Feedback on FRCEM Intermediate SAQ - 28 September 2017 Performance

Candidate Number:
CandidateName:

Qno Question title Category Your score Max score Average

1 CC3 - Therapeutics And Safe Prescribing Common Competences 3.0 3 2.0

2 C3AP1b - Major trauma – Abdominal Acute Presentations 3.0 3 2.1

3 PAP16 – Atraumatic limb pain Acute Presentations 3.0 3 2.3

4 PP2 - Peripheral venous cannulation Procedural Competences 3.0 3 0.7

5 PAP13 – Neonatal presentations Acute Presentations 3.0 3 1.6

A1C - Preoperative Assessment - Specificanaesthetic Anaesthetic

6 3.0 3 1.7
Evaluation Competences CT1&2

7 CAP20 - Limb Pain & Swelling – Atraumatic Clinical Presentations 3.0 3 1.1

8 CAP20 Atraumatic Limb Pain Clinical Presentations 3.0 3 1.1

9 PP6 - Pleural Tap Procedural Competences 3.0 3 1.5

10 CAP14 - History Taking / Fever in all age groups Clinical Presentations 3.0 3 1.5

11 Breathlessness - CAP6 Respiratory 3.0 3 1.0

12 CAP3 - Acute Back Pain Clinical Presentations 3.0 3 1.1

results in the ED

C3AP3 - ABGs Interpretation of abnormalbloodgas

13 AcutePresentations 3.0 3 1.6

Anaesthetic
14 Induction of general anaesthesia
Competences CT1&2
3.0 3 1.4
16 CAP35 - Ventilatory Support Clinical Presentations 3.0 3 2.3

17 PAP3 - Acute life-threatening event (ALTE) Acute Presentations 3.0 3 1.7

18 PP7 - Intercostal Drain – Seldinger Procedural Competences 3.0 3 1.6

Anaesthetic
19 Critical Incidents
Competences CT1&2
3.0 3 2.0

20 CC10 - Infection Control Common Competences 3.0 3 1.7

21 CAP5 - Trifasicular Block Clinical Presentations 3.0 3 1.1

ICM5 - Connects mechanical ventilator andselectsinitial

22 ICMwithinACCS 3.0 3 1.7
settings

23 PAP2 - Accidental poisoning and self harm Acute Presentations 3.0 3 2.3

24 CMP4 - Septic Patient Clinical Presentations 3.0 3 1.0

25 C3AP1c - Major Trauma - Spine Acute Presentations 3.0 3 1.7

26 PP10 - Abdominal Paracentesis Procedural Competences 3.0 3 1.0

27 CAP33 - Traumatic Limb & Joint Injuries - shoulder Clinical Presentations 3.0 3 2.6

28 CAP17 Headache Clinical Presentations 3.0 3 1.4

29 PMP6 - Unconscious Child Major Presentations 3.0 3 2.3

30 CAP34 - Vaginal Bleeding Clinical Presentations 3.0 3 2.1

31 CC19 - Legal Framework for Practice Common Competences 3.0 3 1.1

32 PP5 - Practical Procedures Lumbar puncture Procedural Competences 3.0 3 2.4

33 C3AP6 - Emergency Airway Care Acute Presentations 3.0 3 1.6

34 CAP7 - Chest Pain Clinical Presentations 3.0 3 1.2

those who will need intubation and ventilation

PAP5 - Breathing difficulties - recognise the criticallyilland

35 AcutePresentations 3.0 3 1.0
36 PP13 - DC Cardioversion Procedural Competences 3.0 3 2.2

37 C3AP8 - Testicular pain Acute Presentations 3.0 3 2.2

ICM9 - Prescribes safe use of vasoactivedrugsand

38 ICMwithinACCS 3.0 3 2.3
electrolytes

39 PAP1 - Rashes in Children - Swollen Face Acute Presentations 3.0 3 2.3

40 CC16 - Health promotion and public health Common Competences 3.0 3 0.9

41 PP1 - Arterial cannulation Procedural Competences 3.0 3 1.8

42 PAP6 - Concerning Presentations Acute Presentations 3.0 3 1.5

43 CAP8 - Confusion Clinical Presentations 3.0 3 2.4

44 PP16 Reduction of dislocation Procedural Competences 3.0 3 1.4

45 CAP10 - Cyanosis Clinical Presentations 3.0 3 1.6

CMP2 - Anaesthetic Competencies: Management of

46 cardiorespiratory arrest
Clinical Presentations 3.0 3 2.2

47 PAP2 - Apnoea, stridor and airway obstruction Acute Presentations 3.0 3 2.6

48 CC17 - Principles of Medical Ethics and Confidentiality Common Competences 3.0 3 1.4

49 CAP11 - Diarrhoea Clinical Presentations 3.0 3 2.3

50 CAP37 - Weakness and paralysis Clinical Presentations 3.0 3 1.9

PP26 - Deliver a fluid challenge safely to an acutely unwell

51 patient
Procedural Competences 3.0 3 2.4

52 CAP15 - Fits/Seizures Clinical Presentations 3.0 3 2.1

53 PAP4 - Paediatric Blood Disorder Acute Presentations 3.0 3 1.9

54 CAP1 - Abdominal Pain including loin pain Clinical Presentations 3.0 3 2.6

55 C3AP4 - Abnormal blood glucose Acute Presentations 3.0 3 1.4

56 CAP29 - Red Eye Clinical Presentations 3.0 3 2.2

57 PP18 - Wound Management Procedural Competences 3.0 3 1.6

58 CAP33 - Painful limbs traumatic Clinical Presentations 3.0 3 1.4

59 CC7 - Prioritisation of patient safety Common Competences 3.0 3 2.0

60 ICM11 - Accidental displacement of tracheal tube ICM within ACCS 3.0 3 1.5
 Total marks Total marks
Category
achieved available
Acute Presentations 45.0
Anaesthetic Competences CT1&2 9.0
Clinical Presentations 63.0
Common Competences 18.0
ICM within ACCS 9.0
Major Presentations 3.0
Procedural Competences 30.0
Respiratory 3.0

Pass mark 113

1-CC3-Therapeutics and Safe Prescribing
(Common Competences)
A 65-year-old-lady patient takin warfarin for atrial fibrillation presents to AED with no bleeding. She was treated by her GP
for chest infection. Her INR is checked and is raised at 7.0.
a-What is the antibiotic drug caused prolonged INR? (1 mark)
b-What is your management? (1 mark)
c-What advice would you give this patient regarding her warfarin therapy beyond the initial 24 hours? (1mark)

a-Clarithromycin (macrolides) (liver enzyme inhibitor)

b-INR 5.0 – 8.0 and no bleeding — withhold 1 or 2 doses of warfarin and lower the maintenance dose. If high risk of bleeding,
give Oral Vitamin K (1-3) mg
Recheck INR 2-3 day later. Resume the baseline dose of warfarin if INR less than 5.

c-Return to hospital if there is bleeding, review medications with her GP. Stop or change antibiotic, Follow up with
hematologist.
2-C3AP1b-Major Trauma-Abdominal
(Acute Presentations)
A 28 year-old-male presented with penetrating stab wound in epigastrium with blood pressure (90/55).
Erect chest X-ray done and shown below:
a-What is the definitive management? why? (1mark)
b-What other (2) indications of your definitive management in penetrating injury? (1mark)
c-What (2) management in ED? (1mark)

a-
-Laparotomy
-Why? - Penetrating injury & hypotension.

b-Penetrating plus
1-Evisceration or
2-Gun shot with trajectory tracts or
3-Bleeding from mouth, urethra or rectum.

