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NSWFaculty

TRIALFELLOWSHIPEXAMINATION

RoyalPrinceAlfredHospital2015.1

WRITTENEXAMINATION

ShortAnswerQuestions

• 30Questions• 180minutes(Noreadingtime)• Answerallquestions• Writeyouranswersonthisquestionpaper.• Writeyournameonthetopofthefirstpageofeachanswer

• WriteyourDEMT/FACEMwhowillmarkyourpaperhere:

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Question1A3½yearoldboyaccompaniedbymumpresentstoEDwithpainfulleftlegandongoinglimpleftlegforlastfourdays.Accordingtomumthereisnohistoryoffallortrauma.Onexamination,heisholdingleftleginslightflexionandisunabletoweightbear.YoudecidetodoapelvicX-ray.Hisobservationsare:Pulse95bpmBP90/60mmHgRR22/minSats97%airTemp37.1C

Right Left1.DescribetheabnormalityontheXR(1mark)

2.Whatisthemostlikelydiagnosis?(1mark)

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3.List8importantcausesofatraumaticlimpinachildthisage(4marks)123456784.List4assessmentparameters(Kochercriteria1999)arethemostusefulforsuspectedsepticarthritisinachildwithapainfulhip(4marks)1234

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Question2An84year-oldfemaleattendedyourEDafterallegedlytaking38tabletsofParacetamol16hoursago(total19grams).ObservationsarestableandherGCSis15.1.List8investigationsyouwouldperformandwhy(2marks)12345678

2.State3elementsrequiredtodemonstratecompetence(3marks)123

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3.Sherefusestreatmentandwantstodischargeherself.Uponassessment,youfindthatshelackscapacity.Listyourimportantactionsandexplaineach(5marks)12345

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Question3AdiabeticpatientarrivestotheEDandrequiresfluidresuscitation.Hehasbilateralbelowkneeamputations.SeveralattemptstoestablishIVaccessfailed.YoudecidetogowiththeIOroute.1.List3alternativeanatomicalsitesthatareavailableforintraosseousaccess?(3marks)1232.Whatistheclinicalindicationforintraosseousaccess?(1mark)3.List4contraindicationsforIOinsertion(2marks)12344.Listthe4maincomplicationsassociatedwithintraosseoususe?(2marks)1234

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5.List4diagnosticstudiesthatcanbeobtainedviaintraosseousaccessthataccuratelyequatestoivcollection(2marks)1

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Question4A25yearoldmalewasassaultedwithabaseballbat.HehadawitnessedLOCfor5minutesandGCSwas10whenparamedicsattended.OnarrivaltotheED,hehadageneralisedseizurefollowingwhichhebecameagitatedandcombativewithaGCSof8.HisleftpupilisdilatedandhehasalreadyvomitedatsceneandtheED. R L

1.Describethe4abnormalitiesonthisCT.Giveasmuchdetailsaspossible(2marks)12342.List9importantinitialstepsinthispatient’sinitialprimarysurvey,includingendpointswhereappropriate(6marks)1234

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567893.Describe4methodsofreducingintracranialpressureinthispatientandtherationaleofeachmethod(2marks)1234

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Question5A45yearoldfemalehaslongstandinglowbackpainwasdischargedtheprecedingdaybyaJMOinyourEDwithadiagnosisofmalingering.ShenowpresentstotheEDwithasuddenandseverelowerbackpainradiatingdownthelegs.Inthedepartmentshewasunabletocontrolherselfandwasincontinentofurine.1.What6featureswouldsuggestcaudaequinasyndrome?(3marks)123456

2.Listtheessentialtesttoaidtheassessmentofapatientwithsuspectedcaudaequinasyndrome(1mark)3.YouinvestigateandfindthattheJMOdidnotexaminethepatient,wrotenonotesandwasheardbytheEDRNtotellthepatientthatthereisnothingwrongwiththemandtheyshouldnothavecometotheED,again.YouaretheJMO’ssupervisor.Outlinethestepstohowyouwouldapproachtothissituationwithdetails.(4marks)123456

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4.Outlinethe4mostimportantimmediatestepsinthetreatmentanddispositionofthispatient(2marks)1234

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Question6An18month-oldboyisbroughtbyhisworriedmothertotheEDwitharashandspotsinhisbuccalcavity.Heisalsopyrexial(T38.9°C).

