ExamA:Questions
A1. Atraumapatientisbroughtintotheresuscitationroomwithanobviously unstablepelvis.Despiteongoingfluidresuscitationwithbloodproductsthepatient remainshaemodynamicallyunstable,hasaprofoundmetabolicacidosisandcontinuestodeteriorate.Focusedassessmentwithsonographyintrauma(FAST)scanis positive.
WhichofthefollowingisMOSTimportantinthemanagementofthispatient’s bleeding?
A.Administrationoftranexamicacid
B.1:1:1ratherthan1:1:2transfusionratioforplasma:platelets:blood
C.Treatmentwithinterventionalradiology
D.Urgentdamagecontrolsurgery
E.Maintainingnormothermiaandionizedcalciumlevels >0.9mmol/l
A2. Apatienthasbeenadmittedtotheintensivecareunit(ICU)withseveresepsis andurgentlyrequiresacentralvenouscatheter(CVC).YoudecidetoinserttheCVC intotherightinternaljugularvein(IJV).
Whichofthefollowingapproachestocentrallineinsertionisthebest?
A.Landmarkapproach;lateraltothecarotidarterypulsation
B.Audio-guidedDopplerultrasoundguidanceinthehead-upposition
C.Landmarkapproach;medialtothecarotidarterypulsation
D.Audio-guidedDopplerultrasoundguidanceinthehead-downposition
E.Two-dimensional(2D)ultrasoundguidance
A3. Ofthefollowingpathologies,whichisthecommonestcauseforend-stagerenal failureintheUnitedKingdom?
A.Hypertension
B.Polycystickidneydisease
C.Vasculitis
D.Renalarterystenosis
E.ImmunoglobulinA(IgA)nephropathy
A4. WhichofthefollowingmethodsofhumidificationisabletogeneratethehighestrelativehumidityinanICUventilatorcircuit?
A.Heatandmoistureexchangefilter(HME)
B.Cascadehumidifier
C.Cold-waterbath
D.Hot-waterbath
E.Ultrasonicnebulizer
A5. WhichofthefollowinggaspatternsseenonplainerectabdominalX-rayismost suggestiveofsignificantbowelpathologyrequiringsurgery?
A.Largegasbubbleinthestomach
B.Gasinthesmallbowel
C.Gasinthesmallbowelandfluidlevelsatthesameheightwithinloops
D.Gasinthelargebowel
E.Gasinthesmallbowelandrectumonly
A6. Youareabouttointubateapatientwithalife-threateningexacerbationof asthma.
WhichofthefollowingagentsisMOSTlikelytoimprovelungmechanicsand bronchospasm?
A.Atracurium
B.Ketamine
C.Propofol
D.Thiopentone
E.Fentanyl
A7. Inanormaladultpatient,aredbloodcelltravellingfromtheaortatotheportal veinismostlikelytopassthroughwhichstructures?
A.Inferiormesentericartery,superiorrectalartery,rectalveins
B.Coeliactrunk,leftgastro-omentalartery,splenicvein
C.Rightgastricartery,shortgastricvein,splenicvein
D.Superiormesentericartery,rightcolicvein,inferiormesentericvein
E.Coeliactrunk,gastroduodenalartery,epigastricvein
A8. Apatientisundergoingchemotherapyforacuteleukaemia,isneutropenic andhasapersistenttemperatureandcoughdespitetreatmentwithbroad-spectrum antibiotics.Acomputedtomographyscanofthethoraxrevealspulmonarynodules withsurroundinghalosofground-glassopacity(‘halosign’).Antigentestingonbronchoalveolarlavagesamplessuggestsadiagnosisof Aspergillus
WhichofthefollowingwouldbetheBESTtreatmentforthispatient?
A.Voriconazole
B.AmphotericinBdeoxycholate
C.Fluconazole
D.Flucytosine
E.Posaconazole
A9. Amalepatientwithjaundicehasthefollowingbloodresults:
Bilirubin200 µmol/l(3–17 µmol/l)60%conjugated Reticulocytes <1%(<1%)
Aspartatetransaminase(AST)450IU(<35IU)
Alkalinephosphatase(ALP)300IU(<250IU)
Internationalnormalizedratio1.4(0.8–1.2) Ceruloplasmin33mg/dl(20–35mg/dl)
WhichofthefollowingistheMOSTlikelycauseofthepatient’sjaundice?
A.Alcoholiccirrhosis
B.Primarysclerosingcholangitis
C.Wilsondisease
D.Pancreaticcancer
E.Haemolysis
A10. Apatientreturnsfromanaorticvalvereplacement(AVR)operationtothecardiacintensivecareunit(CICU).Hehasatrialandventricularepicardialpacingwires insitu,connectedtoatemporarypacingbox.Thepost-operativeelectrocardiogram (ECG)demonstratesarateof80bpmwithapacingspikeimmediatelyfollowedbya Pwavethen220mspausebeforeanarrowQRScomplex. Whichofthefollowingismostlikelytodescribethissituation?
A.VVIpacing
B.AOOpacingwithfirst-degreeheartblock
C.DDDpacingwiththeAVdelaysetat200ms
D.VOOpacingwithretrogradeatrialcontraction
E.AAIpacingwithunderlyingfastatrialfibrillation
A11. WhichofthefollowingistheLEASTinvasivemethodofcalculatingcardiac output?
A.Lithiumdilution,e.g.LiDCO
B.Thermodilution,e.g.PiCCO
C.IndirectFickmethod
D.OesophagealDoppler
E.Volumeclamp(Penazmethod),e.g.Finapress
A12. A54-year-oldmanwithnopreviousmedicalhistoryisadmittedwithshortnessofbreathandpleuriticchestpain4daysaftera16-hourflight.Acomputed tomography(CT)scanhasdemonstratedbilateralpulmonaryemboli,andechocardiographyhasrevealedrightheartdysfunction.Hisheartrateis112bpm,blood pressureis104/52andoxygensaturationsare94%on50%inspiredO2 WhichwouldbetheMOSTappropriatetreatment?
A.Anticoagulatewithlowmolecularweightheparin(LMWH)
B.AnticoagulatewithvitaminKantagonists
C.Thrombolyzeusingalteplase
D.Anticoagulatewithunfractionatedheparininfusion(UFH)
E.Anticoagulatewithdabigatran
A13. A74-year-oldfemalepatientpresentswithsuddenonset,spontaneous,rightsidedweakness.Thereisnohistoryoftrauma,andshereportsnohistoryofpain. Twodayslater,sheremainsalertandoriented.Neurologicalexaminationstillreveals decreasedtoneandpowerintherightarmandlegwithdiminishedreflexesand right-sidedneglectduetohomonymoushemianopia. Whichofthefollowingisthemostlikelydiagnosis?
A.Transientischaemicattack(TIA)
B.Partialanteriorcirculationsyndrome(PACS)
C.Carotidarterydissection
D.Totalanteriorcirculationsyndrome(TACS)
E.Malignantmiddlecerebralarteryinfarct
A14. A54-year-oldpatientisventilatedwithpneumonia.Hehasplateauandpeak endexpiratorypressuresof28and12cmH2 Orespectively.HisO2 saturationare92% withanFiO2 of0.4andarterialbloodgasfindingsareasfollows:pH7.26,PaO2 8.2 kPa,PaCO2 7.6kPa.Anechocardiographyrevealsanejectionfractionof44%and pulmonaryarterialpressureof55mmHg. WhatistheMOSTlikelycauseofthispatient’spulmonaryhypertension(PH)?
A.Hypoxiaandhypercapnia
B.Chronicpulmonaryhypertension
C.Acuteleftventriculardysfunction
D.Anacutepulmonaryembolism
E.Pulmonaryatelectasis
A15. WhichofthefollowingindicationshastheLEASTstrongevidencebasefor initiatingabloodtransfusion?
A.Haemoglobin(Hb) <70g/linapreviouslywellpatientadmittedtotheintensive careunit
B.Ashockedtraumapatientwithmassivebloodlossunresponsivetocrystalloids
C.Hb <70g/linastablepatientadmittedwithanacuteuppergastrointestinal bleed
D.Hb <70g/linapatientwithsepticshockonvasopressinandnoradrenaline
E.Hb <100g/linapatientintheintensivecareunitwithahistoryof cardiovasculardisease
A16. A54-year-oldmalepatientisadmittedtotheintensivecareunitwithelectrolytederangementandacuterenalfailurefollowinginitiationoftreatmentforhis Burkittlymphoma.Bloodtestresultsincludethefollowing:
WhichofthefollowingisLEASTtrueregardingthiscondition?
A.Completecorrectionofelectrolytederangementswithfluids,filtrationand electrolytereplacementshouldoccur
B.Itoccurswithincreasedfrequencyinthosepatientswithbulky,rapidly proliferatingtumours
C.Itoccursspontaneouslybutisoftenprecipitatedbyinitiationofchemotherapy treatment
D.Electrolytederangementsresultfromreleaseofintracellularcontentsastumour cellslyse
E.Treatmentwithrasburicaseismoreeffectiveatreducinguricacidlevelsthan allopurinol
A17. A74-year-oldpatientwith Clostridiumdifficile diarrhoea,hasawhitecellcount (WCC)of18 × 109/l,atemperatureof39°Candevidenceofileus.
WhichofthefollowingistheBESTtreatmentregimen?
A.Intravenousmetronidazole
B.Oralvancomycinandoralmetronidazole
C.Oralfidaxomicin
D.Oralvancomycinandintravenousmetronidazole
E.Oralvancomycin
A18. A38-year-oldpatienthasdevelopedacuterespiratorydistresssyndromefollowingaviralpneumonia.Heisintubatedandventilatedbutshowinglittlesignof improvement.Adecisionismadetoreferhimtothelocalextracorporealmembrane oxygenation(ECMO)centre. WhichofthefollowingcriteriacontributemosttohisMurrayscoreforECMO referral?
A.PaO2 /FiO2 ratioof25kPa
B.PEEPof8cmH2 O
C.Complianceof38ml/cmH2 O
D.HalfofthechestX-rayshowinginfiltrates
E.UncompensatedhypercapniawithapH <7.2
A19. A60-year-old,160-kgmanwithahistoryofobstructivesleepapnoeahasbeen referredtointensivecare.Heisintype2respiratoryfailureafteranintentionaloverdoseofbenzodiazepines.HeishaemodynamicallystablebuthasaGlasgowComa Score(GCS)of5andismakingsnoringnoises.Youdecidetointubateandtransferto intensivecareforsupportivemanagement. Whichofthefollowingismostappropriatestatement?
