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?