Pray for me and my Family

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 Feedback 2 March 2017
London
Frcem Intermediate
Prepared by:
Hani Hammouda
and all members in this group
I’m just one member of this group

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Email:
[email protected]
00966562372833
http://facebook.com/hanywaheb134
 FRCEM
GROUPS
FRCEM Primary, Intermediate SAQ, Intermediate SJP &
MRCEM OSCE

1-FRCEM Primary
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2-A-FRCEM Intermediate SAQ

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2-B-FRCEM Intermediate SJP

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3-MRCEM (OSCE) Objective Structured Clinical Examination
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FRCEM Final Examinations

4-FRCEM FINAL Clinical SAQ

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5-FRCEM FINA Critical appraisal SAQ

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6-FRCEM FINAL QIP (no viva)

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 7-FRCEM FINAL OSCE
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8-FRCEM OET/IELTS
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1-CC3-Therapeuticsandsafeprescribing
(Common Competences)
A 40 year-old-female patient presented to ER with history of giddiness and syncope. These symptoms were started after she had
recent history of loose stool and vomiting multiple episodes for which she took treatment. She is complaining of bipolar disorder
and she is on lithium medications.
a-Give (2) reasons why we are using drug level monitoring? (1 mark)
b-Give (2) possible reasons, why was lithium level raised in this patient? (1 mark)
c-Give (2) other drugs that have narrow therapeutic index? (1 mark)

https://www.nps.org.au/australian-prescriber/articles/therapeutic-drug-monitoring-which-drugs-why-when-and-how-to-
do-it

a-
For some drugs, therapeutic drug monitoring helps to increase efficacy (vancomycin), to decrease toxicity (paracetamol) and to
assist diagnosis (salicylates).

Any 2 of :

The appropriate indications for therapeutic drug monitoring (and examples) include:
1-(Diagnosing toxicity) when the clinical syndrome is undifferentiated (unexplained nausea in digoxin)
2- avoiding toxicity (aminoglycosides, cyclosporin)
3- (Dosing ) after dose adjustment (usually after reaching a steady state)
- assessment of adequate loading dose (after starting phenytoin treatment)
- dose forecasting to help predict a patient's dose requirements1 (aminoglycosides)
4-(monitoring)- assessing compliance (anticonvulsant concentrations in patients having frequent seizures)
- diagnosing under treatment ( prophylactic drugs such as anticonvulsants, immunosuppressants)
- diagnosing failed therapy (therapeutic drug monitoring can help distinguish between ineffective drug treatment, non-
compliance and adverse effects that mimic the underlying disease).

b-Possible causes are:

1-Narrow therapeutic index (0.6-1.2mmol/l) it means that small elevation on the normal level, it causes toxicity.
2-Those patient with bipolar disorder are prone for a dosage increase accidentally.
3-Dehydration, electrolytes imbalances, kidney function impairment.
4-Interactions with other medications.

c-
1- Digoxin
2- Warfarin Sodium Tablets
3- Theophylline
4- Carbamazepine
5- Phenytoin
6- Procainamide
7- Levothyroxine Sodium
2-C3AP1b-Major trauma (MT) -Abdominal
(Acute Presentations)
15 year-old-footballer had blunted abdominal trauma, presented with left side chest pain and upper abdominal pain, FAST done,
and it was normal, the patient hemodynamically stable.
a-What is the diagnosis (cause) of abdominal pain? (1 mark)
b-What is your investigation? (1 mark)
c-What is your management? (1 mark)

a-Blunt Splenic Injury (rupture)

b-Contrast Helical CT scan of Abdomen

c-ABCDE approach, (2) IV cannula, bloods, G & S, cross match, IV fluid, IV analgesic, N.P.O, N.G.T and refer to surgical
team on call, involve ED senior, close monitoring in resuscitation area.

3-PAP16-Atraumatic limb pain

(Acute Presentations)
An 11-year-old boy presents with his parents to the ED having developed a limp over the last week.
a-What is the X-ray view? What is the abnormality in X-ray? (1mark)
b-Name and describe the radiological sign associated with this abnormality? What is the most complication? (1 mark)
c-Give (2) differential diagnosis? (1 mark)
a-lateral frog leg view - (S.U.F.E) right hip

b-Trethowan's sign (Klein line drawn above superior border of femoral neck should transect femoral epiphysis), -Avascular
necrosis.

c-1-Septic arthritis 2-Osteomylities

4-PP8-Intercostal Drain – open

(Procedural Competences)
30 year-old-male patient presented with R.T.C with trauma left side of chest X-ray done and shown below:
a-What borders of safe triangle? (1mark)
b-How to avoid neurovascular injury? (1mark)
c-Give (2) complications? (1mark)
a-lateral border of pectoralis major and anterior border of latissimus dorsi just anterior to midaxillary line.

b-insert in safe triangle in 5th intercostal space above the 6th rib just anterior to midaxillary line.

c-
1-Injury to Intra-thoracic organs (lung, diaphragm, heart, pleura)
2-Malposition (extra-pleural/or insertion in subcutaneous tissue
3-Hematoma &bleeding.

5-PAP13-Neonatal presentations
(Acute Presentations)
A 20-year-old female who is 39 weeks pregnant presents to the ED in active labor. An obstetrician is called and within 10
minutes of her arrival, the patient has delivered her baby. You are managing the care of the newborn baby.

a-After turning on a stopwatch, what will you do immediately in managing this newborn? (1 mark)
b-Besides heart rate and breathing, what two further features will you assess in this newborn? (1 mark)
c-The newborn starts to cry, when will you clamp theumbilical cord? (1 mark)

a- Dry the baby, remove the wet towels, and cover the baby with dry towels

b-
-Activity/muscle tone (e.g. limp, active movements)
-Color (e.g. pale, blue, pink)
-Grimace reflex irritability (e.g. grimace, cry)

c-For healthy term infants delaying cord clamping for at least one minute or until the cord stops pulsating following delivery
improves iron status through early infancy
6-Transfer Medicine
(Anesthetic Competences CT1&2)
33 year-old-male patient need to be transferred to I.C.U on O2 10L/min for 15 minutes
a-What monitoring is required en-route? (1 mark)
b-How much oxygen is required for transfer – show your calculation? (1 mark)
c-Which size oxygen cylinder will you need for transfer? (1mark)

a- Continuous ECG/ Non-invasive BP /pulse oximetry and capnography.

b- 2 x [flow (L/min) x length of transfer (min)] = 2 x [10 x 15] = 300 L

c-Size D oxygen cylinder (340 L)

7-CAP33-Traumatic isolated left lower limbinjury.

