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UNIVERSITYHOSPITAL,GEELONGFELLOWSHIPWRITTENEXAMINATION

WEEK25–TRIALSHORTANSWERQUESTIONSSuggestedanswersPLEASELETTOMKNOWOFANYERRORS/OTHEROPTIONSFORANSWERSPleasedonotsimplychangethisdocument-itisnotthemastercopy!

Question1(18marks)

a. Definepsychosis.(1mark)• Distortion/lossofcontactwithreality• Withoutanycloudingofconsciousness

b. Listthefive(5)DSMIVcriteriaforthediagnosisofSchizophrenia.(5marks)

• Symptomsinvolvingatleast2of:o Delusionso Hallucinationso Grosslydisorganisedorcatatonicbehaviouro Disorganisedspeecho Negativesymptoms

• Social/occupationaldysfunction• Duration>6months• ExclusionofSchizoaffective/mooddisorder• Exclusionofsubstanceabuse/medicalcause

YouareprovidingmedicalassistanceattriageonabusySundaynight.A34yearoldmanpresentstotriage.Heappearsintoxicated,agitatedandhaspressureofspeech.Herequestsexcisionofalesiononhisforeheadthathasbeenpresentforover20yrs.Duringthediscussion,hesuddenlypullsoutaknifeanddeclaresthatifwedon’tcutoutthisthing,he’lldoithimself.Thetriagenursehasrequestedhehandovertheknifeandhestates“Youwillhavetofightmeforit”.

c. Definethissituation. (1mark) • CodeBlackorarmedthreat

d. Listfive(5)featuresofhispresentationthatraiseconcernsaboutimmediateviolence.(5marks)

• Agitation-motor• Agitation-verbal• intoxication• Pressureofspeech-indicatorofMentalHealthdisorder• Knife• Statedthreattouseknife• Attitudetoassistance

Thepatientisdisarmedandrequiresphysicalandchemicalrestrainttoallowassessment.e. Listyourpreferredinitialpharmacologicaltreatmentwithdoserangeandrouteofadministrationinthe

caseof:i. Patientbeingcompliantwithmedicationadministration:(3marks)NB:appearsintoxicated-dosesmustbesafe

• Olanzepine5-10mgorally• Diazepam5-10mgorally

ii. Patientbeingnon-compliantwithmedicationadministration:(3marks)NB:appearsintoxicated-dosesmustbesafe

• Midazolam5-10mgIMorIV• Lorazepam1-2mgIMorIV• Haloperidol5-10mgIMorIV• Droperidol5-10mgIMorIV• Ziprasidone10-20mg+/-lorazepam1-2mgIM

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

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Question2(12marks)WithrespecttoheadinjuryintheAdulttraumapatient:

a. Listfour(4)riskfactorsthatwouldleadyoutoobtainanurgentCTbrain(iewithinthefirst1hour).(4marks) NB:factorshouldrelatespecificallytoindicationsforCTBinCHI-notrelatingtoothersignificantinjuriesrequiringurgentCT

• GCS<13onarrival• GCS<15at2/24• Suspectedopen/depressedskull#• SignofBOS#• Posttraumaticseizure• Focalneurologicaldeficit• 1episodeofvomiting

b. Listfour(4)riskfactorsthatwouldleadyoutoobtainasemi-urgentCTBrain(iewithinthefirst8

hours).(4marks)• LOC/Amnesia+Age≥65• LOC/Amnesia+Hxofbleeding/clottingdisorders• LOC/Amnesia+Dangerousmechanism,(Ped/cyclistvscar,ejectionfromMVC,fall>1m/5

stairs)• LOC/Amnesia+30minretrogradeamnesiaofeventsimmediatelybeforeCHI

WithrespecttoheadinjuryinthePaediatrictraumapatient:

c. Listfour(4)variationswhencomparedtoAdultguidelines,intermsofriskfactorsforwhichCTBrainisrecommendedforthePaediatricpatientwithinthefirst1hour.(4marks)

• NAIsuspicion• GCS<14or<1yrold<15• Tensefontanelle• <1yr->5cmbruise/swelling/lac• ≥2of:≥3vomitingepisodes/LOC>5min/dangerousmechanism/abnormaldrowsiness/

