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UNIVERSITYHOSPITAL,GEELONG

FELLOWSHIPWRITTENEXAMINATIONWEEK29–TRIALSHORTANSWERQUESTIONSSuggestedanswersPLEASELETTOMKNOWOFANYERRORS/OTHEROPTIONSFORANSWERSPleasedonotsimplychangethisdocument-itisnotthemastercopy!

Question1(18marks)An84yearoldwomanisbroughttoyouremergencydepartmentbyherdaughter,whoishercarer.Herdaughterisfrustratedwithhermotherbecauseshecannotmobilisetoday.Thetriagenurseapproachesyouwithaconcernofpossibleelderabuse.

a. Listfour(4)behavioursthatthecarermaydisplaythatwouldsupporttheconcernofelderabuse.(4marks)• Statedaggressiveverbalisation• Tension/argument/antagonismbetweenpatientandcarer• Signsofunduestress• Inconsistentaccounts• Defensive• Disengaged• Failureofcarertoallowstafftobealonewithpatient• Evidenceofpsychiatricdisorder• Evidenceofintoxication

b. Listfour(4)examinationfeaturesthatwouldsupporttheconcernofelderabuse.(4marks)

• Poorsanitation• Signsoflocaltrauma• Unexplainedbruiseorwelts• Unexplainedfractures• Untreatedphysicalconditions-egpressuresores,infections• Restraintmarksegropemarkstowrists• Brokenspectacles• Weightloss• Dehydration• Malnutrition

Thepatientappearsunwellandfrail.Youmakeaclinicaldiagnosisofleftlowerlobepneumonia.Nopasthistoryisavailable.

Hervitalsigns:BP75/60mmHgHR140bpmRR40bpmTemp39.6°CO2sat86%onroomair

Thepatientfailstorespondtoyourescalationoftreatment.Thedaughtersaysshewants“everythingdone”.c. Listfive(5)factorsthatyouwouldconsiderwhendiscussingthisrequestwiththedaughter.(5marks)

• Pre-statedpatientwishesandautonomy• ClarifypresenceorabsenceofAdvancedHealthDirective(orsimilardocument)oranyenduringpowerof

attorney• DutyofCare-Toidentifyandtreatreversiblepathology,ifreasonablebeliefofadvantagetolifeorQOL• Pre-morbidQOL.• ResultsofCTandothertests• Otherstakeholders-otherNOK,EDnursing,GP,ICUcolleagues• ActuallimitsofMx,andtheirindications.IncludesRxgoalsanddispositiondestination.• Timingofactions• Medicolegal,ethical• Personalbiases

Thedaughterreportsthatthepatientisaregisteredorgandonorandwishestopursuethepossibilityoforgandonation

d. Listfive(5)criteriathatmustbemetfortheconsiderationoforgandonation.(5marks)• Consent• PermissionfromtheCoroner • Age(0-75)• Braindeath(irreversiblelossofbrainfunction)• Maintainedonaventilatorwithintactcirculation• NoPHxofmalignancy(except1°braintumour/minorskinlesions)• Nomajoruntreatedsepsis(Rxsepsismaybeconsidered)• Nomajorbloodborneillnesses(egHIV,HepC)

“List”=1-3words“State”=shortstatement/phrase/clause

Question2(13marks)A35year-oldwomandriverwasinvolvedinamotorvehiclecollision.Shewaswearingaseatbelt,self-extricatedherselfandwasambulantatthescene.Whilegivingdetailstothepolice,shereportedneckpainwhichwasnotpresentforthefirst10minutespostcollision.Shearrivesbyambulanceinsittingpositionwithoutspinalimmobilisation.Arigidcervicalcollarisplacedattriage.Hermaincomplaintisofmoderateseverityneckpain.

