THE WRITTEN EMERGENCY MEDICINE FELLOWSHIP COURSE
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MODULE 13 short answer questions


saq 1.

A 66 year old woman presents to the emergency department with fever and malaise. She has a past medical history of locally invasive breast cancer currently treated with Avastin (bevacizumab). Her last therapy was 6 days prior. She has no known drug allergies.
 
On arrival to the emergency department her vital signs are:
 
HR      134      /min
BP       89/60   mmhg
RR       28        /min
Sats     90%     RA
T          39.6     oC

​Question 1. (6 marks)
 
Describe 3 immediate therapeutic actions you will immediately undertake.

 
Must include:
- administration of double gram –ve cover antibiotics (1 mark for each Abx, but must specify dose)
            Piperacillin/tazobactam 4.5g, ticarcillin clavulinate 3.1g or cefepime 2g
            PLUS gentamicin 5-7mg/kg IV
- fluid resuscitation (2 marks – 1 for fluid, 1 for endpoint)
            20ml/kg crystalloid stat titrated to a reasonable endpoint (SBP 90, Cap refill 2s, HR 100, urine output >0.5mg/kg)
- administration of oxygen for sats >95% (1 for oxygen, 1 for endpoint)
 
Question 2. (10 marks)
 
Give 5 investigations will you order and justification for each? 

 
Must include (1 mark for Ix and 1 mark each justification)
- blood cultures – septic screen
- urine culture – septic screen
PLUS any of
- chest xray – evaluate for source of infection
- FBC  - check neutrophil count
- blood gas – check electrolytes and acid base balance
- euc – check renal function, electrolytes and bicarbonate.
 
Question 3. (4 marks)
 
The lab rings you to tell you the patient’s blood count sent on arrival has clotted. A repeat has been sent and will be ready in 45 minutes. How and why will this effect your immediate management of this patient?

 
Must include (thematically)
- the patient has possible febrile neutropenia (1 mark), and evidence of septic shock (1 mark)
- the Abx given in question 1 will be administered empirically on this basis, independently of the full blood count (1 mark)
- therefore the delay to FBC will not affect the immediate management of this patient. (1 mark)

saq 2.

A 78 year old female presents to your department with increasing dyspnoea and lethargy. She describes a decrease in her exercise tolerance from being able to walk 200m to 50m over 6 months.
 
Her vital signs are:
HR      96        /min
BP       134/65 mmHg
RR       18        /min
Sats     96%     RA
T          37.2     oC
 
She has been seen by your intern who has performed a full blood count, the results of which are shown below.
 
HB                                              92        mg/dL
White cell count                       8.7       x109/L
Platelet count                           474      x109/L
 
Haematocrit                            .31
MCV                                          76        fL
MCHC                                       22        g/dL
 
Neutrophils                             6.32     x109/L
Lymphocytes                           2.1       x109/L
Monocytes                              0.3       x109/L
Basophils                                0.02     x109/L
Eosinophils                             0.02     x109/L
 
Question 1. (7 marks)
 
Give 6 important findings from the full blood count and the likely underlying diagnosis.

 
Must include:
- Significant anaemia 
- decreased haematocrit, MCV and MCHC
- Mild thrombocytosis 
- normal white cell count
 
Likely diagnosis – iron deficiency anaemia
 
Question 2. (4 marks)
 
Give 4 other investigations will you ask for from the emergency department?

 
Must include:
- iron studies
 
PLUS any of:
- Faecal Occult Blood Test (FOBT)
- Reticulocyte count
- B12 level
- folate level
- group and hold
- blood film
 
Question 3. (3 marks)
 
Give 3 criteria for initiating blood transfusion in this patient?


Must include:
- Hb <70 or <90 with a history of ischaemic heart disease
- Significant symptoms impacting on functional status
- Haemodynamic instability
 

saq 3.

A 6 year old boy presents to the emergency department with his mother. He is complaining of a sore throat and decreased oral intake.
 
On examination he has large erythematous tonsils without any pus.
 
A full blood count has been taken by your registrar and is shown below.
 
HB                                              68        mg/dL
White cell count                       1.7       x109/L
Platelet count                           44        x109/L
 
Haematocrit                             .29
MCV                                           84        fL
MCHC                                        36        g/dL
 
Neutrophils                             1.12     x109/L
Lymphocytes                           0.1       x109/L
Monocytes                               0.3       x109/L
Basophils                                 0.02     x109/L
Eosinophils                              0.02     x109/L
 
Question 1. (5 marks)
 
Describe the blood film.

