Emergency Medicine Viva Examination – Term 3

Question 1
A 25 year old female presents to the ED with right iliac fossa abdominal pain.
a) List your differential diagnosis - the list is large, but should have included
  • Ectopic pregnancy
  • Ovarian Torsion
  • Ovarian Cyst
  • Appendicitis

The differential diagnosis should be tailored to the patients age and gender. While AAA is an important entity not to miss, it is not seen in this age group. Gastroenteritis does not present with focal abdominal signs and should not have been included.
b) What Investigations would you order?
The pivotal tests were a beta-HCG and Pelvic USS. Urinalysis should have also been included. Ancillary blood tests included FBC, EUC, CRP.
c) Her vital signs were P 120 bpm, BP 70/50, RR 20, Pulse Ox 100%, GCS 14/15. How would you manage this patient?
The key to this was to recognise the patient was in shock. You needed to call for senior help soon and refer early to eother O&G if pregnant or to the general surgery team if not. Fluid resuscitation was important - initial fluid should have been normal saline or Hartmanns with a target SBP of 80 mmHg (concept of hypotensive resuscitation). A few of the candidates discussed the potential need for blood products if there was no response to crystalloid resuscitation. Analgesia is also important and was not addressed by a large number of candidates - should have been judicious use of parenteral narcotics.

Question 2.
A 36 year old male presents with acute onset of shortness of breath. He has a history of asthma.
a) What are the signs of severe respiratory distress?
  • Inability to speak
  • Diaphoresis
  • Tripod positioning
  • Extreme tachypnoea (RR > 30)
  • Hypoxaemia (Pulse Ox < 90%)
  • Accesory muscle use, intercostal recession
  • Tracheal tug
  • Stridor
  • Silent chest on auscultation
  • Tachycardia or bradycardia
  • Pulsus paradoxus
b) What investigations would you order
  • ABG
  • CXR
  • Spirometry
  • Ancillary blood tests - FBC, EUC, CRP
c) Your patient has severe acute asthma. Outline your management of this patient.
  • Supplemental oxygen
  • Continuous salbutamol nebulisers
  • Ipratropium Bromide 500 mcg x 3 doses nebuliser
  • Prednisone 50 mg STAT or Hydrocortisone 100 mg iv STAT
  • Consideration of BiPAP
  • Adjunctive therapies if initial therapies fail - Magnesium, adrenaline, inhaled anaesthetic agents
  • Intubation and mechanical ventilation if BiPAP failure

Question 3
An 84 year old male presents to the ED with chest pain. Shortly after arrival, he becomes unresponsive. He is in ventricular fibrillation. Outline your management of this patient.
This was a basic question and for which you needed to describe basic and advanaced life support as per the algorithms. You needed to recognise that this was a shockable arrhythmia, and their should have been a discussion about the 

Emergency Medicine Viva Examination

Here are the answers to the viva examination from last week.

1. A 72 year old female falls onto her oustretched arm. Please describe her X-ray findings.
The X-ray demonstrated a fracture to the distal radius. No displacement. Approximately 45 degrees of dorsal angulation. This is consistent with a Colles fracture.
In the answer, you were expected to describe the fracture. This should include discussion about the bone involved, site, displacement and angulation. Some of you commented on whether the fracture was open or closed - this is a clinical assessment - not a radiological assessment.

2. An 80 year old male collapses in the local shopping centre. He is brought to the hospital by ambulance and his rhythm strip is shown.
This was a rhythm strip showing a bradycardic rhythm with a ventricular rate of approximately 30-40 bpm. There is atrial activity. There is no relation between the atrial and ventricular activity. This patient has 3rd degree AV block.

3. A 21 year old male presents with sudden onset of SOB. Describe the findings on his chest X-Ray.
There is a large left sided pneumothorax with complete collapse of the left lung. There is significant mediastinal shift to the right. These radiological findings are consistent with tension pneumothorax.


4. A 70 year old male presents with sudden onset of right flank pain radiating into his groin. He has a past medical history of hypertension. His vital signs are; T 37.5, P 100, BP 100/60, GCS 15. Urinalysis shows moderate microscopic haematuria. What is your provisonal and differential diagnosis.
Most of you gave answered with renal colic as your provisional diagnosis, however this would be unusual in an elderly male with no history of renal colic. This patient has a AAA until otherwise proven (in fact a significant proportion of patients with AAA will have haematuria) The differential diagnosis for this presentation would include renal colic and testicular torsion. The key to this differential was the sudden onset of pain, ruling many of the other pathologies out which were proposed. 

Painful visual loss

A 32 year old female presents to the ED with a 3 day history of visual loss and pain on eye movement. There is no history of trauma. She describes a similar episode 2 years previously which she did not seek medical attention for. She notes that red objects appear pink in her affected eye.
On physical examination, her visual acuity is 6/60 in the affected eye. There is no visual field defect and the pupil reflexes are normal. The eye is not red and the anterior chamber is normal. Fundoscopy is unremarkable. Based on her symptoms a provisional diagnosis of optic neuritis is made.

