GCS 16 - Home



MH SAQ practice gen med / spec medA 35 year-old female is brought to the ED by her husband. She has not been feeling well and is becoming irritable, agitated and is constantly sweaty. She is known to have hyperthyroidism and last week underwent surgery. Examination reveals a HR 144 bpm and T 38.4°C.1. What three clinical features are most relevant to assess for thyroid storm? (3 marks)temperature >37.8oCtachycardia out of proportion to the fever – cardiovascular collapseCNS disturbance in 90%(Dunn)2. List 4 specific drugs that would be used to treat this patient and outline their mechanism of action. Provide doses where appropriate. (4 marks)propylthiouracil – 900mg loading, 300mg maintenance daily, reduces iodination in the thyroid gland, but does not reduce release, reduced conversion of T4 to T3 Lugols iodide – inhibits release from thyroid gland, give >1hr after PTUPropranolol – most important vs morbidity and mortality - 60-80mg q 4hr – treats fever, tachycardia, tremor immediately, inhibits T4 to T3 conversionHydrocortisone – 100mg q 6 hrly - inhibits T4 to T3 conversion3. Apart from supportive measures such as ivi fluids, correcting fluid or electrolyte imbalance, external cooling, outline options for refractory thyroid storm (3 marks)peritoneal dialysisplasmapheresischarcoal haemoperfusionA 22 year old female medical student is brought in by ambulance following a short seizure at home. She has recently returned from her elective in Malawi. Her student friends are unsure if she took any of her medications because they gave her nightmares. She is now drowsy and not orientated. You call public health and they do not suspect Ebola. 1. Name the most likely causative organism (1 mark)Plasmodium Falciparum may cause cerebral malaria with coma, fits, oculogyric crisis and focal neurological signs. Diarrhoea, cardiac failure, pulmonary oedema and shock may occur. Deterioration can be rapid. 2. A BSL is normal. What other initial blood tests will you arrange immediately and what would you expect for each? (4 marks) blood for thin and thick film – view malaria parasitesFBC - malaria may cause anaemia, neutropenia and thrombocytopeniaVBG Metabolic acidosis pH <7.3 indicates severe malaria or EUC with ARF indicates severe malariaPCR falciparum3. Public health calls back as there has been 5 cases of Ebola confirmed in Malawi in the clinic the medical student was at. Outline the important issues. (5 marks)Ensure patient in isolation and wearing a maskNotify ED/ ID/ ICU/ hospital staff/ executive (not media)Ensure all staff who will care for patient follow PPE procedure for suspected Ebola patients – impervious mask, impervious gown, hood, gloves, face mask Contact tracing - ensure public health involved in follow up contacts Ensure patient continues to have treatment for malaria – admit ID/ isolation roomA 19 year old university student presents to the ED via ambulance. She is confused and has a widespread purpuric rash but no meningism. Her temperature is 38.7°C, HR 140 /min, BP 70/30 mmHg.a. What is the likely diagnosis? (1 mark)Meningococcal Septicaemiab. List 4 immediate drug management priorities with doses. (4 marks)Immediate antibiotic administration ceftriaxone 2g IVIV fluids initial bolus 30ml/kg then further 20ml/kg titrated to responseNoradrenaline if poor response to fluid bolus 10mg in 100mls at 1-20mls/hr aim MAP >65 (or other reasonable dosing schedule)PPE for staff particularly airway Drc. What other management needs to be considered? (2 marks)Prepare for physiologically difficult intubation Public health notification and staff plus contact prophylaxisTreatment of coagulopathyDisposition ICU d. The patient is deteriorating despite aggressive intervention. The parents arrive in the resus room and 5 minutes later the patient has a cardiorespiratory arrest. Outline 3 issues around having the parents present in the resus room. (3 marks)Many documented benefits for family: reduced PTSD, helps grief, seeing that everything done, felt supported patient, aids family cohesion/bonding. Negatives are can disrupt the resus and