INITIATION ROAD BLOCK EXAM

    INITIATION ROAD BLOCK

    QUESTION 1.

    A 32 year old motorbike rider is brought into your department after being struck by a motorbike. The front tire ran directly over her abdomen just inferior to the costal margins.
     
    Her vital signs are:
                            HR                    128      /min
                            BP                    90/44   mmHg
                            RR                    29        /min
                            Sats                  94%      6L O2
                            T                      35.8     oC

    i. (5 marks)
     
    What is the evidence for the empiric use of tranexamic acid in this patient?

    ii. (5 marks)
     
    The patient has a venous gas taken in the resus room. The results are shown below.

    Give the 2 primary disturbances present and justify your answer.

    iii. (8 marks)
     
    Based on the VBG results use the following table to list two major pathologic processes you are concerned about, and three injuries which may contribute to each.
    iv. (4 marks)
     
    The patient is taken to CT scan, and a copy of the image is reproduced below.
     
    List four (4) major abnormalities present?
    v. (1 mark)
     
    What grade of kidney injury is this?

    vi (4 marks)
     
    Give 4 indications for operative management of this patient. (4 marks)
    vii. (5 marks)
     
    Give five (5) elements important in a massive transfusion protocol.
    viii. (6 marks)
     
    Give 6 endpoints you would use to judge the efficacy of your transfusion.
    ix. (2 marks)
     
    Is there any evidence for the use of low BP targets (permissive hypotension) in trauma?

    QUESTION 2.

    You are the ED consultant on duty in a regional hospital with no obstetric or neonatal specialist services. A primigravid 25 year old patient presents to your emergency department at 8am. She is 31 weeks pregnant with appropriate antenatal care which has elicited no complications of pregnancy.
     
    She describes severe rhythmic lower abdominal pains which have been in progress for the past 4 hours.
    i. (2 marks)
     
    Give 2 differential diagnoses for this presentation.
    ii. (8 marks)
     
    Outline 4 features (not inclusive of vital signs) you will assess on clinical examination and the rationale for each.
    iii. (5 marks)
     
    Your examination indicates that preterm labour is in progress without any major complications to further medication administration.
     
    Give 5 steps in management you will now institute.
    iv. (4 marks)
     
    List 4 contraindications to tocolytic therapy in patients with preterm labour.

    Question 3.

    An 18 year old man presents to your emergency department with an acutely painful right testicle. He is visibly distressed by the pain and is vomiting at triage. He has no past medical history of note. He states the pain began more than 4 hours ago.
     
    His vital signs are:
    HR                    110      /min
    BP                    135/92 mmHg
    RR                    24        /min
    Sats                  98%      RA
    T                      37.4     oC

    ​
    i. (4 marks)
     
    List 4 differential diagnoses for this presentation.

    ii. (3 marks)
     
    What further features on examination would support a diagnosis of testicular torsion?
    ​
    iii. (6 marks)
     
    Your resident  who has primary care of the patient returns to you and asks you to approve an ultrasound of the testicle.

    Outline of two issues in this case which may limit the utility of ultrasound in this patient.

    ​
    iv. (2 marks)
     
    Your resident returns to you to say the surgical registrar is refusing to see the patient until an ultrasound is performed. At this stage the patient has been in your department 45 minutes.
     
    Outline your next actions.

    Question 4.

    An 82 year old female is brought in by the ambulance after being found faecally incontinent on her bathroom floor. It is unclear how long she has been there. Her neighbours in the apartment block have not seen her for 3 days. On arrival to the ED she is confused and disoriented. Her medication list includes warfarin, telmisartan, atorvastatin and digoxin.
     
    Her vital signs are:
     
    HR                    45        /min
    BP                    99/66   mmHg
    RR                    28        /min
    Sats                  92%      RA
    T                      33.1     oC

    i. (3 marks)
     
    The patient’s ECG is reproduced below. 
     
    Give 3 abnormalities which relate to this lady’s presentation.

    ii.  (4 marks)
     
    The resident brings you a venous blood gas which is reproduced below.
     
