O&G ~ Short Answer

Question 1.

A 28 year old woman who is 32 weeks pregnant is brought in by ambulance to your base hospital. She complains of seeing flashing lights and having headaches. At triage, her vital signs are:

– Pulse rate 80 beats/minute

– Blood pressure 135/95mmHg

– Glasgow Coma Score of 15/15

As you start to assess her she has a grand mal seizure.

 

A.) What is the most likely diagnosis?

Show Answer

  • Eclampsia

(1 mark)

 

B.) What are the other complications in this scenario?

Show Answer

  • Base hospital
  • Likely no specialist neonatal services
  • Baby only 32 weeks gestation

(2 marks)

 

 C.) What is your immediate management?

Show Answer

  • Left lateral position
  • Resuscitation
    • Airway
      • Support until seizure terminates
      • If does not will need intubation and ventilation
      • Will be difficult airway – get anaesthetic help
    • Breathing
      • O2 to maintain O2 sats > 95%
    • Circulation
      • 2 x large IVC
      • Fluid bolus
    • Deformity
      • Stop seizures
        • MgSO4 bolus 4-6 g over 10-20 mins
        • Then infusion 1-2 g/hr
      • BP control
      • Emergent consult O&G for CTG and delivery of baby

(7 marks)

 

 D.) Give options for further BP control and what are their drawbacks?

Show Answer

  • Hydralazine
    • 5mg IV repeat every 20 mins
    • Hard to titrate; can over-shoot and cause hypotension
  • Labetalol
    • 20 mg IV then 40-80 mg every 10 min the infusion 1-2 mg/min titrated
    • Easier to titrate
    • IV formula not available in Australia
  • Nifedipine
    • 10 mg Po repeat every 30 mins
    • Oral, slow
  • Sodium nitroprusside
    • 25-5.0 mcg/kg/min infusion
    • Potential foetal and maternal cyanide toxicity
    • Last resort

(4 marks)

 

E.) What is HELLP syndrome and how does it present?

Show Answer

  • Haemolysis, elevated liver enzymes, low platelets
  • Epigastric or RUQ pain
  • +/- HTN

(2 marks)

 

F.) What are the laboratory results usually seen in HELLP syndrome?

Show Answer

  • Schistocytes on blood smear
  • Platelet count < 100, 000/mcL
  • Elevated ALT and AST but below levels usually seen in viral hepatitis i.e. <500 IU/L
  • Normal of elevated renal function
  • Abnormal coagulation

(4 marks)

 

 G.) What are the complications of eclampsia and HELLP syndrome?

Show Answer

  • Spontaneous hepatic and splenic haemorrhage
  • End-organ failure
  • Placental abruption
  • ICH
  • death of foetus
  • aspiration

(4 marks)

Author: J Haire

Ref: Tintinalli p. 697-8


 

Question 2.

A 32 year old multiparous woman presents via ambulance with marked per vaginal bleeding

following the precipitous delivery at home of her term infant 15 minutes previously. The infant is well and is under the care of the neonatal service. The ambulance service has been unable to establish intravenous access and her blood pressure is now unrecordable.

 

A.) What are the issues here?

Show Answer

  • Post-partum haemorrhage
  • Haemorrhagic shock

(2 marks)

 

B.) What are the likely causes?

Show Answer

  • Uterine atony
  • Cervical/vaginal/vulval lacerations
  • Uterine rupture
  • Uterine inversion
  • Retained placenta
  • Coagulopathy

(5 marks)

 

C.) List 4 risk factors for this condition?

Show Answer

  • Multiple pregnancy
  • Polyhydramnios
  • Large baby
  • Abnormal uterus e.g. fibroids
  • Prolonged or precipitant labour
  • Coagulopathy
  • Previous PPH
  • Forceps/operative delivery
  • Past Csection ? increased risk of adherent placenta

(4 marks)

 

D.) What is your initial management?

Show Answer

  • Emergent O&G consult – likely will need OT
  • Establish IV access
  • Send CXM
  • IV fluid bolus 1L and call for blood
  • Transfuse with O neg initially ? group specific ? CXM
  • Rub fundus/uterine massage and compression
  • Check birth canal for lacerations – suture
  • Manual removal of placental remains
  • Syntocin 10 U IV and start infusion (40 IU in 1L NSaline at 250 ml/hr)
  • Ergometrine 0.25-0.5 mg IV
  • IDC

(8 marks)

 

 E.) What further measures can be attempted in ED to stop the bleeding?

Show Answer

  • External abdominal aortic compression
    • Firmly place hand with palmar aspect caudad into abdomen just above umbilicus
  • Prostaglandins
  • Tranexamic acid
  • Factor VII
  • Bimanual pressure
  • Uterine tamponade
    • Packing
    • Foley balloon
    • Rusch catheter
    • Sengstaken-Blakemore tube

(4 marks)

Author: J Haire

Ref: Dunn p. 598-9


 

Question 3.

A 55 year old man is brought to hospital by ambulance complaining of severe headache, vomiting and blurred vision. On initial examination his BP is 260 / 145, similar in both arms. His Glasgow Coma Score is 14. CT scan reveals no abnormality.