(Clinical Presentation)
A 12 years-old-male is brought to ED with a swollen, painful right ankle after falling in roller-skates. he is unable to weight
bear on his right foot. On examination thereis swelling and tenderness over the medial malleolus. An X-ray ofhis ankle has
been performed and is shown below:
a-What is the abnormalities in this X-ray? (1 mark)
b-What is the complication? (1 mark)
c-What is your management? (1 mark)
a- (Salter Harris type III)Tillaux fracture.

b-Growth plate arrest (The involvement of the epiphyseal plate may cause premature closingresulting in limb shortening and
abnormal growth.)

c-Analgesia/bed rest/backslap/elevation/refer to orthopaedics

8-CAP24-Painful Ear (Clinical Presentation)
35 year-old-male patient whilst performing a full examination of a patient presenting with dizziness, you examine the patients
ears. Regarding the viewseen on otoscopy below of the left ear:

a-What is the finding on the image? (1 mark)

b-Regarding Weber and Rinne tests what results would you typically expect for both tests?
c-How is this condition usually managed in the first instance? (1 mark)

a. Perforated tympanic membrane

b-Conductive deafness in the same ear:

Weber test -sound is loudest in the left ear
Rinne test-negative in the left ear (BC > AC) and positive in the right ear (AC > BC)

c. Conservatively-
Analgesic, antibiotic, most perforations will heal spontaneously within 6 – 8weeks. The patient should be advised to keep the
ears dry and avoidinserting anything into the ear.

9-PP26-Deliver a fluid challenge safely to an

acutely unwell patient(procedural competences)
An 85 year-old-male patient is brought into AED by ambulance looking unwell. His observations are: temp 39.5°C, BP 90/50,
HR 115 bpm, RR 20, Sat 94% on air. known case of heart failure. His bloods are shown below:
Hb 12 g/dL (M:13 – 18, F:11.5 – 16)
Platelets 350 x 10^9/L (150 – 400)
WCC 18 x 10^9/L (4 – 11),
a-How will you give fluid? (1 mark)
b-What are noninvasive methods to reasses the response? (1 mark)
c-Bedside method to assess the fluid response? (1 mark)
a-Fluid challenge (250-500 ml0.9 Na CL) Bolus over 10-15 minutes.

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

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

http://www.osce-aid.co.uk/osce.php?code=osce_feverinareturnedtraveller

a- any 2 of:
1-Timing of symptoms Onset, course and duration?
2-Travel history Which countries? Urban / rural environment? Types of accommodation? Dates of entering each
country/returning home?

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

b-Complicated falciparum malaria

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

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

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

11-Breathlessness-CAP6 (Respiratory)
An 18-month-old girl is brought to ED by her mum after she had a choking episode while playing with a TV remote control
a-What is the possible diagnosis? (1 mark)
b-Give (2) complications of this diagnosis if left untreated? (1 mark)
c-What is the definitive management of this condition? (1mark)
a. Foreign body (button battery) in the esophagus

b-Any two of:

-Esophageal (mucosal erosion/ulceration/necrosis/stricture
-Esophageal perforation (neck swelling, crepitus, pneumomediastinum)
-Esophageal fistula e.g. into trachea, aorta
-Gastrointestinal (hemorrhage /perforation)

c-Endoscopic removal of the foreign body

12-CMP6-Unconscious patient
(Clinical Presentation)
A 69-year-old lady with a history of type 2 diabetes mellitus for which she takes metformin, is brought to AED by ambulance.
She has been in bed for the last couple of days with a Flu-like illness. She is drowsy, confused and dehydrated. Her blood
resultsare shown below:
PH 7.3 (7.35-7.45)
K+ 4.5 mmol/L (3.5 – 5.3)
Na+ 145 mmol/L (135 – 145)
Urea 25 mmol/L (2.5 – 6.7)
Creatinine 170 mmol/L (50 – 150)
Glucose 32 mmol/L
HCO3 16 mmol/l
a-What is your diagnosis? (1 mark)
b-Give (2) things to do immediately? (1 mark)
b-Calculate this patient’s osmolality, showing your workings? (1 mark)

a-HHS

b- ABCDE approach /I.V access, I.V fluids,Insulin, low molecular weight heparin,antibiotics.

c- Calculated osmolality = [2 (Na+ K) + Glucose + Urea] = [(2 x (145+4.5) + 32 + 25]= 356mOsm/kg

(N.B. normal serum osmolality is 275 – 295 mOsm/kg)
13-CAP20-Limb Pain and Swelling-Atraumatic
(Clinical Presentation)
A 23 year-old-male presents to ED with an acutely swollen and very painful right index finger. He sustained a minor puncture
wound to the pulp of his right index finger a few days ago after a cat bite. He has since developed tight swelling and redness of
the entire right index finger.

a-What diagnosis should be considered in this patient? (1 mark)

b-Give (2) of the cardinal signs of this diagnosis. Not shown in the picture? (1 mark)
c-What is your management? (1 mark)

a-Flexor tendon sheath infection(tenosynovitis)

b-
-Tenderness over flexor tendon
-Extreme pain on passive extension

c-Diagnosis is clinical.
-Analgesic titrate to pain, rest, elevation, refer urgently for tendon sheath exploration, irrigation, drainage +/- debridement and
intravenous antibiotic therapy

