Short Fellowship quiz

Due to its widespread prescription (which is often diverted to illicit use) oxycodone is now the most frequently abused of the opioids in Australia. (Link)

The cross reaction rate (i.e. clinical reaction) is estimated to be 0.3%. This is lower than the cross reactivity rate (from skin testing) of 5%. (Link)

Anisocoria is unequal pupillary size in each eye. When it is when greater in the dark, it suggests physiologic anisocoria if it dilates and sympathetic system disease, such as Horner’s syndrome if it does not dilate. When greater in bright light it indicates a parasympathetic problem, usually due to third nerve palsy or Holmes Adie (tonic) pupil. A Marcus Gunn pupil does not cause anisocoria. (link)

Apart from myelofibrosis, the other choices usually only cause mild hepatomegaly. (Link)

The correct answer is 10% – this is three times the rate in the normal general population. (Link)

Variability is not a quality dimension

The right upper arm is the preferred position as blood flowing to the right upper arm is least diluted by the shunt, if a patent ductus arteriosus is present. (Link)

All mammalian bites should have copious wound irrigation under pressure for up to 20 minutes with large quantities of normal saline (0.9%). This can be achieved by using an 18-19G cannula (with the needle removed) attached to a 20mL syringe. Primary closure can then follow if the injury is < 6 hours old. Prophylactic antibiotics are indicated for high risk wounds that include: >8 hours from time of injury; cat bites; human bites; rat bites; other bites unable to be adequately irrigated; in the immunocompromised patient; bites involving the hand, head and neck, face, genitals, ligaments, vessels, or joints. Severe established infection requires IV piperacillin+tazobactam 4+0.5 g or ticarcillin+clavulanate 3+0.1 g or amoxycillin + clavulanate 1.2g IV 6/24. Amoxycillin-clavulanate can also be used orally for less severe infections and prophylaxis (875+125 mg (child 2 months or older: 22.5+3.2 mg/kg up to 875+125 mg) orally, 12-hourly for 3-5 days). Oral penicillin has inadequate strength and coverage for all likely pathogens. (Link)

Indications for systemic anticoagulation in patients with superficial thrombophlebitis include: the presence of a DVT; an affected vein segment ≥ 5 cm in length; thrombosis close to the saphenofemoral/saphenopopliteal junction; ongoing risk factors for thrombosis. However it is not required for superficial thrombophlebitis of the long saphenous vein following endovenous ablation therapy due to lower risk of thromboembolism than from spontaneous thrombosis in this group of patients. (Link).

ECG changes of STEMI are absent in 25-40% of post arrest patients with acute coronary occlusions, but many of these will have STEMI equivalents.  Also 80% of all post arrest patients > 45 years of age have an acute coronary occlusion. Although  this suggests that all patients should have an urgent coronary angiogram, evidence suggests that only those with ECG features of acute ischaemia (AOMI) at 10 minutes post arrest who are not comatose will benefit. (Link)

The total WCC can normally be as high as 30,000 in the first month of life, but drops to 15,000 by 12 months. At 3 months, the normal range is ,6000 – 1,7500. (link)

Indications for drainage of a parapneumonic effusion include: height > 1/3 hemithorax; pleural fluid pH < 7.2, LDH > 1,000 U/L or glucose < 3.3 mmol/L; loculated effusions; WCC > 100,000 mm3 or ongoing sepsis despite antibiotic therapy. (link)

Beta-hydroxybutyrate levels are high in DKA and are measured by bedside blood analysis but not bedside urinalysis. Only acetoacetate is measured in bedside urinalysis. Serum ketones are usually > 3mmol/L, HCO3 is usually < 15 mmol/L and glucose > 11mmol/L (or known diabetic). Measured serum sodium is depressed by about 3.5 mmol/L for every increase in serum glucose of 10mmol/L above 5mmol/L, so a Na around 130 is common. (link)

Fentanyl and morphine are considered safe during lactation as are methadone, buprenorphine and naltrexone as their serum concentrations are usually < 3% of maternal concentrations. There is some potential for sedation and withdrawal with codeine and hydroxymorphone. Oxycodone (CNS depression in 20%), pentazocine, propoxyphene, and pethidine should be avoided. (link)

Pertussis infection usually has a 1-2 week catarrhal phase with a clear nasal discharge. The cough is usually non productive and there is an absence of significant fever, despite the ongoing symptoms. (link)