SCE
2007.1
SCE 6
An 84 yo woman is brought by ambulance to the
emergency
department. She lives independently at home and has a
past
history of cardiac failure. She complains of one week of
vomiting, weakness and diminished coping abilities at
home. Her medications are Frusemide 40 mg orally daily,
and oral potassium supplements. Her observations on
arrival are: GCS 15, BP 150/90 mmHg, RR 24 /min,
SpO2
99% on room air, Temp 37oC. A registrar shows you her
ECG. (Question 1 and ECG outside)
• DESCRIBE and INTERPRET her ECG.
• These are her pathology results. Please DESCRIBE
and INTERPRET them.
• OUTLINE your TREATMENT of her
HYPERKALEMIA.
• Soon after treatment has commenced, the charge
nurse NOTIFIES YOU that the patient was GIVEN
100 units of INTRAVENOUS INSULIN IN
ERROR. DESCRIBE YOUR MANAGEMENT
NOW.
• What factors may have contributed to this error
occurring?
PATHOLOGY RESULTS
Sodium 136 mmol/L (135 - 145)
Potassium 8.0 mmol/L (3.5 – 5.0)
Chloride 94 mmol/L (92 - 107)
Bicarbonate 20 mmol/L (20 - 34)
Urea 14.0 mmol/L (3.1 – 8.3)
Creatinine 0.15 mmol/L (0.07 – 0.11)
Glucose 5.1 mmol/L (3.6 – 7.7)
SCE 4
A 3 year-old boy is brought to your department by his
mother with abdominal pain and vomiting. The mother is
concerned that the child may have ingested some of her
Iron
(Ferrogradumet) tablets.
She is sure that there are more than 10 tablets missing
from
the bottle.
Each Ferrogradumet tablet contains 105mg of elemental
Iron.
• How would you clinically assess the risk of toxicity
for this child?
• List and justify your investigations in this child.
• Discuss the options for decontamination in this
child.
• Describe your specific Rx for Fe toxicity in this
case.
• These are the patient’s arterial blood gases. Describe
and interpret them.
pH 7.30
pCO2 28 mmHg
pO2 120 mmHg
Bicarbonate 16 mmol/l
2006.2
SCE 3
A 19 year-old primigravida woman presents to your
emergency department with central abdominal pain.
She is 30 weeks pregnant and has no past medical history.
Her initial observations are:
GCS 15, BP 170/110mmHg, Heart rate 100 per minute,
Respiratory rate 24 per minute, Sp02 99% room air,
Temperature 37 degrees C
• What differential diagnoses do you consider for her
abdominal pain? (This question was given outside
the room)
• What are the diagnostic criteria for pre-eclampsia?
• You diagnose preeclampsia. How would you
manage this patient?
• What are your (other) options for managing her
blood pressure?
• These are her pathology results (provide result
sheet). Describe and interpret these results.
PATHOLOGY RESULTS
Hb 84
Platelets 88 x 109 / l
WBC 12.7 x 109 / l
Bilirubin 44 umol/l
ALT 300 u/l
AST 270 u/l
GGT 42 u/l
ALP 96 u/l
LDH 518 u/l
2004.2
SCE 4
A 40 year old woman presents to the emergency
department
with two days of fever and gradual onset of moderately
severe thoracic pain. Associated symptoms include
myalgia
and lethargy. There is no history of trauma. She
underwent
a mastectomy for breast cancer 3 months previously and
has
been undergoing chemotherapy and radiotherapy at your
hospital. On examination you note tenderness over the
midthoracic
vertebrae. Her vital signs are: 38.5oC, HR 90, RR
20, BP 120/80 and SpO2 98% (on room air).
• What differential diagnoses do you consider for
her back pain?
• What investigations would you perform and why?
• Describe her FBE results (Hb 81/Plats 160/WCC
0.7/Neut 0.4)
• In light of her FBE result what is the key
management issue now?
• What factors do you consider when choosing
antibiotics for this patient?
• The patient states that she has been told she has
secondary cancer in the spine. She requests that a
“Not for Resuscitation” order be included in her
file. What issues do you consider in relation to her
request?
2003.2
SCE 4
A 57 year old man presents to your ED by ambulance.