c-
1-ABCDE Approach with high flow o2 100%
2-I. V access, blood tests (FBC, amylase, lipase, U&Es, LFTs), G&S, Cross match, I.V fluids (consider early Blood
transfusion)
3-Strong analgesic titrate to pain /Prophylactic antibiotics/ updates tetanus/NGT, NPO and urinary catheter.
4-Surgery referral.
3-PAP16-Atraumatic limb pain
(Acute Presentations)
An 11-year-old boy presents with his parents to the ED having developed a limp over the last week.
a-What is the X-ray view? What is the abnormality in X-ray? (1mark)
b-Name and describe the radiological sign associated with this abnormality? What is the most complication? (1 mark)
c-Give (2) differential diagnosis? (1 mark)

a-lateral frog leg view - (S.U.F.E) right hip

b-
-Trethowan's sign (Klein line drawn above superior border of femoral neck should transect femoral epiphysis), in this X-ray
not.
-Avascular necrosis.

c-
1-Septic arthritis
2-Osteomylities

4-PP2-Peripheral venous cannulation

(Procedural Competences)
A 50-year-old-male presented with fracture left hip and prepared for operation.
a-What site of peripheral venous cannulation? (1 mark)
b-What is the flow rate of gauge cannula 18? (1 mark)
c-How to decrease risk? (1 mark)

a-left antecubital fossa (basilica /cephalic vein)

b-105 ml/min

c-Consent, appropriate site &size, avoid veins over joint, avoid tortious veins, Aseptic technique, local anesthetic spray, wear
gloves, blood flashback, secure cannula, sharps bin, apply tourniquet above the insertion site not more than 1 min, if 2 attempts
failed call expert.
5-PAP13-Neonatal presentations
(Acute Presentations)
A 2 days old infant baby presented to ED by his mother with inability to breath,cyanosed and CRT more than 2 and chest X-
ray done and shown below:
a-What are the abnormalities in the X-ray? (1 mark)
b-What are your differential diagnosis? (1 mark)
c-What is your management? (1 mark)

a-
1-Trachea, mediastinal and the heart shift to the right side.
2-left lung hypoplasia, absent left cardiac shadow, absent left (costophrenic &costocardiac) angles.
3-Multiple gas locules in left hemithorax, left hemidiaphragm obscured

b-
1-Congenital diaphragmatic hernia.
2-Cyanotic congenital heart disease.
3-Esophageal tracheal fistula.
4-Meconium aspiration.
5-Pneumonia

c-
1-Call for (help/anesthetist/pediatric surgery), involve ED senior
2-ABCDE approach with high flow O2/I. V access, bloods, ABG, I.V fluids and consider inotropic.
3-NPO, (NGT with suction), intubate immediately without bag and mask ventilation.

Notes:
Ventilation by bag and mask in diaphragmatic hernia may cause distention of the stomach and must be avoided as it may limit
expansion of the hypoplastic lung
6-A1C-Preoperative Assessment-Specific
Anestheticevaluation
(AnestheticCompetencesCT1&2)
A 50-year-old-male-Patient with cardiovascular issue need to do for him anesthesia
a-What's his ASA Classification System? (1 mark)
b-What is Malampati score in the image? Give (2) other features for difficult airway? (1 mark)
c-What time for last ate and last drink? (1 mark)

a-ASA Class III.

b-
-Malampati Class II
-Difficult airway / Intubation (LEMON)
-Look externally (facial trauma, large incisors, beard and large tongue
-Evaluate 3-3-2 rule.
-Malampati
-Obstruction.
-Neck Mobility

c-2 hours for drink and 6 hours for food

7-CAP20-Limb Pain & Swelling-Atraumatic
(Clinical Presentations)
A 60-year-old-male plumber attends with a painful and swollen right knee. He has been sent to the ED by his boss as he is
finding it difficult working.
a-What is the diagnosis? (1 mark)
b-What is the main complication this patient may develop? (1 mark)
c-Outline two aspects of your treatment? (1 mark)

a-Prepatellar & Infrapatellar bursitis

b-Infective bursitis /Septic arthritis/Secondary osteoarthritis/loss of function.

c-Rest (which may involve the use of crutches) /short course of NSAID/Avoidance of the causative activity, aspirate fluid for
culture and sensitivity, and start antibiotics (e.g. co-amoxiclav), bloods (FBC, ESR AND CRP), knee X-ray, involve
orthopedics
Notes:
-Persistent symptoms may necessitate elective excision of the bursa. Infective bursitis may occur (fever and cellulitis are clues
to this):

8-CAP20-Atraumatic Limb Pain

(Clinical Presentations)
A 6-years-old-child is brought to ED complaining of a painful and swollen right lower limb after falling off a push bike. On
examination the right lower limb is grossly swollen and the patient refuses to walk due to pain. He is neurovascularly intact.
An X-ray is performed which is shown below:
a-What are the findings in X-ray?
b-Patient given morphine 0.1mg/kg but still in pain,what treatment will you give(dose & route)?
c-What splint will you apply for him?

https://www.tamesidehospital.nhs.uk/documents/FracturedFemurPIL.pdf

a- (Floating knee Type I)

Spiral fracture of lower shaft of right femur plus spiral fracture upper shaft of ipsilateral tibia

b-Any answer
1-Further, titrated intravenous morphine. The College recommendation is 0.1 -0.2mg/kg as an initial dose.
2-Regional anesthesia. (F.N.B or F.I.N.B)
3-Intravenous paracetamol which might reduce his opiate requirements.
4-Consider a sub-dissociative dose of intravenous ketamine, 0.3mg/kg.
5-You may allow him to continue to use nitrous oxide in the meantime.
c- (Non-operative treatment)
-initial skin traction (Pediatric Thomas splint) for the femoral fracture with closed reduction and casting or splinting for the
tibial fracture.
-A hip Spica cast is applied when sufficient femoral healing has occurred.

Notes:
-NSAIDs are best avoided, since open reduction and internal fixation is the likely operative plan.

https://online.boneandjoint.org.uk/doi/full/10.1302/2058-5241.1.000042
9-PP6-PleuralTap
(Procedural Competences)
A 54-year-old-woman presents to AED complaining of a week’s history of worsening breathlessness. Chest x-ray shows alarge
left-sided effusion.
a-What is the site of pleural tap? What is the position? (1 mark)
b-What are the complications? (1 mark)
c-How to decrease risk? (1 mark)

a-
1-Between 7th& 9th rib spaces and between posterior axillary line and midline (above the rib below)
2-Seated position leaning slightly forward resting the head on arms or pillow on adjustable bedside table.

b-Dry tap, Pneumothorax, Major bleeding, Fluid build up, intrathoracic injury (liver, spleen, heart or pleura), malposition,
failed technique.

c-Confirm ID, Consent, proper (site, position, adequate anaesthesia and equipment), aseptic technique, guided U/S, slow
drainage Maximum (1.5 L), confirm success (clinically& radiologically), trained operator.

10-CAP14-HistoryTakingIFeverinallagegroups
(Clinical Presentations)
A 25-year-old male patient presents to AED complaining of fever, myalgia and lethargy. He has recently returned from a
holiday in Malaysia. (endemic area)
a-Give (2) important questions to ask? (1 mark)
b-Give (4) features indicating cerebral malaria? (1 mark)
c-What is your management? (1 mark)

http://www.osce-aid.co.uk/osce.php?code=osce_feverinareturnedtraveller
a- any 2 of:
1-Timing of symptoms Onset, course and duration?
2-Travel history Which countries? Urban / rural environment? Types of accommodation? Dates of entering each country /
returning home?

