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MH SAQ practice questions PathologyYour registrar asks you for advice. A 50 year old female has presented following a collapse and is now increasingly confused . Her only injury is a minor abrasion to her forehead. You have the following blood/urine results thus far: Patient weight 65kgGlucose 16.4 Na 111K 4.2 Urea 7.2 Creatinine 102 Hb 13.1 WCC 12.2 Plt 175 Urine Osmolality 125 Urine Na 42 1. What is her calculated Na? (1 mark)114-115 mmol/l2. What is her calculated osmolality (1 mark)2Na + Glu + U = 245 mmol/kg3. What are 12 criteria for SIADH on history, examination and investigations? (6 marks)hyponatraemiahypotonicityurinary Na >20mmol/l urine osmolality > plasma osmolality or > 200mosm/kgeuvolaemia or normovolaemianormal renal functionnormal hepatic functionno cardiac disease/ CCFno thyroid diseaseabsence of drugs affecting renal water handlingcorrection of Na with fluid restriction normal cortisol4. She remains confused and then has a seizure. What is your specific treatment and endpoints. (2 marks)3% NS 60-70ml/hour for 4 hoursAim increase Na by 0.5 to 1 mmol/ hourA 32 year old lady who is 36 weeks pregnant presented with headache, drowsiness and her observations and results are as follows:Pulse 110 bpm BP180/110mmhgRR24/minSats 96%air; Hb 9gm/dl WCC 8 x109/LPLT 34 x109/LLFT: AST 120 u/L, ALT 135 u/L, LDH 750 u/L1. What is the diagnosis? (2 marks)Pre-eclampsia with HELLP variant (haemolysis, elevated liver enzymes and low platelets)2. What 2 anti-hypertensive drugs would you consider to treat her blood pressure? (2 marks)Labetalol 10 mg IV followed by IV infusion 1-2mg/minHydralazine IV – second line (Hydralazine remains the drug of choice for women with asthma or congestive heart failure)NB nifedipine an alternative option3. You have paged the PICU doctor and obstetrician to your resuscitation room, however, your patient starts to have a seizure. What are the first four things you would do? (4 marks)Left lateral position and support airway/administer Oxygencheck BSL and treat if lowMagnesium Sulphate 4-6Gram IV (over 5 min) followed by maintenance infusion 1G/hrMidazolam 3-5mg IV PRN to control seizures4. What are the 4 signs of maternal toxicity with magnesium sulphate which would predict either respiratory or cardiac arrest? (2 marks)Loss of patellar reflexesRespiratory rate < 10Slurred speech, weakness, feeling extremely sleepy, double visionMuscle paralysisA 52 year-old female is presenting to the ED with a 3 day history of feeling generally unwell with nausea and abdominal pain. She is apyrexial (T 36.7°C), HR 78 and BP 85/50mmHgBlood results are as follows:Na 126mmol/LK5.7 mmol/LGlucose 2.3mmol/ LCalcium 2.6mmol/L1. What is your provisional diagnosis for this woman? (2 marks)Addison's disease with Addisonian crisis2. List the 2 main pathophysiological causes for this presentation? (2 marks)adrenal gland failure HPA axis failure eg3. What other blood investigations will be helpful in confirming your diagnosis? (2 marks)Cortisol level ACTH Short Synacthen test4. List four management steps and rationale behind each.(4 marks)Hydrocortisone 100mg IV ;To replace steroidsIV N/Saline 1L 1 hour; Fluid ResuscitationDextrose 10% 500ml; Correct HypoglycaemiaFludrocortisone; Replace mineralocorticoidA 7 year old child presents to the ED with a 12 hour history of headache and photophobia, but no rash.Urea and Electrolytes as followsNa+125mmol/LK+3.7mmol/LU3.2Cr51a. Give 2 possible neurological diagnoses for the symptoms described. (2 marks)Meningitis, intracranial haemorrhage, Migraine, Encephalitisb. What is the neurological cause for the Hyponatraemia? (1 mark)Meningitisc. What are 2 complications of