Monash Health Practice Exam 2017 Question 27 Jon Dowling Deputy Director Emergency Services Peninsula Health Deputy Censor Victoria
Question 27 A 48 year old woman with shortness of breath for 2 days. She has a history of diabetes and depression. Her LMO has been treating her for an URTI without improvement. On assessment she is awake and oriented. Her vital signs are: BP 150/90 mmHg HR 120 /min Sats 99% RA Temp 36.8°C
ABG
About the exam Close to the real thing Individual markers No standard setting Individual marks for questions
When approaching your results Benchmark against your peers Don’t worry about individual questions unless You are discovering new information. If you are still studying new information then you are not ready Do not underestimate the negative effects of failing the real exam
Question 27 Deliberately placed 17 marks with a ‘Pass’ mark of 12 Aka – the last question Deliberately placed 17 marks with a ‘Pass’ mark of 12 17 gettable marks Pretty much done poorly (with a few exceptions) Had this question been Q1 pass rate would have been much higher 9/45 ‘pass rate’ = 20% 5 scored zero 22/45 (50%) scored 8 or under
Question 27 The biggest issue………. TIMING
When approaching these questions……. Place yourself in the moment What would you do if you had this patient present to your department? What treatment would be mandatory?
ABG
Question 27 part a What is the Acid base abnormality High (expanded, increased) Anion gap metabolic acidosis Incomplete resp compensation Errors “Metabolic acidosis”
Part b A-a gradient Delta gap Expected K (FiO2 – PaCO2/R) – paO2 Complete the table showing calculations A-a gradient (FiO2 – PaCO2/R) – paO2 Delta gap Delta Anion gap/Delta Bicarb 0.6 Expected K Wording of question 0.5 increase in K for every 0.1 decrease in pH 1.5 mmol change
Part b Corrected Na Errors Complete the table showing calculations Corrected Na Measured Na + (measured Glucose minus normal)/3 Errors Not showing calculations Simple maths errors Putting wrong qualifying statement
Part C What is the diagnosis? DKA Fluid resuscitation Insulin List three essential treatments including dosages What is the diagnosis? DKA Fluid resuscitation Insulin Potassium
Part C Fluids Insulin Lack of appreciation K will fall Antibiotics Errors Fluids Insufficient detail – “Saline 1L stat” No indication of degree of dehydration No titration, no indication of requirement for dextrose Insulin Insufficient detail – “Actrapid”, “Actrapid infusion” with no indication of titration Lack of appreciation K will fall Antibiotics
Part D BSL (mandatory) CT Brain Plus one other Decreased LOC. List 3 Ix with justification that should be urgently done BSL (mandatory) CT Brain Plus one other
Part D Not checking BSL Inadequate justification Errors Not checking BSL Inadequate justification “EUC – check electrolytes”
Final Thoughts….. Read the question Practice your timing Whole exam practice Timing, timing, timing If you spend an extra minute on every question you will miss the last 3 questions (at least) The last 3 questions might be worth 50 marks! Place yourself in the moment Don’t write medical student level answers