“list” = 1-3 words university hospital, geelong … · week 1– trial short answer questions...
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UNIVERSITYHOSPITAL,GEELONGFELLOWSHIPWRITTENEXAMINATION
WEEK1–TRIALSHORTANSWERQUESTIONSSuggestedanswersPLEASELETTOMKNOWOFANYERRORS/OTHEROPTIONSFORANSWERSPleasedonotsimplychangethisdocument-itisnotthemastercopy!
Question1(18marks)9minutes A40yearoldmalepresentstotheEDwithfeverandconfusionfor24hours.Hehasjustreturnedfromonemonthback-packingthroughPapuaNewGuineaandIndonesia.Hisobservationsare:PR120bpmBP130/80mmHgRR16bpmTemp39.5°CGCS13(V3)
a. Listfour(4)likelydifferentialdiagnosesforthispresentation.Foreachdiagnosislisttheexpectedincubationperiodpriortoclinicalfeatures.(8marks)
NB: GCS↓ Don’tpickaDDxforwhichyouhavenoideaofincubationperiod!
Differentialdiagnosis(5marks)
Expectedincubationperiod(5marks)
Malaria-Cerebral/FalciparumMANDATORY
Falciparum:6–30days(98%onsetwithin3monthsoftravel)Vivax:8daysto12months(almost½haveonset>30daysaftercompletionoftravel)
Typhoidfever-MANDATORY 8-14days(3days-1month)Japaneseencephalitis(endemicarea) 3–14days(1–20days)Entericfever 7-8days(3-60daysScrubTyphus 6-20daysLeptospirosis(wildrodents/water) 7-12daysDengue(notusuallyACS) 4-8days(3-14)Meningitis-bacterial Hours-daysPneumonia Hours-daysViralencephalitis 3–14days(1–20days)
b. Listfour(4)keyinvestigationsthatyoumayperformtoassistwiththediagnosis.(4marks)NB “toassistwiththediagnosis”
• Bloodfilms-T&T• Bloodcultures• Serology-Dengue• Serology--viral• CTB
c. Listtwo(2)specificmedicationsthatyouwouldconsiderasempirictreatmentpriortoobtaining
confirmatorytestsforthispatient.Foreach,listyourdoseandroute.(6marks)
Medication(2marks)
Dose(2marks)
Route(2marks)
1 Ceftriaxone 2g IV
2 Artesunate(1stlineseveremalaria) OR(ifparenteralartesunateisnotimmediatelyavailable)quininedihydrochloride
2.4mg/kg20mg/kg
IV
Youshouldknowthefeatures/Dx/Mxof:Malaria,Dengue,Typhoid,Yellowfever,Travellers’Diarrhoea&Schistosomiasis
“List”=1-3words“State”=shortstatement/phrase/clause
ClickontheimagebelowtoviewtheentirePDF(&print/saveifnecessary)
Ihaven’tfoundabetterarticlethanthisonthistopic-stillrelevantdespiteitsage
Question2(8marks)6minutes
A59yearoldobeseman receives5mgof intravenousmorphine foranalgesia forabdominalpain.Thirtyminuteslater,hisGCShasfallento12andinvestigationsareperformed. ReferenceRange FiO2 0.21 pH 7.24 7.35-7.45 pCO2 92mmHg 35-45 pO2 45mmHg 80-95 Bicarbonate 49mmol/L 22-28 Baseexcess 10 -3-+3 O2saturation 78% >95 Lactate 1.2mmol/L <1.3 Na+ 142mmol/L 134-146 K+ 3.8mmol/L 3.4-5 Cl- 86mmol/L 98-106 Glucose 11.4mmol/L 3.5-5.5 Haemoglobin 184g/L 135–180 CarboxyHb 7% <6%
a. Providetwo(2)calculationstohelpyoutointerprettheseresults. Derivedvalue1: A-agradient=150-(1.25x92)-45=-10thereforenonA-agradient Derivedvalue2: ExpectedHCO3=
ACUTE:foreveryincreasedin10ofCO2above40,HCO3↑by1from24=24+5=29 CHRONIC:forevery↑in10ofCO2above40,HCO3↑by4from24=24+(5x4)=44 Thereforefullcompensationwithsuperimposedmetabolicalkalosis
Simplerespiratoryalkalosis:Acute↓ HCO3-2in10minevery10mmHg↓ PCO2.Minimumof18∴<18highlysuggestiveofmetabolicacidosis(pCo2valuescannotbenegative)Chronic ↓ HCO3-5ifsustainedfor2-3days
