Saq questions from demt discussion Group: November 2014 Note

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d. A senior nurse complains to you that one of the junior doctors involved in this case has been caught stealing a box of ciprofloxacin. A formal incident report has been filed and the nurse wants you to “deal with the JMO”. The doctor says he only wanted to take some as prophylaxis against possible meningococcus.

What key principles should you consider in your discussion with the JMO?



  • Non-judgemental, non-confrontational, confidential, document discussion.

  • “Stealing” drugs is potentially serious – disciplinary/employment ramifications

  • Doctor needs counselling - ?apology etc

  • Concern about infection not entirely unreasonable though prophylaxis only indictaed if meningococcus confirmed & close exposure (e.g. suctioning, intubation)




63. A 24 year old women who is 10 weeks pregnant presents with suspected pulmonary embolus.
a. List five clinical features that would increase her likelihood of having PE. (5 marks)
utilise Well's criteria - 5 of clinical evidence DVT, alternative dx less likely Cf PE, tachycardia, immobilisation/surgery - recent/within 4/52, haemoptysis, active Ca
b. Describe the utility of the following investigations in this patient. (5 marks)





Investigation

Utility

1

D Dimer

Can effectively exclude PE in low risk patients however more false positives in normal pregnancy (rises with gestation)

2

CXR

May provide alternative diagnosis - pneumonia, LVF

3

Lower limb US

If positive can avoid CTPA/VQ and radiation risks; negative scan cannot exclude PE


4

CTPA

High rates of nondiagnostic studies in pregnancy (35%) Cf. VQ. Increased lifetime risk of breast ca. Comparable radiation. Useful if CXR abnormal/underlying lung disease

5

VQ

First line imaging investigation. Low rates nondiagnostic VQ in pregnancy (4%). Not useful if CXR abnormal.

c. The patient has been diagnosed with pulmonary embolism. What are the ECG changes below? (1 mark)

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TWI V1-4, III, AVF

d. What do the ECG changes suggest? (1 mark)
acute right ventricular strain/right ventricular dilation likely due to massive PE
e. The patient becomes hypotensive. List 4 treatment options (2 marks)
fluids, inotropes, thrombolysis, embolectomy


64. A 30 year old man presents with a left sided spontaneous pneumothorax.
a. What are 3 features to elicit on evaluation that will help determine your management? (3 marks)
primary/secondary (underlying lung disease), symptomatic, size >2cm or >20% depending on guidelines used
b. Give a clinical circumstances in which each of the following would be appropriate. (3 marks)


Management

Clinical circumstances

Observation

Primary, asymptomatic, small pneumothorax

Primary, minimal symptoms, large also acceptable



Aspiration

Primary, symptomatic, large pneumothorax

Secondary, asymptomatic, small pneumothorax



Intercostal catheter/ pneumocath/ pigtail catheter

Secondary and large, secondary and symptomatic

Failed aspiration


c. List 6 complications of intercostal catheters. (3 marks)

Answer (mandatory) - 6 of bleeding/haemothorax, organ injury (mediastinum/liver/spleen/diaphragm), pain, failure to drain (kinking/blockage), infection, scarring, complications procedural sedation, dislodgement



65. A 5 year old girl is brought to the ED, with worsening asthma for the last 4 hours.
a. What are 4 clinical features of life threatening asthma? (4 marks)
Answer (2 of mandatory) - 4 of confusion, coma, exhaustion, poor respiratory effort, silent chest, cyanosis, hypotension
b. On assessment she is unable to speak, has marked use of accessory muscles, RR 60 /min, Pulse rate 160/min and oxygen saturation of 89% on room air.
List your immediate management, including any drug doses. (4 marks)
Ventolin 6 puffs by MDI or nebuliser Q20min x3 then review, Ipratropium bromide 4 puffs Q20 min, Prednisolone 1mg/kg (methylpred/hydrocort alternatives)
c. Despite appropriate escalation of management the patient's condition deteriorates over several hours and they are intubated in the ED. Give ventilation settings and justify. (6 marks)


Parameter

Setting

Justify

Respiratory Rate

<10/min

Normal RR in 5y 20-30, answer should be less than this to allow time for expiration

