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 3 April 2013 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)

An adult female patient, with no significant medical or surgical history, presents to a district hospital in rural South Africa. She displays a small punctate bite mark with surrounding redness/swelling on her lower leg. She says she was bitten by a spider 2 days before. Her blood pressure is 100/67; her pulse 96bpm; her respiratory rate is 26bpm; she is sweaty and clammy; her temperature is 38.1C; GCS is 15/15. a) Describe your initial management of this patient, including wound management and antimicrobials. (5) b) Describe types of spiders in South Africa that are potentially harmful to humans and the mechanism of action of their venom. (10) c) What antidotes are available in South Africa? (2) d) Discuss the acute management of a patient with tetanus. (4) e) What else should be considered in the differential diagnosis in this patient? (4) [25]

a)

b)

c)

Write short notes on the clinical presentation and management of patients with i) Acute hypermagnesaemia. (3) ii) Acute hypercalcaemia. (4) A 32-year-old male presents with a facial injury. Write short notes on your approach to diagnosing and managing the patient if he is suspected to have i) Temporomandibular joint dislocation. (3) ii) Le Fort II fracture. (3) You have been asked to lead Clinical Governance for your Emergency Department. i) Define Clinical Governance. (1) ii) Define an Adverse Incident. (2) iii) Write short notes on how a Morbidity and Mortality meeting should be run to be highly effective. (5) iv) Explain the difference between Type I and Type II thinking. (4) [25]

a)

With regard to analgesia in emergency care, write short notes on the mechanism of action, side effects, precautions and contra-indications of the following medication i) COX-2 inhibitor non-steroidal anti-inflammatory drug. (6) ii) Entonox. (6)

PTO Page 2 Question 3b)

-2b) A 74-year-old woman with a history of congestive heart failure presents with diffuse abdominal pain that started 2 hours ago. She describes the pain as severe and she is in significant distress. She has a temperature of 39.5C, pulse 110bpm, Blood Pressure 95/60 mmHg. Her cardiovascular exam is unremarkable except for an irregularly irregular heartbeat. She has a distended abdomen with hypoactive bowel sounds and diffuse tenderness to palpation on abdominal examination. There is no focal tenderness, rebound or guarding. On rectal examination there is profuse soft, dark brown stool that is guaiac positive. Notable blood results include a White Blood Cell Count of 16 x 109/l and lactic acid level of 4mmol/l. i) Which important abdominal emergency should be considered? Explain your answer. (2) ii) How would you diagnose this condition? (1) iii) How would you manage this patient? (4) A 60-year-old male presents with a 2 day history of an acutely swollen, hot big toe. Discuss your approach to the patient, focusing on your differential diagnosis, necessary investigations, and management. (6) [25]

c)

A 65-year-old homeless female patient is brought into the Emergency Department in which you are working, during midwinter, with a history of accidental hypothermia. a) Tabulate the degrees of severity of accidental hypothermia by clinical symptoms, range of core temperature and treatment of the hypothermia. (12) b) You elect to rewarm the patient. Describe the efficacy of the various rewarming techniques making specific reference to rewarming rates. (6) c) Define Rescue Collapse and Afterdrop as they relate to Accidental Hypothermia. (4) d) Describe the effects of Pethidine on shivering. (3) [25]

A 36-year-old female patient presents to the Emergency Department in which you are working in septic shock following an incomplete abortion. a) Differentiate between the following terms i) Infection. ii) Systemic Inflammatory Response Syndrome (SIRS). iii) Sepsis. iv) Severe Sepsis. v) Septic Shock. (10) b) You elect to start Adrenaline (Epinephrine) for the patient mentioned in (a) above. Define the following terms i) Inotrope. ii) Chronotrope. iii) Dromotrope. iv) Lusitrope. (8) c) Describe the acute management of this patient with reference to Early Goal Directed Therapy in Severe Sepsis and Septic Shock. (7) [25]

PTO Page 3 Question 6

-36 a) A 2-year-old patient known with Tetralogy of Fallot is brought to the Emergency Centre by his mother as he has become increasingly distressed and more cyanosed over the last 4 hours. Write short notes on your immediate management of this patient. (6) An 8-month-old boy presents with a congested nose of 5 days duration and a worsening cough. On examination you notice a temperature of 38.1 C, a runny nose and bilateral wheezing on chest auscultation. His chest x-ray shows hyperinflation with no areas of consolidation. i) List 4 microbiological agents that could be responsible for this illness. (2) ii) Discuss findings on history or examination that would result in you admitting this patient. (5) iii) Write short notes on your management of this patient. (6) A 52-year-old patient with a pacemaker, presents to you complaining that he is experiencing palpitations. Write short notes on possible causes for this patients complaint and how you would manage this patient. (6) [25]

b)

c)

