UNIVERSITYHOSPITAL,GEELONG
FELLOWSHIPWRITTENEXAMINATIONWEEK2–TRIALSHORTANSWERQUESTIONSSuggestedanswersPLEASELETTOMKNOWOFANYERRORS/OTHEROPTIONSFORANSWERSPleasedonotsimplychangethisdocument-itisnotthemastercopy!
Question1(18marks)9minutesA72yearoldwomanpresentswithtearingchestpainsuggestiveofdissectionofheraorta.
a. Statethree(3)prosfortheutilityofchestXrayinthispresentation.(3marks)NB:FocusPros/consonclinicalrelevance-notcheap/easy(rapidmaybeokbutusuallybetteralternatives)• MayshowfindinghighlysuggestiveofTAD-egdoublelumensign• Mayshowalternativediagnosis(egpneumomediastinum)• Maybeperformedbedside(avoidstransferringunstablepatient)
b. Statethree(3)consfortheutilityofchestXrayinthispresentation.(3marks)
• Poorsensitivity-~60%screeningtestonly,cannotbeusedtoruleoutTAD,highfalse–ve• Poorspecificity–widenedmediastinumonAPorsupine,highfalse+ve• Doesn’tdefineextent/typeofTAD• MaydelayformalIx
c. Listsix(6)ChestXrayfindingsthatsupportthediagnosisofthoracicAorticdissection.(6marks)
NB:although"normal"in~15%-thisdoesnot"supportthediagnosis"• Widenedmediastinum(56-63%)• abnormalaorticcontour(48%)• aorticknuckledoublecalciumsign>5mm(14%)• pleuraleffusion(L>R)• trachealshift• leftapicalcap• deviatedNGT
d. Statesix(6)keyissuesinthemanagementofapatientwithproventhoracicAorticdissection.(6
marks)• Analgesiae.g.titratedIVmorphinewillhelpwithBPcontrol• EstablishRxaims/limitations• Definitivetreatmentisurgenttominimisemorbidityandmortality• Bloodpressurecontrol(endpointsBP100-120mmHgandHR60-80/min)
o BBlockerfirst(e.g.labetolol10mgaliquotsIVq10mins)o vasodilatorifnecessarysubsequentlyegGTN
• Involvingascending/arch-StanfordA-Refercardiothoracics-Surgicalemergency-considerationforSx/endovascularmanagement
• Descending-StanfordB-surgicaldiscussion-usuallymedicalmanagement• Complications:
o hypotensive-urgentsurgicalreview§ (DDx-bloodloss,haemopericardiumwithtamponade,valvedysfunction,L
Ventriculardysfunction)• Avoidpericardiocentesis&inotropes
“List”=1-3words“State”=shortstatement/phrase/clause
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Question2(13marks)6minutesA4yearoldmalepresentstoEDafterhavinginsertedapeanutintohisnostril.Thechildisextremelydistressedandwillrequirechemicalsedationforremoval.Thechildweighs20kg.
a. Listyourchoiceofpreferredmedication,routeofadministrationanddose/s.(3marks)NB:
• IMpreferable-IVOkbutchildisdistressed,IVwillbemoredistressing&isunnecessary• Aschildisdistressed,needadosethatisgoingtobesedating,notjustanalgesic• Mayspecifyarepeatdosedependingonresponse• Ifrepeatdosenotspecified,dosemustbeadequatetocausesedation• AnynasaladministrationisCI• Ketamine: Lowdose<60withnorepeatspecifiedisnotadequate
Medication(1mark)
Routeofadministration(1mark)
Dose/s(1mark)
Ketamine
IM Initialrange3-7mgacceptable=60-140mgSubsequenttomax10mg/kg(analgesia2-4mg/kgsedation5-10mg/kg)
Midazolam IM 0.1-0.2mg/kg2-5(max)mg(0.1-0.2mg/kgtomax5mg/adult)
b. Otherthansedation,list4possiblecomplicationsofyourpreferredmedicationchoice.(4marks)Ketamine MidazolamVomiting~15%AirwayhypersalivationTransientlayngospasm,stridor(esp.ifURTI)Resp.depression/Transientapnoea/desaturationAgitation/hallucination/cryingNightmaresEmergence(uncommoninchildren)
Resp.depression/Transientapnoea/desaturationHypotensionHyperstimulation
c. Listfive(5)indicationsforENTremovalofthisnasalforeignbodyasopposedtoremovalintheEmergencyDepartment.(5marks)
