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QUESTION 1

This child presents with a painful right eye, pyrexia and inability to move eye on examination.

[pic]

What is the diagnosis? [1] march 2011

|Orbital cellulitis |

Name 2 possible causative organisms. [1]

|s. aureus, strep.pneumoniae |

| |

What is the likely source of infection? [1]

|Sinuses,local trauma,haematological |

List 3 complications. [1.5]

|.cst, cerebral abscess,ON compression - blindness |

Name one essential investigation? [1]

| |

|Ct scan of orbit and sinuses |

[B] A 50 year old man presents with an acute red eye

List 4 causes of a red eye [2]

|Acute iritis |

|Corneal ulceration |

|Scleritis |

|Conjunctivitis |

[pic]

On examination you find the above

What is the diagnosis and causative organism? [1 mark]

|Corneal dendritic ulcer |

|Herpess Simplex |

Give 3 management steps/treatments for corneal ulceration [1.5 mark]

|Acyclovir eye drops |

|Look for vesicles in ophthalmic division |

|Slit lamp examination for - Hypopyon |

|Ophthalmology Referral |

QUESTIONS march 2011

A 24 year old man is brought in by ambulance c/o severe back pain and a painful erection.

He is of Afro Caribbean decent and is known to suffer from sickle cell disease.

On examination he is in considerable discomfort & SOB, his abdomen is soft and he has obvious priapism.

Describe 4 steps in your management of his priapism [2 marks]

| Analgesia |

|Adequate hydration |

|Corpus cavernosum |

|Exchange Transfusion |

Name 3 investigations would you perform and reasons why? [3 marks]

|HB – check for the severity of anaemia ie drop of > 2gms |

|Reticulocyte count – low in aplastic crisis |

|Low platelets in hypersplenism |

|WCC – Infection |

|Leucopenia in Parvovirus |

| |

| |

| |

|ABG’s – hypoxia in chest syndrome |

|CXR – Lung infarction/pneumonia |

|CT head – if acute neurology – crerbral infarction |

List 3 indications for exchange transfusion in sickle cell anaemia [3 marks]

|Acute infarctive strokes |

|Severe acute chest syndrome |

|Priapism not resolved by analgesia and adequate hydration |

List 3 indications for blood transfusion in sickle cell patients [2 marks]

|Sudden severe anaemia eg – acute splenic sequestration |

|Acute chest syndrome |

|During pregnancy |

QUESTION 3 Oct 2010

A 60 year old man is brought in following a bout of fresh haematemesis.

He is known to suffer from duodenal ulcers. He looks pale but is conscious and his BP is 140/100.

His pulse is 95, his sats are 98 % on RA and his RR is 18. Apart from his ulcers he has no other medical problems.

You start initial management and gain access and take bloods.

His Hb = 6 so you start a blood transfusion. The patient develops a temperature of 38.8 oC

You suspect an acute transfusion reaction. Other than assessing and resuscitating the patient, name two next management steps? [2 marks]

| |

|Stop transfusion |

|Recheck the blood bag |

List 4 symptoms of acute transfusion reaction, other than pyrexia. [2 marks]

|Chills |

|Back pain/loin pain |

|Chest tightness |

|Flushing |

|Nausea |

|Joint pain |

What is the definition of massive blood transfusion? [1 mark]

|Replacement of whole volume of blood within 24 hours |

Fill in table for the ROCKALL scoring system. Write ‘BLANK’ in boxes which do not contribute to the score [5 marks]

Page 245 OHCM

| |Score = 0 |1 point |2 points |3 points |

|Age | | | | |

|Shock | | | | |

|Co morbities | | | | |

|Endoscopic | | | | |

|diagnosis | | | | |

|Endoscopic stigmata of | | | | |

|recent haemorrhage | | | | |

QUESTION 4 Oct 2010

[A] You receive an ambulance alert that they are bringing in a 25 year old male who has been found collapsed in the street. He is unresponsive and very cold, with no external signs of injury.