a. Listfour(4)featuresonhistoryorexaminationthatwouldmandatetheneedforcervicalspineimaging.(4marks)• Highriskmechanism-rollover,highspeed(>100km/hr)• Neurologicalsymptoms-(paraesthesiainextremities)• Neurologicalsigns• PastHxofneckpathology(eg.Sx,injury,disease-RA,Ankspond)• Alteredconsciousstate(↓GCS,confusion,intoxication)• Associatedinjuries(CHI,distractinginjury)

b. Assumingtheabsenceofallofthesefeatures,listthree(3)lowriskfactorsofthispresentationasstatedthatallow

safeassessmentofrangeofmovementofhercervicalspine.(3marks)NB:“asstated”-mechanism/tenderness/alertness/intoxicationarenotstated

• Ambulantatthescene• Delayedonsetofneckpain• SittingintheED

_____/5

c. Adecisionismadetoprogresstoimaging.Stateone(1)importantproandoneimportantconfortheimagingoptionsbelow.(6marks)

NB:Useaclinicallyrelevantpro/conthatanswersthequestion-whywouldwechoose/notchooseaparticulartest?NotCost/ease/easytointerpret

Imagingoption

Pros Cons

Plainxrayseries

• Identifiesmostmajorabnormalities• Likelytogetadequateimagesinyoungpatient• Canbeusedincombinationwithclinical

examinationtosafelyclearC-spine• Canbeperformedintraumabay• LessradiationthatCT(butstillsignificant

radiation)

• Maymisssubtleinjuries• Filmsmaybeinadequate• Imagesmaybedifficulttointerpret• IffilmsnormalbutinadequateROMthenCT

orMRIIrequired

CTCSpine

• Sensitiveforbonyinjury+accurate• Imagesother(nonbony)structuresinneck• RadiationequivalencetoC-spineseriesiflow

doseprotocolused• Difficultbodyhabitus• Pre-existingC-spinepathology

• Radiationtothyroid/breast/pregnancy• Doesnotexcludecertainpathologye.g.

ligamentousinjury,discpathology,epiduralhaematoma,orcordcontusion

• TransfergenerallyrequiredfromED• Requiresspecialistinterpretation

MRICspine

• Accuratelyidentifiesacutespinalcordpathologyrequiringintervention-disclesion/epiduralhaematoma+otherpathologye.g.cordcontusion,ligamentousinjury.

• Noradiation

• Lesssensitiveatdelineatingbonyinjuries• Time(duration)• Patientfactors.E.g.Claustrophobia.• ContraindicationsrelatedtometalFBetc.• Requiresspecialistinterpretation• Availability(otheranswersbetter)

Question3(13marks)

A16yearoldgirlpresentstotheemergencydepartmentwithlowerabdominaldiscomfortandpervaginalbleedingof24hourduration.Shethinksthatshemaybepregnantonthebasisofonemissedperiod(LNMP6weeksago).

a. Completethetablebelow,demonstrating,inlistformat,yourunderstandingoftheroleofaurinepregnancytestinthispatient.(4marks)

Significanceofapositiveresult • Likelytruepositive

• Lowfalse+verate• Willneedquantitativetoassessgestation&forF/U

Significanceofanegativeresult • Rulesoutpregnancyin97%• LNMP6weeks-expect+veresultifpregnant• False-ve:

- Poorlyperformed/notwaitedlongenough- Diluteurine- Stripsoutofdate- Striperror

Herurinarypregnancytestispositive.

b. Listtwo(2)circumstancesinwhichavaginalspeculumexaminationwouldbeindicatedforthispatient.(2marks)

• Heavybleeding>NMP(suggestingCxproducts)• Trauma• Rape/unconsentedpenetrationforforensicexamination• Knownvaginalpathology• Remote/noO+Gserviceonsite

Atransvaginalultrasoundshowsanormal6weekintrauterinepregnancy.Thepatientstatesthatshedoesnotwishtocontinueherpregnancy.

c. Listthree(3)factorsonhistorythatyouwouldseekfromthepatientwithrespecttothisstatement.(3marks)

