Monash Health Practice Exam 2017 Question 27 Jon

Monash Health Practice Exam 2017 Question 27 Jon Dowling Dep ut y D ir ect or Emerge ncy S ervice s Peninsula He alth Dep ut y C ensor 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 mm. Hg 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 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 Q 1 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 Complete the table showing calculations • A-a gradient § (Fi. O 2 – Pa. CO 2/R) – pa. O 2 • 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 p. H § 1. 5 mmol change

Part b 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 List three essential treatments including dosages • What is the diagnosis? DKA • Fluid resuscitation • Insulin • Potassium

Part C Errors • Fluids § Insufficient detail – “Saline 1 L 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 Decreased LOC. List 3 Ix with justification that should be urgently done • BSL (mandatory) • CT Brain • Plus one other

Part D Errors • Not checking BSL • Inadequate justification § “EUC – check electrolytes”

Final Thoughts…. . • Read the question • Practice your timing § Whole exam practice § 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