3-Risk factors: (SPACES) Sexual history, Procedures, Animal contact, Contacts, Eating & drinking, Swimming
4-Prevention

b- Complicated falciparum malaria

1-CNS: impaired consciousness or seizures.
2-Respiratory: pulmonary edema or ARDS.
3-GIT: jaundice.
4-Renal: renal impairment.
5-Metabolic: acidosis (ph. less than 7.3), hypoglycemia (less than 2.2mmol/L).
6-CVS: shock (BP less than90/60).
7-Blood: spontaneous bleeding, DIC, Anemia (HB less than 8G/dl) and hemoglobinuria

c-Treatment:
1-I. V fluids, analgesic and antipyretics
2-I. V Quinine.
3-Malarone ® (atovaquone with proguanil hydrochloride)
4-Riamet ® (artemether with lumefantrine

Notes:
3-Risk factors:(SPACES)
Sexual history
Procedures (hospitalization, blood products received, Any vascular access, Piercings or Intravenous drug-use)?
Animal contact (Any bites received (animals or insects), Close household contact with animals?
Contacts (Any close contacts also unwell? Known diagnosis? Treatment?)
Eating & drinking (Did they eat any high-risk foods e.g. street meat, unpasteurized milk, did they drink unsterilized water?)
Swimming (Any swimming in natural lakes/rivers/Any activity involving water)?

11-Breathlessness-CAP6 (Respiratory)
A 72-year-old woman, who has smoked all her life, presents to AED after falling with malaise, weight loss, a persistent cough,
she fell down, confused, O2 sat 85%, Her chest X-ray is shown below:
a-Describe the abnormality seen on the X-ray and give Differential diagnosis? (1 mark)
b-What is the cause of fall? (1 mark)
c-What is your management? (1 mark)
a-
-Right Apical lung shadowing.
-Differential diagnosis:
• Pancoast tumor, Carcinoma, Metastases (often multiple), Benign lung tumour
• TB
• Abscess
• Loculated effusion
• Hydatid cyst
• Arteriovenous (AV) malformation
• Aspergilloma
• Rheumatoid nodule

b-
-Hypoxia
-SVC obstruction
-Secondary epilepsy or (SIADH) / hyponatremia

c- ABCDE Approach with high flow oxygen maintain (Spo2 94-98%), I.V access, bloods, ABG, sputum culture, I.V fluids,
respiratory specialist, involve ED senior

12-CAP3-AcuteBackPain
(ClinicalPresentations)
A 35-year-old known intravenous drug user (IVDU), presents to ED complaining of feeling generally unwell with low back
pain which is worse at night and has been progressively worsening over the last couple of weeks. On examination he is pyrexic
(39.1°C), and has
midline tenderness to gentle spinal percussion over vertebra L4/L5.
a-What is the most likely diagnosis? (1 mark)
b-The patient complains of weakness in his lower legs and states that he is having difficulty passing urine. What complication
has most likely occurred? What investigation? (1 mark)
c-What is your management? (1 mark)

a-Acute Spinal infection: Discitis (+/- vertebral osteomyelitis/epidural abscess)

b-Cauda equine syndrome/ MRI spine.

c-Analgesic titrate to pain, I.V access, bloods, blood culture, I.V antibiotics (6 weeks of I.V antibiotics followed by 6 weeks of
oral antibiotics is the commonly used regimen), bracing top, involve neurosurgery urgently.

13-C3AB3-ABGs of abnormal blood gases results in

ED (Acute Presentations)
A 16 year-old-girl brought to AED with rapid breathing her family found a paper where she written (Ihave to go, the life
doesn’t worth), she has taken tablets, A.B.G showed:
Ph: 7.48 (7.35-7.45)
PO2: 13.1 (10-14)
PCO2: 3.2 (4.5-6.0)
HCO3: 22.1 (22-26)
BE: 1.2 (-2 to 2)
a-What is ABG interpretation? What is your possible diagnosis? (1 mark)
b-How will you assess this patient? (1 mark)
c-Give (2) treatment in ED will improve this patient? (1 mark)
a-Respiratory alkalosis possible diagnosis is (Acute Salysilates toxicity)

b-Assessment = (clinical + serial Salicylates level every 2 hours + Paracetamol level +blood sugar + ECG
+ serial ABG, K+ level, risk assessment (Modified SAD PERSONS Scale).

3-
-Consider activated charcoal & gastric lavage within 1-hour, high flow O2, IV fluids,
-Consider urine alkalinizing (target urine 7.5 – 8.5) if the plasma salicylate concentration is above 500
mg/L
-Hemodialysis is indicated in severe poisoning (> 900 mg/L or > 700
mg/L with acidosis
-address self-harm issues.

Notes:
Look at (Hco3) why? if low (HCO3 15) it means mixed respiratory alkalosis and metabolic acidosis and it indicates severe
toxicity in assessment

14- A3 - Induction of General Anesthesia

(Anesthetic Competences CT1&2)
A 40 year-old-patient known Asthmatic presented with life threatening asthma and deteriorated.
a-What drug of choice for R.S.I? (1mark)
b-What is your rational? (1mark)
c-Give (2) causes of difficult ventilation? (1mark)
a-ketamine 1-2 mg/kg.

b-
1-Relatively cardiovascular stability.
2-Bronchodilator.

c-
1-Auto peep / Hyperinflation / air trapping.
2-Pneumothorax.

15-cap12-Dizziness and Vertigo

(Clinical presentation)
A 45 year-old-male-patient with dizziness, ataxia, nystagmus and blurred vision.
1-What is your possible diagnosis? What are the causes? (1 mark)
2-What clinical pictures indicative central cause than peripheral vertigo? (1 mark)
3-What is the management? (1 mark)

https://www.rcemlearning.co.uk/references/vertigo/
a-
-Central vertigo (Cerebellar stroke)
-Migraine (most common cause) / otomastoiditis /TIA /Cerebellar tumour / Acoustic neuroma / Multiple
sclerosis

b-
1-Unaffected by head position
2-Little systemic upset
3-Central-type nystagmus Horizontal, rotatory or vertical, Bidirectional, Not suppressed by visual fixation
4-Head impulse test is negative
5-Persistent, severe or prolonged vertigo
6-New-onset headache
7-Abnormal response to the Hallpike manoeuvre
8-Prolonged, severe imbalance
9-No other ENT symptoms such as hearing loss, tinnitus or aural
fullness
10-Signs and symptoms do not match any of the features of peripheral
causes of vertigo
11-Focal neurological signs and symptoms
12-Generally there are co-existing neurological deficits e.g. ataxia, depressed level of consciousness.
Rarely, vertigo may be the only finding
c-
-ABCDE approach and supportive treatment, separate peripheral from central, vestibular suppressants,
CT/MRI head scan, consider anticoagulant if no intracerebral hemorrhage, involve ED senior, involve
ENT physician.

Notes:
How to differentiate between Peripheral and Central from Examination

(HINTS) With Central Vertigo

-Head Impulse test -ve: no corrective saccades.

-Nystagmus: vertical or torsional.
-Test of skew: vertical correction on (tested by asking the patient to fix on a distant point, then covering one eye).

16-CAP35-Ventilatory Support
(Clinical Presentations)
A 50 year-old-male with head injury, picture of ventilator button RR 10 VT 500ml
a-What is your setting in ventilator machine in respect to RR? (1.5 marks)
b-What (2) non-pharmacological interventions to decrease I.C.P? (1.5 marks)

a-
1-Start RR by 12/min and (titrate) RR to maintain Normocapnia (PaCo2 4.6-6kpa)
2-TV (6-8 ml/kg) /I:E ratio 1:2 /PEEP 5cm H2O.
3-Maintain normoxia (O2 sat94-98%), Normothermia, Normoglycemia, normotention
b-
1-30 degrees head up elevation of bed. Or reverse Trendelenburg position
2-Loosening of cervical collar and ETT tie or tape.
3-Controlled ventilation.