b. Usingthescenarioandthederivedvalues,definetheprimaryabnormality/s.(2marks) • Respiratoryacidosis:
o Acuteonchronic• Superimposedmetabolicalkalosisnotaccountedforbycompensationforrespiratoryacidosis
o secondarytovomitinginsettingabdominalpain
c. Usingthescenarioandthederivedvalues,definethesecondaryabnormality/s.(2marks)• MetabolicalkalosisascompensationforchronicRespacidosis
d. Provideaunifyingexplanationfortheseresults.(2marks)• Chronicrespacidosissecondarytopossiblehypoventilationfromobesity,+/-obstructive
sleepapnoea• Respiratorydepressionandhypercapniaexacerbatedbyopioids->lifethreateninghypoxia• Acutedeteriorationsecondarytodepressioncentralrespiratorydrivefromadministration
opioidswithnoevidenceofunderlyingV/Qmismatch• Metabolicalkalosisinsettingofabdominalpainandpossiblevomiting/GIlosses
Question3(12marks)6minutes
A42yearoldfemalepresentsviaprivatecartotheEDwithsevererightflankpain.
Herobservationsare:BP70 PR150 RR16 Temp37°C GCS15
a. Listfour(4)likelydifferentialdiagnosesforthisscenario.(4marks)
NB: Dxneedstoexplainobswhichshowshock.Ie“ectopicpregnancy”isnotcorrect Rupturedovariancystmaycausethispicturebutmostcysticbleedingisusuallycontained
• Intra-abdo/retroperitonealbleed• Rupturedectopicpregnancywithhaemorrhageshock• Pyelonephritiswithsepsis-egG-ve• Renalcolicwithobstruction&sepsis• Rupturedappendicitiswithperitonitisandsepsis
b. Listfour(4)investigationsthatyouwouldperformtoassistwiththediagnosis.Stateone(1)justificationforeachchoice.(8marks)
NB: “toassistwiththediagnosis” “straighttotheatre”isnotaninvestigation
Investigation Justification
FASTscan
Rapidlydiagnoseintraperitonealbleed/fluidascauseforshock
CTabdo/pelvis
Diagnoseretroperitonealbleedorfreefluid,hydronephrosis/perinephricstranding,aorta,biliarydisease,intraperitonealgasetc
CTKUB Dxobstructedkidney/renalcalculi
OnlyifContrastCIaswouldexpectacontrastscan
βhCG
SupportsDxpregnancy/ectopic
FWT ScreenforUTI
Question4(14marks)6minutes
A72yearoldmalepresentstoEDwithextremeshortnessofbreath.HehasahistoryofCOPDandisotherwisewell.Heis70kg.Hehasnotbeengivenanymedications.Hisobservationsare: BP130PR120RR36Temp38.2°CGCS15
a. List three (3)medications thatyouwouldconsiderusing forhis initial treatment. Listdoseandrouteofadministration.(9marks)
Drug(3marks)
Delivery(3marks)
Dose(3marks)
Ventolin Neb(useairifsats>88%)
5-10mg
(carefulwithoverdosing)
Steroid:
Prednisolone
Dexamethasone
Hydrocortisone
Ō
IV
IV
50mg
10mg
250mg
Antibiotic:
Penicillin
Ceftriaxone
IV
IV
2.4g
1g
Hedoesnotrespondtoyourtreatmentandrequiresintubation.
b. Stateyourinitialventilatorsettings.(3marks)
Ventilatorsettings
Rate Low8-10
Tidalvolumes 6-8ml/kg
I:Erate Loweg1:4(prolongedexpiatoryphase)
c. Statetwo(2)reasonsforyourchoiceoftheseventilationsettings.(2marks)
• Controlled/Permissivehypercapnia-allowlongexpirationandpreventdynamichyperinflationwithpermissivehypercapnia
• ReduceIPs• Lungprotectiveventilation/sedation• Preventdynamichyperinflation/barotraumabyallowingforlongexhalationandlowI:E• Minimiseriskofvolutrauma
Question5(12marks)6minutes
A6yearoldboypresentswith1dayofthisrash.
