INTERLUDE EXAM 2.

    INTERLUDE 2.

    QUESTION 1.

    A 21 year old male presents with the ambulance as a resuscitation call. Your team is assembled in resus, waiting. He has a history of asthma requiring ICU admission. On arrival to the ED he has a chest silent to auscultation, with the following vital signs:
     
    • HR                   132      /min
    • RR                   45        /min
    • O2 sats            90%     15L O2 NRB
    • BP                    110/80 mmHg
    • GCS                 15
    i. (6 marks)
     
    Describe your immediate management.
    ii. (12 marks)
     
    Despite your measures above, the patient deteriorates and is successfully intubated. Describe your ventilation strategy, including 2 underlying principles.

    QUESTION 2.

    A 4 year old child presents with his parents. He has a fever, and has been feeling lethargic and nauseous for 10 days. He has no medical history of note.
     
    A set of vital signs is taken:
    • HR                   140      /min
    • RR                   50        /min
    • O2 sats            95%     on RA
    • BP                    90/71  mmHg
    • GCS                 15
    i. (5 marks)
     
    A full blood count is taken as part of the work up and the results are shown below. Describe and interpret the results and give a likely diagnosis

    ii (2 marks)
     
    During your consultation with the patient’s mother she tells you this is the patient’s 4th visit to the ED this week. When questioned it she denies ever having been seen by a consultant or registrar. Outline your next 2 actions.
    iii. (4 marks)
     
    Your Director asks you to investigate the complaint after the patient has been admitted. Outline the steps you would take.
    iv (2 marks)
     
    Briefly outline 2 steps you could take in order to enact your quality improvement.

    Question 3.

    A 16 year old boy presents to you after an episode of syncope during a soccer game. His blood pressure at triage is recorded as 96/54.

    i. (5 marks)
     
    An ECG is taken when he is moved into the acute area. It is shown below. Describe and interpret the ECG.

    ii. (9 marks)
     
     Give 2 options for the emergent management of this rhythm and a pro and con of each.
    ​
    iii. (7 marks)
     
    The patient’s ECG post reversion is shown below. Describe and interpret it.

    ​

    Question 4.

     
    An 18 year old girl presents with her parents. She has a history of anorexia nervosa and has been refusing to eat for the last 2 weeks.

    i. (6 marks)
     
    List 6 investigations will you undertake in this patient and give a reason for each.
    ii. (9 marks)
     
    Outline criteria that you would use to admit this patient to an inpatient medical unit rather than an eating disorders (mental health) unit.

    iii. (3 marks)
     
    The patient’s VBG is shown below. Describe the acid base balances present.
    iv. (2marks)
     
    Give 2 calculations to support your results.

    Question 5. (continues into q6).

    A 30 year old man presents via ambulance after a prolonged entrapment in an MVA. He has injuries to his head, chest and abdomen, and has been intubated by the prehospital team.
     
    On arrival his vital signs are as follows:
     
    • HR                   140      /min
    • RR                   16        /min    (ventilated)
    • O2 sats            97%     on 100% O2
    • BP                    90/71  mmHg
    • GCS                 3                      (intubated)
     
     
    A massive transfusion is commenced. Shortly afterwards a ROTEM sample is run to assess the patient’s coagulation. A normal ROTEM sample is given for comparison, and both are shown below.
    NORMAL ROTEM PROFILE
    PATIENT INITIAL ROTEM SAMPLE
    i. (5 marks)
     
    Describe the main ROTEM findings and which blood product they indicate.
    ii. (5 marks)
     
    After the initial resuscitation of the patient, the ROTEM sample is repeated and the results are shown below. Describe the findings and their implications.

    ​
    iii. (4 marks)
     
    The patient is taken emergently to the CT scanner. The patient’s CT scan of the brain is shown below. Give the main findings.

    question 6 (continues from q5)

    The patient from question 5 has an associated extradural haematoma. Urgent theatre is planned, and the neurosurgical registrar asks you to arrange a consent with the next of kin.

    i. (2 marks)
     
    Outline your response to this.

    ii. (5 marks)
     
    Give the components of informed consent.
    iii. (4 marks)
     
    The Neurosurgical registrar cannot reach any of the patient’s next of kin, nor can she contact her consultant for advice. She asks you under what grounds she should proceed. Outline the rationale for your response, and any actions you will take.

    ​

    question 7.

    A 2 year old girl presents as a resus call with the ambulance. She has had 45 minutes of seizures at home and is still seizing. She has a temperature of 39.6 degrees. The ambulance have given 2mg of IM midazolam, and have been unable to establish IV access.

    i. (5 marks)
     
    Outline your procedure for establishing emergent vascular access in this child.
    ii. (8marks)
     
    Outline your immediate management of the patient post insertion of vascular access.
     
    iii. (3 marks)
     
    The child is transferred to PICU. On review of the record you note that she was discharged as a viral infection from ED 2 days prior. Outline your actions in response to this.

    iv. (5 marks)
     
    You are asked to meet with the parents and explain events. List the elements of open disclosure.
     

    question 8.

    A 42 male presents to resus with severe vomiting. He has no medical history of note. He is transferred from the ambulance to the resus room with the following vital signs:
     
    • HR       135      /min
    • BP        85/42  mmHg
    • T          39.6     oC
    • RR        16        /min
    • GCS      15
     
    i. (3 marks)
     
    Your registrar presents you with a point of care venous blood gas. She notes that due to the patient’s degree of haemodynamic compromise she found IV access very difficult. The blood gas is shown below. List the major acid base abnormalities.
     

    ii. (5 marks)
     
    An ECG is immediately taken from the patient, and is shown below. Describe and interpret the ECG.

    iii. (6 marks)
     
    Outline your next management steps.

    question 9.

    A 23 year old woman presents to your department with headache. She describes a migratory, generalised headache that has gradually developed and has been largely persistent for 2 weeks. She describes varying and transient neurologic symptoms including blurred vision, dizziness and difficulty concentrating. The headache severity varies irregularly. Her only medication is the oestrogen only contraceptive pill
     
    Her vital signs are:
     
    • HR                   90        /min
    • RR                   16        /min
    • O2 sats            99%     on RA
    • BP                    131/71 mmHg
    • GCS                 15
    i.  (6 marks)
     
    List 6 differential diagnoses for this presentation.

    ii. (4 marks)
     
    A contrast CT scan of the patient’s brain is performed, and an image is shown below. Give 2 major abnormalities and the diagnosis

    ​
    iii. (2 marks)
     
    Outline 2 management steps you will now institute.

    question 10.

    A 5 year old girl is brought in by her parents. They are concerned that she may have ingested her grandmother’s iron tablets, thinking they were chocolate lollies. The ingestion occurred 45 minutes ago. The child is well. No other medications were involved.

    i. (4 marks)
     
    Outline your investigation strategy for this child.

    ii. (4 marks)
     
    The patient’s abdominal xray is shown below. Describe the major findings and the implications.

    iii. (5 marks)
     
    Blood tests are taken from the child approximately 1 hour after the ingestion, and the results are shown below. Describe your actions and further investigation strategy.

    iv. (2 marks)
     
    The child’s repeat blood tests at 7 hours are shown below. Outline your next action.