17-PAP3-Acute life-threatening event (ALTE)

(Acute Presentations)
A baby is brought into ED by parents after they witnessed ALTE (BRUE) For 30 seconds he was full term on normal vaginal
delivery,now all vital signs within normal.

a-What age group? (1mark)

b-What features from (history and examination) indicates low risk factors? (1mark)
c-He looks normal, what (2) features indicates that he looks normal? (1mark)

a-Less than 12 months.

b-Full term, 30 Seconds ALTE symptoms (less than 1 minute), looks well.

c-No apnea, No change in color or tone, No gagging or shocking, No decrease in G.C.S

18-PP7-lntercostal Drain-Seldinger
(Procedural Competences)
A 65-year-old patient, who has smoked all his life, presents to AED complaining of a sudden pain in his
left chest and shortness of breath, patient on warfarin, A chest X-ray is performed which is shown below:
a-What is the diagnosis (described in full)? What is your immediate action? (1 mark)
b-Give (2) indications and (2) contraindications? Seldinger technique(1 mark)
c-Give (2) complications? How will you decrease the risk? Seldinger technique(1 mark)
a-
-Large left-sided secondary spontaneous pneumothorax
-Chest drain insertion – (Seldinger technique) fifth intercostal space (Safe triangle) just anterior to
midaxillary line

b-Indications
1-A pneumothorax (In any ventilated patient/Tension pneumothorax after initial needle
decompression/Persistent or recurrent pneumothorax after simple aspiration)
2-Large secondary spontaneous pneumothorax in patients aged over 50 years

contraindications
1-Relative (Coagulopathy).
2-Absolute (Hemothorax).

c-Complications
1-Haemorrhage
2-Infection at the drain site or in the pleural cavity

Decrease risk
-Confirm Id of the patient and site of the pneumothorax, Gain consent, appropriate position, site on x-ray
and mark on the Patient, Aseptic technique, appropriate local anesthesia, Guided by U/S, confirm success
(clinically and radiologically), continuous cardiac monitoring, resuscitation drugs and equipment and
check I NR.

Notes:
Other indications for Seldinger technique:
3-Malignant pleural effusions
4-Empyema and complicated parapneumonic pleural effusion
5-Post-surgical

19-Critical Incidents (anesthetic competencesT1&2)

A 37 year-old-male-patient presented to ED having been involved in road traffic collision, with facial injury
a-Give (2) causes of airway obstruction in facial injury? (1mark)
b-Give (2) immediate action? (1mark)
c-Rather than simple equipment, what (2) actions will you ask the nurse to do? (1mark)
a-
1-Distorted anatomy of airway (oropharynx/larynx/trachea).
2-Aspiration of (foreign bodies/broken teeth/blood/vomits)/decreased GCS

b-
1-Spine immobilization, jaw thrust with suctioning and oropharyngeal airway.
2-BVM with application of high flow O2 +/- ETT (Intubation)

c-
1- Call for difficult airway trolley.
2- BURP, MILS, Video-laryngoscope, bougie, stylet, LMA, surgical airway kit.

20-CC10-InfectionControl
(CommonCompetences)
A 30 year-old-male came from influenza epidemic area
a-How to protect yourself from infection rather than hand hygiene?
b-What willyou do if patient come inside ER?
c-Who will you inform?
a-PPE / Vaccination / avoid close contact / avoid touching eyes, nose and mouth.

b-Isolation / Inform local authorities / alert all staff / nasopharyngeal swap

c-Infectious disease specialist / infection control department / health protection agencies

21-CAP5-Trifasicular Block
(Clinical Presentations)
A 60 year-old-male-patient presented with syncope with normal vital signs, ECG done and is shown below:

a-What is the diagnosis of ECG? (1 mark)

b-What is the possible cause of syncope in this patient? (1 mark)
c-Give (2) treatments? (1 mark)

a-Trifasicular block.(R.B.B.B+L.A.H.B+1st degree A.V block)

b-Transient globular cerebral hypoperfusiondue to arrhythmia.

c-
-Temporary (transcutaneous / transvenous) pacing.
-permanent trans venous pacing

22- I CM5-Connectsmechanical ventilator and

selects initial setting
(I CM within ACCS)
A 25-year-old-woman is brought into the ED with signs ofsevere sepsis. She was intubated and transferred to ITU. You
arenow following up her progress a week later and you note she hasbeen diagnosed with ARDs.
a-Give two features of Lung protective ventilation strategy in ARDS? (1.5 mark)
b-What is the possible complication? (1 .5 mark)

a- Both of:
1-Low tidal volume
2-Low end-inspiratory plateau pressure

b- Any two of:

1-Volutrauma (lung damage secondary to high tidal volume causing over distension and rupture of alveoli)
2-Barotrauma (lung damage secondary to high airway pressure e.g. Pneumothorax, pneumomediastinum)
3-Atelectrauma (lung damage secondary to shear and strain of collapsible lung units opening and closing)
4-Biotrauma (lung damage secondary to release of proinflammatory cytokines and immune-mediated injury)
Ventilator setup
*Calculate predicted body weight
*Select any ventilator mode
*Achieve a TV of 6 – 8 mL/kg predicted body weight
*Set RR to maintain adequate MV of about 100 mL/kg (not > 35/min)
*Set PEEP to at least 5 cmH2O (but much higher is probably better)
*Set FiO2 to maintain SpO2 88 – 95% or PaO2 55 – 80 mmHg
*Aim for plateau pressure (measured during an inspiratory hold of 0.5 sec) < 30 cmH2O and preferable as low as possible
while maintaining reasonable blood gas parameters
*pH goal = 7.30 – 7.45 (if < 7.15 increase TV, give NaHCO3)

23-PAP2 Accidental poisoning and self harm.

(Acute presentation)
A 16-year-oldmale presents to the Emergency Department after having taken an intentional overdose of paracetamol 2 hours
ago. He tells you he has taken twenty 500 mg tablets along with a bottle of whiskey. He weighs 70 kg, has no past medical
history of note and his examination is unremarkable.
a. When should paracetamol levels be tested in this patient? (1 mark)
b. Once blood results are available what are the indications for prescribing NAC in this patient? what investigation? (1 mark)
c- Patient said I feel happy when I eat drugs what is your action? (1 mark)

a- At 4 hours from ingestion paracetamol. (after 2 hours from presentation in ED)

b-
-High paracetamol level (above treatment line), abnormal INR, creatinine or ALT.
(Venous gas, FBC, U&Es, LFTs, clotting)

c-Assess his capacity, consider refer for psychiatric assessment

24-CMP4-Septic patient
(clinical presentation)
A 35 year-old-male-patient presented with Right hand swelling, history of trauma 1week ago.BP(85/55) HR 122 b/min and
image shown below:
a-What is your diagnosis? (1 mark)
b-What is the main complications? (1 mark)
c-What is your management? (1 mark)

a-Hand infection (Cellulitis class III with signs of marked systemic illness.)

b-
1-Locally (Acute limp Ischemia,Necrotizing fasciitis or gangrene)
2-Systemically (End organ dysfunction) *Lung (ARDS) *Brain (encephalopathy) *Liver (DIC) *Kidney (AKI) *Heart (HF)

SEPSIS SIX
c-ABCDE approach with high flow O2, I.V access, blood tests (FBC,CRP), Blood culture, I.V broad spectrum antibiotics,
ABG (lactate), I.V fluids, urinary catheter, X-ray right hand, consider inotropic, involve hand surgery for consideration of
Drainage & debridement, involve ED senior.
25-C3AP1c-MajorTrauma-Spine
(AcutePresentations)
A 60 year-old-male-patient presented with historyof a Fall from 20 feet, X-ray done and shown below:

a-What is the abnormality in X-ray? (1 mark)

b-What other (2) modalities of investigations? (1 mark)
c-What is your management? (1 mark)

a-L1 Anterior compression fracture.

b-
1-CT whole spine
2-MRI whole spine.

c-Management: ABCDE approach

1-Analgesics (I.V Morphine 2.5-10) titrate to pain
2-Immobilization, Neurovascular assessment.
3-Refer to Orthopedic / Neurosurgeon team.
26-PP10-Abdominal Paracentesis
(Procedural Competences)
A 65-year-old man, with a known history of chronic alcohol abuse, presents to AED with a grossly distended abdomen. You
suspect gross ascites secondary to chronic liver disease. The patient is found to have a temperature (38.5oC) and mild
abdominal tenderness on examination, and his inflammatory markers are raised on his admission bloods
a-What diagnosis should be considered and how should this be investigated? (1 mark)
b-What is the site of insertion? What are the complications? (1 mark)
c-How to decrease Risk? (1 mark)

a- Spontaneous bacterial peritonitis – diagnostic paracentesis.(protein, LDH, Gram stain, cell count) and bloods.

