Embed Size (px)
Citation preview
UNIVERSITYHOSPITAL,GEELONG
FELLOWSHIPWRITTENEXAMINATIONWEEK19–TRIALSHORTANSWERQUESTIONSSuggestedanswersPLEASELETTOMKNOWOFANYERRORS/OTHEROPTIONSFORANSWERSPleasedonotsimplychangethisdocument-itisnotthemastercopy!
Question1(18marks)A10yearoldgirlpresentstotheemergencydepartmentafterafallfromthemonkeybarsafterschoolandcomplainsofapainfulelbow.
a. Statefour(4)abnormalitiesshowninthisx-ray.(4marks)
• Posteriordislocationelbow-MANDATORY• Radialhead#-completedisplacement-SH1-MANDATORY• Medialepicondylefracture-MANDATORY(Youshouldnotseethemedialepicondyleona
truelateral/commonassociationwithposteriorelbowdislocation)• Posteriorfatpad(subtle)• Softtissueswelling
Afterfullassessment,thegirlisconfirmedtohavethisisolatedinjury.Sheisfasted.Shehasreceivednoprehospitaltreatment.ShedoesnotcurrentlyhaveIVaccess.
b. Listfive(5)techniquesforanalgesiainthefirst20minutesofthispresentation.(5marks)
• Immobiliseinsling• Distraction-TV/Ipad• N20• I/Nfentanyl1-1.5mcg/kg• IMketamine-1-2mg/kg/IV-5-10mgaliquots• IV(otherarm)morphine0.1mg/kgbolusfollowedby1mgaliquots
c. Listfour(4)indicationsforcorrectivetreatmentintheemergencydepartment.(4marks) (OTispreferredgivencoexistingradialheadandmedialepicondyle)• Ncompromise• Acompromise• Ongoingseverepain• Significantdelaytotheatre
Anindicationforurgentcorrectivetreatmentexists.You attempt cannulation and fail 3 attempts. The patient’s mother becomes very distressed andrequests no further attempts at cannulation. She is verbally aggressive towards you. Correctivetreatmentisstillrequiredsemiurgently.Statefive(5)pointstodemonstratehowyouwouldhandlethissituation.(5marks)(NB:correctiveRxstillrequired)
• Attemptverbalde-escalationincludingApologise/empathise• (Ifunabletobedeescalated,considerutilisingotherseniorstafftoassist/removeself)• Explainconsequencesofdelayedreduction-aimingforbestoutcomeforthechild• ExplainthatIVwillberequiredeventually• Provideoptionstomother-egIVplacementafterIMketamine/Nitrous/gaseousinduction• UseoptionmutuallyagreedonaboveegfacilitatetransfertoOT
“List”=1-3words“State”=shortstatement/phrase/clause
2
Question2(14marks)A24yearoldwomanwhoispregnantpresentswithpervaginalbleeding.a. Completethetablelistingthesuspectedfindingsatthestatedstageofpregnancy.(6marks)
Stageofpregnancy QuantativeΒHCG Transvagainalultrasound
Transabdominalultrasound
<4weeks<1000 - -
5weeks>(1000-)1500 Gestationalsac -
6weeks5000-20000 Foetalpole Sac+/-pole
7weeks>(15000)20000 Foetalheart/cardiac
activityPole+/-heartactivity
NB:thereissignificantvariabilityinreality-butapproximatenumbersshouldbeknownb. Statethree(3)specificfindingsonultrasoundthatdefineafailureofpregnancy.(3marks)(NBnotjust“blightedovum”withoutqualificationwhatthefindingsareonUS)
• Sac>10-12mmwithoutayolksac• Sac>(18-)25mmandnofoetalpole• FoetalpoleorCRL≥7mmandnocardiacactivity
3
Question3(12marks)A65yearoldmalepresentswith4daysofscrotalpain.