• Parentalrequest• FailureofEDremoval• Childnotfasted• Delayedpresentation-nasalpassageassociatedwith++Swelling• Significantepistaxisprior• PriornasalsurgeryandhighlodgedFB• Congenitalanatomicalabnormality• Likelytobetechnicallydifficulte.g.posteriorposition• Resourcelimitationse.g.stafforspaceunavailabilityforproceduralsedation
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Question3(11marks)6minutes
a. Statethedefinitionofpriapism.(1mark)• prolongedpenileerection(exacttimedurationisnotuniversallyagreedand∴notrequired)• unrelatedtoongoingsexualstimulation• unrelievedbyejaculation
A35yearoldmalepresentstoEDwithpriapism
b. Listfive(5)likelycausesofpriapisminthisman.(5marks)NB:keepit“likely”foramanthisage
• Lowflow:o Idiopathico Medications:
§ Sidenafil(Viagra)§ Intracavernosumagents(egpapverine)§ AntiHT(CCB,αantagonists)§ Antipsychotics(chlorpromazine/clozapine)§ Antidepressants(SSRI)§ Anticonvulsants(Navalproate)§ Warfarin§ Hormones(testosterone)§ Maxolon§ Omperazole
o Recreationaldrugs(heroin,cocaine)o Leukaemia/Thalassemia/SCAo Malariao Amyloidosis,gouto Highspinallesiono (Spider-blackwidow)
• Highflow:o Trauma
§ fistulaformation§ SCtrauma
c. Listtwo(2)simplestepsthatmayhelptoresolvethepriapisminthispatient.(2marks)• Micturition• Exercise• Icetopically
d. Listtwo(2)medicationsthatmaybeusedtoresolvethepriapisminthispatient.(2marks)
• Oralpseudoephedrine• Intracavernosuminjectionofmetaraminol/phenylephrine• Treatreversiblecause-chemoforleukaemia
e. Stateone(1)keyprocedureforthispatientintheemergencydepartmentiftheabovestepsfail
toresolvethepriapism.(1mark)• AspirationofcorpuscavernosumunderLA(20-30mltomax300mlover15min)
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Question4(12marks)6minutes
An88yearoldfemalepresentsfollowingafall.
a. Statesix(6)abnormalfindingsshowninthisscan.(6marks)• RChronicSDH10x2.5cm-hypodense(>2/52old)• LAonChrSDH11x3cmhyperdenseandhypodense• (Signsofraisedintracranialpressure):
o Midlineshift3-4mmtoRo Lossofgrey/whitematterdifferentiationo Llateralventricleeffacemento Sulcaleffacement
• RExternalventriculardrainintoRlateralventricle
Thepatientisconfirmedtobeahostelresident.Sheisindependentlymobilewithmilddementia.Sheisunabletoprovideanopinionabouthercare.
b. Statesix(6)factorsthatwouldleadyoutopursueactivemanagementforthispatient.(6marks)• Lackofsignificantcomorbidities• Goodpremorbidqualityoflife• Warfarinuse-willneedreversal• ConfirmedHxofphysicalabuse• Advancedcaredirectives-forallcare• MedicalPowerofAttorneyrequest• AdvicefromhospitalMedicalSuperintedant
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Question5(14marks)6minutes
A38yearoldmalecollapseswhileexercising.Hespontaneouslyrecoversduringtransportbyambulance.HisECGisshown.
a. Statethree(3)abnormalitiesshownonthisECG.(3marks)• Rate-Ventricular75-130,atrialrate300bpm• Rhythm-Atrialflutterwithvariableblock2:1,3:1• TwaveflatteningV5-V6
b. Stateyourdisposition.(2marks)• Monitoredbed(1)undercardiology(1)
c. Statefour(4)pointsofjustificationforyourchosendisposition.(4marks)• Syncopesuggestshaemodynamicallysignificantarrhythmia• UnlessnoncardiacprecipitantforAflutterispresent• Rate/rhythmcontrol• FacilitatesemiurgentECHOpriortodischarge(probably)• +/-angio
ThepatientwishestodischargeagainstadvicesoonaftertheECGistaken.
