OSCE

Question

Your patient has a pneumothorax and requires a pigtail chest X-ray. Outline your approach.

Answer

My approach is to confirm need, prepare appropriately, then perform the procedure, then ensure good post-procedure care. So I'll confirm the indication, explore any alternatives such as monitoring a small non-traumatic haem ophorex. I'll confirm no contraindications and explore any alternatives. For consent, I'm going to explain the alternatives, complications and reasons to the patient. For preparation, I'll do this in the resource room, full non-in vasive monitoring and supplemental oxygen on the patient. I'll have an experienced nurse assistant. I'll prepare my equipment, so I'm going to do this sterile procedure with sterile gloves, gowns, drapes, appropriate hand hygiene. I'll also get my local anesthetic, my chest strain kit with an appropriate size pigtail, so 14 if small. I find ball with very small, 14 if large and make sure I've got my underwater sealed chest strain and I'll make sure that the connections are compatible. Prior to procedure, I'll do a timeout, ensure correct placement and place. For the procedure itself, sit the patient up sitting 45 degrees, locate and mark the appropriate space, triangle safety, so mid axilla line between pec major and lat delta, so 15 to costal space. I'll confirm by checking this to the mid arm point. I'll have the patient put their arm behind their head and clean and drape . Once cleaned and draped, then local anesthetic. I'm going to be, I'm going to draw back, insert, draw back, infiltrate and continue until I'm in the pleural space. Then I'm going to remove this needle, wait a few, wait five minutes and now with the introducer needle, with saline, go into the same space, aspirating continuously. Once aspirating, air, stop, take note of the depth, verbal ize depth to assistant, feed the guide wire, noting depth, remove guide needle, small cut at the side of guide wire, insert dilator, remove dilator, insert pigtail, go to depth that final fenestration is within the pleural space, noting the depth from previous, remove the guide wire, connect under water seal drain, post procedure care, so ensure the drain is worked, we've ensured that there's bubbling and swinging, secure the drain with tape plus or minus suture, confirm the placement with a chest x-ray, ongoing monitoring, I'll be asking the, to monitor for bubbling, swinging and any volume drained, as well as regular obs, hourly and then we 'll document. In terms of complications, if there's no bubbling, I'm concerned for either a blocked or disconnected tube or it could mean re-expansion of the lung , so perform a chest x-ray to confirm and re-examine the patient and the tube. If there's no swinging, again this could mean a blocked or dislodged tube or it might mean the lung has expanded, so re-chest x-ray, re-examine patient and the tube. That's it.

Question

Teach the intern a generic approach to performing procedures.

Answer

It's helpful to have a structured approach to procedures. This is my approach. You should read widely and find your own approach . I recommend a good start is Robert and Hedges clinical procedures in emergency medicine. So first you want to confirm that it's appropriate to perform the procedure. I'll go into this. Second it's prepare to perform the procedure. Third perform the procedure and four post procedural care. So for confirming it's appropriate to perform the procedure you need to confirm the indications. Confirm that there's no indications and consent the patient explaining alternatives and complications. For preparing to perform the procedure I do the four S's of preparedness. Space, staff, stuff and systems. So space make sure you're doing in the right place. Staff make sure you know who you need so this might include an assistant or a procedural sedation, someone to perform procedural sedation. For stuff this is your equipment. This includes your own PPE, sterile gear, gloves and the procedural equipment. You should lay out your equipment in the order that you will use it. Then for systems you should make sure that you've done a timeout prior especially if the patient's going to be sed ated or this is a high-risk procedure. Then performing the procedure itself . So position the patient appropriately and perform the procedure. Then post procedural care confirm that your procedure has been successful. Then monitor for complications and manage those complications.

Question

Outline your approach to front of neck axis.

Answer

I'll stand to the patient's left, scalpel, budgie, tube, perform a laryngeal handshake to identify the cricothyroid membrane. If I can palpate the cricothyroid membrane, I'll do a trans verse horizontal stab incision through the cricothyroid membrane. I'll turn the blade 90 degrees, aiming the sharp edge towards the feet. I'll slide the tip of the budgie into the trachea, stopping at 15, early hold up, suggesting false passive, and I'll rail raid a lubricated cuff tube into the trachea, inflate cuff, ventilate, and confirm with capnography. If I cannot palpate the cricothyroid membrane, I'll make a large vertical midline incision, blunt the section with my fingers to separate the tissues, identify and stabilize the larynx, and proceed with a horizontal cut as above.

Question

on the steps of pericardiosynthesis.

Answer

My practice is ultrasound guided and generally using a 5 inch 18 gauge spinal needle hooked to a 60 mil syringe. I would also consider using pigtail catheter and using cell dinger technique. So I'll confirm the need, consider sedating the patient if the procedure, giving procedural sedation to the patient if the procedure is non-emergent. Sit the patient up 45 degrees. Prep the skin with chlorhexidine and sterile drapes. Under ultrasound I will identify the site for the largest area of effusion with the best view. Or my most common place will be at the left of the 4/5 intercostal space. So 4/5 intercostal lateral to the left sternal border. So I aspir ate continuously whilst advancing the needle under vision and then aspirate 50 mils of fluid. If the fluid aspirated is not bloody then I have excluded vent ricular puncture. If the blood is aspirated I would confirm placement in the per icardial space with agitated saline test before doing any sort of, before placing guide wire and inserting pigtail drain. If my aspiration is successful I would expect rapid improvement in the patient's symptoms. Bye.

Question

Outline your steps for perimortem c-section.

Answer

Continue ACLS. Do not delay to go to theatre. You're aiming to do this at the 4 minute mark. Aseptic technique, not sterile. Use a size 10 scalpel, make a midline vertical incision from the top of the fundus to the symphys pubis. Blunt the sect to the peritoneum. Using a size 10 scalpel, make a 5cm vertical incision at the uterus. Use your fingers to lift the uterine away from the fetus, then extend the uterine incision vertically with scissors. Reach in, grasp and deliver a head or foot of the fetus, and then have external uterine pressure to help you deliver the fetus. When the baby's out, clamp the cord in two places, cut between the clamps, hand baby to the neonatal team, then deliver the placenta, then clean and pack the ut erus.

Question

Your patient has a pneumothorax and requires a pigtail chest strain. Outline your approach.

Answer

My approach, so first confirm the needs, so pneumophoric, pleural effusion and poiema. Exclude contraindications, overlying skin infection , coagulopathy. Consent the patient, including letting them know about complications, pain, hemorrhage, neurovascular injury, infection. So for patient positioning or position the patient head up 45 degrees with their arm that we're doing the procedure at behind their head, abducted, externally rotate. Locate where we're going to put the pigt ails, so locate a safe triangle, triangle safety, so lateral to pec major, medial lat dorsi, 4/4/5 intercostal space, anterior to the mid-axillary line. To double check that we 're in the right spot, I have the patient's arm by the side and mark the mid-arm point and that's generally your best spot. So procedure itself, once we've located the space, we'll go between the ribs, so above to avoid the neurovascular bundle, inject the lignocaine to skin and within muscle and periosteum. Then using a larger needle and syringe, insert in the same track aspir ating into a withdrawal of a pleural fluid or air. Then remove that syringe and thread the guide wire through the needle, then remove the needle, use a scalpel against the guide wire, then use the dilator over the wire into the pleural space. Then remove the dilator, pass the p igtail or the catheter over the guide wire into the pleural cavity, controlling the guide wire once in or all the way, so all drainage holds within the pleural cavity. Remove the guide wire and take samples of pleural fusion and place using a skin suture, so you simply interrupt it on either side and then attaching to the drain. Then use a dress with a water permeable transparent dressing, so the insertion site is visible and connect to underwater seal drain or hump valve. Post-procedural care, make sure the valve is working, confirm placements with chest x-ray. And yeah, that's it.

Question

Explain finger thoracostomy.

Answer

Indication, tension pneumothorax, peri arrest or arrested patient where pneumothorax is suspected. PPE on, clean double glove, locate your triangle with safety 15 to costals, clean with claw hex or similar, then with a scalpel make an incision into the chest wall following the curve of the rib force four or five centimeters, then blunt dissect with forceps into your pleura, remove the forceps, finger in sweeping to lung, confirm either blood, air or lung up, remove finger, then can apply a seal over incision with continuous monitoring or convert to chest drain.