Tidal volume

5-7ml/kg

Decreases barotrauma


Peak inspiratory pressure

35-50cmH20

Necessary to overcome high airway pressures

PEEP

0-5cm H20

Patient has high intrinsic PEEP - low extrinsic PEEP prevents gas trapping

I:E ratio

1:4-8

Allows time for expiration

d. After connecting to the ventilator the patient suddenly deteriorates becoming progressively hypotensive and tachycardic. Give three possible causes. (3 marks)


Answer (mandatory)- dynamic hyperinflation/gas trapping, tension pneumothorax, effect of induction agents, other (hypovolaemia, equipment failure - tube dislodgement/O2 not connected)
e. What is your first step in management? (1 mark)
disconnect the patient from the ventilator/hand ventilate


66. A 42-year-old man is brought to your ED by ambulance with acute confusion. His wife states that he is previously well and on no medications, but his health has been deteriorating for three months, with tiredness and 10kg weight loss despite an enormous appetite. She also states that, on the bright side, he has become completely impervious to the cold and the extra money they’ve spent on groceries has been saved on heating bills.
Observations are:

A intact

B RR 40 /min, sats 100%, chest clear

C HR 140 /min, BP 180/100 mmHg, CR 2 sec

D E4(staring & bulging), V4 (agitated & aggressive), M5 (localising to pain), no focal neurology

E Temp 38.5°C, BSL 10, vomiting, no rash or other signs

a. What is your provisional and differential diagnosis for this man’s clinical picture? (3 marks)

Provisional diagnosis:
Differential diagnosis:


  • Most likely thyroid storm

  • But also other causes of confusion & high temperature e.g.

    • Infection (meningoencephalitis, sepsis of any source)

    • Too much drug: e.g. salicylates, TCAs, anticholinergics, amphetamine/cocaine,

    • Too little drug: e.g. withdrawal of etoh/benzos, heat stroke, phaeochromocytoma)

b. What conditions may precipitate this clinical picture? (2 marks)




  • Nasty precipitants eg acute MI, sepsis, trauma, IV contrast

  • UnderDx/Rx TTX esp Graves

  • Also XS thyroxine or too little antithyorid Rx

c. How will you treat him in the ED? (5 marks)




  • Address ABC/ good supportive care, esp:

    • O2 & IV fluids, because high risk of dehydration & cardiovascular collapse

    • Sedation eg benzodiazepine

  • Get help: from endocrinologists, and needs ICU

  • Investigations:

    • Endocrine blood tests esp TFT

    • Seek and treat nasty DDx and nasty precipitants e.g. sepsis, ingestion, MI

  • Specific ED Rx of thyroid storm:

    • IV B-blocker

    • Hydrocortisone 100mg IV

    • Carbimazole load PO/NGT (exact dose I’d look up) then after 4h add Lugols iodine drops)


67. A 40-year-old female has been brought in following increasing confusion and agitation at home this morning. She has had no other symptoms. She is day 3 after normal vaginal delivery of a healthy baby at another hospital, but her antenatal history is unknown.
Ambulance officers report a generalised tonic-clonic seizure in the ambulance which required 5mg IV midazolam to terminate, followed by ongoing drowsiness and confusion. On arrival in the ED she begins to seize. ED staff and ambulance officers activate the ‘arrest call’ button and transfer her to the Resuscitation Room.
When you arrive she is being nursed on a bed and a provisional trainee is supporting her airway with jaw thrust. Her intravenous cannula has tissued.
On examination:

Airway: snoring / partly obstructed

RR 40 /min

O2 saturations 95%

HR 130 /min

BP 180/100 mmHg

Generalised tonic-clonic seizure

Afebrile
a. List the causes of seizure you would consider in this patient. (4 marks)




    • Eclampsia – timing unusual because post-partum but still likely

    • Cerebral venous sinus thrombosis

    • Meningoencephalitis e.g. post-epidural

    • Hypoxia e.g. due to pulmonary embolus

    • Plus at least one not directly related to pregnancy / delivery: e.g., hypoglycaemia, toxic ingestion, structural intracranial e.g. bleed, epilepsy

b. What is your initial management? (4 marks)


  • Form a team and assign roles


  • Address ABCs esp airway: simple adjuncts initially eg suction, NPA and lie on side

    • Breathing: high flow O2 and nasal CO2 monitor

    • Circulation: IV/IO access and send bloods / bedside BSL

  • Stop the fit: 2nd step of classic status epilepticus regime: Midazolam IV/IO/IM 5mg

  • Seek and treat a cause from the list above, esp eclampsia (see drugs in Q3)

  • Get help:

    • Obstetrics, renal / neurology, ICU

c. If you suspect eclampsia, what initial drugs/ dose/route/rate would you administer? (2 marks)




  • Magnesium sulphate: officially 4G IV over 30 mins is RNS OG policy, but it comes in 10mmol amps. Closest is 20mmol (=5G). Safe enough to give over 20 mins provided you dilute it and watch the BP. Followed by IV infusion.