A.Intubationislikelytobedifficult;therefore,non-invasiveventilationshouldbe trialledfirst
B.Seniorhelpshouldbecalledifthereisdifficultyinintubatingafterfour attempts
C.Thepatientshouldbetransferredtotheoperatingtheatreinanticipationofa difficultairway
D.Givenhisbackgroundofobstructivesleepapnoea,heislikelytorequire ventilationforsometime;thereforeyoushouldproceedimmediatelytoa percutaneoustracheostomy
E.Cricoidpressuremaybereducedifthereisdifficultyintubating
A20. A73-year-oldmanisadmittedtohospitalwithshortnessofbreathandcough. Hehasamedicalhistoryofhypertensionandasthma,forwhichhetakesramipriland asalbutamolinhaler,respectively.Hehassmoked20cigarettesperdaysinceadolescenceanddrinks15to20unitsofalcoholperweek.Hehasmoderaterespiratory distresswitharespiratoryrateof28,oxygensaturationsof91%inair,aheartrate of105bpmandbloodpressureof155/95.Anarterialbloodgas(ABG)isperformed withthefollowingresults:
pH7.28
pO2 7.1kPa pCO2 8.9kPa HCO3 38.1mmol/l
Whatisthemostlikelycauseofhisshortnessofbreathandcough?
A.Pulmonaryembolus
B.Asthma
C.Pneumonia
D.Chronicobstructivepulmonarydisease
E.Sideeffectoframipril
A21. Whichofthefollowingcomplicationsismostfrequentlyseenafterpulmonary arterycatheter(PAC)insertionviatheinternaljugularvein?
A.Carotidarterypuncture
B.Anarrhythmiarequiringtreatment
C.Bacterialcolonization
D.Pulmonaryinfarction
E.Pulmonaryarteryrupture
A22. Youhaveapatientrequiringanurgentfreshfrozenplasma(FFP)transfusion. WhichofthefollowingcombinationsisMOSTappropriate?
A.ApatientwithbloodgroupABreceivingFFPgroupedA
B.ApatientwithbloodgroupAreceivingFFPgroupedB
C.ApatientwithbloodgroupBreceivingFFPgroupedO
D.ApatientwithbloodgroupAreceivingFFPgroupedAB
E.ApatientwithbloodgroupABreceivingFFPgroupedO
A23. Whichofthefollowinganticoagulantsismostlikelytobeaffectedbyasuddenfallinapatient’sglomerularfiltrationrate(GFR)?
A.Warfarin
B.Dabigatran
C.Rivaroxaban
D.Apixaban
E.Heparin
A24. Youareabouttoperformarapidsequenceinduction(RSI)onapatientin convulsivestatusepilepticus(CSE).Whichofthefollowingagentsismostlikelyto terminatetheseizures?
A.Atracurium
B.Ketamine
C.Propofol
D.Rocuronium
E.Thiopentone
A25. Youareexplainingtoamedicalstudenthowtodiagnoseacuterespiratory distresssyndrome(ARDS).InrelationtotheBerlincriteria,whichofthefollowing descriptionswouldbestfitwithadiagnosisofARDS?
A.Hypoxaemia3daysafteralargemyocardialinfarction.Transthoracic echocardiogramshowsmoderateleftventricularimpairmentwithakinesisof theapex.PaO2 /FiO2 ratiois35kPa.
B.Hypoxaemia5daysafteraseverebronchopneumonia.ChestX-rayshows collapseoftheleftlowerlobe.PaO2 /FiO2 ratiois30kPa.
C.Hypoxaemia2daysafteragastrointestinal(GI)bleedrequiringtransfusionof onecirculatingvolume.ChestX-rayshowsdiffusepatchyinfiltrates.PaO2 /FiO2 ratiois45kPa.
D.Hypoxaemia4daysafteranepisodeofpancreatitiswithaGlasgowscoreof4. ChestX-Rayshowsdiffusepatchyinfiltrates.PaO2 /FiO2 ratiois30kPa.
E.Hypoxaemia5daysaftercoronaryarterybypassgraftsurgery.Apulmonary arterycathetershowsapulmonarycapillarywedgepressureof25mmHg. Computedtomographyscanshowspulmonaryinfiltrates.PaO2 /FiO2 ratiois 25kPa.
A26. Youareaskedtoreviewapatientwithknownpancreaticcancerintheemergencydepartment.Hehashypotensionanddehydrationasaresultofprolonged vomiting.Youareconcernedthathehasgastricoutflowobstruction. Whichofthefollowingsetsofbiochemicalresultswouldbestfitwithgastricoutflowobstruction?
A.7.5511.1kPa6.3kPa53mmol/l132mmol/l3.0mmol/l93mmol/l
B.7.3712.0kPa4.1kPa22mmol/l166mmol/l3.7mmol/l131mmol/l
C.7.2912.8kPa3.3kPa16mmol/l134mmol/l2.1mmol/l113mmol/l
D.7.2614.5kPa1.6kPa8mmol/l136mmol/l4.7mmol/l102mmol/l
E.7.5410.4kPa6.1kPa46mmol/l127mmol/l2.7mmol/l128mmol/l
pHPaO2
A27. A47-year-oldmanwithalcoholiclivercirrhosisandascitesisadmittedto hospital.Heisfebrilewithabdominalpainanddelirium.Routinebloodtestsshow increasedwhitebloodcells(WBC)andC-reactiveprotein(CRP)withnormalelectrolytesandrenalfunction.Anascitictapshows500WBCs/µlandorganismsvisible onmicroscopy.
Whatisthemostlikelyorganism?
A. Klebsiellapneumoniae
B. Escherichiacoli
C.Enterobacteriaceae
D. Streptococcuspneumoniae
E. Staphylococcusaureus
A28. A61-year-oldmanhasbeenadmittedtotheemergencydepartment.He hasadiagnosisofacutemyeloidleukaemiaandisreceivingchemotherapy.Hehas beenunwellfor24hoursandhasatemperatureof38.5°C.Hisneutrophilcountis 0.4 × 109 /l.
Whatantibioticregimenisthemostappropriate?
A.Tazobactam/piperacillin
B.Ceftriaxone
C.Tazobactam/piperacillinandgentamicin
D.Ceftriaxoneandgentamicin
E.Ceftriaxone,vancomycinandgentamicin
A29. A64-year-oldmanwasadmitted6hoursagotohospitalwithseverechest painandshortnessofbreath.Youarecalledtoseehimashisbloodpressurehas fallenoverthepasthour.Heisdrowsy,diaphoretic,coldtothetouchandhas widespreadcracklesonauscultationofhislungfields.His12-leadelectrocardiogram (ECG)showsalargeST-elevationmyocardialinfarction(STEMI).Hisvitalsignsare asfollows:heartrate95/min;bloodpressure80/48;respiratoryrate32/min;SpO2 92%on10loxygen.Hehasavenouslactatelevelof6.3mmol/l.
Youdiagnosecardiogenicshock.Whichinterventionhasthestrongestevidenceof benefit?
A.Intra-aorticballoonpump(IABP)
B.Dobutamine
C.Leftventricularassistdevice(LVAD)
D.Revascularizationtherapy
E.Levosimendan
A30. Youareaskedtoreviewapatientsufferinganacuteexacerbationofasthma intheemergencydepartment,withallofthefollowingsignspresent.Whichofthe signsgivesthegreatestcauseforconcern?
A.Respiratoryrate:32
B.PaCO2 :4.9kPa
C.Peakexpiratoryflow(PEF):38%ofpredicted
D.Inabilitytocompletesentencesinonebreath
E.ChestX-rayshowingbibasalconsolidation
A1. Atraumapatientisbroughtintotheresuscitationroomwithanobviously unstablepelvis.Despiteongoingfluidresuscitationwithbloodproductsthepatient remainshaemodynamicallyunstable,hasprofoundmetabolicacidosisandcontinues todeteriorate.Focusedassessmentwithsonographyintrauma(FAST)scanispositive.
WhichofthefollowingisMOSTimportantinthemanagementofthispatient’s bleeding?
A.Administrationoftranexamicacid
B.1:1:1ratherthan1:1:2transfusionratioforplasma:platelets:blood
C.Treatmentwithinterventionalradiology
D.Urgentdamagecontrolsurgery
E.Maintainingnormothermiaandionizedcalciumlevels >0.9mmol/l
Answer:D
Shortexplanation
Tranexamicacidadministration,maintainingnormothermiaandionizedcalciumlevelsareimportant;however,theywillnotstopthispatient’smassiveongoingbleeding.Thepatientisdeterioratingdespiteongoingresuscitationwithbloodproducts, socontrolofbleedingisimperative.Thispatientishaemodynamicallyunstableand acidotic,andhisorherFASTscanispositive;immediatedamagecontrolsurgeryis recommendedinpreferencetointerventionalradiology.
Longexplanation
Patientspresentingwithhaemorrhagicshockshouldbetreatedwithrapididentificationofthecauseandsourcecontrolinconjunctionwithfluidresuscitationwithblood products.Initialfluidresuscitationshouldbecommencedwithcrystalloidsandearly useofbloodproductstotargetasystolicbloodpressureof80to90mmHguntilthe bleedinghasbeencontrolled.Thebloodpressureshouldbehigherinthecontextofa traumaticbraininjury.
ThePragmatic,RandomizedOptimalPlateletandPlasmaRatios(PROPPR)trial demonstratedasignificantdecreaseintherateofexsanguinationforthosewho receivedbloodproductsina1:1:1ratherthana1:1:2plasma:platelet:redbloodcell ratio.Despiteatrendtolowermortalityseeninthe1:1:1treatmentarm,therewasno significantdecreaseinmortalityat24hoursor30days.Fibrinogenreplacementwith
fibrinogenconcentrateorcryoprecipitateshouldoccurwithfibrinogenlevelsbelow 1.5to2g/l.
Measurestomaintainnormothermiaandionizedcalciumlevels >0.9mmol/lare requiredtominimizethecoagulopathythatcanoccurwithmassivebloodtransfusionsandthecoagulopathyoftrauma.Traumapatientswhoarebleedingorwhoare atriskofsignificanthaemorrhageshouldreceivetranexamicacidassoonaspossible, eitherinthepre-hospitalenvironmentorstartingintheemergencydepartment.