 
Must include:
Pancytopaenia (1 mark each)
            Anaemia
            Leucopenia
            Thrombocytopenia
Decreased haematocrit
normal MCV/MCHC
 
Question 2. (4 marks)
 
List 4 differential diagnoses.

 
Must include:
Haematological malignancies
            Lymphoma
Plus any of
- other haematological malignancies
- myelodysplasia
- marrow failure due to drugs or viral infection
- other reasonable cause of pancytopaenia (drugs, thyroid disease etc)
 
Question 3. (4 marks)
 
Give four (4) features that will you examine the child for?

 
Must include (1 mark each):
- Regional lymph node enlargement
- hepatomegaly
- splenomegaly
 
Plus any of
- rash
- focus of infection
- evidence of bruising/bleeding

saq 4.

A 67 year old female presents with left sided thigh pain. There is no history of trauma. Her vital signs are:
 
HR      86                    /min
BP       153/92             mmHg
RR       20                    /min
Sats     99%                 RA
T          36.8                 oC
 
An xray of the affected area is shown below.
Picture
Question 1. (3 marks)

Give 3 important features of the x-ray.

 
Must include:
- circumscribed lytic lesion in outer femoral cortex at junction of proximal and middle 3rd of bone
- several other small lytic lesions seen in medial cortex distal to this
- no fracture seen
 
Question 2.  (5 marks)
 
Select pathology results are shown below.

Describe the major abnormalities.
 

Na+                              135      mmol/L
K+                                4.6       mmol/L
Cl-                                103      mmol/L
HCO3-                         18        mmol/L
 
Urea                            18        mmol/L
Creatinine                   180      umol/L
 
Ca2+                             3.79     mmol/L
Mg2+                            0.85     mmol/L
PO43-                           0.78     mmol/L
 
Must include:
Critical hypercalcaemia 
Elevated renal indices
Urea:creatinine ratio 100 
Mildly decreased bicarbonate
Normal anion gap (therefore Dx NAGMA)

Question 3. (1 mark)
 
What is the most likely diagnosis?

 
Must include:
- multiple myeloma
 
Question 4 (3 marks)
 
What management will you institute for this patient?

 
Must include:
- fluid load 20ml/kg aiming urine output 1ml/kg.hr
- administration of  palmidronate infusion 60-90mg over 4-6 hrs
- referral to an appropriate service (haematology, oncology or internal medicine)

SAQ 5.

A 63 year old man presents with fever and abdominal pain. He has no medical history of note. His vital signs on arrival are:
 
HR      105      /min
BP       120/80 mmHg
RR       29        /min
Sats     99%     RA
T          39.6     oC
 
His full blood count is shown below.
 
HB                                              88        mg/dL
White cell count                       136      x109/L
Platelet count                           44        x109/L
 
Haematocrit                             .31
MCV                                           82        fL
MCHC                                        34        g/dL
 
Neutrophils                             1.12     x109/L
Lymphocytes                           0.70     x109/L
Monocytes                               0.3       x109/L
Basophils                                 0.02     x109/L
Eosinophils                              0.02     x109/L
 
Smear – heterogeneous blasts noted.

Question 1. (7 marks)
 
What are the major abnormalites, and what is the likely diagnosis?

 
Must include:
- normocytic & normochronic  anaemia (2 marks)
- thrombocytopenia (1 mark)
- massive rise in white cells (hyperleucocytosis) (1 mark)
- neutropaenia (1 mark)
- lymphopenia (1 mark).
 
Therefore the diagnosis is likely acute myeloid leukaemia (AML) (1 mark).
 
Question 2. (3 marks)
 
Give 3 likely complications of this presentation?

 
Must include
- neutropenic sepsis
- acute tumour lysis syndrome
- leukostatic crisis and tissue hypoxia
 
Question 3. (3 marks)
 
Give 3 management points that you will institute?

 
Must include:
- administration of IV fluids 20-40ml/kg NaCl0.9% (1 mark)
- cover for sepsis with an appropriate antibiotic and dose (1 mark)
- referral to haematology for induction chemotherapy (1 mark)


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