Scoring Systems

Question 1

Describe use, parameters and interpretation of HAS BLED score

Answer 1

Use to assess bleeding risk for AF anticoagulant treatment
Superseded by ORBIT score (NICE recommends)

Parameters - 1 point for each

• HTN
• renal disease
• liver disease
• stroke hx
• prior major bleeding or predisposition to bleeding
• labile INR
• 65+
• other medication that predisposes to bleeding
• alcohol use over 8 units a week

1 and below can give
2 consider
3+ is high risk of bleeding

Question 2

Wells score for DVT

Answer 2

1. Low risk is < 2 - D-dimer
2. higher needs USS within 4 hours

• Active cancer (Tx ongoing, within 6 months or palliative)
• Paralysis, paresis or plaster immobilisation of lower extremities
• bedridden > 3 days, or major surgery in last 3/12
• Localised tenderness deep vein system
• Entire leg swollen
• Calf swelling > 3cm
• unilateral pitting oedema
• Collateral superficial veins (non-varicose)
• Previous DVT
• - 2 An alternative dx as likely as DVT

Question 3

GCS scoring adults

Answer 3

Eye opening scores

• 4: Spontaneously
• 3: To verbal command
• 2: To pain
• 1: No response

Best motor response scores

• 6: Obeys command
• 5: Localizes pain
• 4: Flexion withdrawal
• 3: Flexion abnormal (decorticate)
• 2: Extension (decerebrate)
• 1: No response

Best verbal response scores

• 5: Oriented and converses
• 4: Disoriented and converses
• 3: Inappropriate words; cries
• 2: Incomprehensible sounds
• 1: No response

13-15 - mild

9-12 - moderate

< 8 severe

Question 4

CHADsVASc score

Answer 4

• Males scoring > 1 or females score > 2 should be anticoagulated

CHADSVASc

Points

C

Congestive cardiac failure

1

H

hypertension

1

A₂

> 75 years old

2

D

Diabetes mellitus

1

S₂

Previous stroke or TIA

2

V

Known vascular disease

1

A

Aged 65-74

1

Sc

Female

1

Question 5

ORBIT score

Answer 5

assessing bleeding risk in AF

ORBIT

Points

Sex

Haemoglobin (F < 12, M < 13)

2

Age > 74

1

Bleeding history

2

Renal function eGFR < 60

1

Concomitant use of anti-platelets

1

Question 6

Fontaine classification for peripheral arterial disease

Answer 6

• Fontaine classification
  
  • I - asymptomatic, II - intermittent claudication, III - rest pain, IV - tissue loss/gangrene

Question 7

Jones criteria

Answer 7

Jones criteria - rheumatic feveer

Diagnosis requires - evidence of strep. Infection + 2 major or 1 major + 2 minor

• Evidence of recent streptococcal infection
  
  • Hx of scarlet fever, +ve throat swab, ↑ ASOT > 200 U/ml or Dnase B titre
• Major criteria
  
  • Arthritis
  • Pancarditis
  • Sydenham’s chorea
  • Erythema marginatum
  • Subcutaneous nodules
• Minor criteria
  
  • Fever
  • Arthralgia - unless arthritis met as major
  • ↑ acute phase proteins (ESR, CRP)
  • Prolonged PR interval on ECG - except if carditis meets major criteria

Question 8

Duke’s criteria

Answer 8

duke’s criteria - infective endocarditis

Diagnoses: 2 major or 1 major + 3 minor or 5 minor

Major

Minor

• Persistent bacteraemia (> 2 +ve blood culture, 12 hours apart)
• Echocardiogram findings - vegetations seen
• +ve serology for bartonella, coxiella, brucella
• Predisposing RF - murmur, IVDU, etc
• Fever > 38 or high CRP
• Evidence of immune complex formation - splinter haemorrhages, haematuria
• Vascular phenomena - major arterial emboli (stroke, PE)
• Positive echo that doesn’t meet the major criteria

Question 9

Parkland’s formula

Answer 9

fluids for firsr 24 hours in burns

• Modified parkland formula - used for directing fluid requirements, volume of crystalloid fluid to be given in first 24 hours
  
  • Adults - 4mL (Hartmann’s) x weight (kg) x % TBSA burned
  • Children - 3mL (Hartmann’s) x weight (kg) x % TBSA burned
  • Give 50% calculated in 8 hours post burn and 50% in remaining 16 hours