b-
1-In peritoneal cavity, patient lie flat (1/3-1/2 way between ASIS and Umbilicus 15 cm lateral and 2–3 cm below the
umbilicus, avoiding vessels or scars away from the epigastric arteries)

2-Persistent fluid leak from puncture site, hollow viscus injury (bowel, stomach or bladder), laceration of major blood vessels,
hematoma, infection, failed procedure

c- Consent, appropriate (site, position and anesthesia), Guided by U/S, examine for shifting dullness and fluid thrill, Aseptic
technique, Z technique, urinary catheter

27- CAP33-Traumatic Limb&Joint Injuries-

shoulder(Clinical Presentations)
A 25-year-old rugby player attends ED complaining of a severely painful right shoulder after being tackled at a match.
An X-ray has been performed by triage before you see the patient, and is shown below:
a-What abnormalities are seen on the x-ray? What is the diagnosis? (1 mark)
b-What is mechanism and cause of injury? (1 mark)
c-Give another injury that is associated with this diagnosis? (1 mark)
a-
-Widening of the glenohumeral gap, and lightbulb sign (abnormally symmetrical appearance of humeral head)
-Posterior shoulder dislocation.

b-A blow to the anterior portion of the shoulder, axial loading of an adducted and internally rotated arm, or violent muscle
contractions following a seizure or electrocution

c-Tuberosity and surgical neck fractures of the humerus/Reverse Hill-Sachs lesions/Injuries to the labrum/Rotator cuff injuries

28- CAP17-Headache
(Clinical Presentations)
A 30-year-old male patient presents to AED complaining of a 30-minutes history of a severe headache. He is complaining of a
sharp stabbing pain behind his left eye which woke him up a couple of hours after he went to sleep after returning from the
pub. He is in distress and restless with the pain, and the nurses tell you they noticed him banging his head against the wall in
the waiting room.
a-Cluster headache

b-(Ipsilateral lacrimation, rhinorrhea, nasal congestion, eyelid swelling,

flushing, conjunctival injection, constriction of the pupil, ptosis).

b. 100% high flow oxygen AND sumatriptan 4 mg subcutaneously (or 20 mg intranasally)

29- PMP6-Unconscious Child

(Major Presentations)
4-year-old is brought to ED by his concerned parents. He has been lethargic and losing weight over the preceding two weeks
and has suddenly become more unwell with abdominal painand profuse vomiting. On examination he is tachycardic,
tachypneic and clinically dry, BP85/55.RBS is 10 mmol/L
a-What is the diagnosis? What fluid will you give him? (1 mark)
b-Give (2) features indicates Cerebral edema? (1 mark)
c-Give (2) bedside tests for confirming diagnosis? (1 mark)

a-D.K.A -10 ml /kg.(Further fluid should be given by intravenous infusion at a rate that
replaces deficit and provides maintenance over 48 hours.

b- Increasingly confused, drowsy or losing consciousness /headache increased by lying down/respiratory pattern is irregular.

c-VBG/Urine dipstick (ketonuria)/blood ketones

30- CAP34-Vaginal Bleeding
(Clinical Presentations)
30 weeks pregnant patient came with vaginal bleeding after trauma,Rh status is negative,abdominal pain Score 6/10.
a-What treatment (Dose and Route)? (1 mark)
b-How will you monitor fetus in ED? (1 mark)
c-Patient became more hypotensive and pain increased. What is the cause? (1 mark)

a-Anti D 500 IU IM to the deltoid muscle / Morphine 2.5-10 mg I.V / 0.9 Nacl 500 cc I.V infusion.

b-C.T.Gcontinuousmonitoring for 4-6 hrs / Fetal doppler U/S / Umbilical artery Doppler U/S /kleihauer test

c-placenta abruption.

31- CC19-Legal Framework for Practice

(Common Competences)
A 25 year old man is brought into hospital after a seizure. Seizure activity was witnessed by the paramedics. The patient denies
any alcohol or illicit drug consumption. He is otherwise fit and well, with no medical history and no regular medications. A CT
scan is performed which is normal. The patient is completely recovered and you have arranged neurology follow-up in the
first-fit clinic.
a-When to inform DVLA? (1 mark)
b-When to drive in TIA in group 1cars? (1 mark)
c-When to drive in first Seizure in group 2cars? (1 mark)
a- If the patient still driving despite advice and every reasonable effort to persuade him to stop driving.

b- After 1month free.

c-5 years seizure free (with treatment if necessary)

32- PP5-Practical Procedures Lumbar puncture

(Procedural Competences)
A 60 year-old-male patient presented with 2 hours history of severe sudden onset occipital headache
associated with photophobia and vomiting,subarachnoidhemorrhagesuspected,CT scan done and normal.

a-After what time will you order for L.P? (1 mark)

b-WHAT site for L.P? What is the position? (1 mark)
c-What test will you use for L.P? (1 mark)
a-12 hours.

b-
-L3-L4 L4-L5 L5-S1
-Position
- (seated flexed )
- (Flexed RT or LT Lateral decubitus) fetal position.

c-Xanthochromia (spectrophotometry)

33- C3AP6-Emergency Airway Care

(Acute Presentations)
A 40 year-old-female Obese patient in attempts to intubate her,shedesaturated to O2 78%
a-Give (2) causes of desaturation in this obese patient? (1 mark)
b-Give (2) other causes of desaturation? (1 mark)
c-What is your management of desaturation in this obese patient? (1 mark)

a-Increased metabolic rate / increased O2 demand / increased Co2 production / decreased functional residual capacity /
decreased O2 reserve

b-Primary lung pathology / Insufficient respiratory drive (CO or Meth poisoning) / old age / pregnancy / sepsis /
hyperthyroidism / anemia.

c-Call for help /Anesthetist / raise the head 20-30 degree / clear airway / re-oxygenate 3-5 minutes 100% BVM/ passive apneic
oxygenation/ consider NIV PEEP 10cm H2O.
34- CAP7-ChestPain
(Clinical Presentations)
A 40 year-old-female presented with severe retching and vomiting followed by excruciating retrosternal chest and upper
abdominal pain,X-ray chest done and shown below:
a-What are the abnormalities in X-ray? (1 mark)
b-What is the differential diagnosis? (1 mark)
c-What is your management? (1 mark)

a- Pneumomediastinum, Left pleural effusion and Left pneumothorax. Subcutaenous emphysema.

b- Borhaeve syndrome, Mallory weiss tear, Pancreatitis, MI, Pericarditis Lung abscess, Spontaneous pneumothorax
c-

35-PAPS-Breathing difficulties-recognize the

critically ill and those who will need
Intubation and ventilation
(Acute Presentations)
A 3-year-old-girl is brought to ED because her mother is concerned that she is coughing. She was eating a snack when she
suddenly started coughing and gasping and her mother suspects she may have inhaled a peanut. She is alert and shows no signs
of upper airway obstruction. On examination she has unilateral wheeze and decreased breath sounds on the left side. A chest
X-ray had been performed which is shown below:
a-Give two features that would be suggestive of partial upper airway obstruction. (1 mark)
b-Describe the abnormalities seen on the chest x-ray and state where the foreign body is most likely located. (1mark)
c- Give two possible complications if left untreated? What is your management?. (1 mark)

a-Any two of
Tachypnoea, Change in sound of voice or cry, Barking cough, Hoarseness
Stridor, Poor air entry, Nasal flaring, Dysphagia, Drooling)

b-
-Asymmetric lung density with increased lung volume on the left and relative lucency on the left, mediastinal shift to the right
side.
-Left sided air trapping (i.e. obstructive emphysema) with right mediastinal shift (due to valve mechanism through peanut).
-There is most likely partial airway obstruction of the left main bronchus. There is no foreign body seen

c-
-Any two of
-Complete airway obstruction, Pneumonia, Atelectasis, Abscess, Bronchiectasis)
-Treatment is by removal of the foreign body under general anesthetic with a bronchoscope with ENT. Initial treatment of a
choking child is as per APLS protocols.