  • Hydralazine: 5mg IV over 10 mins, can repeat.




68. You are the director of a tertiary ED which is a level one trauma centre. Recently the directors of trauma and haematology have both written to you regarding your department’s haphazard use of blood products in the severely injured. You search your intranet and realise that you do not have a policy.
a. What are 3 triggers for massive transfusion? (3 marks)

Massive Haemorrhage with shock or anaemia, ie Immediate need for uncrossmatched blood due to rapid haemorrhage and anaemia

Blood loss exceeding 150 mL/min

Need for at least 4 RBC units in the setting of uncontrolled bleeding

Replacement of 50% of total blood volume within 3 hours (pprox.. 35mL/kg in an adult)

Coagulopathy in the setting of blood transfusion

b. Name 4 physiological or biochemical parameters that should be measured early and often. (2 marks)
• Temperature;

• Acid–Base Status;

• Ionised Calcium;

• Haemoglobin;

• Platelet Count;

• PT/INR;

• APTT; and

• Fibrinogen Level.


c. What is the indication for Cryoprecipitate delivery? (2 marks)
Cryoprecipitate is used primarily as a source of fibrinogen (but also contains FVIII, VWF and FXIII). This is found in adequate amounts in FFP, and in dilutional coagulopathy FFP alone may be adequate. Coexisting DIC may increase fibrinogen requirements. Empirical use is unnecessary. Use should be guided by fibrinogen determinations.
d. What are the targets for Hb, Platelets and INR in massive transfusion? (3 marks)
Hb>80g/L;

Platelets >50x109/L; and

PT and APTT<1.5 x control.


69. A 14 month old girl presents via ambulance to your tertiary ED. She was eating a sausage when she appeared to choke and turn blue. Parental back blows were given.
On arrival the child is drooling, has mild respiratory distress, is upset and has Sats of 96% on 6L 02, a RR of 34 /min and a mild stridor.
A neck x-ray has been done and is shown below.

a. What is the major abnormality on the neck x-ray? (2 marks)
Large radio opaque FB (Snag) in allecular and partially occluding upper airway

b. List and justify 3 options to managing her airway issue. (6 marks)

1. Straight to OT with ENT/paeds anaes: has airway now, prob safest, could go bad on way up to OT, may not be possible if in small place

2. ED RSI : if loses airway needs first aid (back blows) then direct laryngoscopy with magills for FB removal; should be achievable in all EDs (backup Cric)

3. Delayed RSI/sedation in ED after getting help down to ED (eg anes/ENT etc). Good approach if remains stable, issues with OT etc etc
c. What are 2 ways an unwitnessed bronchial foreign body aspiration may present in children. (2 marks)
present with persistent or recurrent cough, wheezing, persistent or recurrent pneumonia, lung abscess, focal bronchiectasis, or hemoptysis


70. A 27 year old woman is brought in by housemates to your tertiary ED. She had been not seen for 2 days and was found beside her bed slumped on the floor.
Her observations are:

GCS 13


P 128 /min

BP 95/50 mmHg

T 34.7 °C
a. What are the 3 most important abnormalities on the UELFT? (3 marks)

Renal failure, rhabdomyloysis , hepatitis (?ischaemic)

Sodium 136 mmol/L 137-145

Potassium 4.0 mmol/L 3.2-5.0

Chloride 92 mmol/L 98-111

Bicarbonate 23 mmol/L 22-31

Urea 23.2 mmol/L 2.5-7.5

Creatinine 424 μmol/L 60-110

Est. of GFR 15 mls/min >90

Glucose 3.6 mmol/L 3.5-5.5

Osmol-calc 292 mmol/L 280-300

Bili Tot. 10 umol/L 2-20

ALT 720 U/L <55

AST 15 U/L 5-50

ALKP 89 U/L 20-110

GGT 23 U/L 15-73
CK >103000 U/L 20-200

CRP 1.2 <10


b. List the principles of your fluid management. (4 marks)
ivf crystalloid eg NS, bolus to make restore BP systolic >100 then aim euvolaemic clinically. And then use iDC to guide UO , Aim at least 100ml/hr urine ; consider frusemide/alkalisation to achieve this for rhabdo. Watch for signs volume overload
c. List 6 differential diagnoses. (3 marks)
drug overdose; head injury; hypoglycaemia, seizure, attempted suicide (eg asphyxiation), exac established underlying renal disease; sepsis; SAH ; ethanol abuse


