Download - University Hospital, Geelong Emergency Medicine Trial ... · you to come and see a 50 year old male patient at the request of one of the night registrars who is having difficulty

IDNUMBER:

UniversityHospital,Geelong

EmergencyMedicine

TrialFellowshipExam

ShortAnswerQuestions(SAQ)

Week29

DIRECTIONSTOCANDIDATE

1. Answereachquestioninthespaceprovidedinthisquestionpaper.

2. Donotwriteyournameonthisquestionpaper.

3. Enteryourexaminationnumberinthespacebelow.

4. Crossoutanyerrorscompletely.

5. Donotbegintheexamuntilinstructedtodoso.

6. Donottakeexaminationpaperormaterialsfromthisroom.

7. Thebookletbindermayberemovedduringtheexam.

QUESTION&ANSWER

BOOKLET

UniversityHospital,Geelong-FellowshipExamShortAnswerQuestionsWeek29

1

Question1(18marks)An84yearoldwomanisbroughttoyouremergencydepartmentbyherdaughter,whoishercarer.Herdaughterreportsthatthepatientishavingdifficultwithmobilisationtoday.Thetriagenurseapproachesyouwithaconcernofpossibleelderabuse.

a. Listfour(4)behavioursthatthecarermaydisplaythatwouldsupporttheconcernofelderabuse.(4marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

4. ________________________________________________________________________

b. Listfour(4)examinationfeaturesofthepatientthatwouldsupporttheconcernofelderabuse.(4marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

4. ________________________________________________________________________


2

Question1(continued)Thepatientappearsunwellandfrail.Youmakeaclinicalandradiologicaldiagnosisofleftlowerlobepneumonia.Hervitalsigns: BP 75/60 mmHg

HR 160 bpm(sinustachycardia)

RR 50 bpm

Temp 39.6 °C

O2sat 86% onroomair

GCS 10 (E3,V3,M4)

Thepatientfailstorespondtoyourescalationoftreatmentoverthenext1hour.Thedaughtersaysshewants“everythingdone”.

c. Listfive(5)factorsthatyouwouldconsiderwhendiscussingthisrequestwiththedaughter.(5marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

4. ________________________________________________________________________

5. ________________________________________________________________________


3

Question1(continued)Thedaughterreportsthatthepatientisaregisteredorgandonorandwishestopursuethepossibilityoforgandonation.

d. Listfive(5)criteriathatmustbemet,ingeneral,fortheconsiderationoforgandonation.(5marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

4. ________________________________________________________________________

5. ________________________________________________________________________


4

Question2(13marks)A35year-oldwomandriverwasinvolvedinamotorvehiclecollision.Shewaswearingaseatbelt,self-extricatedherselfandwasambulantatthescene.Whilegivingdetailstothepolice,shereportedneckpainwhichwasnotpresentforthefirst10minutespostcollision.Shearrivesbyambulanceinsittingpositionwithoutspinalimmobilisation.Arigidcervicalcollarisplacedattriage.Hermaincomplaintisofmoderateseverityneckpain.

a. Listfour(4)featuresonhistoryorexaminationthatwouldmandatetheneedforcervicalspineimaging.(4marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. ________________________________________________________________________

4. ________________________________________________________________________

b. Assumingtheabsenceofallofthesefeatures,listthree(3)lowriskfactorsofthispresentationasstatedthatallowsafeassessmentofrangeofmovementofhercervicalspine.(3marks)

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________


5

Question2(continued)c. Adecisionismadetoprogresstoimaging.Stateone(1)importantproandone(1)

importantconfortheimagingoptionsbelow,forthispatient.(6marks)

Imagingoption Pro(3marks)

Con(3marks)

Plainxrayseries

CTCSpine

MRICspine


6

Question3(13marks)A16yearoldgirlpresentstotheemergencydepartmentwithlowerabdominaldiscomfortandpervaginalbleedingof24hourduration.Shethinksthatshemaybepregnantonthebasisofonemissedperiod(LNMP6weeksago).

a. Completethetablebelow,demonstrating,inlistformat,yourunderstandingoftheroleofaurinepregnancytestinthispatient.(4marks)

Significanceofapositiveresult(2marks)

1.

2.

Significanceofanegativeresult(2marks)

1.

2.

Herurinarypregnancytestispositive.

b. Listtwo(2)circumstancesinwhichavaginalspeculumexaminationwouldbeindicatedforthispatient.(2marks)

1. ________________________________________________________________________

2. ________________________________________________________________________


7

Question3(continued)

Atransvaginalultrasoundshowsanormal6weekintrauterinepregnancy.Thepatientstatesthatshedoesnotwishtocontinueherpregnancy.

c. Listthree(3)factorsonhistorythatyouwouldseekfromthepatientwithrespecttothisstatement.(3marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

Thepatient’sparentsarriveanddemandtoknowwhatiswrongwithher.

d. Listfour(4)stepsthatyouwouldtakeinresponsetothisrequest.(4marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

4. ________________________________________________________________________


8

Question4(12marks)

An18monthboypresentswith24hoursofvomitingandbloodydiarrhoea.

a. OtherthanHaemolyticuraemicsyndrome,listfour(4)likelycausesforthispresentation.(4marks)