a. Whatisthediagnosis?(1mark)• Fournier’sgangrene• (testicularabscess)
b. Statethesignificanceofthiscondition?Statethree(3)pointsofsignificance.(3marks)• Aggressiveinfection• Anaerobicandaerobicbugs• Usuallysecondarytoperirectaldiseaseorminortrauma• NeedsaggressiveRx• Mortalityhigh(40%)
c. Listtwo(2)riskfactorsforthedevelopmentofthiscondition?Statetwo(2)pointsofsignificance.(2
marks)• Obesity• Immunocompromise:
o DMo Alcoholismo Chronicsteroiduse
Analgesiaisprovided.Dispositionisarranged.d. Listtwo(2)keytreatmentstepsthatyouwouldinstituteinthefirst20minutesofyourcare.Provide
one(1)justificationforeachchoice.(4marks)
Managementtask Justification
Fluidresus Aggressive
IVabs Broadspectrum-meropenum+clindamycin+vancomycin
BSLstabilisation Maximisewoundhealing
Reduceadditionalsystemiccomplicationsofhyperglycaemia
e. Listtwo(2)treatmentmethodsthatareutilisedfordefinitivetreatment.(2marks)• Sx-early,aggressivedebridement• Hyperbaricoxygen-adjuncttodebridement(iepost)
4
Question4(12marks)
A25yearoldmanisintubatedfordecreasedconsciousstatefollowingapolydrugoverdose.Thepatientremainsinyouremergencydepartmentovernight.Followingyourwardroundinthemorningyouassessthepatientasbeingsuitableforextubation.
a. Listfour(4)patientfactorsthatarerequiredtoallowsafeextubationofthispatient.(8marks)
Patientfactor(4marks)
Howwouldyouensureadequacyofeachfactor(4marks)
Adequatespontaneousventilation
• TV• ETCO2• ABG• NoCXR/chestfindings
Adequateoxygenation
• ABG-PaO2>60onFiO2<40%• Lowoxygenrequirement•
Cardiacstability • Stablerhythm• Stableobs• Vasopressors-absentorlowdose• QRSwithinnormallimits
Adequateconsciousstate • sustainedeyeopeningtoverbalcommands• Nocontinuoussedative
Adequatestrength/NMblockadewornoff
• Canliftheadoffpillow• Raisearmsfor15sec• Claphands
Acid/basestate • Nosignificantacidosis
Yousuccessfullyperformextubation.
b. Listfour(4)stepsinyourpost-extubationcareofthispatient.(4marks)• Resuctionoropharynx• Assessadequacyofventilation• LorRlateralposition• Supplementaloxygenation• Donotleavepatientuntiladequateventilationconfirmed
5
Question5(11marks)
A75yearoldmanpresentsfollowingacollapse.
a. Statefive(5)abnormalitiesshowninthisECG.(5marks)
• Failuretocapture• Sinusbrady45bpm• STDinnormalimpulsesinII• TWIinnormalimpulsesinII• 2nddegreeHBwith2:1conduction(NB:Notfailuretosenseorfailuretopace)
b. Listsix(6)possiblecausesforthisECGproblem.(6marks)• electrodetipoutofposition• pacemakervoltagetooloworbatterydead• leadwirebroken• oedemaorscartissueatelectrodetip• myocardialperforationbyleadwire• myocardialinfarction/ischaemiaatleadwire• hyperkalaemia
6
Question6(12marks)
A35yearoldmanpresentswithrightsidedfacialswelling24hoursafterbilateralwisdomtoothremoval.
1markforfinding,1markforadequatedescriptionofthesiteoftheabnormality
a. Statetwo(2)abnormalfindingsintheCTscanlabelled1 (2marks)• Extensivesurgicalemphysema• Withinsofttissueplanesbetweenmuscular&vascularstructuresinR>Lsideofneck
b. Statetwo(2)abnormalfindingsintheCTscanlabelled2 (2marks)• Subcutaneoussurgicalemphysema&gas• Anteriorly&lateraltouppertrachea(nocompression)
c. Statetwo(2)abnormalfindingsintheCTscanlabelled3. (2marks)
• Pneumomediastinum• smallamountgasaroundtrachea&anteriortoarchofaorta
d. Listsix(6)possiblecomplicationsofthiscondition.(6marks)
Need2underlinedtoget>2(iemax2/4ifthesearenotbothmentioned)• Pain-2˚tosubcutaneousair&thuspressureontissues• Disfigurement- facial,neckswelling-temporary• Deepseatedinfection- pharyngealabscess
mediastinitis-potentiallylifethreatening→spreadtolungs,heart• Pressure fromsubcutaneousair-airwaycompromise,compressionofmajorairways/aorta,potentiallyheartviapneumopericardium&∴ heartfailure• Gasembolism-unlikelytooccurindelayedsetting
