Question1:

A20yomaleattendswithagrosslyswollenpainfulhandfromapunchinginjuryat36hours.Thereisbrokenskinoverthe3rdMCPjoint.

(a) Whatcomplicationsmayarisefromthisinjury?(20%)(b) Outlineyourexamination(20%)(c) Giventheappearanceofthehandshown,whatinvestigationswouldyourequest,assuming

nocomorbiditiesandthatthisisanisolatedinjury?(20%)(d) Whataretheindicationsforadmission?(20%)

Question2:

A45yomaleisbroughttoLauncestonEDbyambulancefromapropertynearLauncestonTasmania.Hereportsthathehasbeenbittenonthehandinthefield“byatigersnake”20minutesearlier.Apressurebandageandsplintwereappliedinthefield.Heexperiencedabriefsyncopewithinafewminutesofthebiteandnowcomplainsofmilddiscomfortinthehand,visualblurringandfeelinglightheaded.

(a) Sequenceyourmanagementsteps(35%)(b) WhatistheroleforVDKinthisman?(10%)(c) Whatlaboratorytestsareappropriatetothemanagementofthiscase?(30%)(d) CompletethetablefortheclinicalpresentationofTigersnakeenvenomationinhumans?

(30%)Symptom/sign/labresult present/absent(crossout

incorrectanswer)Severepainatthebitesite present/absent

Defibrinatingcoagulopathy present/absentAnti-coagulantcoagulopathy present/absentMyolysis(clinicallysignificant) present/absentPresynapticparalysis present/absentPostsynapticparalysis present/absent

Question3:

ImmediatelyuponcommencingTigersnakeantivenomtherapya45yomaledevelopsseveredyspnoea,throat“tightness”andlightheadedness.

(a) Describeyourimmediateactions.(70%)(b) Describethehypersensitivityreactioninvolved.(30%)

Question4:

A45yomalehasbecomeunresponsiveafewsecondsafterreceiving500mcgofIMadrenalineforfloridanaphylaxis(hypoxia,hypotension,welting,wheezeandtongueswelling)tosnakebiteantivenom.

(a) Youelecttointubateusingketamineandsuxamethonium(assumingthattherearenocontraindications).Completethetablebyenteringdifficultiesthatyoumayanticipateandenteringtheimmediateremediesthatyou’dinstituteforthese.

Potentialdifficulty Remedy1. 1.2. 2.3. 3.4. 4.5. 5.

Question5:

A45yomalehasbecomeunresponsiveafewsecondsafterreceiving500mcgofIMadrenalineforfloridanaphylaxis(hypoxia,hypotension,welting,wheezeandtongueswelling)tosnakebiteantivenom.

(a) Outlinetheventilationstrategythatyouwillemployinthiscase.

Question6:

A47yoCaucasianmalewhohasapriorhypoxicbraininjury(secondarytoanaphylaxis)complicatedbyseizures.Heisbroughttoyourdepartmentwithanongoinggeneralizedseizuredespitehavinghad15mg(0.2mg/kg)ofmidazolamen-route.HisBGLis12.0mmol/L.Notrauma.Noothercomorbidities.

(a) Assumingthattherearenodrugallergies,inthetablebelowsequencethenextfourmedicationsthatyouwouldusetocontrolthisseizure

Medication Immediatepotentialcomplications

(b) Recordtheimmediatecomplicationsthatyouwouldanticipatewithusingthesemedications

Question7:

Whistrestraininga47yomalewithaconvulsiveseizureanursewaskneedinthecheek,includingtheorbitandnose.Sheexperiencedimmediateepistaxis,facialpainandvisualblurring.(photo)

(a) Assumingthatthisisanisolatedfacialinjurywithoutlossofconsciousness,listsixpotentialimmediateocularcomplicationsthatyouwouldexclude.(25%)

(b) Whatnon-occularcomplicationswouldyouseektoexclude?(25%)(c) Describeyourmanagementofaprobableacutelyfracturednose.(25%)(d) Whataretheclinicalsignsoforbitalcompartmentsyndrome?Whatistheimmediate

management?(25%)

Answers

Question8:

YouworkinametropolitanED.Inworkingthroughyouralgorithmforstatusepilepticusyouelecttousepropofolasafourthlineagent.Younotethatthepatienthasashort,thickneck,protuberantteethandahypertrophictracheostomyscar.

(a) Whatisyourapproachtothissituation?(30%)(b) Describe4-10stepsinperforminganemergencysurgicalairway.(50%)(c) Whatare5potentialcomplicationsofthisprocedure?(20%)

Question9:

A70yofemaleattendswithacute,non-traumaticpainlessrightunioccularblindness.

(a) List5potentialaetiologiesforthispresentation(50%)(b) WhataretheclinicalfeaturesthatwouldsuggestGiantCellArteritis?(30%)(c) WhatisthetreatmentforGiantCellArteritis?(10%)(d) WhatarethecomplicationsofdelayedtreatmentofGiantCellArteritis?(10%)

Question10:

A55yomalefarmhandattendswithpalpitationsfor8hoursandisfoundtobeinAF.Hehasnohistoryofrheumaticfever,IHD,hypertension,valvularheartdisease,previouscerebralischaemia,peripheralvasculardiseaseordiabetes.HeisnormotensiveandhasnoECGevidenceofischaemia.Thisishisfirstepisode.ApartfromtheAFhisechoisnormal.