Rapidcontrolofthesourceofthehaemorrhageiscrucial.Tourniquetscanbeused preoperativelyasaninterimmeasuretostoparterialbleedinginlife-threatening extremityinjuries.Interventionalradiologyorsurgicalinterventioncanbeusedto managepatientswithpelvicorintra-abdominalbleeding.Patientswithsuspected pelvicfracturesshouldhaveapelvicbinderappliedimmediatelytoreduceany ongoingbleeding.Treatmentforpelvicfracturesinpatientswhoarehaemodynamicallyunstableincludesexternalfixation,preperitonealpelvicpackingandinterventionalradiology.PatientsshouldhaveaninitialFASTscanintheresuscitation room.Ifthisispositive,surgicaltreatmentwithlaparotomyandpackingisrecommendedinpreferencetoangiography.Resuscitativeendovascularballoonocclusion oftheaorta(REBOA)hasbeenusedasanemergencyinterimmeasureforunstable patients.
Damagecontrolinpreferencetodefinitivesurgeryisrecommendedforthose patientswithseverehaemorrhageshockandongoingbleeding.Thisisparticularly thecaseinthosewhoarehypothermic( 34˚C),acidotic(pH 7.2)orcoagulopathic orpatientswhohaveinaccessiblemajorvenousinjuryorrequiretime-consuming procedures.
References
HolcombJB,TilleyBC,BaraniukS,etal.Transfusionofplasma,platelets,andred bloodcellsina1:1:1vsa1:1:2ratioandmortalityinpatientswithseveretrauma: thePROPPRrandomizedclinicaltrial. JAMA. 2015;313(5):471–482.
MagnoneS,CoccoliniF,ManfrediR,etal.Managementofhemodynamicallyunstablepelvictrauma:resultsofthefirstItalianconsensusconference. WorldJEmerg Surg.2014;9(1):18.
SpahnDR,BouillonB,CernyV,etal.Managementofbleedingandcoagulopathyfollowingmajortrauma:anupdatedEuropeanguideline. CritCare.2013;17(2):R76.
A2. Apatienthasbeenadmittedtotheintensivecareunit(ICU)withseveresepsis andurgentlyrequiresacentralvenouscatheter(CVC).YoudecidetoinserttheCVC intotherightinternaljugularvein(IJV).
Whichofthefollowingapproachestocentrallineinsertionisthebest?
A.Landmarkapproach;lateraltothecarotidarterypulsation
B.Audio-guidedDopplerultrasoundguidanceinthehead-upposition
C.Landmarkapproach;medialtothecarotidarterypulsation
D.Audio-guidedDopplerultrasoundguidanceinthehead-downposition
E.Two-dimensional(2D)ultrasoundguidance
Answer:E
Shortexplanation
TheNationalInstituteforHealthandCareExcellence(NICE)guidancerecommends theuseof2DultrasoundimagingforCVCinsertionintotheIJVinallelectivesituations,anditshouldbeconsideredinallclinicalscenariosincludingemergencysituations.Audio-guidedDopplerultrasoundisnotrecommendedforCVCinsertion.
Longexplanation
TheNICEguidanceontheuseofultrasoundlocatingdevicesforplacingCVCs(NICE Guidance49,published2002)isclearinitsrecommendationfortheuseof2Dultrasoundintheinsertionofallelectivelinesanditsconsiderationforallemergency lines.2Dultrasoundprovidesreal-timeimagingoftheanatomy,allowingdifferentiationbetweenthearteryandvein,thereforeloweringtheriskofarterialpuncture. Audio-guidedDopplerultrasound,bycomparison,doesnotgenerateanyimagebut doesgenerateasoundfromflowingbloodtohelplocatethevessels.Audio-guided DopplerultrasoundisnotrecommendedintheNICEguidance.
The2Dultrasoundfindingsthatassistdifferentiationoftheveinfromtheartery include:
1.Wallthickness–thickerintheartery
2.Compressibility–veinismorecompressiblebecauseofthelowerpressureinthe vein.However,inextremelyhypotensivestates,thedifferenceislesspronounced, andextracareshouldbetaken
3.Pulsatility–arterialflowismorepulsatile
4.Colour-waveDoppler–arterialflowismorepulsatile
Venousflowcanalsobepulsatile,andarteriescanalsobecompressed,sotheprecedingfindingsaretoassistdifferentiationratherthanbeingabsolute.
Thelandmarktechniquecanstillbeusedinanemergencysituationandinvolves passingtheneedlealongtheexpectedpathofthevein,withreferencetosurfacelandmarks.Thistechniqueisassociatedwithahigherincidenceofcomplications,suchas arterialpunctureandpneumothorax.Theuseofultrasoundguidanceispreferredin allclinicalsituations,solongasthereisnoinappropriatedelaytolineplacement.
References
TheAmericanInstituteforUltrasoundinMedicine(AIUM). AIUMPracticeGuidelines fortheUseofUltrasoundtoGuideVascularAccessProcedures.Laurel,MD:AIUM, April2012.
NationalInstituteforHealthandCareExcellence(NICE).Guidanceontheuseof ultrasoundlocatingdevicesforplacingcentralvenouscatheters (Technology AppraisalGuidance49).London:NICE,2002.
A3. Ofthefollowingpathologies,whichisthecommonestcauseforend-stagerenal failureintheUnitedKingdom?
A.Hypertension
B.Polycystickidneydisease
C.Vasculitis
D.Renalarterystenosis
E.ImmunoglobulinA(IgA)nephropathy
Answer:A
Shortexplanation
Thecommonestcausesofchronickidneydiseasethatleadtoend-stagerenalfailure intheUnitedKingdomarethefollowing:
Diabetes(20–40%)
Hypertension(5–25%)
GlomerulardiseasewhichincludesIgAnephropathy(10–20%),idiopathic (5–20%),interstitialdisease(5–15%)
Rarercausessuchaspolycystickidneydisease,renalarterystenosisand vasculitiswitheachrepresentinglessthan5%.
Longexplanation
Chronickidneydisease(CKD)isageneraltermforadisorderofrenalstructureor functionlastingmorethan3months.Itisconsideredonacontinuumbetweennormal kidneyfunctionandend-stagerenalfailurerequiringlong-termdialysis,transplantationorprecedingdeath.PatientswithCKDmorecommonlydevelopco-morbidities andrequireintensivecarethanthegeneralpopulation.Equally,patientsrequiring criticalcarearemoreatriskofdevelopinganacutekidneyinjury(AKI)andsubsequentlychronickidneydisease.
CKDisalmostalwaysaprogressivecondition,althoughonly1%ofpatientswith CKDwillreachend-stagerenalfailure.However,thecostandmorbidityburdenof thosewhodoplacesahugerequirementonresources.Itisimportanttodetectand referCKDpatientsearlybecausedelaysleadtopooreroutcomes.PatientswithCKD whopresenttohospitalareatanincreasedriskofdevelopingAKI,whichwilllikely leadtoalong-termdeclineinrenalfunctionandworseoutcomesthanthosepatients withoutCKD.
Filtrationisnotthesolefunctionofthekidney.However,estimatedglomerular filtrationrate(eGFR)isthebestmeasureofoverallkidneyfunctionandtherefore presenceofCKD.AneGFR <60mL/min/1.73m2 isassociatedwithapooreroutcomethanthatinpatientswithCKDandahighereGFR.Itisimportanttoconsider othermarkersofkidneyfunctionwhenmanagingapatientwithAKIorCKD,includingalbuminurialevels,proteinuria,structuralabnormalitiesonimaging,electrolyte balance,bloodpressureandhistologicalchangesseenonbiopsy.
CKDprognosisandriskcanbeestimatedonthebasisofstagingusingeGFRand albuminuria.eGFRstages(mL/min/1.73m2 )includethefollowing:Grade1(>90), Grade2(60–89),Grade3a(45–59),Grade3b(30–44),Grade4(15–29)andGrade5 (<15).Stagingbasedonalbuminuria(mg/g)rangesfrom:A1(<30),A2(30–300)and A3(>300).
ThecausesofCKDareincreasinginincidenceintheUnitedKingdomandare associatedwithotherco-morbiditiessuchasheartdiseaseandstroke,whichmake CKDpatientsmorelikelytopresenttohealthservices.Similarly,thepresenceofCKD complicatesthetreatmentofotherco-morbiditiesandofICUcare,oftenlimitingdrug choicesordosesandrequiringincreasedmonitoringandcarewithelectrolytes,nutritionandfluidbalance.
References
GoddardJ,TurnerAN,CummingAD,StewartLH.Kidneyandurinarytractdisease.InBoonNA,ColledgeNR,WalkerBR,HunterJAA. Davidson’sPrinciples andPracticeofMedicine.20thedition.Edinburgh:ChurchillLivingstoneElsevier, 2006:p.486.
KidneyDisease:ImprovingGlobalOutcomes.KDIGO2012clinicalpracticeguideline fortheevaluationandmanagementofchronickidneydisease. KidneyIntSuppl. 2013;3(1).
TheUKRenalAssociationwebsite.http://www.renal.org/(lastaccessedApril 2015).
A4. WhichofthefollowingmethodsofhumidificationisabletogeneratethehighestrelativehumidityinanICUventilatorcircuit?
A.Heatandmoistureexchangefilter(HME)
B.Cascadehumidifier
C.Cold-waterbath
D.Hot-waterbath
E.Ultrasonicnebulizer
Answer:E
Shortexplanation
HMEsachieveapproximately70%efficiency,andcold-waterbathsachieve30%efficiency,whichcanbeimprovedtoalmost90%ifthewaterisheated.Acascadewater bathissimilartoahotwaterbathwiththegasbubbledthroughthewater.Nebulizers,especiallyactiveonessuchasanultrasonicdevice,achievethehighesthumidity, whichcanexceed100%.
Longexplanation
Failuretohumidifygasesdeliveredtoapatientviaaventilatorwillleadtodryingof thepatient’sairwaysandthebuild-upofthicksecretions,inflammationandpotential infection.Deliveryofhumidifiedgasisalsoanimportantmethodofreducingheat lossfromthepatient.
Absolutehumidityismeasureding/m3 andisthemassofwatervapourinaunit ofgas,whichwillvarywithtemperature.Relativehumidityistheamountofwater vapourpresent,asapercentageofthemaximumachievableatthetemperatureand pressureinquestion.
