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UNIVERSITYHOSPITAL,GEELONGFELLOWSHIPWRITTENEXAMINATION
WEEK25–TRIALSHORTANSWERQUESTIONSSuggestedanswersPLEASELETTOMKNOWOFANYERRORS/OTHEROPTIONSFORANSWERSPleasedonotsimplychangethisdocument-itisnotthemastercopy!
Question1(18marks)
a. Definepsychosis.(1mark)• Distortion/lossofcontactwithreality• Withoutanycloudingofconsciousness
b. Listthefive(5)DSMIVcriteriaforthediagnosisofSchizophrenia.(5marks)
• Symptomsinvolvingatleast2of:o Delusionso Hallucinationso Grosslydisorganisedorcatatonicbehaviouro Disorganisedspeecho Negativesymptoms
• Social/occupationaldysfunction• Duration>6months• ExclusionofSchizoaffective/mooddisorder• Exclusionofsubstanceabuse/medicalcause
YouareprovidingmedicalassistanceattriageonabusySundaynight.A34yearoldmanpresentstotriage.Heappearsintoxicated,agitatedandhaspressureofspeech.Herequestsexcisionofalesiononhisforeheadthathasbeenpresentforover20yrs.Duringthediscussion,hesuddenlypullsoutaknifeanddeclaresthatifwedon’tcutoutthisthing,he’lldoithimself.Thetriagenursehasrequestedhehandovertheknifeandhestates“Youwillhavetofightmeforit”.
c. Definethissituation. (1mark) • CodeBlackorarmedthreat
d. Listfive(5)featuresofhispresentationthatraiseconcernsaboutimmediateviolence.(5marks)
• Agitation-motor• Agitation-verbal• intoxication• Pressureofspeech-indicatorofMentalHealthdisorder• Knife• Statedthreattouseknife• Attitudetoassistance
Thepatientisdisarmedandrequiresphysicalandchemicalrestrainttoallowassessment.e. Listyourpreferredinitialpharmacologicaltreatmentwithdoserangeandrouteofadministrationinthe
caseof:i. Patientbeingcompliantwithmedicationadministration:(3marks)NB:appearsintoxicated-dosesmustbesafe
• Olanzepine5-10mgorally• Diazepam5-10mgorally
ii. Patientbeingnon-compliantwithmedicationadministration:(3marks)NB:appearsintoxicated-dosesmustbesafe
• Midazolam5-10mgIMorIV• Lorazepam1-2mgIMorIV• Haloperidol5-10mgIMorIV• Droperidol5-10mgIMorIV• Ziprasidone10-20mg+/-lorazepam1-2mgIM
“List”=1-3words“State”=shortstatement/phrase/clause
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Question2(12marks)WithrespecttoheadinjuryintheAdulttraumapatient:
a. Listfour(4)riskfactorsthatwouldleadyoutoobtainanurgentCTbrain(iewithinthefirst1hour).(4marks) NB:factorshouldrelatespecificallytoindicationsforCTBinCHI-notrelatingtoothersignificantinjuriesrequiringurgentCT
• GCS<13onarrival• GCS<15at2/24• Suspectedopen/depressedskull#• SignofBOS#• Posttraumaticseizure• Focalneurologicaldeficit• 1episodeofvomiting
b. Listfour(4)riskfactorsthatwouldleadyoutoobtainasemi-urgentCTBrain(iewithinthefirst8
hours).(4marks)• LOC/Amnesia+Age≥65• LOC/Amnesia+Hxofbleeding/clottingdisorders• LOC/Amnesia+Dangerousmechanism,(Ped/cyclistvscar,ejectionfromMVC,fall>1m/5
stairs)• LOC/Amnesia+30minretrogradeamnesiaofeventsimmediatelybeforeCHI
WithrespecttoheadinjuryinthePaediatrictraumapatient:
c. Listfour(4)variationswhencomparedtoAdultguidelines,intermsofriskfactorsforwhichCTBrainisrecommendedforthePaediatricpatientwithinthefirst1hour.(4marks)
• NAIsuspicion• GCS<14or<1yrold<15• Tensefontanelle• <1yr->5cmbruise/swelling/lac• ≥2of:≥3vomitingepisodes/LOC>5min/dangerousmechanism/abnormaldrowsiness/
Amnesia>5min
Youshouldbefamiliarwiththefollowing:APHIRST,NICE,CanadianCTB,NewOrleans,CHALICE,CATCHandPECARN.Dunnhasaverygoodsummaryofeach-theoriginalarticlesarebelow.Youmustachieveexpert,evidencebasedpracticeinthisarea.ClickontheimagebelowtoviewtheentirePDF(&print/saveifnecessary)
Seenextpageforsummariesofeach
1.APHIRST2.NICE3.Canadian4.NewOrleans5.Comparison6.CHALICE 7.CATCH8.PECARN
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NICE
Paeds:NICE
CHALICE
CATCH PECARN→
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Question3(12marks)
a. WhatisthePerichondritisoftheear?(1mark)• Infectionoftheauricularsofttissueoverlyingthecartilage
b. Listthree(3)causesofperichondritisoftheear.(3marks)
• Trauma§ Lacerations§ Burns
• Earpiercing• Surgicalwound
c. Otherthananalgesia,list(3)keycomponentstothemanagementofperichondritisoftheear.(4marks)
• Hotsoaks• OralAbs-DunnssaysFluclox,generallyneedtocoverPseudomonas-Cipro• Reviewin24-48/24
d. WhatisChondritisoftheear?(1mark)
• Infectioninvolvingtheauricularcartilage
e. Whatclinicalfeaturedifferentiatesperichondritisoftheearfromchondritisoftheear?(1mark)• Deformityoftheexternalear(auricle)
f. Listthree(3)differencesinthemanagementofChondritisoftheear,ascomparedtoPerichondritisofthe
ear?(3marks)• IVabsrequired-flucloxvstazocin• Admissionrequired• Surgicaldrainage
ThisresourceisproducedfortheuseofUniversityHospital,GeelongEmergencystaffforpreparationfortheEmergencyMedicineFellowshipwrittenexam.Allcarehasbeentakentoensureaccurateanduptodatecontent.Pleasecontactmewithanysuggestions,concernsorquestions.DrTomReade(StaffSpecialist,UniversityHospital,GeelongEmergencyDepartment)Email:[email protected] November2017
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Question4(12marks)
A46yearoldwomanpresentswithchestpain.Hervitalsignsare:BP130/60mmHgRR22/minTemperature36.5°CGCS15
a. Whatisaunifyingdiagnosisforthispatient,basedonthisECG?(1mark)• Pericarditis
b. Listthree(3)abnormalitiesshowninthisECGthatsupportthisdiagnosis.(3marks)
• Sinustachycardia-rate110• PRdepression• WidespreadSTE• (STDaVr)
c. Listfour(4)keyinvestigationsthatyouwouldperform.Stateone(1)justificationforeachchoice.
(8marks)
Investigation Justification
ECHO • Demonstrateamountofpericardialfluid• Demonstratethickenedpericardium• Assessforevidenceofcardiactamponade• (Localisedwallmotionabnormalities)
FBE • Lymphocytosissuggestsviralcause• WCC<4>15suggestsbacterialcause
U+E • Uraemiaasacause
Troponin • DxPancarditis• DxMyocarditis
ESRorCRP • Raisedlevelssupportinflammatoryprocess• Levelscanbeusedtofollowdiseaseprogress
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Question5(12marks)A25yearoldwomanpresentsfollowingastingfromanunknownanimalwhilstcamping.