d. Listfive(5)questionsthatmustbeansweredforthispatienttobelegallyallowedtodischargehimselfagainstmedicaladvice.(5marks)NB:adutyofcareexists-so“Isthereadutyofcare?”isnotananswer
• Isassessmentcomplete?• Whydoeshewanttoleave?• Isthepatientcapable,competent(Capacityassessmentseewk1&Dunnpage273-4)ofrefusingtreatment?• Cansomeoneelselegallydetermineconsent?• WhatistheriskofDAMA?• Whatistheriskofthepatientofrestraint?
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Question6(12marks)6minutes
Apreviouslywell48yearoldfemalepresentstoEDwithacuteurinaryretentionandlossofperinealsensation.
a. Listthree(3)likelydifferentialdiagnoses.Foreachdiagnosis,statehowyouwouldconfirmeachdiagnosis.(6marks)
Diagnosis(3marks)
Methodofconfirmationofdiagnosis(3marks)
Spinalcordinjury-haematoma
• CTSpine• MRIspinalcord
Spinalcordinfection• epiduralabscess• transversemyelitis• discitis
• CTSpine• MRIspinalcord
Cancer• Epiduralmetastasis• Primarypelvictumour
• CTSpine
Systemicdisease• MS• GBS
• MRIB&Spine• Clinical• LPforGBS
Spinalarterythrombosis
• CTSpine
Lesslikely(givenpreviouslywell):• Progressiveneurologicaldisease• Diabeticneuropathy
b. Listsix(6)keyfeaturesthatyouwouldseekonhistory.(6marks)
• HOPCo Backpain-progressionofsymptomso Trauma-mechanismo Infectivesymptomso IVDUo Embolicsymptomso MSsymptoms-esp.eyepaino Recentspinalanaesthesia-egdelivery
• FHxo MS/otherdiseasesaslisted
• Smoking• Systems
o Symptomsofmetastasis
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Question7(11marks)6minutes
A29yearoldfemaleisbroughtinbyafriendafterbeingfoundinanagitatedstate.Sherefusesallassessmentexceptforanarterialbloodgasandelectrolytesonroomairasdisplayedbelow.
a. Providetwo(2)calculationstohelpyoutointerprettheseresults.(2marks)
Derivedvalue1:AG-AG=9.5=NormalaniongapmetabolicacidosisDerivedvalue2:ExpectedpCO2=36=respiratoryalkalosisSimplemetabolicacidosis:PCO2= 1.5xHCO3-+8
LowerlimitofcompensationPCO2=10 Or PCO2=lasttwonumbersofthepHbetween7.4and7.1
§ combinationof↓HCO3&↓pCO2occursinmetabolicacidosis&respiratoryalkalosisifonlyonedisorderispresentitisusuallyeasytodeterminewhichisoccurring→Hxusuallystronglysuggestsdisorder→NetpHchangeusuallyindicatesthedisorderifonlysingle1°disorder→↑aniongapor↑Cl-definethe2majorcausesofmetabolicacidosis (AG>20highlysuggestive,>30definiteformetabolicacidosis)
§ Commonsituationis↓HCO3&↓pCO2,butpCO2is>thanpredictedbyexpectedcompensation∴metabolicacidosisandassociatedrespiratoryacidosis2°tohypoventilationeg.severeDKA,severesepsis,coexistingrespiratorydisease,arrest,collapse&ICpathology
Herfriendconfirmsthatshehasbeendepressedlatelyandhasaccesstoherparentsandgrandparentsmedications.Shewaswitnessedtoingestaboxoftablets4hoursago.b. Assumingasoleingestant,statethemostlikelytoxicagentinvolved?(1mark)
• Digoxintoxicity-byfarmostlikely• Possible:
o SpironolactoneODo AspirinOD(hypokalaemianothyperkalaemia)
c. What is your risk assessment for this patient based on these blood results? Provide one (1)justificationforyourassessment.(2marks)
• Riskassessment:Potentiallylife-threatening• Justification:severehyperkalaemiaassociatedwithsignificantdigtoxicity(K>5.5100%deathwithouturgentintervention)
d. Listfive(5)medicationsthatyoumayusetostabilisethispatient(nottoincludemedicationsforrapidsequenceinduction).Includestartingdosesforeachmedication.(5marks)
