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UNIVERSITYHOSPITAL,GEELONG
FELLOWSHIPWRITTENEXAMINATIONWEEK10–TRIALSHORTANSWERQUESTIONSSuggestedanswersPLEASELETTOMKNOWOFANYERRORS/OTHEROPTIONSFORANSWERSPleasedonotsimplychangethisdocument-itisnotthemastercopy!
Question1(18marks)A25yearoldmanpresentsfollowingadivingexpedition.
a. Listfour(4)featuresonhistorythatwouldsupportthediagnosisofdecompressionillness.(4marks)• MSS:Largejointpain(largesinglejtmostcommon)• Vestibular:Tinnitus,Hearingloss,dizziness,unsteadygait• Pulm:Chestpain,SOB,cough• Waist/loinpain• Headache• LOC• Behavioural/moodchange• Divecharacteristics-long,deepdives,rapidascent,shortsurfaceintervals-multipleinterval• PriorepisodesofDCI
b. Listfour(4)featuresonexaminationthatwouldsupportthediagnosisofdecompressionillness.(4marks)• AnyCNSfinding-inclcerebellare.g.nystagmus,hearingloss,ataxia• AnyPNSfinding-patchy/multiplesitesmotororsensorychange• Balance-sharpenedRhombergs• Hearingloss• Nystagmus• Normalappearingjoints(noinflammation)withseverejointpain• Cyanosis• Haemodynamicinstability• Pruriticerythematousrash
c. Whatistheroleofinvestigationsinestablishingthediagnosisofdecompressionillness?Statetwo(2)pointsinyour
answer.(2marks)• Clinicaldiagnosis• ShouldnotdelaytransferHBOifDxclear• IXtoR/oothercausesegCTBtoR/OotherDx• CXR+/-intravascularemboli(iflargeemboli)• DopplerUSoverRV/Subclavianwillusuallyshowmicrobubbles(maybepresentinasymptomatic)
d. StateyourthresholdforconsultationwithaHyperbaricOxygenfacilityinthesettingofdiving.(1mark)
• Low-Consultwithhyperbaricspecialistinanyonewithsuspecteddecompressionillnessevenifmild
e. Listthree(3)justificationsforyourstatementofthresholdforconsultationwithaHyperbaricOxygenfacilityinthesettingofdiving.(3mark) • Seekspecialistopinion• Anysymptomorsign(maybesubtle)ofDCImaybeanindicationforrecompression• EarlyinstitutionreducesthedelayedeffectsofDCI• Shortertimetofirsthyperbaricoxygentreatmentasswithbetteroutcomese.g.<12hrs• BenefitslikelyevenifdelayedRx(upto14/7)
f. Listfour(4)theoreticbeneficialeffectsforHyperbaricoxygentherapyinDecompressionillness.(4marks)
• ↓bubblevolume• Improvesoxygenationofischaemictissue• ↓ICP• Inhibitssecondaryinflammatory&reperfusioninjury• Improvesbrainmetabolism
AdditionalQs:Q.Statethedefinitionofdecompressionillness.(1mark)
• Termthatencompassesarterialgasembolismanddecompressionsickness(barotraumaofascentwithintravascular+/-extravascularbubbles(generallynitrogen))
(TermintroducedbecauseRxofeitherconditionisrecompression.Prognosisdiffersforboth)
“List”=1-3words“State”=shortstatement/phrase/clause
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Question2(12marks)A29yearoldmanpresentsfollowingahighspeedmotorbikecollision.
