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UNIVERSITYHOSPITAL,GEELONG
FELLOWSHIPWRITTENEXAMINATIONWEEK23–TRIALSHORTANSWERQUESTIONSSuggestedanswersPLEASELETTOMKNOWOFANYERRORS/OTHEROPTIONSFORANSWERSPleasedonotsimplychangethisdocument-itisnotthemastercopy!
Question1(18marks)A35yearoldmanexperiencesafallandsustainsanisolatedleftwristinjury.
a. Statetwo(2)abnormalfindingsinthesexrays.(2marks)
• #distalradius-transverse,impacted,dorsalangulation,extraarticular• #scaphoid-waist
Youdecidetocorrecttheabnormalitywithalocalanaesthetic,manipulationandplaster.
b. Listfive(5)patient-relatedcontraindicationstotheperformanceofthisprocedure.(5marks)• Refusaltoconsent• Noncompliantwithprocedure/uncooperativept• Compoundinjury-skinbreach• UncontrolledHT• Allergytoprilocaine• FailuretoobtainIVaccessindorsumhand• Raynaud’ssyndrome• Buerger’sdisease
c. Listyourpreferreddruganddoseforthisprocedure.(2marks) Drug:prilocaine Dose:0.5%1ml/kg=max3mg/kg(someupto5mg/kg)
Duringtheprocedurethepatientexperiencesaseizure.Thepatientistransferredtoaresuscitationcubicleandisplacedintheleftlateralposition.
d. Listfive(5)stepsinthemanagementofthistoxicity,forthispatient.(5marks)• Check/reinflatecuff• Stopdrug• Bz• Intralipid• Haemodialysis
e. Listfour(4)potentialerrorsthatmayhaveledtotheseizure.(4marks)• Cufffailure/leak• FailuretoinflatecufftosufficientBP• Incorrectprilocainedoseadministration• Incorrectmedicationchoice-eglignocaine• Inadvertentincorrectmedication
“List”=1-3words“State”=shortstatement/phrase/clause
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Question2(12marks)
a. RegardingRheumaticfever,listthefive(5)majormanifestationsthatareincludedinthemodifiedJonescriteria.(5marks)
• Migratoryarthritis(predominantlyinvolvingthelargejoints)• Carditisandvalvulitis(eg,pancarditis)• Centralnervoussysteminvolvement(eg,Sydenhamchorea)• Erythemamarginatum• Subcutaneousnodules
b. RegardingRheumaticfever,listthefour(4)minormanifestationsthatareincludedinthemodifiedJonescriteria.(4marks)
• Arthralgia• Fever• Elevatedacutephasereactants(erythrocytesedimentationrate[ESR],C-
reactiveprotein[CRP])• ProlongedPRinterval
c. RegardingRheumaticfever,listtwo(2)investigationsthatassistwithdefinitivediagnosis.(2marks)
• ASOTtitre-rise• ThroatculturesforGroupAstrep
d. RegardingRheumaticfever,listone(1)patientgroupinAustralasiathatismostlikelytoexperiencethedisease.(1mark)
• Indigenous
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Question3(12marks)
A35yearoldwomanpresentswithdecreasedvisioninherrighteye.
a. Whatisthediagnosisforhercondition?(1mark)
• Retinaldetachment
b. Listtwo(2)differentaetiologiesthatareassociatedwiththiscondition. (2marks)• Myopia• Cataractremoval• Oculartrauma• Vitreousdiseases• Fluoroquinoloneuse• Marfan’ssyndrome
c. Listtwo(2)featuresthatyouwouldexpectthepatienttoreportinthepatternofhervisualloss.
(2marks)• Slowonsetoverhours
o “likeashadeovertheeye”/darkcurtain/shadow• Flashesorfloaters
d. Otherthanretinalappearance,listthetwo(2)mainfeaturesthatyouwouldexpecton
examination.(2marks)• Visualfielddefect• ↓VA
ThepatientisreferredtotheOphthalmologyteam.
