First round and Revival Round; MCQ1. A 68-year-old alcoholic with cirrhosis is highly agitated, disoriented, and diaphoretic. Vital signs: temperature 38.0°C; heart rate 132/min; respiratory rate 24/min; blood pressure 160/100 mm Hg. Initial pharmacotherapy should include:A. Diazepam (Valium).B. Lorazepam (Ativan).C. Pentobarbital (Nembutal).D. Ethanol drip.E. Valproic acid (Depakote)

KEYThe correct answer is B.Explanation:This patient's history and clinical picture is consistent with delirium tremens (DTs). Initial drug treatment should be with a benzodiazepine. Considering this patient's age (>60 years) and history of cirrhosis, lorazepam would be the appropriate choice because this drug does not produce active metabolites, which can lead to toxicity. Fluid and electrolyte deficits should be corrected, and thiamine should be administered. In addition, searching for other etiologies of altered mental status, fever, and tachycardia is important. It must be remembered that DTs are life threatening and are a more severe form of alcohol withdrawal.

2. Choose the appropriate statement about alcohol ingestion and heart disease:A. Chronic alcohol ingestion can lead to a restrictive cardiomyopathy.B. If heart failure does develop, discontinuing alcohol will not change the prognosis.C. High-output congestive heart failure may be due to a thiamine deficiency.D. If a patient with alcoholic cardiomyopathy continues to drink, mortality rate is greater than 70% over the next 3 years.E. The most common dysrhythmia associated with a drinking binge is ventricular tachycardia.

KEYThe correct answer is D. Explanation:Chronic alcoholics may develop a clinical picture identical to that of dilated cardiomyopathy. Stopping the consumption of alcohol can halt the progression of disease. With continued alcohol use, mortality rate approaches 75% within the next 3 years. While beriberi heart disease leads to a high-output congestive heart failure, alcoholic cardiomyopathy is associated with a low-output state. Binge drinking, or “holiday heart syndrome,” causes atrial fibrillation more than any other dysrhythmia

3. The National Institutes of Health Stroke Scale (NIHSS):A. Offers no prognostic information.B. Measures motor and sensory defects only.C. Does not include a measurement of level of consciousness.D. Includes vision changes, but not language.E. Can help identify patients who are likely to respond to fibrinolytic therapy.

KEYThe correct answer is E. Explanation:The NIHSS can be used easily, is reliable and valid, provides insight to the location of vascular lesions, and can be correlated with outcome in patients with ischemic stroke. It focuses on six major areas of the neurologic examination: (1) level of consciousness, (2) visual function, (3) motor function, (4) sensation and neglect, (5) cerebellar function, and (6) language. The NIHSS is used most by stroke teams. It enables the consultant to rapidly determine the severity and possible location of the stroke. A patient's score on the NIHSS is strongly associated with outcome, and it can help identify those patients who are likely to respond to thrombolytic therapy and those who are at higher risk to develop hemorrhagic complications of thrombolytic use.

4. A 21-year-old man presents to the ED. He has a known history of type 1 diabetes. He is hypotensive with BP of 95/65 mm Hg, tachycardic at 120 beats per minute, and tachypneic at 30 breaths per minute. Laboratory results reveal a WBC 20,000/μL, hematocrit 45%, platelets 225/μL, sodium 131 mEq/L, potassium 5.3 mEq/L, chloride 95 mEq/L, bicarbonate 5 mEq/L, BUN 20 mg/dL, creatinine 0.9 mg/dL, and glucose 425 mg/dL. Arterial blood gas reveals a pH of 7.2. Urinalysis reveals glucosuria and ketosis. There is a fruity odor to his breath. Which of the following provides the strongest evidence for the diagnosis?A. Hypotension, tachycardia, and tachypneaB. Glucose of 425 mg/dL, ketosis, and leukocytosisC. Glucose of 425 mg/dL, ketosis, pH 7.2, and bicarbonate of 5 mEq/LD. Glucose of 425 mg/dL, hypotension, and fruity odor to breathE. Glucosuria, hypotension, and leukocytosis

KEYThe correct answer is CExplanation:(Rosen, pp 1639-1644.) The triad of hyperglycemia, ketosis, and acidosis is diagnostic for DKA. All abnormalities in DKA are connected and are based on insulin deficiency. When hyperglycemia surpasses the renal threshold for resorption, glucose is excreted in the urine. This causes an osmotic diuresis that in combination with decreased oral intake and vomiting leads to dehydration and electrolyte abnormalities. Cells, unable to receive glucose from the circulation, switch to starvation mode by increasing proteolysis. The liver starts producing ketoacid subsequently causing acidemia. The acidotic patient increases RR, in an attempt to blow off excess carbon dioxide, and bicarbonate is used up in the process.