14-A3-InductionofGeneralAnesthesia
(AnestheticCompetencies)
40 year-old-male patient presented with facial burn after GAS explosion G.C.S 15/15 and all vital signs within normal.
a-Give two signs of airway obstruction? (1 mark)
b-Give two immediate actions if intubation failed? (1 mark)
c-which intubating drug may be contraindicated in burn in that patient? (1 mark)
a-
-Hoarseness, stridor, agitation
-pharyngeal, laryngeal edema, cyanosis.

b-
-Call for help& anesthetist, cease intubation attempts, raise the head 30 degree.
-Re-oxygenate using BVM ventilation O2 100% before the SpO2 reaches the steep part of the oxyhemoglobin dissociation
curve: this point is 92%.

c-Suxamethonium

15-CAP21-Neck pain(Clinical Presentation)

40 year-old-lady patient presented with Atraumatic Neck Pain and right deltoid weakness.
a-Which nerve root is involved? (1 mark)
b-Give (2) indications of imaging studies? (1 mark)
c-How to check sensory lesion? (1 mark)
https://www.rcemlearning.co.uk/references/non-traumatic-neck-pain/

a-C5 and C6 Roots.

b-
1-Possible cord compression and or spinal canal stenosis. (radiculopathy and or myelopathy)
2-Neck pain associated with red flags or persistent neck pain beyond 6 weeks.

c-Check sensation in:

1-Regimental badge area (loss of sensation in the area below the deltoid muscle as the nerve innervates this area.
2-Thumb

https://www.practicalpainmanagement.com/pain/spine/neck-pain-diagnosis-management?page=0,1

Notes:
Red flags in spontaneous neck pain:

-Presentation in patients less than 20 or over 55 years of age

-Constant, progressive pain
-Past history of carcinoma
-Systemic steroids
-Drug abuse, HIV
-Systemically unwell
-Weight loss
-Persisting severe restriction of cervical flexion
-Inflammatory disorders such as ankylosing spondylitis and rheumatoid disease

16-CAP25-Palpitation(Clinical Presentations)
A 61-year-old woman, with a history of hypertension, presents to AED complaining of sudden onset palpitations which came
on about 2 hours ago. Her observations are: BP 125/95, HR 150 bpm, RR 20, Sat98% on room air, temp 36.7C. Her ECG is
shown below:
a-Interpretation of ECG? (1 mark)
b-Give (2) investigations will you do? What bedside test will you do? (1 mark)
c-His BP drops to 80/55 what is your immediate action? (1 mark)
a-Atrial fibrillation with rapid ventricular rate with RBBB

b-
1-FBC (for infection)
2-U&E (for predisposing factors)
3-TFTs (for hyperthyroidism)
4-Clotting Profile(INR,APTT) for HASBLED criteria
5-Cardiac enzymes(Troponin) (for IHD)

-Echocardiography,portable chest X-ray.

c-Synchronized DC Shock 120-150 J biphasic.

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

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

a-What age group? (1 mark)

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

a-> 3 months.

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

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

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

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

b-C.T.G continuous monitoring for 4-6 hours / Fetal doppler U/S / Umbilical artery Doppler U/S / kleihauer test

c-Placenta abruption.

19-CAP37-Weakness and paralysis

(Clinical Presentations)
33 year-old-male patient presented with eyedisorder, image shown below:
a-What are the findings in this patient? What is your diagnosis? (1mark)
b-Give (2) causes? (1mark)
c-Give (2) investigations? (1mark)

a-
-Esotropia(a convergent squint),diplopia.
-Intorsion of right eyeball
- Abducens Nerve (6th Cranial Nerve) palsy

b-
1-More common: Vasculopathy (diabetes, hypertension, atherosclerosis), trauma, idiopathic.
2-Less common: Increased intracranial pressure, giant cell arteritis, cavernous sinus mass ,multiple
sclerosis, sarcoidosis/vasculitis, post myelography, lumbar puncture, stroke, Chiari Malformation,
hydrocephalus, tuberculosis meningitis.

c-CT/MRI,LP.

20- CC10-Infection Control

(Common Competences)
An 80 year old lady is brought to AED with profuse waterydiarrhoea ongoing for 2 days. She was discharged from hospital
aweek ago where she had been having treatment for a UTI.
a-Besides hand hygiene how will you prevent transmission? (1mark)
b-Other than antibiotics, what other type of drug increases the risk of C. difficile colitis? (1 mark)
c-What is the first line treatment for C. difficile colitis? (include dose and duration) (1mark)
a-Isolation / wear PPE /contact precaution /alert all staff / inform Infection control department, involve infectious disease
specialist, wipe any shared with disinfectants

b-Acid suppressing drugs e.g. PPI or H2-receptor antagonist.

c- Metronidazole 400 – 500 mg t.d.s for 10 – 14 days

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

a-What is your diagnosis? (1mark)

b-What is the possible cause of syncope in this patient? (1mark)
c-What is your (2) treatments? (1mark)
a-Tri-fascicularblock.(R.B.B.B+L.A.H.B+1st degree A.V block)

b-Transient globular cerebral hypo-perfusion due to arrhythmia.

c-
-Temporary(transcutaneous/transvenous) pacing.
-Permanent transvenous pacing

22- I CM5-Connects mechanical ventilator and

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

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

b- Any two of:

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

23-PAP2-Accidental poisoning
(Acute Presentations)
A 14 year old male has been brought into the Emergency Department by ambulance after being found unconscious in a locked
garage following an attempted suicide attempt. He hasattached the exhaust pipe with a hose into the interior of the car. It is not
known how long he had been inside the garage. High anion gap acidosis,lactate 2.6,CoHb 20%
a-What are non-respiratory causes of cyanosis? (1mark)
b-What is the possible diagnosis? (1mark)
c-What is your immediate management? (1mark)

a-
1-CNS (impairing ventilation)e.g.(ICH,Drugoverdose,Tonic-Clonicseizure)
2-cardiovascular system. (congenital heart disease,heartfailure,valvular heart disease,MI)
3-blood(Methemoglobinemia,polythythemia,congenital cyanosis)
4-Others(Sepsis, High altitude,hypothermia,obstructive sleep apnea)

b- Severe Carbon monoxide poisoning.