need to be removed, needs a dedicated staff member to look after family.A 40 year old male presents with swelling and pain in his right ankle. There is no history of recent trauma.a. What are 4 major differential diagnoses?Septic arthritis, Gout, reactive arthritis (Reiter’s), RA, other sero-negative arthritis, drug inducedb. What are 4 important features you would enquire about on history?Known rheumatologic disorder, previous Gout, recent STI, diarrhoeal or viral illness. Family history, IBD, Systemic symptoms (fever/chills, sweats, lethargy)c. List and justify 4 investigations you would you order.FBC; ? anaemia of chronic diseaseESR and CRP; confirm inflammatory processHLA B27; ?ASRheumatoid factor and ANA rule out otherJoint aspirate can diagnose septic arthritis, gout and pseudo-goutSTI testsStool tests confirm recent GI infectionNB; x-rays of little valued. Following full assessment you are confident your patient has an STI. What are your 4 management priorities?For arthritis analgesia (typically NSAID’s), Inform patient, medical certificate as required.For STI’s, AB’s doxycycline 100mg 7 days, azithromycin 1G or similar.Contact tracing, Advice re unprotected sex, Follow up and retesting.A 45 year old man presents to the ED with a rash on his palm which is intensely itchy. The SHO thinks it is Scabies. A picture is shown below.a. Describe 2 features of the rash. (2 marks)Erythematous linear popular rash suggestive of burrowsb. Give the Diagnosis and one differential. (2 marks)Diagnosis: ScabiesDifferential: Insect bites, dermatitis or psoriasisc. What causes the itching? (1 mark)Itch caused by reaction to the faeces, eggs and the mites themselves later during diseased. What are 2 other features of this condition? (2 marks)Tends to be worse at night and during winter months, tends to affect multiple household members, if undiagnosed lasts for years (7 year itch), can become superinfectede. What are 2 treatments that could be given to this patient? (2 marks)Scabicide – e.g permethrin Antihistamines- tablets or creamsSteroid cream/ointment- 1% hydrocortisoneCrotamiton- anti pruritic topical f. What further advice would you give to the patient? (1 mark)Advise thorough hygiene and treatment of all household membersadvise to boil wash all clothing and bedding See GP if not effective or returnsA 42 year old man has been found outside the ED fitting. He is dishevelled and smells strongly of alcohol. His BM is 2.4a. What is the definition of status epilepticus? (1 marks)Status epilepticus is seizure lasting > 30mins or more than one seizure wiith failure to recover between fits. b. Name 3 steps in managing his fitting. (2 marks)Treatments: support airway and give high flow oxygen. And check BMGive 4mg IV lorazepam or 10mg iv diazemuls. Pabrinex IV replacement and then give 50mls 50% dextrose or 500mls 10% dextrose IV.May need phenytoin 18mg/kg IV or thiopentone 4-3-5mg/kg. c. List 3 reasons for organising an urgent CT head on this man.(3 marks)Reasons for CT. May have intracranial bleed requiring surgery.May have meningitis.encephalitis and need LP and look for SOL. Possibility of closed head traumad. Give 4 reasons why alcoholics are more prone to fit. (4 marks)more likely to have head injury with complications. Alcohol withdrawal. coagulopathy making bleeds worse, impaired gluconeogenesis causing low BMA 72 year old diabetic female is brought to your Emergency Department by ambulance. She complains of feel generally unwell for the last two days with abdominal pain, cough and fevers.Vitals signs:Pulse121/minBP89/58mmHgRR28/minSats89% Room AirTemp39.8 oCa. List 3 key steps in this patient’s management. (3 marks)Resuscitation - 1/2 markScreening / diagnosis e.g. blood cultures / biochemistry etc. - 1/2 markAntibiotics - broad spectrum cover required - 1 mark1/2 mark each for any two of:Source ControlMonitoringDisposition Boundary of Careb. List your resuscitation goals for the first 6 hours. (4 marks)1 mark each up to 4 marks from:CVP 8-12 mmHgMAP >65 mmHgUrine output >0.5ml/kg/hrCentral venous sats >70% or mixed venous sats >65%Lactate clearancec. The