a. Listthree(3)clinicallyrelevantdifferencesbetweenwaspstingsandbeestings.(6marks)
Featureofsting Wasp Bee
Frequencyofbites
Muchlesscommon Morecommon
Frequencyofanaphylaxis
Muchlesscommon Morecommon
Number
Multiple 1sting
Serumsickness
N Y
Massiveenvenomation: Numberofstings
>50stings >20stings
Haemoglobinuria
N Y
Rhabdomyolysis
N Y
Multipleorganfailure
N Y
Haemolysis
Y N
Myocarditis
Y N
Hepatitis
Y N
Death(bothduetoanaphylaxis)
Muchlesscommon Morecommon
b. Listthree(3)clinicalfeaturesofabullantbite.(3marks)
• Repeatedstings• Localwheal&flare• Anaphylaxis• Death-associatedwith-priorstings&ACEinhibitoruse
c. Listthree(3)clinicalfeaturesofanAustralianscorpionsting.(3marks)• Nighttime• Uncommon• Minorlocaleffects:
o painlocalised,severalhrso inflammationo oedemao paraesthesiao hyperalgesiao numbness/tinglingseveraldays
• Systemiceffectsuncommono nausea,vomiting,malaise,tachycardia
• Notlifethreatening
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Question6(12marks)(samepatientasquestion5)
a. Whatistheclinicaldefinitionofanaphylaxis?(1mark)3components:
• severe/lifethreatening• generalised/systemic• hypersensitivity/allergicreaction
b. Ingeneral,listtwo(2)indicationsforapatienttousetheirownEpipen.(2marks)
• Cutaneoussymptoms +
• Signofanothersysteminvolvement:o dizziness/faintnesso SOBo chesttightnesso oralswelling/lumpo voicechangeo nausea/vomit
c. Otherthantheindicationsforuse,listfour(4)instructionsthatyouwouldgiveapatientwith
respecttothetechniqueofEPipenuse.(4marks)• Howtoopen• Identifycorrectendforapplication• Appropriatesite(lateralthighisrecommended)• Forcerequired• Durationofholdingin(10sec)• Call000ASAPafterEPIPENuse
Thepatientexperiencesanaphylaxis.ShehasIVaccess.Adrenalineisgiveninappropriatedoses.Shefailstorespondtomaximumadrenalinetherapy.
d. Listfive(5)additionalmedicationsthatyoucouldinitiateinthissituation.(5marks)• Steroids(althoughoflittlebenefitacutely,useearlyasdurationofanaphylaxiscannotbe
predicted)• Salbutamol• H1antagonists• H2antagonists• Glucagon(ifpttakingBBlockers)• MgSO4IV(forrefractorybronchospasm)• Ketamine(inductionagentmayimprovebronchospasm)
ClickontheimagebelowtoviewtheentirePDF(&print/saveifnecessary)
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Question7(12marks)Duringyourroutinepathologyresultcheckingyounoticethefollowingresultofapatientseenbyanotherdoctorinyouremergencydepartmenttwodaysago.Thepatientrecordsshow:35yearoldwoman,15weekspregnantwithleftflankpainanddysuria.Noallergies.Rxtrimethoprim.F/Uprn.
MICROSCOPYLeucocytes>1000x10^6/L(<2x10^6/L)RedBloodCells 220 x10^6/L(<13x10^6/L)SquamousEpithelialCells +STANDARDBACTERIALCULTURE
1.Escherichiacoli>10^9cfu/LSENSITIVITIES:AmpicillinSAugmentinSCefotaximeSCephalothinSCotrimoxazoleSGentamicinSNitrofurantoinSTrimethoprimR
a. Statefour(4)clinicalproblemswiththispatient.(4marks)• Clinicalfeaturesofpyelonephritis+pregnancy=admissionandIVAbsinmostcases• CItochosenAbsgiven(categoryC)→adverseevent• Organismculturednotsensitive→needsAbschangeandurgentreview• Inappropriatefollowup-ShouldhaveplanforMSUfollowup(not“prn”)• PregnancywithdelayedRxincurs↑riskofmiscarriage• EColiassociatedwithsignificantcomplications(Gram-vesepsisisbad)
b. Listfour(4)keystepsthatyouwouldundertakeinthiscase.Stateone(1)justificationforeachstep.(8
marks)NB:thisisonetimewhereIwouldgroupthe“medicalcare”asonestep,seeingtherearenumerousotherstepstocover-ie.Not:1.Recallpt 2.IVabs 3.IVfluids 4.Admit
Step Justification
Contactpatient • ReturnASAPforRVandappropriateMx
Opendisclosure • Bestpractice• Optimiseptunderstandingofsituation• Reducefuturelegalprocessrelatingtopresentation
ClinicalreassessmentwithviewtourgentIVabsandadmission
• Rapidmedicaladmissiontodelayfurtheradverseeffects
Obstetricreview • Withrespecttopossiblyteratogenicantibiotic-closespecialistfollowuprequired
QI-Rootcauseanalysis • ↓similarfutureevents
DebriefwithDrinvolved • Identifyknowledgegaps/educate/support/supervise
Documentation • Optimiseongoingcareforpatient/Legalimplicationstocase
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Question8(12marks)A34yearoldmanpresentsleftanklepainfollowingafallataBBQ.