Question 10

stages of CKD

Answer 10

• Stage 1: GFR _>_90mL/minute/1.73m² with other evidence of CKD e.g. sediment, structure
• Stage 2: GFR 60-89 mL/min/1.73m² with other evidence of CKD
• Stage 3a: moderate, GFR 45-59 mL/min/1.73m²
• stage 3b: moderate, GFR 30-44 mL/min/1.73m²
• stage 4: severe, GFR 15-29 mL/min/1.73m²
• stage 5: established renal failure, GFR < 15 mL/min/1.73m² or on dialysis

Question 11

stroke scoring triage assessment A&E - ROSIER

Answer 11

• ROSIER score - to be used to triage patient’s on presentation to assess likelihood of stroke
  
  • Stoke is likely if scoring > 0
  • Exclude hypoglycaemia first
  • Assessment:
    
    • -1 point - loss of consciousness/syncope; seizure activity
    • +1 point - asymmetric face weakness, asymmetric arm weakness, asymmetric leg weakness, speech disturbance, visual field defect

Question 12

Glasgow score

Answer 12

for pancreatitis

• Modified Glasgow criteria - severity scoring for acute pancreatitis, to be completed within 48 hours
  
  • Any patient > 3 in first 48 hours → severe, HDU/ITU referral
  • Mnemonic (pancreas)
    
    • PaO2 < 8kPa on ABG
    • Age > 55 years
    • Neutrophilia – WBC > 15x 10⁹/L
    • Calcium <2mmol/L
    • Renal function – urea >16mmol/L
    • Enzymes – LDH >600iu/L or AST > 200 iu/L
    • Albumin < 32 g/L (serum)
    • Sugar – blood glucose > 10mmol/L

Question 13

scoring for Upper GI bleed pre-endoscopy

Answer 13

Glasgow-BLATCHFORD score

used to risk stratify patient admitted with upper GI bleed

• > 6 associated with >50% risk of needing an intervention
• NICE if > 0 - IP OGD, if 0 - OP OGD
• the parameters:
  
  • urea
  • Hb
  • systolic BP
  • pulse (bpm)
  • melaena
  • syncope
  • known liver failure
  • known cardiac failure

Question 14

scoring for upper GI bleed

Answer 14

rockall score

• assess mortality
• pre-endoscopy out of 7, post-endoscopy our of 11
  
  • NICE prefers blatchford for pre-Ix determination of timing for OGD
• if > 0 should have inpatient OGD, if 0 - urgent OP OGD
• factors:
  
  • age
  • SBP
  • comorbidities - IHD/cardiac failure, liver failure, renal failure, metastases
  • endoscopy dx - Mallow weiss, all other, GI malignancy
  • at endoscopy - no blood or dark red spot or blood in upper GI tract (spurt, adherent clot)

Question 15

GCS core components and overall maximum marks

Answer 15

out of 15

M - 6

S - 5

E - 4

Question 16

describe motor components GCS brief

Answer 16

out of 6

1. No motor response
2. Extension to pain
3. Abnormal flexion to pain
4. Flexion/Withdrawal to pain
5. Localizes to pain
6. Obeys commands

Question 17

describe the eye component GCS brief

Answer 17

out of 4

1. No eye opening
2. Eye opening in response to pain stimulus
3. Eye opening to speech
4. Eyes opening spontaneously

Question 18

describe the verbal component of GCS (brief)

Answer 18

out of 5

1. No verbal response
2. Incomprehensible sounds
3. Inappropriate words
4. Confused
5. Oriented

Question 19

Well’s score PE with mneumonic

Answer 19

EAT CHIPS

• Evidence of oedema of DVT (> 3cm) = 3
• A - alternative diagnosis is less likely = 3
• T - tachycardia = 1.5
• C - cancer = 1
• H - haemoptysis = 1
• I - immobilisation 3+ days = 1.5
• P - previous DVT or PE = 1.5
• S - surgery in last month (major) = 1.5, don’t double count if immobile

less 4 is low probability PE

over 4 is high probability of PE

Question 20

Parklands formula adults

Answer 20

% burns x weight x 4

Question 21

severity of UC flares

Answer 21

• mild - < 4 stools/day, small amount of blood
• moderate - 4-6 stools/day; varying blood; systemically well
• severe - > 6 bloody stools/day + systemic upset (fever, HR > 90, anaemia < 10, ESR > 30)