c-
-Call for help, anesthetist and pediatrician) ABCDE Approach with high flow O2 100%, consider early intubation &
ventilation, I.V access, bloods, I.V fluids, ABG, ECG, involve ED senior, discuss with NPIS.
-Consider admission for observation, consider hyperbaric O2

24-CAP38-Wound Management
(Clinical Presentations)
A 30year-old-man-patient presented with wrist wound after 12 hours,image done and shown below:
a-What is your immediate action? (1mark)
b-What features from (History and Examination) indicates prone wound? (1mark)
c-What intervention will you do to decrease risk of tetanus? (1mark)
a-
-ABCDE approach, I.V access, I. V analgesia, control bleeding, Neurovascular assessment,Dressing (clean with NSS and
irrigate)
-Exploration&Debridement,remove foreign bodies, X-ray Wrist, blood tests/ Involve Orthopedics and or plastic surgery.
-Prophylactic antibiotics

b-
1-More than 6 hours and need surgical intervention.
2-Significant Devitalized tissue in the image.

c-
-Irrigation with copious N.S &remove foreign bodies, removehematoma, prophylactic Broad-spectrum antibiotics.
-Tetanus toxoid in one arm I. M plus Tetanus human immunoglobulin 250-500 I.U in the other arm I. M.

25-C3AP1c -Major Trauma–Spine

(Acute Presentations)
A 60 year-old-malepresented with history of a fall from 20 feet, X-ray done and shown below:
a-What is the abnormalities in X-ray? (1mark)
b-What other (2)modalities of investigations? (1mark)
c-What is your management? (1mark)
a-L1 Anterior compression fracture (wedge fracture)

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

c-ABCDE approach with high flow O2 with C-Spine protection, whole spine immobilization and protection with board, I.V
access, bloods, I.V analgesic titrate to pain (morphine 2.5-10 mg), neurological examination, apply corset or brace, refer to
orthopedics

26-PP2-Central venous cannulation

(Procedural Competences)
A 45 year-old woman is brought into ED in cardiac arrest, during resuscitation, your consultant asks you to insert a femoral
central line.
a-Describe the anatomical landmarks used to identify the femoral vein? (1 mark)
b-Give (2) contraindications to femoral line insertion? (1 mark)
c-How can you improve the technique of central line insertion? (1 mark)
a-The surface anatomy of the femoral vein is identified for venipuncture by palpating the point of maximal pulsation of the
femoral artery immediately below the level of the inguinal ligament (at the mid-inguinal point) and marking a point
approximately 0.5-1 cm medial to thispulsation.

b-Any two of:

Absolute
1-Venous injury (known or suspected) at the level of the femoral veins or proximally (i.e., iliac veins or inferior vena cava)
2-Known or suspected thrombosis of the femoral or iliac veins on the proposed side of venous cannulation
3-Ambulatory patient (because ambulation increases the risk of catheter fracture and migration)
Relative
1-Presence of bleeding disorders (innate or iatrogenic from the use of anticoagulants or thrombolytics)
2-Distortion of anatomy due to local injury or deformity
3-Previous long-term venous catheterization (which increases the risk of venous thrombosis)
4-Absence of a clearly palpable femoral artery
5-History of vasculitis
6-Previous injection of sclerosing agents
7-Previous radiation therapy

c-Confirm I.D &site,consent, adequate anaesthesia, AMPLE history, aseptic technique, U/SS guided

27-C3AP7-Needlestick Injury. (Acute Presentations)

Nurse presented with Needlestick Injury after injecting patient in ward

a-What are high risk needlestick injuries? (1mark)

b-Features of high-risk HIV if source is unknown? (1mark)
c-Which other infectious disease should be screen? (1mark)

a-
●Hollow, wide-bore needle
● Visible blood on the device
● Gloves not worn or worn but torn
● Deep puncture wound
● Injury with needle that had been placed in the donor’s artery or vein.
● Contaminated material injected.
● Exposure through broken skin or mucous membranes

b-
● Terminal HIV-related illness
● Acute liver disease
● IVDU (past or present)
● Recipient of blood products or organ.
● From a country with a high prevalence of blood-borne viral disease.
● Homosexual men.

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

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

b-Give (2) additional features? (1 mark)
c-Give (2) treatments you could give in AED to relieve his symptoms. (1 marks)

a. Cluster headache

b- (Ipsilateral lacrimation, rhinorrhea, nasal congestion, eyelid swelling,flushing, conjunctival injection, constriction of the
pupil, ptosis).

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

29-PMP6-Unconscious Child
(Major Presentations)
An 8 year old is brought to ED by his parents with fever,headache and myalgia over the past 24 hours with increasing lethargy
over the last few hours. On examination you note he is
pyrexia (temp 38.7°C), drowsy and photophobic. There is no focal neurology but Kernig’s sign is positive,BP90/50,mottled
skin.
a-What is your diagnosis? (1mark)
b-Which drug to give immediately? (1mark)
c-What will be the CT finding? What are indications for CT head scan? (1mark)
a-Meningococcal septicemia.

b-Intravenous ceftriaxone 80 mg/kg.

c-
-Frontal sinusitis,empyema, abscess formation,cerebral edema or midline shift.
-Signs of raised I.C.P, irregular breathing, CNIII palsy, decreased or fluctuating consciousness