Question

How do you perform a beers block?

Answer

I'm going to confirm the appropriateness to do the procedure and I'll do appropriate preparation and perform the procedure. So for the appropriateness I'll confirm the indication. I'll exclude any contraindications namely hypertension, non-compliant patient, burn or crush injury to the limb. I 'll consent the patient with key concerns being failure of procedure, local anesthetic toxicity, pain, skin injury. With our alternatives being procedural sed ation, hematoma block. For my preparation I'll have this patient in a monitored resource capable cubicle. I'll require a nurse assistant. My main equipment will be cardiac monitoring, adjunctive analgesia, IV access times two, double pneumonic blood pressure cuff, a local anesthetic ideally 0.5% prilocaine given at 0.5 mils per kilo and I'll have my equipment for complications so a sodium bicarb emulsion available. And in regards to situational awareness the department must be safe as this is a potentially resource intensive procedure. For the procedure itself first thing I'll do is gain IV access to both limbs. The affected limb distal to the injury. Then I 'm going to give some adjunctive analgesia so 50 microns of fentanyl to the non- affected limb. Then we'll elevate that limb for two minutes. Then we're going to inflate the cuff 100 milligrams 100 above the systolic, maximum 300. I'll confirm that there's no radial pulse and that the patient is tolerating the cuff up. Then I'll administer 0.5 mils per kilo of 0.5% priloc aine IV and we'll then be on the affected arm. We'll be assessing for the adequacy of the block and we'll perform the manipulation. If the patient's beginning to not tolerate the proximal cuff then we can inflate the distal cuff then deflate the proximal cuff so this that area will hopefully have local anesthetic. And then 20 to 40 minutes after we've given the local anesthetic I will do a trial deflation. So deflate for five seconds then re-inflate whilst assessing for evidence of local anesthetic toxicity. If none then deflate the cuff and ongoing care will be continuing monitoring of the patient namely for anesthetic toxicity.

Question

What is the management of a patient presenting with a spontaneous pneumothorax?

Answer

Management is based on the patient factors and pneumothorax factors. With a patient with underlying lung disease or larger or sympt omatic pneumothorax being less likely to self-resolve and require more invasive treatment. So if there's patients unstable or there's evidence of tension, immediate decompression. If the patient is stable, the two patient groups is someone with no underlying lung disease, so primary spontaneous pneumothor ax, versus someone with underlying lung disease, e.g. COPD, which is secondary pneumothorax. Then my two, when we then we group these two patients into whether or not it's large, so greater than two centimeters at the apex, or if they're symptomatic, so if they're breathless, versus if it's both small and minimal symptoms. So in starting from less severe to more severe, if it's a patient with no underlying lung disease, so primary spontaneous, no shortness of breath, then these are someone that we can observe. For instance, they could be in the ED for four hours, repeat chest x-ray and if unchanged, small or same, then discharge with strict safety netting and a repeat x-ray in two weeks. If again, if no underlying lung disease, but it's greater than two centimeters at the apex of the lung, or symptomatic, then we can aspirate versus pigtail. If they have underlying lung disease and it's small and asymptomatic, these patients I would still not do not send home and these patients need to be admitted to hospital with oxygen therapy. If they have underlying lung disease and it's a large pneum ophorex, so greater than two centimeters at the apex, and/or they're short of breath, then I would generally pigtail catheter. All patients on discharge need follow-up, so they'll need return to the hospital for worsening shortness of breath, follow-up with respiratory or GP, no air travel until fully reserved, lifelong no driving unless they've get VATS or bilateral pleurodectomy and smoking cessation. The best resource for this is BTS guidelines.

Question

Teach your surgical airway to an advanced stage trainee who is about to go on their real rotation. They're a competent intubator but have no experience with surgical airways.

Answer

I'm going to explain my approach to surgical airway. We don't have long today, so after we speak now, I want you to review the New South Wales Emergency Institute guidelines on surgical airway. It's got a great structure and useful video. Secondly, I want you to mentally rehearse this procedure until you feel confident. And then finally, I'm keen to organise for you to give a tu te on this topic to some of our junior registrars in a few weeks. So my approach is first, I establish the indication for the surgical airway. I do my preparation before the procedure. Then we do the procedure itself. My approach being scalpel, bougie, tube. Then we move to post-procedure monitoring. So the indication is a can't-oxygenate, can't-ventilate scenario. So make sure you declare this situation to the room so that everybody's got the same shared mental model that you're performing a surgical airway. The alternatives to surgical is a needle crike if they're under 10 years old and relative contraindications include severe tracheal injuries. So my preparation for staff, you need an airway assistant. You should ideally be doing this in the resource room where you're doing the intubation, but this is a critical procedure. Your stuff or equipment is you need PPE, including your own glove, gown, surgical mask, protective airway, eyewear. Your equipment, the crucial is scalpel, bougie, lubricate, size 6 tube. The extra things you might need, you'll need is also your syringe, sutures, BVM, ventilator. In terms of systems, you should be calling for help at this point as well. So the procedure itself. So first I declare to the room that I'm performing a surgical airway now. I position the patient with neck extended. I'm right-handed, so I stand on the patient's left and I use my left hand to perform the laryngeal handshake. So you stabilize the larynx with your thumb and middle finger and then you palpate the cricofibroid membrane with your index finger of that hand. Then with your right hand, you make a horizontal incision through the cricofibroid membrane into the trachea. I turn my blade down or rotate it down so the blade is facing the patient's feet and then I'll insert a bougie and advance it 15 centimetres . If you get early hold-up, that means you've created a face- path passage. Then I railroad the lubricated size 6 tube until the cuff is inside the trachea. Do not let go of the tube. Have your assistant remove the bougie, inflate the tube and connect to oxygen, or connect to your BVM. Now your post-procedure. So you're going to handbag this patient with 100% FiO2 and you're going to confirm placement with your end-tidal CO2, chest auscultation and later a chest X-ray and you're going to secure this tube with tape plus or minus sutures. You'll do your other post-resus or post-intubation care as standard. The other things I haven't mentioned is if you're unable to identify the cricofibroid membrane, then you'll need to do a vertical incision and blunt dissection prior to your horizontal cut. To do this, you're going to make a long midline vertical incision starting from 2cm above the sternal notch and then you're going to blunt dissect down until you can palpate the larynx or trachea and perform your horizontal incision as I described earlier . (shouting)

Question

Explain post-procedure care following a chest strain for he mo or pneumothorax. you

Answer

My goal is to confirm procedure success, seek and treat complications and ensure ongoing appropriate care and monitoring. We're going to review the patient, the equipment, ensure we've got appropriate investigations and then our miscellaneous like housekeeping, making sure appropriate drugs, documentation, disposition and patient knows what's going on. So for the patient we're going to repeat top to toe but ensuring focusing on making sure that breathing circulation is improved or unchanged and making sure that disability that they're waking up from any sedation and they've got ongoing adequate analgesia. For equipment I've start from the patient and move away so I'm going to review the chest drain itself so make sure it's adequately secured, look for any pneumothorax, look for any misting. Then I'm going to ensure that it's connected to the three-way drain correctly. If this is haem othorax I'm going to be looking in the collection drain at how much blood is drained. If one litre, over one litre, refer to cardiothoracics immediately. Then I'm going to be assessing for any swinging so we should see oscillating of the fluid in the underwater seal drain with respiration and we're also going to and if there's a pneumothorax I'll be looking for any bubbling. Then on to investigations, all these patients need a repeat chest x- ray, confirm that we're in the correct space. If there's ongoing concerns there's a role for ultrasound and CT. Then they're miscellaneous things so all of my patients I'll give them kefazolin empirically, ensure that we've documented, that we've referred on to the appropriate team and then inform the patient that's the succeeder of this procedure's success and any issues. Ongoing care, again for patient monitoring, ongoing minimal hourly SATs blood pressure, heart rate, respiration, pain score, make sure that I've got ongoing analgesia. Then we need them to, then every hour we 're going to have nursing staff assess the drain site, assess that the drain is securely attached and not obstructed, look into the collection to look at blood and what blood and fluid has been collected. For blood we need to refer to cardiothoracics for a quodamion or VAT if there's more than , after the initial drain, if there's more than 300 each hour, more than 300 after the initial drain, meals in the first hour or over 200 meals per hour for three hours in a row or one and a half days in the first 24 hours. For the underwater seal drain, the two things we think about is bubbling and we think about swinging. For bubbling we anticipate bubbling if it's a pneumothorax as the air is resolved and it may stop. If there's bubbling that then stops this means that the either there's the tube has been blocked, disconnected, obstructed or that there's resolution so we need to review the patient and repeat chest x-ray and then looking for swinging. So if it's no more, no swinging this means that it's ever the pathology is resolved or that the tube is in no longer in the pleural space so we need to reassess the patient include repeat chest x-ray. Other things of note is we need to be when thinking about transport we need to always make sure that it's a low level chest, we need to make sure that suction is turned off during transport, we should not clamp during transport but be ready to clamp if there's accidental disconnection. That is the core. Thank you.