1.Whatchangesareshownandwhatisthediagnosis?(2marks)122.List2acutecomplicationsofthiscondition(2marks)123.Whatlaboratoryfindingswouldbeexpectedwiththisdiagnosis(3marks)1234.IntheED,thechildstartsfitting.Theyareplacedontheirsidewithoxygengivenbymask.Anivisplaced.Outlineyourimmediatemanagementincludingdrugdoses(3marks)1

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Question7A29yearoldfemalepresentstotheEDwithlowerabdominalpain.Observationsarestable,bloodtestsarewithinnormalrangeandherpregnancytestisnegative.1.Which4riskfactorssuggestpelvicinflammatorydisease?(2marks)12342.Whenshouldtreatmentbeinitiated?(2marks)123.Whatarethe4mainindicationsforhospitaladmission?(2marks)12344.Whatdischargetopicsshouldbediscussedwiththepatient?(4marks)1234

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Question8A35year-oldfemaleisbroughttotheEDbyherhusband.Shehasnotbeenfeelingwellandisbecomingirritable,agitatedandisconstantlysweaty.Sheisknowntohavehyperthyroidismandlastweekunderwentsurgery.ExaminationrevealsaHR144bpmandT38.4°C.1.Whatthreeclinicalfeaturesaremostrelevanttoassessforthyroidstorm?(3marks)1232.List4specificdrugsthatwouldbeusedtotreatthispatientandoutlinetheirmechanismofaction.Providedoseswhereappropriate.(4marks)12343.Apartfromsupportivemeasuressuchasivifluids,correctingfluidorelectrolyteimbalance,externalcooling,outlineoptionsforrefractorythyroidstorm(3marks)123

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Question9Apatientpresentstotheemergencydepartmentaftersustainingmultiplelacerationstothesoleofthefootfromoystershellsafterwalkingonthebeach.Youwishtoperformaregionalblocktotheplantaraspectofthefoot.

1.Namethe3nervesinvolvedandtheircutaneousdistribution(3marks)

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2.WherewouldyouinsertLAtoanaesthetisetheseregions(3marks)

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4.What4otherissuesmustbeaddressedinthetreatmentofthisinjuryprioratdischargeincludingdrugdoseswhereappropriate(4marks)

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Question10A25year-oldmaleinvolvedinamotorbikeaccidentwasbroughttotheEDatatertiarylevelcentre.AtraumaserieswasperformedwithanormalCXRandC-spineXray.Thefollowingradiologicalimagingwasundertaken.Vitalsignsare:RR20sat99%onroomairHR115BP80/50GCS15

1.ListtheabnormalitiesonthisXray(2marks)

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2.Whatclinicalsignsareassociatedwiththisinjuryonexamination(1mark)

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3.Givethe4mostlikelycausesofhypotensioninthispatient(2marks)

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4.Listthefivemostimportanttreatmentanddispositionpriorities,astheteamleader,intreatingthispatient’shypotension.Givedetails(5marks)

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Question11A38year-oldfemalewasbroughttotheEDbyherhusband.ShewasagitatedbutisnowdrowsyandherGCSis13.AnECGwasperformed.

1.Younoteawidecomplextachycardia.DescribethetwootherimportantfindingsontheECG(2marks)122.Whatisthelikelydiagnosis(1mark)?

3.HerGSCdecreasesto10andyoudecidetoproceedwithintubation.

HR120BP95/70Sats98%onNRMRR30Temp36.8degrees

NS500mlsbolusisstarted.