e. Listthree(3)managementstepsforthispatientwhileintheemergencydepartment.(3marks)
• Antiemetic(notmaxolon-↑IOP)• Padeye• Bedrest
f. Whichtwo(2)factorshavethemajorinfluenceonprognosisinthiscondition?(2marks)
• %ofretinainvolved• TimetodefinitiveRx(surgery)
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Question4(12marks)
a. Listfive(5)factorsthatimproveadaptationtoshiftwork. (5marks)• Circadianprinciplesinrostering-clockwiseshiftrotation• Lightexposureintheworkplace• Avoidcaffeine/nicotine/alcoholnearbedtime(eachcanbe1mark)• Regularmealspromotessleep• Regularexercisepromotessleep
b. Regardingrostering,listseven(7)barrierstobestpracticerostering.(7marks)• Inadequatestaffnumbers/skillmix• Equalnightshiftallocationtoallstaff• Educationsessions• Exampreparation• Requirementformanagementmeetings• Historicalprecedent• Rostersunacceptabletostaff• Awardrestrictions• Financialpressuresinc.minimisationofovertime
ThisresourceisproducedfortheuseofUniversityHospital,GeelongEmergencystaffforpreparationfortheEmergencyMedicineFellowshipwrittenexam.Allcarehasbeentakentoensureaccurateanduptodatecontent.Pleasecontactmewithanysuggestions,concernsorquestions.DrTomReade(StaffSpecialist,UniversityHospital,GeelongEmergencyDepartment)Email:[email protected] November2017
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Question5(10marks)
A45yearoldmanpresentswithpalpitations.Hehasnochestpain.
Onexamination:BP140/60mmHgRR20/minOxygensaturation98%on6LviaHudsonmaskGCS15
a. Listfive(5)abnormalitiesshowninthisECG.(5marks)• Irregular• BC~140msec• BeattobeatvariationinQRSduration(classically,amplitudeshouldnotvary)• Tachycardia~300• LAD• AbnormalRwaveprogressioninchestleads
b. StateaunifyingdiagnosisfortheseECGfindings. (1mark)• WPWAF
.c. List two(2)alternative,definitivetreatmentoptions for thispatient.Stateone(1) justification
foreachchoice.(4marks)• DCR
Justification:Urgentcardioversionisrequired,duetoriskofdeteriorationtoVF(despitelackofhaemodynamiccompromise)
• Flecainide Justification:Flecainideistheonlysuitabledrugchoice-slowsconductioninaccessorypathways
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Question6(13marks)Anunknown32yearoldwomanisinvolvedinasingleoccupanthighspeed,rollovermotorcarcollision.Onarrivalsheisconfused.Herobservationsare:BP100/60mmHgsupineHR135/minRR28/minOxygensaturation92%on6LviaHudsonmaskGCS13E4V4M5
a. Listone(1)positivefindinginthisxray.(1mark)
• Advancedpregnancy
PrimarysurveyrevealsnoabnormalityincludingFASTscannegative.Secondarysurveyrevealsnolimbinjury.
b. Listthree(3)radiologicalinvestigationsthatyouwouldperform.Stateone(1)justificationforeachchoice.(6marks)
Radiologicalinvestigation Justification
CTB • GCSwithCHICXR • RR28mechanismCTCspine • DecreasedGCS
• Mechanism
c. Listthree(3)keypathologyinvestigationsthatyouwouldperforminthiscase.Stateone(1)justificationforeachchoice.(6marks)
Pathologicalinvestigation Justification
FBE • Estimationofbloodloss.• Maybeanaemicassocwithpregnancy• Pltcount-?pre-existing↓Plt
G+H • RiskofautoimmunisationKleihauer • IfRh-veBloodalcohol • Possiblecauseof↓GCSBSL • PossiblecauseforcollisionPolicebloods • ForensicdocumentationDruglevels-incparacetamol • +/-otherdrugsifaccess
• ifPHxMajorPsychiatricillnessparasuicidesUrinedrugscreen • ifPHxMajorPsychiatricillnessparasuicides
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Question7(12marks)A49yearoldwomanpresentsviaambulancetotheEmergencyDepartment.Shehasmoderatelyseverethoracicbackpain.