The
ambulance officers state that he has a past history of
COPD
and asthma. He is a smoker and has been unwell for at
least
24 hours. They found him to be severely short of breath
and
have been treating him with continuous oxygen and
nebulised salbutamol en route.
• What factors need to be considered in deciding if
this man needs intubation?
• These are his arterial blood gases (pH 7.12, pCO2
91, pO2 271, sat 100%, BE –1,HCO3 30)
Describe these findings. Would you intubate him
on these gases?
• You assess him as an acute exacerbation of COPD
and you intubate him. What is your management
immediately following intubation.
• This is his CXR (shows large right sided bullae).
What does it show?
• This is the CT scan of his chest (confirms multiple
large bullae). What does it show?
JUNE 2003
SCE 1
A 74 year old lady is sent to the Emergency Department
by
her GP because of abnormal blood tests. She has been
feeling non specifically unwell, tired and lethargic for two
weeks. She has no abdominal pain. She has a past history
of
bladder cancer and colonic cancer. Her vital signs on
arrival
are HR 72, BP 130/80, 36.5oC, RR 18. Her electrolytes
show Na+ 138, K+ 7.1, Cl- 109, HCO3 11, Urea 33, Creat
0.53, WCC 21.5 x 109/L, neutrophils 18.8 x 109/L, Hb 128
and platelets 459 x 109/L.
• Interpret these results. Prompt to calculate anion
gap if not done.
• She deteriorates but remains conscious. This is her
ECG (which shows a slow idioventricular
rhythm). Interpret her ECG.
• Describe the immediate treatment.
• Her ECG has normalised. What further assessment
will you undertake?
• An ultrasound shows bilateral hydronephrosis.
The urine shows blood, protein, leucocytes and
nitrates. What would be her ongoing management?
• This is her ultrasound (showing bilateral
hydronephrosis, hydroureter). Can you please
interpret these films?
Endotracheal tube in situ
Occasional spontaneous respirations
GCS 3
SpO2 100% (100% oxygen)
HR 110/min
BP 130/80 mmHg
Pupils 4 mm (equal & reactive)
This is his ECG.
1. Describe the ECG. (1 min) (2 marks)
2. (3 min)
(a) Discuss your options in management of this man’s
myocardial infarction
(b) What re the risks and benefits of giving
thrombolysis in this patient?
3. It is now 20 minutes since his intubation. These are his
blood gases on 100% oxygen.
pH 7.13 (7.35 – 7.45)
pCo2 44 (35 - 45 mmHg)
pO2 87 (80 – 100 mmHg)
BE -15 (-3 - +3)
HCO3 15 (24-32 mmol/L)
What are the likely causes of the blood gas results? (2
min)
(3 marks)
4. What are you going to tell this patient’s family? (1 min)
(1 mark)
Supp.
5. What are the advantages and disadvantages of biphasic
defibrillation over monophasic defibrillation?
2001.2
SCE 5 - Paediatric
A 14-month-old baby boy is brought to the Emergency
Department. His parents have noticed that he has been
vomiting all day and becoming increasingly lethargic.
At triage, the nurse notices that he has grunting
respirations,
is tachpneoic and appears to be mottled.
P 160 /min, RR 50 /min, T 35.8 oC, SaO2 96% on Room
Air. He weighs 12 kg.
1. What is your initial approach in managing this child
2. You estimate this child to be 10% dehydrated. What
action(s) would you take?
3. The bedside BSL comes back as 28.5 mmol/L and this
this child’s ABG on supplemental oxygen and his initial
electrolytes. Could you interpret these please?
PH
6.990
PCO2 9.8
mmHg 1.3 kPa
mmHg 32.1 kPa
HCO3 2.3 mmol/L
BE -29.1
Na 128 (N 135 – 145 mmol/L)
K 3.7 (N 3.5 – 5.0 mmol/L)
Cl 98 (N 95 – 110 mmol/L)
HCO3 <5 (N 18 – 25 mmol/L)
Glucose 28.5 (N 4 – 8 mmol/L)
Urea 5.6 (N 2.5 – 6.4 mmol/L)
Creat 0.05 (N 0.05 –0.10 mmol/L)
PO2 241
4. What further actions would you take?
2002.1
SCE 3 – Medical
A 51 year old male is brought by ambulance to your
Emergency Department (non-tertiary, outer suburban
hospital). He was found in his care sitting upright,
“fitting”
and pulseless. Bystander CPR was commenced
immediately. An ambulance attended within minutes and
this man was found to be in VF. After 7 DC shocks and
IV
adrenaline he had return of spontaneous circulation.