(a) CalculatehisCHADS2score(b) Whatisthepurposeofthisscore(c) WhatisthepurposeoftheHASBLEDscore(d) InthetablebelowList4pharmacologicmanagementoptionsforthispatientandlisttwo

clinicallyimportantpros(excludinghypersensitivityreactions)foreach

Medication Pros Cons1. 1(i). 1(i)

1(ii) 1(ii)2. 2(i) 2(i)

2(i) 2(ii)3. 3(i) 3(i)

3(ii) 3(ii)4. 4(i) 4(i)

4(ii) 4(ii)

Question11:

A30yoIVdruguserisBIBAwithacutestridor.En-routehehasbeengivenadrenaline500mcgIM,ventolinandoxygen.HehasanIVinplace.

Heisalert,diaphoretic,andpale,febrileT-38.5C,PR100SR,BP120/80,RR20,Sats96%R/A.Hehasimpairedmouthopeningandabdominalrigidity.Hereportsfeelingunwellandcomplainsofdifficultyswallowingandbackpainandoverthepastthreedays.

(a) WhatisyourDDxforthispresentation?(40%)(b) Whatisthepathophysiologyoftetanus(20%)(c) Whataretheprioritiesinthemanagementofthismanwithgeneralizedtetanus?(40%)

Question12:

A24yofemaleisBIBAwithfever,mutismandincreasedmuscletone.

(a) List5druginducedsyndromesthathavehyperthermiaasapresentingsign.(10%)(b) Whatarethecardinalfeaturesofthehistoryandclinicalexaminationthatdefinethisas

NeurolepticMalignantSyndromeasdistinctfromHyperserotonism?(40%)(c) WhataretheindicationsforintubationinthiswomanwithNMS?(25%)(d) Howwouldyoumanageherhyperthermia?(25%)

Question13:

A55yomaleisBIBAwithsevereCPof45minutesduration.Hehashadoxygen,600mcgofGTN,300mgoforalaspirinfollowedby250mlsofNSforhypotension.ECGattached(assumestandardcalibrationandpaperspeed)

(a) WhatisthediagnosisfromthisECG?(15%)(b) Whatarethemostlikelycausesforacutehypotensioninthissetting?(30%)(c) WhataretheprincipalinterventionsforcardiogenicshockinAMI?(20%)(d) List8absolutecontraindicationstogivingfibrinolytictherapy.(35%)

Question14:

A74yo,normallyactiveandindependentfemalepresentswithlightheadedness.PR30bpm,BP70/40.Sheisonnomedications.Shedenieschestpainatanystage.

(a) WhatisthediagnosisfromthisECG?(20%)(b) Whatareyouroptionsformanagingthisconditionacutely?(40%)(c) Describethestepsinexternalpacing(40%)

Question15:

A22yofemaleattendswithasuddenonsetsevereunilateralheadache.

(a) WhatfeaturesonhistoryandexaminationsupportthediagnosisofAcuteSub-arachnoidHaemorrhage?(20%)

(b) Whatfeaturessupportthediagnosisofhemicrania?(20%)(c) WhatistheoptimaltimingforanLPtoexcludethediagnosisofSAH?(10%)(d) Describeyourprocedure/techniqueforlumbarpuncture.(30%)

TheLPresult(afteranegativeCTforSAH)follow:

(e) Whatisthenextstepinthediagnosticworkupgiventhisresult?(20%)

Question16:

A28yomalehasbeenBIBA.

Assaultedbya“business”partnerinacarparklateatnight.

Foundunconscious,pronewhenpeoplewerealertedbyyelling.

Hehasastabwoundtotherightlateralchestandabluntskullinjurywithbogginess.

GCS–3,PR140,BP70/40,RR36,Satsnotaccurate(poorperipheralperfusion),pupilsequal4mm,sluggish.

Pre-hospitalMx:intercostalneedlerightchest,3sideddressingrightchest,IVC,NS250mls,oxygen,collar.

(a) Howdoyoumanagehisshock(25%)

(b) DescribeyourtechniqueforICCinsertionforastabbedchest(25%)(c) Describeyourapproachtointubationinthissituation(25%)(d) WillyouintubatebeforeorafterICCinsertion?Justifyyourdecision.(25%)

Answers16

Question17:

Youhaveintubatedapatientwithasevereheadinjuryfromanassault.

HisCTisattached.

(a) ListtheabnormalitiesonthisCT(50%)(b) Wouldyouprovideseizureprophylaxis?(20%)(c) Outlineyourmanagementanddefineyourphysiologicaltargetsintheinitialresuscitation

forthispresentation.(30%)

Question18:

Athreeyearoldchildisbroughtinbyhermotherinwiththepresentingcomplaintofvomiting.

Herinitialobservationsare:Temp37C,PR120,normalcolour,RR18,Oxygensaturation99%R/A,GCS15,pupils3mm,brisklyreactive.

After10minutesinthewaitingroomthetriagenotesthatshehasastaggeringgait.YouarecalledtoreviewherintheCINroom.

Sheispaleanddrowsywithgenerallyreducedtone,PR88,RR10,pupils2mmandslightlysluggish.

(a) Outline5essentialstepsinherresuscitation(20%)(b) Apartfromingestionslist4potentialaetiologiesforherpresentation(20%)(c) List5potentialtoxicologicalaetiologiesforthispresentation(20%)(d) Youlearnthathermotherhadgivenmethadonetosettleherbehaviour.Whatisyour

response?(20%)