Hyponatraemia? (2 marks)Seizure, anorexia, headache, drowsiness, nausea and vomiting, tachycardia and about 10 million othersd. List 5 investigations you would perform in the ED for a patient with Hyponatraemia. (5 marks)Urinalasis, FBC, U&Es, LFTs, BM/glucose, urine osmolality, ECG, CXr, consider CT head, LP if no signs of raised ICPA two month old infant has been brought in following a brief seizure. She has had coryzal symptoms and high fevers for two days. She has no relevant past history and no allergies. On examination: HR 110 /min, BP 80/45 mmHg, Temp 39.7°C. There is no rash and no clear focus of infection but the child is ill-appearing and drowsy.a. What investigations are required?InvestigationJustificationWCC (FBC)Other inflammatory markers – CRP etcAt 2 months most would consider too young to assess on purely clinical grounds.Could comment that WCC/CRP do not confirm/exclude SBIElectrolytesSick child – possible abnormality of fluids in/outUrinePart of septic workup – especially as going to give antibioticsCSFPart of septic workup. While this could be a “simple febrile convulsion” with another source of sepsis LP is mandatory in this settingBlood cultureSepsis workupA lumbar puncture is performed:CSF white cell countNeutrophils 120 (nil)Lymphocytes 25 (<5)CSF red cell count 200CSF Protein 1.2 (< 0.4 g/L)CSF glucose 0.4 (> 2.5 mmol/L)b. Interpret these results.Highly suggestive of bacterial meningitis. Likely a “traumatic tap” but ratio of RBC:WBC still indicates too many WBCsc. List and justify the medications you would use to treat this child.MedicationJustificationDoseCefotaximeCould choose ceftriaxone though under 3 months usually cefotaxime (hepatic immaturity)50mg/kg 6th hourly(ceftriaxone 100mg/kg 12th hourly)Ben PenicillinTo cover listeria60mg/kg 4th hourlyVancomycinFor resistant S pneu – local practice varies – depends on local prevalence. Some wait for CSF gram stain or antigen studies30 mg/kg 12th hourlyDexamethasoneGive before or with antibiotics. Reduce hearing loss in Hib meningitis (JAMA 1997). Decrease poor outcomes (GOS) & death (NEJM 2002)0.15 mg/kgParacetamolFor fever15mg/kgd. A senior nurse complains to you that one of the junior doctors involved in this case has been caught stealing a box of ciprofloxacin. A formal incident report has been filed and the nurse wants you to “deal with the JMO”. The doctor says he only wanted to take some as prophylaxis against possible meningococcus.What key principles should you consider in your discussion with the JMO?Non-judgemental, non-confrontational, confidential, document discussion.“Stealing” drugs is potentially serious – disciplinary/employment ramificationsDoctor needs counselling - ?apology etcConcern about infection not entirely unreasonable though prophylaxis only indictaed if meningococcus confirmed & close exposure (e.g. suctioning, intubation)A 27 year old woman is brought in by housemates to your tertiary ED. She had been not seen for 2 days and was found beside her bed slumped on the floor.Her observations are: GCS 13P 128/minBP95/50mmHgT 34.7°Ca. What are the 3 most important abnormalities on the UELFT? (3 marks)Renal failure, rhabdomyloysis , hepatitis (?ischaemic)Sodium136 mmol/L 137-145Potassium4.0 mmol/L 3.2-5.0Chloride 92 mmol/L 98-111Bicarbonate23 mmol/L 22-31Urea23.2 mmol/L 2.5-7.5Creatinine424 μmol/L 60-110Est. of GFR15 mls/min >90Glucose 3.6 mmol/L 3.5-5.5Osmol-calc 292 mmol/L 280-300Bili Tot. 10 umol/L 2-20ALT720 U/L <55AST15 U/L 5-50ALKP89 U/L 20-110GGT23 U/L 15-73CK >103000 U/L 20-200CRP1.2 <10b. List the principles of your fluid management. (4 marks)ivf crystalloid eg NS, bolus to make restore BP systolic >100 then aim euvolaemic clinically. And then use iDC to