MODULE 16 short answer questions.
saq 1.
A 36 year old woman with a history of chronic thyroid disease presents to the emergency room with confusion and a productive cough. Her vital signs are:
HR 65 /min
BP 87/70 mmHg
T 33.8 oC
RR 15 /min
Sats 99% RA
GCS 7
Initial pathology is shown below.
Free T4 0.12 pmol/L
TSH 0.01 mU/L
Question 1. (3 marks)
What is the diagnosis? Give 2 complicating diagnoses which should be considered?
Must include:
Acute hypothyroidism/myxoedema coma
Plus other diagnoses to be considered
Question 2. (4 marks)
Give 4 interventions you will undertake for this patient.
Must include:
Question 3. (3 marks)
Give 3 indications for ICU admission for this patient.
Ongoing hypotension requiring inotropes or thyroxine infusion
Severe sepsis
Persistently decreased GCS
HR 65 /min
BP 87/70 mmHg
T 33.8 oC
RR 15 /min
Sats 99% RA
GCS 7
Initial pathology is shown below.
Free T4 0.12 pmol/L
TSH 0.01 mU/L
Question 1. (3 marks)
What is the diagnosis? Give 2 complicating diagnoses which should be considered?
Must include:
Acute hypothyroidism/myxoedema coma
Plus other diagnoses to be considered
- Sepsis
- Panhypopituitarism
Question 2. (4 marks)
Give 4 interventions you will undertake for this patient.
Must include:
- Administration of 500mcg IV levothyroxine
- Administration of 200mg IV hydrocortisone (RE PHP)
- Administration of an appropriate broad spectrum antibiotic with dose (eg ceftriaxone 1g IV or piperacillin/tazobactam 4.5g)
- Referral to endocrinology/ICU
Question 3. (3 marks)
Give 3 indications for ICU admission for this patient.
Ongoing hypotension requiring inotropes or thyroxine infusion
Severe sepsis
Persistently decreased GCS
saq 2.
A 10 year old patient presents with his mother with a reduced level of consciousness. He has developed respiratory distress over the course of the day, and she is convinced that his asthma has “flared up”.
His vital signs on arrival to the emergency department are:
Urgent arterial blood gas analysis is performed and the results are shown below.
pH 7.02
PCO2 17 mmHg
PO2 112 mmHg
HCO3- 6 mmol/L
Na+ 131 mmol/L
K+ 6.5 mmol/L
Cl- 91 mmol/L
Glucose 21 mmol/L
Lactate 1.1 mmol/L
Urea 5.7 mmol/L
Creatinine 60 umol/L
Question 1. (3 marks)
What are the two major acid base abnormalities on the ABG? Which is the primary disturbance?
Must include:
Question 2. (2 marks)
Calculate a derived value that allows you to interpret the primary disturbance.
Must include:
Question 3. (1 mark)
What is the most likely diagnosis?
Must include:
Diabetic ketoacidosis
Question 4. (2 marks)
Correct the Na and K for the derangements in the ABG.
Must include:
Na (corrected) = 131 + (glucose-5)/3 = 131 + 5.3 = 136
K+ rises by 0.5 above 5 for each 0.1 pH drop below 7.4 .: expect a K+ of 7.0 for pH 7.02
Question 5. What critical intervention will you institute to manage this patient? (2 marks)
Must include:
His vital signs on arrival to the emergency department are:
- HR 145 /min
- BP 91/60 mmHg
- RR 42 /min
- Sats 99% RA
- T 37.2 oC
- GCS 10
Urgent arterial blood gas analysis is performed and the results are shown below.
pH 7.02
PCO2 17 mmHg
PO2 112 mmHg
HCO3- 6 mmol/L
Na+ 131 mmol/L
K+ 6.5 mmol/L
Cl- 91 mmol/L
Glucose 21 mmol/L
Lactate 1.1 mmol/L
Urea 5.7 mmol/L
Creatinine 60 umol/L
Question 1. (3 marks)
What are the two major acid base abnormalities on the ABG? Which is the primary disturbance?
Must include:
- Metabolic acidosis (primary) (2 marks)
- Respiratory alkalosis
Question 2. (2 marks)
Calculate a derived value that allows you to interpret the primary disturbance.
Must include:
- ANION GAP = Na – HCO3 – Cl = 131 – 6 – 91 = 36
- This is therefore a Raised anion gap metabolic acidosis
Question 3. (1 mark)
What is the most likely diagnosis?
Must include:
Diabetic ketoacidosis
Question 4. (2 marks)
Correct the Na and K for the derangements in the ABG.
Must include:
Na (corrected) = 131 + (glucose-5)/3 = 131 + 5.3 = 136
K+ rises by 0.5 above 5 for each 0.1 pH drop below 7.4 .: expect a K+ of 7.0 for pH 7.02
Question 5. What critical intervention will you institute to manage this patient? (2 marks)
Must include:
- Short acting insulin infusion at 0.05-0.1 IU/Kg per hr (approx. 1.5-3 units/hr)
- Note: 1 mark for short acting insulin, 1 mark for dose
saq 3.
