2008



2008.2 SAQ 3

A 46 year old man presents with one hour of severe left sided abdominal pain, radiating to the left loin. An abdominal CT scan reveals a 6 mm stone in the lower third of the left ureter with a mild hydronephrosis.

Discuss the analgesic and other treatment options in this patient. (100%)

The overall pass rate for this question was 71/81 (87.6%).

The examiners felt that the question may have been somewhat ambiguous in that the current pain status of the patient was not explicit. Strong answers required a discussion of the pros and cons of currently available pharmacological agents, criteria for admission and consideration of possible urological interventions. Poor answers failed to address the above issues or failed to address the question.

Model Answer (David Lang)

Key issues:

• Stone unlikely to pass spontaneously at this size (approx 20% chance)

• Patient likely to experience ongoing discomfort ± complications due to same; needs full management plan in order to minimise same as

• Unlikely to be admitted acutely

Treatment options

• Outpatient vs inpatient

• Ideally all patients with a 6mm stone would be admitted for ongoing pain management, however resources not sufficient to allow for same

• Outpatient management

o Aim is to have patient pain-free / in minimal discomfort prior to discharge

o Analgesia

▪ Simple

• Pros

o NSAIDs effective

o Can be discharged if managing pain adequately on simple oral analgesia

• Cons

o May not be sufficient

o Vomiting may exclude oral route

o Adverse effects eg gastric irritation

o Do not alter underlying process

▪ Opiate iv

• Pros

o Gold standard analgesia

• Cons

o Cannot go home if requiring iv opiates

o Adverse effects eg compound nausea / vomiting

o Do not alter underlying process

o Antiemetics

▪ Pros

• Symptomatic relief

▪ Cons

• Ineffective orally (home) if vomiting

• Do not modify underlying process

o Alpha1 antagonists

▪ Pros

• May increase rate of spontaneous stone passage

• Can be used orally as outpatient

▪ Cons

• Adverse effects especially postural hypotension

o Overall outpatient

▪ Pros

• Avoids huge drain on hospital resources, for possibility that issue may resolve spontaneously

▪ Cons

• Patient suffering

• For what may eventually need surgical intervention

• Inpatient management

o Pros

▪ Can administer iv opiates / antiemetics / PR NSAIDs

▪ Potential for definitive surgical treatment (ureteroscopy / YAG laser)

▪ Decrease complication rate (eg hydronephrosis → nephropathy)

o Cons

▪ Resource drain

▪ Appreciable rate of spontaneous resolution → admission not necessarily required

• Overall

o Analgesic / other treatment options of renal colic

o Balance of resource demands and acting in patients best interests. Need to personalise decision making based on individual aspects of each patient’s presentation.

SAQ 6

A 58 year old patient who is undergoing Continuous Ambulatory Peritoneal Dialysis for end stage renal disease presents with a 6 hour history of severe abdominal pain and vomiting.

His observations are:

Temp 38.8oC

PR 110 per min

BP 150/90 mmHg

RR 22 per min

O2 Sat 98% on oxygen 6 LPM

Describe your assessment. (100%)

The overall pass rate for this question was 47/77 (61.0%).

The examiners felt that this was a straight forward question addressing a typical ED presentation. Good answers based their assessment on eliciting evidence pro or con the numerous differentials in the diagnosis. Poor answers failed to think beyond bacterial peritonitis as a cause or dealt with management issues rather than assessment.

1994 Describe the management of a 62 year old man who presents to your Emergency Department with a letter from a local GP, which reads, “Dear Doctor, this patient’s creatinine is 0.74 (normal range 0.06 - 0.10), having been 0.08 when I checked it six months ago. Please admit and treat”.

2007 A 58 year old patient who is undergoing Continuous Ambulatory Peritoneal Dialysis for end stage renal disease presents with a 6 hour history of severe abdominal pain and vomiting.

His observations are:

Temp 38.8oC

PR 110 per min

BP 150/90 mmHg

RR 22 per min

O2 Sat 98% on oxygen 6 LPM

Describe your assessment. (100%)

2011 A 57 year old man with chronic renal failure has been brought to your emergency department following a syncopal episode post-haemodialysis.

GCS 15

HR 90 /min

BP 95/50 mmHg

RR 16 /min

Temperature 37.4 0C

O2 Saturation 98 % on room air

Describe your assessment of this patient (100%)

1992 A 21 year old male presents with unilateral scrotal pain.

(a) Outline the possible diagnoses and the indicators (by either history, examination or investigations) which would support these diagnoses.

(b) Outline the management strategies of the non-surgical conditions mentioned.

1995 Outline the assessment and management of a previously well 26 year old man who presents with an acutely painful, red and swollen left testis

1998 A 60 year old male presents with right sided flank pain which radiates to the groin.

(a) What is your differential diagnosis?

(b) Discuss the merits of the various medical imaging techniques available to investigate this patient.

(c) What are the indications for early urological referral in a patient with renal colic?

2000 Describe the aetiology, complications and Emergency Department management of priapism.

2003 Discuss the various imaging investigations available in the evaluation of renal colic.

2004 A 52 year old man has been referred to you by his general practitioner because of the recent development of macroscopic haematuria.

(a) Describe your assessment of this patient. (80%)

(b) Outline your disposition of this patient. (20%)

2007 A 46 year old man presents with one hour of severe left sided abdominal pain, radiating to the left loin. An abdominal CT scan reveals a 6 mm stone in the lower third of the left ureter with a mild hydronephrosis.

Discuss the analgesic and other treatment options in this patient. (100%)

2010 A 50 year old man presents to the emergency department with priapism for 4 hours.

(a) List the possible causes of priapism in this man (30%)

(b) Describe your management (70%)

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