Question

Explain how you do a pigtail catheter. You have under one minute.

Answer

I'll confirm the indication, exclude contraindications, consent the patient. I'll perform in the recess room with full non-invasive monitoring oxygen on patient. I'll have an experienced assistant. I'll prepare my equipment, sterile equipment, so PPE, gloves, gown. I'll have my local anaesthetic, chest strain kit, underwater sealed drain. With my equipment laid out in the order I'll use it. I'll do a team timeout and I'll locate my landmark, triangle safety, position the patient 45 degrees, hand of affected side behind head, clean and drape the skin, infiltrate my local anaesthetic to the pleura, wait, insert guide needle into the same tract, then insert guide wire through the needle, then remove the guide needle. Now whilst controlling the wire, small cut to skin at the base of the wire, then insert the introducer, not going into pleura, then remove the introducer, then insert the pigtail, all fenest rations within the pleura, attach the chest strain, ensure bubbling plus swinging, then secure the tube. My other post procedure care will be a chest x-ray to confirm placement, ongoing observations of bubbling, swinging and hourly vital signs. If there's a loss of bubbling or swinging, I'll be examining the tube to exclude blockage, disconnection, making sure the patient has not clinically deteriorated and I'll also confirm with the chest x-ray that there has been lung expansion.

Question

What airway and breathing issues need to be considered in the management of severe trauma of the pregnant patient?

Answer

Potential difficult airway due to soft tissue edema and breast enlargement. Higher aspiration risk due to delayed gastric emptying. For breathing, functional residual capacity is decreased. And there are increased tidal volumes. Bag valve mask is more difficult. Further chest strains should be placed higher as the diaphragm has moved up higher, so third or fourth intercost al.

Question

What are your modifications to your primary survey in the obstetric trauma?

Answer

There are two patients to consider in this resuscitation. However, maternal resuscitation is the priority as survival of the fetus is dependent on optimal management of the mother. My trauma team will include an obstetrician. My primary survey will be modified to include left uterine displacement as well as an urgent CTG to consider placental abruption as a source for occult bleeding.

Question

You're in a tertiary center. You will be getting a patient with hemorrhagic shock, second to trauma. What is your management of this patient? Say it in under 30 seconds.

Answer

I'll call a level one trauma and massive transfusion protocol. I'll assume team leadership, delegate roles. We will complete a primary survey. We will cease any bleeding in the ED, e.g. pelvic binder direct pressure. We're going to resuscitate this patient with warm balanced blood products in a one to one to one ratio. We're going to be targeting permissive hypertension MAPA 65. Also we'll give one gram of TXA and we will be facilitating early definitive care such as VEDA or Angio.

Question

What is your approach to traumatic cardiac arrest?

Answer

The patient has zero chance of survival unless the underlying causes are addressed. My approach is to open the airway, protecting C-spine, int ubate the patient, give fluid bolus, control any sites of hemorrhage, either with direct pressure or tourniquet, decompress the chest with bilateral finger thoracostomies. I would perform a FAR scan. If there is evidence of pericardial tamponade, resuscitative thoracotomy. Other things of note is to consider potential medical causes, so of arrest that have then caused minor trauma, so arrest then minor trauma, so in which case treat as medical. You can consider conventional ALS. I would do a FAR scan. You can consider conventional ALS after all reversible causes have been addressed, however after 10 minutes cease resuscitation.

Question

You're in a tertiary hospital and are about to care for a man in hemorrhagic shock due to blunt trauma. What is your management of this patient?

Answer

For this hemodynamically unstable trauma patient, I'll activate a level 1 trauma and massive transfusion protocol. I will assume team leadership and allocate roles. I will brief my team that our goal will be to complete a primary survey and concurrently instigate damage control resuscitation. We will gain a minimum of two 18-gauge IV lines and resuscitate this patient with warmed, balanced blood products in a 1 to 1 to 1 ratio of packed red blood cells, FFP and platelets. I'll be targeting a MAPA 65, Temp 36, pH greater than 7.2, lactate less than 4, calcium greater than 1. I'll also be giving this patient 1 gram of trans-examic acid over 10 minutes. We will also attempt to stop the bleeding, whether that this is in ED with direct pressure, like tourniquet pelvic binder, or expedine damage control surgery or interventional radiology.

Question

You have been called to a code black in the waiting room. There is an adult man who is acutely agitated. On triage there is history of him having a head strike. What is your management of this patient? Two minutes.

Answer

This patient is acutely agitated with head strike. My goal will be to reduce the risk of harm to himself, staff and department. My priority will be to gain control of the situation and seek and treat causes of agitation. In practice, my key steps will be assume team leadership, identify myself to the patient as the person in charge. I'm going to ask him to come to the resus room. I'm going to be attempting verbal de-escalation and I'm going to offer calming medications, lorazepam 2mg and lanzapam 10mg. If this is unsuccessful, I'll place the patient under an appropriate detention order. I'll use show of force with security present and move the patient out of the waiting room and have them take the oral meds. If this is unsuccessful, then we're going to enact physical 5-point restraint as a bridge to chemical restraint. My chemical restraint will be 10mg of IM-troperidol and we 'll repeat this after 10 minutes if the patient is not calm. If this fails, my escalation includes the addition of IV- midazolam, IM-ketamine or rarely RSI. Once we have control of the situation, my priority will be post-sedation care and now the exclusion of any sinister causes for his agitation. So we're going to do a full primary survey including full non-invasive monitoring and tidal CO2. This patient requires no special. For my investigations at the bedside, I'm going to get a B GL. I'm going to have VBG for exclude hyponatremia as a cause and then I'm going to send off bloods, including key will be alcohol and thyroid function. Then next step will be an urgent CT brain to exclude intrac ranial bleed. This patient will need to be sedated but safe for CT. So he's going to need full non-invasive monitoring and an airway level nurse and registrar to take him to CT. And then it'll be reviewing from there.

Question

What is your assessment of a patient presenting with chest pain?