guide UO , Aim at least 100ml/hr urine ; consider frusemide/alkalisation to achieve this for rhabdo. Watch for signs volume overloadc. List 6 differential diagnoses. (3 marks)drug overdose; head injury; hypoglycaemia, seizure, attempted suicide (eg asphyxiation), exac established underlying renal disease; sepsis; SAH ; ethanol abuse. A 55 year old woman is brought in with a GCS of 7.There is no sign of trauma. There is a history of ethanol abuse. P 105 /min, BP 100/40 mmHg, afebrile, Sats 98 2L NP, RR 34 /min.a. What is the acid-base abnormality? (1 mark)Resp alk incomplete metabolic compensation suggesting acute b. What are the 3 other significant findings? (1 mark) Hyperchloraemia, anaemia; raised lactate; borderline na and k, mild carboxyHb; negative BEc. What is the likely diagnosis (with justification) and what are 2 differentials? (3 marks)GI bleed leading to hepatic encephalopathy: known etoh, resp alk common, low Hb Gi blood common trigger for enceph; DDx: OD eg aspirin; Head injury, stroke; psychogenic d. Outline your major goals of management. (5 marks) Requires intubation and ventilation; followed by urgent CTbrain to exclude head injury/CVA; followed by blood transfusion/coagulopathy correction and urgent endoscopy; needs lactulose, avoid large volumes sodium; Start PPI, consider octreotide if known varices.; ceftriaxone Also needs family discussion as very unwell . disposition ICU under gastroA 60 year old woman presents to ED with the primary complaint of being a ‘funny colour’.Blood results reveal:Bilirubin 60 (1-20)AST 400 (4-45)ALT 200 (0-45)GGT 125 (0-60)Amylase 100 (25-136)a. What is the predominate pattern of these blood results? (1 mark)hepatocellular damage/transaminitisb. What are your 4 most likely differential diagnoses? (4 marks)infectious – viral hepatitis (A,B,C)toxins/drugs – paracetamol/alcohol/prescribed medicationstumour – benign, malignant, metastaticimmune – autoimmune, related to systemic illness?consider haemolysis if unconjugated hyperbilirubinaemia, but transaminitis doesn’t fit this picture, would have to be 2 processesc. List 5 further investigations you would order in the ED to assist your diagnosis. Briefly justify each one. (5 marks)FBC – look for haemolysis, bone marrow suppression (alcohol, tumour) (?retics, haemolytic screen) (would want conjugated vs unconjugated bili)Serology – hepatitis A,B,CAlcohol/paracetamol level or other drug levels – toxin induced transaminitis?Albumin/coags – will identify degree of liver failure, chronic picture, won’t point to specific diagnosisCXR – looking for primary malignancyHepatic USS – tumours, cirrhosis, (duct obstruction although not obstructive picture)A 74 year old lady presents to ED with a history of being found on the floor at home confused.Her arterial blood gas is shown belowFI O2 = 6 litres O2pH 7.29(7.35 – 7.45)pO2 80 mmHg(35 – 45)pCO2 64 mmHg(90 – 100)Bic 30 mmol/lBase excess+3a. What do these blood results indicate? (Interpret these results) (3 marks)Pt is acidaemic. Acute on chronic respiratory acidosis with partial/incomplete metabolic compensation (for full chronic expect HCO3:pCO2 ratio up 4:10, so PCO2 up by 20, bic should be up by 8 = 32.) Type 2 respiratory failure as evidenced by raised pCO2 and relative hypoxia on 6 l O2. (Some people worked out the Aa gradient - ?accuracy on 6l, what is FiO2?.)