patient requires inotropic haemodynamic support. Which inotrope should be used? (1 mark) Noradrenaline - 1 markd. The patient is intubated for respiratory failure. List the four key components of your ventilation strategy for this patient? (2 marks)1/2 mark for each of :Tidal volume 6ml/kgPlateau pressure <30 cm H2OPEEP Titrated to FiO2 Minimum 5 cm H2O - Maximum 24 cm H20FiO2 Titrated to Sats 88-95% or PaO2 55-80 mmHgAnswers taken from Surviving Sepsis Campaign International Guideline for Management of Severe Sepsis and Septic Shock 2012 and ARDSnet NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol SummaryA 34 year old man presents 10 days after a business trip to Papua New Guinea. He has had fevers, malaise, generalised aches and frequent episodes of diarrhoea. His vital signs are:HR 130 /minBP 100/50 mmHgTemp 38 °CSats 98% on aira. List 10 potential causes of fever and illness in this man. MalariaDengueTyphoid/paratyphoidGIT infections – cholera, shigella, salmonella, E coli diarrhoea, giardiasis etcViral hepatitis Typhus/rickettsial diseasesMelioidosisJapanese or Australian (Murray Valley) encephalitisNon-exotic/”normal” infections – LRTI, UTI, STI, cellulitis etc etc etcb. What blood tests will you request?InvestigationJustificationFBCPart of fever workup. ?malaria anaemiaEUCUnwell, diarrhoea potential derangementLFTHepatitis possibleBlood culturePart of workupMalaria filmsIdeally 3 sets over 48 hours (practice varies)Falciparum +/- vivax antigen> 95% sensitive for PFc. List 5 major complications of severe Plasmodium falciparum malaria.any 5 of:Haemolysis/anaemiaSplenic enlargement/ruptureCerebral malaria – delirium, coma, seizuresARFNon-cardiogenic pulmonary oedemaHypoglycaemiaLactic acidosisd. What are the two main choices for the urgent initial treatment of severe Plasmodium falciparum malaria?1. Artesunate (2.4mg/kg IV) then oral2. Quinine (20mg/kg IVI over 4 hours)A 42-year-old man is brought to your ED by ambulance with acute confusion. His wife states that he is previously well and on no medications, but his health has been deteriorating for three months, with tiredness and 10kg weight loss despite an enormous appetite. She also states that, on the bright side, he has become completely impervious to the cold and the extra money they’ve spent on groceries has been saved on heating bills. Observations are:A intactBRR 40 /min, sats 100%, chest clearCHR 140 /min, BP 180/100 mmHg, CR 2 secDE4(staring & bulging), V4 (agitated & aggressive), M5 (localising to pain), no focal neurologyETemp 38.5°C, BSL 10, vomiting, no rash or other signsa. What is your provisional and differential diagnosis for this man’s clinical picture? (3 marks)Provisional diagnosis:Differential diagnosis:Most likely thyroid storm But also other causes of confusion & high temperature e.g.Infection (meningoencephalitis, sepsis of any source)Too much drug: e.g. salicylates, TCAs, anticholinergics, amphetamine/cocaine, Too little drug: e.g. withdrawal of etoh/benzos, heat stroke, phaeochromocytoma)b. What conditions may precipitate this clinical picture? (2 marks)Nasty precipitants eg acute MI, sepsis, trauma, IV contrastUnderDx/Rx TTX esp GravesAlso XS thyroxine or too little antithyorid Rxc. How will you treat him in the ED? (5 marks)Address ABC/ good supportive care, esp:O2 & IV fluids, because high risk of dehydration & cardiovascular collapseSedation eg benzodiazepineGet help: from endocrinologists, and needs ICUInvestigations:Endocrine blood tests esp TFTSeek and treat nasty DDx and nasty precipitants e.g. sepsis, ingestion, MISpecific ED Rx of thyroid storm:IV B-blockerHydrocortisone 100mg IVCarbimazole load PO/NGT (exact dose I’d look up) then after 4h add Lugols iodine drops)A 40-year-old female has been brought in following increasing confusion and agitation at home this morning. She has had no other symptoms. She is day 3 after normal vaginal delivery of a healthy baby at another hospital, but her antenatal history is unknown.Ambulance officers report a generalised tonic-clonic seizure in the ambulance which required 5mg IV midazolam to terminate, followed