30-CAP34-Vaginal Bleeding
(Clinical Presentations)
15 year-old-girl presented with vaginal bleeding and suspected ectopic pregnancy,refusing to give urine sample
a-Give (2) immediate investigations? (1mark)
b-What is your management? (1mark)
c-what are special considerations in this case? (1mark)

a-Abd U/S,serum BHCG and Rh status

b-
Call OBY&GYN/ History &Examination,ABCDE Approach with high flow o2, I.V access, bloods,analgesic titrate to
pain,NPO, NGT, I.V fluids,G&S, cross match / Observation with Full monitoring, ask for legal representative, involve ED
senior

c-
-Inform social service, pediatrician, ask for legal representative, police, I.C department (risk of STI) / GUM Clinic, ring her
G.P
31-CC19-Legal framework for practice
(Common Competences)
35 year-old-lady presented with complain of her husband hit her,she came with her child and her mother.
a-What is your immediate action? (1mark)
b-She wants to go, What advice to her? (1mark)
c-Who will you inform? (1mark)

a-Patient safety and treatment is priority,analgesic/make an emergency plan/Monitor the woman and her children’s safety by
asking about any escalation of violence/child protection order/child safeguarding/inform police/make report/Document all

b-Empower her to take control of decision making; ask what she needs and present her with choices / persuade her to wait and
talk with social services and inform police / law enforcement / counselling

c-Social services/ED senior/police(Domestic violence)

32-PP5-Practical Procedures Lumbar puncture

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

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

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

a-12 hours.

b-
-L3-L4 L4-L5 L5-S1
-Position
- (Seated flexed)
-(Flexed right or left Lateral decubitus) fetal position.

c-Xanthochromia (spectrophotometry)
33-PP1-Arterial cannulation
(Procedural Competences)
You are working on an intensive care unit when a patient is admitted from an emergency department following a large mixed
overdose. Your consultant asks you to insert an arterial radial line.

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

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

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

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

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

b-Complications:
-Pain / Hematoma/bleeding / Infection / Permanent ischemic damage
-Pseudoaneurysm formation / Thrombosis / Arteriovenous fistula
-Air embolism / Compartment syndrome / Nerve injury (median nerve)

c- Reasons for dampened / no waveform:

1-Bubbles in catheter or system / Improper zero or transducer calibration
2-Cannula(displacement into tissues/clotting/kinking/tip against vessel wall)
3-Incorrect stopcock position / Loose connection / Compliant tubing
4-Loss of counter-pressure from bag / Loss of IV fluid
5-Tubing kink / Monitor off/incorrect settings.
34-CAP7-Chest pain
(Clinical Presentations)
(Patient presented with central chest pain, ambulance team gave him GTN and Aspirin 300mg/po. The chest pain 9/10
a-What is your diagnosis? (1mark)
b-What (2)drugs will you give? (1mark)
c-What is the definitive management? (1mark)

a-Acute posterior MI.

b-Morphine 2.5-10 mg I.V (pain 9/10)/Clopidogrel 600mg (p.o)

c-PPCI.

35-PAPS-Bronchiolitis(Acute Presentations)
4 months baby with (Temp 37.8) (O2 sat 91%). symptoms of coryza,persistentcough,crackles.
a-What is your possible diagnosis? (1mark)
b-Give (2) indications of intubation? (1mark)
c-Give (2) indications for admission rather than O2 Sat %? (1mark)
a-Bronchiolitis

b-indications of intubation
-> increased WOB despite NIV
-> deterioration despite CPAP
-> not tolerating CPAP and continuing to desaturate
->apnea
-> transport

C-
-RR more than 70 b/min
-Apnea/feeding difficulty more than 50%of normal.

36-PP13-DC Cardioversion
(Procedural Competences)
37 year-old-male with central chest pain & BP 85/55.
a-What features from (history and examination) indicates instability? (1mark)
b-What DC shock if the patient is VT? (1mark)
c-What DC shock if the rhythm changed to atrial flutter? (1mark)

a-Central chest pain (Myocardial Ischemia) / shock(85/55)

b-Synchronized DC shock 120-150 j (biphasic)

c-Synchronized DC shock 70-120 j(biphasic)

37-C3AP8-Testicular pain(Acute presentation)
A 14 year-old-male presents to AED with an acutely painful, red, swollen scrotum. After examining the patient, your clinical
suspicion for testicular torsion is equivocal.
a-Give (2) signs to confirm testicular torsion? (1 marks)
b-What is your investigation? What is the definitive treatment? (1 marks)
c-Most common diagnosis if there is no torsion? (1 marks)

1-Loss of cremasteric reflex (an immediate contraction of the cremaster muscle that pulls up the testis ipsilaterally).
2-Tender testis retracted upwards (lifting the testis increases pain).

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

c-Torsion of testicular or epididymal appendage (Appendix torsion)

-Age 0-11 year, the most common Differential diagnosis if no testicular torsion is (Appendix torsion) 62%

-Age 12-16 year, the most common Differential diagnosis if no testicular torsion is (Appendix torsion) 32%

-Age 17-40 year, the most common Differential diagnosis if no testicular torsion is (Epididymitis) 27%
38-ICM9-Safe use of vasoactive drugs and electrolytes
(ICM within ACCS)
30 year-old-man patient presented with chronic diarrhea severe hypokalemia 2.4 mmol/L, need 40 mmol/L KCL infusion with
1000 ml 0.9 N. S)
a-What is the rate of the infusion? (1mark)
b-What is your investigation? Why? (1mark)
c-Give (2) complications? (1mark)

a-10 mmol/L KCL per hour so, 40 mmol/L over 4 hours so,250 ml/hour.

b-
-Mg++
-Hypokalemia always associated with hypomagnesemia, Correction of Mg++ ease correction of K+.

c-
-Phlebitis.
-Arrhythmia.
-Cardiac arrest.

39-PAP7-Dehydration secondary to diarrhea and

vomiting(Acute Presentations)
A 3-year-old girl is brought to the ED by her concerned parents. They tell you she has been vomiting for the last 24 hours and
experienced diarrhea for the last 8 hours. She is taking small amounts of oral fluid and has passed urine once in the last 24
hours. On examination you note the child appears irritable and has pink, warm extremities. She has sunken eyes and you note
dry lips and oral mucosa. Her observations at triage are: HR 150, RR 35 and a CRT of 2 seconds. She has no significant past
medical history and her immunizations are up to date.