36-PP13-DC Cardio-version
(Procedural Competences)
A 57 year-old-man has two hour history of palpitations. On examination he is sweaty and has a BP of 100/50 but denies chest
pain or breathlessness.
a-Name two diagnoses which would explain this ECG picture? (1 marks)
b-He then drops his BP to 80/60. What treatment is required? (1 mark)
c-Failed 3 shocks what next step?(1 mark)
a-Monomorphic VT&SVT with aberrant conduction.(BBB)

b-Synchronized DC shock 120-150J biphasic.

c-Amiodarone 300 mg over 10-20 mins.

Notes:
-Synchronized 70-120 joles biphasic (narrow complex tachycardia)
-Synchronized 120-150 joles biphasic (wide complex tachycardia)

-You have to mention biphasic and you have to mention Synchronized

-Regarding (Amiodaron) you have only (2) doses

-300 mg over (10-20) mins in unstable VT
-300 mg over (20-60) mins in stable VT

37-C3AP8-Testicular pain
(Acute presentation)
A 14 year-old-male presents to AED with an acutely painful, red, swollen scrotum. After examining the patient, your clinical
suspicion for testicular torsion is equivocal.
a-Give (2) signs to confirm testicular torsion? (1 marks)
b-What is your investigation? What is the definitive treatment? (1 marks)
c-Most common diagnosis if there is no torsion? (1 marks)
1-Loss of cremasteric reflex (an immediate contraction of the cremaster muscle that pulls up the testis ipsilaterally).
2-Tender testis retracted upwards (lifting the testis increases pain).

b-Doppler ultrasound /Surgical Scrotal Exploration for reversal of torsion or (orchidectomy and orchidopexy) for the
remaining testes.

c-
1-Torsion of testicular or epididymal appendage
2-Epididymo-Orchitis.
3-Trauma / Incarcerated hernia / Mumps.

38- I .C.M9-Prescribes safe use of vasoactive drugs

and Electrolytes
(ICM within ACCS)
40 year-old-male presented with sweating, SOB, BP 80/50, Atropine given 3mg, ECG done and shown below:
a-What is ECG diagnosis? (1 marks)
b-Give (2) treatment for hypotension? (1 marks)
c-What is the vasopressor drug will you give? (1 marks)

a-Complete heart block

b-
-Raise the leg and I.V fluid(fluid challenge 250-500 ml 0.9 Na Cl bolus)
-Transcutaneous pacing.

c-
-Adrenaline 2-10 mcg/min
-Isoprenaline 5mcg /min

39-PAP-Rashes in Children- Swollen Face

(Acute presentation)
A 10-year-old-man, known to have an allergy to nuts, is brought into ED by a concerned friend. They had been eating at a
nearby Thai restaurant when he developed a widespread itchy rash and difficulty breathing. His blood pressure at triage is
75/50 mmHg.
a-What systemic manifestation? (1 marks)
b-How much 0.3 ml of adrenaline equal in mg? (1 marks)
c-Give additional (2) treatments? (1 marks)
a-
-Airway (pharyngeal or laryngeal edema with hoarseness and stridor),
-Breathing (bronchospasm with tachypnea, dyspnea, hypoxia and wheeze)
-Circulation (peripheral vasodilation, hypotension with tachycardia, shock and collapse).
-Skin and mucosal changes(flushing, pruritus, urticarial, angioedema)

b-0.3 mg (1/1000 Adrenaline)

c-IM/IV Chlorphenamine 5-10mg and IM/IV Hydrocortisone 100 mg

40- CC16-Health promotion and public health

(Common Competences)
Regarding to Alcohol consumption
a-Define harmful alcohol?
b-What is safe limit for women?
c-what (2) advice rather than stop?
a-Pattern of alcohol consumption that cause harmful effects on (physical, social and psychological health) .

b-Maximum 14U/weak.

c-
1-Spread the recommended amount of alcohol consumed over 3 days or more, as much as 14 units a week.
2-Limiting the amount of alcohol consumed on any one occasion.
3-If she wants to cut down, try to have several alcohol-drink-free days each week.

41- PP1-Arterial cannulation

(Procedural Competences)
You are working on an intensive care unit when a patient isadmitted from an emergency department following a large
mixedoverdose. Your consultant asks you to insert an arterial radial line.

a-Give (2)indications,(2) contraindications? (1 marks)

b-Give (2) complications? (1 marks)
c- After inserting an arterial line, you note the trace isinadequate. Give four reasons for inadequate arterialtracing?(1 marks)

a-Indications
1-Continuous accurate BP monitoring and or Inability to use non-invasive BP monitoring ( severe burns, morbid obesity)
2-Frequent blood sampling and or Frequent ABG sampling

Contraindications:
Absolute:
Absent pulse / Full thickness burns at cannulation site / Inadequate circulation / Raynaud’s syndrome / Buerger disease)

Relative
Anticoagulation / Atherosclerosis / Coagulopathy /Inadequate collateral flow / Infection at cannulation site / Partial thickness
burn at cannulation site / Previous surgery in the area / Synthetic vascular graft)

b-Complications:
-Pain / Hematoma/bleeding / Infection / Permanent ischemic damage
-Pseudoaneurysm formation / Thrombosis / Arteriovenous fistula
-Air embolism / Compartment syndrome / Nerve injury (median nerve)
c- Reasons for dampened/no waveform:
1-Bubbles in catheter or system / Improper zero or transducer calibration
2-Cannula(displacement into tissues/clotting/kinking/tip against vessel wall)
3-Incorrect stopcock position / Loose connection / Compliant tubing
4-Loss of counter-pressure from bag / Loss of IV fluid
5-Tubing kink / Monitor off/incorrect settings.

42- PAP6- Concerning Presentations

(AcutePresentations)
A 4 year-old-girl presented with blood in underwear,she has poor eye contact brought by mother.
a-What is your immediate action? (1 marks)
b-What is your possible diagnosis? (1 marks)
c-Give (2) features supporting your diagnosis? (1 marks)

-Analgesia titrate to pain, treat any injury, Send patient to place of safety, call paediatricion, Social services, Child protection
order, Child Safegaurding (ask if there is any children at home), Inform police, involve ED senior, consider skeletal survey.

b-Female genital mutilation (Child Abuse).

c-Genital injuries, blood on underwear, poor eye contact, Delayed presentation, no history of blood disorders,piles, fissures, or
injury and recurrent attendance in medical record

43-CAP8-Confusion
(Clinical Presentations)
A 69 year-old-male patient with known chronic kidney disease is sent to AED by his GP with ECG which
is shown below:
a-What are the findings in ECG? (1 marks)
b-Give one investigation? (1 marks)
c-Give (2) treatment with mechanism of actions? (1 marks)

a- (Tall Tented Twave) – Hyperkalemia.

b-K level (U&Es)

c- Management (in patients with potassium > 6.5 mmol/L or ECG changes):

c-
1-Cardiac protection: 10 ml 10% I.V Ca gluconate
2-Trans-cellular shift: (ECC-ICC)
-Insulin and glucose:10U (short acting soluble insulin) with 50 ml 50% glucose over 15 minutes
-Salbutamol: 5mg neublizer
3-Potassium excretion: Ca resonium (15 g t.d.s PO or 30 g PR)

44- PP16-Reduction of dislocation

(Procedural Competences)
30 year-old-male-patient presented with deformity in his arm after fell down,X-ray done and shown below:
a-What is your diagnosis? (1 marks)
b-How will you assecc neurological damage? (1 marks)
c-How will you reduce it? (1 marks)
a-Posterior elbow dislocation (humerus displaced anteriorly&radius and ulna displaced posteriorly)

b-Median nerve injury (assess sensation over palmar surface and fingertips of lateral 3.5 digits)
Ulnar nerve injury (assess sensation over the palmar &dorsal surface of medial 1.5 digits)
Radial nerve injury (assess sensation over dorsal surface of lateral 3.5 digits and associated dorsum of the hand (superficial
branch)

c- Reduction Choose between the following techniques for reduction of

posterior dislocations:(consent for procedural sedation and reduction)

• Flex the elbow to 60 * with countertraction on the upper arm. Pull onthe fully pronated forearm at this angle. Slight flexion at
the elbow maybe necessary.

or

• Alternatively, lever the olecranon forward with both thumbs whileholding the elbow flexed and while an assistant provides
traction on theforearm.

