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:tomre@barwonhealth.org.au 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

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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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