(This is an old question, not enough info for SID, etc.)b. Name 4 conditions you should consider in the differential diagnosis for the woman’s presentation. (4 marks)1. Acute/infective exacerbation of COPD2. Central cause - ?1o ICH, TBI due to fall3. Toxins – opioid or sedative overdose with respiratory depression4. (?PE – on background COPD) or one of the belowThere is a wide differential, eg hypoglycaemia, PE, pneumonia with sepsis, trauma to chest wall – difficult to mark!c. List your immediate management priorities. (3 marks)1. Remove high flow O2Ensure patent/protected airway 2. Manage breathing and respiratory failure - ?bronchodilators, (steroids), n/p O2, BiPAP, aim for O2 sats 90% and aim to reduce hypercarbia, improved respiratory functionC – treat associated or induced hypotension, dehydration, arrhythmias…3. Treat associated injuries/conditions, eg. spinal immobilisation if appropriate.(Plenty of management things but focus on the immediate). One suggestion was to consider ceiling of care, goals of care – would mention this before mentioning intubation)A 17 year old male is brought to ED by ambulance, complaining of abdominal pain and vomiting. He appears confused and is unable to prvide a good history. On examination his vitals are: Temp 37.9 oC, BP 100/50 mmHg, HR 110 /min.Blood tests taken on arrival show:Na 140 mmol/l(135-145)K 5.0 mmol/l(3.5-5.5)Chloride100 mmol/l(95-110)Creatinine0.1 mmol/l(0.03-0.08)Urea16 mmol/l(3.0-8.3)Glucose40mmol/l(3.3-8.3)Hb167g/l(135-175)PCV50%(41-53)Plt224(140-400)WCC21.8(4-11)Neutrophils19.2(4-11)pH7.133(7.35-7.45)pC0224.8(35-45)p02112(90-100)HCO38.3(24-32)BE-19.6Sa0296.8% a. List the major abnormalities. (4 marks ? for each)Marked hyperglycaemiaSevere metabolic acidosisElevated anion gap of 27 (includes K)Mild respiratory acidosis as expected C02 20.45 +/- 2High osmolality 336Elevated WCC: sirs/sepsisCorrected Na 149 elevatedPotassium normal but secondary to shift with dehydration and acidosis so whole body stores likely lowb. What is the diagnosis? (1 mark)DKAc. What is your initial management? (5 marks)Initial fluid resus correct shock then 500ml/hr for 4 hrs (titrate to response) Crystalloid of choiceInsulin 0.1 units/kg/hr initial rateK+ replacement 10mmol/hr and monitorProphylactic LMW heparinTeat precipitantDisposition ICU/HDUA 30 year old man presents after 24 hours of vomiting. He looks sweaty and unwell.Initial observations: Temp 37.2°C, HR 120 /min, BP 80/50 mmHg, RR 22 /min, Sa02 99% on room air.Initial lab results:Hb154 g/L(110-165)WCC13.3 x109/L(3.5-11)Plt239 x109/L(140-400)Na130 mmol/L(135-145)K5.2 mmol/L(3.5-4.5)Cl101 mmol/L(100-110)HC0321mmol/L(22-33)Urea10.7mmol/L(3-8)Creat94umol/L(50-100)Ca (total).39mmol/L(2.15-2.6)Alb48g/L(33-47)Gluc4.1mmol/L(3-7.8)a. What are the abnormalities? (2 marks)(must grade levels of abnormality for full marks)Mild hyponatraemia Mild hyperkalaemiaMild metabolic acidosis with normal anion gap of 13b. List your differential diagnosis with most likely listed first. (7 marks)HypoaldosteronismHyperemesis from cannabisGastritisHypoadrenalism (although normal glucose against)Drugs (ACE inhib, K sparing diurectics, CAH inhibitors)Renal Tubular acidosisKetosis SepsisPanreatitisAny other reasonable cause c. What test is used to confirm the most likely endocrine diagnosis? (1 mark)Short Synacthen testA 55 year old man is referred to your ED by his GP with a complaint of being “generally unwell”. He has a history of hypertension.The patients chemistry and venous blood gas are shown below:Na 144mmol/L(135-145)K1.7mmol/L(3.3-4.9)Cl85mmol/L(98-106)HC0340mmo/L(3.0-8.0)Creat0.08umol/L(0.05-1.12)pH7.56(7.35-7.45)pC0244mmHg(35-45)p0268mmHg(90-100)a. Describe and summarise the results. (4 marks)Life threatening hypokalaemia (mandatory to pass)HypochloraemiaMetabolic alkalosis with elevated bicarbonateAnion Gap 20Normal renal functionExpected C02 43 – appropriate resp compensationBorderline hypoxia (likely secondary to hypoventilation)Hypochloraemic hypokalaemic metabolic acidosisb. What is your differential diagnosis? (6 marks)Loss of HydrogenRenal: