP with a 3 month history of worsening pain at the base of her right thumb. She is married with 2 small children. She denies previous trauma. She reports a sharp pain, which is aggravated by the movements of the wrist and thumb.

An x-ray is performed which demonstrates no abnormalities. A focussed examination elicits tenderness over the right radial styloid and the 1st dorsal compartment, in addition to pain with resisted abduction of the right thumb.

Q1 - What is the most likely diagnosis?

Q2 - What clinical test is often performed?

Q3 - What are the management options?

Learn more @ app.pulsenotes.com