On arrival in the Emergency Department he has:
2001.1
SCE 6 - Resuscitation
You are called to the resuscitation room to assist with the
management of a 25 year old man with acute severe
asthma.
He has been in the Emergency Department for 30
minutes,
during which time he has received continuous nebulised
salbutamol, 200 mg hydrocortisone, and 0.5mg nebulised
ipratropium. IV saline is running. CXR shows no
infection
or pneumothorax.
Arterial Blood Gases on oxygen 15 litres per minute by
face
mask are:
pH 7.32 (7.35 – 7.45)
pO2 92 mmHg (N > 80)
pCO2 45 mmHg (35 – 45)
HCO3 23 mmol/L (24 – 32)
The man has had several ward admissions for asthma but
no
ICU admissions. He is alert, with a RR of 35 and a quiet
chest. He indicates through words and phrases that he
does
not want to be intubated. There are currently no ICU beds.
1. How would you continue this patient’s treatment?
2. Despite your therapy, the patient’s CO2 rises and O2 sats
fall. Prior to becoming too drowsy to protest, the patient
continues to indicate that he does not want to be
intubated because of fear of complications. Will you
intubate this patient anyway?
3. You decide to intubate this patient, how would you
intubate and ventilate this patient?
4. After intubation, the patient’s blood pressure drops
from
140/85 to 90/70. What actions would you take?
2000.1
SCE 6
A demented 79 year old man is brought to your ED with
severe abdominal pain by his daughter with whom he
lives.
He has no history of abdominal surgery.
The patient's vital signs are:
Temperature 37.2
Pulse rate 120 beats per minute
BP 110/60mmHg
Respiratory rate 28 per minute.
1. These are the patient’s blood results. Could you please
summarise the major abnormalities?
Na 136 mmol/L (136 - 148)
K 4.9 mmol/L (3.8 - 5.0)
Cl 102 mmol/L (95 - 110)
Urea 17.8 mmol/L (2.5 - 6.4)
Cr 198 umol/L (60 - 120)
Glucose 12.1 mmol/L
Total protein 56 g/L (66 - 82)
Albumin 28 g/L (33 - 50)
Bilirubin (total) 20 umol/L (5 - 20)
AST 27 U/L (5 - 52)
ALT 28 U/L (4 - 35)
Alk Phos 124 U/L (18 - 116)
GGT 79 U/L (8 - 78)
Amylase 90 U/L (20 - 100)
WCC 24.9 x 109/L (4.0 - 11.0)
Hb 160 g/L
Plt 505 x 109/L (150 - 400)
APTT 28 secs (23 - 35)
INR 1.3
pH 7.25 (7.35 – 7.45)
pCO2 32 mmHg (35.0 – 45.0)
pO2 140 mmHg (83.3 – 100.0)
BE - 10 (-3.0 – 3.0)
HCO3 14 mmol/L (22.0 – 33.0)
FiO2 Hudson mask at 10 l/min
2. This is the patient’s abdominal X-ray. What does it
show?
3. In light of the presentation, blood results and X-rays
what is your differential diagnosis?
4. What is your management plan?
5. The working diagnosis is ischaemic bowel. Everyone
including the family agree that surgery is not appropriate.
The ED doctor asks you how he should now manage the
case. What will be your advice?
6. This case has caused particular distress to an intern
involved in the care. How will you handle this?
SCE 3
A 32 year old female with known end stage renal disease
on
continuous ambulatory peritoneal dialysis, presents to
your
Emergency Department after feeling light-headed several
times in the evening. She appears mildly unwell, but tells
the triage nurse she feels much better. She is triaged to a
non-monitored bed in your acute assessment area. Her
vital
signs are: PR 95/min, BP 200/125, T 36.0C. A 12 lead
ECG is performed.