a. Listfive(5)diagnosticfeaturesofthisrash.(5marks)
• Targetlesions• Welldemarcated/discreteinitially• Coalescewithmoreadvanceddisease• Centralareausuallyslightlyoffcentre• Centreareamaybepale/erythematous/darkrad/purple• Widespread,nosparedareas(mildtendstobeperipheral)• Varyingsizes
b. List5likelycausesforthisrash.(5marks)
Herpessimplexvirus Mycoplasma Drugssulphas,penicillinsNSAID’sphenothiazinesanticonvulsants
VirusesVaricellaCMVAdenoHepatitisViralimmunisation
CollagenVascularDiseaseProtozoanInfectionFungalInfectionSkinAllergies
c. Listtwo(2)featuresofthisdiseasethatdifferentiatesmildtoseveredisease.(2marks)
• Epithelialloss→absent→EMultiformaepresent→SJSvsTEN• %BSAinvolved<10%→SJS>30%→TEN
Question6(14marks)6minutesA52yearoldmalepresentstoEDwithchestpain.HisECGisshown.
a. Statefour(4)abnormalitiesshownonthisECG.(4marks)• Wenckebachtype,Mobitztype12nddegreeHB• STEII,III,aVF(1mm,2mm,2mmrespectively)• STDV2-V6,I,aVL• BiphasicTwavesI,aVL,V2,V3
b. Statefour(4)significantimplicationsofthesefindings.(4marks)
• InfSTEMI-meetscriteriaforurgentreperfusionRx• Likelyposteriorinvolvement
o largeinfarcto carewithMorph/GTN&fluidloadif↓BP
• Anticipatefurtherbradycardia/block/-vechronotropicinstability
c. List two (2) specific complications that youmay anticipate for this patient within the first 30minutesofyourcare.Stateone(1)specifictreatmentforeachcomplication(4marks)
Complication(3marks)
Specifictreatment(3marks)
Cardiogenicshockwith
hypotension
FluidsUrgentPCI(betteroutcomesincariogenicshockcfthrombolysis)
CHB/bradycardia Atropine-300-600mcgPaceAdrenaline(carewith+veChronotropes)Isoprenaline(AVnodesuppliedbyRCA90%)
Ventriculararrhythmiasesp
VT/VF-
DCR
↑Pain UrgentPCIFentanylforongoingpain
Question7(13marks)6minutes
a. Completethefollowingstatementwithfive(5)statements.(5marks)
Apersongivesvalidinformedconsentifthey:
• havecapacitytogiveinformedconsenttothetreatmentormedicaltreatmentproposed• havebeengivenadequateinformationtoenablethepersontomakeaninformeddecision• havebeengivenareasonableopportunitytomakethedecision• havegivenconsentfreelywithoutunduepressureorcoercionbyanyotherperson• havenotwithdrawnconsentorindicatedanyintentiontowithdrawconsent
b. Listthree(3)circumstancesinwhichapatientcanbelegallyheldagainsthis/herwishes.(3
marks)
• Insituationsinwhichurgenttreatmentisrequiredtopreventmorbidityormortalityand:• Thepatientisa:
o Minoro RecommendedundertheMentalHealthacto MedicalPowerofAttorneyexistsandagreestodetainmento Abnormalmentalstateo Significantphysiologicalderangemento Undertheinfluenceofalcohol/drugso Behaviourinconsistentwithpersonality(fromfamily,friends,GP,oldnotes)
c. Definemedical"negligence".(1mark)
• Negligenceisafailuretotakereasonablecaretoavoidcausinginjuryorlosstoanotherperson
d. Listthefour(4)legalconditionsrequiredtoprovenegligence.(4marks)• adutyofcareexists• breachofduty-thatthebehaviororinactionofthedefendantinthecircumstancesdidnot
meetthestandardofcarewhichareasonablepersonwouldmeetinthecircumstances• damage-thattheplaintiffhassufferedinjuryorlosswhichareasonablepersoninthe
circumstancescouldhavebeenexpectedtoforesee• causation-thatthedamagewascausedbythebreachofduty