by ongoing drowsiness and confusion. On arrival in the ED she begins to seize. ED staff and ambulance officers activate the ‘arrest call’ button and transfer her to the Resuscitation Room.When you arrive she is being nursed on a bed and a provisional trainee is supporting her airway with jaw thrust. Her intravenous cannula has tissued.On examination: Airway: snoring / partly obstructedRR 40 /minO2 saturations 95%HR 130 /minBP 180/100 mmHgGeneralised tonic-clonic seizure Afebrilea. List the causes of seizure you would consider in this patient. (4 marks)Eclampsia – timing unusual because post-partum but still likelyCerebral venous sinus thrombosisMeningoencephalitis e.g. post-epiduralHypoxia e.g. due to pulmonary embolusPlus at least one not directly related to pregnancy / delivery: e.g., hypoglycaemia, toxic ingestion, structural intracranial e.g. bleed, epilepsyb. What is your initial management? (4 marks)Form a team and assign rolesAddress ABCs esp airway: simple adjuncts initially eg suction, NPA and lie on sideBreathing: high flow O2 and nasal CO2 monitorCirculation: IV/IO access and send bloods / bedside BSLStop the fit: 2nd step of classic status epilepticus regime: Midazolam IV/IO/IM 5mgSeek and treat a cause from the list above, esp eclampsia (see drugs in Q3)Get help: Obstetrics, renal / neurology, ICUc. If you suspect eclampsia, what initial drugs/ dose/route/rate would you administer? (2 marks)Magnesium sulphate: officially 4G IV over 30 mins is RNS OG policy, but it comes in 10mmol amps. Closest is 20mmol (=5G). Safe enough to give over 20 mins provided you dilute it and watch the BP. Followed by IV infusion.Hydralazine: 5mg IV over 10 mins, can repeat.A 58 year old Chinese Australian woman presents with fatigue. On examination she has a pulse of 95 /min, BP 100/45 mmHg and sats of 98% RA. She is afebrile. She appears deeply jaundiced. Bloods are done and appear below FBE. Hb 39 RCC 0.95 MCV 129 Retics 31.58% WCC 5.4 Neut 4.26 UELFT Na 137 K 3.6 Cl 106 HCO3 17 Urea 4.4 Cr 66 Bili 137 ALT 5 LDH 693 GGT 20 ALP 79 a. Interpret the blood tests and provide a provisional and differential diagnosis. (3 marks) Autoimmune haemolytic anaemia; any other haemolytic anaemia (RBC disorders; lead poisoning; G6PD etc);,occult GI bleed in cirrhotic;b. List 3 other pathology tests with a brief justification you would order to help determine the diagnosis. (3 marks) Blood film (abnormal RBC morphology); retics (raised in HA); Coombs test (+ = immune mediated); haptoglobin (decreased in HA); coags (bleeding diathesis)c. Briefly outline your management. (4 marks)Grossly anaemic but HD stable will require transfusion in conjunction with therapy directed at cause Thus obtain blood for XM Correct coagulopathy if present Transfuse PRBC x3 initially . Aim for Hb >70 initially Wait for full XM, avoid crystalloid, Oneg unless active bleeding Does not need ‘resuscitation’ unless evidence active bleeding Rx process eg prednsiolone for AIHA (haematology advice) Aggressively Mx/Ix if evidence GI bleed: (PPI, octreotide, scopes, CTAs)A 35 year old woman arrives after being brought in by friends due to her altered level of consciousness. Last seen 4 hours ago. They state she has been upset recently and has been commenced on 2 new medicines by her GP. Her GCS is 10, P 130 /min, BP 102/44 mmHg. She is Afebrile.a. List 4 key ECG features you would look for on initial assessment and justify those. (4 marks)Wide QRS (Na channel blocking drugs); long QTc (K+ blockers; antidepressants, antipsychotics); R wave positive in avR or deep S in 1 (na channel blockers);; ST-T changes (SAH, ICH); P waves vs AF vs SVT (tachycardic P130); Congenital abnormalities eg Brugada; HCM b. List 3 key examination findings and relate these to differential diagnoses for her presentation. (3 marks)Pupil size and reaction: pinpoint; opioids, cholinergics; dilated, amphetamines, anticholinergics; asymmetric (raised ICP) Chest crackles: unilateral (aspiration); bilateral (aspiration, APO post opioid) Clonus (serotoninergic drugs Signs of head trauma/BOS # Focal neuro abnormality (SAH, ICH, hypoxic