FCEM(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA
Incorporated Association not for gain Reg No 1955/000003/08

Final Examination for the Fellowship of the College of Emergency Medicine of South Africa 19 March 2012 Paper 1 (3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more than one is required for the one answer)

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a) b)

c) d) e)

f)

Define syncope by using the appropriate key words to describe the condition. (3) Which groups of cardiac conditions may present with syncope, to the Emergency Centre, with serious clinical repercussions to the patient, if missed by the attending emergency physician? (3) Name 2 examples (specific diagnoses) of each group of cardiac conditions described in 1b) above. (6) List the diagnostic ECG criteria for the 2 examples you have listed in 1c) above. (6) Which other malignant, non-cardiac, conditions of syncope, need to be excluded, before the attending physician may consider discharging the patient? (3) Pair the most appropriate research study design(s) with the following measures of exposure/intervention and effect: i) Odds Ratio. ii) Prevalence. iii) Incidence. iv) Relative Risk. (4) [25]

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A mother brings her 3-year-old son into the Emergency Centre with the history that he might have swallowed some of the items he was playing with. He had been playing with coins, miniature batteries and fridge-magnets. a) Write short notes on the potential clinical dangers associated with ingestion of each of these three types of foreign bodies in children. (15) b) If one of the foreign bodies lodges in the proximal oesophagus or hypopharynx, describe two methods you could safely use to remove the foreign body. (10) [25]

PTO/Page-2-Question 3

Her extended family brought her to you as she is agitated and breathless. (5) c) Describe in detail the specific management for local anaesthetic agent toxicity. Describe your approach to this situation. (6) Write short notes on the clinical presentation and management relevant to two novel illicit drugs (of your choice).-23 A medical officer in the Emergency Centre calls you for assistance following the administration of a local anaesthetic agent for a Bier’s Block. (10) d) Describe your feedback to the medical officer in question regarding the use of the Bier’s Block. (7) A mother brings her 5-year-old son to your emergency centre. Discuss some of the ethical and medical issues facing you in her management in the Emergency Centre. a) Describe the types of local anaesthetic agents and cite two examples of each type. On your assessment today you diagnose a Torus fracture of the right distal Radius. (3) Explain the difference between a body packer and a stuffer. (3) Describe the emergency management of a patient who presents with stimulant-induced hyperthermia. The mother is furious and is threatening to sue the hospital. They are visibly upset. (6) [25] An 80-year-old female presents to your emergency centre. (10) Discuss medical and non-medical challenges faced when dealing with an adolescent male with Down’s syndrome in your emergency centre. He was examined and sent home by a junior doctor without investigation or treatment. (7) Write short notes on the therapeutic use of cocaine in the Emergency Centre. (4) b) Describe the clinical features of local anaesthetic agent toxicity. (8) 4 5 a) b) c) PTO/Page-3 Question 6 . with respect to clinical relevance. and how to address them. She is known with terminal carcinoma of the colon. (6) [25] a) b) c) d) e) Discuss the clinical presentation and management of a patient who presents to your Emergency Centre following cocaine ingestion. He was seen there 2 days ago with wrist pain.

“Rapid versus standard intravenous rehydration in paediatric gastroenteritis: pragmatic blinded randomised clinical trial” by freedom et al and answer the following questions a) What statistical tests could have been used for the comparison between the proportions of participants who were rehydrated at two hours? (4) b) What statistical tests could have been used for the comparison between the time to discharge between the two groups? What would make you choose on test over the other? (6) c) What is the difference between continuous and categorical data (give examples)? (3) d) What is the difference between parametric and non-parametric data (give examples)? (3) PTO/Page–4 Question 6e) .-3- 6 Please read the attached abstract.

-4e) f) How could you calculate 95% confidence intervals if you know the mean and standard deviation of a sample? (3) The authors describe a “validated dehydration scale”. What is this? (6) [25] .