NB:MentalHealthactsvaryacrossAus&NZ-theactbelowispresentedtogivesomeguidelinesandexplanations
AnexcerptfromMentalHealthAct2014(Vic)
TheinformedconsentofapersonmustbesoughtbeforetreatmentormedicaltreatmentisgiventothepersonundertheMentalHealthAct2014.AllpeoplearepresumedtohavecapacitytogiveinformedconsenttotreatmentormedicaltreatmentregardlessoftheirageorlegalstatusundertheMentalHealthAct.TheMentalHealthActsetsout:
• therequirementsforinformedconsent• thecircumstancesinwhichtreatmentcanbeprovidedtoapatientwithoutthepatient’sinformed
consentandtheprocessthatmustbeundertakenbeforeprovidingthattreatment• theprocessforprovidingmedicaltreatmenttoapatientwhodoesnothavecapacitytogiveinformed
consenttomedicaltreatment.InformedconsentTheinformedconsentofapersonmustbesoughtbeforetreatmentormedicaltreatmentisgiventoapersoninaccordancewiththeMentalHealthAct.Apersongivesinformedconsentifthey:
• havecapacitytogiveinformedconsenttothetreatmentormedicaltreatmentproposed• havebeengivenadequateinformationtoenablethepersontomakeaninformeddecision• havebeengivenareasonableopportunitytomakethedecision• havegivenconsentfreelywithoutunduepressureorcoercionbyanyotherperson• havenotwithdrawnconsentorindicatedanyintentiontowithdrawconsent.
CapacityThepersonseekinginformedconsentofanotherpersontoatreatmentormedicaltreatmentmustpresumethattheotherpersonhasthecapacitytogiveinformedconsent.Thismeansthateveryonemustbepresumedtohavecapacitytomakedecisionsabouttheirtreatmentormedicaltreatment,regardlessoftheirage(e.g.youngpeopleorolderpersons)orwhethertheyareapatientundertheMentalHealthAct.TheMentalHealthActcontainsanumberofguidingprinciplestoassistapersonwhoisrequiredtodeterminewhetherapersonhascapacitytogiveinformedconsent.Adequateinformation
Apersonhasbeengivenadequateinformationtomakeaninformeddecisionif:• theyhavebeengivenanexplanationoftheproposedtreatmentormedicaltreatment,includingthe
purpose,type,methodandlikelydurationofthetreatmentormedicaltreatment• theyhavebeengivenanexplanationoftheadvantagesanddisadvantagesofthetreatmentormedical
treatmentincludinginformationabouttheassociateddiscomforts,risksandcommonorexpectedsideeffectsofthetreatmentormedicaltreatment
• theyhavebeengivenanexplanationofanybeneficialalternativetreatmentsthatarereasonablyavailable,includinganyinformationabouttheadvantagesanddisadvantagesofthesealternatives
• theyhavereceivedanswerstoanyrelevantquestionsthatthepersonhasaskedandanyotherrelevantinformationthatislikelytoinfluencetheperson’sdecision
• theyhavebeengiventherelevantstatementofrightsandhadthatstatementexplainedtotheminamannerthatthepersonismostlikelytounderstand.
ReasonableopportunityApersonhasbeengivenareasonableopportunitytomakeadecisionif:
• thepersonhasbeengivenareasonableperiodoftimetoconsiderthemattersinvolvedinthedecision• thepersonhasbeengivenareasonableopportunitytodiscussthedecisionwiththeregisteredmedical
practitionerorotherhealthpractitionerproposingthetreatmentormedicaltreatment• thepersonhasbeengivenareasonableamountofsupporttomakethedecision• thepersonhasbeengivenareasonableopportunitytoseekanyotheradviceorassistanceinrelationtothe
decision.