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

4. _________________________________________________________________________

b. Listfour(4)featuresonexaminationthatwouldsupportthediagnosisofhaemolyticuraemicsyndrome.(4marks)

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

4. _________________________________________________________________________


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c. Listfour(4)laboratoryfindingsthatareconsistentwithhaemolyticuraemicsyndrome.(4marks)

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

4. _________________________________________________________________________


10

Question5(12marks)A64year-oldmanpresentstoyourEmergencyDepartmentwithchestpain.AnECGistaken-BothhispreviousrestingECG(“ECG1”)andECGhiscurrentECGwithpain(“ECG2”)areshown-refertothepropsbookletpage1.

a. Statefive(5)abnormalfindingsinECG1.(5marks)1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

4. ________________________________________________________________________

5. ________________________________________________________________________

b. Statetwo(2)differentabnormalfindingsshowninECG2.(2marks)

1. ________________________________________________________________________

2. ________________________________________________________________________


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c. StatethesignificanceofthechangesinECG2,whencomparedtoECG1.Includereferencetoevidencebasedcriteriainyouranswer.Includefive(5)statementsinyouranswer.(5marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

4. ________________________________________________________________________

5. ________________________________________________________________________


12

Question6(12marks)A3yearoldmalepresentswithshortnessofbreath.

ACXRistaken-refertothepropbookletpage2.

a. Whatisthediagnosis?(1mark)

___________________________________________________________________________

b. Statefive(5)radiologicalfeaturesinthisCXRthatsupportthisdiagnosis.(5marks)

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

4. _________________________________________________________________________

5. _________________________________________________________________________


13

Question6(continued)c. Listsix(6)factorsthatyouwouldconsiderwhendeterminingdispositionforthis

patient.(6marks)

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

4. _________________________________________________________________________

5. _________________________________________________________________________

6. _________________________________________________________________________


14

Question7(12marks)A23yearoldmanwithadecreasedlevelofconsciousnessisbeingassessedinyourEmergencydepartment.Anarterialbloodgasistaken-refertothepropsbookletpage3.Hisarterialbloodgasresultswithreferencerangesareshownbelow:

a. Providefour(4)calculationstohelpyoutointerprettheseresults.(4marks)Derivedvalue1:

___________________________________________________________________________

___________________________________________________________________________

Derivedvalue2:___________________________________________________________________________

___________________________________________________________________________

Derivedvalue3:___________________________________________________________________________

___________________________________________________________________________

Derivedvalue4:___________________________________________________________________________

___________________________________________________________________________


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b. Usingthisscenarioandthederivedvalues,listthree(3)likelypotentialcausesfortheabnormalresults.(3marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

c. Statetwo(2)prosandthree(3)consfortheuseofbicarbonateinthispatient.(5

marks)

Pros:

1. ________________________________________________________________________

2. ________________________________________________________________________

Cons:

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________


16

Question8(13marks)Completethetablebelow,bystatingone(1)expecteddose-dependentclinicaleffectforeachdoserangeofVenlafaxineoverdose.Statealsoone(1)pointofmanagementofvenlafaxineoverdoseforeachdoserangeupuntil>7grams-forthisdoserangestatethree(3)managementsteps.(10marks)

Doserange Clinicaleffect(4marks)

Managementindicated(6marks)

<1.5g

1.

1.

>3-4.5g

1.

1.

>4.5-7g

1.

1.

>7g

1.

1.

2.

3.


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a. Listthree(3)criteriathatmustbemetinapatientwithavenlafaxineoverdosefortheuseofactivatedcharcoal.(3marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________


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Question9(18marks)

Youhavejustcommencedyourmorningshiftintheemergencydepartment.Anurseasksyoutocomeandseea50yearoldmalepatientattherequestofoneofthenightregistrarswhoishavingdifficultyplacingacentralvenousline.ThepatientrequiresintravenousaccessforseverecellulitisthathasbeenresistanttooralantibioticsandtheregistrarwasunabletoobtainperipheralIVaccess.Onyourarrival,theregistrarnotesthathewasonlypartiallyabletoinsertarightinternaljugularcatheterandhas“lost”thewireinthepatient.Achestxraythathehasperformedconfirmsthattheguide-wireisintheSVCandrightatrium.

a. Listthefive(5)elementsofopendisclosure.(5marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

4. _______________________________________________________________________

5. _______________________________________________________________________


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b. Otherthanopendisclosure,listsix(6)KEYmanagementstepsforthissituation.(6marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

4. _______________________________________________________________________

5. _______________________________________________________________________

6. _______________________________________________________________________

c. Listthree(3)stepsthatcouldbeusedtodeterminethataregistrarissafetoperformacentralvenouslineunsupervised.(3marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________


20


d. Listfour(4)limitationsthatcouldbeplacedontheinitialperformanceofunsupervisedinsertionofacentralvenousline.(4marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

4. ________________________________________________________________________


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IDNUMBER:

UniversityHospital,Geelong

EmergencyMedicine

TrialFellowshipExam

ShortAnswerQuestions(SAQ)

Week29

PROPBOOKLET


1

Question5

ECG1 PreviousrestingECG

ECG2 CurrentECGwithpain


2

Question6


3

Question7