5. A 71-year-old man is found lying on the ground one story below the balcony of his apartment. Paramedics bring the patient into the ED. He is cool to touch with a core body temperature of 96°F. His HR is 119 beats per minute and BP is 90/70 mm Hg. His eyes are closed, but they open when you call his name. His limbs move to stimuli, and he answers your questions but is confused. On examination, you note clear fluid dripping from his left ear canal and an area of ecchymosis around the mastoid bone. Which of the following is the most likely diagnosis?A. Le Fort fractureB. Basilar skull fractureC. Otitis internaD. Otitis externaE. Tripod fracture

KEYThe correct answer is B.

Explanation:(Tintinalli, pp 1700-1701.) The skull base comprises the floors of the anterior, middle, and posterior cranial fossae. Fractures in this region typically do not have localized symptoms. However, indirect signs of injury may include visible evidence of bleeding from the fracture into surrounding soft tissue. Ecchymosis around the mastoid bone is often described as Battle sign and periorbital ecchymosis is often described as "raccoon eyes." The most common basilar skull fracture involves the petrous portion of the temporal bone, the external auditory canal, and the tympanic membrane. It is commonly associated with a torn dura leading to cerebrospinal fluid (CSF) otorrhea or rhinorrhea. Other signs and symptoms of a basilar skull fracture include hemotympanum (eg, blood in the tympanic cavity of the middle ear), vertigo, decreased hearing or deafness, and seventh nerve palsy. Periorbital and mastoid ecchymosis develop gradually over hours after an injury and are often absent in the ED. If clear or pink fluid is seen from the nose or ear and a CSF leak is suspected, the fluid can be placed on filter paper and a "halo" or double ring may appear. This is a simple but nonsensitive test to confirm a CSF leak. Evidence of open communication, such as a CSF leak, mandates neurosurgical consultation and admission.

Le Fort factures typically result from high-energy facial trauma and are classified according to their location. A Le Fort I involves a transverse fracture just above the teeth at the level of the nasal fossa, and allows movement of the alveolar ridge and hard palate. A Le Fort II is a pyramidal fracture with its apex just above the bridge of the nose and extending laterally and inferiorly through the infraorbital rims allowing movement of the maxilla, nose, and infraorbital rims. A Le Fort III represents complete craniofacial disruption and involves fractures of the zygoma, infraorbital rims, and maxilla. It is rare for these fractures to occur in isolation; they usually occur in combination. (c and d) Otitis interna and externa are inflammation of the inner ear and outer ear, respectively, and are not relevant in acute trauma. (e) Tripod fractures typically occur from blunt force applied to the lateral face causing fractures of zygomatic arch, the lateral orbital rim, the inferior orbital rim, and the anterior and lateral walls of the maxillary sinus. These fractures present clinically with asymmetrical facial flattening, edema, and ecchymosis.

Second round; Short answer1. What does the CT reveal?

Answer: Acute subdural hematomaExplaination: This image shows an acute right frontal-parietal subdural hematoma. The patient also has a left occipital extracranial hematoma. This represents the classic coup and contrecoup injury pattern seen in many head injuries. Acute blood (immediate up to 3 days) is hyperdense on CT scan with Hounsfield units (HU) between 50 and 90. Subacute subdurals (3 days to 2 weeks) is isodense on CT scan with between 20 and 50 HU. Chronic subdurals (greater than 2 weeks) are hypodense on CT scans, approximately 5–10 HU. A mixture of densities suggests a mixture of subdural types. Subdural hematomas are more common in elderly patients with only 20% surviving to hospital discharge. All acute subdural hematomas should be evaluated by a neurosurgeon (Marx et al., 2006:346, 373)

2. What is a diagnosis of a radiograph of the wrist that demonstrates volar and proximal displacement of a large fragment of radial articular surface, volar displacement of the carpus, and a radial styloid fracture? Answer: Barton fracture Explanation: (Tintinalli) This description best describes a Barton fracture. A Colles fracture involves dorsal angulation of the distal radius; the distal radius fragment is displaced proximally and dorsally. Colles fractures have radial displacement of the carpus, and the ulnar styloid may be fractured. Unlike the Colles, the Smith fracture has volar angulation of the distal radius, and the fragment is displaced proximally and volar. The fracture typically extends in an oblique fashion from the dorsal surface 1–2 cm proximal to the articular surface. Galeazzi and Monteggia injuries are fracture dislocations of both of the forearm bones.

3. What is the diagnosis? Photo from: http://accessemergencymedicine.mhmedical.com/Index.aspx Answer: Bilateral pulmonary hypertension

4. A man with idiopathic thrombocytopenic purpura and platelet count of 56,000/mm3 came to the emergency department with a cut to his face while shaving. His vital signs are normal, and the wound showed no active bleeding. What would you do? Answer: (Tintinalli) Direct pressure Explanation: Management of this patient requires only direct pressure, as patients with platelet counts exceeding 50,000/mm3 infrequently necessitate other specific treatments.

5. What can be clinical of the patient of this ultrasound? Answer: Gastric discomfort, abdominal pain, jaundice, asymptomatic. Explanation: (Cosby, pp 187-188, 207; Ma, pp 176-177, 180-181; Lyon, pp 62-63.) This figure showed upper abdominal ultrasound focused on gall bladder. There were hyperechoic round masses with acoustic shadow in gall bladder which were compatible with gall stones. Patients with gall stones can present with wide range of clinical e.g. abdominal discomfort, acute abdominal pain(if develop cholecystitis), jaundice if the stones cause obstruction of bile duct or even no clinical at all.

Final round1: OSCE in a form of Rally tournament will cover the following categories:1. Simulation cases cover:

a) Medicine

b) Surgery

c) OB-GYN

2. Spot diagnosis

a) Imaging including x-ray, ultrasonography, CT scan

b) EKG

c) Skin lesion

d) Fundoscopy

e) Traffic/ Hazard symbols

3. Toxicology

a) Snakes and animal hazards

b) Toxidromes

4. Mass casualty

a) Table top model on how to manage mass casualty incidents

i. Firing

ii. Transportation accident

iii. Terrorist

iv. Disaster

Final round2; CASE scenarioScenario: As leader of the emergency team you were called to resuscitate a 57 year-old man who arrested on the ward post-operatively. The initial rhythm was ventricular fibrillation. Following defibrillation (1 x 200J biphasic), 1 mg adrenaline IV and 2 minutes of CPR he had an idioventricular rhythm with a rate of 40 but remained pulseless. CPR was continued for a further 2 minutes and 1.2 mg atropine was administered. The patient then had return of spontaneous circulation and was intubated, as he remained unconscious.

1. Describe this post return to spontaneous circulation ECG: Answer: There is an underlying sinus rhythm with normal axis. The QRS complexes are high voltage with markedly prolonged QT intervals. There is a broad complex (~120 msec) QRS occurring on every second T wave.This is consistent with bigeminal ventricular premature contractions with recurrent R-on-T phenomenon.

2. He arrested again with ECG as shown.

What would you do?Answer: Revert to sinus rhythm following 200J biphasic defibrillation.

However, the ECG monitor showed that he soon returned to the rhythm shown in his post-intubation ECG.

3. Post intubation arterial blood gas was performed

What further management is necessary?Answer: Correction of moderate hypokalemia (1.5 – 3.5 mmol/L) with potassium and administration of magnesium for impending torsades de pointes.

4. The ECG was done again after K supplement.

Describe the ECG:Answer: Atrial fibrillation (irregularly irregular with absent P waves) with a heart rate of ~ 100/min.Normal axisQRS complexes meets voltage criteria for left ventricular hypertrophy(Sokolow and Lyon criteria: S(V1) + R(V5 or V6) > 35 mm; Framingham criteria: S(V1 or V2) + R(V5 or V6) > 35 mm)Prolonged QT interval (QTc ~500)ST depression (up to 2-3 mm) predominantly in anterolateral leads (I,II, aVL and V3-V6)Widespread biphasic T waves

5. What is your primary diagnosis?Answer:

a. Post cardiac arrest with ROSCb. Torsade de pointes due to hypokalemiac. LVH

6. What can be causes of LVH in this patient?Answer:

a. Long standing hypertensionb. Hypertrophic cardiomyopathy

7. What is the most appropriate management in this patient to gain neurological function?Answer: Therapeutic hypothermia