1. Inflammation Matt and Tom

2. Jenga Williams, aged 62, enters your clinic. He twisted his ankle jumping over a bollard, and is worried that he might have sprained it. You observe his ankle and note there are signs of acute inflammation. What might you see? (5) Rubor (redness) Calor (heat) Tumor (swelling) Dolor (pain) Functio laesa (loss of function)

3. Jenga’s ankle is very painful. What 3 substances activate pain pathways from cell damage? (3) K+ 5-HT (serotonin) Bradykinin What substance sensitises pain pathways by binding to prostanoid receptors, increasing activity of Na+ channels? Prostaglandins *This is why NSAIDS (which inhibit production of prostaglandins) have analgesic properties.

4. Marvin is a 22 year old man who comes into your clinic complaining of a 5 week history of bloody stools, colicky pain located in the right iliac fossa, and weight loss. Name 2 possible diagnoses? (1) Crohn’s (most likely given pain location and age) Ulcerative colitis Appendicitis IBS Gastroenteritis Tapeworm

5. One of the features of Crohn’s disease is stricture formation. Strictures form due to chronic inflammation and scarring. What are the 3 key features of chronic inflammation? (1) Ongoing inflammation Ongoing tissue destruction Ongoing attempts at repair ***THIS IS EXTREMELY HIGH YIELD. KNOW IT.***

6. So what’s going on with this fairly busy diagram? What are the 4 processes, in sequence that leads to the recruitment of neutrophils to the acute inflammatory site?

7. 1. Margination: prostaglandins/nitric oxide dilate vessel, reduction in laminar flow, neutrophils move to side of vessels

8. 2. Adhesion: -TNF and IL-1 encourage P/E-Selectin expression on endothelial cells - Chemokines activate integrins on neutrophils from low affinity state to a high affinity state, which interact with ICAM

9. 3. Emigration: - Histamine and nitric oxide cause retraction of endothelial cells - Neutrophils emigrate through endothelium (diapedesis)

10. 4. Chemotaxis: neutrophils move up concentration gradient of inflammatory mediators

11. A 44 year old man, Graham Slee, is on the wards with suspected pneumonia. You are asked by the nurse to take a routine set of observations. You take the following: BP 130/80 Temperature 37.9 o HR 85 RR 21 Which of the following can we say is true of this patient? a)This patient has SIRS b)This patient has sepsis c)This patient has severe sepsis d)This patient has septic shock e)We cannot tell if any of the above are true

12. You check Graham’s bloods, which were taken earlier that morning, and you note the WBC under your observations in the patient notes: BP 130/80 Temperature 37.9 o HR 85 RR 21 WBC 14 X 10 9 /L Now which of the following can we say is true of this patient? a)This patient has SIRS b)This patient has sepsis c)This patient has severe sepsis d)This patient has septic shock e)We cannot tell if any of the above are true

13. So we know that severe sepsis = sepsis with organ dysfunction. Which of the following in combination with positive SIRS criteria most strongly indicate severe sepsis? a)Resp rate of 28 b)Coughing up lots of thick green sputum c)Oxygen sats < 90% d)Acidosis e)Pleuritic chest pain

14. Name a decision making tool that can be used to decide to admit someone with pneumonia or not Confusion Urea Resp rate 30+ BP less than 90 systolic or 60 diastolic Over 65 years old

15. So we know that severe sepsis = sepsis with organ dysfunction. Which of the following in combination with positive SIRS criteria most strongly indicate severe sepsis? a)Very high levels of serum creatine kinase b)Very high levels of serum creatinine c)Low serum calcium d)Loin pain e)Vomiting

16. What is the management for someone with Sepsis? Give high-flow oxygen Take blood cultures Give empirical IV antibiotics Measure FBC & serum lactate Start IV fluid resuscitation Start accurate urine output measurements