Answer

My goal of assessment is early recognition and exclusion of potential life threats, but this is a very broad differential. Some of my top concerns are ACS, myopericarditis, cardiac tamponade, aortic dissection, PE, tension pneumothorax, perforated esophagus. For ACS, my history, I'm concerned if there's pain on pressure, worse on exertion, risk factors of previous MI, hyperlipidemia, hypertension. Examination less helpful, but I will assess for features of cardiogenic shock or heart failure. Top investigation is ECG, looking for STEMI or STEMI mimics or STT changes. Then troponin is a marker of cardiac damage. For myopericarditis, my concern in history, chest pain that 's retrospect sternal, pleuratic, or pain that's worse positional, so worse when flat, better when upright. Potential history of causes such as viral or radiation. Pericardial friction rub or any signs of tamponade. ECG, sinus tachycardia, pericarditis features, so wide-per iod ST elevation, PR depression, ultrasound looking for pericardial effusion plus or minus tamponade. Then on to tamponade itself, due for any history of cancer, radiation, thoracic surgery, pericarditis. On exam, cardiogenic shock, descended JVP, muffled heart sounds. ECG, looking for low amplitude, ECG with low amplitude and electrical alternans and tachycardia. Ultrasound looking for pericardial effusion with signs of tamponade. So dilated IVC, right atrial collapse in syncope, right ventricle collapse in diastole, swinging heart. For aortic dissection, any pain features such as sudden, severe, sharp tearing going into the back, any associated syncope, paracesia, flank pain, risk factors. So elderly, hypertension, connective tissue disorder, cocaine. On examination, hypertension, hypotension, very concerning, asymmetrical pulses, diastolic murmur concerning for aortic regurg, any neurological signs , weakness, paracesia, hornus. Key investigations at the bedside is ultrasound looking for dissection, flap or tamponade. And in practice, most commonly will be CT, angio. And for lung, for PE, pain, that's my history, pain that's pleuritic with associated shortness of breath, any history of DVT or calf pain, any history of homoptysis, risk factors, any recent surgery, oral contraceptive pill, immobilization, known DVT. Examination concerning often not found, but if they're in shock state, so hypertensive, tachycardic, elevated JVP, look for signs of DVT, calf tend erness, leg swelling, look for hypoxia. At the bedside, echo, looking for dilated IVC, regional wall abnormality, clock and transit and also check for doper of the legs, looking for DVT. And then D-dimer is considered, but CTPA is gold standard. In this pneumophorex, any pain that I can is pleuritic, sudden onset, history of trauma or connective tissue disease. And then looking for unequal air entry, on exam unequal air entry, hyper-resonant, distended JVP, ultrasound, lack of lung sliding, lack of B-lines, lung point, and then chest x-ray for lack of normal pleural markings. And then considering other things such as GI, so perforated gastric ulcer, or brohubs, so any abdominal cysts and tender abdomen, other abdosis symptoms. Other things I'll consider would be pulmonary pneumonia and chest wall musculoskeletal.

Question

What is your differential diagnosis for an adult patient presenting with syncope?

Answer

Potentially lethal things include cardiac arrhythmia, so br ady or tachyarrhythmia from any cause. So I'll be concerned if they had any sort of palpitations or ECG changes. Structural cardiac issues, so that is like a right vent ricular infarct due to MI, valvular disease, or dissection or an obstructive shock such as tamponade or PE. Other things I'll consider are orthostatic hypotension, so second to volume depletion or autonomic dysfunction, as seen in Parkinson's disease or diabetic neuropathy. And then we've got our neuromediated, so your vasovagal or situational, so in that I'll be looking if they had preceding light headedness, nausea, diatheresis, or if there was an event prior such as a painful or dist ressing stimulus, or if it was post-micturation, post-exercise.

Question

What is your assessment of a patient presenting with dysp nea?

Answer

My goal of assessment is to first seek and treat or exclude potential life threats, then after that consider less acute or sinister diagnoses. My top differentials for lung is pneumothorax, bronchospasm , pneumonia, PE. For cardiac, I'm concerned for heart failure, ACS, tampon ade, other causes, potential anemia, vene cause, lung cancer. So for pneumothorax, I'm concerned if this is sudden onset, associated with pleuritic chest pain, associated obstructive shock on exam, unequal chest air entry, resonance of percussion, chest x-rays showing loss of lung markings or signs of tension, ultrasound, lack of lung sliding, lack of B-lines. For bronchospasm, so asthma, COPD, on history, any known history of asthma, COPD, any family history, smoking history, on examination, any prolonged exp iratory phase, wheeze, silent chest. For pneumonia, any infective symptoms, namely any cough, any risks of infection, so known productive cough or history of aspiration. For PE, symptoms, pleuritic chest pain, associated syncope, cough symptoms, then risk factors including recent surgery, immobilization, oral contracept ive pill, previous PE. And then for cardiac issues, so heart failure, any nocturn al dyspnea, so patient were quiet and sitting up on multiple pillows to sleep, any fluid gain , peripheral edema, any known history of hypertension or cardiac disease. ACS associated chest pain, with key thing being ST elevation on ECG or raised troponin. Ectampinad associated chest pain, it could be pleuritic, features of obstructive shock on exam, ultrasound, signing of dilated IVC, constricted right atrium during scythia, constricted right ventricle during diastole. And for our sinister causes, anemia, gradual onset, any history of bleeding or chronic disease, lung cancer, chronic cough, weight loss, night sweats, high packed smoking history.

Side 1

My time for shock.

Side 2

C4

Side 3

Shoulder abduction.

Side 4

C5 C6

Side 5

Show the IDduction.

Side 6

C6 C7

Side 7

Flexion of the elbow. - Okay.

Side 8

Flexelbo C5 C6

Side 9

extension of the elbow

Side 10

Wrist flexion.

Side 11

Reflection C6 for C7.

Side 12

C6 C7

Side 13

wrist extension

Side 14

Wrist extension C6

Side 15

Finger abduction.

Side 16

T1 one. [ Silence ] ------------------------------d9e6d6d5e2--

Question

You are doing a morning ward round in the extended care unit. You're seeing a patient who has a shoulder reducing the ED overnight. They 're reporting weakness and paresthesia. Demonstrate your examination of this patient.

Answer

My goal of examination is to ascertain the cause of the weakness and the altered sensation. I'm especially concerned about an axillary nerve injury or a brachial plexus injury. I'll also be confirming that the shoulder is in joint and that there's no other missed injuries. So, firstly on inspection, confirm that the shoulder appears in joint. I'll look for any bruising that might indicate neuropraxia. I'm looking specifically in the axilla. I'm going to palpate my joint lines. I'm humorous, looking for any significant pain, thinking that we might have a missed fracture. On movement, I'm going to assess movement and power. So, I'm going to do active movement against resistance, taking note of any weakness or pain. So, first line with shoulder, abduction, abduction, flex, extend. And then we're going to look at elbow, flex and extend, wrist, flex and extend. Looking specifically at peripheral nerves in the hand. So, looking at radial, so we get thumb up against resistant medium, squeeze my finger, AIN, make the okay, and ulnar ab duction against the finger. Next on the reflex, checking triceps, bicep, brachial radialis. I'll be concerned for like a triceps loss of reflexes and brachial plexus injury. On sensation, I'm going to start with pin prick, plus light touch. And I'll be doing dermatomes as well as the peripheral nerves. So, first looking at Reginald's patch, axillary C5, lateral arm C6, middle finger C7, medial forearm C8, medial arm T1. Now we're going to look at the hands, thumb for radial nerve, base of thumb for radial nerve, second digit ulnar, fifth digit medium, and medial cube foss T11. Thank you.

Question

What is your assessment of a patient presenting with dipl opia?

Answer

On history, the first thing is to work out if it's monoc ular, which will persist when the unaffected eye is closed, but will resolve when the affected eye is closed. But in binocular, it will improve when either eye is closed . In binocular diplopia, the key details to figure out is if it's separated horizontally or vertically. Binocular horizontal is usually due to disease of the med ial or lateral rectus, so cranial nerves 3 or 6. And if it's vertical, that's more common to be a problem with cranial nerves 3 or 4. I also ask around about pain or headache, so eye pain might make you concerned for... . . . . . . . . . . . . . I need to redo this one.

Question

Your patient is presented following a moderately high speed MVA and is being placed in C-spine precautions. Clinically clear their C-spine. *sigh*

Answer

In this patient I would use Nexus criteria so I'll examine the patient to see if they've got any focal neurology and I'll also examine them to see if there's any midline tenderness. If they are also GCS, if they have no focal neurology, no midline tenderness and they're GCS 15 with no intoxication and no distracted injury then I can clinically clear the sixth one .

Question

What is your examination of a patient presenting with lower back pain? Yeah, so I'll look at systemic features. So I need a set of bulbs including temperature any fever That's concerning for this card us then I'll assess the back So I'll look at look at the back looking for any lordosa assessing their lordosis or feel so Pell panel on the spinal processes and paraspinal spinal process pain being concerning for fracture or cancer parasp inal more in keeping with MSK I also assess the movements of the lumbar spine Then I'll go on to perform a lower limb neurological exam. So inspecting for any wasting I'll expect in field tone and I'm going to do power or myot omes I'm going to have bilateral decrease in power in quarter equina and then I'm going to do perform reflexes and decrease the in quarter equina And I'll go on to do sensation both pinprick and light touch in dermatonal So inguinal L1 medial fire L2 out of outer calf L3 in the calf L4 outer leg L5 Now I'm going to pinprick and light touch the perianal region I'll assess gait looking at a ferny foot drop. I'll also do a straight leg raise and I'll consider PR Bye.