K 2.1 mmol/L (3.8 - 5.0)
Urea 22 mmol/L (2.5 - 6.4)
Cr 490 umol/L (60 - 120)
Mg 0.1 mmol/L (0.7 – 1.1)
1. As you are taking her history, she suddenly becomes
pale
and presyncopal. What are the potential causes,
especially in a patient with end stage renal disease?
2. A monitor is attached. Here is the strip. The patient is
awake and confused, with BP 90 systolic. What do you
do?
3. These are the blood results (K+ 2.1, Urea 22, Cr 490,
Mg2+ 0.1). What do you do now?
4. It is time to exchange the intraperitoneal dialysate. The
draining fluid is yellow and cloudy. What will you do?
5. There are no ICU or CCU beds available in your
hospital, and the patient’s usual physician requests
transfer to another hospital with available ICU beds.
How do you arrange the transfer?
1999.2
SCE 2
A 70 year old female is brought by her family to the
Emergency Department with worsening confusion over
the
past 10 days. For the past 4 days she has had several
episodes of vomiting. Her relatives state that the patient
has
been drinking a large amount of water over the past
couple
of months, trying to "cleanse her body". The patient
normally lives alone and manages all activities of daily
living.
On arrival, the patient is drowsy but rousable. She is
disoriented in time, person and place. Her pulse rate is
85/min, blood pressure 125/75. She is afebrile and in no
respiratory distress. She has been triaged to an acute care
area, and her family is present.
The GP's referral letter includes these results:
Result Normal Range
Na 96 mmol/L (136 - 148)
K 2.8 mmol/L (3.8 - 5.0)
Cl 66 mmol/L (95 - 110)
Urea 7.4 mmol/L (2.5 - 6.4)
Cr 50 umol/L (60 - 120)
Glucose 6.8 mmol/L
1. Outline your initial assessment of this patient.
2. How do you now manage this patient?
3. While awaiting transfer to ICU, the patient's level of
consciousness decreases and she begins to have a
generalised convulsion. What treatment will you
commence?
1999.1
SCE 4
A 67 year old woman of a non-English speaking
background presents to the Emergency Department with
severe epigastric pain, vomiting and fevers for the past 24
hours. She has a past history of cholelithiasis documented
on ultrasound 18 months ago. She is assessed by a Junior
Medical Officer (JMO) who notes her to be tachycardic
and
febrile with BP 170/110. The patient is noted to have mild
scleral jaundice, is clinically moderately dehydrated and
has
marked tenderness in the epigastrium with percussion
tenderness across the epigastrium and right upper
quadrant.
An intravenous cannula is inserted, and blood drawn.
Intravenous fluids are commenced and an abdominal Xray
ordered. The JMO asks you to review the patient, having
received the following blood results:
Result Normal Range
Na 143 mmol/L (136 - 148)
K 4.3 mmol/L (3.8 - 5.0)
Cl 109 mmol/L (95 - 110)
Urea 13.2 mmol/L (2.5 - 6.4)
Cr 128 umol/L (60 - 120)
Glucose 13.2 mmol/L
Total protein 70 g/L (66 - 82)
Albumin 41 g/L (33 - 50)
Bilirubin (total) 69 umol/L (5 - 20)
AST 84 U/L (5 - 52)
ALT 75 U/L (4 - 35)
Alk Phos 180 U/L (18 - 116)
GGT 192 U/L (8 - 78)
Amylase 1654 U/L (20 - 100)
WCC 21.2 x 109/L (4.0 - 11.0)
Hb 15.2 g/L (11.5 - 16.5)
Plt 112 x 109/L (150 - 400)
APTT 45 secs (23 - 35)
INR 2.2
1. What is your diagnosis?
2. How do you manage the patient?
3. Imaging shows a dilated biliary tree with common bile
duct dilated to 10mm. The surgical team organises an
immediate ERCP. On review of the patient, her BP is
now 80/50. What do you now do?
4. After 2.5l of fluid the CVP is 16 but BP is still 80/50.
What do you now do?
SCE 5
A 19 year old woman is brought to the Emergency
Department by her partner after 24 hours of increasing
confusion and fevers. She had an episode of collapsing
after
getting up from a chair earlier in the day. She is 10 days
post partum, after having had a vaginal delivery. Since
discharge on day 2, the patient had complained of
persistent
vaginal bleeding. On arrival, she is triaged to an acute
care
area and you are called to assist a Junior Medical Officer.