71. A 58 year old man with a PPM presents to your rural ED with palpitations intermittently for 8 hours.
His observations are:

P 60 /min

BP 123/54 mmHg

Sats 96 % RA

GCS 15
An ECG is done and is shown below.

a. What is the ECG diagnosis? (2 marks)


Failure to sense (spikes occurring after native QRS during absolute refractory period)
b. List 4 possible causes. (4 marks)

battery weak, lead damage, electrolyte imbalance, myocardial ischaemia; fibrosis at lead tip; dislodgment of lead ; sensitivity needs adjusting

c. Outline the major consideration of arranging his disposition. (4 marks)
Rural hosp ; no immed risk unless begins trying to pace on T wave , then risk VF. Thus

Obtain receiving hosp cardiology advice first

needs TF to centre with PPM facilities

urgency depends on cause (thus initial screen in rural ED )

needs to be escorted by paramedics able to respond if arrhythmia and remain monitored

Depending on location and timing road vs air




72. A 58 year old Chinese Australian woman presents with fatigue. On examination she has a pulse of 95 /min, BP 100/45 mmHg and sats of 98% RA. She is afebrile. She appears deeply jaundiced.
Bloods are done and appear below

FBE. Hb 39

RCC 0.95

MCV 129


Retics 31.58%

WCC 5.4


Neut 4.26

UELFT Na 137

K 3.6

Cl 106


HCO3 17

Urea 4.4

Cr 66

Bili 137



ALT 5

LDH 693


GGT 20

ALP 79
a. Interpret the blood tests and provide a provisional and differential diagnosis. (3 marks)

Autoimmune haemolytic anaemia; any other haemolytic anaemia (RBC disorders; lead poisoning; G6PD etc);,occult GI bleed in cirrhotic;

b. List 3 other pathology tests with a brief justification you would order to help determine the diagnosis. (3 marks)
Blood film (abnormal RBC morphology); retics (raised in HA); Coombs test (+ = immune mediated); haptoglobin (decreased in HA); coags (bleeding diathesis)
c. Briefly outline your management. (4 marks)
Grossly anaemic but HD stable will require transfusion in conjunction with therapy directed at cause

Thus obtain blood for XM

Correct coagulopathy if present

Transfuse PRBC x3 initially . Aim for Hb >70 initially

Wait for full XM, avoid crystalloid, Oneg unless active bleeding

Does not need ‘resuscitation’ unless evidence active bleeding

Rx process eg prednsiolone for AIHA (haematology advice)

Aggressively Mx/Ix if evidence GI bleed: (PPI, octreotide, scopes, CTAs)




73. A 55 year old man comes into ED with a history of gastroenteritis for 4 days.
His ECG is shown below.

a. What is the most important abnormality? (1 mark)


Long QT
b. List 3 important features to obtain from the history of presenting complaint. (2 marks)
Medication history esp macrolides; antipsychotics; antihistamines, antiarrhythmics, antidepressants; diuretics

History of known QTc congen

Comorbid disease contributing eg thyroid dysfunction; IHD, myocarditis renal dis

Extent of GI losses: dehydration etc

Severity of illness: abdo pain, fevr; blood in stool

c. List the most likely cause in this context and then 2 alternate differentials. (2 marks)

Likely hypo K (Mg or Ca); DDx drug use with impaired excretion eg ARF ; medication interaction; overdose; congenital cause; alcoholism (hypoMg);
d. List and justify your immediate management priorities. (5 marks)
At risk for arrhythmia

Monitored bed

IV access urgent VBG

Avoid any meds that prolong QT

Replace volume; monitor progress with UO, thirst, obs

Replace electrolytes via IV infusion eg K+ 10mmol/hr

Symptomatic Rx: antiemesis, analgesia

Have Mg ready




74. A 25 year old man is brought into your regional ED after a bicycle accident. He is not moving his legs and has limited upper limb movement. He has a soft stridor.
His vitals are:

GCS 14


P 62 /min

BP 80/40 mmHg

Sats 95 % 10L O2
A CT neck is done as part of his assessment.

a. Describe the major abnormalities. (3 marks)


Bilateral facet dislocation atC6/7 with posterior displacement by one vertebral width and spinal cord impingement. Large haematoma anterior to C5-T3 causing tracheal and airway compression at subglottic and glottis level
b. Outline your management of his airway and breathing. (7 marks)

Needs airway soon but not NOW.

