· Web viewA 47 year old male arrives via ambulance with lethargy, extreme shortness of breath and wheeze despite IV adrenaline. He has a past history of poorly controlled asthma

week 5 - Respiratory

WRITTEN EXAMINATIONSHORT ANSWER QUESTIONS

EXAMINATION TIME: 69 Minutes

Question 1 (13 marks) 6 minutes

An 18 year old male presents with chest pain.

A CXR is taken:

i) State two (2) abnormal findings shown in this xray. (2 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

Question 1 (continued)

ii) State four (4) likely precipitating causes. For each cause, state the definitive management of the condition. (8 marks)

Precipitating cause (4 marks)

Definitive management options (4 marks)

1.

2.

3.

4.

Soon after this xray is taken, the patient becomes distressed and is noted to have a BP of 75/40 with HR 170 /min.

iii) State two (2) immediate steps in the treatment of this patient. (2 marks)

1. ________________________________________________________________________

2. _______________________________________________________________________


A 47 year old male arrives via ambulance with lethargy, extreme shortness of breath and wheeze despite IV adrenaline. He has a past history of poorly controlled asthma and morbid obesity. You decide to intubate him soon after arrival.Arterial blood gases are taken on arrival to the department on 50% oxygen- refer to the props booklet page 5.

i) Provide two (2) calculations to help you to interpret these results. (2 marks)

Derived value 1: _____________________________________________________________

___________________________________________________________________________

Derived value 2: _____________________________________________________________

__________________________________________________________________________

ii) Using the scenario and the derived values, define the primary acid/base abnormality/s. (2 marks)

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

iii) Using the scenario and the derived values, define the secondary acid/base abnormality/s. (2marks)

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________


iv) Provide a unifying explanation for these gases in this clinical context. State three (3) points. (3 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

v) State five (5) key aims in your support of this patients’ ventilation. (5 marks)

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

4. _________________________________________________________________________

5. _________________________________________________________________________

Question 2 Arterial blood gas

Reference rangeFiO2 0.50

pH 7.12 ( 7.35- 7.45 )

pCO2 80 mmHg ( 35-45 )

PO2 246 mmHg ( 80- 95 )

Bicarbonate 18 mmHg ( 22-28 )

Base excess - 14 ( -3 - +3 )

O2 saturation 99 % ( > 95 )


A previously well 23 year old is brought to your ED acutely short of breath after developing left sided chest pain.

A Chest xray is taken on arrival:


i) State five (5) abnormalities shown on this xray. (5 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

4. _______________________________________________________________________

5. _______________________________________________________________________

ii) List three (3) key steps in your treatment of this patient. State one (1) justification for each step. (6 marks)

Treatment step Justification1.

2.

3.


A 65 year old female, non- English speaking, Italian lady presents with about 1 cup of haemoptysis.You are unable to obtain any medical history.Her observations are:

BP 135/65 mmHg

HR 80 bpm

GCS 15

i) List five (5) likely differential diagnoses for this presentation. (5 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

4. _______________________________________________________________________

5. _______________________________________________________________________


ii) Other than a CXR, list four (4) key investigations that you would consider ordering in the emergency department for this patient. (4 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

4. _______________________________________________________________________

A Chest Xray shows unilateral changes. She experiences a large volume haemoptysis (estimated blood loss 500 ml).

iii) State six (6) key steps in the treatment of this patient over the next 30 minutes. (6 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

4. _______________________________________________________________________

5. _______________________________________________________________________

6. _______________________________________________________________________


Three (3) Xrays from three (3) different patients are shown in the props booklet- pages 5, 6 & 7.

i) For Xray 1, state where the foreign body lies. (1 mark) Props booklet- Page 5

___________________________________________________________________________

ii) For Xray 1, list two (2) options for the nature/composition of the foreign body. (2 marks) Props booklet- Page 5

1. _______________________________________________________________________

2. _______________________________________________________________________

iii) For Xray 1, list three (3) factors that would mandate urgent removal of the foreign body. (3 marks) Props booklet- Page 5

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

iv) For Xray 2, state where the foreign body lies. (1 mark) Props booklet- Page 6

___________________________________________________________________________

v) For Xray 2, state what the nature/composition of the foreign body is. (1 mark) Props booklet- Page 6

________________________________________________________________________


vi) For Xray 2, state your disposition. Provide two (2) points of justification for this choice. (3 marks) Props booklet- Page 6

Disposition:_________________________________________________________________

Justification:

1. _______________________________________________________________________

2. _______________________________________________________________________

vii) For Xray 3, state where the foreign body lies. (1 mark) Props booklet- Page 7

___________________________________________________________________________

viii) For Xray 3, state your disposition. Provide two (2) points of justification for this choice. (3 marks) Props booklet- Page 7