Hyperaldosteronism, primary (Conn’s) or secondary, Cushing’s, Bartter’s syndrome)Upper GI: VomitingDrugs: corticosteroids, diureticsGain of bicarbonateSodium bicarb tabletsSecondary hyperparathyroidismA previously well 2 year old boy presents acutely unwell with tachypnoea and abdominal pain. VBG results are shown below. pH 7.20Pc02 25BIC 10BASE EXCESS -16.4k 4.5NA 138cL 96List the further investigations you request at this time with justification for each. (7 marks)BSL –r/o hypoglycaemiaHb –may be significantly lowered if intrabdominal haemorrhageWBC –nonspecific –but high elevation in infection/inflammatory conditions and abnormal cell lines if underlying/undiagnosed leukaemia etcCr/Urea –rule in/out acute renal failureLFTs –elevated in some tox (eg paracetamol) or primary liver diagnoses eg.Consider tox screens as guided by full Hx/exam for eg serum iron/salicylate/paracetamol levelsUA –glucose/protein to support DKA, blood if renal trauma, nitrites, wbc if UrosepsisCXR –free gas if intrabdominal perf, pneumonia as a causeFAST scan at bedside –looking for intrabdominal fluid ?blood ?ascites secondary to liver failure, and to r/o cardiac tamponade as a potential obscure cause of hypoperfusionFurther investigations as guided by Full Hx/Ax and other results may include:CT abdomen, formal USS abdomen, air insufflation enema if intussusception, formal skeletal survey if NAI suspectedWhat are the 3 most concerning potential diagnoses for this child. (3 marks)DKAIntrabdominal surgical emergency egToxicological eg Iron OverdoseNAI with intrabdominal injurySepsis eg urospesis, pneumoniaA 5 year old boy has been brought to your ED with a 2 day history of fever, cough and lethargy.He has the following vital signs:Temp 38.8 degreesPulse 145 /minBP 90/40 mmHgRR 40 /minO2 sats 91% room airExamination of his chest reveals decreased breath sounds and crackles in the right lung base.He has had a venous blood gas taken:pH 7.18 (7.35 – 7.45)pCO2 21 mmHg (35 – 45)pO2 25 mmHg (80 – 100)HCO3- 8 mmol/L (22 - 32)BE -18.5 mmol/L (-3 - +3)Na 140 mmol/L (135 – 145)K 5.7 mmol/L (3.5 – 5.0)Cl 98 mmol/L (100 – 110)Glucose 38 mmol/L (3.0 – 7.8)1. In point form, provide explanation for all the abnormalities shown on the VBG.(8 marks)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2. What is your diagnosis, based on all the clinical information? (2 marks)________________________________________________________________________________3. List your 5 main treatment steps, with drugs and doses where appropriate. (5 marks)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________1.Moderately severe acidaemia – pH decreased 7.18Metabolic acidosis – reduced HCO3 and BEHigh anion gap 34 – Diabetic ketoacidosis, other possible causes renal failure, lactic acidosisAppropriate respiratory compensation – pCO2 reducedNa corrected for glucose is approx. 151 – elevated suggesting total body water loss / dehydrationK is elevated but when corrected for pH is likely to be approx. 4.7 which is in normal rangeCl reduced to maintain electrical neutrality in face of excess anionsGlucose elevated in DKAPass 6 of 82.Diabetic ketoacidosis exacerbated by pneumoniaPass 2 of 23.Insulin infusion 0.1U/kg/hrIV fluid – initial bolus 20ml/kg N/S, then replace deficit plus maintenance over 24hrsIV antibiotics – benzylpenicillin 60mg/kg and roxithromycin 4mg/kgK replacement – add 20-40mmol/L to fluids when K below 4.5 -5.0Dextrose – add 5% dextrose to N/S when glucose below 12-15(must havePass 3 of 5Total Pass 11/15 corrects to 7/10A 69 year old man has been brought to the ED after an overdose of an unknown quantity ofquetiapine and diazepam. He was found on the floor of his apartment by his landlord. Due to areduced level of consciousness, he has been intubated.His blood results are shown:Na 136 mmol/L (135 – 145)K 8.3 mmol/L (3.5 – 5.1)Cl 101 mmol/L (100 – 110)HCO3 16 mmol/L (22 – 32)Urea 15 mmol/L (2.9 – 8.2)Creatinine 285 umol/L (64 – 108)Glucose 7.3 mmol/L (3.0 – 7.8)1. List the abnormalities on the blood results, giving likely possible causes of each abnormality.