a. Statefour(4)abnormalfindingsinthisX-ray.(4marks)• #Lsuperiorpubicramus• #Linferiorpubicramus• Pubicsymphysisdiastasis• Lsacral#• Indistinctsuperiorborderofthebladdersuggestiveofrupture
b. Statefour(4)prosfortheuseofaFASTscaninthispatient.(4marks)
• Freefluidwouldstronglysupportbladderrupture/otherintraabdobleed• Immediateresults:
o -vewillaiddispositionplanninge.g.IRvstheatreo +vescanmayincreasesurgicalresponse/rapidtransfertoeitherOTorCT
• BedsideinED(ptdoesnotrequiretransferoutofdept)• Noninvasive/noradiation/nocontrast• Repeatable
c. Statefour(4)consfortheuseofaFASTscaninthispatient.(4marks)• Falsenegativeif<(150-)200mlbleed• Falsenegativeforretroperitonealinjuries• Falsenegativeforholloworganinjuries• False+veinthesettingofascites• Operatordependent• Requirestrainingandcredentialing• Bodyhabitusdependent
Question3(12marks)
a. Listthree(3)indicationsfortheutilisationofNon-invasiveVentilationthataresupportedbyhighlevelevidence.(3marks)• Respiratoryfailurecausedby:
o APOo COPDo Immunosuppression
b. Listthree(3)indicationsfortheutilisationofNon-invasiveVentilationthataresupportedbylowlevel
evidenceonly.(3marks)• Pneumonia• ARDS• Asthma• Children• Preoxygenation
c. Listfour(4)physiologicalbenefitsofBi-levelPositiveAirwayPressuresupport(BiPAP)inCOPD. (4
marks)• IPAP-reducesWOB• Increasesendinspiratoryvolume• EPAPpreventsthenormalphysiologicalcollapseduringexpiration• Alveolistaypatient-increasestimeforgasexchange• Increasesarterialoxygenation• IncreasesCO2elimination• WOBdecreased-noenergyrequiredtoreopencollapsedalveoli • Enablesclosedcircuitandthereforehigh/constantFiO2avoidinghyperoxia
(StrictlyspeakingavoidanceofETTmaybeconsideredaphysiologicalbenefit,becauseofthephysiologicaldeteriorationthatmayoccuratinduction/duringprolongedventilation)
d. Listtwo(2)patientfactorsthatmustbemettoinitiateBiPAP.(2marks) • Spontaneousventilation/abletoinitiateeachbreath• Alert/Abletocooperate/tolerate
AdditionalQ:
Q:AssumingthattheBiPAPmachinehasbeentestedandisfunctioningcorrectly,statefour(4)stepsinsettinguptheBiPAPmachineforuseinapatientwithCOPD.(4marks)NB:States“settingupthemachine”so“explaintopt”or“reassurept”arenotappropriateanswers
• Fitmask,ensuretightsealandcomfortable• Setoxygenflowrate-titratetomaintainasuitablesatlevel• IPAP10(range10-12)titrateupto15-20ormaximumtolerated,adjustaccordingtoCO2• EPAP4(range4-6)adjustaccordingtoSpO2• Adjustthesensitivityofinsp/exptriggerstomaxptsynchronicity
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Question4(12marks)
A7yearoldboyhastheselesionsonhislegsforthepast7days.His4yearoldsisterhasthesameskineruptions.
a. Whatisthemostlikelydiagnosis?(1mark)
• Impetigo+/-Bullous
b. Statethree(3)featuresofthispresentationthatsupportthisdiagnosis.(3marks)• Familymemberalsosimilarlesions• Yellow/browncrust• Exposedareas• Erythematousbase
c. Listfour(4)stepsinthetreatmentofthispatient.Stateone(1)justificationforeachchoice.(8marks)
Treatmentstep(4marks)
Justification(4marks)
Analgesia PainfulconditionAntibiotictopicallyBactroban(Mupirocin)
Topical-treatmentofchoiceforlocalisedimpetigo
Antibioticoralflucloxacillinorcephalexinorally
Suchextensiveimpetigoprobablyrequiresoral(isolatedlesionsdonot)+/-presenceofsecondarycellulitisfromskinbreakdown
Removecrusts Infectionwon’tclearunlessbacteriacontainingcrustsareremovedReducethenidusofinfectionandallowbetterpenetrationoftopicalabx
Isolatefromschool/coverlesions
Highlycontagious
Followup LMOSwabsfor?resistantMRSAwhichwillalterprescribedabsTreatsister/householdcontacts-oftenmultiplepeopleinhousewithimpetigoParenteraleducationandexplanation:ensuresbetteradherencetoRxplanandongoingengagementwithHCP
Question5(12marks)A64yearoldmanpresentstoyourtertiaryhospital,emergencydepartmentwith1hourofchestpainandshortnessofbreath.