Disposition:_________________________________________________________________

Justification:

1. _______________________________________________________________________

2. _______________________________________________________________________

Question 5 Xray 1 (2nd Xray is shown on the following page)

Question 5 Xray 2 (1st Xray is shown on the previous page)

Question 5 Xray 3 (1st and 2nd Xray are shown on the previous pages)


i) State the definition of “decompression illness”. (1 mark)

___________________________________________________________________________

___________________________________________________________________________

A 25 year old male presents following a diving expedition.

ii) List five (5) features on history that would support the diagnosis of decompression illness. (5 marks)

1. ____________________________________________________________________

2. ____________________________________________________________________

3. ____________________________________________________________________

4. ____________________________________________________________________

5. ____________________________________________________________________


iii) List five (5) features on examination that would support the diagnosis of decompression illness. (5 marks)

1. ____________________________________________________________________

2. ____________________________________________________________________

3. _____________________________________________________________________

4. ____________________________________________________________________

5. ____________________________________________________________________

iv) What is the role of investigations in establishing the diagnosis of decompression illness. State three (3) points in your answer. (3 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________


A 52 year old Italian woman presents to your emergency department with gradually increasing breathlessness over the last 3 days. It is 1 week since her last chemotherapy treatment for cancer.Her observations on arrival are:

BP 130/60 mmHg

PR 110 /min

RR 28 /min

Temp 37.8 °C

Oxygen saturation 90% Room air

A CXR is taken-

i) State six (6) abnormalities shown in this xray. (6 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

4. _______________________________________________________________________

5. _______________________________________________________________________

6. _______________________________________________________________________


Her FBE shows normal Hb and platelet counts. Her WCC is 1.5 (ref 4-11) and her neutrophil count is 0.4 (ref 2.0- 7.5).

ii) State your antibiotic choice/s. (2 marks)

___________________________________________________________________________

___________________________________________________________________________

iii) State two (2) points to justify your choice/s. (2 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

iv) Other than U+E and LFT, list four (4) key investigations that you would order for this patient in the emergency department. (4 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

4. _______________________________________________________________________

Question 7


A 27 year old woman presents to your emergency department with left calf pain for the last 2 days. She underwent a left knee arthroscopy 10 days ago. She is otherwise healthy and takes no medications.

a. List four (4) features on examination that would increase your suspicion for pulmonary embolism. (4 marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

4. ________________________________________________________________________

b. List four (4) positive ECG findings that would support the diagnosis of Pulmonary Embolism. (4 marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

4. ________________________________________________________________________


c. List four (4) positive CXR findings that would support the diagnosis of Pulmonary Embolism. (4 marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

4. ________________________________________________________________________

d. State two (2) advantages in the performance of a CTPA versus a VQ scan for this patient. (2 marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. Question 8 (continued)

e. State four (4) indications for thrombolysis for Pulmonary embolism. (4 marks)

1. ________________________________________________________________________

2. ________________________________________________________________________

3. ________________________________________________________________________

4. ________________________________________________________________________


A 69 year old female presents to ED with 24 hours of fever. You suspect a community acquired pneumonia.

i) State the four (4) components of the “CORB” scale for assessment of pneumonia severity. (4 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

4. _______________________________________________________________________


ii) State the eight (8) components of the “SMART-COP” scale for assessment of pneumonia severity for a patient less than 50 years of age. (8 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

4. _______________________________________________________________________

5. _______________________________________________________________________

6. _______________________________________________________________________

7. _______________________________________________________________________

8. _______________________________________________________________________

iii) What is the role of these scoring systems for the Emergency Department patient? State four (4) points in your answer. (4 marks)

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

4. _______________________________________________________________________


A chest xray is performed reveals lobar pneumonia.

Selected blood results are taken:


iv) What is the significance of the abnormalities for each of the variables listed, for this patient? State one (1) point for each variable. (4 marks)

Variable Significance for this patient(4 marks)

Haemoglobin(1 mark)

White cell count

(1 mark)

Haematocrit(1 mark)

Neutrophil(1 mark)


An 18 year old year old female presents with a 2 week history of malaise, cough and shortness of breath. A CXR shows a large right pleural effusion.

A pleural aspirate is taken- see the props booklet- page 2

i) List five (5) likely differential diagnoses for this patient. For each diagnosis, state how the diagnosis would be confirmed. (10 marks)

Diagnosis

(5 marks)

How is the diagnosis made?

(5 marks)

1

2

3

4

5


ii) List four (4) indications for therapeutic needle thoracocentesis in this patient. (4 marks)

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

4. _________________________________________________________________________

Question 10

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· Web viewA 47 year old male arrives via ambulance with lethargy, extreme shortness of breath and wheeze despite IV adrenaline. He has a past history of poorly controlled asthma