What 4 pieces of equipment other than standard resus equipment would you want to have ready in preparation for this patient? [2 marks]

|Warmed fluids |

|Humidified oxygen |

|Low reading thermometer |

|Warm blankets/bair hugger |

He arrives and is found to have no pulse, his temperature is reading 28 C.

CPR is commenced. List 3 modifications to the standard algorithm that need to be made in the hypothermic patient? [3 marks]

|No adrenaline or amiodarone until temp reaches 30 degs |

|Every 4th cycle adrenalinbe until 32 degs |

|If temp < 30 c and in pulseless VT/VF give 3 shocks then delay further shocks until temp > 30 c |

What rate should you aim to rewarm the patient? [1 mark]

|0.5 – 2 c/hr |

What is the complication of rewarming too rapidly? [1 mark]

| |

|Cerebral oedema |

|Pulmonary oedema |

[B] A homeless man presents to your ED with a painful left hand.

[pic]

What is the diagnosis? [1 mark ]

|Frost bite |

Give two interventions which are indicated [1 mark]

|Rewarm in water at 41 c for 20 – 30 mins |

|Analgesia |

|Afterrewarming let area dry in warm air |

|Elevate limb |

Name two interventions which are contraindicated [1 mark]

|Amputation |

|Surgical debridement of eschars |

QUESTION 5 march 2009

A 35 year-old male with known asthma presents to the ED with acute asthma exacerbation. In the past 12 months, he had been admitted twice to ITU with life threatening asthma, the last being within the previous month. He is known to have good compliance with his multitude of asthma control medications. His GP has re-commenced him on Prednisolone 40 mg o.d. the previous day. In the preceding 2 hours, he has had 3 home nebulisers (Salbutamol) prior to calling the ambulance.

His respiratory rate is 35/min, pulse rate 130/min, BP 95/60 mmHg. His arterial blood gases on arrival were pH 7.1, PaO2 8.4, PaCO2 11.2, BE minus 4. Despite adequate management, including high flow oxygen, repeated nebulised _-agonist and IV Magnesium, he continues to deteriorate with his RR dropping to 7/min, HR 145/min, unrecordable BP and drowsiness. The intensivist advises immediate intubation/ventilation, but is unable to get down to ED for about an hour (and you are the most competent personnel available).

Give 4 anatomical predictors of a difficult airway [2 marks]

|LEMON mneumonic |

Following Preoxygenation, what are the three treatment (medication) steps?

[1.5 marks]

|Pretreatment - opioid analgesia |

|Induction Agent |

|Paralysis Agent |

What is the correct head / neck positioning in such patients, how is this position achieved and why? [1.5 marks]

| |

| |

|Place the patient in the sniffing position for adequate visualisation |

|Flex the neck and extend the head |

|This position helps to align the oral, pharyngeal and laryngeal axes and facilitates visualisation of the glottis opening |

What are the four steps to ensure / confirm correct tube placement? [2 marks]

|Co2 – end tidal calorimetry |

|CXR |

|Auscultation 3 or 5 point auscultation |

|Visualise passage thro the vocal cords |

| |

After three failed attempts at intubation, you are unable to adequately oxygenate with BVM (despite correct head & neck positioning). What would be your next step (you are still the most competent personnel available)? [1 mark]

| |

|LMA |

What would the next step if the above step failed, and you are unable to ventilate or oxygenate the patient? [1 mark]

| |

|Needle cricothyroidotomy |

What would this patient require if the above step proves inadequate? [1 mark]

| |

|Surgical cricothyroidotomy |

QUESTION 6 oct 2008

A 14-year-old male patient attends your ED following laceration of his foot with a garden fork

Your junior doctor attended to the patient but is unsure about Tetanus immunization in general.