    Give 2 acid-base disturbances present and provide 2 derived values to support your answer.
    ​
    iii. (12 marks)
     
    List 6 investigations you will perform now in this patient. Give a justification for each.

    iv. (4 marks)
     
    Give 4 methods which you will use to actively rewarm this patient. (4 marks)

    Question 5.

    A 35 year old male presents to your department after catching his right foot underneath a door.
     
    A clinical image of the foot is reproduced below.

    i.  (2 marks)
     
    Describe the important findings in the image.
    ii. (5 marks)
     
    Describe your technique to anaesthetise this patient to exam and treat him.

    iii. (6 marks)
     
    The patient has the injured toenail with him in his pocket.
     
    Describe the treatment you will provide including your disposition & management.

    question 6.

    A 46 year old male with a history of gastro-oesophageal reflux and intravenous drug use presents to the emergency department with sudden onset central abdominal pain. On examination he has a rigid abdomen to palpation, and his vital signs are:
     
    HR        125                   /min
    BP        98/42               /min
    RR        29                    /min
    Sats      99%                  RA
    T          38.4                  oC
     
    A CT scan of his abdomen is organised, and an image is shown below.

    ​
    i.  (5 marks)
     
    What are the important findings on the CT image?

    ii. (4 marks)
     
    Give 4 differential diagnoses for the CT findings.
    iii. (8 marks)
     
    Describe your immediate management (8 marks)

    question 7.


    A 38 year old female presents to your emergency department with severe constant right upper quadrant pain. She complains of urine that is darker colour than normal and significant sweating overnight. She also feels nauseous and has no appetite. On examination she has severe right upper quadrant tenderness and notable ocular jaundice.
     
    Her vital signs are:
     
                            HR                   125      /min
                            BP                    89/52   mmHg
                            RR                    29        /min
                            Sats                 98%     RA
                            T                      39.6     oC

    i. (6 marks)
     
    Give 3 pathology tests will you perform on this patient and a justification for each?
    ii. (8 marks)
     
    Selected pathology is shown below. Describe the results and their implications.

    iii (3 marks).
     
    What are the advantages of ultrasound over CT in imaging this patient? (3 marks)

    question 8.

    A 48 year old male presents to your department after being struck in the right eye with a squash ball. He is complaining of blurred vision and a headache. His right orbit is swollen and bruised but there are no other major injuries.

    i. (5 marks)
     
    For each category listed below give the requested number of features you will examine for and the injuries they may represent:

    PUPIL - 2 features
    EYE MOVEMENT - 2 features
    LIP - 1 feature.
    ii. (2 marks)
     
    A CT scan of the patient’s face is shown below.
     
    What are the two major abnormalities?

    iii (4 marks).
     
    What are the indications for surgery in this fracture?

    question 9.

    A 46 year old patient presents to your hospital with 20 minutes of crushing central chest pain. You do not have PCI facilities in your institution. The nearest cardiac catheter laboratory is 40 minutes away.

    i. (4 marks)
     
    His ECG is shown below. Give 3 major abnormalities and a likely diagnosis.
    ii. (6 marks)
     
    Explain three issues you would consider in determining whether to send this patient for primary PCI or use thrombolysis in the ED.

    iii. (6 marks)
     
    Logistic factors prevent the timely transfer of the patient to the PCI facility and a decision is taken in consultation with cardiology to deliver primary thrombolysis. List the medications in sequence that you will give to achieve this.

    iv.  (1 mark)
     
    One hour after lysis the patient is pain free and the ST segments have resolved. What is your time frame for transferring them to a PCI centre?

    question 10.

    A 16 year old apprentice presents to your emergency department after an industrial accident. A large glass pane dropped from a height onto his right arm on a building site.
    i. (5 marks)
     
    His initial xray is shown below.  Give five (5) important features of the xray.
    ii. (8 marks)
     
    List 4 structures which may be damaged in association with this orthopaedic injury, and give a clinical sign you will assess for to evaluate the structure.

    iii. (4 marks)

    Give four (4) interventions or consultations you will undertake as part of your management

    CLICK SUBMIT to finish: