· web viewlist three (3) causes of acute fulminant hepatic failure in a previously well patient...

Candidate name

Fellowship course Week 13 – General Medicine

WRITTEN EXAMINATIONSHORT ANSWER QUESTIONS

EXAMINATION TIME: 69 Minutes

Candidate nameQuestion 1 (14 marks) 6 minutes

A 45-year-old male presents to ED with vertigo and ataxia.

A CT scan is taken:

Candidate nameQuestion 1 (continued)

i) State four (4) abnormal findings shown in this image. (4 marks)

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

4. _________________________________________________________________________


ii) List five (5) key investigations that you would perform in this patient. Provide one (1) justification for each choice. (10 marks)

Investigations(5 marks)

Justification(5 marks)

1

2

3

4

5


A 34 year old male presents with upper abdominal pain.

Liver function tests are taken.

a. List five (5) likely differential diagnoses. (5 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

4. _______________________________________________________________________

5. _______________________________________________________________________


b. List three (3) features of these investigations that support established cirrhosis. (3 marks)

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

c. In addition to information given, list four (4) other features that would indicate severe hepatic disease for this patient. (4 marks)

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

4. _________________________________________________________________________

Candidate nameQuestion 2

Reference range

Total bilirubin 125 µmol/ L 0- 20

Protein 65 g/L 60- 80

Albumin 37 g/L 33- 47

Alkaline phosphatase 118 U/L 30- 100

γGT 450 U/L 0-50

AST 2854 U/L 0- 35

ALT 2785 U/L 0- 40

LDH 205 U/L 120- 250

Hb 125 g/L 115- 165

WCC 5x 109/l 4.0- 11.0

Plt 95 x 109/l 150- 400

INR 1.8

Candidate nameQuestion 3 (12 marks) 6 minutesAn 84 year old female presents with a new onset left hemiparesis.

a. State the two (2) therapeutic options that utilise interventional radiology. ( 2 marks)

1. _________________________________________________________________________

2. _________________________________________________________________________

b. List three (3) possible indications for the use of interventional radiology for this patient. (3 marks)

1. _______________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________


The patient undergoes thrombolysis. Standard consent procedures are followed. Shortly after thrombolysis is commenced, the patient suffers a haemorrhagic stroke that is confirmed on CT.

c. List four (4) options for the reversal of thrombolysis. (4 marks)

1. _______________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

4. _________________________________________________________________________

d. List three (3) considerations/ factors that may lead to a decision to not reverse thrombolysis in this case. (3 marks)

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________


A 40 year old male presents to the ED with fever and confusion for 24 hours. He has just returned from back- packing through Papua New Guinea and Indonesia.

His observations are:

PR 120 bpm

BP 130/80 mmHg

RR 16 bpm

Temp 39.5 °C

GCS 13 (V3)

i) List five (5) likely differential diagnoses for this presentation. For each diagnosis, list the expected incubation period prior to clinical features. (10 marks)

Differential diagnosis(5 marks)

Expected incubation period(5 marks)

1.

2.

3.

4.

5.


ii) List five (5) key investigations that you may perform to assist with the diagnosis. (5 marks)

1. _______________________________________________________________________

2. _____________________________________________________________________

3. ____________________________________________________________________

4. _______________________________________________________________________

5. _______________________________________________________________________

iii) List two (2) specific medications that you would consider as empiric treatment prior to obtaining confirmatory tests for this patient. For each, list your dose and route. (6 marks)

Medication(2 marks)

Dose(2 marks)

Route(2 marks)

1.

2.


A 62 year old female presents to ED with massive haematemesis. She has a history of alcohol dependence.Her vital signs on presentation are:

BP 70 mmHg

HR 150 /min

RR 16 /min

Temp 37°C

GCS 15

i) List five (5) likely differential diagnoses for the cause of her bleeding. (5 marks)

1. ____________________________________________________________________

2. ____________________________________________________________________

3. ____________________________________________________________________

4. ____________________________________________________________________

5. ____________________________________________________________________

ii) List three (3) indications for urgent (< 1 hour) gastroscopy. (3 marks)

1. _____________________________________________________________________

2. _____________________________________________________________________

3. _____________________________________________________________________


She has 2 large IV access, full external monitoring and is referred to the gastroenterology service.

iii) Other than endoscopy, list four (4) steps in the management of her haemodynamic state. List one (1) detail for each step. (8 marks)

Management(4 marks)

Detail(4 marks)

1.

2.

3.

4.


A 52 year old male presents to ED with recent onset of non-traumatic, macroscopic haematuria.

i) List five (5) likely differential diagnoses for this presentation. (5 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

4. _______________________________________________________________________

5. _______________________________________________________________________


ii) Other than true haematuria, five (5) causes of dark brown urine. (5 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

4. _______________________________________________________________________

5. _______________________________________________________________________

iii) List three (3) causes of red cell urinary casts. (3 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________


i) List three (3) causes of acute fulminant hepatic failure in a previously well patient (each to be a different pathological aetiology). (3 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

A 50 year old male presents with suspected decompensated chronic liver failure.

ii) List six (6) likely precipitants for this decompensation. (6 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

4. _______________________________________________________________________

5. _______________________________________________________________________

6. _______________________________________________________________________


iii) Complete the table demonstrating two (2) of the neurological features of each of the different stages of hepatic encephalopathy. (8 marks)

Grade Neurological feature(8 marks)

1.

2.

3.

4.

Candidate nameQuestion 7 (continued)The patient is noted to have ascites.

iv) List three (3) potential benefits of performing abdominal paracentesis for this patient. (3 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

v) List three (3) common complications of performing abdominal paracentesis in a patient with chronic liver disease. (3 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________


A 65 year old male presents with a headache. He has not experienced trauma prior to the headache onset.His observations are:

BP 255/150 mmHg supine

HR 90 /min

Temperature 37°C

i) Other than phaechromocytoma and idiopathic hypertension, list six (6) likely underlying causes for his hypertension. (6 marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

4. _______________________________________________________________________

5. ______________________________________________________________________

6. ________________________________________________________________________

You have a strong suspicion of the diagnosis of phaeochromocytoma.

ii) List three (3) drugs in your preferred regime to treat the blood pressure in this setting (doses are not required). (3 marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________


iii) List three (3) investigations that may be performed to assist in the diagnosis of phaeochromocytoma. (3 marks)

1. _____________________________________________________________________

2. _____________________________________________________________________

3. _____________________________________________________________________


A 67 year-old man presents to the ED with 12 hours of severe upper abdominal pain, fever, nausea and vomiting. He appears jaundiced.Initial assessment:He is exquisitely tender and guarded in his epigastrium and right upper quadrant.His vital signs are:

BP 110/60 mmHgHR 90 bpmRR 22 bpmTemperature 38.2 °C

a. Other than pancreatitis, list three (3) likely differential diagnoses. (3 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

Initial investigations are taken.

b. State three (3) key interpretation facts with respect to these results. (3 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________


c. List four (4) factors of this patient’s presentations that predict severe disease. (4 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

4. _______________________________________________________________________

a. List two (2) limitations for the use of Ranson’s criteria. (2 marks)

1. ________________________________________________________________________

2. _______________________________________________________________________

Candidate nameQuestion 9

Reference range

Na 135 mmol/L 135 – 145 K 3.9 mmol/L 3.5 – 5.0 Cl 100 mmol/L 95 – 110 HCO3 27 mmol/L 20 – 31 Urea 4.1 mmol/L 2.7 – 7.8 Creatinine 62 mcmol/L 50 – 100

Anion gap 8 mmol/L 5 – 15

Total protein 76 g/L 60 – 80 Albumin 44 g/L 35 – 50 ALP 577 IU/L 40 – 115 ALT 972 IU/L <65 GGT 226 IU/L <55 Bilirubin TOTAL

89.4 mcmol/L <25

Lipase 8523 IU/L 8 – 78

Candidate name

Question 10 (20 marks) 9 minutesA 35 year old female presents with suspected thyroid storm.

i) State four (4) diagnostic features of thyroid storm. (4 marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

4. ________________________________________________________________________

ii) List three (3) likely precipitants for thyroid storm. (3 marks)

1. _____________________________________________________________________

2. _____________________________________________________________________

3. _____________________________________________________________________


iii) List four (4) medications that may be used for this patient. For each medication, state one (1) reason why this medication is used. (8 marks)

Medication

(4 marks)

Why is this medication used?

(4 marks)

1

2

3

4


iv) List one (1) medication that is specifically contraindicated in thyroid storm (1 mark)

________________________________________________________________________

v) Other than intravenous fluids and oxygen, list four (4) non-medicinal treatments that may be utilised for this patient. (4 marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

4. ________________________________________________________________________

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