Amnesia>5min

Youshouldbefamiliarwiththefollowing:APHIRST,NICE,CanadianCTB,NewOrleans,CHALICE,CATCHandPECARN.Dunnhasaverygoodsummaryofeach-theoriginalarticlesarebelow.Youmustachieveexpert,evidencebasedpracticeinthisarea.ClickontheimagebelowtoviewtheentirePDF(&print/saveifnecessary)

Seenextpageforsummariesofeach

1.APHIRST2.NICE3.Canadian4.NewOrleans5.Comparison6.CHALICE 7.CATCH8.PECARN

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NICE

Paeds:NICE

CHALICE

CATCH PECARN→

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Question3(12marks)

a. WhatisthePerichondritisoftheear?(1mark)• Infectionoftheauricularsofttissueoverlyingthecartilage

b. Listthree(3)causesofperichondritisoftheear.(3marks)

• Trauma§ Lacerations§ Burns

• Earpiercing• Surgicalwound

c. Otherthananalgesia,list(3)keycomponentstothemanagementofperichondritisoftheear.(4marks)

• Hotsoaks• OralAbs-DunnssaysFluclox,generallyneedtocoverPseudomonas-Cipro• Reviewin24-48/24

d. WhatisChondritisoftheear?(1mark)

• Infectioninvolvingtheauricularcartilage

e. Whatclinicalfeaturedifferentiatesperichondritisoftheearfromchondritisoftheear?(1mark)• Deformityoftheexternalear(auricle)

f. Listthree(3)differencesinthemanagementofChondritisoftheear,ascomparedtoPerichondritisofthe

ear?(3marks)• IVabsrequired-flucloxvstazocin• Admissionrequired• Surgicaldrainage

ThisresourceisproducedfortheuseofUniversityHospital,GeelongEmergencystaffforpreparationfortheEmergencyMedicineFellowshipwrittenexam.Allcarehasbeentakentoensureaccurateanduptodatecontent.Pleasecontactmewithanysuggestions,concernsorquestions.DrTomReade(StaffSpecialist,UniversityHospital,GeelongEmergencyDepartment)Email:tomre@barwonhealth.org.au November2017

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Question4(12marks)

A46yearoldwomanpresentswithchestpain.Hervitalsignsare:BP130/60mmHgRR22/minTemperature36.5°CGCS15

a. Whatisaunifyingdiagnosisforthispatient,basedonthisECG?(1mark)• Pericarditis

b. Listthree(3)abnormalitiesshowninthisECGthatsupportthisdiagnosis.(3marks)

• Sinustachycardia-rate110• PRdepression• WidespreadSTE• (STDaVr)

c. Listfour(4)keyinvestigationsthatyouwouldperform.Stateone(1)justificationforeachchoice.

(8marks)

Investigation Justification

ECHO • Demonstrateamountofpericardialfluid• Demonstratethickenedpericardium• Assessforevidenceofcardiactamponade• (Localisedwallmotionabnormalities)

FBE • Lymphocytosissuggestsviralcause• WCC<4>15suggestsbacterialcause

U+E • Uraemiaasacause

Troponin • DxPancarditis• DxMyocarditis

ESRorCRP • Raisedlevelssupportinflammatoryprocess• Levelscanbeusedtofollowdiseaseprogress

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Question5(12marks)A25yearoldwomanpresentsfollowingastingfromanunknownanimalwhilstcamping.

a. Listthree(3)clinicallyrelevantdifferencesbetweenwaspstingsandbeestings.(6marks)

Featureofsting Wasp Bee

Frequencyofbites

Muchlesscommon Morecommon

Frequencyofanaphylaxis

Muchlesscommon Morecommon

Number

Multiple 1sting

Serumsickness

N Y

Massiveenvenomation: Numberofstings

>50stings >20stings

Haemoglobinuria

N Y

Rhabdomyolysis

N Y

Multipleorganfailure

N Y

Haemolysis

Y N

Myocarditis

Y N

Hepatitis

Y N

Death(bothduetoanaphylaxis)

Muchlesscommon Morecommon

b. Listthree(3)clinicalfeaturesofabullantbite.(3marks)

• Repeatedstings• Localwheal&flare• Anaphylaxis• Death-associatedwith-priorstings&ACEinhibitoruse

c. Listthree(3)clinicalfeaturesofanAustralianscorpionsting.(3marks)• Nighttime• Uncommon• Minorlocaleffects:

o painlocalised,severalhrso inflammationo oedemao paraesthesiao hyperalgesiao numbness/tinglingseveraldays