Answer

My goal of examination is to exclude any of the high-risk clinical syndromes such as corticoina, cancer, fracture, discitis, inflammatory arthritis. So first I'm looking at the patient from a systemic point of view, you 're going to need a set of bulbs including temperature, any fever or sepsis concerning for discitis. Then I'll look at the back, I'm going to look, assessing several doses, looking for any overlying erythema, and I feel along the spinal process and paraspinal, spinal process pain concerning for fractural cancer, paraspinal more in keeping with MSK, and I'm going to assess their movement at the lumbar spine. Now I'm going to go on to perform a lower limb neuro exam, inspect for any wasting, and look at tone, which I anticipate to be normal, and then power, a decrease in corticoina, reflex decrease in corticoina, sensation I'm going to do pin prick, then light touch and dermatomal distribution. So inguinal L 1, lateral thigh L2, inner thigh L3, outer calf L4, so inner calf L4, outer calf L5, lateral foot S1, and then I'm going to also check perianal sensation, pin prick and light touch. Next after this we're going to assess gait , looking for any foot drop, and I do a straight leg raise looking for sci atic nerve irritation, and I'll consider PR if there's other signs or history concerning for corticoina.

Question

Your patient is presented with a wrist drop. Demonstrate your examination.

Answer

My goal of examination is to first exclude stroke, then I 'll be attempting to localise the lesion, whether it's radial nerve palsy, brachial plexus injury, C7 radiculopathy, or rare causes such as lead poisoning, thiamine deficiency, motor neurone disease. On examination, the first thing I'll do is a screening stroke exam, so just checking for any facial weakness, visual field defect, speech defect or other limb weakness. Then on inspection I'm going to confirm the wrist drop. If there's radial deviation, then this is likely a C7 or posterior interosseous lesion. Then I'm going to look carefully to see if there's any bru ising or injury in the distribution of the radial nerve. On tone, I'm looking to see if there's increased tone, this is concerning for stroke. On power, I'm going to check all major movements, shoulder abduction, flexion extension at the elbow, flexion including with half pronation to test brachioradial is specifically. I'm going to test wrist extension and finger movements. The key patterns I'm looking for is if we've got a weak br achioradialis and weak wrist and finger extension, this is concerning for radial nerve palsy. If there's weakness of the triceps with weak finger and wrist extension, this is concerning for C7 radiculopathy. And in stroke, I'm concerned if there's generalised weakness with worse extension. In terms of next, I'll do reflexes. If the brachioradialis is reduced, that's consistent with radial nerve palsy. If tricep is, then this is not radial nerve palsy. It's concerning for a C7 lesion or brachial plexus lesion. I'm going to test sensation. I'm going to test the dermatomes and sensation at radial ul nar median at the hand. I'm going to do a special test looking for sparing maneuver . [MUSIC PLAYING]

Question

What is your assessment of a patient presenting with dipl opia?

Answer

My differential for monoocular diplopia is eye issues such as cataract, macular degeneration. For binocular, this is anything affecting the function of the eye muscles. So it could be an ischemic or hemorrhagic shock, could be isolated cranial nerve pathology, there will also be systemic issues such as MS, diabetes, myasthenic gravis, thyroid disease. So on history , first thing I'll do is establish if it's monocular or binocular. If it's bin ocular, I'll then ask around the speed of the onset. Sudden onset is concerning for vascular cause. I'll also ask around associated symptoms. Headache would be concerning for temporoartoritis or subarachnoid hemorrhage. Then I'll ask around the cause. If it's worse with fatigue, that's potential myas thenic gravis. Finally, I'll get a general past medical history but also ask specifically around trauma and any autoimmune or neoplastic conditions. On examination, again I'll establish if this is monocular or binocular. So if it closes, if it resolves with the closing of one specific eye but not the other, that is monocular. If it resolves with the closing of either eye, binocular. Next I'll be doing visual acuity. After that I'll inspect the eye from the outside in. So I'm going to be looking for ptosis for Horner's, proptosis in thyroid disease. I'm going to look at the pupils. My fixed dilated pupil will be concerning and will need neuroimaging. I'm going to look at pupils at breast. So third nerve palsy will show people in third nerve, down and out, fourth will appear up. And then I'm going to do my eye movements in a H pattern. As part of my examination, I'll also perform a full cranial and nerve exam and a full gross neuro exam.

Question

Demonstrate your examination of a patient presenting with painful acute vision loss.

Answer

My biggest concern is acute angle closure glaucoma. I'll also be examining for herpetic keratitis, anterior uveitis, foreign body orbital cellulitis. On examination I'll first confirm the visual loss and then we'll do with a Snellen chart, then I will do inspection. So on general inspection severe pain, headache and vomiting concerning for a patient with glaucoma. Periorbital looking specifically for any vesicular rash or so for herpetic keratitis or cellulitis in orbital cellulitis. Then looking at lids again for cellulitis, proptosis, then sclera, significant inflammation or chemosis concerning for keratitis or glaucoma. And then looking at the iris, we might be hazy and anterior uveitis and glaucoma and we'll also be looking for a hypopion in uveitis. Looking at the pupil, fixed, semi dil ated in glaucoma. Then moving on to more of my equipment. So first with my fingers or a pen torts checking visual fields and eye movements. Then with pen tor ts looking for RAPD plus a semi dilated pupil in glaucoma. Then on termometry, raise the intraocular pressure greater than 40 concerning for glaucom a. Then we'll also check fluorescein looking for dendritic ulcer in herpes ker atitis. We're going to invert the eyelid if there's concern for foreign body. We're going to do cotton wool to the eye looking for decreased sensation in herpetic keratitis. And then roll for fundoscopy looking for pronounced cupping in glaucoma and slit lamp looking for visible cells or flare in uveitis.

Question

Teach your examination for a patient presenting with ataxia .

Answer

So the first thing I do is assess for evidence of stroke. So essentially a rosier. So I'll check to see if there's any asymmetrical facial arm or leg weakness, check if there's any speech disturbance. So checking if they can say British Constitution, baby hippopotamus, and also check if there's visual field defect. If yes to any of these, then consider stroke as a cause. Next, I'll confirm the ataxia and assess the gait. Do this from a distance and with good length. You wanna look if it's normal or for specific patterns. So the patterns I look for is you look for your hemiparegic gait. So this is just essentially stroke. So legs is stiff and it's moved in an arc and the arm on the same side is flexed at the elbow and not swinging. Then you wanna look for your classic ataxic or cerebellar gait. So broad-based, unsteady, irregular steps and often veering to one side. You can look for peripheral causes. So if there's a single foot drop, then that's concerning for, that makes you think things like common perineal lesion. And then if it's bilateral stepping gait, then that's like a bilateral foot drop. So often you're thinking a shark foot or motor neuron disease or sensory ataxia. If it's a waddling gait, you think about arthritis or myopathy and then think if it's is it a Parkinsonian gait, so small shuffling steps, lots of steps to turn. So after that, I do some extra gait tests. So I do the heel-toe walking, so that's more sensitive. And then I check if there's truncular ataxia. So you sit the patient on the bed with their arms crossed. And then, and that makes you be concerned about if there's truncal ataxia, that makes you think for a central cerebellar lesion. Next, check your cerebellar examinations. So this makes you think about posterior circulation, strokes, alcohol intoxication. So you do your dysdiadochinesia, do dysmetria and check for nystagmus. Next, looking to see if this is a sensory issue. So I do Romberg's. So to do this, you have the patient stand, but stand with their legs together, have them close their eyes and see if essentially they lose balance. This is potentially dangerous to the patient and you. So be careful for that. And then also check reflexes and you'll have loss of deep tendon reflexes in your Miller-Fisher variant of Gilabari.