Potentially difficult ++

MILI and gentle technique mandatory

Careful planning

preO2 as much as possible

Support BP: fluids then pressors as likely neurogenic shock (must have pressor available if not given pre induction). Induction drug must be HD Ok (eg ketamine fentanyl, not big dose props)

Mandatory backup surgical option considered

Options depend on access in institution ; thus OT with fibreoptic/gas; definitie trache primarily with ENT; glidescope in ED with bougie etc. Consider other injuries in decision making



75. You are the director of an urban district ED. Your short stay unit has been suffering with prolonged length of stays and high admission rates.
a. List 5 contributing factors to these issues. (5 marks)
Inappropriate pt selection: ; Lack of senior oversight; lack of clear guidelines for use; use as holding ward for admitted pts; lack of allied health/multidisc input; community support options eg respite NH places etc; ambulance delays ; social factors in ED population; staff training inadequate; nursing support /staffing levels; inpatient team access to admitting power; lack of SOPS for common conditions
b. Outline the key steps in improving the short stay unit’s length of stay and admission rates. (5 marks)
Start with overview of current process; review existing literature; review hospital/obs unit policies as stand; consult major stakeholders then

Clear guidelines for admission; staffed by ED; regular senior review required; senior decision for admit; care plans for common conditions; multidisciplinary input; must keep to accepted standards eg LOS <24 hrs; admission rate less than 10-20% ; audit of performance




76. A 35 year old woman arrives after being brought in by friends due to her altered level of consciousness. Last seen 4 hours ago. They state she has been upset recently and has been commenced on 2 new medicines by her GP. Her GCS is 10, P 130 /min, BP 102/44 mmHg. She is Afebrile.
a. List 4 key ECG features you would look for on initial assessment and justify those. (4 marks)

Wide QRS (Na channel blocking drugs); long QTc (K+ blockers; antidepressants, antipsychotics); R wave positive in avR or deep S in 1 (na channel blockers);; ST-T changes (SAH, ICH); P waves vs AF vs SVT (tachycardic P130); Congenital abnormalities eg Brugada; HCM

b. List 3 key examination findings and relate these to differential diagnoses for her presentation. (3 marks)
Pupil size and reaction: pinpoint; opioids, cholinergics; dilated, amphetamines, anticholinergics; asymmetric (raised ICP)

Chest crackles: unilateral (aspiration); bilateral (aspiration, APO post opioid)

Clonus (serotoninergic drugs

Signs of head trauma/BOS #

Focal neuro abnormality (SAH, ICH, hypoxic BI etc)

Self harms signs (cutting, strangulation) ? suicidal

Ketotic breath, Kussmaul resps (met acidosis , DKA)
c. List 5 key historical features you would ask her friends and justify. (3 marks)
Names of medicines doses , empty packets; Comorbidities particularly diabetes, depression, SCZ, bipolar; prior self harm suicidailty recently; any recent illnesses partic headache, fever; illicit drug use; social supports/family;


77. A 55 year old woman is brought in with a GCS of 7.There is no sign of trauma. There is a history of ethanol abuse. P 105 /min, BP 100/40 mmHg, afebrile, Sats 98 2L NP, RR 34 /min.

a. What is the acid-base abnormality? (1 mark)


Resp alk incomplete metabolic compensation suggesting acute
b. What are the 3 other significant findings? (1 mark)
Hyperchloraemia, anaemia; raised lactate; borderline na and k, mild carboxyHb; negative BE
c. What is the likely diagnosis (with justification) and what are 2 differentials? (3 marks)