BI etc) Self harms signs (cutting, strangulation) ? suicidal Ketotic breath, Kussmaul resps (met acidosis , DKA)c. List 5 key historical features you would ask her friends and justify. (3 marks)Names of medicines doses , empty packets; Comorbidities particularly diabetes, depression, SCZ, bipolar; prior self harm suicidailty recently; any recent illnesses partic headache, fever; illicit drug use; social supports/family; A 72 year old man comes in with change in facial appearance and mild headache. a. What are the key clinical findings from this photo? (2 marks) R facial droop, Forehead sparing on left b. What is the likely diagnosis with justification? (2 marks) Bells palsy as sparing suggests LMN lesion c. What other findings would you search for on physical exam? (2 marks) Herpetic lesions (ears, nose, eyes), other focal neuro abnormality particularly multiple other CNs; ticks in ear/folds; d. Outline your disposition and management plan (4 marks)Usually home if confirmed bells; give Prednisolone consider valaciclovir if <72hr; needs attention to eye care and advice re taping, lubrication; prognosis advice re likely full recovery but risk of partial or non recovery; GP FU with neurology if persisting or DDX not excludedA 50 year old woman presents to ED with a 4 days history of malaise, intermittent fever, and the rash depicted here.a. Describe this rash. (3 marks)Picture of left hand palmar aspectMultiple haemorrhagic lesions along the palmar aspects of fingers – appearance of petechiae or purpura, suggestive of septic emboli.The diagnosis is Janeways lesions, indicative of sub-acute bacterial endocarditis.b. List 4 important examination findings that would be relevant in this case. (4 marks)1. Elevated temperature – may be intermittent2. Cardiac murmur3. Other septic emboli – Roths spots, Oslers nodes, petechiae4. Signs cardiac failure – S3, lat apex, pulmonary oedema…c. Name the 4 most relevant investigations that you would perform in the ED. (4 marks)Blood culturesFBCESR/CRP, inflammatory markers?coagulation screen?Echocardiogram – debate as to whether this is a ED Ix – would preface by saying if signs acute valvular dysfunction or cardiac comprimiseA 70 year old man with type 2 diabetes presents to your ED with 24 hours of malaise. His initial observations are: HR 120 /min and BP 70/40 mmHg. His bedside BSL is 11.2 mmol/L and his central capillary refill is 5 seconds. He is confused and review of past notes indicates that this is new and he has a history of alcoholism.a. What are the 3 most likely causes of this presentation? (3 marks)Sepsis, Haemorrhage, Cardiogenicb. What key initial investigations will you perform? (4 marks)Any of: VBG with stat profile, RUSH USS exam, ECG, urine analysis, CXR, Clotting screenc. You perform a PR that shows heavy melena, the patient then has a large fresh haematemesis. List 4 initial management. (2 marks half a point for each)Blood and products avoiding with permissive hypotension Terlipressin 2g IV(or vasopressin/octreotide)Cefotaxime 1g IVVitamin K 10mg IV, . This 24 year old female presented to the emergency department complaining of painful lumps and redness confined to her lower legs which had developed over the last two weeks.a. List your main differential diagnosis with the most likely listed first. (5 marks)Erythema nodosum Cellulitis Contact dermatitisInsect bitesBurnsErythema multiformeHSPTraumaErythema induratumWell’s syndromePanniculitisb. List the most likely aetiologies for the most likely diagnosis. (5 marks)minimum of 3 from bold list Streptococcal pharyngitisSulphonamides other drugs and vaccines e.g. OCPIBDPregnancySalmonella YersiniaIdiopathicSarcoidosisRickettsial infectionsEponymous – Bechet’sHansen’s diseaseNeoplasia (lymphoma)Tuberculosis EBV Hep B Chlamydia A 55 year old man is brought to the ED after being found collapsed at home. He has a medication alert bracelet indicating he has type 1 diabetes.His observations are:GCS12BP90/60mmHgHR130/minRR30/minTemp 38°CA photograph of the patient’s left thigh is taken and is shown below.a. Give 3 differential diagnoses. (3 