GivenconsentfreelywithoutunduepressureorcoercionInformedconsentmustbefreelygiven.Apersonmustnotfeeltheyhavetogiveinformedconsentsimplybecausetheclinicianbelievesitisnecessaryfortheirtreatmentorintheirbestinterestsortopleaseafamilymemberorcarer.HavenotwithdrawnconsentApersoncanwithdrawconsentatanytime.Apersoncanwithdrawconsentverballyorinwriting.Apersoncanwithdrawconsentbeforethetreatmentstartsorduringacourseoftreatment.Ifthepersonwithdrawsconsent,thetreatmentmuststop.Apersonwithdrawsconsentiftheysayorindicatebytheirbehaviourthattheydonotconsenttothetreatment.ProvidingtreatmentwhenapatientdoesnotgiveinformedconsentTheMentalHealthActrequiresthatpatientsaregiventreatmentfortheirmentalillness.Onlythepatientcangiveorrefuseinformedconsenttotreatment.Nootherpersonorbodyauthorisedbylawtomakedecisionsforthepatientcangiveorrefuseinformedconsenttotreatment.ThismeansthataguardianorapersonresponsibleundertheGuardianshipandAdministrationAct1986oranagentundertheMentalTreatmentAct1988cannotgiveorrefuseinformedconsentonbehalfofapatient.However,theMentalHealthActpermitsanauthorisedpsychiatristtomakeatreatmentdecisionforapatientwho:
• doesnothavecapacitytogiveinformedconsenttothetreatmentproposedbytheauthorisedpsychiatristor
• hascapacitytogiveinformedconsenttothetreatmentproposedbytheauthorisedpsychiatristbuthasnotgiveninformedconsenttothattreatment.
Theauthorisedpsychiatristcanmakeatreatmentdecisionforthepatientiftheauthorisedpsychiatristissatisfiedthatthereisnolessrestrictivewayforthepatienttobetreatedotherthanthetreatmentproposedbytheauthorisedpsychiatrist.TheMentalHealthActdoesnotpermitanauthorisedpsychiatristtomakeatreatmentdecisionaboutelectroconvulsivetreatmentorneurosurgeryformentalillnessforapatient.Seeelectroconvulsivetreatmentandneurosurgeryformentalillnessformoreinformation.DeterminingtheleastrestrictivetreatmentIndeterminingwhetherthereisnolessrestrictivewayforthepatienttobetreated,theauthorisedpsychiatristmusthaveregard,totheextendthisisreasonableinthecircumstances,toallofthefollowing:
• thepatient’sviewsandpreferencesabouttreatmentofhisorhermentalillnessandanybeneficialalternativetreatmentsthatarereasonablyavailableandthereasonsforthoseviewsandpreferences,includinganyrecoveryoutcomesthatthepatientwouldliketoachieve
• theviewsandpreferencesofthepatientexpressedinhisorheradvancestatement• theviewsofthepatient’snominatedperson• theviewsoftheguardianofthepatient• theviewsofacarer,iftheauthorisedpsychiatristissatisfiedthatthetreatmentdecisionwilldirectly
affectthecarerandthecarerelationship• theviewsofaparentofthepatient,ifthepatientisundertheageof16years• theviewsoftheSecretarytotheDepartmentofHumanServicesifthepersonisthesubjectofa
custodytoSecretaryorderoraGuardianshiptoSecretaryorder• thelikelyconsequencesforthepatientiftheproposedtreatmentisnotperformed• anysecondpsychiatricopinionthathasbeengiventotheauthorisedpsychiatrist.
ProvidingmedicaltreatmenttoapatientwhodoesnothavecapacityMedicaltreatmentcanbeadministeredtoapatientifthepatientgivesinformedconsenttothemedicaltreatment.Apatientwithcapacitycanrefusemedicaltreatment.Therequirementsforinformedconsenttomedicaltreatmentarethesameastherequirementsfortreatment.SubstituteconsenttomedicaltreatmentTheMentalHealthActsetsoutrequirementsforwhocanprovidesubstituteconsentforpatients18yearsoraboveandpatientsunder18yearsofage.AdultpatientsMedicaltreatmentmaybeadministeredtoapatient18yearsorolderwhodoesnothavecapacitytogiveinformedconsenttomedicaltreatment,withtheconsentofthefirstpersonofthefollowinglistedbelowwhoisreasonablyavailable,willingandabletomakeadecisionabouttheproposedmedicaltreatment:
• apersonappointedbythepatientundersection5AoftheMedicalTreatmentAct(thepatient’smedicalagentorguardian)
• apersonappointedbytheVictorianCivilandAdministrativeTribunaltomakedecisionsconcerningtheproposedmedicaltreatment
