Question 1

The "CURB 65" score is a useful mnemonic for poor prognosis in patients with pneumonia. Prognosis is worst for patients who have many of the following:

• Confusion
• Uraemia
• Respiratory rate >30 breaths per minute
• Blood pressure < 90 mmHg systolic, or < 60 mmHg diastolic
• 65 years old or greater

Question 2

(Picture from: EMedicine)

Which of the following medications should a patient with a mechanical heart valve be taking:

Mechanical valves are at significant risk of thrombus forming on them, even when coated with teflon. Such thrombus could embolise causing for example a CVA. To reduce this possibiliy patients should be on warfarin lifelong with INR of 3.0.

Prophalytic antibiotic are needed only before and immediately after procedures involving possible entry of infection into blood stream, such as tooth removal, endoscopy, and most surgical procedures.

Mechanical valves rarely suffer problems with rejection.

In comparison bioprosthetic porcine tissue valves only need anticoagulation for the first 3 months.

For more inforamtion see this eMedicine article on Prosthetic Heart Valves.

Question 3

The guideline states that the following are features of acute severe asthma:

• Peak expiratory flow (PEF) 33-50% of best (or % predicted if recent best unknown)
• Inability to complete sentences in one breath
• Respiratory rate at least 25 breaths per minute
• Pulse rate at least 110 beats per minute

The following are listed as life threatening features:

• PEF < 33% of best or predicted
• SpO2 < 92%
• Silent chest, cyanosis or feeble respiratory effort
• Bradycardia, dysrhythmia, or hypotension
• Exhaustion, confusion, or coma

Since a pulse rate of less than 60 beats per minute is bradycardia, this is the correct option.

For more information on this topic you should refer to the British Guideline on the Management of Asthma published by the British Thoracic Society and Scottish Intercollegiate Guidelines Network. This guideline can be obtained via www.brit-thoracic.org.uk.

Question 4

In 2004 the National Institute for Clinical Excellence (NICE) produced a guideline entitled "Chronic Obstructive Pulmonary Disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care." This can be accessed via the following link: www.nice.org.uk/pdf/CG012_niceguideline.pdf.

The guideline recommends that: "LTOT is indicated in patients with COPD who have a PaO2 less than 7.3 kPa when stable or a PaO2 greater than 7.3 and less than 8 kPa when stable and one of: secondary polycythaemia, nocturnal hypoxaemia (oxygen saturation of arterial blood [SpO2] less than 90% for more than 30% of time), peripheral oedema or pulmonary hypertension. To get the benefits of LTOT patients should breathe supplemental oxygen for at least 15 hours per day. Greater benefits are seen in patients receiving oxygen for 20 hours per day."

Smoking in the presence of oxygen is a fire hazard.

The partial pressures of oxygen referred to in the guideline relate to patients breathing 'room air' that is comprised of 21% oxygen.

Question 5

In nephrotic syndrome, protein is passed in the urine. The proteins lost include naturally occurring anti-clotting factors, and loss of these predisposes patients to thrombotic disorders particularly deep venous thrombosis and pulmonary embolism.