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Whatmedicationswouldyougiveduringthenext5-20minutespriorandduringtheintubation?Includedoseswhereappropriate(5marks)123454.Afterintubationshehasageneralisedseizure.Whatmedicationswouldyougiveatthispoint(2marks)?1

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Question12YouareworkingataruralEDlocatednearanAustralianskifield.Youreceivea27yearoldmanwhohasfallenintoafrozenlakewhilehiking.Hehasarrivedtoyourresuscitationroom30minutesaftersubmersion.Hiscoretemperatureis27.40C1.Definehypothermiaandhypothermiaseverity?(2marks)12342.WhatfourfeaturesofhypothermiaaredemonstratedonanECGotherthanVF?(2marks)12343.HisrhythmonthemonitorchangestoVF.ACLSalgorithmisstartedwithbreathsandcompression,butnocessationofVFafter3roundsofdefibrillationand1mgofadrenalineiv.HowwillyounowdifferyourresuscitationcomparedtotheusualACLSalgorithm?(4marks)12344.Whatarethe2maintypesofwarmingand2giveexamplesofhoweachcanbeachieved?(2marks)12

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Question13Itis1600onSaturdayafternoon.A75yearoldwomanwithabackgroundofCRFonperitonealdialysisanddietcontrolleddiabetespresentswithretrosternalchestpainradiatingtoneckandbotharmswhichstarted60minutespreviously.Sheiswellfunctioninginthecommunityandheronlymedicationsareirbesartan,calciumandvitaminD.Shehasnoallergies.SheisvitallystableandthefollowingECGisperfomed:

1.WhatarethediagnosticfeaturesontheECG?(1mark)1232.Ifyouwereworkingatanurbanmajorreferralhospitalwith24houron-callPCIcapabilities,wouldyouactivatethePCIteam–theyhavenoaccesstotheECGandwillactonyourrecommendationandoutlineyourreasoning?(2marks)

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3.IfyouwereworkingataruralemergencydepartmentwouldyougivethombolysisconsideringthatatthistimetheavailabilityoftransfertoPCIis3hours(2marks)4.List10features(4history,3ECGand3otherinvestigations)thatwouldincreasethediagnosticpossibilityofSTEMIoverpericarditis(5marks)12345678910

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Question14Yourregistrarasksyouforadvice.A50yearoldfemalehaspresentedfollowingacollapseandisnowincreasinglyconfused.Heronlyinjuryisaminorabrasiontoherforehead.Youhavethefollowingblood/urineresultsthusfar:Glucose16.4 Hb13.1Na111 WCC12.2K4.2 Plts175Urea7.2Creatinine102 Patientweight65kgUrineOsmolality125 UrineNa421.WhatishercalculatedNa?(1mark)

2.Whatishercalculatedosmolality(1mark)3.Whatare12criteriaforSIADHonhistory,examinationandinvestigations?(6marks)1234567891011124.Sheremainsconfusedandthenhasaseizure.Whatisyourspecifictreatmentandwhatisyourendpoint.(2marks)12

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Question15

1.Whatisthisdevice?(1mark)2.Describe2clinicalsituationswhenyoumightconsiderusingthisdeviceinED?(1mark)123.Howcanyouconfirmtheplacementofthisdevice?(3marks)1234.Describeclinicalsituationswhenthisdevicewouldbeinappropriate/contraindicated.(5marks)12345

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Question16A22yearoldfemalemedicalstudentisbroughtinbyambulancefollowingashortseizureathome.ShehasrecentlyreturnedfromherelectiveinMalawi.Herstudentfriendsareunsureifshetookanyofhermedicationsbecausetheygavehernightmares.Sheisnowdrowsyandnotorientated.YoucallpublichealthandtheydonotsuspectEbola.1.Namethemostlikelycausativeorganism(1mark)2.ABSLisnormal.Whatotherfourinitialbloodtestswillyouarrangeimmediatelyandwhatwouldyouexpectforeach?(4marks)12343.Publichealthcallsbackastherehasbeenanewreportof5casesofEbolaconfirmedinMalawiintheclinicthemedicalstudentwasat.Outlinetheimportantissues.(5marks)12345

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Question17A70kg26yearoldmanisinvolvedinahousefireinanenclosedroom.Hehasburnstothewholeofhishead,theventralaspectsofbotharmsand3%onhischest.1.Whatarethesignsthatwouldalertyoutoanairwayprobleminthispatient?(4marks)12342.Calculatethe%burn(1mark)

3.Whatfluidwouldyouchart(typeandamount)eachhourforthefirst8hours–showyourcalculation?(3marks)4.Whatanalgesiawouldyougiveandbywhatroute?(1mark)5.Whatwouldyouaimhisurineoutputtobe?(1mark)

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Question18A2yearoldboyisbroughtintotheEDbyhismotherafterswallowinghisoldersister’searring.