 

A.) What is this condition?

Show Answer

  • Hypertensive encephalopathy

(1 mark)

 

 B.) What is the treatment?

Show Answer

  • Reduction in BP

(1 mark)

 

 C.) Pick 4 drugs that could be used for treatment and outline their doses, advantages and disadvantages.

Show Answer

  • GTN
    • 50mg in 50 mls 5% Dextrose
    • 3-20 ml/hr
    • Advantages
      • Familiar
      • Accessible
      • Easy to titrate
    • Disadvantages
      • Tachyphylaxis
      • Reactive tachycardia
      • Headache
    • Esmolol
      • 500 mcg/kg loading dose over 1 min then infusion of 0.200 mcg/kg/min
      • Advantages
        • Easily titratable
        • Controls heart rate too
      • Disadvantages
        • Contraindicated in COAD, asthma, DM
        • Decreases PR
        • Unfamiliar
        • Expensive
      • Sodium nitroprusside
        • 50mg in 50 mls 5% Dextrose; 0-20 ml/hr
        • Advantages
          • Titratable
          • Effective
        • Disadvantages
          • Unfamiliar
          • Need to protect from light
          • Potential for cyanide toxicity
        • Metoprolol
          • 1-15 mg IV in 1mg boluses
          • Advantages
            • Familiar
            • Accessible
            • Controls PR
          • Disadvantages
            • Less titratable
            • B blocker contraindications

(12 marks; no orals; reasonable choices)

 

 D.) What is your aim?

Show Answer

  • Reduce MAP by 15-20%

(1 mark)

 

 E.) What are the risks?

Show Answer

  • Hypotension
  • Can lead to ischaemic infarction
  • Autoregulation of cerebral perfusion may be impaired

(2 marks)

Author: J Haire

Ref: Tintinalli p.441-5


 

Question 4.

A morbidly obese but otherwise healthy 30 year old woman is brought to your emergency department suffering from shortness of breath after a 3 day viral prodrome.

You estimate her weight to be 150kg.

 

Her vital signs are

HR 125 /min

BP 80/60 mmHg

RR 34 /min

Temperature 38.8 0C

O2 Saturation 85 % 8 litres of O2 /min

A chest X-ray reveals an extensive bilateral infiltrate

 

 A.) What are the life-threats in this patient?

Show Answer

  • Septic shock
    • Febrile
    • Tachycardic
    • Hypotensive
  • Respiratory failure
    • Tachypnoea
    • O2 sats low despite high flow O2
    • Due to community acquired pneumonia + possible atypicals and viral cause

(2 marks)

 

 B.) What problems will her obesity cause?

Show Answer

  • Difficult airway
  • Difficult IV access
  • Drug dosing changes
    • Whether based on ideal or total body weight depends on drug
  • Bariatric nursing
  • Equipment issues e.g. Trolleys, CT scan etc.

(4 marks)

 

C.) Describe the techniques that can be used to facilitate IV access

Show Answer

  • Using longer catheters
  • Improve vessel access
    • Heat, light
    • Reactive hyperaemia
  • Ultrasound
  • Vessel choice
    • Medial Cubital V
    • Basilica V
    • Cephalic V
    • Dorsum of hands
    • External jugular
  • Central lines
    • Femoral V
    • positioning to roll away fat
    • Feed catheter 3-5 cm further

(3 marks)

 

 D.) How would you address this patient’s hypotension?

Show Answer

  • IV access
  • Aims
    • MAP > 65 mmHg
    • HR < 100 bpm
    • UO > 30 ml/hr
    • Lactate clearance > 10%
  • Initial fluid bolus 1L NSaline and repeat (not mg/kg)
  • If no response then move onto vasopressors
  • Central IV access and arterial line
  • Noradrenaline 6mg in 100 mls NSaline; 3-20 ml/hr; titrate to BP
  • Continue to reassess fluid status e.g. with IVC ultrasound and response to IV fluids

(5 marks)

 

 E.) How would you perform an RSI on this patient?

Show Answer

  • Maximise pre-oxygenation
    • Sit up
    • 15L NRB or NIV
  • Stabilise BP
    • As above
    • Have push-dose pressors ready
  • Prepare
    • Bariatric wedge
    • Optimal position (ear to sternal notch)
    • Most experienced intubator
    • Video laryngoscope
    • Bougie
    • 2 person BMV technique
    • Size 4 and 5 LMA ready
    • Cricothyroidotomy kit ready and landmarks marked and infiltrated with LA + adrenaline
  • drugs
    • ketamine 100-200 mg Iv titrated to effect
    • suxamethonium 1mg/kg based on total body weight = 150 mg push

(6 marks)

 

 F.) What ventilation parameters would you choose?

Show Answer

  • TV 8 mg/kg based on ideal body weight (45.5 kg + 0.9 kg/cm for every cm > 152 cm)
  • RR starting at 12-16 bpm
  • Titrate to pCO2
  • PEEP 10 mmHg

(2 marks)

 

 G.) Which antimicrobials will you start?