• Systemiceffectsuncommono nausea,vomiting,malaise,tachycardia

• Notlifethreatening

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Question6(12marks)(samepatientasquestion5)

a. Whatistheclinicaldefinitionofanaphylaxis?(1mark)3components:

• severe/lifethreatening• generalised/systemic• hypersensitivity/allergicreaction

b. Ingeneral,listtwo(2)indicationsforapatienttousetheirownEpipen.(2marks)

• Cutaneoussymptoms +

• Signofanothersysteminvolvement:o dizziness/faintnesso SOBo chesttightnesso oralswelling/lumpo voicechangeo nausea/vomit

c. Otherthantheindicationsforuse,listfour(4)instructionsthatyouwouldgiveapatientwith

respecttothetechniqueofEPipenuse.(4marks)• Howtoopen• Identifycorrectendforapplication• Appropriatesite(lateralthighisrecommended)• Forcerequired• Durationofholdingin(10sec)• Call000ASAPafterEPIPENuse

Thepatientexperiencesanaphylaxis.ShehasIVaccess.Adrenalineisgiveninappropriatedoses.Shefailstorespondtomaximumadrenalinetherapy.

d. Listfive(5)additionalmedicationsthatyoucouldinitiateinthissituation.(5marks)• Steroids(althoughoflittlebenefitacutely,useearlyasdurationofanaphylaxiscannotbe

predicted)• Salbutamol• H1antagonists• H2antagonists• Glucagon(ifpttakingBBlockers)• MgSO4IV(forrefractorybronchospasm)• Ketamine(inductionagentmayimprovebronchospasm)

ClickontheimagebelowtoviewtheentirePDF(&print/saveifnecessary)

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Question7(12marks)Duringyourroutinepathologyresultcheckingyounoticethefollowingresultofapatientseenbyanotherdoctorinyouremergencydepartmenttwodaysago.Thepatientrecordsshow:35yearoldwoman,15weekspregnantwithleftflankpainanddysuria.Noallergies.Rxtrimethoprim.F/Uprn.

MICROSCOPYLeucocytes>1000x10^6/L(<2x10^6/L)RedBloodCells 220 x10^6/L(<13x10^6/L)SquamousEpithelialCells +STANDARDBACTERIALCULTURE

1.Escherichiacoli>10^9cfu/LSENSITIVITIES:AmpicillinSAugmentinSCefotaximeSCephalothinSCotrimoxazoleSGentamicinSNitrofurantoinSTrimethoprimR

a. Statefour(4)clinicalproblemswiththispatient.(4marks)• Clinicalfeaturesofpyelonephritis+pregnancy=admissionandIVAbsinmostcases• CItochosenAbsgiven(categoryC)→adverseevent• Organismculturednotsensitive→needsAbschangeandurgentreview• Inappropriatefollowup-ShouldhaveplanforMSUfollowup(not“prn”)• PregnancywithdelayedRxincurs↑riskofmiscarriage• EColiassociatedwithsignificantcomplications(Gram-vesepsisisbad)

b. Listfour(4)keystepsthatyouwouldundertakeinthiscase.Stateone(1)justificationforeachstep.(8

marks)NB:thisisonetimewhereIwouldgroupthe“medicalcare”asonestep,seeingtherearenumerousotherstepstocover-ie.Not:1.Recallpt 2.IVabs 3.IVfluids 4.Admit

Step Justification

Contactpatient • ReturnASAPforRVandappropriateMx

Opendisclosure • Bestpractice• Optimiseptunderstandingofsituation• Reducefuturelegalprocessrelatingtopresentation

ClinicalreassessmentwithviewtourgentIVabsandadmission

• Rapidmedicaladmissiontodelayfurtheradverseeffects

Obstetricreview • Withrespecttopossiblyteratogenicantibiotic-closespecialistfollowuprequired

QI-Rootcauseanalysis • ↓similarfutureevents

DebriefwithDrinvolved • Identifyknowledgegaps/educate/support/supervise

Documentation • Optimiseongoingcareforpatient/Legalimplicationstocase

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Question8(12marks)A34yearoldmanpresentsleftanklepainfollowingafallataBBQ.

a. Statefour(4)abnormalfindingsinthesexrays.(4marks) • Comminuteddistalfibulafracture(WeberC)• Disruptionofthedistaltib/fibsyndesmosis• Medialmalleolar#• Latersubluxationofthetalus