Question

Demonstrate your examination on a patient who has been punched to their right eye. You'll be demonstrating on a healthy volunteer.

Answer

My goal of the examination is to rule in or out significant injury to the orbital surrounding structures, the most site-threatening potentials being retrobulbar hemorrhage, causing orbital compartment syndrome, ruptured globe, as well as orbital blowout fracture. I'll also be looking for other injuries such as lid, cornea , lens dislocation, retinal detachment, traumatic arthritis. So on growth inspection, I'm looking for any readily apparent injury, e.g. penetrating injury and ensuring that the patient has no airway breathing circulation disability concerns. Then I'm doing my detailed inspection from the outside in. So first looking at the eyelids for any lacerations. Hard tight eyelids would be concerning for orbital compartment syndrome. Then I'm inspecting for blowout fracture, so I'm palpating over the step of the infraorbital rim as well as checking for loss of sensation at the infra orbital nerve. Then looking at the growth orbit, looking for proptosis concerning for orbital compartment syndrome. Then looking at the sclera, extensive subconjunctival hem orrhage, bloody chemosis, also concerning for orbital compartment syndrome. At this point, I'm also looking for any lacerations or foreign bodies. Then looking at the iris for hythema and looking at cloud ing of the iris in traumatic glaucoma. And then looking at pupils, inspecting for a teardrop pupil and penetrating injury. Then looking further pupil assessment, I'm going to look at extraocular movements. They're going to be limited in orbital compartment syndrome , ruptured globe or orbital wall fracture. And doing pen torch, RAPD, again concerning for orbital compartment syndrome as well as retinal detachment. Then we're moving on to using our tools, so looking at a tonometer, so checking eye pressures. If there's pressures greater than 40 plus vision loss, then I'll proceed to lateral canthotomy and cantholosis. I will also check visual acuity on the tone chart, consider fluorescein, fundoscopy, and slit lamp examination.

Question

What is your assessment of a patient presenting with pain less acute vision loss?

Answer

My top differentials are central retinal artery occlusion, central retinal vein occlusion, temporal arteritis, internal carotid artery occ lusion, as well as retinal detachment and vitreous hemorrhage. My history will confirm the symptoms and the timing. For temporal arteritis specifically, I'm going to ask if there's any associated headache, jaw caudication, scalp tenderness or diplopia and I'll also look at risk factors for stroke and if they've had any history of polymyalgia rheumatica. For central retinal artery occlusion, again I'm anticipating this to be sudden and I'll be assessing on history for stroke risk factors. For retinal vein occlusion, I'll be looking again at stroke risk factors, any autoimmune or any previous ocular surgery. For retinal detachment, the history I'm looking for a description of a dark descending curtain that may be associated flashes and floaters and trauma and for vitreous hemorrhage, I'm anticipating a history of floaters or history of diabetes or trauma. On examination, I'm going to do visual acuity unaided and pinholded as well as then looking at the outside of the eye . On examination, any outside the eye I'm working in. I'll start with palp ating over the temporal region which will be concerning for temporal arter itis. I'm going to look carefully at all the structures of the eye going from outside in but anticipate that will be normal on gross examination. My key looking at using my equipment, I'm going to use my pen torch to check for an RAPD which will present in things affecting the optic nerve but the temporal arteritis, retinal artery occlusion. I'll do fundoscopy for retinal artery occlusion looking at a pale disc with cherry red spot. Also we got pale in temporal arteritis. For vein occlusion on fundoscopy that blood and funda appearance and if there's some opaqueness is concerning for retinal detachment. With my tonopen, I'll also check for any raised pressure which may be a complication of retinal vein occlusion. My key investigations, so these patients if I may require TIA workup. At the bedside ECG for a fib, ultrasound might see retinal detachment. In my lab I'm looking for raised E ASR, CRP and white cell count for temporal arteritis and I'll also do TIA workup blood slippers. Imaging has less of cause. I'll do CT angio if looking for concern for carotid artery stenosis. There may be a role for MRI to give details about injury to the optic nerve and of course the biopsy for temporal arteritis is gold standard.

Question

Your patient has presented after being punched in the face to the owner is complaining of a painful eye. Outline your examination.

Answer

My differential diagnosis includes major head and brain trauma but also regarding the orbit, concern about most sight threatening things being a retrobulvar hemorrhage leading to orbital compartment syndrome, a orbital blowout fracture or a ruptured globe which could be even though it's a blunt trauma can you know patient if for example they were wearing a ring. On my gross inspection I 'm looking for any readily apparent injury, any ABCD concerns. So on my detail inspection I look from outside in so first looking at their eyelids looking for any lacerations, hard tight eyelids concerning for orbital compartment syndrome. Two, I'm looking specifically for evidence of a blowout fracture so I'm palpating for a step over the inferior orbital rim and I'm also checking for loss of sensation at the inferorbital nerve and supraorb ital nerve. Next looking at the orbit the gross orbit looking for any evidence of proptosis concerning for orbital compartment. Next looking at the scl era so if there's any looking... you you you [BLANK_AUDIO] [BLANK_AUDIO] [BLANK_AUDIO] [BLANK_AUDIO] [BLANK_AUDIO] [BLANK_AUDIO] [BLANK_AUDIO] [BLANK_AUDIO]

Question

What is your history for a patient presenting with lower back pain?

Answer

So I'll take a pain history, so asking around sight, where it began, onset, so when it first started, what it feels like, character, radiation, wherever it goes anywhere, any associated symptoms, what the time course, so how long it's been going on for, if things change, is there anything that makes it worse or better, and also ask around severity. Then review, I always review my red flag specifically, so for corticoina, ask around bilateral limb weakness, any change in bowel bladder, any saddle with paracesia for cancer, if there's any history of cancer, weight loss, night sweats, nocturnal pain, or that the symptoms have been gradual onset. Ask around fracture, so concerning if it was sudden onset, improved when lying down, or if there's any history of major or minor trauma, with minor trauma being concerned for cancer or osteoporosis. I ask around discitis or abscess, so if they've got any fever, malaise, any history of immune compromise, IVDU or diabetes. Also think about inflammatory arthritis, so if there's any morning stiffness.

Question

You've been approached by your intern who is about to see a patient with left-sided facial droop. Triage note reports crew Bell's Palsy. Teach your assessment, that is history and examination, to an intern regarding facial droop and the diagnosis of Bell's Palsy.

Answer

Bell's palsy is a diagnosis of exclusion. So our first priority is going to be to exclude acute stroke. Our other differentials are going to include intercranial mass, MS, maleficent variant, Guillain-Barre. We're going to think about ear issues such as otitis media, otitis externa, infectives, so herpes zoster, mumps. Also need to consider neoplastic and make sure that this isn't second to trauma. So if when you see the patient there's any doubt in your mind that it could be stroke, come see me immediately. So on history, you're going to establish the symptoms. And I want you to ask specifically if there's any diplopia, dysphasia, dizziness. They're all red flags. Establish the time course. Bell's palsy is generally rapid. A gradual onset is more concerning. Also it's worth asking specifically if there's been any recent viral illnesses or trauma. And on past medical history, make sure you ask about stroke risk factors and if they've got any history of tumours to face and neck. On examination, first thing we need to do is rapidly exclude a large territory stroke. So confirm that their forehead is involved in the weakness. If there's forehead sparing, this is a stroke until we prove otherwise. Also make sure that there's no asymmetric arm or leg weakness. Ensure that there's no speech disturbance and that there's no visual field defect. Once you've done that, then it's time to go on for your cranial nerve exam. You want to pay special attention to 345. So if there's any diplopia, that's concerning for the F ischer variant of Guillain-Barre. And then when you check your facial nerves, cranial nerve 7 , you need to be really certain that there is not forehead sp aring. Other things to do is make sure when you're looking at the weakness, if the eyelids are unable to close fully, this patient's going to need patch and drops. In terms of our extra test, you need to examine for Ramsey- Hunt, so looking in the ears for any vesicles. You need to also inspect and palpate over the face for any masses. And to finish your neuro exam, you want to exclude Guillain -Barre Miller-Fischer variant, so confirm that there's no ataxia and the patient has normal reflexes.

Question

What is your assessment of patient presenting with hyponat remia?