marks)No model answer providedb. Name the antibiotics, routes and doses you would use. (2 marks)No model answer providedc. Give a detailed description of management priorities for this patient. (5 marks)No model answer providedA 55 year old woman has been referred to the ED by her GP with a 2 day history of bilateral legweakness. Her GP suspects Guillain-Barre syndrome.1. List 6 differential diagnoses for this patient’s weakness. (Do not include GBS) (6 marks)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2. List 3 cardinal features on examination you would expect to find that would be consistentwith classical Guillain-Barre syndrome. (3 marks)____________________________________________________________________________________________________________________________________________________________________3. List 3 investigations that will be useful in supporting the diagnosis of GBS. Include theexpected findings. (6 marks)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4. List 2 life-threatening complications of GBS. For each complication, mention how you willdetect its presence or severity. (4 marks)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________1.Spinal cord compression / cauda equine compression – tumour, abscess, haematomaTransverse myelitisTraumatic spinal cord injurySpinal cord infarct – embolic/thromboticMyopathies – eg myasthenia gravisElectrolyte – hypoK periodic paralysisToxins – tick paralysis, botulismPass 4 of 62.Symmetrical ascending weaknessLoss of reflexesMinimal sensory lossPass 2 of 33.LP – raised CSF protein with raised WCCNerve conduction studies – consistent with peripheral demyelinationAnti-ganglioside antibodies – raised(will accept MRI – no spinal cord pathology found)(also C. jejuni serology - positive)Pass 2 of 64.Respiratory failure – monitor FVC regularlyAutonomic dysfunction – cardiac monitoring, regular BP measurementPass 2 of 4Total pass 10/19 corrects to 5/10A 67 year old man has been brought to your ED after being found on the floor of his bedroom withan altered level of consciousness.After initial assessment, you conclude that his altered level of consciousness is due to hyponatremia,with a serum sodium level of 112.1. List 5 features of collateral history you would like to obtain to help you elucidate the causeof his hyponatremia. Include a reason for each crucial piece of history. (5 marks)__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2. List 5 investigations you would use to help you elucidate the cause of his hyponatremia.Include the result for which you will be looking. (5 marks)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________After a short period of time, the patient begins to have a seizure.His vital signs are:Temperature 36.0Pulse 110 /minBP 120/85 mmHgO2 sats 98% room air3. List your 2 initial pharmacological treatment steps. Include doses and end-points.(4 marks)____________________________________________________________________________________________________________________________________________________________________1.Hx organ failure – heart, renal, liver – causes hypervolemic hypoNaDrug history – drugs that cause SIADH, diureticsMental health history – drugs that cause SIADH, water intake for psychogenic polydipsiaIntercurrent illnesses – eg sepsis, pancreatitis, gastroenteritis– causes of hypovolemic hypoNaMalignancy – SIADH(other things may ne acceptable)Pass 3 of 52.Urea/creat – renal failureBSL – cause of dilutional hyponatremiaTFTs- hypothyroidismCXR – lung malignancy – SIADHLFTs – liver failureUrine Na – elevated in SIADH >20-40Serum K – for typical low Na / high K ratio in Addison’s disease(1 mark for test plus reason no ó marks)Pass 3 of 53.Midazolam / diazepam 5mg bolus aiming to terminate seizure, repeat if needed3% saline bolus – approx. 