Hehadbeendrinkingbeerforseveralhoursprior.HehasaPastHistoryofchroniclowerbackpain.Hetakesbuprenorphinepatchesforchronicpain.Hetakesnootherregularmedications.YouhaveIVaccess.Hehasanisolatedankleinjury.HisPBTis0.25.

b. Statefour(4)issuesinyourapproachtohisanalgesicregimeforthefirst1hour.(4marks)NB:NotPCAin1sthour

• PBT0.25-Carewithhaemodynamics&reductioninGCS• AsaresultofBup.Patches→WillberelativelyresistanttoIVnarcotics/willrequirehigh

dosemorphine• Close/carefulobservationrequiredpostIVanalgesia• Stronganalgesiawillberequired-IV2.5mgbolusMorphine/KetamineIVboluses• Employnonmedicinaltechniquesto↓analgesicrequirementsASAP-splint/reduce/

elevate

Itbecomesapparentthatthepatientisafamousfootballer.

c. Statefour(4)techniquesthatyoucouldemploytomaintainthepatients'privacy.(4marks)• Alias/de-identifyoncomputersystem• Usecubicleindiscretearea• Keepcurtain/doorclosed• InformdirectRNstaffandRNinchargeanddirecttominimisediscussion/notdiscuss

presencewidelyatworkandwhenleftfromwork• Informmedialiaisonofficer• ExpediateRxwithoutcompromisingcaretootherpt’s• Stafftraininginethicsandptprivacy

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Question9(18marks)A3year-oldboyisbroughttoyourdepartmentbyhismotherwithabdominalpainandvomiting.ThemotherisconcernedthatthechildmayhaveingestedsomeofherIron(Ferrogradumet)tablets.Sheissurethattherearemorethan10tabletsmissingfromthebottle.EachFerrogradumettabletcontains105mgofelementalIron.

a. Listthree(3)clinicalfeaturesthatyouwouldseektoassesstheriskoftoxicity.(3marks) • Weight

o 1000mgminimumingestionassumedo likelyweight~15kg→65mg/kg,if10kg→100mg/kgif20kg→50mg/kgo <20mg/kg:asymptomatico 20-60mg/kg:GITo 60-120mg/kg:systemico 120mg/kg:potentiallylethal

• SymptomsofGITphase(onset30min-6/24)o vomiting(vomitingisthemostsensitivemarkerofserioustoxicity)o diarrhoeao abdopaino H+M

• Indicatorsofshock

b. WhatistheroleofSerumIronlevelsinthetreatmentofthispatient?State(3)pointsinyouranswer.(3marks)• Confirmingestion• Peakat4-6/24• Noclearcorrelationwithlevelandtoxicity• Peaklevels>90micromol/Lthoughttobepredictiveofsystemictoxicity

c. Listfour(4)keyinvestigationsforthischildthatwillassistwithanestimationofseverityoftoxicity.(4marks)

NB:“List”onlyrequired-nojustificationorexplanationrequestedthereforenonerequired• ABG(AGMetabolicacidosisinsevere,metabolicalkalosisfromupperGITlosses)• AXR(Tabletsinstomach→indicationforWBI)• Glucose(PerDunn:>8correlateswellwithtoxicserumlevels-ToxHBsaysdoesnotcorrelatewithtoxicity)

• WCC(PerDunn:>15correlateswithsystemictoxicity-ToxHBsaysdoesnotcorrelatewithtoxicity) • ErectCXR(ifabdominalperforationsuspected)• Clotting(Dunn:↑INR/↑APTT,ToxHB-nomention)• LFT(Dunn:hepatoxicity,ToxHB-nomention)

d. Whatdecontaminationmaybeofbenefitinthisingestion?(1mark)

• WBI

e. Listthree(3)indication/sforthisdecontamination.(3marks)• Symptomatic• >60mg/kg(Dunnsays>20mg/kg)• AXRshowstablets

f. Whatspecificantidotethatmaybeofbenefitinthisingestion?(1mark)

• Desferrioxamine

g. Listthree(3)indicationsfortheuseofantidoteinthispatient.(3marks)• Systemictoxicity

o Alteredconsciousstateo ↓BPo ↑PRo ↑RR

• Serum>90micromol/lat4-6/24post