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

b. List four features of clinical dehydration present in this child? (1 mark)
c. Describe the fluid replacement regime that should be used in this child? (1 mark)
a-Viral gastroenteritis

b-Decreased urine output/Irritable/Sunken eyes/mucous membranes/Tachycardia/Tachypnoea

c-As the child is clinically dehydrated and tolerating oral fluids initial management is with oral rehydration solution (ORS).50
ml/kg (deficit replacement) plus maintenance fluids over 4hoursIf oral fluid is tolerated, the child can be discharged from ED
40-CC16-Health promotion and public health
(Common Competences)
Regarding to Alcohol consumption
a-Define harmful alcohol?
b-What is safe limit for women?
c-what (2) advice rather than stop?
a-Pattern of alcohol consumption that cause (psychological,organic or physical) harm .

b-Maximum 14U/weak, 3U/day for male and female.

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

41-C3AP9-Urinary retention(AcutePresentations)
A 72 year old male attends your department. He has been unable to pass urine for the last 16 h. He has severe suprapubic
discomfort and is very distressed. He managed two drops for the triage nurse when asked for a urine sample.
a-Which important examination should be performed prior to catheterization and what would it specifically assess? (1mark)
b-He is catheterized and has a residual volume of 1.6 liters. Over the next three hours, he passes 230, 300 and 250 mls of
urine.What does it mean and what is your action? (1mark)
c-What important factors must be documented in his notes regarding this procedure and his presentation that will guide short-
and long-term management plans? (Nice guidelines) (1mark)

a-Examination
1-Gross neurological examination including pupils
2-DRE describing size, consistency and texture of the prostate
3-Scrotal examination
4-Any PR tenderness and stool
5-Perianal tone and perianal sensation

b-
1-Post obstructive diuresis
2-The diuresis may be prolonged for several days
3-Hypovolaemia and death is possible
4-Serial monitoring of electrolytes and renal function is necessary
5-He should be admitted, an iv started and strict fluid balance maintained
c-Documentations

Procedure
1-Consent gained
2-Ease of procedure
3-Type and size of catheter
4-Volume drained from bladder by catheter insertion
5-Hourly urine output

History
1-Frequency
2-Nocturia
3-Post micturition dribble
4-Double micturition
5-Hesitancy
6-Strangury
7-The extent and duration of these symptoms
8-Previous urological surgery
9-Constipation and tenesmus
10-Drug history

Notes:
Post obstructive diuresis can be a problem after relief of retention. Some patients can pass as much as 8 -20 L/day. Cardiac
failure or renal insufficiency patients, especially if they have marked peripheral oedema, are at high risk. Severe dehydration
and postural hypotension can occur. Hourly urine outputs must be recorded and should be less than 200 ml/h as a general rule.
High risk patients for this condition are often found to have a RV>1000 ml and impaired renal function. Up to 70% of men will
have recurrent retention within one week if the bladder is simply drained.

42-PAP15-Pain in children
(Acute Presentation)
A 5-year-old is brought into ED after pulling a pan of boiling water off the stove onto herself. She has partial thickness burns
covering her half of anterior trunk, half of left arm and left forearm. She has superficial epidermal burns to her right anterior
upper arm.
a- Calculate the total body surface area affected by burns using the Lund-Browder diagram provided. (1 mark)
b-What analgesia (including route and dose) would be most appropriate to give this patient? (1mark)
c-Give two non-pharmacological adjuncts that could be used to help manage the pain?
(1 mark)
a. Anterior trunk (13%/2) + [half left arm and left forearm (2%+1.5%)] = 10%

(N.B. Erythema (superficial burn in right arm) should not be included when calculating burn area)

b. Intranasal diamorphine 0.2 ml volume containing 0.1 mg/kg or intravenous morphine 100 micrograms/kg.

c. Any two of:

1-Cooling packs and dressings for burns
2-Parent and family member involvement
3-Child-friendly environment.
4-Explanation with reassurance.
5-Distraction with toys, blowing bubbles, reading or storytelling/*Play specialist

43-CAP4-Agrressive disturbed behavior

(Clinical Presentations)
A 23 year old man is brought into AED by his girlfriend, complaining of hearing voices. Whilst in the department he becomes
increasingly agitated and aggressive towards staff.Despite attempted
de-escalation, the patient refuses oral treatment and it is decided that the patient requires rapid tranquilisation to keep both the
patient and staff safe
.

a-Give (2) possible causes of aggression? What drug should be used first line in this patient? (1mark)
b-What bedside tests? After what time of IM drug will you repeat? (1mark)
c-He developed acute dystonic reaction, What drug (including dose and route) should be given immediately to this patient?
(1mark)

a-
Functional mental health disorders (depression, anxiety,manic depression, and schizophrenia).

Organic mental health disorders (dementia, delirium, head injury, chronic substance misuse/withdrawal, temporal lobe
epilepsy, intracranial tumors, encephalitis, and metabolic disturbances (e.g. hypoglycemia, hypo/hyperthyroidism).

- (IM lorazepam)

b-Blood sugar/ABG/ECG (15-30minutes.) and if there is partial response to lorazepam.

c. Procyclidine 5 mg IV or benztropine 1 – 2 mg IV

Notes:
Functional mental health disorders
are those that are not due to a simple structural abnormality of the brain. Examples include depression, anxiety,
manic depression, and schizophrenia.