GI bleed leading to hepatic encephalopathy: known etoh, resp alk common, low Hb Gi blood common trigger for enceph; DDx: OD eg aspirin; Head injury, stroke; psychogenic

d. Outline your major goals of management. (5 marks)
Requires intubation and ventilation; followed by urgent CTbrain to exclude head injury/CVA; followed by blood transfusion/coagulopathy correction and urgent endoscopy; needs lactulose, avoid large volumes sodium; Start PPI, consider octreotide if known varices.; ceftriaxone Also needs family discussion as very unwell . disposition ICU under gastro


78. A 72 year old man comes in with change in facial appearance and mild headache.

a. What are the key clinical findings from this photo? (2 marks)


R facial droop, Forehead sparing on left
b. What is the likely diagnosis with justification? (2 marks)
Bells palsy as sparing suggests LMN lesion
c. What other findings would you search for on physical exam? (2 marks)
Herpetic lesions (ears, nose, eyes), other focal neuro abnormality particularly multiple other CNs; ticks in ear/folds;
d. Outline your disposition and management plan (4 marks)
Usually home if confirmed bells; give Prednisolone consider valaciclovir if <72hr; needs attention to eye care and advice re taping, lubrication; prognosis advice re likely full recovery but risk of partial or non recovery; GP FU with neurology if persisting or DDX not excluded


79. A 22 year old man presents having taken an overdose 2 hours ago. His family state he may have taken aspirin.

a. What clinical features might the patient have? (4 marks) (any of)


  1. GIT

      1. nausea and vomiting.

      2. There can be significant dehydration, from this as well as increased insensible respiratory losses.

  2. Eighth cranial nerve involvement:

      1. Tinnitus

      2. Deafness

      3. Vertigo

  3. Respiratory:

      1. An ARDS (non-cardiogenic pulmonary edema) type syndrome may occur.

  4. Hyperthermia.

  5. CNS:

      1. Confusion/ altered conscious state.

      2. Seizures

      3. Cerebral oedema with coma and death.

b. State 2 biochemical abnormalities that might be evident. (2 marks)



  • Hypergylcaemia

  • Hypoglycaemia

  • Respiratory alkalosis

  • Mixed respiratory alkalosis and metabolic acidosis

  • Hypokalaemia

c. What are the indications for urinary alkalinisation? (2 marks)



  • Symptomatic poisoning

  • Acid-base abnormalities

  • Serum salicylate levels > 2.2 mmol/L

d. What patients can be discharged? (2 marks)



  • Asymptomatic.

  • Two falling salicylate levels within the therapeutic range, 3 - 4 hours apart.

  • Normal biochemical results, including ABGs.

  • Low risk psychiatric assessment




80. A 60 year old woman presents to ED with the primary complaint of being a ‘funny colour’.

Blood results reveal:

Bilirubin 60 (1-20)

AST 400 (4-45)

ALT 200 (0-45)

GGT 125 (0-60)

Amylase 100 (25-136)

a. What is the predominate pattern of these blood results? (1 mark)
hepatocellular damage/transaminitis
b. What are your 4 most likely differential diagnoses? (4 marks)
infectious – viral hepatitis (A,B,C)

toxins/drugs – paracetamol/alcohol/prescribed medications

tumour – benign, malignant, metastatic

immune – autoimmune, related to systemic illness

?consider haemolysis if unconjugated hyperbilirubinaemia, but transaminitis doesn’t fit this picture, would have to be 2 processes
c. List 5 further investigations you would order in the ED to assist your diagnosis. Briefly justify each one. (5 marks)
FBC – look for haemolysis, bone marrow suppression (alcohol, tumour) (?retics, haemolytic screen) (would want conjugated vs unconjugated bili)

Serology – hepatitis A,B,C

Alcohol/paracetamol level or other drug levels – toxin induced transaminitis

?Albumin/coags – will identify degree of liver failure, chronic picture, won’t point to specific diagnosis

CXR – looking for primary malignancy

Hepatic USS – tumours, cirrhosis, (duct obstruction although not obstructive picture)




81. An 18 year old factory worker is rushed to ED having sustained a chemical burn to his eye. He thinks the chemical had ammonia in it. It is now 20 minutes since the accident.
His eye is pictured here.


a. Describe the picture. (3 marks)

There is marked clouding/opacification of the entire cornea, limbal ischaemia (must note), conjunctival haemorrhage, swelling, inflammation, inflammation of the eyelid tissues. These features are consistent with a significant/severe alkali corneal chemical burn.