2mL/kg bolus aiming for seizure termination and small rise in Na (about 5)1 mark for drug, 1 mark for restPass 2 of 4TotAL PASS 8/14 corrects to 5.5/101. List 5 factors will influence your choice of antibiotics. State how each factor will affect yourchoice. (5 marks)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Her vital signs are:GCS 15Pulse 135 /minBP 75/45 mmHgRR 22 /minO2 sats 98% on room airTemp 39.5 degreesYour assessment does not reveal any localising signs for her illness.2. List the escalating steps in her treatment in the ED. Provide doses and end-points whereappropriate. (5 marks)_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________1.Likely neutropenia based on recent chemo – use local protocol eg pip/taz + gentamicinNon neutropenic – Hx and Ex to localise infection for guided treatmentPresence of infected line – use vancomycin as wellPt allergies eg penicillin – use ceftazidimeResults of Ix – targeted Abs for likely sourceResults of previous Ix – resistant organisms – may need to use different Abs eg meropenemPass 3 of 52.End-points are pulse <100, BP >90 systolic, MAP >65mmHg, good end-organ perfusionIV fluids – bolus N/S 1000mL, repeat if needed, stop when CVP reaching >12cm H2O (or someother reasonable endpoint)Insert CVL and arterial line if not-responsive to fluid and need for inotropesNoradrenaline infusion start at 5mcg/min via CVL – increase aiming for MAP >65mmHgBroad spectrum Abs – pip/taz 4.5g, gentamicin 5-7mg/kg, vancomycin 30mg/kg loading dose1 mark for end-points, 1 mark for each step with details (no ó marks)Pass 4 of 5Total pass 7/10A 60 year old man presents with a painful left hand. You note some increased heat, redness and swellingAn x-ray is done and reproduced here.Give four abnormal findings on the image provided.Give three aetiologies for this appearance.Outline five (5) key features of his treatment and discharge planning.AnswersQ1.Air in soft tissuesDIP joint dislocation ring fingerHealed fracture shaft distal phalanx little fingerFracture base middle phalanx ring fingerFused PIP joints middle and index fingersSub-periosteal bone cysts ring ?middle fingers?metallic foreign body PIP joint middle fingerQ2.TraumaOsteomyelitis Necrotising fasciitisCharcot joint/jointsInfected wound/foreign bodyQ3. SupportiveAnalgesia/anti-pyreticElevation +/- splintingSpecific IV antibiotic: broad spectrum i.e. Tazobactam IV normal saline if likely necrotising fasciitisSurgical referral: general/orthopaedic for possible OT treatmentEuglycemic treatment(+/- HBO)Reduction of acute dislocation/fractures under ring blockA 30yo IV drug user is BIBA with acute stridor. En-route he has been given adrenaline 500mcg IM, ventolin and oxygen. He has an IV in place. He is alert, diaphoretic, and pale, febrile T-38.5C, PR 100SR, BP 120/80, RR 20, Sats 96% R/A. He has impaired mouth opening and abdominal rigidity. He reports feeling unwell and complains of difficulty swallowing and back pain and over the past three days.What is your DDx for this presentation? (40%)What is the pathophysiology of tetanus (20%)What are the priorities in the management of this man with generalized tetanus? (40%)Answers 11 DDx for this presentation?Dystonic drug reaction, tetanus, hypocalcemia, seizures, strychnine toxicity, infections of the head, neck and central nervous system, neuroleptic malignant syndrome, serotonin syndrome. (Not malignant hyperthermia in this context)Marking 11(a). 40% of the total score for this question8% per Differential (max 40%)Pathophysiology of tetanusClostridium tetani, toxin, axonal transport proximally to the presynaptic GABA-nergic terminal , blocks synaptobrevin, inhibits vesicle binding and release of inhibitory neurotransmitters (eg GABA, not acetylcholine)Results in muscular spasm and autonomic instabilityMarking 11(b). 20% of total for this question.Critical in bold. Pass/fail only (zero or 20%)Mx priorities 1.Secure the airway (RSI), 2.tetanus toxoid and3. Immunoglobulin, 4.metronidazole, 5.prevent spasm (diazepam, MgSO4, vecuronium), 6.anticipate autonomic instability (extremely labile BP and heart rate).Marking 11(c). 40% of the total for this question.Fails if candidate doesn’t intubate (zero)6% per item up to 40%(NB. Although C. tetani is penicillin sensitive, penicillin is avoided because of its anti-GABA effects)Overall Pass = 60% ................
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