Which wounds are Tetanus prone, name four? [2 marks]

|Puncture wounds |

|Animal bites |

|Wounds contaminated by soil/manure |

|Wounds that contain devitalized tissues |

|Compound # |

|Burns |

Describe how C.tetani spores causes muscle spasm and rigidity? [2 marks]

| |

|The spores germinate in anaerobic conditions producing tatanospasmin, an exotoxin which blocks inhibitory neurones in the CNS |

Using the grid below, explain when the various tetanus vaccine / Immunoglobulin are required depending on the patient’s immunisation status[6 marks]

| |Vaccine |Vaccine |Tetanus |

|Immunisation |(clean wound) |(tetanus prone wound) |Immunoglobulin |

|Status | | |(tetanus prone wound) |

|Fully immunised, ie, |NONE |NONE |Only if high risk |

|has received a total | | | |

|of 5 doses of tetanus | | | |

|vaccine at appropriate intervals | | | |

|Primary immunisation |none |none |Only if high risk |

|complete. Boosters | | | |

|up-to-date, but not | | | |

|completed | | | |

|Primary Immunisation |Reinforcing dose and the doses to|Reinforcing dose and the doses to|yes |

|incomplete or boosters not |complete schedule |complete schedule | |

|uptodate. | | | |

|Not immunised or |Immediate dose then completion of|Immediate dose then completion of|yes |

|immunisation status |5 dose course |5 dose course | |

|not known or uncertain | | | |

QUESTION 7 Oct 2010

Ambulance phone ahead to say they are bringing a 36/40 who is about to deliver

List 4 pieces of equipment for the foetus other than standard resus equipment that you would get ready [2 marks]

|Resusitaire |

|Radiant heat source |

|Cord clamp |

|Umbilical catheterisation equipment |

The baby is delivered in the ED - list 3 factors you would consider/assess before assessing the babys heart rate? [3 marks]

|Dry and remove wet towels and cover baby |

|Start clock/note time |

|Assess tone |

|Assess breathing |

|Assessed at 1,5,10 minutes |

| |

CPR is commenced, describe the landmarks, technique and ratio for compressions [2 marks]

|2 thumbs can press on the lower third of the sternum, just below an imaginary line joining the nipples, with the fingers over the spine |

|at the back |

| |

|3:1 |

Drugs are rarely necessary but if you were to have 3 drugs ready to help the resuscitation what would they be and what doses would you use? [3 marks]

|Iv adrenaline 10 mcg or 0.1 mg of 1 in 10000 |

|Iv sodium bicarbonate 2-4 ml/kg |

|Iv dextrose 10% 2.5 ml/kg |

|Iv naloxone 200 mcg in full term |

QUESTION 8

A 22 yr old man presents with a 2/7 history of pain on inspiration and mild SOB. He has no previous significant history, including pulmonary.

On examination he is 6ft, slim with a P100, BP 120/60, a central trachea and reduced AE on the left side of his chest.

You decide to perform an X ray-(shown below).

[pic]

What is the main xray finding? [1 mark]

| |

|Large > 2cm left primary pneumothorax |

You decide to aspirate as per BTS guidelines, where and what volume are you allowed to aspirate. [1 mark]

|Please read 2010 dec guidelines |

|2nd intercostal space left midclavicular line upto 2.5 L |

Repeat Xray shows no significant difference from the first. You decide to place a chest drain.

What steps do you take next [1 mark]

|Informed consent for procedure |

|Premedication with opiate or benzodiazepine |

What are the anatomical landmarks for chest drain placement ? [1.5 marks]

| |

|5th intercostal space just anterior to the mid axillary line between latissimus dorsi and pectoralis major |

What is the maximum of dose of the following [1 mark]

a) Plain Lignocaine (Lidocaine)

|3 mg/kg or 200mg in total |

b) Lignocaine, with adrenaline?