• Assessmentofcompetency• Reasoning• Understanding• Socialsupports• ?independent/dependant• PriorSTOP/pregnancies• Comorbiditiesincludingsignificantmedicalorpsychiatric

Thepatient’sparentsarriveanddemandtoknowwhatiswrongwithher.

d. Listfour(4)stepsthatyouwouldtakeinresponsetothisrequest.(4marks)• Reassureparents• Assesscompetency• Respectprivacyifcompetent• Explaintoptimportanceoftellingparents• Encouragepttodisclose• Disclose-ifpatientisnotcompetent• Bearinmindthepossibilityofsexualassault

Question4(12marks)

An18monthboypresentswith24hoursofvomitingandbloodydiarrhoea.

a. OtherthanHaemolyticuraemicsyndrome,listfour(4)likelycausesforthispresentation.(4marks)

NB:Analcausesinc.fissurelesslikelygivenassociatedvomiting-needtothinkofothers• InfectiveGastro(egSalmonella)• Cow'smilk/soyprotein-inducedcolitis• Meckel'sdiverticulitis(needstobeitis,ratherthanjust..um)• Intussusception• Henoch-Schönleinpurpure• Ironingestion• Volvulus• Haemophilia• Inflammatoryboweldisease

b. Listfour(4)featuresonexaminationthatwouldsupportthediagnosisofhaemolyticuraemic

syndrome.(4marks)• Pallor• Haematuria• Hypertension(50%)• Encephalopathy• Seizures(40%)• Hepatosplenomegaly• Peritonealsigns• Ileus• Associatedpneumococcaldisease(as1°problemwith2°HUS )

c. Listfour(4)laboratoryfindingsthatareconsistentwithhaemolyticuraemicsyndrome.(4

marks)• AKI-UreaandCreatinineelevated• Anaemia• Elevatedreticulocytecount• Decreasedhaptoglobinlevel• Haemolysis(fragmentedbloodcells)onbloodfilm• WBCs:Leftshift• PositiveCoombsTest• Thrombocytopaenia• FDPselevatedbutAPPT,PTnormal• Bilirubin,ALT/AST/LDHelevated• Urinemicro-haematuria/proteinuria/dysmorphicRBCs/casts

Question5(12marks)A64year-oldmanpresentstoyourEmergencyDepartmentwithchestpain.ECG1 PreviousrestingECG ECG2 CurrentECGwithpain.

a. Statefive(5)abnormalfindingsinECG1.(5marks)

• Sinusbrady-rate~40• PoorRwaveprogression• LBBB• BiphasicTwavesI,aVL5-6• TwavesinvertedaVL

b. Statetwo(2)differentabnormalfindingsECG2.(2marks)

• STEI1mm,aVL2mm,V2-V44mmV51mm• STEI,aVLV5concordanttoQRS• STEV2-V4>25%ofprecedingSwave • STDII,III,aVF,V6• STDIII,aVf>1mmconcordanttoQRSvector

c. StatethesignificanceofthechangesinECG2,whencomparedtoECG1.Includereferencetoevidencebasedcriteriainyour

answer.Includefive(5)statementsinyouranswer.(5marks) • Changessuggestacuteischaemia-STEMI• Givenchestpain,isanindicationforurgentCardiologyRV/reperfusiontherapy • ConcordantSTE1mminI,V5,aVL-+ve• DiscordantSTE>5mminV2,V3,V4• ConcordantSTD2mminIII,aVF• ModifiedSgarbossaCriteria:

≥1leadwith≥1mmofconcordantSTelevation≥1leadofV1-V3with≥1mmofconcordantSTdepression≥1leadanywherewith≥1mmSTEandproportionallyexcessivediscordantSTE,asdefinedby≥25%ofthedepthoftheprecedingS-wave

Background:- Inpatientswithleftbundlebranchblock(LBBB)orventricularpacedrhythm,infarctdiagnosisbasedontheECGisdifficult- ThebaselineSTsegmentsandTwavestendtobeshiftedinadiscordantdirection(“appropriatediscordance”),whichcanmaskor

mimicacutemyocardialinfarction.- However,serialECGsmayshowdynamicSTsegmentchangesduringischemia.- AnewLBBBisalwayspathologicalandcanbeasignofmyocardialinfarction.