Organic mental health disorders

are due to an identifiable impairment of the brain. Examples include dementia, delirium, head injury, chronic
substance misuse/withdrawal, temporal lobe epilepsy, intracranial tumours, encephalitis, and metabolic disturbances
(e.g. hypoglycaemia, hypo / hyperthyroidism).
44-PP16-Reduction of dislocation / fracture
(Procedural Competences)
37 year-old-male-patient presented with ankle dislocation with intact Neurovascular Examination,image shown below:
a-What are the (4) indications for urgent reduction rather than neurovascular injury? (2marks)
b-Give (2) things to do after reduction? (1mark)

a-
1-Gross deformity.
2-Severe stretching of the skin.
3-Severe pain not responding to strong analgesic.
4-Fracture appear in X-ray.
5-Open fracture dislocation.
6-Dislocation for more than 24 hours.
7-Amputation of distal foot.

b-
1-Recheck neurovascular status and repeat X-ray.
2-Immobilize in a P.O.P slab/Refer the patient to the orthopedicsteam immediately.
45-CAP10-Cyanosis
(Clinical Presentations)
33 year-old-patient with Amyl Nitrite presented with S.O.B, cyanosis, nurse noticed dark strange color on blood sample.
a-What is your diagnosis? (1mark)
b-How to confirm your diagnosis? (1mark)
b-What is the specific treatment? (1mark)

a-Methemoglobinemia.

b-Direct measurement of Methemoglobin on A.B.G

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

46-Airway management
(Common Competences)
A 27-year-old-man is brought into ED having been involved in a road traffic collision. He has a reduced GCS and the trauma
teammake the decision to intubate the patient. The view seen atlaryngoscope is shown below:
a-What Cormack ‐Lehane grade is this? (1 mark)
b-Name the four structures labelled. (2 marks)
a- Grade I (vocal cords are fully visible)

b-All four of
A: vocal cords
B: trachea
C: epiglottis
D: piriform fossae

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

http://www.osce-aid.co.uk/osce.php?code=osce_feverinareturnedtraveller

a- any 2 of:
1-Timing of symptomsOnset, course and duration?
2-Travel history Which countries?Urban/rural environment?Types of accommodation?Dates of entering each
country/returning home?

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

4-Prevention

b-Complicated falciparum malaria

1-CNS:impaired consciousness or seizures.
2-Respiratory:pulmonary edema or ARDS.
3-GIT:jaundice.
4-Renal:renal impairment.
5-Metabolic:acidosis(ph. less than 7.3), hypoglycemia(less than 2.2mmol/L).
6-CVS:shock(BP less than90/60).
7-Blood:spontaneous bleeding, DIC, Anemia (HB less than 8G/dl)and hemoglobinuria
c-Treatment:
1-I. V fluids, analgesic and antipyretics
2-I. V Quinine.
3-Malarone ® (atovaquone with proguanil hydrochloride)
4-Riamet ® (artemether with lumefantrine

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

48- CC17- Principles of Medical Ethics and

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

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

b-What other conditions in which will you disclose? (1 marks)

a-
- Make patient safety and treatment your priority, analgesic titrate to pain, update tetanus, prophylactic antibiotics, Involve ED
senior, involve surgery, make report, Try your best to have consent from patient to inform police and if he refused discuss with
Trust legal department and your medical defense union then inform police,
- Document it all.

B- Before breaching confidentiality, the patient's consent should first be sought. If consent is refused you
should discuss the matter further with your Trust legal department and your medical defense union.
Breaching confidentiality
Examples of instances where confidentialit y may be breached include disclosures:

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

2-Relating to the courts or litigation, e.g. specific requests from a judge for relevant information
3-Relating to statutory regulatory bodies, e.g. DVLA, where a patient poses a threat to the public
4-In the public interest, e.g. patient has disclosed involvement in se rious criminal activity such as
terrorism
5-To protect the patient or others, e.g. patient expresses homicidal intent towards a specifi c person
49- CAP11-Diarrhoea(Clinical Presentations)
A 42-year-old man presents to AED complaining of a 2 dayhistory of diarrhea. He has been opening his bowels and passing
watery stool about 6 times a day, and today he has noticed freshblood in his stool. He has not been vomiting but iscomplaining
ofcrampy lower abdominal pain.

a-Give (2) infective causes for bloody diarrhea? (1 mark)

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

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

b-
1-Ulcerative colitis.
2-Crohn’s disease
3-Colorectal malignancy
4-Ischaemic colitis

c-
FBC – (Anaemia, Leucocytosis)
U&Es – (AKI, Hypokalaemia, Hyponatraemia/Hypernatraemia)
Stool sample –(Culture,microscopy and sensitivity for organisms )
AXR – (if clinical features suspicious for toxic megacolon

50-PP20-Initial assessment of the acutely unwell

(Procedural Competences)
25- year-old-lady is brought into AED by her housemates feeling generally unwell with myalgia and a headache which has
been getting worse over the last 24 hours and nausea.Her observations are: temperature 38.6oC, HR 105 b/pm, BP110/75, RR
16/min. She is alert (GCS 15) but feels lethargic. On examination she has no focal neurological signs.
a-Give (4) clinical signs of meningitis? (1 mark)
b-What is the antibiotic of choice (dose & route)? What further drug should be considered? (1 mark)
c-Give (2) indications for CT scan? (1 mark)
a- (Specific features)
1-Severe headache (Thunderclap headache)
2-Stiff neck / Back rigidity.
3-Photophobia
4-Kernig’s sign (person unable to fully extend at the knee when hip is flexed)
5-Brudzinski’s sign (person’s knees and hips flex when neck is flexed).
6-Focal neurological deficit (including cranial nerve involvement and abnormal pupils)
7-Seizures
8-Bulging fontanelle in children (but this patient is adult)
9-Impaired consciousness

b-
-Ceftriaxone 2g IV
-Dexamethasone 16mg. I. V

c-
1-Signs suggesting raised intracranial pressure.
2-Focal neurological signs
2-Respiratory insufficiency

51-Procedural sedation (Anesthetic Competences)

30 year-old-male-patient with shoulder dislocation after propofol this capnogram
a-What are (2) causes of this capnography? (1mark)
b-What areyour (2) actions? (1mark)
c-What will you do before discharging this patient? (1mark)

a-
1-Hypoventilation.
2-Propofol apnea.
3-Respiratory depression.
b-
1-Call for (help & Anesthetist)/raise the head 20 to 30 degree.
2-Suction/Ensure patent airway,100% O2 via BVM.

c-
1-GCS should return to patient GCS baseline.
2-Vital signs should return to patient baseline.
3-Nausea, vomiting, pain and respiratory compromise should be addressed.