a. Statefive(5)theabnormalfindingsinthisECG.(5marks)• RhythmAflutter(wavesinV1/II)• Failuretosense-inappropriatespikeafter1stQRSinV4,V5,V6(bluearrow)• STE2mmaVFisolatedleadSTE-nativeQRS• STD1mmaVL,V2,I• TW-biphasicI,aVL• +/-FailuretocaptureI,II,III(greenarrow)
(NB:Thepresenceofanappropriatelypacedbeatisnotanabnormalfinding)
b. WhatisthesignificanceofthefindingsinthisECGforthispatient?Providethree(3)statements.(3marks)
• GivensymptomsandSTE/STDpattern-RxasINFSTEMI• PPMmaynotbefunctioningappropriately(givenfailuretosense)-probablyrelatingtounderlying
ischaemia• Anticipate further rhythm disturbance given PPMmalfunction/ Inf STEMI/ underlying need for
PPM
c. Listfour(4)stepsinthetreatmentforthispatientoverthenext15minutes.(4marks)NB:“tertiaryhospital”
• STEMIcall/Urgentcardiologyreferral• Aspirin300mg(decreaseabsolutemortalityby3%,administrationpriortoreperfusionappearstobeimpindecrmortality)
• Clopidogrel/Ticagrelor(reducesabsoluteCVScxrateby2-3%)• Heparinbolus5000IU• Morphine-cautioususegivenpossibilityofRVinvolvement• FluidbolusifBP↓-RVinvolvement• FacilitatetransferforPCI<1/24• Preparefortranscutaneouspacing+/-obtainPPMmagnet• (IfPCI>1/24thenthrombolyseifnoCI)• (TrytoconfirmSTEinIIorIIIwithrepeatECGinmeantime)
Question6(12marks)
A29yearoldmanpresentswithfeverandacuteankleandwristpainwithnohistoryoftrauma.
JointfluidresultsAppearance CloudyMicroscopy WCC50,000(Mainlyneutrophils)Gramstain NobacteriaseenCrystals Noneseen
a. Listfour(4)likelydifferentialdiagnosisfortheseresults.(4marks) • Septicarthritis-mostimportanttoconsider/exclude• GonococcalReiterssyndrome• Gout-lesslikelynocrystals• Pseudogoutlesslikelynocrystals
b. Listfour(4)furtherinvestigationsthatyouwouldperformintheEmergencydepartment.Stateone(1)justificationforeachchoice.(8marks)
Investigation(4marks)
Justification(4marks)
Jointfluidculture IdentifycausativeorganismsandmayalterantibioticvoiceanddurationtreatmentSTIscreenUrethralswab,PCRurine
SensitiveforgonorrhoeaorotherSTI
AnkleandwristXR Identityoccultfractures,degenerativediseaseFBE CRP Elevation supports diagnosis of infections/inflammation (Marker of potential
bacterialsepsis)Bloodculture Indicatedearly inmanagement if febrile to identifyorganismand guide antibiotic
treatment-mayofferlittlebenefitoverJointfluidm,c+sGlucose undiagnoseddiabetesmayprolonghealingtine,early identificationandtreatment
willimproverecoverytimes
WCC may be much lower in septic arthritis (2000 - 100,000) Ie lower virulence organisms, immunocompromised
Question7(12marks)A7yearoldboypresentstoyouremergencydepartmentaftersustaininganeyeinjuryatschool2hoursprior.Onarrival,heisactivelyvomiting.