1.Whatinthehistorywouldalertyoutothepresenceofaforeignbody?(3marks)123

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2.YoureviewtheXray.DoyouthinktheFBisinthetracheaoroesophagusandwhy?(1mark)3.Whereintheoesophagusmightaforeignbodybecomelodged?(3marks)1234.Describe3instanceswherethisFBwouldneedtoremovedurgently(3marks)123

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Question19

A19yearoldgirlisbroughtinbyherfriendafteranepisodeofcollapse.Theyhadbeentakingecstasyanddancingallnight.Shehasatemperatureof39degrees,HR140bpm,BP190/110.Sheappearsdehydrated,agitatedandhasarestingtremor.Sheiscatheterisedwiththeaboveurine.

1.Whatisthelikelydiagnosis?(1mark)2.Whatisthemostimportantelectrolyteresultyouwouldwanttoknowbeforestartingtreatmentandwhy?(2marks)3.ThelaboratoryringyouwithanurgentNaresultof112mmol/l.NamefourfurtherstepsintheEDmanagementincludingdrugdosesandroutewhereappropriate.(4marks)12344.Name3clinicalsignsinthispatientthatwouldbestcorrelatewithserotonintoxicity(3marks)123

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Question20A42yearoldmanfelloffhisbicyclewhentravellingat20km/h.Hecomplainedofleftforearmpain.HehadthefollowingX-raystaken.

1.WhataretheabnormalitiesontheX-ray?(2marks)

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2.Listthe2mostlikelynerveinjuries(2marks)123.Yourregistrardecidestoperformproceduralsedation.Outlineyourchecklistwithdetailsofeachofthemajorarea.(6marks)123456

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Question21A57yearsoldmalepresentedtoEDwithasuddenonsetredpainfulrighteye.Yoususpectadiagnosisofacuteglaucoma1.WhatarethefeaturesofacuteGlaucomaonexamination?(4marks)12342.Howdoesglaucomacauseblindness?(1mark)

3.Listthe5mostrelevanttopicalmedicationsusedinprimaryopenangleglaucomaandexplainwhytheyareused:(5marks)12345

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Question22A32year-oldalcoholicdiabeticmalepresentswithapainfulfacialswellingfromatoothabscesswhichhasbeengettingworseover2days.Heisofnofixedaddressandhasbeenunabletogettoadentist.HisvitalsignsshowaHR:110bpm,BP120/75;RR24withsaturationof94%andauraltempof38.5degreesC.Hisneckandthroataretendertopalpationandareswollen.Hehasdifficultyopeninghismouthandisunabletoprotrudehistongue.Histongueappearsdisplacedsuperiorlyandanteriorly.1.Whatisthelikelydiagnosis?(1mark)2.Whatarethe2seriouscomplicationsofthisdiagnosis?(2marks)123.Listyourtop3treatmentpriorities(3marks)1234.Listtheantibioticchoicesthatmaybeusefulandstatetherationalforyourchoice.(4marks)1234

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Question23A32yearoldladywhois36weekspregnantpresentedwithheadache,drowsinessandherobservationsandresultsareasfollows:Pulse110bpm Hb9gm/dlBP180/110mmhg WCC8x109/LRR24/min PLT34x109/LSats96%air LFT:AST120u/L,ALT135u/L LDH750u/L1.Whatisthediagnosis?(2marks)2.What2anti-hypertensivedrugswouldyouconsidertotreatherbloodpressure,statedoses?(2marks)123.YouhavepagedthePICUdoctorandobstetriciantoyourresuscitationroom.Yourpatientstartstohaveaseizure.Whatarethefirstfourthingsyouwoulddo?(4marks)12344.Whatarethe4signsofmaternaltoxicitywithmagnesiumsulphatewhichwouldpredicteitherrespiratoryorcardiacarrest?(2marks)1234