(8) c) Under what circumstances can a venous blood gas analysis be used in place of an arterial blood gas analysis in the Emergency Centre? (4) d) What level of positive end-expiratory pressure (PEEP) would you set on the ventilator for this patient? Describe the equal pressure point theory in your answer. whilst ventilating the same patient as in 2a) above? (2) A 64-year-old male. He has had two previous intensive care unit admissions during which he was ventilated. (4) ii) Name two other ECG indications. presents to your Emergency Centre. (8) b) Write short notes on the physiological changes that occur during the transition from spontaneous ventilation to intubation and positive pressure ventilation that take place in this type of patient at risk of cardiac arrest. He is confused. who is on insulin maintenance therapy. (2) PTO/Page 2 Question 2ciii) . i) Which clinical decision tool may aid you to consider reperfusion therapy for this patient? Please list the criteria for this tool. pale and sweaty with a respiration rate of 20 breaths per minute and blood glucose reading of 11mmol/L. Please state from which guidelines they are derived.FCEM(SA) Part II THE COLLEGES OF MEDICINE OF SOUTH AFRICA Incorporated Association not for gain Reg No 1955/000003/08 Final Examination for the Fellowship of the College of Emergency Medicine of South Africa 20 March 2012 Paper 2 (3 hours) All questions are to be answered. agitated and extremely uncooperative. His ECG examination shows a left bundle branch block. known diabetic patient. His blood gas readings are within normal limits. Each question to be answered in a separate book (or books if more than one is required for the one answer) 1 A 45-year-old male with a history of poorly-controlled asthma presents to the Emergency Centre with severe bronchospasm. His oxygen saturations are 80% on a non-rebreather mask and his respiratory rate is seventy breaths per minute. (2) How would you compromise minimising the effect of both the anatomical and physiological dead spaces. a) Write short notes on the concept of delayed sequence intubation. for providing immediate reperfusion therapy in ST segment elevation myocardial infarct (STEMI) patients. (5) [25] 2 a) b) c) Explain the differences between the anatomical and physiological dead spaces whilst providing positive pressure ventilation to a patient.

and explain the potential pathology each would include or exclude. as an indicator for reperfusion therapy? (3) A family member of a deceased patient lodges a complaint with your emergency centre. (3) [25] 5 A 24-year-old pregnant female presents to the Emergency Centre in which you are working following a motor vehicle accident. and nerve supply. including details of muscle origin. (2) ii) Use of Ketamine as a rapid sequence induction (RSI) drug in head injured patients. Your investigation’s outcome concluded that this case was an adverse event.-2What recent medical evidence. during a weekend shift. a) Describe the diagnostic criteria for this diagnosis. (4) iii) Retinal detachment. regarding sensitivity and specificity. (8) Write short notes on the following causes of acute monocular visual loss. SpO291% on room air. (5) b) List the investigations you would perform prior to making this diagnosis. (6) d) Discuss your management of this patient including disposal. insertion. concerning the patient’s final moments. Her vital signs are as follows BP 95 mmHg Systolic. She claims to have wearing a safety belt and denies any loss of consciousness. RR 18 bpm. She complains of abdominal tenderness a) Describe your assessment of this patient. and a feeling of hopelessness. (4) Write short notes on the following i) Indication for emergency physicians to perform front room (Emergency Centre) thoracotomies. (6) PTO/Page 3 Question 5b) . including details of clinical presentation and management i) Central retinal artery obstruction. concerning the care that was provided. He states that this is having an impact on his personal and professional life. (6) [25] 4 a) b) c) Explain the intrinsic and extrinsic movements of the eye. You diagnose that he may have a major depressive episode. HR 100 bpm. insomnia. (6) Illustrate the visual pathway. (4) ii) Central retinal vein obstruction. (2) iv) The benefits in the use of thumb immobilising splints over standard wrist splints in patients with newly diagnosed scaphoid fractures. (8) c) List the types of anti-depressant agents and give two examples of each. indicate on your diagram the visual field defects resulting from interruption of the pathway at different points. Please describe the differences between an adverse event and a near miss (adverse incident). (2) iii) Use of S-100B serum protein levels in head injured patients.(2) [25] iii) d) e) 3 A 30-year-old male patient presents to your emergency centre complaining of perpetual exhaustion. of an ECG left bundle branch block is there.

(7) Describe the specific precautions you would take in this patient. Write short notes on its clinical features and management. (6) [25] 6 a) b) c) d) . i) What clinical features are used to grade the condition? (2) ii) What laboratory tests are helpful in confirming the diagnosis? (1) iii) How should the patient be managed for his encephalopathy? (3) A patient with cirrhosis presents to your Emergency Centre and you suspect spontaneous bacterial peritonitis. (2) iii) Ischiorectal abscess. (2) A patient with known alcoholic liver disease presents to your Emergency Centre with hepatic encephalopathy. (7) Describe rhesus isoimmunisation and how you would prevent it in this patient. (2) ii) Anal fissure. (5) What should be your diagnostic strategy be in an 18-year-old female with suspected acute appendicitis? Include reference to the sensitivity and specificity of selected tests where appropriate.-3b) c) d) Describe the investigations you would perform in this patient and those you would specifically avoid. (2) iv) Rectal prolapse (in a 75-year-old female). (5) [25] Write short notes on the presentation and management of patients with the following conditions i) Pilonidal abscess.