(6 marks)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________2. What is the most likely clinical scenario responsible for the above blood picture?(2 marks)__________________________________________________________________________________3. List your management steps for his hyperkalaemia. Give doses. (4 marks)__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________MARKING SHEET SAQ Q 281.Severe hyperkalaemia – cellular shift due to metabolic acidosis, renal failure, cell death with rhabdoHigh anion gap metabolic acidosis – renal failure, lactic acidosis lost likelyRenal failure – urea/creat less than 100 – suggests intrinsic renal failure – most likely due to rhabdo1 mark for each process, 1 mark for explanation (no marks for just saying X is high or Y is low)Pass 4 of 62.Rhabdomyolysis due to prolonged period on floor following sedative overdose(accept compartment syndrome)1 mark for rhabdo, 1 mark for whyPass 1 of 23.Ca gluconate (membrane stabilisation) – 20mL 10%Intra-cellular shift- Serum alkalinisation (hyperventilation and HCO3) aim pH high normal- Insulin / dextrose – 10U/50mL 50%- Salbutamol – 5mg nebs via ETTRemoval- NG resonium 30g(consider dialysis in refractory cases)Pass 3 of 4Total pass 8 of 12 corrects to 6.5/10SAQ 10 – CSF resultReference rangeAppearanceclear, colourlessGlucose3.0mmol/L2.8 - 4.0Protein750mg/L150 - 500WBCPolymorphs20x106/L<5Lymphocytes111x106/L<5Red cells8x106/L<5Organismsno organisms seenSerum Glucose5.0SAQ 10A 30 year old woman presents to the ED complaining of fever, headache, arthralgia and photophobia. She has been unwell for 5 days. Her symptoms initially started like an upper respiratory tract infection, and have not improved despite oral antibiotics.1. List five (5) contraindications for lumbar puncture.A lumbar puncture is performed and the results are shown on the opposite page.2. What are the two (2) most likely diagnoses?3. List 3 features of the CSF that support your diagnoses4. List two (2) pros and two (2) cons for the administration of intravenous antibiotics in this patientProsConsOverall – Anna Davis?????Handwriting still makes a differenceWhen there are multiple points (eg list 5 order makes a diff and adds emphasis to important pointsGave a lot of 10s/14 which was my bare minimum to passBreakdown - part 1 out of 5, part 2 out of 2, part 3 out of 3, part 4 out of 4.Total 14. ???????1. List 5 contraindications to a lumbar puncture1. Expected candidates to know 5 contraindications to LP Many candidates said the same indication but broke it up into several parts which I thought was not as good as grouping themeg Better candidates said suspected coagulopathy eg low platelets, raised inr (very few mentioned a MP rash which I would think would be important) compared with those who listed different sorts of coagulopathy separatelyAnother example - infection around LP site is 1 point though some listed cellulitis and abscess around lumbar area as separateBetter answers were put in order of most important eg suspected raised intracranial pressure prior to spinal surgery seemed a better perspective???????Mine in order????Suspected raised intracranial pressure - altered concious state, unilateral dilated pupil, papilloedema, hypertension bradycardiafocal neurological signs??coagulopathy as one - not broken up into 5 different sorts to cover