HMEsuseahygroscopicmaterialtocaptureexhaledwatervapourasexpired gascoolsandpassesthroughthefilter.Ascoldinspiredgasthenpassesbacktothe patient,itiswarmedandalsopicksupwaterfromthefiltermaterial.Thismethod becomesinefficientwithtimebutalsoprovidesabacterialbarrierbetweenthepatient andventilator.
Hot-waterbathsandthecascadehumidifierarecommonlyusedinICUsbecause theyprovideagoodlevelofhumidificationinarelativelyefficientway.Thereare risksofthermalinjurytothepatientifthewaterisheatedtotoohighatemperature; therefore,thesesystemsoftenhavethermostatsandalarmsinplace.
Nebulizersarenotcommonlyusedforhumidificationbecausetheycanleadto fluidoverloadandproducesuchsmalldropletsizesthatwatervapourdepositsinthe alveolibutnottheupperairways.Forthisreason,theyarebetterusedformedication delivery.
Reference DavisPD,KennyGNC. BasicPhysicsandMeasurementinAnaesthesia.5thedition.London:Elsevier,2003.
A5. WhichofthefollowinggaspatternsseenonplainerectabdominalX-rayismost suggestiveofsignificantbowelpathologyrequiringsurgery?
A.Largegasbubbleinthestomach
B.Gasinthesmallbowel
C.Gasinthesmallbowelandfluidlevelsatthesameheightwithinloops
D.Gasinthelargebowel
E.Gasinthesmallbowelandrectumonly
Answer:E
Shortexplanation
Alargegastricbubbleisrarelyconcerning,oftenoriginatingfromnasogastricfeeding orairswallowing.Gasinthesmallorlargebowelisanormalfinding,solongasthe bowelisofanormalcalibre.Gaswithfluidlevelscanalsobenormal,suggestingan ileusbutnotnecessarilyobstruction.Anabsenceofgasthroughoutthelargebowel withgasonlyseenintherectumisabnormalandhighlysuggestiveofamechanical largebowelobstruction.
Longexplanation
Largebowelobstructionisasurgicalemergency.Itisimportanttodistinguishtrue mechanicalobstructionfrompseudo-obstructionorileus.Theincidenceoflarge bowelobstructionincreaseswithage.Thecommonestcausesarecancers,strictures, diverticulitisandvolvulus.Faecalimpactionmayleadtodilatedloopsoflargebowel proximaltotheblockage,andpseudo-obstructioncanleadtodilatedloopsandperforation,thelatterrequiringemergencysurgery.
Largebowelobstructionmaybeworsenedbyacompetentileocaecalvalve,asgas andfluidpressuresbuildupandarenotabletoreleasebackintothesmallbowel.The presenceofdilatedloopsleadstolargefluidshifts,ischaemia,boweloedema,venous obstruction,electrolytedisturbances,perforation,sepsisand,ifnottreated,death.
ImagingmayincludeanerectchestX-raytolookforfreegasunderthediaphragm. Classically,acontrastabdominalX-raywasperformed,althoughcomputedtomography(CT)scanshavelargelyreplacedtheneedforthis.CTshouldbeperformed withoralandintravenouscontrasttodemonstratecompletefrompartialobstruction. Water-solublecontrastispreferredbecauseoftherisksofperitonealcontamination duetobowelperforation.
Treatmentisusuallysurgical.Pseudo-obstructionmaybemanagedconservatively providedthereisalowthresholdofsuspicionforperforation.Initialresuscitation measuresshouldincludeanasogastrictubeonfreedrainage,fluidandelectrolyte replacementandbroad-spectrumantibiotics.Volvulusandstricturesmaybedecompressedorstentedandfurtherinvestigatedwithcolonoscopy.Thosewithdiverticulitisoramalignantobstructionrequiresurgery.Intussusceptionisamorecommon causeofobstructioninchildrenthaninadults.Thebowel‘telescopes’inonitself, oftenwithapolyporlesionatthecentre.Thismaybeamenabletogasinsufflationto reducetheintussusceptionormayrequiresurgicalintervention.
References
KahiCJ,RexDK.Bowelobstructionandpseudo-obstruction. GastroenterolClinNorth Am.2003;32(4):1229–1247.
MariniJJ,WheelerAP. CriticalCareMedicine:Theessentials.4thedition.Philadelphia: Lippincott,Williams&Wilkins,2009,p226.
A6. Youareabouttointubateapatientwithalife-threateningexacerbationof asthma.
WhichofthefollowingagentsisMOSTlikelytoimprovelungmechanicsand bronchospasm?
A.Atracurium
B.Ketamine
C.Propofol
D.Thiopentone
E.Fentanyl
Answer:B
Shortexplanation
Thiopentoneandatracuriumcancausebronchospasm,propofolhaslittleeffect,and opioidsmayprecipitatebronchospasmandchest-wallrigidity.Ketamineisabronchodilator.
Longexplanation
Theclassicalrapidsequenceinduction(RSI)usesjusttwodrugs:thiopentoneand suxamethonium.Thereareoftenclinicalscenariosinwhichthiscombinationshould
bealtered,duetoeitherdetrimentaleffectsoftheseagents(e.g.suxamethoniumin apatientwithahighpotassium)orthepresenceofalternativeagentsthatmayhave morebenefit(e.g.propofolforlaryngealrelaxation).
Musclerelaxantsdonotterminatebronchoconstriction.Themajorityofthemcan causesignificanthistaminerelease,particularlysuxamethoniumandthebenzylisoquinoliniumssuchasatracurium,whichinturncancausehypotensionandbronchospasm.Themusclerelaxantthathastheleasthistaminereleaseassociatedwithits useisvecuronium.
Withregardtotheintravenousinductionagents,propofol,thiopentoneand ketamineareinwidestuseinday-to-daypractice.Propofol,whichispresentedasa lipid-wateremulsion,causesrapidinductionofanaesthesiaandsuppressionoflaryngealreflexestoagreaterextentthanthiopentone.Ithasnoeffectonbronchospasm. Thiopentone,whichisathiobarbiturateinductionagent,alsocausesrapidinduction ofanaesthesia.Itcauseslesssuppressionofthelaryngealreflexesandcancauseboth laryngospasmandbronchospasm.Ketamine,aphencyclidinederivative,haslittle effectonthelaryngealreflexes,andapatentairwaycanpotentiallybemaintained. Thereisanincreaseintheproductionofsecretions,andthesecantriggerthepreservedreflexesandcauselaryngospasm.Conversely,itreliablycausesbronchodilation,andisthereforeofbenefitpatientswithasthma.
OpioidsareoftengivenaspartofamodifiedRSI,tosuppressthelaryngeal responsetointubation.Allopioidscauserespiratorydepression.Brain-stemsensitivitytocarbondioxideisreduced,butitsresponsetohypoxiaislargelyretained.If opioidsaregiveninappropriatelyearlyaspartofamodifiedRSIandpreoxygenation isinitiated,thehypoxicstimuluswillfailtobetriggered,andcarbondioxidelevelscanrisedangerously.Similarlytothemusclerelaxants,histaminereleaseiswell recognized,especiallyfromrapidadministration.Forbothclassesofdrug,sloweror morediluteinjectionwillreducethehistamine-relatedsideeffects.
References
SmithT.Chapter6:Hypnoticsandintravenousanaestheticagents.InSmithT,PinnockC,LinT. FundamentalsofAnaesthesia.3rdedition.Cambridge:Cambridge UniversityPress,2009,pp569–584.
Chapter8:Generalanaestheticagents,Chapter9:Analgesics,andChapter11:Muscle relaxantsandanticholinesterases,inSection2:Coredrugsinanaestheticpractice. InPeckT,HillS,WilliamsM. PharmacologyforAnaesthesiaandIntensiveCare.3rd edition.Cambridge:CambridgeUniversityPress,2008.
A7. Inanormaladultpatient,aredbloodcelltravellingfromtheaortatotheportal veinismostlikelytopassthroughwhichstructures?
A.Inferiormesentericartery,superiorrectalartery,rectalveins
B.Coeliactrunk,leftgastro-omentalartery,splenicvein
C.Rightgastricartery,shortgastricvein,splenicvein
D.Superiormesentericartery,rightcolicvein,inferiormesentericvein
E.Coeliactrunk,gastroduodenalartery,epigastricvein
Answer:B
Shortexplanation
Therectalandepigastricveinsdrainintotheinferiorvenacavaandaretwoofthe collateralconnectionsbetweentheportalandsystemiccirculations.Therightgastric arterysuppliestherightandinferiorportionsofthestomach,whereastheshortgastricveindrainsthesuperiorandleft-sidedportions.Therightcolictogetherwiththe
middlecolicveinsdraindirectlyintotheportalvein,whereastheinferiormesenteric veindrainsthedescendingcolonandrectumintothesplenicvein.
Longexplanation
Thenormalarterialsupplyofthegutisviathreelargeanteriorbranchesoftheaorta: thecoeliactrunk,superiormesentericarteryandinferiormesentericartery.These vesselsmaybethreatenedbytraumaorsurgerytothedescendingaorta,includingruptureofanabdominalaorticaneurysm.Infarctionorischemiawillmanifest asischaemicgutfollowedbyperforationandperitonitis.Ischaemiccolitiscarries highmorbidityandmortalityandrequiresurgentinterventiontorestoretheblood supply.
TheceliactrunkarisesatapproximatelyT12,immediatelyaftertheaortaemerges fromthediaphragm.Itdividesintotheleftgastric,commonhepaticandsplenic arteries,whichinturnsupplythelessercurvatureofthestomach,theliver,the gallbladderandtheduodenumandspleen,pancreasandgreatercurvatureofthe stomach.
Thesuperiormesentericarterysuppliestheportionofthegutderivedfromthe embryologicalmid-gutincludingthedistalduodenum,jejunum,ileum, ascendingcolonandproximalportionsofthetransversecolon.Thebloodsupply runsthroughthemesentryinconnectedloopsforming‘arcades’,whichinturn giverisetothevasarecta.
Theinferiormesentericarterysuppliesthedistalportionsofthegutderivedfrom thehind-gut.Itbranchesintotheleftcolic,sigmoidandrectalarteries.The territoryoftheleftcoliccrosseswiththatofthemarginalarterysuppliedbythe superiormesentericarteryasitsuppliestheportionofthecolonatthesplenic flexure.