| |

| |

|7mg/kg |

Name 2 techniques are used for placement of chest drains? [1 mark]

|Seldinger |

|Open |

An omental tag has been described as a means of securing a chest drain; describe an “omental tag” [1 mark]

| |

|An omental tag of tape has been described which allows the tube to lie a little away from the chest wall to prevent tube kinking and |

|tension at the insertion site |

Name five items described in the NPSA alert relating to the placement of chest drains [2.5 marks]

|Failure to follow manufacturer’s instructions |

|The site of insertion and poor positioning |

|Inadequate Imaging |

|Not following national guidelines |

|Excessive pressure on the dilator resulting in visceral perforation |

QUESTION 9

The new FY2 is confused. He asks you for advice on who needs C spine imaging following an injury.

In adults and children aged above 10, list four indications for requesting immediate three-view plain C-spine x-ray in a patient with suspected neck injury (NICE) [2 marks]

|Neck rotation to 45d left and right |

|Midline tenderness |

|Dangerous mechanism |

|Definitive diagnosis of c-spine injury required urgently, for example prior to surgery |

List six dangerous mechanism of injury in patients with suspected neck injuries [3 marks]

|Ejection from motor vehicle |

|High speed motor vehicle collision |

|Fall from greater than 1m or five stairs |

|Diving [axial load to head |

|Rollover motor accident |

In adults and children aged above 10, list four indications for immediate CT imaging of the cervical spine [2 marks]

| |

|Neurology despite normal x ray |

|Inadequate plain film series |

|Intubated patients |

|GCS below 13 on initial assessment |

In patients with suspected head injury, list six indications for immediate CT Head [3 marks]

|Post traumatic seizure |

|GCS less than 15 at 2hrs after the injury |

|Suspected open or depressed skull fracture |

|Any sign of basal skull fracture |

|GCS less than 13 on initial assessment |

|More than 1 episode of vomiting in adults |

QUESTION 10 Oct 2010

[A] A 75 year old woman has been brought into the ED via ambulance. She was found on the floor by her carer at 7am. She complains of pain in her right hip and cannot move it. The triage nurse notes it is shortened and externally rotated.

What is the national guidance for admission time for patients with fracture neck of femur? [3 marks]

|CEM GUIDELINES |

|All patients to be admitted within 1 hour of diagnosis |

|90% of patients should be admitted within 2 hours of arrival |

|100% of patients to be admitted within 4 hours of arrival |

All ED’s must develop fast track protocols for admission of patients with fracture NOF. List 4 parameters of assessment in this protocol? [2 marks]

|CEM guidelines |

|MEWS score |

|ECG |

|CXR |

|Falls assessment – NICE guidelines 2004 [2009 FCEM saq] |

|Bloods fbc,u&e,g&s,glucose |

List 4 parameters of treatment in the fast track protocol? [2 marks]

|Iv opiates |

|Iv fluids |

|DVT prophylaxis |

|Food/drink |

[B] A 75-year-old with left lobar pneumonia has presented to Emergency Department with a temperature of 38.9C, respiratory rate of 32 breaths /min, BP of 130/70mmHg. PR 110/min. His wbc was 15 X109/L, Hb 12.5g/dL, Platelets 250 X 109/L, urea 24mg/dL, Creatinine 140μmol/L, Na 142mmol//l, K 3.8mmol/L.

He was alert on arrival and presented a personally signed “advance directive” stating that he has prostate cancer and he does not want treatment.

He suddenly deteriorated whilst in the department and went into shock, with reduced level of consciousness. The daughter tells you that he should not be admitted to ITU or ventilated according to his “advance directive”.

What are the principles of the Mental Capacity Act 2005? [3 marks]

|A person must be assumed to have capacity unless it is established that he lacks capacity |

|A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without |

|success. |

|A person is not to be treated as unable to maka a decision merely because ha makes an unwise decision |

|A decision made, under this decision for or behalf of a person who lacks capacity must be done in his best interests. |

|Before the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way |

|that is less restrictive of the person’s rights and freedom of action. |

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