• apersonappointedunderaguardianshiporderwithinthemeaningoftheGuardianshipandAdministration
Actwithpowertomakedecisionsconcerningtheproposedmedicaltreatment(thepatient’sguardian)• apersonappointedbythepatient(beforethepatientbecameincapableofgivinginformedconsent)asan
enduringguardianwithinthemeaningofGuardianshipandAdministrationActwithpowertomakedecisionsconcerningtheproposedtreatment(thepatient’senduringguardian)
Patientsunder18yearsofageMedicaltreatmentmaybeadministeredtoayoungpatientunder18yearsofagewhodoesnothavecapacitytogiveinformedconsenttomedicaltreatment,withtheconsentof:
• apersonwho,inrelationtothepatient,hasthelegalauthoritytoconsenttomedicaltreatmentandwho,inthecircumstances,isreasonablyavailable,willingandabletomakeadecisionabouttheproposedmedicaltreatmentor
• theauthorisedpsychiatrist.Amedicaltreatmentdecisionmaybemadebythefirstpersonwhois‘reasonablyavailable,willingandable’tomakeadecisionaboutthepatient’smedicaltreatment.Theauthorisedpsychiatristmayconsenttomedicaltreatmentbeingadministeredtoapatientwhodoesnothavecapacitytogiveinformedconsentiftheauthorisedpsychiatristissatisfiedthatthemedicaltreatmentwouldbenefitthepatient.MakingasubstitutedmedicaltreatmentdecisionTheMentalHealthActrequirestheauthorisedpsychiatristtohaveregardtothefollowingmatterstotheextentthatisreasonableinthecircumstanceswhendeterminingwhetheramedicaltreatmentwouldbenefitapatient:
• thepatient’sviewsandpreferencesaboutmedicaltreatmentandanybeneficialalternativemedicaltreatmentsthatarereasonablyavailableandthereasonsforthoseviewsandpreferences,includinganyrecoveryoutcomesthatthepatientwouldliketoachieve
• theviewsofthepatient’snominatedperson• theviewsoftheguardianofthepatient• theviewsofacarer,iftheauthorisedpsychiatristissatisfiedthatthetreatmentdecisionwilldirectlyaffectthe
carerandthecarerelationship• theviewsofaparentofthepatient• theviewsoftheSecretarytotheDepartmentofHumanServicesifthepersonisthesubjectofacustodyto
SecretaryorderoraGuardianshiptoSecretaryorder• ifthemedicaltreatmentislikelytoremedytheconditionoflessenthesymptomsofthecondition• thelikelyconsequencesforthepatientifthemedicaltreatmentisnotperformed• anysecondopinionofaregisteredmedicalpractitionerthathasbeengiventotheauthorisedpsychiatrist.
Iftheauthorisedpsychiatristisoftheopinionthatapatientwhodoesnotcurrentlyhavecapacitytogiveinformedconsenttomedicaltreatmentislikelytohavecapacitytogiveinformedconsentwithinareasonableperiodoftime,theauthorisedpsychiatristmustnotconsenttothemedicaltreatmentunlessthedelayinadministeringorperformingthemedicaltreatmentcouldresultinseriousharmto,ordeteriorationin,thementalorphysicalhealthoftheperson.UrgentmedicaltreatmentTheMentalHealthActpermitsa‘healthpractitioner’toperformmedicaltreatmentonapatientwhodoesnothavecapacitytogiveinformedconsenttothemedicaltreatmentwherethemedicaltreatmentneedstobeperformedasamatterofurgency.Amatterofurgencymeanswheremedicaltreatmentneedstobeperformed:
• tosavethepatient’slifeor• topreventseriousdamagetothepatient’shealthor• topreventthepatientsufferingorcontinuingtosuffersignificantpainordistress.
Thereisnorequirementthatthehealthpractitionerseektheconsentofanyotherpersonwhoislegallypermittedtogiveconsenttomedicaltreatmentonbehalfofthepatientwherethehealthpractitionerissatisfiedthatthemedicaltreatmentisrequiredasamatterofurgency.However,ifsuchapersonisreasonablyavailable,willingandabletogiveconsenttotheurgentmedicaltreatment,thatperson’sconsentshouldbesoughtasamatterofgoodclinicalpractice.Thereisnorequirementthatthe‘healthpractitioner’beregisteredundertheHealthPractitionerRegulationNationalLaw(Victoria)Act2009.Ahealthpractitionerwhoingoodfaithcarriesoutorsupervisesthecarryingoutofmedicaltreatmentinthereasonablebeliefthattherequirementsforurgentmedicaltreatmenthavebeencompliedwithisnot:
• guiltyofassaultorbattery• guiltyofprofessionalmisconductorunprofessionalconduct• liableinanycivilproceedingsforassaultorbattery.