Thevenousdrainageofthegutispredominantlyintotheportalvein,takingnutrientrichbloodtotheliver.Thissystemformskeycollateralswiththesystemicvenous networkatfourpoints:theoesophagealveins,therectalveins,theparaumbilical(portal)veinsandafewsmalltwigsconnectingthecolicandretroperitonealveins.These sitesbecomeimportantincasesofraisedportalvenouspressureeitherduetothrombusorhepaticfibrosis,mostcommonlyduetoalcoholiccirrhosis.
Inhealth,themainportalveinformsfromthemesentericplexusanalogoustothe territoryofthesuperiormesentericartery(i.e.theileal,jejunalandrightandmiddle colicveins).Theterritoryoftheinferiormesentericarteryisdrainedviathesuperior rectal,sigmoidalandleftcolicveinsintotheinferiormesentericvein.Thisdrainsvia thesplenicveinintotheportalvein.Theleftandrightgastricveinsdraindirectly intotheportalvein,alongwiththecystic,pancreatoduodenalandgastro-omental (gastro-epiploic)veins.
Reference MooreKL,AgurAMR,DalleyAF. EssentialClinicalAnatomy.5thedition.Baltimore, MD:LippincottWilliams&Wilkins,2014.
A8. Apatientisundergoingchemotherapyforacuteleukaemia,isneutropenic andhasapersistenttemperatureandcoughdespitetreatmentwithbroad-spectrum antibiotics.Acomputedtomographyscanofthethoraxrevealspulmonarynodules withsurroundinghalosofground-glassopacity(‘halosign’).Antigentestingonbronchoalveolarlavagesamplessuggestadiagnosisof Aspergillus. WhichofthefollowingwouldbetheBESTtreatmentforthispatient?
A.Voriconazole
B.AmphotericinBdeoxycholate
C.Fluconazole
D.Flucytosine
E.Posaconazole
Answer:A
Shortexplanation
Thispatienthasinvasiveaspergillosis.Allofthemedicationslistedareantifungals, butfluconazoleandflucytosinearenotusedtotreatinvasive Aspergillus disease. AlthoughamphotericinBhasactivityagainstaspergillosis,liposomalamphotericin Bisusedinpreferencetodeoxycholatepreparationsbecauseofitsimprovedactivityandsideeffectprofile.Voriconazoleisrecommendedasfirst-linetreatment,and posaconazolehasbeenrecommendedassalvagetreatmentorisappropriatetobe usedasprophylaxisforat-riskpatients.
Longexplanation
Invasiveaspergillosisoccurscommonlyinimmunocompromisedpatients,such asthosewithneutropenia,post-transplantimmunosuppressionoractiveacquired immunedeficiencysyndrome.Pre-existinglungdiseaseandmedicalco-morbidities, includingcriticalillness,arealsoriskfactors.Thecommonestfeatureispersistent fever.Cough,dyspnoeaandhaemoptysiscanoccurwithpulmonaryinvolvement (thecommonestsiteofinfection),andneurologicalsignsandseizuresmayoccurwith neurologicalinvolvement.Theclassical‘halosign’seenonchestcomputedtomographyisanodulesurroundedbyground-glassopacification.
Thereareanumberofdifferentclassesofantifungalswithdifferingmechanisms ofactionandactivityagainstdifferentfungi:
Drugsthatattackthecellmembrane:
❜ Azoles
Triazoles
Fluconazole
Itraconazole
Voriconazole
Posaconazole
Imidazoles
Ketoconazole
Miconazole
❜ Polyenes:
AmphotericinB(Theoriginalintravenouspreparationusesadeoxycholate dispersionindextrose.Newerlipidformulations,includingliposomalor lipidcomplexes,areassociatedwithlesstoxicityandbettersideeffect profiles.)
Nystatin
❜ Allylamines
Terbinafine
Drugsthatattackthecellwall:
❜ Echinocandins
Anidulafungin
Caspofungin
Micafungin
Drugsthatactintracellularly:
❜ Griseofulvin
❜ Flucytosine
Thechoiceforprescribingthespecificantifungalagentshouldbeinlinewithlocal guidelines.Britishrecommendationsforthetreatmentofsystemicfungalinfections areasfollows:
Aspergillosis
❜ First-linetreatmentshouldbevoriconazole;ifcontraindicated,liposomal amphotericinshouldbeused.
❜ AlternativetreatmentssuchasCaspofungin,itraconazoleandposaconazole canbeusedassalvagetreatments.
Invasivecandidiasis:
❜ Anechinocandinisthefirstchoice;however,inuncomplicated Candida albicans infectionsandinpatientswithnorecentazoleexposure,fluconazole canbeusedasanalternativefirstlinetreatment.
❜ Alternativetreatmentsincludevoriconazoleoramphotericin ± flucytosine.
Cryptococcosis
❜ Cryptococcalmeningitisrequires2weeksoftreatmentwithbothamphotericin andflucytosine,followedbyacourseoffluconazoleforatleast8weeks.
❜ Fluconazolealonecanbeusedtotreatmildercryptococcosisinfectionsoras prophylaxis.
Histoplasmosis
❜ Severediseaseshouldbetreatedwithamphotericin.
❜ Itraconazoleisanoptioninthetreatmentofmilderhistoplasmosisinfections orasprophylaxis.
References
JointFormularyCommittee. BritishNationalFormulary (online).London:BMJGroup andPharmaceuticalPress.http://www.evidence.nhs.uk/formulary/bnf/ current/5-infections/52-antifungal-drugs/treatment-of-fungal-infections(accessedJuly2015).
LewisRE.Currentconceptsinantifungalpharmacology. MayoClinProc.2011; 86(8):805–817.
SherifR,SegalBH.Pulmonaryaspergillosis:clinicalpresentation,diagnostictests, managementandcomplications. CurrOpinPulmMed.2010;16(3):242–250.
TacconeFS,VandenAbeele,BulpaP,etal.Epidemiologyofinvasiveaspergillosisin criticallyillpatients:clinicalpresentation,underlyingconditions,andoutcomes. CritCare.2015;19:7.
A9. Amalepatientwithjaundicehasthefollowingbloodresults:
Bilirubin200 µmol/l(3–17 µmol/l)60%conjugated
Reticulocytes <1%(<1%)
Aspartatetransaminase(AST)450IU(<35IU)
Alkalinephosphatase(ALP)300IU(<250IU)
Internationalnormalizedratio1.4(0.8–1.2)
Ceruloplasmin33mg/dl(20–35mg/dl)
WhichofthefollowingistheMOSTlikelycauseofthepatient’sjaundice?
A.Alcoholiccirrhosis
B.Primarysclerosingcholangitis
C.Wilsondisease
D.Pancreaticcancer
E.Haemolysis
Answer:A
Shortexplanation
Thispatienthasjaundiceduetoaconjugatedhyperbilirubinaemia,thusexcluding prehepaticcausessuchashaemolysis.Hisliverfunctiontests(LFTs)demonstrate hepatocellulardysfunctionratherthanthecholestaticpictureseenwithprimarysclerosingcholangitisorpancreaticcancer.Hisceruloplasminlevelisnormal,suggesting thathedoesnothaveWilsondisease;therefore,alcoholiccirrhosisisthemostlikely ofthesediagnoses.
Longexplanation
Bilirubinisproducedfrombreakdownofredbloodcells.Itcombineswithalbumin andistransferredtotheliverinitsunconjugatedstate.Hereitseparatesfromalbuminandisconjugatedwithglucuronicacidbytheactionofglucuronyltransferase. Conjugatedbilirubintravelswithinbiletotheintestine,wherebacterialproteasesact toconvertittourobilinogenintheterminalileum.Someurobilinogen(unconjugated) isreabsorbedviatheportalveinandislostintheurinebutthemajority( 90%)is lostinthefaecesasstercobilin.
Therearemanycausesofjaundice.Itcanbeclassifiedas:
Prehepatic:
❜ Increasedbilirubinproduction–haemolysis(hereditaryandacquired haemolyticanaemias),haematomaresorption,
❜ Impairedconjugation–Crigler-Najjarsyndrome
❜ Impairedhepaticuptakeofbilirubin–Gilbertsyndrome
❜ Physiologicalneonataljaundiceoccursduetoamixtureofincreasedbilirubin productionandimmatureglucuronyltransferaseenzymes
Hepatic:
❜ Cirrhosis
❜ Metabolic:primaryandsecondarynon-alcoholicsteatohepatitis
❜ Genetic:hereditaryhaemochromatosis,alpha-1antitrypsindeficiency,Wilson disease,Dubin-Johnsonsyndrome
❜ Neoplastic:hepaticmetastasis
❜ Autoimmune:primarybiliarycirrhosis,autoimmunehepatitis
❜ Infection:hepatitis(A,C,orE),liverabscess,leptospirosis
❜ Vascular:heartfailure(livercongestion),hepaticischaemia
❜ Toxin:alcoholichepatitis
❜ Pregnancy:cholestasisofpregnancy(intrahepaticcholestasis),HELLP syndrome
❜ Drugtoxicity
Hepatocellular:amiodarone,highlyactiveantiretroviraltherapy(HAART), halothane,non-steroidalanti-inflammatorydrugs(NSAIDs),omeprazole, rifampicin,selectiveserotoninreuptakeinhibitors(SSRIs),paracetamol, totalparenteralnutrition(TPN)
Mixed:amitriptyline,enalapril,phenytoin
Cholestatic:tricyclicantidepressants(TCAs),steroids,erythromycin Extrahepatic(patientsoftenhavepalestoolsanddarkurine–asignof obstructivejaundice)
❜ Neoplastic:pancreaticcancer,cholangiocarcinoma
❜ Autoimmune:primarysclerosingcholangitis
❜ Other:commonbileductstone,portallymphadenopathy
TestPrehepaticHepaticExtrahepatic
Bilirubin(3–17 µmol/l) ↑ (unconjugated∗ )
AST(<35IU)
ALP(<250IU)
Albumin(40–50g/l)
Reticulocytes(<1%) ↑ /
(conjugated
(conjugated∗∗ )
∗ Unconjugatedhyperbilirubinaemia <20%conjugatedbilirubin.
∗∗ Conjugatedhyperbilirubinaemia >50%conjugatedbilirubin.
References
BMJBestPractice–AssessmentofJaundice.Availableathttp://bestpractice.bmj .com/best-practice/monograph/511.html(accessedAugust2015).
RocheSP,KobosR.Jaundiceintheadultpatient. AmFamPhysician 2004;69(2):99–304.