Answer

My goals of assessment are to confirm the diagnosis, severity, acuity and cause. For history I'm going to look at potential causes, so take a drug history, look at any diuretics, intake history for query potomania and past medical history around renal failure, cardiopatia, liver failure and I'll also be looking on whether or not that they've had a low sodium documented recently and then history and severity, whether they've got any neurosymptoms , headache, vomit, lethargy, confusion, ataxia. My examination is going to be establishing the fluid status, so is this are they euvolemic, hypovolemic or hyper volemic and what is their mental status, are they seizure, coma, confused. My investigations, my most important will be my serum osmolarity and urine sodium and osmolarity and I'll also be doing other tests such as liver function, renal function. But for establishing the cause, if they're hypovolemic with a high urine sodium or higher, then this is consistent with renal failure or diure tics, low or normal sodium losses elsewhere, e.g. skin. If they're euvolemic with a high urine osmolarity and high sodium, this is SIODH. If they're normal osmolar ity, this is water intoxication, hyperthyroidism and hypervolemic. We'll be looking at my other investigations such as LFTs etc.

Question

What is the modified Scarboza crown?

Answer

used for evaluating left bundle blanch block in the setting of chest pain. So the modified Scarbosa is proportionately excessive discordance. So if there's discordant SD elevation by more than 25% of the depth of the preceding S wave, or if there's any essentially more than one mil of concordant SD elevation or ST depression.

Question

What are the causes of hyponatremia based on your fluid status and tests?

Answer

Hypovolemic plus high urine sodium means that this is renal losses e.g. through to diuretics or renal failure. Normal or low sodium means that the losses are coming from elsewhere e.g. GI tract. For euvolemia, high urine osmolarity is SIADH with normal or low urine sodium being low normal osmolarity, water and toxin hyperthyroidism. For hypervolemia, your main differential is renal failure, liver failure, cardiac failure. So look at your other investigations such as renal function, LFTs and such. and such.

Question

What is the definition of a brewery and what makes it a low -risk brewery?

Answer

Brief, resolved, unresponsive episode. Occurs in less than 12 month old. Less than one minute duration. Sudden onset with return to baseline state. They must have cyanosis, altered breathing, well one or more of cyanosis, altered breathing, change in tone or change in consciousness. There must be no other explanation. For it to be low risk they must have no concerning features on history and exam and all the following. They must be over 60 days, must be born greater than 32 weeks, cannot have any CPR by a trained professional and it must be the first event and again the event must last less than one minute.

Question

What are the antibiotics for infant with sepsis and caeser?

Answer

Benzylpenicillin 60mg/kg, Kefotaxine 50mg/kg IV, as well as acyclovir 20mg/kg IV if herpes is suspected. If IV access is unavailable, give 100mg/kg of IM-Kef-Triax one. sign.

Question

You're in a tertiary hospital. Your triage nurse has come to you with concern about an 8 day old neonate. He has come in due to poor feeding. You find that he is difficult to rouse, he appears pale and is mottled. His heart rate is 105, rest rate 70, cap refill 5 seconds, saturations are unrecordable. What is your initial management?

Answer

I'll move this child to resus and place on resuscitaire. I 'll call for a full resus team. I'll allocate roles including a senior clinician to support the mother. I'll then lead and coordinate the resuscitation of this critically unwell infant. For airway and breathing we'll place this infant on a 100% FIO2 by a non-rebriever. We'll also ensure that the airway is patent and if the child becomes apneic we'll support ventilation with BVM. For circulation we'll gain dual IV access. If there's a delay we will gain IO access. We'll start with a 10 ml per kilo bolus of 0.9% normal saline and we'll repeat this up to 40 ml per kilo with end point being capillary refill less than 2. We will also treat potential sepsis empirically with kefataxine 50 mg per kilo benzoyl penicillin 60 mg per kilo. If there's still evidence of shock post fluid bolus I'll commence on tropic support adrenaline 1 mic per kilo per minute so 0.1 mic per kilo per minute. We'll also gain an ECG - if the child is in SVT we'll perform DC cardioversion of 1 joule per kilo synchronized. For disability we'll make sure we get an urgent BSL. If the child is hypoglycemic we'll give 2 ml per kilo of 10% dextrose IV. Next I'll see if we can treat other specific neonatal conditions so we'll consider a duct dependent cardiac lesion so if the child is not improving rapidly to the oxygen or the fluid bolus or if an exam they've got murmur, a large pre or post duct al sats difference, poor femoral pulses and I'll give prostate gland infusion at 0.1 micrograms per kilo per minute monitoring for apneas. Next I'll consider surgical emergencies to examine and take history for interception clorox sten osis and refer to surgeons as appropriate. We'll check carefully for seizures and treat with midazolam, make sure it's not due to hyponatremia and also consider pyridoxine. I'll also examine for unusual genitalia for adrenal hyperplasia and check a VBG. If there's hyponatremia, if they're hyponatrem ic and hyperkalemic on VBG I'll give hydrocortisone 25 milligrams per kilo. All this is also specifically examined for NAI as a potential cause and we 'll also consider metabolic issues so make sure we've got appropriate blood sent off.

Question

Your pediatric patient has presented with query decay. What is your assessment of this child?

Answer

My goal of assessment is to confirm DKA, assess the severity and seek any precipitants, as well as detect and treat any complications . For history I'm going to find out if this is their first presentation, if there was any preceding illness as a precipitant, so any fever, any other symptoms, and check about insulin adherence, including checking if there's been pump failure. On examination I'm going to assess for severity of dehydration, look for shock, poor perfusion, tachycardia, hypertension, decreased tissue turg or, and assess for potential precipitants, so head to toe exam. In terms of investigations, my key will be a VBG and ketones to confirm diagnosis, assess severity and complications, so severity based on pH, severe if less than 7.1, bicarb less than 5, moderate if pH between 7.1 and 7.2, and mild if between 7.2 and 7.3. Looking at the gas, I'll also look at assessing and correcting potassium, sodium, and looking at glucose. Other bloods I'll do an EUC looking for evidence of AQI, septic screen, including cultures of febrile, and check urine for ketones, plus or minus culture.

Question

What is your management of a child presenting with life-th reatening asthma?

Answer

If a child has maximal work of breathing, increased respiratory rate, is confused and drowsy, not moving, cyanosed or other signs of anaphylaxis, I'm concerned for life-threatening asthma. My management is respiratory support, so oxygen via high- flow nasal cannula or BiPAP whilst giving inhaled bronchodilators. So in the 1-5 year, I'll give 2.5 SbU2N continuously and 250mg of Ipatropium via nebulizer continuously. In over 6, 5 of SbU2N and 500mg of Ipatropium continuously. I'll also consider IM adrenaline, 10mg per kilo. I'll gain IV access and give dexamethasone 0.6mg per kilo. I'll also give magnesium sulfate 0.2mg per kilo, max of 8, over 20 minutes. And amilofulin 10mg per kilo, IV, over 30 minutes. This needs to be done with cardiac monitoring and not in the same line as the magnesium. These children will also of course need paediatric intensive care admission. And I would avoid intubating where possible. If intubated, they'll need a very slow ventilation and hyp ocapnia, permissive hypercapnia.

Question

Your triage nurse has come to you concerned about an unwell neonate. We'll review the neonate is eight days old, pale, mottled, heart rate 105, respirate 70, cap refill, five seconds and an unrecordable SAT. What is your management? Say it in under one minute.

Answer

We'll manage you a full team with the child and resource under resuscitate. We'll give 100% Fi2 and support airway and breathing as required. We'll gain IV or IO access, give a 10ml per kilo bolus of normal saline, repeat up to 40ml per kilo in total. If they're still shocked despite this, I'll start an adrenaline infusion. Give all patients empiric antibody to Keflaxcine and benzop enicillin. If hypoglycemic, give 2ml per kilo of 10% dextrose. ECG if they're in SVT, give a synchronised DC shock of 1 joule per kilo. Other things I'll seek and treat will be duct dependent les ion. If so, start a prostaglandin infusion at 0.1 microns per kilo. If surgical pathology, urgent referral to surge. If there's seizure, treat with midazolam plus or minus pyr idoxine. If prolonged, if there's congenital adrenal hypoplasia, give 25mg IV hydrocortisone. Other things I'll do is specifically look for trauma, second to NII. I'll also ensure appropriate investigations are sent and VB G metabolic screen. This child I will be referred to PICU.