Reduction is confirmed by a ‘clunk’ and restoration of the normaltriangular relationship of the elbow landmarks. Once
reduced, recheckpulses and sensation, immobilize in an above elbow POP backslab at 90 *and X-ray again (looking for
associated fractures). Consider admission foranalgesia and observation for possible significant limb swelling. If unable to
reduce, refer for reduction under GA.
Fig 1:
-With the elbow flexed to 60 degrees provide traction to the pronated forearm and counter -traction to
the distal humerus

Fig 2:
-Lever the olecranon forwards whilst traction is being provided to the forearm

Fig 3:
-Position the patient prone with the abducted humerus resting upon the bed and pronated forearm
hanging towards the floor. Provide traction to the forearm and downward pressure to the olecranon
45- CAP10-Cyanosis
(Clinical Presentations)
A 33 year-old-male with Amyl Nitrite presented with SOB, cyanosis, nurse noticed dark strange color on blood sample.
a-What is your diagnosis? (1 marks)
b-How to confirm your diagnosis? (1 marks)
b-wWhat is the specific treatment? (1 marks)

a-Methaemoglobinemiae.

b-Direct measurement of methaemoglobin on A.B.G or coximetry.

b-1% Methylene blue 1-2 mg/kg.

46- CMP2-Anaesthetic Competencies:

Management of Cardiorespiratory arrest
(Clinical Presentations)
You are infiltrating local anesthetic around a large wound on a patient’s thigh. The patient begins to complain of a metallic
taste in the mouth associated with numbness to the tongue.

a- What is the likely diagnosis and what is the most important immediate management step? (1 mark)

b-The patient becomes pale and poorly responsive. A member of nursing staff informs you the patient’s blood pressure is
unrecordable, however they can feel a weak central pulse. What drug should be considered in this patient? (1 mark)

c-How to decrease Risk? (1 marks)

a-Local anesthetic toxicity. The most important step in the management of mild toxicity is to stop any administration of local
anesthetic.

b-I.V lipid emulsion (intralipid) in local anesthetic toxicity related cardiac

arrest and considerationof use in circulatory collapse.

C-
● Clear and accurate dose calculations.
● Dose reduction in frail patients and those at the extremes of ages.
● Local anesthetic injected slowly and with regular aspiration (to avoid accidental intravenous injection).
● Use of adrenaline as a vasoconstrictor to reduce the systemic absorption of local anesthetic.
● Regional nerve blocks to anaesthetize large areas.
● Use of ultrasound to facilitate nerve blocks.
● Close monitoring

48- CC17- Principles of Medical Ethics and Confidentiality

(Common Competences)
Young male patient presented with knife wound to buttocks,he asked you not tell police,
Ambulance crew said (he came from area of frequent knife crimes).

a-What is your immediate action? (1 marks)

b-What other conditions in which will you disclose? (1 marks)
a-
- Make patient safety and treatment your priority, analgesic titrate to pain, update tetanus, Involve ED senior, involve surgery,
make report, Try your best to have consent from patient to inform police and if he refused discuss with Trust legal department
and your medical defense union then inform police,
- Document it all.

B- Before breaching confidentiality, the patient's consent should first be sought. If consent is refused you
should discuss the matter further with your Trust legal department and you r medical defense union.

Breaching confidentiality
Examples of instances where confidentiality may be breached include disclosures:

1-Required by law , e.g. notification of a communicable disease

2-Relating to the courts or litigation, e.g. specific requests from a judge for relevant information
3-Relating to statutory regulatory bodies, e.g. DVLA, where a patient poses a threat to the public
4-In the public interest, e.g. patient has disclosed involvement in serious criminal activity such as
terrorism
5-To protect the patient or others, e.g. patient expresses homicidal intent towards a specific person

49- CAP11-Diarrhoea(Clinical Presentations)

A 42-year-old man presents to AED complaining of a 2 dayhistory of diarrhea. He has been opening his bowels and passing
watery stool about 6 times a day, and today he has noticed freshblood in his stool. He has not been vomiting but iscomplaining
ofcrampy lower abdominal pain.

a-Give (2) infective causes for bloody diarrhoea. (1 mark)

b-Give (2)non-infective causes for bloody diarrhoea. (1mark)
c-Give (2) investigations you would perform in this patientin AED, with rationale. (mark)

a- (CCESS)
-Campylobacter spp / C. difficile colitis
-E. coli spp / Entamoeba histolytica)
-Shigella / Salmonella

b-
1-Ulcerative colitis.
2-Crohn’s disease
3-Colorectal malignancy
4-Ischaemic colitis
c-
FBC – (Anaemia, Leucocytosis)
U&Es – (AKI, Hypokalaemia, Hyponatraemia/Hypernatraemia)
Stool sample –( Culture,microscopy and sensitivity for organisms )
AXR – (if clinical features suspicious for toxic megacolon

50- CAP37-Weakness and paralysis

(Clinical Presentations)
An 85 year-old-woman is brought to ED complaining of neckpain following a fall. She has a history of chronic neck pain. She
iscomplaining of muscle weakness bilaterally, particularly in herarms and hands and a burning sensation in her upper limbs.
Onexamination you note symmetrical motor loss, greater in the distalupper limb than the proximal upper limb, and greater in
the upperlimb than the lower limb

a-What is the most likely diagnosis? (1 mark)

b-What is the most likely mechanism of injury? (1 mark)
c-What investigation should be performed in this patient? (1mark)

a-Central cord syndrome

b-Hyperextension injury of cervical spine in patient with pre-existingcervical stenosis (e.g. frontal fall with facial impact)

c-MRI whole cervical spine.

51-PP26-Deliver afluid challenge safely to an
acutely unwell patient
(procedural competences)
An 85 year-old-male patient is brought into AED by ambulance looking unwell. His observations are: temp 39.5°C, BP 90/50,
HR 115 bpm, RR 20, sats 94% on air. known case of heart failure. His bloods are shown below:
Hb 12 g/dL (M:13 – 18, F:11.5 – 16)
Plts 350 x 10^9/L (150 – 400)
WCC 18 x 10^9/L (4 – 11),
a-How will you give fluid ? (1 mark)
b-What are non invasive methods to reasses the response? (1 mark)
c-Bedside method to assess the fluid response? (1 mark)

a-Fluid challenge (250-500 ml0.9 NaCL) Bolus over 10-15 minutes.

b-
-Target MAP: 65MMHG
-Target U/O : 0.5Ml/Kg/HR
-Resolution of end-organ mal-perfusion(e.g.HR,GCS)

c-
-Echo for (I.VC) & Lung.
-Passive leg raising test.
52-CAP15-Fits/Seizures
(Clinical presentation)
Status epilepticus Patient received two doses of benzodiazepines still seizing,taking,allergic to phenytoin

a-What drug will you give? (1 mark)

b-Still seizing what is your immediate action? (1 mark)
C-Give (2)contraindications of using Suxamethonium? (1 mark)

a-phenobarbitone 20mg/kg I.V inf over 5 minutes.