A10. Apatientreturnsfromanaorticvalvereplacement(AVR)operationtothecardiacintensivecareunit(CICU).Hehasatrialandventricularepicardialpacingwires insitu,connectedtoatemporarypacingbox.Thepost-operativeelectrocardiogram (ECG)demonstratesarateof80bpmwithapacingspikeimmediatelyfollowedbya pwavethen220mspausebeforeanarrowQRScomplex. Whichofthefollowingismostlikelytodescribethissituation?
A.VVIpacing
B.AOOpacingwithfirst-degreeheartblock
C.DDDpacingwiththeAVdelaysetat200ms
D.VOOpacingwithretrogradeatrialcontraction
E.AAIpacingwithunderlyingfastatrialfibrillation
Answer:B
Shortexplanation
TheatriumispacedwithanarrowQRS,suggestinganintrinsicratherthanpaced ventricularrhythm.TheprolongedAVnodaldelayisconsistentwithfirst-degree heartblock(normalis120to200ms).ThispacemakercouldbesettoDDDpacing,but
iftheAVdelaywassetat200ms,thepacemakerwouldinitiateaventricularpacing spike200msafterthepwaveintheabsenceofanativeventriculardepolarization withinthattime.Thereisnoevidenceofventricularpacing,andfastatrialfibrillation inanAAImodewouldcausethepacemakertoinhibitandnotpace.
Longexplanation
Pacemakerscanbetemporaryorpermanent,andtheycanbeconnectedtotheheart viatranscutaneouspads,atemporarypacingwire,epicardialorendocardialwires (afteropenheartsurgery)orthroughanimplantedtransvenouspacingsystem.They cansenseorpaceandmaybeconnectedtoanyofthefourchambersoftheheart. Pacingsystemsarenamedaccordingtoaseriesoflettersasfollows:
FirstletterSecondletterThirdletterFourthletterFifthletter
Chamber paced Chamber sensed Responseto sensingProgrammability
Antitachydysrhythmia function
A–AtrialA–AtrialO–NoneO–NoneO–None V–VentricularV–VentricularI–InhibitP–SimpleS–Shock D–DualD–DualT–TriggerM–MultiP–Pacing O–NoneO–NoneD–Inhibit andTrigger C–Communicating R–Ratemodulation D–Shockand Pacing
Intrinsicbeatsarealmostalwaysbetterco-ordinatedandmoreeffectiveatgeneratingacardiacimpulsethanpacedbeats,andthereforeitisalmostalwayspreferable toallowanativerhythmtoexistifpossible.Becausethefocusofthedepolarizationin apacedventricularbeatdependsontheleadplacement,theQRScomplexisbroad, ratherthantherapidorganizedQRScomplexgeneratedthroughtheAVnodeand conductingsystem.PacingspikesarevisibleonanECGormonitor,andifcapture isobtained,eachspikewillbeimmediatelyfollowedbyadepolarization.Iftheatria arepaced,andtheAVnodeandconductionpathwaysareintact,thenthedepolarizationwillpropagatealongtheconductionsystemandleadtoanormalventricular depolarizationandQRScomplex.
First-degreeheartblockisaprolongeddelayattheAVnode(morethan200ms). Second-degreeheartblocksarepartialdyssynchronybetweentheatriaandventricleswithsomebeatsconductedandsomedroppedandcanbedividedbetweentype 1(e.g.Mobitz2:1)andtype2(Wenkebachphenomenon).Third-degreeheartblock iscompleteAVnodedissociation.DisruptiontotheAVnodeiscommonafteraorticvalvesurgerybecauseofthesurgicalproximitytotheconductingsystem.Many disturbanceswillresolveafterafewdays,butsomepatientswillrequirepermanent pacingsystems.
References
DiproseP,PierceJMT.Anaesthesiaforpatientswithpacemakersandsimilardevices. BritJAnaesthesCEPDRev,2001;1(6):166–170. HamptonJR. TheECGMadeEasy.6thedition.Edinburgh:ChurchillLivingstone, 2003.
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27, or 36. And here, in this benign attention to the comfort of sick people, you will observe the usual effect of a fine art to soften and refine the feelings. The world in general, gentlemen, are very bloodyminded; and all they want in a murder is a copious effusion of blood; gaudy display in this point is enough for them. But the enlightened connoisseur is more refined in his taste; and from our art, as from all the other liberal arts when thoroughly mastered, the result is, to humanise the heart.
A philosophic friend, well known for his philanthropy and general benignity, suggests that the subject chosen ought also to have a family of young children wholly dependent upon his exertions, by way of deepening the pathos. And, undoubtedly, this is a judicious caution. Yet I would not insist too keenly on such a condition. Severe good taste unquestionably suggests it; but still, where the man was otherwise unobjectionable in point of morals and health, I would not look with too curious a jealousy to a restriction which might have the effect of narrowing the artist’s sphere.
So much for the person. As to the time, the place, and the tools, I have many things to say, which at present I have no room for The good sense of the practitioner has usually directed him to night and privacy. Yet there have not been wanting cases where this rule was departed from with excellent effect.
L B , whose works are variously adjudged by the critics, owes much to the fact that he was possessed of a distinct and definite sense of humor.
It is that which saves many of his long and dull stretches of verse from utter unreadability.
His facile rhymes, apparently tossed off with little of or no effort, embody in the best possible manner his graceful fun.
The ottava rima of Don Juan, though often careless, even slovenly as to technical details, is surely the meter best fitted for the
theme.
Juan embarked the ship got under way, The wind was fair, the water passing rough; A devil of a sea rolls in that bay, As I, who’ve crossed it oft, know well enough; And, standing upon deck, the dashing spray Flies in one’s face, and makes it weather-tough; And there he stood to take, and take again, His first—perhaps his last—farewell of Spain.
I can’t but say it is an awkward sight
To see one’s native land receding through The growing waters; it unmans one quite, Especially when life is rather new. I recollect Great Britain’s coast looks white, But almost every other country’s blue, When gazing on them, mystified by distance, We enter on our nautical existence.
So Juan stood, bewildered on the deck:
The wind sung, cordage strained, and sailors swore, And the ship creaked, the town became a speck, From which away so fair and fast they bore. The best of remedies is a beef-steak Against sea-sickness: try it, sir, before You sneer, and I assure you this is true, For I have found it answer so may you
“And oh! if e’er I should forget, I swear But that’s impossible, and cannot be Sooner shall this blue ocean melt to air, Sooner shall earth resolve itself to sea, Than I resign thine image, oh, my fair! Or think of anything excepting thee; A mind diseased no remedy can physic.”
(Here the ship gave a lurch and he grew sea-sick.)
“Sooner shall heaven kiss earth!” (Here he fell sicker.)
“Oh, Julia! what is every other woe?
(For God’s sake let me have a glass of liquor; Pedro, Battista, help me down below.)
Julia, my love! (you rascal, Pedro, quicker)
Oh, Julia! (this curst vessel pitches so) Beloved Julia, hear me still beseeching!” (Here he grew inarticulate with retching )
He felt that chilling heaviness of heart, Or rather stomach, which, alas! attends, Beyond the best apothecary’s art, The loss of love, the treachery of friends, Or death of those we dote on, when a part Of us dies with them as each fond hope ends No doubt he would have been much more pathetic, But the sea acted as a strong emetic
AFTER SWIMMING THE HELLESPONT
If, in the month of dark December, Leander, who was nightly wont (What maid will not the tale remember?)
To cross thy stream, broad Hellespont;
If, when the wint’ry tempest roar’d, He sped to Hero nothing loath, And thus of old thy current pour’d, Fair Venus! how I pity both!
For me, degenerate, modern wretch, Though in the genial month of May, My dripping limbs I faintly stretch, And think I’ve done a feat to-day
But since he crossed the rapid tide, According to the doubtful story, To woo—and—Lord knows what beside, And swam for Love, as I for Glory;
’Twere hard to say who fared the best: Sad mortals, thus the gods still plague you! He lost his labour, I my jest; For he was drowned, and I’ve the ague.
Thomas Hood, versatile alike in humorous or pathetic vein, was a prolific and successful punster. If the form could be forgiven anybody it must be condoned in his case. He also was apt at parody and often blended pathos and tragedy with his humorous work.
FAITHLESS NELLY GRAY
A PATHETIC BALLAD
Ben Battle was a soldier bold, And used to war’s alarms; But a cannon-ball took off his legs, So he laid down his arms!
Now, as they bore him off the field, Said he, “Let others shoot, For here I leave my second leg, And the Forty-Second Foot!”
The army-surgeons made him limbs; Said he, “they’re only pegs: But there’s as wooden Members quite As represent my legs!”
Now Ben he loved a pretty maid, Her name was Nelly Gray; So he went to pay her his devours, When he devoured his pay!
But when he called on Nelly Gray, She made him quite a scoff; And when she saw his wooden legs, Began to take them off!
“O, Nelly Gray! O, Nelly Gray! Is this your love so warm? The love that loves a scarlet coat Should be more uniform!”
Said she, “I loved a soldier once, For he was blithe and brave; But I will never have a man With both legs in the grave!
“Before you had those timber toes, Your love I did allow; But then, you know, you stand upon Another footing now!”
“O, Nelly Gray! O, Nelly Gray! For all your jeering speeches;
At duty’s call I left my legs, In Badajos’s breeches!”
“Why then,” said she, “you’ve lost the feet Of legs in war’s alarms, And now you cannot wear your shoes Upon your feats of arms!”
“O, false and fickle Nelly Gray! I know why you refuse: Though I’ve no feet some other man Is standing in my shoes!
“I wish I ne’er had seen your face; But now, a long farewell! For you will be my death; alas! You will not be my Nell!”
Now when he went from Nelly Gray His heart so heavy got, And life was such a burden grown, It made him take a knot!
So round his melancholy neck
A rope he did entwine, And, for his second time in life, Enlisted in the Line.
One end he tied around a beam, And then removed his pegs, And, as his legs were off of course He soon was off his legs!
And there he hung, till he was dead As any nail in town For though distress had cut him up, It could not cut him down!
A dozen men sat on his corpse, To find out why he died And they buried Ben in four cross-roads, With a stake in his inside!
NO!
No sun no moon!
No morn no noon
No dawn no dusk no proper time of day
No sky no earthly view
No distance looking blue
No road no street no “t’other side the way”
No end to any Row
No indications where the Crescents go—
No top to any steeple—
No recognitions of familiar people—
No courtesies for showing ’em
No knowing ’em!