Question

What is your management of a child presenting with severe D KA?

Answer

My goals of therapy will be to treat the shock and dehyd ration, reverse ketosis, correct acidosis and hypoglycemia, monitor and treat for any complications, namely cerebral edema, hyper or hypokalemia, hypoglycemia, as well as identify and treat the underlying illness or precipitant. I rarely deviate from the RTH guideline. So we're going to manage this patient in the recess room with full non-invasive monitoring. We're going to nurse them head up to theoretically reduce the risk of cerebral edema. So first, looking at dehydration, if they're shocked, I'll give a fluid bolus of 10 mL per kilo sodium chloride, 0.9%, plus or minus of potassium. Then for rehydration, we're going to get a 1 liter bag of saline, 0.9%, and if their potassium is less than 5.5, add 40 mL of potassium. Then use the RTH guidelines for the exact mL per hour. For reversal or ketosis, I'll start an insulin infusion on 0.1 units per kilo per hour for the majority of patients, going less for some cases, namely if they're going to have less monitoring or a higher risk for cerebral edema. Other things we'll be doing specifically are monitoring hourly gases and one-to-one nursing where possible, monitoring for cerebral edema, looking for headache, irritability, lefty, vomiting, changing conscious state, and monitor for hypogly cemia, hypokalemia. If severe, this patient will need ICU management.

Question

What is the definition of a simple febrile seizure?

Answer

Usually occurs between six months and six years and the definition is they must have fever and all the following generalized tonic-clonic seizure, duration of less than 15 minutes, complete recovery within one hour and the seizure does not reoccur within the same febrile illness.

Question

Teach a junior RMO about the approach to neonatal jaundice.

Answer

- Yeah, so the best resource I've found is RCH, which is really good, and it sort of breaks up into sort of age and history examination. So the first thing to remember is that most of the jaundice we see is physiological, but we need to be aware of pathological jaundice. So any, the big ones is if, is onset, so if it's early onset, less than 24 hours of age, that is pathological. If the child is unwell in any way, or has any other concerns on history, then you've gotta think about pathological. And if it's prolonged, greater than two weeks, then we really need to think about pathological causes as well. So in terms of history, you wanna, the big thing is you wanna know when it started. You wanna check if there's any antenatal problems, so including mum's blood group and antibodies. Ask around the delivery, so birth trauma instrumental delivery puts at risk. Work out about feeding, so whether they're breasts performing or what their weight gain. Generally find out about their output as well, so specifically ask about dark urine and pale stools, 'cause that suggests a biliary obstruction. So in terms of examination, you wanna look at their tone, hydration status, do a neurological exam, look at the, look if there's any bruising or anything like that, feel for hepatosplenomegaly. So in terms of investigation, so if it's before 24 hours, or greater than two weeks, you should investigate in all of these patients and admit all of these patients. So I'd recommend, and the causes then is usually sepsis or hemolysis. So these patients early should all get a CVE, they should all get a Coombs test, and they should all get total bilirubin as well as your conjugated and unconjugated. If it's prolonged, that's also concerning for sepsis, hemolysis, breast mingled jaundice, hyperthyroid, so these ones need, same as the two weeks, they need their serum bilirubin, FBE, LFTs, they need group and DAT, and they need the thyroid function . Yep, so that's your main thing. So big things to think about is pathological, sepsis, hemolysis, in all age groups, in the greater than two weeks, you consider your breast milk and your hypothyroidism. In your sort of peak onsets and common time they have it, between 24 hours and two weeks, your differential is physiological jaundice, dehydration, sepsis, hemolysis, again, breast milk jaundice, breathing, birth trauma. That's it, that's long, sorry.

Question

You are in a regional emergency department during late shift. There is no anesthetic support. You're in the resource room managing a 55-year-old man who you suspect has epiglottitis. You've already instigated treatment, steroids, antibiotics, adrenaline nebs. Despite this, the patient has deteriorated and is now in severe respiratory distress. He has a respiratory rate of 25, SATs of 86% on 15 liters via non-rebreather. His heart rate is 100. His blood pressure is 140 over 70. How would you secure this patient's airway?

Answer

I'll hit the emergency bell, assemble my team. I'll brief the team that this is a physiologically and anatomically difficult intubation due to the hypoxia and epicotitis. We thus will need to have a double setup for intubation. So most experienced airway operator at the head for intub ation and a second operator fully prepped and in position for surgical airway. Prior to induction, we're going to optimize this patient's oxygenation and ventilation. So I'm going to escalate to a BVM with PEEP. I'm also going to apply high flow nasal prongs. Hi. With oxygen. We're going to position the patient with tragus in line with sternum and we're going to have the neck marked in preparation for surgical airway. My equipment will include a video laryngoscope, size 4 blade, size 6 ET tube, bag valve mask and surgical airway kit open and ready. I'll not be using a supraglottic airway as it may worsen the epiglottic obstruction. My induction drugs will be ketamine, 1 milligram per kilo, rocuronium, 1.6 milligram per kilo. Prior to induction, I'll be verbalizing our airway plan. So we're going to have a single attempt of video laryngoscope. If failed, at the time of SATS to 80%, we'll be proceeding to, if failed or SATS 80%, proceed to front of neck access. Once intubated, post intub ation care will include confirming the tube placement with n-tidal CO2, chest auscultation, chest x-ray, ventilate using a lung protective strategy, ongoing sedation with titrate propofol . We're going to review that we're treating the epiglottitis , appropriate antibiotics, and arrange retrieval to a tert iary center for care under the intensive care unit with ENT. To summarize my key modifications, double airway setup, we've planned for single ETT, then front of neck access. Of course, if this was not emergent, we would want a wake fiber optic.

Side 1

A child is choking in your department, what is your management?

Side 2

I'll review this patient immediately. If they're alert with an effective cough I'll let them find their own position reassure them and encourage coughing whilst continuously assessing for deterioration. If they have an ineffective cough I will be calling for help ENT and anesthetics. I will be commencing first aid. Five back blows followed by five chest thrusts then I 'll open the airway and remove the foreign body if I can visualize it. Then I 'll be repeating the that process. If the child becomes unresponsive we will start we'll commence CPR starting with compressions. Prior to each attempt at ventilation I'll use direct laryngoscope and McGill forceps to attempt to remove the foreign body. If we cannot relieve the obstruction and improve the child within one minute if the foreign body is below the cords I'm going to perform a purposeful right main bronchus intubation then I'll be withdrawing the tube back to the normal depth and I'll be ventilating the child right side down to ventilate their left lung. If the foreign body is above the cords then we will be caught I'll be performing a needle or a cric if they're under five and if they're above five surgical airway. These children will require transfer to theater for removal foreign body plus definitive airway.

Side 3

I generally crike in under 8 years old.

Question

What is your management of a child with choking episodes?

Answer

If the cough is effective, allow them to cough and assess for deterioration. If ineffective cough, call for anaesthetics and ENT to assist with airway secure. Also give first aid, 5 back blows, 5 chest thrusts, then open the airway, look to see if you can see the obstructing foreign body and remove if seen under direct vision. If not seen, repeat 5 back blows, 5 chest thrusts. If the patient becomes unresponsive, start CPR beginning with compressions. 15 to 2. At the beginning of each attempt at ventilation, use direct laryngoscopy to visualize if there is a foreign body. If you can see the foreign body, remove it with McGill forceps. If the obstruction is not relieved, continue CPR. If the foreign body is above the vocal cords, do a needle or surgical cricothyroidotomy. If the foreign body is below the vocal cords, perform an intentional right main bronchus intubation to advance the foreign body with the ET tube. Then pull back the ET tube and position the patient right side down, so left lung up, to ventilate the left lung. If unable to intubate, apply positive pressure ventilation in an attempt to force the foreign body in the left or main right bronchus. Immediate transfer to feeder for removal of the foreign body and establishment of a definitive airway. [ Silence ]