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Question24A4yearoldmaleisbroughttoyouremergencydepartmentbyhisparentsbecauseheishavingdifficultybreathing.Younoticethereisanaudiblewheeze,RR36andheisabletospeakinsentences.1.List6featuresofacutesevereasthma(2marks)1234562.Listthemedicationsyouwoulduseinitiallyincludingdosesinthischildifyouidentifiedthefeaturesofmoderateseverityasthmapriortobeingabletoplaceaniv(4marks)12343.Whatarethesignsofsalbutamoltoxicity?(4marks)1

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Question25A22yearoldmalewithknowncerebralpalsypresentedtoEDwithaseizure.HecomplainsofworseningheadacheandisknowntohaveVPshunt.HisobservationsarestableandGCS15.1.Listthe2mostlikelycausesofworseningheadacheinthisman?(2marks)122.Howdoyouinterpretshuntfunctionafterlocatingandpressingthechamber?(2marks)123.What2radiologicalinvestigationswillyouarrangeforasuspectedblockedVPshunt.Explainyourrationalforeach(2marks)124.Theneurosurgicalregistrarasksyoutoperformashunttap.Outlinethesteps(2marks)4.Whatarethepossibleoutcomesoftheshunttapandwhatistheirsignificance?(2marks)12

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Question26Theconcernedparentsofa2dayoldinfantpresentforreviewatyouremergencydepartment.Theyhavenotedthatthereismarkedyellowingoftheskin.Younotethattheyellowdiscolourationextendsfromtheheadtothetrunkbutnottothearmsorlegs.1.List6differentialsyouwouldconsiderforthisneonate.(3marks)1234562.ListthemostrelevantinvestigationswhichyouwouldconsiderintheED.(5marks)123453.Theconjugatedbilirubinlevelisgreaterthan15%ofthetotal(measuredlevelat15microM/L).Whatwouldbethenextappropriateinvestigationandwhy?(2marks)

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Question27A25yearoldmalepresentedtoyourEDaftertakinganoverdoseof100tabletsofaspirin300mg.1.Listthreespecificclinicalfeaturesofaspirintoxicitythatyoumightexpecthimtodevelop?(3marks)1233.AVBGisperformed.Whatwouldyouexpect?(3marks)1234.Whatreasonswouldyouconsiderhaemodialysis?(4marks)1234

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Question28A52year-oldfemaleispresentingtotheEDwitha3dayhistoryoffeelinggenerallyunwellwithnauseaandabdominalpain.Sheisapyrexial(T36.7°C),HR78andBP85/50mmHgBloodresultsareasfollows:Na126mmol/LK5.7mmol/LGlucose2.3mmol/LCalcium2.6mmol/L1.Whatisyourprovisionaldiagnosisforthiswoman?(2marks)2.Listthe2mainpathophysiologicalcausesforthispresentation?(2marks)123.Whatotherbloodinvestigationswillbehelpfulinconfirmingyourdiagnosis?(2marks)124.Listfourmanagementstepsandrationalebehindeach(4marks)1234

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Question29A5yearoldboyhasbeenbroughttoyouremergencydepartmentafteraroadtrafficaccident.Hehashadabloodtransfusioncommencedbytheretrievalserviceforhaemorrhagicshock.Thesecondunithasalreadybeencommenced.1.Whatisthedefinitionofmassivetransfusioninthischild?(2marks)2.Listeightpotentialcomplicationsofmassivetransfusionforthischild(4marks)123456783.Ifhewastohaveacardiacarrest.Whatarethe4likelycauses(4marks)1234

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Question30

A2yearoldboyweighingabout20kgwasbroughttoyourregionalEDbyhismotherhavingaccidentallyswallowedhydrochloricacidkeptnearaBBQ.Theingestiontookplace20minutespriortoarrival1.Whatare5featuresthatwouldalertyoutoimpendingairwaycompromise?(5marks)123452.Howwouldyoudecontaminatethisingestion?(1mark)3.Whataretheindicationsforendoscopywithinthefirst24hours?(4marks)1234