(3 marks) – Must include limbal ischaemia or whitening around cornea, conclude a severe or significant alkali burn.
b. What is your immediate management? (4 marks)
1. Copious Irrigation – water, normal saline, continuous, high volume, aim for pH <8 (may say 7.5) on litmus paper.

2. Analgesia – topical amethocaine or equiv, systemic titrated to pain score

(3. Treat associated burns (skin, other eye))

4. Refer Opthalmology given severity of burn


c. Name 3 things you would do to assess this injury, including prognostic indicators. (3 marks)
1.Hx – collateral history, confirm chemical involved – industrial alkali?

2. Exam – slit lamp -assess for limbal ischaemia (prognostic indicator), depth of burn

(pH if not mentioned above, litmus paper)

3. Visual acuity




82. A 74 year old lady presents to ED with a history of being found on the floor at home confused.
Her arterial blood gas is shown below

FI O2 = 6 litres O2


pH 7.29 (7.35 – 7.45)

pO2 80 mmHg (35 – 45)

pCO2 64 mmHg (90 – 100)

Bic 30 mmol/l

Base excess +3
a. What do these blood results indicate? (Interpret these results) (3 marks)

Pt is acidaemic. Acute on chronic respiratory acidosis with partial/incomplete metabolic compensation (for full chronic expect HCO3:pCO2 ratio up 4:10, so PCO2 up by 20, bic should be up by 8 = 32.)

Type 2 respiratory failure as evidenced by raised pCO2 and relative hypoxia on 6 l O2.

(Some people worked out the Aa gradient - ?accuracy on 6l, what is FiO2?.)

(This is an old question, not enough info for SID, etc.)

b. Name 4 conditions you should consider in the differential diagnosis for the woman’s presentation. (4 marks)
1. Acute/infective exacerbation of COPD

2. Central cause - ?1o ICH, TBI due to fall

3. Toxins – opioid or sedative overdose with respiratory depression

4. (?PE – on background COPD) or one of the below

There is a wide differential, eg hypoglycaemia, PE, pneumonia with sepsis, trauma to chest wall – difficult to mark!
c. List your immediate management priorities. (3 marks)
1. Remove high flow O2

Ensure patent/protected airway

2. Manage breathing and respiratory failure - ?bronchodilators, (steroids), n/p O2, BiPAP, aim for O2 sats 90% and aim to reduce hypercarbia, improved respiratory function

C – treat associated or induced hypotension, dehydration, arrhythmias…

3. Treat associated injuries/conditions, eg. spinal immobilisation if appropriate.

(Plenty of management things but focus on the immediate). One suggestion was to consider ceiling of care, goals of care – would mention this before mentioning intubation)




83. A 25 year old previously fit and well man presents to the ED with chest pain following a tackle at rugby.
An ECG is attached.



a. Describe the ECG. (3 marks)

Sinus rhythm, rate 100 bpm, regular

Axis - RAD

pr interval normal

qrs complexes narrow

Large r wave in V1, low voltage and negative complexes V5-6

Not pathognomonic for any particular pathology

b. What are 3 possible causes of the ECG appearance? (3 marks)
Given stem = trauma

1. Pneumothorax

2. Myocardial contusion (not high velocity trauma so less risk)

3. Lead misplacement – unusual axis, V1 and lateral lead appearance, or idiopathic


c. How would you further assess this patient? (4 marks)
Hx – severity of injury and mechanism , previous cardiac hx, prev pneumothorax, previous ECG

Exam – ABC stability (look for tension pneumothorax), tracheal deviation, chest sounds, hypotension, assess for C spine injury, secondary survey

Ix – Trauma series - CXR, C spine xray, (?pelvis), bedside USS for pneumothorax, pericardia effusion

(4 marks) way too much for 4 marks! Must include something from each Hx/exam/Ix, some assessment of severity and Ix for pneumothora




84. A 1 year old presents to your ED with a history of a few days of fever and general unwellness.
A picture of his hand is attached.

a. List 4 differential diagnoses for this patient. (4 marks)
1. Kawasakis disease

2. Staph scalded skin syndrome or toxic shock, can be strep

3. Drug induced – Stevens-Johnsons or similar

4. Consider traumatic burn, neglect, (?NAI), although stem not suggestive


b. List 4 other features you would look for on examination to support your most likely diagnosis. (4 marks)

1.(Elevated temperature?)