Show Answer

  • Severe CAP + possible atypical (bilateral infiltrates) + possible viral
  • Ceftriaxone 1g od IV + Azithromycin 500 mg od IV + oseltamivir 75mg bd

(3 marks)

Author: J Haire

Ref: Tintinalli p. 2012-17


 

Question 5.

This 65 year old woman with diabetes presented one week after some minor trauma to her right foot.

 O&G Pix1 SA

A.) List the abnormalities seen in this picture

Show Answer

  • Large necrotic ulcer medial aspect of right forefoot; deep, erythematous edges; purulent and necrotic material within ulcer
  • Previous amputation of large toe
  • Erythema medial aspect 2nd toe and over midfoot
  • Callous at base of where great toe should be
  • Skin atrophy (wrinkled and loss of hair) distal leg

(4 marks)

 

B.) What is this likely to be?

Show Answer

  • Diabetic foot ulcer

(1 mark)

 

C.) What are the differential diagnoses?

Show Answer

  • Venous ulcer
  • Arterial ulcer
  • Infective
  • Malignant

(3 marks)

 

 D.) What investigations will you perform?

Show Answer

  • For osteomyelitis
    • X-ray
    • Bone scan or MRI
  • Swab for m/c/s
  • Doppler US for arterial flow

(3 marks)

 

 E.) What is the management for this?

Show Answer

  • Surgical debridement
  • Antibiotics
    • Amoxycillin + clavulanate PO
    • If severe piperacillin/tazobactam or ticarcillin/clavulanate

(2 marks)

Author: J Haire

Ref: Tintinalli p. 1421-22


 

Question 6

This 24 year old female presented to the emergency department complaining of painful lumps and redness confined to her lower legs which had developed over the last two weeks.

O&G Pix2 SA

 A.) Describe the abnormalities in this picture

Show Answer

  • Patchy erythematous areas over the anterior leg
  • Minor swelling of the lower leg

(2 marks)

 

 B.) What is this?

Show Answer

  • Erythema nodosum

(1 mark)

 

C.) List 6 potential causes of this condition

Show Answer

  • Infectious
    • Fungal
      • Blastomycosis
      • Coccidioidomycosis
      • Histoplasmosis
      • Dermatophyte
    • Bacterial
      • Strep
      • Campylobacter
      • Yersinia
      • Tuberculosis
      • Leprosy
    • Parasitic
      • Leishmaniasis
      • Toxoplasmosis
    • Viral
      • Herpes simplex
      • EBV
    • Drugs
      • Sulphonamides
      • OCP
      • Penicillin
      • Bromides
      • Vaccines
    • Sarcoidosis
    • IBD
    • Pregnancy
    • Behcet syndrome
    • Leukaemia + lymphoma
    • Idiopathic

(6 marks)

 

 D.) What is the treatment?

Show Answer

  • Treat underlying disease
  • Symptomatic
    • Bed rest
    • Leg elevation
    • NSAIDs

(3 marks)

Author: J Haire

Ref: Tintinalli p. 1639


 

Question 7.

A 70 year old man with past history of COAD presents with two days of rash and fever. His only medications are metered aerosol inhalers of salmeterol and fluticasone.

His observations are all within normal limits.

O&G Pix3 SA

A.) Describe the skin abnormalities

Show Answer

  • Diffuse erythema
  • Diffuse scaling

(2 marks)

 

B.) What is this condition?

Show Answer

  • (Exfoliative) Erythroderma

(1 mark)

 

 C.) List the causes of this condition

Show Answer

  • Psoriasis
  • Eczema
  • Drug eruption
  • Lymphoma (Sezary syndrome)
  • Idiopathic

(4 marks)

 

D.) What are the complications of this condition?

Show Answer

  • Heat loss & hypothermia
  • Dehydration ? renal failure
  • high output CCF
  • sepsis
  • electrolyte disturbance
  • hypoproteinaemia

(4 marks)

Author: J Haire

Ref: Tintinalli p. 1617 & Dunn p. 219-20


 

Question 8.

A 25 year old man is brought to the emergency department complaining of chest pain for 48 hours.

O&G Pix4 SA

A.) Describe the main abnormalities in this ECG

Show Answer

  • St elevation in (1mm); aVL (2mm); V1 (1mm); V2 (4mm); V3 (3mm); V4 (2mm)
  • ST depression III (2mm)
  • Hyperacute t waves V2-4

(3 marks)

B.) What is the most life-threatening diagnosis?

Show Answer

  • Anterior septal MI

(1 mark)

C.) What is the differential diagnosis and what goes against them?

Show Answer

  • Benign early repolarisation
    • But not widespread
    • Reciprocal ST depression in III
  • Pericarditis
    • No PR depression
    • No opposite changes in aVF
    • Reciprocal ST depression in III
  • LV aneurysm
    • No q waves
  • Hypothermia
    • No Osborn waves
  • Hyperkalaemia
    • QRS not wide
    • Not all T waves peaked

(8 marks)

D.) What is an investigation that may be done in the emergency department that may help?

Show Answer

  • Bedside echo looking for wall motion abnormality

(1 mark)

Author: J Haire

Ref: ECG in Emergency Medicine and Acute Care p. 60-65


 

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