1. Monash Health Practice Exam 2017 Question 27
Jon Dowling
Deputy Director Emergency Services
Peninsula Health
Deputy Censor Victoria

2. 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

3. ABG

4. About the exam Close to the real thing Individual markers
No standard setting
Individual marks for questions

5. 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

6. 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

7. Question 27
The biggest issue……….
TIMING

8. 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?

9. ABG

10. Question 27 part a
What is the Acid base abnormality
High (expanded, increased) Anion gap metabolic acidosis
Incomplete resp compensation
Errors
“Metabolic acidosis”

11. 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

12. 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

13. 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

14. 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

15. 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

16. Part D Not checking BSL Inadequate justification
Errors
Not checking BSL
Inadequate justification
“EUC – check electrolytes”

17. 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