NB:Death-fromthisconditionisveryunlikelyAlsoacceptable:• Lossofincomeforpatientdthospitalisation/convalescentperiod• Hospitalacquiredconditions- pneumonia
DVTfromimmobilisationIVsitephlebitisdrugallergy(eg.Ab’s)
7
ClickontheimagebelowtoviewtheentirePDF(&print/saveifnecessary)
8
Question7(11marks)A74yearoldmanisbroughttoyouremergencydepartmentwith1weekofshortnessofbreathandchestpain.Hisobservationsare:HR 110 /minBP 135/870 mmHgsupineTemperature 38°C
a. Providetwo(2)calculationstohelpyoutointerprettheseresults.Statethesignificanceofeachfinding.(2marks)
• Derivedvalue1:A-agradient=91• Significance:VQmismatchorR-Lshuntexists• Derivedvalue2:ExpectedPCo2=0.9xHCO3+9=0.9x30+9=36• Significance: concomitant respiratory alkalosis exists in addition to metabolic
alkalosis
b. Usingthescenarioandthederivedvalues,definetheprimaryacid/baseabnormality/s.(2marks)• Hypochloraemiac,metabolicalkalosis• Respiratoryalkalosis
c. Listfive(5)likelyunifyingexplanationforthesegasesinthisclinicalcontext.(5marks)
• RaisedAagradient:o Pneumoniao PEo COPD-infectiveexacerbationo Asthmao Pneumothoraxo Boorhaaveso Interstitiallungdisease+infection
• Vomitingo Secondarytosepsiso Secondarytoantibioticso Secondarytocodeine/tramadol/oxycodoneforpain
9
Question8(12marks)
A65yearoldmanpresentswithaheadache.Hehasnotexperiencedtraumapriortotheheadacheonset.Hisobservationsare:HR 90 /minBP 255/150 mmHgsupineTemperature 37°C
a. Otherthanphaechromocytomaandidiopathichypertension, listsix(6) likelyunderlyingcausesforhishypertension. (6marks)
• SOLegtumour• Stroke-ischaemicorSAH• Toxic-egMethamphetamines• SuddenwithdrawalofAntiHT• Renalarterystenosis• Cushings/Connssyndrome• Extremepain/anxiety
Youhaveastrongsuspicionofthediagnosisofphaeochromocytoma.
b. Listyourpreferreddrugregimetotreatthebloodpressureinthissetting(dosesarenotrequired).(3marks)
• IVmorphine• IVphentolamine• +/-nitroprusside• Βblockersonlyafterαblockade
c. Listthree(3)investigationsthatmaybeperformedtoassistinconfirmationofthediagnosisof
phaeochromocytoma.(3marks)• Urinarycatecholamines/metabolites• Plasmafreemetanephrine• (123metaiodobenzlguanidinescan)• CT/MRItolocalisetumour
ThisresourceisproducedfortheuseofUniversityHospital,GeelongEmergencystaffforpreparationfortheEmergencyMedicineFellowshipwrittenexam.Allcarehasbeentakentoensureaccurateanduptodatecontent.Pleasecontactmewithanysuggestions,concernsorquestions.DrTomReade(StaffSpecialist,UniversityHospital,GeelongEmergencyDepartment)Email:[email protected] November2017
10
Question9(18marks)
A35yearoldmanpresentstoyouremergencydepartmentafterahighvoltageelectricalinjury.
a. Statefour(4)featuresofthisphotographthatsuggestasignificantinjury.(4marks)• Fingerinvolvement• Tissueloss-deeptissueinvolvement• Discolourationofburn-white/black-suggestingfullthicknessburn• Mottlingofhand-suggestingthrombosis
b. Listsix(6)systemic/distantcomplicationsfromthepassageofhighcurrentthroughthebody.(6marks)
• Colonicischaemia• Pancreatitis• Boneischaemia• GBitis• Smallbowelischaemia• Vascularspasm&thrombosis• Rhabdomyolysis• Death
c. WhatistheroleofthepresentingECGinhousehold(240V)electricalexposure?State2pointsin
youranswer(2marks)• PatientswithoutECGchangesonpresentationareunlikelytoexperiencelife
threateningarrhythmias• ECGchangesmandatesfurthermonitoring
d. Listsix(6)indicationsforongoingECGmonitoringfollowinganelectricalexposure.(6marks)
• ECGchanges• Documentedarrhythmias• Highvoltage(>1000V)• Lossofconsciousness• Seizure• Previouscardiacdisease(especiallyarrhythmias)• Troponinrise