a. Listfive(5)indicationsfortheperformanceofxraysofherthoracicspine.(5marks)• Trauma• Presenceofneurology• Known/suspectedmalignancy• Othermedicalconditionthatmaypredisposetopathologicalfractures-eg
Osteogenesisimperfecta• Associatedfever(especiallyifimmunocompromised/IVDU)
Reference range
Na 140 (135-145)
K 5.0 (3.5- 5.0)
Urea 28.2 (2.5- 6.4)
Creatinine 0.13 (0.05- 0.1)
Calcium 5.5 (2.1- 2.8)
Albumin 30 g/L (35-50)
AP 150 IU/L (0-120)
GGT 115 IU/L (<50)
ALT 152 IU/L (<55)
AST 125 IU/L (0-50)
Bili Total 15 µmol/L (0-19)
T. Protein 61 g/L (60-82)
b. Provideone(1)calculationtohelpyoutointerprettheseresults. (1mark)• Calculation:CorrectedCa=5.5+(40-30)x2/100=5.5+0.2=5.7
(IONIZEDCa++(corrected)=measuredCa+++(40–serumalbuming/l)x0.02)
c. Statealikelyunifyingexplanationfortheseresultsinthisclinicalcontext.Includethree(3)pointsinyouranswer.(3marks)
• Significanthypercalcaemia• Renalimpairment↑Ur:Crsuggestiveofdehydration• MildLFTabnormalitiesc/wmets• Possibledehydrationa/wmetastaticbonydisease
d. Listthree(3)keystepsinthespecifictreatmentofherbiochemicalstate. (3marks)• Rehydration-NS(notHartmannsascontainsCa)• Loopdiuretics(avoidthiazidediuretics)-maintainhighurineoutput• Bisphosphonates• Steroids• NotOestrogen(onlyinpostmenopausalprimaryhyperparathyroidism)
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Question8(11marks) A32yearoldmanhasbeenhitinthe“groin”withacricketballthepreviousevening.Heiscomplainingofapainfulswollenscrotum.
a. Listthree(3)positivefindingsthatyoumayanticipateonaformalultrasound.Listone(1)injurythateachfindingisassociatedwith.Foreachofthesefindings,identifywhetherthefindingisanindicationforsurgicalexploration-yes/no.(9marks)
Ultrasoundfinding Injuryassociated Indicationforexploration
Parenchymalheterogeneity Intratesticularhaematoma
Yes
Lossofcontinuityoftunicaalbuginea Tunicarupture
Yes
Haematocele Testicularrupture
Yes
Noflowtotesticle Testiculartorsion
Yes
Theultrasoundisreportednormal.
b. Listyourdisposition.Stateone(1)justificationforyourchoice.(2marks)
Disposition: Admissionunderurology
Justification: Anormalultrasoundshouldnotpreventexplorationofa grosslyabnormaltesticleonphysicalexamination
9
Question9(18marks)A65yearoldmanpresentswithapainfulleftlowerleg.
a. Youareconcernedaboutthepossibilityofdeepvenousthrombosis.i. Whatistheroleofage-adjustedcut-offDDimerlevelforthispatient?Statefour(4)pointsin
youranswer.(4marks)• Recent,large,retrospectivestudyidentifiedsafetyofageadjustedcut-offs(ADJUST-PE
study-seebelow)• Ageadjustedcutoffcanbeusedifnon-highrisk• Ageinyrsx10-soadjustedcutoffis650ng/ml• Alevelbelowthiscut-off(inlow-intermediaterisk)cansafelyexcludeVTE
b. Yoususpectadiagnosisofsuperficialthrombophlebitis
i. Listfour(4)indicationsfortheperformanceoflowerlimbultrasoundforthispatient(4marks)• Involvementofupper1/3ofthigh• Clinicalevidenceofextension(>5cm)• Lowerextremityswelling>thanexpectedfromsuperficialphlebitisalone• Diagnosisuncertain
c. Anultrasoundconfirmssuperficialthrombophlebitisonly.
i. Statethree(3)indicationsforanticoagulationtherapyforthispatient.(3marks)• Affectedsegment>5cm• Thrombosisclose(<5cm)tosaphenofemoral/saphenopoplitealjunction• Presenceofmajorriskfactorforongoingthrombosis
NB:differencebetween“Minor”and“major”superficialthrombophlebitis
d. AnisolatedbelowkneeDVTisconfirmedonultrasound.i. State(2)indicationsforanticoagulationtherapyforthispatient.(2marks)NB:propagationrisksaremuchhigherinpatientswithacontinuedriskforthrombosis
• Legincylindricalimmobilisation(plaster/fibreglass)• Prothrombotichaematologicaldisorder
ii. Otherthanwarfarin,listtwo(2)anticoagulationoptionsforthispatient.(2marks)
• Clexane(enoxaparin)• Clexanefor3-5/7,followedbyDabigatran• Rivaroxaban• Apixaban
iii. Assumingthatthereisnoindicationforanticoagulationtherapy,listthree(3)stepsinyour
ongoingmanagementofthispatient.(3marks)• Aspirin• Anti-embolicstocking• RepeatUSat3-7days• Guidelinesforurgentrepresentation
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