Optic neuritis is a condition that causes a reduction in visual acuity. It is frequently painful particularly with eye movement and can be unilateral or bilateral. Colour vision is more commonly affected and there may be visual field defects. The red desaturation test can be used to identify optic neuritis. The patient should be asked to look at a dark red object. Objects will appear pinker in the affected eye. An afferent pupillary defect is commonly present.
Fundoscopy will show papillitis in 30% of pateints, the remainder will have a retrobulbar neuritis.

Optic neuritis is commonly idiopathic or a manifestation of multiple sclerosis. Other causes include viral infections such as measles, mumps, chickenpox, herpes zoster and mononucleosis; inflammatory causes that are contiguous with the optic nerve (meninges, orbit, sinuses), vaccinations and other infections such as syphillis, tuberculosis, crytpococcus and sarcoidosis.

The differential diagosis includes;
  • Ischaemic optic neuropathy
  • Hypertensive retinopathy
  • Orbital or intracranial tumour
  • Toxic or metabolic neuropathy (alcohol, heavy metals, chloroquine)


The work-up of these patients should include a MRI of the brain.

The optic neuritis treatment trial supported the use of intravenous steroids, but not oral steroids. Referrals to neurology and opthalmology should be made. The role of intravenous gammaglobulin


Picture
Papillitis seen in Optic Neuritis

Paediatric UTI – Dispelling the Myths

UTI is a problem that is frequently reported as a source of infection in children, but in a recent paper by Newman, Shreves and Runde some of the dogma surrounding this common problem was examined with some interesting conclusions;
  • Asymptomatic bacteriuria is as common in children as it is in adults, which suggests that a significant proportion of children labelled as having a UTI may just have asymptomatic bacteriuria rather than a pathologic infection.
  • True urosepsis in the paediatric population is rare and less often life threatening than other causes of sepsis and usually limited to high risk groups such as neonates and those with congential anomalies.
  • UTI frequently progresses to pyelonephritis in the paediatric population, and scarring of the renal cortex is a common sequelae of this process.
  • The current evidence does not support the fact that renal scarring results in longer term kidney problems such as hypertension and the need for dialysis.
  • The majority of the literature shows no change in incidence of renal scarring with early vs. late antibiotic administration
  • Prophylactic antibiotics appear to be non-beneficial (although a small benefit may possible)
  • Surgical correction of vesicoureteral reflux is non-beneficial.
  • Imaging of the renal tract after UTI leads to little yield.

Reference
  1. Newman D, Shreves A, Runde D Pediatric urinary tract infection: does the evidence support aggresively pursuing the diagnosis? Annlas of EM; 2013; 

Medical Student Viva Examination – Term 1

Question 1
A 25 year old female presents to the emergency department with a history of right lower abdominal pain. Her LMP was 2 weeks previously and she is otherwise fit and well. She is on no regular medications and has no known allergies.

a. List your differential diagnosis for this woman's presentation:

The differential diagnosis must include;
  • appendicitis
  • ectopic pregnancy
  • ovarian cyst
  • ovarian torsion

Other considerations can include;
  • pyelonephritis
  • renal colic
  • musculoskeletal UTI
  • mittelschmirtz


b. What investigations would you order?
  • FBC
  • CRP
  • EUC
  • Urinalysis +/- microscopy
  • Beta-HCG (urine and serum)
  • Imaging - pelvic and lower abdominal USS
  • Negative marking for CT as first imaging choice in a young woman


c. What is the emergency management for this woman?
  • Vascular access
  • Keep NBM
  • Maintenance intravenous fluids (need to be specific as to fluid type and rate)
  • Fluid resuscitation if hypotensive (crystalloid +/- blood products - need to be specific about targets and amounts of fluids given)
  • Analgesia - must be a parenteral narcotic given in appropriate dosage.
  • Consult - general surgery +/- O&G



Question 2
A 35 year old male presents to the emergency department with SOB. He has a history of asthma, and has audible wheeze on arrival to the ED.

a. What are the signs and symptoms of a patient with severe respiratory distress?
  • inability to speak
  • diaphoresis
  • tripod positioning
  • extreme tachypnoea (RR > 30)
  • hypoxaemia (Pulse Ox < 90%)
  • accesory muscle use, intercostal recession
  • tracheal tug
  • stridor
  • silent chest on auscultation
  • tachycardia or bradycardia
  • pulsus paradoxus


b. Your patient has severe respiratory distress and is taken straight to the resuscitation room. Describe the initial emergency management of this patient.
  • monitored bed
  • supplemental oxygen therapy - maintain SaO2 > 95%
  • NIV with BiPAP
  • continuous salbutamol nebulisers
  • ipratropium 500 mcg q20/60 x 3 doses, then q6H
  • steroid therapy - prednisone or hydrocortisone (should be give an appropriate dose)


c. Your patient continues to deteriorate despite your aggressive initial efforts. What additional interventions could you offer this patient?
  • intravenous salbutamol
  • magnesium
  • ketamine
  • adrenaline
  • intubation and mechanical ventilation
  • inhalational anaesthetic agents