a. Statefour(4)abnormalfindingsinthesexrays.(4marks) • Comminuteddistalfibulafracture(WeberC)• Disruptionofthedistaltib/fibsyndesmosis• Medialmalleolar#• Latersubluxationofthetalus
Hehadbeendrinkingbeerforseveralhoursprior.HehasaPastHistoryofchroniclowerbackpain.Hetakesbuprenorphinepatchesforchronicpain.Hetakesnootherregularmedications.YouhaveIVaccess.Hehasanisolatedankleinjury.HisPBTis0.25.
b. Statefour(4)issuesinyourapproachtohisanalgesicregimeforthefirst1hour.(4marks)NB:NotPCAin1sthour
• PBT0.25-Carewithhaemodynamics&reductioninGCS• AsaresultofBup.Patches→WillberelativelyresistanttoIVnarcotics/willrequirehigh
dosemorphine• Close/carefulobservationrequiredpostIVanalgesia• Stronganalgesiawillberequired-IV2.5mgbolusMorphine/KetamineIVboluses• Employnonmedicinaltechniquesto↓analgesicrequirementsASAP-splint/reduce/
elevate
Itbecomesapparentthatthepatientisafamousfootballer.
c. Statefour(4)techniquesthatyoucouldemploytomaintainthepatients'privacy.(4marks)• Alias/de-identifyoncomputersystem• Usecubicleindiscretearea• Keepcurtain/doorclosed• InformdirectRNstaffandRNinchargeanddirecttominimisediscussion/notdiscuss
presencewidelyatworkandwhenleftfromwork• Informmedialiaisonofficer• ExpediateRxwithoutcompromisingcaretootherpt’s• Stafftraininginethicsandptprivacy
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Question9(18marks)A3year-oldboyisbroughttoyourdepartmentbyhismotherwithabdominalpainandvomiting.ThemotherisconcernedthatthechildmayhaveingestedsomeofherIron(Ferrogradumet)tablets.Sheissurethattherearemorethan10tabletsmissingfromthebottle.EachFerrogradumettabletcontains105mgofelementalIron.
a. Listthree(3)clinicalfeaturesthatyouwouldseektoassesstheriskoftoxicity.(3marks) • Weight
o 1000mgminimumingestionassumedo likelyweight~15kg→65mg/kg,if10kg→100mg/kgif20kg→50mg/kgo <20mg/kg:asymptomatico 20-60mg/kg:GITo 60-120mg/kg:systemico 120mg/kg:potentiallylethal
• SymptomsofGITphase(onset30min-6/24)o vomiting(vomitingisthemostsensitivemarkerofserioustoxicity)o diarrhoeao abdopaino H+M
• Indicatorsofshock
b. WhatistheroleofSerumIronlevelsinthetreatmentofthispatient?State(3)pointsinyouranswer.(3marks)• Confirmingestion• Peakat4-6/24• Noclearcorrelationwithlevelandtoxicity• Peaklevels>90micromol/Lthoughttobepredictiveofsystemictoxicity
c. Listfour(4)keyinvestigationsforthischildthatwillassistwithanestimationofseverityoftoxicity.(4marks)
NB:“List”onlyrequired-nojustificationorexplanationrequestedthereforenonerequired• ABG(AGMetabolicacidosisinsevere,metabolicalkalosisfromupperGITlosses)• AXR(Tabletsinstomach→indicationforWBI)• Glucose(PerDunn:>8correlateswellwithtoxicserumlevels-ToxHBsaysdoesnotcorrelatewithtoxicity)
• WCC(PerDunn:>15correlateswithsystemictoxicity-ToxHBsaysdoesnotcorrelatewithtoxicity) • ErectCXR(ifabdominalperforationsuspected)• Clotting(Dunn:↑INR/↑APTT,ToxHB-nomention)• LFT(Dunn:hepatoxicity,ToxHB-nomention)
d. Whatdecontaminationmaybeofbenefitinthisingestion?(1mark)
• WBI
e. Listthree(3)indication/sforthisdecontamination.(3marks)• Symptomatic• >60mg/kg(Dunnsays>20mg/kg)• AXRshowstablets
f. Whatspecificantidotethatmaybeofbenefitinthisingestion?(1mark)
• Desferrioxamine
g. Listthree(3)indicationsfortheuseofantidoteinthispatient.(3marks)• Systemictoxicity
o Alteredconsciousstateo ↓BPo ↑PRo ↑RR
• Serum>90micromol/lat4-6/24post