52-CAP15-Fits/Seizures
(Clinical presentation)
Status epilepticus Patient received two doses of benzodiazepines still seizing, taking, allergic to phenytoin

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

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

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

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

c-Any (2) of
-Hyperkalemia / rhabdomyolysis / Severe Burn / Spinal Cord Injury / Malignant Hyperthermia / infection / malignant tumor or cancer /
systemic mastocytosis / eye surgery / myxedema / low amount of calcium in the blood / high amount of potassium in the blood /
Anemia / Myasthenia Gravis / angle closure glaucoma / Slow Heartbeat / Disease of the Heart and Blood Vessels / severe liver disease
/ severe renal impairment / major traumatic injury / Poisoning by the Heart Medication Digitalis
53-PAP14-Orbital Cellulitis
(Acute Presentations)
A 10 year-old-boy presented with this picture with differential diagnosis of (Orbital cellulitis & periorbital cellulitis)

a-Give (2) features clinically to Differentiate between them? (1mark)

b-What investigation of choice to Differentiate between them? (1mark)
c-Give (2) causative organisms? (1mark)

a-Orbital cellulitis (ophthalmoplegia / proptosis)

b-C.T Orbit .

c-Common organisms( S. pneumoniae/ S.aureus/ S. pyogenes and H. influenzae).

54-CAP1-Abdominal pain Including Loin

Pain (Clinical Presentation)
A 45 year-old-male patient is brought to AED complaining of severe right sided colicky flank pain which started a couple of
hours ago. He cannot keep still with the pain and describes it as the worst pain he has ever had. He is also complaining of
nausea and has vomited x 2 in the ambulance. He is apyrexial, his HR 105bpm, BP 130/85, RR 16. His bloods are normal.

a-What is the most likely diagnosis? What is the investigation of choice? (1 mark)
b-What analgesic would be most appropriate for your diagnosis? (1 mark)
c-Give two complications of renal calculi? (1 mark)
a- RenalColic /Non-contrast helical CT KUB

b-Rectal diclofenac 100mg.

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

55-C3AP4-Abnormal blood glucose

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

a-Adrenal crisis (also known as Addisonian crisis and acute adrenal insufficiency)

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

c-
-FBC, U & E, LFT, Glucose, Lipase, Blood gases,
-Cortisol &ACTH(expected Low cortisol, raised ACTH)
56-A1C-Preoperative Assessment-Specific
Anestheticevaluation
(AnestheticCompetencesCT1&2)
A 50-year-old-male-Patient with cardiovascular issue need to do for him anesthesia
a-What's his ASA Classification System? (1 mark)
b-What is Malampati score in the image? Give (2) other features for difficult airway? (1 mark)
c-What time for last ate and last drink? (1 mark)

a-ASA CLASS III.

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

c-2Hours for drink and 6 Hours for food.

57-PP18-Wound Management
(Procedural Competencies)
80 year-old-man on steroid and history of DM presented with pretibial laceration with venous insufficiency as shown below
a-How will you manage the wound? (1 mark)
b-Give (2) factors affecting wound healing?(1 mark)
a-
- Clean, irrigation with normal saline/Remove foreign bodies/Remove hematoma/Replace flap without tension/Apply
Steristrips and Mepitel(Don't Suture) /Rest and elevation/Give patient verbal and written advice. (Keep wound clean, dry and
covered. Patient can remove Steristrips /dressing after 7 – 10 days. Seek medical attention if signs of bleeding, dehiscence or
infection).

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

58-PAP17-PainfulLimbsTraumatic
(Acute Presentation)
A 13 year old boy is brought to ED complaining of right knee pain. He is a keen football player, and tells you that over the last
few weeks he has been having mild, intermittent knee pain,especially when he is playing football but this has now become
more continuous and severe. He denies any history of trauma. On examination you note tenderness and swelling at the tibial
tuberosity, and pain is provoked by knee extension against resistance. An x-ray has been performed which is shown below:

a-What abnormality is seen on the x-ray? (1 mark)

b-What is the most likely diagnosis? (1 mark)
c-What is your management? (1 mark)

a-Fragmentation of the tibial tuberosity

b-Osgood-Schlatter disease

C- Analgesia titrate to pain / bed rest / elevation / modified exercise programmed/ physiotherapy for persistent symptoms.
59-CC3 - Therapeutics and Safe Prescribing/Evidence
& Guidelines (Common Competences)
A 50 year-old-man presented with chest infection & productive cough,his (CURB 65 Score is 0),his medications
(Atorvastatin,Bendroflumethiazide and lisinopril) and had penicillin allergy and prescribed (clarithromycin) by his G.P.
a-What is your advice regarding his medicines? Why? (1mark)
b-What principles of antimicrobial stewardship with this patient? (1mark)
c-What aims of antimicrobial stewardship? (1mark)

a-
1-Stop (Atorvastatin)(Risk of Rhabdomyolysis/A.K.I)
2-Reduce dose of (Bendroflumethiazide and lisinopril) (because Clarithromycin is enzyme inhibitor) and potentiates effects of
other drugs.
3-Follow up with his GP.

Microbiology guides therapy where possible.

Indications should be based evidence.
Narrowest spectrum.
Dosage appropriates to the site and type of infection.
Minimize duration of therapy.
Ensure monotherapy where appropriate.
c-
1-To improve patient outcomes and safety, i.e. reduce morbidity and mortality.
2-To prevent antimicrobial resistance.
3-To reduce adverse drug events.
4-To reduce health care-related costs.

60-ICM11-Accidental displacement of tracheal tube

(ICM within ACCS)
A 33 year-old-man is intubated for airway protection following a large mixed overdose. He remains ventilated in the ED whilst
awaiting an ICU bed. 30 minutes after intubation, the nursenotes the patient has become hypoxic with Sat of 78%. Intubation
was uneventful, there was no suspicion of aspiration and he had Sat of 100% both before and after intubation.

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

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

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

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

b-Any no means TT displacement:

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

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