1. How do you assess this patient?
2. The patient's available blood results show the
following:
(see attached sheet given to the candidate).
Result Normal Range
Hb 10.0 g/L (11.5 - 16.5)
WBC 15.5 x 109 /L (4.0 - 11.0)
Plt 101 x 109 /L (150 - 400)
APTT 24 secs (23 - 35)
INR 1.1
pH 7.30 (7.35 - 7.45)
pCO2 34 mmHg (35.0 - 45.0)
pO2 160 mmHg (83.3 - 100.0)
Bic 16 (22.0 - 33.0)
BE - 8.5 (-3.0 - 3.0)
What treatment will you initiate?
1997.2
SCE 4
A 41-year-old man presents to the Emergency Department
with several days of increasing dyspnoea and fevers. He
has
a history of intravenous drug use and is currently on
methadone. On examination his vital signs are: blood
pressure 110/60 mmHg, pulse rate 120 beats per minute,
temperature 38.5 degrees Celsius and respiratory rate is 35
breaths per minute. The patient is having difficulty
speaking, and his SaO2 is 75% on oxygen 14L/minute via
a
non-rebreathing reservoir mask. He is confused, and his
Glasgow Coma Score is 14.
1. Have a look at this CXR and tell me what it shows.
2. What is your differential diagnosis?
3. His initial ABG’s on 14L O2/min via non-rebreathing
reservoir mask are:
pH 7.25 pCO2 50 mmHg pO2 45 mmHg HCO3 16 mmol/L BE -6
mmol/L
Please comment on these gases.
4. How would you treat his hypoxia?
5. What antibiotics will you commence, and why?
6. How would you manage his circulatory status?
1997.1
SCE 6
A 32 year old Korean lady is brought in by her husband.
They speak no English. She is drowsy and
noncommunicative,
but her husband has brought in an empty
bottle of temazepam 10mg prescribed yesterday and
which
normally contained 20 10 mg tablets. Her vital signs are
pulse rate 110/min regular, blood pressure 130/80 mmHg,
respiratory rate 16/min.
1. What initial investigations would you perform, and
why?
Na 149 mmol/L
K 3.1 mmol/L
Cl 102 mmol/L
HCO3 18 mmol/L
urea 4.2 mmol/L
creat 0.06 mmol/L
BSL 7.2 mmol/L
2. (a) Could you please comment on these UECs.
(b) What is the anion gap? Is it significant?
(c) What could be the toxicological causes of the
elevated anion gap in this patient?
3. If you suspect ethylene glycol toxicity what clinical
features would you look for?
4. When and how would you start treatment for ethylene
glycol toxicity?
SCE 4
A 66 year old lady is brought to your Emergency
Department by ambulance after being found lying on the
floor of her home by her daughter, who had last visited
her
mother 48 hours previously, when she seemed well. The
patient is responsive but confused. She is triaged to the
resuscitation area of the Department, and is assessed
promptly by a junior doctor. The doctor shows you the
lady’s ECG and asks for guidance in her management.
1. Interpret the ECG.
2. What are the causes and effects of this tachycardia?
3. The patient’s vital signs are as follows. Please comment
on them:
BP 90/45 Resp rate 32/min Temp 39.2 deg C SaO2 86% on room air
GCS 14 SaO2 96% on O2 at 12L/min
Fingerprick BSL is 13 mmol/L
4. The major findings on physical examination are
significant dehydration, crackles at the base of the left
lung field, and a large ulcer on the left ankle. The patient
is generally unkempt. She is confused, but obeys
commands and moves all limbs equally.
What management would you institute, and why?
5. Investigations performed reveal:
FBC: Hb 140 g/L WCC 9.9 x 109/L Platelets 57 x 109/L
Biochem: Na 145 mmol/L
K 3.8 mmol/L
U 21.7 mmol/L
Creat 187 µmol/L
BSL 13.8 mmol/L
CK 1834 mmol/L
ABG’s on O2 12L/min via mask: pH 7.30
pCO2 25 mmHg
pO2 147 mmHg
HCO3 15 mmol/L
BE -8 mmol/L
What are the possible explanations for these results?
6. What further action needs to be taken?