1. iBSc: Question 3 By Alan McLeod

2. Getting the best marks Read the whole question – a latter section may give you a clue about an earlier one. To see how many points you need look at the marks allocated – for example a 3 point question is generally looking for 3 salient points If giving a list answer put the best answers first – examiners will not usually mark answers too far down a list Always write something – it may get you part of a mark and is anonymised so no one will think you are stupid! If you genuinely have no clue then re-write the question to see if this sparks some ideas. If not then move on and come back at the end. And remember – always write something. Good luck!

3. Question 3 Mr El-Hawrini, a 29 year old lawyer has been involved in a motorcycle accident during which he lost consciousness Q3.1 Describe the most vital checks you would make when he arrives into A+E (5)

4. Question 3 A Diagnosis of extradural haemorrhage is made. Q3.2 What blood vessel is responsible for this bleed. (1) Q3.3 List three symptoms from a typical history that might lead to this diagnosis (3)

5. Q3.4 Label the arrowed structures (8) Skull Potential space Subarachnoid space Skull

6. Question 3 In addition to his head injury, Mr El- Hawrini has sustained the fracture pictured Q3.5 What is this fracture (2)

7. Question 3 Bones are capable of self-healing under the right circumstances. Q3.6 Describe the typical pattern of long-bone healing (4) Q3.7 Describe four factors that might interfere with this healing (4)

8. Question 3 Sadly, Mr El-Hawrini dies. You are given the job of delivering the news to his wife – you use the SPIKES protocol. Q3.8 Describe the SPIKES protocol (6)

9. Factors influencing Healing Local Tissue damage Tissue loss Infection Foreign body Systemic Patient age Nutritional status Smoking / alcohol Steroids Systemic illnesses such as diabetes, renal, lung, cardiac.

10. The Answers View these on ‘note view’ rather than on full screen – additional notes are provided for some slides

11. Emergency Management DDanger?Check that the scene is safe RRunCheck for response HHappilyCall for HELP! AAway and Check and secure airway and C- spine BBuyCheck breathing, Resp rate CChocolate!Pulse, Heart rate

12. Emergency Management D‘Disability’ Neuro exam: minimum is pupil size / response + GCS or AVPU E‘Exposure’ 1: Expose to seek injuries 2: Keep warm + take temperature DEFGDon’t Ever Forget Glucose!!!

13. ExtraduralSubduralSubarachnoid Between skull and periosteal dura Between periosteal and meningeal dura Into subarachnoid space Middle meningeal a.Cerebral veinCerebral artery Major traumaTrivial trauma in elderlyBerry aneurysm Loss of consciousness for a short time Lucid period lasting hours – days (as pressure builds up within the skull) Drowsiness, coma, death if no intervention Diagnosed by CT or MRI. Days – months pass (as pressure builds up slowly within the skull) Headache, drowsiness and confusionPossible hemiparesis / sensory loss Coma, death if no intervention (or may resolve on their own) Diagnosed by CT or MRI. Sudden onset intense headache with stiff neck (as aneurysm bursts). Possible papilloedema and retinal haemorrhage Usually vomiting, possible loss of consciousness for hours  days Diagnosed by CT or MRI.

14. Head Trauma Skull Periosteal Dura mata Meningeal Dura mata Potential space Arachnoid mata Subarachnoid space Pia mata Middle Meningeal A. Cerebral Artery Cerebral Vein

15. Extradural Haemorrhage Skull Periosteal Dura mata Meningeal Dura mata Potential space Arachnoid mata Subarachnoid space Pia mata Middle Meningeal A. Cerebral Artery Cerebral Vein

16. Subdural Haemorrhage Skull Periosteal Dura mata Meningeal Dura mata Potential space Arachnoid mata Subarachnoid space Pia mata Middle Meningeal A. Cerebral Artery Cerebral Vein

17. Subarachnoid Haemorrhage Skull Periosteal Dura mata Meningeal Dura mata Potential space Arachnoid mata Subarachnoid space Pia mata Middle Meningeal A. Cerebral Artery Cerebral Vein

18. Monteggia and Galleazzi MedicsMonteggia (a) UnderUlnar shaft PressureProximal Radio- ulnar Joint GetGalleazzi (b) ReallyRadial Shaft DrunkDistal RUJ Fracture-dislocations

19. Bone Healing Mins – 3 days Haematoma and Necrotic tissue 2 days – 2 weeks Phagocytosis Provisional callus 3 weeks on Firm callus Mineralisation Weeks - months Remodeling

20. SPIKES – Bad News… S SETTING UP: Having info ready; involving family as appropriate; location and privacy; time constraints, sit down; connect. P Perception: What does the patient already know of believe? I Invitation: find out what sort of invitation the patient is extending – do they want to know everything or do they wish to be told less K Knowledge: as Invited in simple language E Emotion and Empathy: Assessing the patients emotions and dealing with them empathically S Summary and Strategy: Going back though it all again, identifying points that need futher expalnation and formulating a plan.

21. The End The slides here should allow you to mark your own work – remember 1 mark per answer up to the maximum for the question. Multiply by 3 to get percentage points. I assume a 60% pass mark. Sorry but I am unable to give further advice on answers due to time constraints.