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 4 April 2013 Paper 2 (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)

The management team of your mid-level metropolitan hospital is concerned about your emergency departments preparedness for potentially dangerous infectious diseases. Write short notes on a) The immediate management and investigation of a patient with Pyrexia of Unknown Origin (PUO) who has a recent travel history to central Africa. (5) b) How the emergency department is prepared to deal with a patient with possible anthrax exposure. (5) c) How to manage a patient with features of H1N1 influenza. (5) d) How to manage a patient with possible XDR TB. (5) e) Management protocols to protect your emergency department personnel from possible infectious disease exposure. (5) [25]

You are called to manage an ultra-marathon runner who has collapsed immediately after participating in an endurance event. a) Describe 3 possible underlying metabolic abnormalities that could be responsible. (3) b) Discuss fluid management in such a patient. (4) c) Describe 3 possible performance enhancing agents that could be responsible, and how they would affect your management. (6) d) Describe your management of this patient should they be hyperthermic, and the possible causes for the raised body temperature. (6) e) Discuss possible pre-existing cardiovascular abnormalities and how screening may have diagnosed these before the event. (6) [25]

a)

b)

A 7-year-old child presents after a fall on his outstretched hand. He is complaining of pain in his right elbow. His exam is notable for tenderness over the entire right elbow with limited pronation, supination and flexion. His wrist exam is normal. i) Describe the radiocapitellar and anterior humeral lines, and explain their utility in the interpretation of a radiograph of the elbow in this child. (3) ii) What is the sail sign, and what is its implication? (2) iii) If the elbow x-ray is normal, how would you manage this patient? (3) Write short notes on a clinical decision tool used in the diagnosis of acute appendicitis. (5)

PTO Page 2 Question 3c)

-2c) Write short notes on the following carpal injuries i) Lunate dislocation and peri-lunate dislocation. (6) ii) Dorsal Intercalated segment instability and Ventral Intercalated segment instability. (6) [25]

a)

b)

A 28-year-old male patient presents to the Emergency Department in which you are working complaining of palpitations and light-headedness. You find he has a heart rate of 208 beats per minute. i) Describe the ECG findings pertinent to Wolff-Parkinson-White syndrome. (4) ii) Write short notes on the pharmacological options and preferred pharmacological management of this patient if they were thought to have Wolff-Parkinson-White syndrome. (8) iii) Write short notes on Propafenone for the management of supra-ventricular tachydysrhythmias. Include in your answer Propafenones mechanism of action. (6) A 24-year-old male intern presents to the Emergency Department in which you are working following a needle stick injury. Describe your approach to the risk stratification of this injury. (7) [25]

A 52-year-old patient presents to your emergency department with a corneal foreign body. a) Write short notes on your management of this patient. (6) b) Write short notes on types of devices that are available for monitoring End-tidal Carbon Dioxide levels. In your answer provide an explanation of how these devices work; and pros and cons associated with the use of these devices. (12) c) A 42-year-old patient who is using Dapsone presents to the Emergency Department complaining of a headache and breathlessness. You notice she is tachypnoeic, tachycardic and cyanosed. You apply oxygen, but notice that she remains cyanosed. When you take blood for investigation you notice it to be chocolate brown. i) Describe the pathophysiology of this condition. (3) ii) How would you manage this patient? (4) [25]

a)

b) c)

A 52-year-old patient presents to your Emergency Department complaining of a sudden onset of a severe headache. A CT scan confirms a Subarachnoid Haemorrhage (SAH). i) Describe the Hunt and Hess clinical grading system for cerebral aneurysms and Subarachnoid Haemorrhage. In your answer explain its clinical use. (5) ii) Discuss the Emergency Department management of this patient while awaiting a neurosurgical consult. (10) iii) Write short notes on the sensitivities of Lumbar Puncture and CT scans when used to diagnose this condition. (2) What findings on fundoscopy are associated with raised intracranial pressure? (3) Write short notes on strategies to implement in your Emergency Department to prevent secondary spinal cord damage in patients with spinal injuries. (5) [25]