Thisprotectionfromliabilitydoesnotaffectanydutyofcareowedbythehealthpractitionertoapatient.
Question8(13marks)6minutesA62yearoldfemalepresentstoEDwithmassivehaematemesis.Shehasahistoryofalcoholdependence.Hervitalsignsonpresentationare:GCS15 BP70PR150RR16 Temp37°C
a. Listfive(5)likelydifferentialdiagnosesforthecauseofherbleeding.(3marks)NB:“Massive”“alcoholdependence”&sheisinshock• GOVarices• PUD• Oesophagitis• Alcoholicgastropathy• DU• MWtear• Coagulopathy+gastritis/anyofabove• Aorto-entericfistula• Angiodysplasia
b. Listthree(3)indicationsforurgent(<1hour)gastroscopy.(3marks)• Knownvaricesandongoingmassivehaematemesis/haemodynamicinstability• Persistenthaemodynamicinstabilitydespiteappropriateresuscitation• Ongoingmassivehaematemesis
c. Other than endoscopy, list three (3) steps in the management of her
haemodynamicstate.Listone(1)detailforeachstep.(8marks)
Management(3marks)
Detail(3marks)
Fluids IVnormalsalinebolus250mlReassesswithplanforearlybloodproductsAimforpermissivehypotensione.g.SBP80-90mmHg
Blood-activateMTP Evidencehaemorrhagicshock,startwithO- ifdelay, thenaimrationXMbloodPRBC:FFP:platelets1:1:1
Octreotide 50mcgbolustheninfusion50mcg/hr48hrsDecreases bleeding via increased intragastric pH (noevidence)
Reversecoagulopathy FFP2-4units,prothrombinX20-50IU/kg????,vitaminsK10mgIV
Pantoprazole 80mgIVtheninfusion8mg/hr↓ LOS↓ needforendoscopictherapydoes not reduce transfusion req, re-bleeding, need forsurgeryordeathat30d
NB:Maycombinefluidsandbloodinto1point
Question9(13marks)9minutesA2yearoldfemalepresentstoEDafteraccidentalingestionof2x400mgrapidreleasecarbamazepine
tablets.
a. Listthree(3)mechanismsofpossibletoxicityfromthisexposure.(3marks)
• Nachannelblocker• NAreuptakeinhibitor• Anticholinergic-muscarinicandnicotinic• InhibitscentralNMDAadenosinereceptors
b. Listtwo(2)ECGfindingsthatwouldsuggestsignificanttoxicityfromthisingestion.(2marks)
• 1stdegreeHB• QRSprolongation• Sinustachycardia• DominantRwaveaVR>3mm• R/SratioinaVR>0.7
c. List two (2)methodsofdecontaminationorelimination.Stateone (1) indication foruse in this
patientforeachmethod.(4marks)
Method(2marks)
Indication(2marks)
AC Early&asymptomatic<50mg/kg:allingestionsif>50mg/kg:onlyafterintubatedasneedairwayprotection
MDAC ETT&BSpresent
Haemodialysis Prolongedcoma>48/24haemodynamicinstabilityhighserumlevelsafter48/24
d. Listfour(4)criteria,specifictothisexposure,thatneedtobemettoallowsafedischarge. (4marks)
NB: “specific to this exposure”- safe environment probably ok, “clinically well” probably not- toobroadandapplicabletoanyOD
• Observefor>8/24• Daylighthour• Nosedation• Noanticholinergiceffects• Safeenvironment
ThisresourceisproducedfortheuseofUniversityHospital,GeelongEmergencystaffforpreparationfortheEmergencyMedicineFellowshipwrittenexam.Allcarehasbeentakentoensureaccurateanduptodatecontent.Pleasecontactmewithanysuggestions,concernsorquestions.DrTomReade(StaffSpecialist,UniversityHospital,GeelongEmergencyDepartment)Email:[email protected] April2017