To travelling at all no locomotion,
No inkling of the way no notion
No go by land or ocean
No mail no post
No news from any foreign coast
No park no ring no afternoon gentility
No company no nobility
No warmth, no cheerfulness, no healthful ease,
No comfortable feel in any member
No shade, no shine, no butterflies, no bees
No fruits, no flowers, no leaves, no birds November!
The brothers James and Horace Smith, wrote what was in their day considered lively and amusing humor, but which seems a trifle dry to us. Their greatest work was the Rejected Addresses, a series of parodies on the poets, such as Wordsworth, Southey, Coleridge, Scott, Moore and many others.
One of these, an imitation of Wordsworth’s most simple style, succeeds in parodying his mawkish affectations of childish simplicity and nursery stammering.
THE BABY’S DÉBUT
[Spoken in the character of Nancy Lake, a girl eight years of age, who is drawn upon the stage in a child’s chaise by Samuel Hughes, her uncle’s porter ]
My brother Jack was nine in May, And I was eight on New-Year’s day;
So in Kate Wilson’s shop
Papa (he’s my papa and Jack’s) Bought me, last week, a doll of wax, And brother Jack a top
Jack’s in the pouts, and this it is, He thinks mine came to more than his; So to my drawer he goes, Takes out the doll, and, oh, my stars! He pokes her head between the bars, And melts off half her nose!
Quite cross, a bit of string I beg, And tie it to his peg-top’s peg, And bang, with might and main, Its head against the parlour-door: Off flies the head, and hits the floor, And breaks a window-pane.
This made him cry with rage and spite: Well, let him cry, it serves him right. A pretty thing, forsooth!
If he’s to melt, all scalding hot, Half my doll’s nose, and I am not To draw his peg-top’s tooth!
Aunt Hannah heard the window break, And cried, “Oh naughty Nancy Lake, Thus to distress your aunt: No Drury-Lane for you to-day!”
And while papa said, “Pooh, she may!” Mamma said, “No, she sha’n’t!”
Well, after many a sad reproach, They get into a hackney coach, And trotted down the street
I saw them go: one horse was blind, The tails of both hung down behind, Their shoes were on their feet
The chaise in which poor brother Bill Used to be drawn to Pentonville, Stood in the lumber-room: I wiped the dust from off the top,
While Molly mopp’d it with a mop, And brush’d it with a broom.
My uncle’s porter, Samuel Hughes, Came in at six to black the shoes (I always talk to Sam): So what does he, but takes, and drags Me in the chaise along the flags, And leaves me where I am
My father’s walls are made of brick, But not so tall, and not so thick As these; and, goodness me! My father’s beams are made of wood, But never, never half so good As those that now I see.
What a large floor! ’tis like a town! The carpet, when they lay it down, Won’t hide it, I’ll be bound; And there’s a row of lamps! my eye! How they do blaze! I wonder why They keep them on the ground.
At first I caught hold of the wing, And kept away; but Mr. Thingum bob, the prompter man, Gave with his hand my chaise a shove, And said, “Go on, my pretty love; Speak to ’em, little Nan.
“You’ve only got to curtsey, whisper, hold your chin up, laugh, and lisp, And then you’re sure to take: I’ve known the day when brats, not quite Thirteen, got fifty pounds a night; Then why not Nancy Lake?”
But while I’m speaking, where’s papa? And where’s my aunt? and where’s mamma? Where’s Jack? Oh, there they sit! They smile, they nod; I’ll go my ways, And order round poor Billy’s chaise, To join them in the pit
And now, good gentlefolks, I go To join mamma, and see the show; So, bidding you adieu, I curtsey, like a pretty miss, And if you’ll blow to me a kiss, I’ll blow a kiss to you
THE MILKMAID AND THE BANKER
A Milkmaid, with a pretty face, Who lived at Acton,
Had a black cow, the ugliest in the place, A crooked-backed one, A beast as dangerous, too, as she was frightful, Vicious and spiteful; And so confirmed a truant that she bounded Over the hedges daily and got pounded:
’Twas in vain to tie her with a tether, For then both cow and cord eloped together Armed with an oaken bough—(what folly! It should have been of thorn, or prickly holly), Patty one day was driving home the beast, Which had as usual slipped its anchor, When on the road she met a certain Banker, Who stopped to give his eyes a feast, By gazing on her features crimsoned high By a long cow-chase in July.
“Are you from Acton, pretty lass?” he cried; “Yes” with a courtesy she replied.
“Why, then, you know the laundress, Sally Wrench?”
“Yes, she’s my cousin, sir, and next-door neighbor.”
“That’s lucky I’ve a message for the wench Which needs despatch, and you may save my labor. Give her this kiss, my dear, and say I sent it: But mind, you owe me one I’ve only lent it ”
[Blows a kiss, and exit
“She shall know,” cried the girl, as she brandished her bough, “Of the loving intentions you bore me; But since you’re in haste for the kiss, you’ll allow, That you’d better run forward and give it my cow, For she, at the rate she is scampering now, Will reach Acton some minutes before me.”
H S .
THE JESTER CONDEMNED TO DEATH
One of the Kings of Scanderoon, A royal jester, Had in his train a gross buffoon, Who used to pester The Court with tricks inopportune, Venting on the highest folks his Scurvy pleasantries and hoaxes. It needs some sense to play the fool, Which wholesome rule Occurred not to our jackanapes, Who consequently found his freaks Lead to innumerable scrapes, And quite as many kicks and tweaks, Which only seemed to make him faster Try the patience of his master
Some sin, at last, beyond all measure, Incurred the desperate displeasure Of his serene and raging highness: Whether he twitched his most revered And sacred beard, Or had intruded on the shyness Of the seraglio, or let fly An epigram at royalty, None knows: his sin was an occult one, But records tell us that the Sultan, Meaning to terrify the knave, Exclaimed, “’Tis time to stop that breath: Thy doom is sealed, presumptuous slave! Thou stand’st condemned to certain death: Silence, base rebel! no replying! But such is my indulgence still, That, of my own free grace and will, I leave to thee the mode of dying ”
“Thy royal will be done ’tis just,” Replied the wretch, and kissed the dust; “Since, my last moments to assuage, Your majesty’s humane decree Has deigned to leave the choice to me, I’ll die, so please you, of old age!”
H S
It is to be regretted that the feminine writers of this period showed practically no evidence of humorous scintillation, but we have searched in vain through the writings of Ann and Jane Taylor, Mary Russell Mitford, Felicia Hemans and Letitia Elizabeth Landon,— finding only some unconscious humor, not at all intentional on the part of the authoresses, as they were then called.
William Maginn was also adept at parody, but his work was ephemeral.
The rollicking rhyme of the Irishman is among the most interesting of his poems.
THE IRISHMAN
There was a lady lived at Leith, A lady very stylish, man, And yet, in spite of all her teeth, She fell in love with an Irishman, A nasty, ugly Irishman,
A wild, tremendous Irishman, A tearing, swearing, thumping, bumping, ranting, roaring Irishman.
His face was no ways beautiful, For with small-pox ’twas scarred across, And the shoulders of the ugly dog
Were almost double a yard across Oh, the lump of an Irishman,
The whisky-devouring Irishman, The great he-rogue, with his wonderful brogue, the fighting, rioting Irishman!
One of his eyes was bottle-green, And the other eye was out, my dear, And the calves of his wicked-looking legs Were more than two feet about, my dear.
Oh, the great big Irishman,
The rattling, battling Irishman, The stamping, ramping, swaggering, staggering, leathering swash of an Irishman!
He took so much of Lundy-foot
That he used to snort and snuffle, oh, And in shape and size the fellow’s neck Was as bad as the neck of a buffalo.
Oh, the horrible Irishman,
The thundering, blundering Irishman, The slashing, dashing, smashing, lashing, thrashing, hashing Irishman!
His name was a terrible name indeed, Being Timothy Thady Mulligan; And whenever he emptied his tumbler of punch, He’d not rest till he’d filled it full again
The boozing, bruising Irishman, The ’toxicated Irishman, The whisky, frisky, rummy, gummy, brandy, no-dandy Irishman
This was the lad the lady loved, Like all the girls of quality; And he broke the skulls of the men of Leith, Just by the way of jollity.
Oh, the leathering Irishman,
The barbarous, savage Irishman!
The hearts of the maids and the gentlemen’s heads were bothered, I’m sure, by this Irishman.
Thomas Haynes Bayly, though not especially a humorist, showed the influence of a witty muse in his songs, which were numerous and popular.
She Wore a Wreath of Roses, Oh, No, We Never Mention Her and Gaily the Troubadour Touched his Guitar are among the best remembered.
He was the author of many bright bits of Society Verse, and wrote some deep and very real satire.
WHY DON’T THE MEN PROPOSE?
Why don’t the men propose, mamma? Why don’t the men propose? Each seems just coming to the point, And then away he goes; It is no fault of yours, mamma, That everybody knows; You fête the finest men in town, Yet, oh! they won’t propose
I’m sure I’ve done my best, mamma,
To make a proper match; For coronets and eldest sons, I’m ever on the watch; I’ve hopes when some distingué beau A glance upon me throws; But though he’ll dance and smile and flirt, Alas! he won’t propose
I’ve tried to win by languishing, And dressing like a blue; I’ve bought big books and talked of them As if I’d read them through! With hair cropp’d like a man I’ve felt The heads of all the beaux; But Spurzheim could not touch their hearts, And oh! they won’t propose.
I threw aside the books, and thought That ignorance was bliss; I felt convinced that men preferred A simple sort of Miss; And so I lisped out nought beyond Plain “yesses” or plain “noes,” And wore a sweet unmeaning smile; Yet, oh! they won’t propose.
Last night at Lady Ramble’s rout I heard Sir Henry Gale Exclaim, “Now I propose again ” I started, turning pale; I really thought my time was come, I blushed like any rose; But oh! I found ’twas only at Ecarté he’d propose
And what is to be done, mamma? Oh, what is to be done? I really have no time to lose, For I am thirty-one; At balls I am too often left Where spinsters sit in rows; Why don’t the men propose, mamma? Why won’t the men propose?
Frederick Marryat, oftener spoken of as Captain Marryat was among the most renowned writers of sea stories, and easily the most humorous of the authors who chose the sea for their fictional setting.
His books are well known in all households, and after Dickens there is probably no English novelist who has caused more real chuckles.