• Digibind(5ifHDstable-10ifHDunstable-20ampulesifcardiacarrest)• NAHCO3100ml8.4%IVbolus• Insulin10U&50ml50%Dextrose• AtropineifAVblock-600mcgIVtomax1.8mguntilHR>60• LignocaineifVentriculararrhythmias-100mgIVover2/60
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Question8(12marks)6minutes
a. Statefour(4)keyfeaturesoftheAustralasiantriagescale.(4marks)
• Requiredbecausemostdepartmentsdonothavethecapacitytotreatallpatientsimmediately
• AllpatientsmustbetriagedonarrivalbytrainedRN/MO• Triagedtooneof5categories• Triagecategoriesbasedontimetomedicalreview• Guidelinesexisttoallowstandardisationoftriagingbetweenindividuals• Categoriesareameasurementofurgency• Triageprocesscontinuesandretriagemayoccuratanystageinresponsetochangein
illness• Waitingtimesshouldbemonitoredcontinuouslysothatevennonurgentshouldnotwait>
2/24
b. Statefour(4)problemsassociatedwiththeprocessoftriage,ingeneral.(4marks)• Inter-observervariability• Institutionvariability
o SmallerEDsallocateahigherprioritypersameacuity• Regionalvariability
o FundingaccordingtoATS1-3waitingtimesonlyhaveincreased4-5• Minimalinformationoftenavailable• Lackofprivacyforassessment• Timeload
o Multiplepatientso Lackoftimeforassessmento Documentationrequirementso Delaytotreatment
• Conflictbetweenptsandstaffperceptionofurgency• Lackofevidencetosupportimpactonpatientoutcomes• Fundingallocationbasedontriageallocation
c. Statefour(4)problemsassociatedwiththeprocessoftriageofthepoisonedpatient.(4marks)
• Minimalinformationmaybeavailablefrompsychiatricpt• Lackofprivacyforassessment/maybereluctanttodivulgedetails• PresentationsoonafterpotentiallylethalODmayappearreasonablywell• Appropriatetriagescoreisverydifficultwithoutknowledgeoftoxicopharmacologyof
agentingested• KnowledgetoodetailedfortriageRN-needmedicalinput
ThisresourceisproducedfortheuseofUniversityHospital,GeelongEmergencystaffforpreparationfortheEmergencyMedicineFellowshipwrittenexam.Allcarehasbeentakentoensureaccurateanduptodatecontent.Pleasecontactmewithanysuggestions,concernsorquestions.DrTomReade(StaffSpecialist,UniversityHospital,GeelongEmergencyDepartment)Email:[email protected] April2017
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Question9(18marks)9minutesA48yearoldfemalepresentstoEDwithshortnessofbreath.Thisxrayistakensoonafterarrival.
i) Statesix(6)abnormalfindingsonthisCXR. (6marks)
• LLLopacification• DecreasedvolumeLlung/raisedLhemidiaphragm• Asymmetricalbreastshadows• Laxillaryclips• Lhilarregionsclips• RIJCVC/portocathSVC
Thepatienthasatemperatureof39°C.
ii) Listfive(5)factorsthatwoulddetermineyourantibioticchoice. (5marks) • Patient:
o Neutropaenia/immunocompromiseo Allergies
• Diseasefactors:o Previousculturesandsensitivitieso Localpathogens&resistancepatternso Communityversushospitalacquired(mayinferHAgivenactiveCVCandthereforeactiveRx)o Severitydiseasee.g.POvsIV
• Hospitalfactors:o Localprotocolsandantibioticguidelines
Thepatientrequeststohavea“DoNotResuscitate”order.iii) Statesix(6)issuesinrelationtothisrequest.(6marks)
• IdeallyshouldbeinconjunctionwithRxteam• Ptautonomy• PriorEndofLifeChoicedocumentation• Ptcompetenceingeneral,butespgivenintercurrentillness?competency• Patientperceptionandunderstanding• Taketimeforconsideration• Confidentiality• Confirmfactsofillnessi.e.potentiallyreversiblecondition• Currentdiseasesatee.g.mets,longtermprognosis,diseaseburden• Documentrequest
