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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)
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
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
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.
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.
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)
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)
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)