ModifiedSgarbossacriteriahavebeencreatedtoimprovediagnosticaccuracyoftheOriginalSgarbossacriteria.Themostimportantchangeisthemodificationoftheruleforexcessivediscordance.Theuseofa5mmcutoffforexcessivediscordancewasarbitraryandnon-specific—forexample,patientswithLBBBandlargevoltageswillcommonlyhaveSTdeviations>5mmintheabsenceofischaemia.ThemodifiedruleispositiveforSTEMIifthereisdiscordantSTelevationwithamplitude>25%ofthedepthoftheprecedingS-wave

OriginalSgarbossacriteria(GUSTO-1)1996NEJM• 131of26,003ptwithMI

STEof≥1mminthesamedirectionofQRS(concordant)-score5STDof≥1mminanyleadfromV1-3-score3STEof≥5mmdiscordantwithQRS(iewithQSorrS)-score2score≥3givesspecificityof90%butpoorsensitivity∴presencehighlylikelyMI,absencehaslittlevalue

Followlinkbelowformoreexplanation:

http://rebelem.com/modified-sgarbossa-criteria-ready-primetime/

Question6(12marks)

A3yearoldmalepresentswithshortnessofbreath.

a. Whatisthediagnosis?(1mark)

• LLLPneumonia

b. Listfive(5)radiologicalfeaturesthatsupportthisdiagnosis.(5marks)• PatchychangesLbase• ↓volumeLhemithorax• ↓ribspacingonL• Lhemidiaphragmnotclear• ScoliosistoR

c. Listsix(6)factorsthatyouwouldconsiderwhendeterminingdispositionforthispatient.(6marks)

• Oxygenation(sats>92%)MANDATORY• WorkofbreathingMANDATORY• Hydrationstatus• Consciousstate• Previouspoorresponsetooralantibiotics• Comorbidities-aspasthma/CF• Prematurity• Distancefromhospital• Parentalunderstanding/copingstrategies

ThisresourceisproducedfortheuseofUniversityHospital,GeelongEmergencystaffforpreparationfortheEmergencyMedicineFellowshipwrittenexam.Allcarehasbeentakentoensureaccurateanduptodatecontent.Pleasecontactmewithanysuggestions,concernsorquestions.DrTomReade(StaffSpecialist,UniversityHospital,GeelongEmergencyDepartment)Email:tomre@barwonhealth.org.au April2018

Question7(12marks)A23yearoldmanwithadecreasedlevelofconsciousnessisbeingassessedinyourED.Hisarterialbloodgasresults:

a. Providefour(4)calculationstohelpyoutointerprettheseresults.(4marks)

• Derivedvalue1:o AG=Na-(Cl-HCO3)=140-(105+2)=33=high

• Derivedvalue2:o DeltaGap=Measuredaniongap–Normalaniongap=(AG–12)=33-12=21=1

Deltadel Normal[HCO3-]–Measured[HCO3-](24-[HCO3-])24-222 =pureaniongapacidosis

• Derivedvalue3:o CalculatedOsmolarity=(2x[Na+])+[glucose]+[urea]=280+5+5=290

• Derivedvalue4:o Osmolargap=Osmolality(measured)-Osmolality(calculated)=360-290=70=high

osmolargap (Normal<10) b. Usingthisscenarioandthederivedvalues,listthree(3)likelypotentialcausesforthe

abnormalresults.(3marks)• Alcoholicketoacidosis• MethanolOD• EthyleneglycolOD

c. Listtwo(2)prosandthree(3)consfortheuseofbicarbonateinthispatient.(5marks)

Pros:• Severeacidosismaycausecardiacdysrhythmias• Severeacidosisdecreasescardiaccontractility

Cons:• Noevidencebasetosupport-conflictingstudiesofriskvsbenefit• ParidoxicallyincreasesCNSacidosis• Leadstohyypernatraemia• Leadstohypokalaemia• ShiftstheO2dissociationcurvetotheleft-causesrelativetissuehypoxia• Hyperosmolality

Question8(13marks)a. Completethetablebelow,bystatingone(1)expecteddose-dependentclinicaleffectfor

eachdoserangeofVenlafaxineoverdose.Statealsoone(1)managementofvenlafaxineoverdoseforeachdoserangeupuntil>7grams-forthisdoserangestatethree(3)managementsteps.(10marks)

b. Listthree(3)criteriathatmustbemetinapatientwithavenlafaxineoverdosefortheuseof

activatedcharcoal.(3marks)• >4.5g• <2/24• Alert• if>7gmustbeafterETT

Dose Clinicaleffects Managementindicated

<1.5g

• Nil• Dysphoria• Mydriasis• Sweating• Tremor• Clonus• Tachycardia• HTanyofabovesuggestseizureimminent

• Nilorbenzos

>3g• Seizurerisk>30% • Observe

• Bzifsignsofpre-seizure

>4.5g

• Seizureriskapproaches100%• Hypotension• QRSorQTprolongation

• BZ

>7g

• Hypotension• Hyperthermia• Cardiacdysthrythmias

• EarlyETT• Hyperventilation• NaHCO3• IVfluids• BZ

Question9(18marks)Youhavejustcommencedyourmorningshiftintheemergencydepartment.Anurseasksyoutocomeandseea50yearoldmalepatientattherequestofoneofthenightregistrarswhoishavingdifficultyplacingacentralvenousline.ThepatientrequiresintravenousaccessforseverecellulitisthathasbeenresistanttooralantibioticsandtheregistrarwasunabletoobtainperipheralIVaccess.Onyourarrival,theregistrarnotesthathewasonlypartiallyabletoinsertarightinternaljugularcatheterandhas“lost”thewireinthepatient.Achestxraythathehasperformedconfirmsthattheguide-wireisintheSVCandrightatrium.

a. Listthefive(5)elementsofopendisclosure.(5marks)• Anapologyorexpressionofregret• Afactualexplanationofwhathappened• Anopportunityforthepatient/theirfamilytorelatetheirexperience• Adiscussionofthepotentialconsequencesoftheadverseevent• Anexplanationofthestepsbeingtakentomanagetheadverseeventandprevent

recurrencesb. Listsix(6)KEYmanagementstepsforthissituation.(6marks)

• Closemonitoring• PlaceperipheralIVaccessutilisingultrasound• Arrangeremovalofthecatheter-vascular/cardiothoracic/interventionalradiology• Admissiontoamonitoredarea• Supportthetrainee-seekinformation,suggestnotifyingmedicaldefence• Clinicaldebrief-atthetimeanddistanttimetoreview• Incidentreport• Thoroughdocumentation• Notifyhospitallegal/riskmanagement• (ReviewEDprocedures-supervision,credentialing)

c. Listthree(3)stepsthatcouldbeusedtodeterminethataregistrarissafetoperforma

centralvenouslineunsupervised.(3marks)(NB:notsimply“see1,do1,teach1”)Competencypackagecompeted-shouldinclude:

• Receivedappropriatetraining-abletodiscussallaspectsoftheprocedure• Observedtheprocedure-anumberoftimes,includinginstruction• Performedtheproceduresupervisedanumberoftimes-demonstratedappropriate

competence,actualnumberdependsonprowess,confidence,showingappropriatecare

d. Listfour(4)limitationsthatcouldbeplacedontheinitialperformanceofunsupervisedinsertionofacentralvenousline.(4marks)

• Competencepackagecompleted-theabovecriteriamet• Inconsultation-indirectlysupervised• Selectedpatientswithcorrectindication• Notlikelytobedifficult• Assistanceavailable