2. Lymphadenopathy

3. Conjunctivitis

4. Mucous membrane involvement - Strawberry tongue. lip peeling

5. Polymorphic rash

(4 marks) – any of these acceptable, note the peeling is generally in convalescent so the rash and acute changes may not be present

c. List possible complications of this condition. (2 marks)
vasculitis

coronary artery aneurysms

(2 marks) Tricky is alternative dx given – complications could be seeding infection


85. A 50 year old man presents to ED unable to weight bear on his right leg after falling 4 metres off a ladder.
His x-ray is shown below.


a. Describe the x-ray finding. (2 marks)
Lateral xray of posterior foot, single view. Displaced fracture through the body of the calcaneus with possible further comminution more posteriorly. Bohlers angle is reduced in keeping with the displacement of the posterior portion.
b. List 4 commonly associated injuries or complications of this injury. (4 marks)
1.Axial fractures - # hip, lumbar spine

2. # other calcaneus

3. Compartment syndrome

4. Non-union, malunion and long term disability


c. List your immediate management priorities in this patient. (4 marks)
1. Analgesia

2. elevation and non-weight-bearing, will need backslab

3. Treat other associated injuries, including spinal immobilisation if indicated (may be no. 1?)

4. Consideration of operative management requiring admission under Orthopod

(4 marks) Disposition may not be immediate Mx!


86. A 50 year old woman presents to ED with a 4 days history of malaise, intermittent fever, and the rash depicted here.

a. Describe this rash. (3 marks)

Picture of left hand palmar aspect

Multiple haemorrhagic lesions along the palmar aspects of fingers – appearance of petechiae or purpura, suggestive of septic emboli.

The diagnosis is Janeways lesions, indicative of sub-acute bacterial endocarditis.
b. List 4 important examination findings that would be relevant in this case. (4 marks)
1. Elevated temperature – may be intermittent

2. Cardiac murmur

3. Other septic emboli – Roths spots, Oslers nodes, petechiae

4. Signs cardiac failure – S3, lat apex, pulmonary oedema…


c. Name the 4 most relevant investigations that you would perform in the ED. (4 marks)
Blood cultures

FBC


ESR/CRP, inflammatory markers

?coagulation screen

?Echocardiogram – debate as to whether this is a ED Ix – would preface by saying if signs acute valvular dysfunction or cardiac comprimise


87. A 41 year old man is brought in by ambulance with a one hour history of palpitations associated with chest discomfort. His GCS is 15 and BP 90/60 mmHg.
His ECG is attached.

a. What is the most likely diagnosis? (1 mark)
VT
b. What features on history and ECG are supportive of your diagnosis? (3 marks)

Hx – age over 35

ECG – regular broad complex tachycardia, assume VT as safest approach, see ARC guideline note below

Very high rate 200 bpm

‘Northwest axis’ +ve aVR, neg I, aVF

Brugada’s sign – onset QRS to nadir S >100ms seen in II

Josephson’s sign notching near nadir S wave

Not a RBBB or LBBB pattern

c. Name one algorithm or diagnostic criteria that you use clinically when interpreting an ECG such as this one. (1 mark)
A number of algorithms – Brugadas, ultra-simple Brugadas,….see LITFL VT page, great reference
d. Briefly outline your immediate management priorities. (5 marks)
VT with pulse, unstable patient by AHA criteria (hypotensive, chest pain), treat as per ARC or ILCOR guidelines

1. In resus, attention to airway, breathing, high flow pre-oxygenation

2. IV access for sedation – midazolam, judicious propofol, and volume CSL

3. Reversion strategy – DC shock sync 150 J biphasic, 200J mono (300 acceptable)

Consider chemical reversion while preparing if patient stabilises – amiodarone 300mg IV over 20min, then infusion 900mg over 24hr, or second line if DC CV fails or arrhythmia recurs(not sotalol as hypotensive)

4. Treat cause – ischaemia, toxins (drugs), electrolyte abnormalities, myocarditis, HOCM, treat any complications

5. Supportive cares – volume replacement, optimise electrolytes (K, Mg)

6. (Disposition Coronary care)

(5 marks) Lots to write

Notes -


Keep structure of Resus/Specific Care/Supportive Care/Treat cause/treat complications/disposition in the back of you mind.

Want to keep statements broad so all areas covered eg. say reversion as stem then electrical vs chemical – more opportunity to show breadth of knowledge as expertise encompassing holistic care


NB. For assessment questions always think something from each group – hx/exam/Ix.




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