answerseizures?????abnormality at LP site eg infection or spinal anatomy that would preclude lp eg spina bifida, spinal fusion???????Others?????Patient refusal????Previous complications of LPOther infection eg pneumonia to explain SxPatient agitation?????????????Not correct?????Will not change managementvomiting????????????2. Most likely diagnoses??Was generally answered well, would have thought you would put viral first then partially treated bacterial meningitis didn’t mark down for orderPass fail was mentioning both viral and bacterial meningitispartially treated bacterial meningitis is better than just bacterial meningitisaspetic meningitis was not sufficientIf bacterial meningitis was only mentioned in section 4 s then I allowed them to pass but I thought it was not as good???????3. List the features of CSF that support your diagnosisBest answers conveyed that these results were not 100% diagnostic. best answers conveyed which features suggested viral and which suggested partially treated bacterial. eg high protein suggest meningitis, lymphocytes most prominent WCC sugg viral, PMN may only be marginally raised in partially treated as compared to untreated bact meningitis, glucose low end of normal common in partially treated bact???????Didn’t get full marks but still passed if just listed each feature ie high protein, high lymphocytes as it didn’t demonstrate understanding as well???????2 pros??????Mine in order????antibiotics will treat partially Rx bacterial meningitis which if untreated has high morbidity and mortalityLikely few side effects, can be ceased after culture and PCR exclude bacterial meningitis with little sequealae???????Others not quite as good?treats partial bacterial meningitistreats other source of infection???????Cons??????Potential for side effects including anaphylaxis bacterial resistance ???Requires hospital stay and complications assosciated with this???????Others?????not indicated if viral???A 25 year old lady presents with severe epigastric pain and vomiting.Her biochemistry results are shown below.Biochemistry Reference rangeNa132mmol/L135 - 145K3.9mmol/L3.5 - 5.0Cl101mmol/L101 - 111HCO324mmol/L22 - 32Urea4.6mmol/L2.5 – 7.8Creat60umol/L40 - 80ALP248U/L30 - 120GGT309U/L7 - 64AST27U/L10 - 50ALT55U/L7 - 56Bilirubin43umol/L0 – 20Lipase448U/L0 - 60SAQ 20 continued1. What is your diagnosis?2. What are the two (2) most likely underlying causes and why?3. List four (4) complications of this condition.4. List five (5) features that will help determine prognosis on admission?Feedback SAQ 20 – George BraitbergDistribution of scoresWhy?I judged this as a good final year medical student questionMost candidates answered Qs 1, 2,3 well, so question 4 became the discriminator:“List 5 features that will help determine prognosis on admission”At the FACEM exit level I wanted:An indication of whether a prognostic value went up or down, hence glucose was not enoughA value assigned to a prognostic indicator,e.g. a bad prognosis is when the blood glucose >10 mmol/LWho got an 8?1,2,3 answered well.Q3 teased out the main IMPORTANT complications (not low glucose or low calcium)e.g. local complications of pancreas such as psudocyst or necrosissystemic complications such as SIRS or sepsisLessons learntIf you don’t know the abnormal values turn the prognosis question into defining the normal state. i.e. state that the best prognosis is a normal LDH and you may get away without having to recall the Ranson criteria for an abnormal LDH (>350)If you don’t know the abnormal values avoid listing them - state "acute renal injury" rather than state a creatinine, if this works for the question ................
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