a. Statethemostconcerningabnormalfeatureinthisphotograph.(1mark) • Hyphaema(grade1(<33%)toII(33-50%)
b. State4possiblecomplicationsofthisinjury.(4marks)
• Glaucoma-ofhyphaema• Rebleeding-ofhyphaemia(occursin~10%,commonday3-5,↑inchildren)• Visionloss• Periorbitalcellulitis-fromskinbreach
c. Listfive(5)medicationsthatmaybeusedforthispatient.(5marks)
• Cyloplegics(tropicamide1%)• Acetazolamide(50mmgIVstatthen250mgPOTDS)• Timoptolol(0.5%idropBDifincrIOP)• Antiemetic(notmetoclopamide-theoretically↑IOP)• Analgesia(avoidNSAID)e.g.paracetamol,opioid
d. Statetheexpectedprognosisforthispatients’injury,assumingtheconditiondoesnotdeteriorate.(1
mark)• Good,novisuallosslikely
e. Stateone(1)justificationforthischoiceofprognosis.(1mark)
• Hyphaema<1/3oftheanteriorchamberhaveagoodprognosis
(Mx-GuidedbyOpthal.Resteyes,eyeshield(notapad),restat30°headup(↓furtherbleedingfrom20%→10%),mayneedlaserRxtostopongoingbleeding)
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Question8(8marks)
A2yearoldboyisbroughttoyouremergencydepartmentbyhisgrandparents,havingfoundhimunresponsiveintheirhome.Hehasnosignificantpastmedicalhistory.
a. Providetwo(2)calculationstohelpyoutointerprettheseresults.
(NB:itisavenousgas-soexpectedPC02andA-aetccan’tbecalculated)
Derivedvalues:• AG22• Deltaratio=10/13=0.77
b. Usingthescenarioandthederivedvalues,definetheprimaryacid/baseabnormality/s.
• HAGMA(22)• Respacidosis
c. Usingthescenarioandthederivedvalues,definethesecondaryacid/baseabnormality/s.
• Respalkalosis • NAGAMA
d. Provideaunifyingexplanationfortheseresults.
• Lacticacidosis• ↓GCSsecondaryto
o Sepsiso IngestionegOHA,iron,propranololo Seizureso (Notmethanol/renalfailure/ethyleneglycol
ThisresourceisproducedfortheuseofUniversityHospital,GeelongEmergencystaffforpreparationfortheEmergencyMedicineFellowshipwrittenexam.Allcarehasbeentakentoensureaccurateanduptodatecontent.Pleasecontactmewithanysuggestions,concernsorquestions.DrTomReade(StaffSpecialist,UniversityHospital,GeelongEmergencyDepartment)Email:[email protected] November2017
Question9(18marks)
a. Listfive(5)benefitsofacollocated“ShortStayUnit”associatedwithanED.(5marks)• ↓LOS• Allowsfurtherinvestigation• AllowsEDadmissions/prolongedLOSegfortoxicologypts• AvoidD/Catnight• SparetemporarycapacityformainED(egptawaitingtransport/wardbed)• Safetyvalve-preventunsafeD/cwhennoI/Pteamwilladmit• Financialbenefit-rewardfor↑admissions• KPI-NEATtargetimprovements
b. Listfour(4)limitationsofacollocated“ShortStayUnit”associatedwithanED.(4marks)
• Delaynecessaryadmissions• Deferralofdecisionmaking• FailuretoexcludeseriousDx(egAbdominalemergencies/poisonings)• Accessblockifusedforptawaitingawardbed• Multiplehandoversofstafffor1patient• GenerationofDischargesummaries
c. Listfive(5)predictorsofadmissionfailureforaShortStaypatient.(5marks)• ReferraltoinpatientunitpriortoSSUadmission• Inabilitytowtbear/walk,whenpreviouslyable• NeedforongoingRx• >1activeproblems• Multiplemedicalcomorbidities• ProgressivedeteriorationpriortopresentationdespiteoptimalRxandminimalchangeto
Rxonadmission
d. Listfour(4)examplesofsuitableconditions/problemstoadmittoaPaediatricShortStayUnit.(4marks)
• MinorCHI• Gastro-NGrehydration• Poisoning-mild• Asthma-mild-moderate• Singleseizure• Allergicreaction• Postconscioussedation• LowriskMarine/snakebite
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