NAUTICAL TERMS
All the sailors were busy at work, and the first lieutenant cried out to the gunner, “Now, Mr. Dispart, if you are ready, we’ll breech these guns.”
“Now, my lads,” said the first lieutenant, “we must slug (the part the breeches cover) more forward.” As I never had heard of a gun having breeches, I was very curious to see what was going on, and went up close to the first lieutenant, who said to me, “Youngster, hand me that monkey’s tail.” I saw nothing like a monkey’s tail, but I was so frightened that I snatched up the first thing that I saw, which was a short bar of iron, and it so happened that it was the very article which he wanted. When I gave it to him, the first lieutenant looked at me, and said, “So you know what a monkey’s tail is already, do you? Now don’t you ever sham stupid after that.”
Thought I to myself, I’m very lucky, but if that’s a monkey’s tail, it’s a very stiff one!
I resolved to learn the names of everything as fast as I could, that I might be prepared, so I listened attentively to what was said; but I soon became quite confused, and despaired of remembering anything.
“How is this to be finished off, sir?” inquired a sailor of the boatswain.
“Why, I beg leave to hint to you, sir, in the most delicate manner in the world,” replied the boatswain, “that it must be with a double-wall —and be damned to you—don’t you know that yet? Captain of the foretop,” said he, “up on your horses, and take your stirrups up three
inches.” “Aye, aye, sir.” I looked and looked, but I could see no horses.
“Mr Chucks,” said the first lieutenant to the boatswain, “what blocks have we below—not on charge?”
“Let me see, sir. I’ve one sister, t’other we split in half the other day, and I think I have a couple of monkeys down in the store-room. I say, you Smith, pass that brace through the bull’s eye, and take the sheep-shank out before you come down.”
And then he asked the first lieutenant whether something should not be fitted with a mouse or only a Turk’s-head—told him the gooseneck must be spread out by the armourer as soon as the forge was up. In short, what with dead-eyes and shrouds, cats and cat-blocks, dolphins and dolphin-strikers, whips and puddings, I was so puzzled with what I heard, that I was about to leave the deck in absolute despair.
“And, Mr. Chucks, recollect this afternoon that you bleed all the buoys.”
Bleed the boys, thought I; what can that be for? At all events, the surgeon appears to be the proper person to perform that operation.
Peter Simple.
Douglas Jerrold was an infant prodigy and later a noted playwright; beside being the author of the world famous Caudle lectures.
He was a celebrated wit and punster and though many epigrammatic sayings are wrongly attributed to him, yet he was the originator of as many more.
COLD MUTTON, PUDDING, PANCAKES
“What am I grumbling about, now? It’s very well for you to ask that! I’m sure I’d better be out of the world than—there now, Mr Caudle; there you are again! I shall speak, sir. It isn’t often I open my mouth, Heaven knows! But you like to hear nobody talk but yourself. You ought to have married a negro slave, and not any respectable woman.
“You’re to go about the house looking like thunder all the day, and I’m not to say a word. Where do you think pudding’s to come from every day? You show a nice example to your children, you do; complaining, and turning your nose up at a sweet piece of cold mutton, because there’s no pudding! You go a nice way to make ’em extravagant—teach ’em nice lessons to begin the world with. Do you know what puddings cost; or do you think they fly in at the window?
“You hate cold mutton. The more shame for you, Mr. Caudle. I’m sure you’ve the stomach of a lord, you have. No, sir; I didn’t choose to hash the mutton. It’s very easy for you to say hash it; but I know what a joint loses in hashing: it’s a day’s dinner the less, if it’s a bit. Yes, I dare say; other people may have puddings with cold mutton. No doubt of it; and other people become bankrupts. But if ever you get into the Gazette, it sha’n’t be my fault—no; I’ll do my duty as a wife to you, Mr. Caudle; you shall never have it to say that it was my housekeeping that brought you to beggary. No; you may sulk at the cold meat—ha! I hope you’ll never live to want such a piece of cold mutton as we had to-day! and you may threaten to go to a tavern to dine; but, with our present means, not a crumb of pudding do you get from me. You shall have nothing but the cold joint—nothing, as I’m a Christian sinner.
“Yes; there you are, throwing those fowls in my face again! I know you once brought home a pair of fowls; I know it; but you were mean enough to want to stop ’em out of my week’s money! Oh, the selfishness—the shabbiness of men! They can go out and throw away pounds upon pounds with a pack of people who laugh at ’em afterward; but if it’s anything wanted for their own homes, their poor wives may hunt for it. I wonder you don’t blush to name those fowls again! I wouldn’t be so little for the world, Mr. Caudle!
“What are you going to do? Going to get up? Don’t make yourself ridiculous, Mr. Caudle; I can’t say a word to you like any other wife, but you must threaten to get up. Do be ashamed of yourself.
“Puddings, indeed! Do you think I’m made of puddings? Didn’t you have some boiled rice three weeks ago? Besides, is this the time of the year for puddings? It’s all very well if I had money enough
allowed me like any other wife to keep the house with; then, indeed, I might have preserves like any other woman; now, it’s impossible; and it’s cruel—yes, Mr. Caudle, cruel—of you to expect it.
“Apples ar’n’t so dear, are they? I know what apples are, Mr. Caudle, without your telling me. But I suppose you want something more than apples for dumplings? I suppose sugar costs something, doesn’t it? And that’s how it is. That’s how one expense brings on another, and that’s how people go to ruin.
“Pancakes? What’s the use of your lying muttering there about pancakes? Don’t you always have ’em once a year—every Shrove Tuesday? And what would any moderate, decent man want more?
“Pancakes, indeed! Pray, Mr. Caudle—no, it’s no use your saying fine words to me to let you go to sleep; I sha’n’t. Pray, do you know the price of eggs just now? There’s not an egg you can trust to under seven and eight a shilling; well, you’ve only just to reckon up how many eggs—don’t lie swearing there at the eggs in that manner, Mr. Caudle; unless you expect the bed to let you fall through. You call yourself a respectable tradesman, I suppose? Ha! I only wish people knew you as well as I do! Swearing at eggs, indeed! But I’m tired of this usage, Mr. Caudle; quite tired of it; and I don’t care how soon it’s ended!
“I’m sure I do nothing but work and labour, and think how to make the most of everything; and this is how I’m rewarded.”
Mrs. Caudle’s Curtain Lectures.
“Call that a kind man,” said an actor of an absent acquaintance; “a man who is away from his family, and never sends them a farthing! Call that kindness!” “Yes, unremitting kindness,” Jerrold replied.
Some member of “Our Club,” hearing an air mentioned, exclaimed: “That always carries me away when I hear it.” “Can nobody whistle it?” exclaimed Jerrold.
A friend said to Jerrold: “Have you heard about poor R—— [a lawyer]? His business is going to the devil.” Jerrold answered: “That’s all right: then he is sure to get it back again.”
If an earthquake were to engulf England to-morrow, the English would meet and dine somewhere just to celebrate the event.
Of a man who had pirated one of his jests, and who was described in his hearing as an honest fellow, he said, “Oh yes, you can trust him with untold jokes.”
Jerrold met Alfred Bunn one day in Piccadilly. Bunn stopped Jerrold, and said, “I suppose you’re strolling about, picking up character.” “Well, not exactly,” said Jerrold, “but there’s plenty lost hereabouts.”
Jerrold was seriously disappointed with a certain book written by one of his friends. This friend heard that he had expressed his disappointment. Friend (to Jerrold): “I heard you said it was the worst book I ever wrote.” Jerrold: “No, I didn’t. I said it was the worst book anybody ever wrote.”
Some one was talking with him about a gentleman as celebrated for the intensity as for the shortness of his friendships. “Yes,” said Jerrold, “his friendships are so warm, that he no sooner takes them up than he puts them down again.”
Thomas Moore, called the most successful Irishman of letters of the nineteenth century, early developed a taste for music and a talent for versification. To this add his native wit, and we have a humorist of no mean order.
He wrote epistles, odes, satires and songs with equal facility, and to these he added books of travel and biography and history. His quick wit is shown in his lighter verse and epigrams.
NONSENSE
Good reader, if you e’er have seen, When Phœbus hastens to his pillow, The mermaids with their tresses green Dancing upon the western billow; If you have seen at twilight dim, When the lone spirit’s vesper hymn Floats wild along the winding shore, The fairy train their ringlets weave Glancing along the spangled green;— If you have seen all this, and more, God bless me! what a deal you’ve seen!
LYING
I do confess, in many a sigh, My lips have breath’d you many a lie, And who, with such delights in view, Would lose them for a lie or two?
Nay look not thus, with brow reproving: Lies are, my dear, the soul of loving! If half we tell the girls were true, If half we swear to think and do, Were aught but lying’s bright illusion, The world would be in strange confusion! If ladies’ eyes were, every one, As lovers swear, a radiant sun, Astronomy should leave the skies, To learn her lore in ladies’ eyes! Oh no! believe me, lovely girl, When nature turns your teeth to pearl, Your neck to snow, your eyes to fire,
Your yellow locks to golden wire, Then, only then, can heaven decree, That you should live for only me, Or I for you, as night and morn, We’ve swearing kiss’d, and kissing sworn And now, my gentle hints to clear, For once, I’ll tell you truth, my dear! Whenever you may chance to meet A loving youth, whose love is sweet, Long as you’re false and he believes you, Long as you trust and he deceives you, So long the blissful bond endures; And while he lies, his heart is yours: But, oh! you’ve wholly lost the youth
The instant that he tells you truth!
WHAT’S MY THOUGHT LIKE?
Quest Why is a Pump like Viscount Castlereagh?
Answ Because it is a slender thing of wood, That up and down its awkward arm doth sway, And coolly spout, and spout, and spout away, In one weak, washy, everlasting flood!
OF ALL THE MEN
Of all the men one meets about, There’s none like Jack he’s everywhere: At church park auction dinner rout
Go when and where you will, he’s there Try the West End, he’s at your back Meets you, like Eurus, in the East You’re call’d upon for “How do, Jack?”
One hundred times a day, at least A friend of his one evening said, As home he took his pensive way, “Upon my soul, I fear Jack’s dead I’ve seen him but three times to-day!”
ON TAKING A WIFE
“Come, come,” said Tom’s father, “at your time of life, There’s no longer excuse for thus playing the rake It is time you should think, boy, of taking a wife ” “Why, so it is, father,—whose wife shall I take?”