A 54 year old type two diabetic presents to your department after being found unconscious by his wife. She states that aside from the diabetes he has no major medical problems, but he has been complaining of dysuria for 2 days. On arrival his vital signs are:
HR 120 /min
BP 99/60 mmHg
RR 22 /min
Sats 94% RA
T 39.3 oC
Cap refill 5 s
His bedside BSL reads “High”.
Question 1. (4 marks)
His initial electrolyte profile returns below:
Na+ 153 mmol/L
K+ 5.4 mmol/L
Cl- 124 mmol/L
HCO3- 19 mmol/L
Urea 18 mmol/L
Creatinine 200 umol/L
Glucose 58 mmol/L
Give 4 major abnormalities present.
Must include: (1 mark each)
Plus any of: (any 2 for 1 mark each)
Question 2. (3 marks)
Give 2 derived values from the electrolyte profile and the likely diagnosis.
Must include:
Question 3. (6 marks)
Give 6 interventions you will undertake as part of your management.
Must include:
HR 120 /min
BP 99/60 mmHg
RR 22 /min
Sats 94% RA
T 39.3 oC
Cap refill 5 s
His bedside BSL reads “High”.
Question 1. (4 marks)
His initial electrolyte profile returns below:
Na+ 153 mmol/L
K+ 5.4 mmol/L
Cl- 124 mmol/L
HCO3- 19 mmol/L
Urea 18 mmol/L
Creatinine 200 umol/L
Glucose 58 mmol/L
Give 4 major abnormalities present.
Must include: (1 mark each)
- Profound hyperglycaemia
- Renal failure
Plus any of: (any 2 for 1 mark each)
- Mild metabolic acidosis
- Mild hypernatraemia
- Mild hyperkalaemia
Question 2. (3 marks)
Give 2 derived values from the electrolyte profile and the likely diagnosis.
Must include:
- ANION GAP = 153 – (124+19) = 153 – 143 = 10 : NORMAL
- CALCULATED OSMOLALITY = 2 x Na + urea + glucose = 306 + 18 + 58 = 382 : HIGH
Question 3. (6 marks)
Give 6 interventions you will undertake as part of your management.
Must include:
- Fluid bolus 20ml/kg, repeated for HR 100, cap refill 2sec
- Antibiotics (likely urosepsis): ceftriaxone 1g IV
- Insulin infused at 0.1IU/Kg.hr
- Appropriate VTE prophylaxis eg enoxparin 40mg sc adjusted for eGFR.
- Referral to endocrinology
- Referral to ICU
saq 4.
A 28 year old girl presents to our department with acute confusion. She had been complaining of acute anterior neck pain for the prior 4 days, and has no other medical history of note. She had attended the department the previous evening and had blood drawn. She was subsequently discharged with a diagnosis of “neck strain”. On arrival she has the following vital signs:
HR 150 /min
RR 26 /min
BP 85/58 mmHg
Sats 99% RA
T 39.7 oC
Question 1. (3 marks)
Select results from the previous evening’s presentation are presented below.
Free T4 26 pmol/L
TSH 0.01 mU/L
What do they show, and what is the diagnosis on this presentation?
Must include:
Question 2. (5 marks)
Give 5 interventions you will immediately apply
Must include:
Fluid bolus
Question 3. (3 marks)
Give a brief outline of your approach to the quality control issues in this case.
Must include elements of
HR 150 /min
RR 26 /min
BP 85/58 mmHg
Sats 99% RA
T 39.7 oC
Question 1. (3 marks)
Select results from the previous evening’s presentation are presented below.
Free T4 26 pmol/L
TSH 0.01 mU/L
What do they show, and what is the diagnosis on this presentation?
Must include:
- Hyperthyroidism with suppression of TSH
- Therefore this presentation is thyroid storm/acute thyrotoxicosis
Question 2. (5 marks)
Give 5 interventions you will immediately apply
Must include:
Fluid bolus
- Administration of propranolol 10mg PO titrated to HR 100
- Antithyroid medication, either:
- Carbimazole 10-45mg PO or
- Propothiouracil 200-600mg PO
- Preferably dextrose 20-40ml/Kg aiming for SBP >90 and HR 100
- Active cooling: icepacks to groin/axilla, convected air
- Referral to endocrinology and intensive care
Question 3. (3 marks)
Give a brief outline of your approach to the quality control issues in this case.
Must include elements of
- Case review (eg M&M) and discussion with Dr involved
- Documentation of factors leading to oversight
- Institution of quality control/improvement to prevent recurrence
SAQ 5.
Compare and contrast DKA and HHS using the table below.
ATTRIBUTE
Diabetes type Blood glucose Ketones Fluid deficit Precipitant |
DKA
Predominantly type 1 (insulin dependent) High, usually <25 Present Moderate (5% TBW) Insulin non-compliance |
HHS
Type II (NIDDM) Extremely high (often >30) Usually absent, or present in small concentrations (dehydration) Severe (often >10% TBW) Often secondary to infection |