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 ID: 623868
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Monash Health Practice Exam 2017Question 27
Jon Dowling
Deputy Director Emergency Services
Peninsula Health
Deputy Censor VictoriaSlide2
Question 27A 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
mmHgHR 120 /min Sats 99% RA Temp 36.8°C Slide3
ABGSlide4
About the examClose to the real thingIndividual markers
No standard setting
Individual marks for questions Slide5
When approaching your resultsBenchmark against your peersDon
’
t worry about individual questions unless
You are discovering new information. If you are still studying new information then you are not readyDo not underestimate the negative effects of failing the real examSlide6
Question 27Aka – 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 higher9/45 ‘pass rate’ = 20%5 scored zero22/45 (50%) scored 8 or underSlide7
Question 27The biggest issue……….
TIMINGSlide8
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?Slide9
ABGSlide10
Question 27 part aWhat is the Acid base abnormality
High (expanded, increased) Anion gap metabolic acidosis
Incomplete
resp compensationErrors“Metabolic acidosis”Slide11
Part bComplete the table showing calculations
A-a gradient
(FiO2 – PaCO2/R) – paO2
Delta gapDelta Anion gap/Delta Bicarb0.6Expected KWording of question0.5 increase in K for every 0.1 decrease in pH
1.5
mmol
changeSlide12
Part bComplete the table showing calculations
Corrected Na
Measured Na + (measured Glucose minus normal)/3
ErrorsNot showing calculationsSimple maths errorsPutting wrong qualifying statementSlide13
Part CList three essential treatments including dosages
What is the diagnosis? DKA
Fluid resuscitation
InsulinPotassiumSlide14
Part C Errors
Fluids
Insufficient detail – “Saline 1L stat”
No indication of degree of dehydrationNo titration, no indication of requirement for dextroseInsulinInsufficient detail – “Actrapid”, “Actrapid infusion” with no indication of titration
Lack of appreciation K will fall
AntibioticsSlide15
Part DDecreased LOC. List 3 Ix with justification that should be urgently done
BSL (mandatory)
CT Brain
Plus one other Slide16
Part DErrors
Not checking BSL
Inadequate justification
“EUC – check electrolytes”Slide17
Final Thoughts…..Read the questionPractice 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 momentDon’t write medical student level answers