b-Call for help&Anesthetist / Secure airway (RSI thiopentone 4mg/kg with suxamethonium).

c-Any (2) of
-Hyperkalemia /*rhabdomyolysis/*Severe Burn/*Spinal Cord Injury/*Malignant Hyperthermia.*infection/*malignant tumor or
cancer/*systemic mastocytosis/*eye surgery/*myxedema/*low amount of calcium in the blood/*high amount of potassium in the
blood*Anemia/*Myasthenia Gravis/*angle closure glaucoma/*Slow Heartbeat/*Disease of the Heart and Blood Vessels/*severe liver
disease/*severe renal impairment*major traumatic injury/*Poisoning by the Heart Medication Digitalis

53-PAP4-Paediatric Blood Disorder

(Acute Presentations)
An 18-year-old Jamaican man, known to have homozygoussickle cell disease (HbSS) presents to AED complaining of
SOB,Chest pain
a-What is the differential diagnosis? (1.5 mark)
b-What is your management? (1.5 mark)
a-Acute chest syndrome/pulmonary infarction/Acute chest infection / pulmonary Hypertension

b-
ABCDE approach with high flow O2,I.V access, Analgesia titrate to pain, IV fluids, Avoid triggering factors, Blood transfusions,
Antibiotics, involve hematologist and ED senior

Notes:
(blood transfusion)
-Emergency top-up in aplastic crisis or acute splenic sequestration
-Emergency exchange transfusion in acute stroke, acute chest syndrome, severe sepsis, acute hepatic sequestration or progressive
intrahepatic cholestasis

54-CAP1-Abdominal pain Including Loin

Pain (Clinical Presentation)
A 45 year-old-male patient is brought to AED complaining of severe right sided colicky flank pain which started a couple of
hours ago. He cannot keep still with the pain and describes it as the worst pain he has ever had. He is also complaining of
nausea and has vomited x 2 in the ambulance. He is apyrexial, his HR 105bpm, BP 130/85, RR 16. His bloods are normal.
a-What is the most likely diagnosis? What is the investigation of choice? (1 mark)
b-What analgesic would be most appropriate for your diagnosis? (1 mark)
C-Give two complications of renal calculi? (1 mark)

a- RenalColic / Non contrast helical CT KUB

b-Rectal diclofenac 100mg.

C-
-Impaired renal function or renal failure
-Secondary infection (cystitis, pyelonephritis,Abscess formation)
-Urinary fistula formation
-Hydronephrosis / Ureteric scarring and stricture formation
-Ureteral perforation / Urosepsis

55-C3AP4-Abnormal blood glucose

(Acute presentation)
A 45 year-old-man is brought into AED feeling dizzy,nauseous and lethargic. The paramedics have noted an alert bracelet.
His observations are:
Temp 37.1°C, BP (90/55), HR 105, RR 16, Sat 98% on air, Na 132mmol/L,blood glucose 3.3mmol/L.K5.4mmol/L
a-What is your diagnosis? (1 mark)
b-What is your treatment? (1 mark)
c-What blood tests will you do? (1 mark)

a-Adrenal Crisis or Addisonian crisis or Adrenal insuffieciency

b-Immediate hydrocortisone I.M / I.V fluid resuscitation / Monitor and treat hypoglycemia and other
electrolyte imbalance / treat underlying cause.

c-
-FBC, U&Es, LFTs, Glucose, lipase, Blood gases
-Cortisol & ACTH (expected low cortisol and raised ACTH)
56- CAP29-Red Eye
(Clinical Presentations)
An 80-year-old presents to AED at night with a unilateral red painful eye and blurred vision. He tells you he was sat reading in
bed by lamp light when this first started. The pain in his eye is severe and he is starting to feel nauseous. A picture of his eye is
shown below:

a-Describe the two most obvious abnormalities from this image? (1 mark)
b-What is yourDiagnosis? (1 mark)
c-Give (2) treatment? (1 mark)

a-Acute angle closure glaucoma

b-Ciliary injection and cloudy cornea

b-2% or 4% pilocarpine eye drops given hourly until definitive treatment

(miosis opens the blocked drainage angle),
Acetazolamide 500 mg IV stat then 250 mg/8h PO or IV (decreasesproduction of aqueous fluid)
Beta-blocker e.g. timolol eye drops (decreases production of aqueousfluid)
57-PP18-Wound Management
(Procedural Competencies)
80 year-old-man on steroid and history of DM presented with pretibial laceration with venous insufficiency as shown below
a-How will you manage the wound? (1 mark)
b-Give (2) factors affecting wound healing?(1 mark)

a-
- Clean, irrigation with normal saline/Remove foreign bodies/Remove hematoma/Replace flap without tension/Apply
Steristrips and Mepitel(Don't Suture) /Rest and elevation/Give patient verbal and written advice. (Keep wound clean, dry and
covered. Patient can remove Steristrips /dressing after 7 – 10 days. Seek medical attention if signs of bleeding, dehiscence or
infection).

b-
-Wound factors
-Infection / Tissue viability / Foreign body / Venous sufficiency
-Systemic factors
-Age / Diabetes / Immunosuppressant / Steroids and other medications / Smoking / Poor nutrition / Alcoholism

58-CAP33-Painful Limb Traumatic

(Clinical Presentation)
A 25 year-old-male Rider falling from a horse but the foot remaining trapped in the stirrup,she has severe pain in
hismidfoot,andimage for his foot is shown below:
a-What is your diagnosis? (1 mark)
b-What is the investigation? (1 mark)
c-What is your management? (1 mark)
 a-Any of:
-Lisfranc fracture
-Lisfranc dislocation
-Lisfranc fracture dislocation
-Tarsometatarsal injury
-Midfoot injury

b-X-ray foot.

c-
-Analgesia titrate to pain, neurovascular assessment of right ankle and foot, backslab, elevation, urgent orthopedic referral for
further assessment and management.

59-CC7-Prioritisation of patient safety

(Common Competences)
A 35 year-old-male known diabetic in ED treatment,you ordered 10 IU insulin,the nurse told you she injected 100 IU insulin.
a-What is your immediate action? (1 mark)
b-What are your investigations?What are the causes? (1 mark)
c-Who will you inform? (1 mark)

a-
-ABCDE approach with high flow O2.
-I. V access, blood tests, ABG, repeated doses of 50 ml of D50%, continuous monitoring of Blood sugar.
-Continuous cardiac monitoring, Inform, Reassure and Consent the patient for admission for observation.

b-ABG/*Blood sugar/*U&Es/*incident form/*Document/*near event.

-Causes:
1-Use of abbreviations or incorrect device.
2-Overcrowding and fatigue.

c-Senior ED, Senior administration officer on duty, Head nurse, the patient and his family, Endocrinologist.
60-ICM11-Accidental displacement of tracheal tube
(ICMwithinACCS)
A 33 year-old-man is intubated for airway protection following a large mixed overdose. He remains ventilated in the ED whilst
awaiting an ICU bed. 30 minutes after intubation, the nursenotes the patient has become hypoxic with Sat of 78%.
Intubationwas uneventful, there was no suspicion of aspiration and he had Sat of 100% both before and after intubation.

a-What is the immediate first step in managing this patient? (1 mark)

b-How will you confirm tube displacement? (1 mark)

c-What is your management if tube displacement confirmed? (1 mark)

a-
-Call for help, disconnect ventilator (allows release of trapped gas) and give high flow 100% oxygen through bag valve mask,
connect capnography, attach Water's circuit.

b-Any no means TT displacement:

-look (is Etco2 trace normal square wave? is chest rising? check TT marking at teeth, is TT blocked (suction) is patient biting
TT (atracurium50mg I.V), Has cuff herniated over end of TT (deflate and inflate)

C-Remove TT and call for senior anesthetist, ventilate100% BVM / Guedel airway / 2hands on mask / LMA/ Oral tracheal
intubation if you have skill.