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2003.1 VAQ 3 Quiz Investigation 015 CJJ03
Scenario
A 29 year old woman is brought into the emergency department by a friend after
being found in an agitated state. The woman is reluctant to be assessed and declines to
give a history.
The only available blood test is an arterial blood gas and electrolytes on room air.
Her results
are:
1. List 3 most important diagnosis on this ABG
a. Normal anion gap metabolic acidosis
b. Associated respiratory alkalosis
c. Hyperkalemia (CK = 8.4)
d. A-a gradient – normal
2. List all the differential diagnosis in the case.
a. Overdose is more likely (from the stem therefore D/D
should first include
i. Ammonium chloride overdose
1. Expectorant
2. Dry cell battery
ii. Acetazolamide overdose (Glaucoma pill)
See Page111Tox Handbook for more differentials
A 23 YO with reduced level of consciousness is being assessed in your ED.His ABG is shown.
1: Describe his acid base disorder (4 marks)
2: Outline 3 other important findings on the ABG (1 mark)
3: What is the likely diagnosis? (1 mark)
1:
Severe metabolic academia (pH =6.9, HCO3 =2)
Appropriate respiratory compensation (expected co2 =11 +/- 2) measured = 10
HAGMA (Ag =33),
Pure HAGMA Delta gap =21/22 =1
2:
-Elevated osmloar Gap = 360- (280+ 5.2+ 4.8) = 70 Unmeasured osmotically active
substance present
-Severely elevated lactate = 7 ( ? poor perfusion)
(K+ moderately high but total body K likely normal when corrected for acidosis)
(Glucose normal makes DKA unlikely)
(PA-a 02 = 60 – mildy elevated  mild VQ mismatch ? aspiration)
3: Severe HAGMA with elevated osmolar gap consistent with toxic alcohol ingestion (eg:
Methanol, ethylene glycol etc)
2010.1 VAQ 3
Scenario
A 45 year old man with type 1 diabetes mellitus conscious state is brought in by ambulance
with an altered conscious state
Q1) Describe 4 features of tis ABG
1) Severe Metabolic acidosis High anion gap
2) Additional Respiratory acidosis
a. By Winter formula Expected CO2 is 35 whereas the given vaue is
much higher 66. Anion Gap is 31 raised .
3) Renal impairment – Urea creatininie ratio is normal ( 75:1 ) therefore there
is no prerenal component
4) Hyperglycemia
Q2) How will you explain the results
1) Likely DKA due to increase in the metabolic component ( possibly
noncompliance or infection being the triggers)
2) Secondarily this hasled to low GCS leading to coma , hypoventilation
leading to respiratory acidosis.
2010.1 VAQ 6 Investigation Quiz 020
A 45 year old woman with a past history of depression presents to your emergency
department with 2 weeks of nausea, weakness and lethargy. There has been no vomiting or
diarrhoea.
Q1) Describe the results of this ABG
Incompletely compensated metabolic alkalosis . Expected PCO2 is 49 .But CO2 is only 41
Low oxygen concentration suggesting lung disease
Hypocholremia , hyponatremia & hypokalemic
Q2 ) What are the two likely diagnosis
1) hidden vomiting /Diarrhea – eating disorder
2) Diuretic abuse ( more likely given that both Na & K are less
3) Drug induced SIADH ( antidepressant , SSRI induced)
VAQ 5
A 77 year old man with a history of atrial fibrillation presents to your ED with extreme
lethargy, nausea and vomiting.
His observations are:
GCS 12(E3, V4, M5)
Temp 36
Pulse rate 35
BP 85/50
SaO2 94%2L/min O2 via nasal specs
Biochemistry and Digoxin level are shown.
a) List 5 management priorities and up to two options to manage each, including the dose of
medications where relevant (12 marks)
Issue
Management
Hypotension
IV fluid bolus
Correct bradyarrhythmia
Bradyarrhythmia
Atropine 0.6 mg IV bolus, repeat as needed up to 1.8mg
total
External pacing (unlikely to work)
Hyperkalaemia
Insulin 10 units and 50 mL 50% dextrose simultaneously
as an IV bolus
Salbutamol 5mg nebulised
Sodium bicarbonate 100 mEq IV bolus
Calcium contra-indicated in digoxin toxicity
Digoxin toxicity
Empiric dosing with 2 ampoules; if no reversal of digoxin
toxicity after 30 minutes give a further 2 ampoules
Calculation:
Number of ampoules =
Renal failure
Maintenance of adequate intravascular volume by IV
fluids; avoid overload
Relieve any post renal obstruction
VAQ 7
A previously well 38 year old man presents with a week of worsening vomiting, diarrhoea
and abdominal pain. On the day of presentation to the ED he has become drowsy and
confused.
Observations:
Temp 37oC
Pulse 110/min
BP 120/80 mmHg
GCS 12 (E3, V4, M5)
His liver function tests (LFTs) and coagulation profile are shown
a) Describe the significant positives (2 marks)
Hepatic derangement of LFTs
Impaired synthetic function – high INR, low albumin
b) List 2 differentials for the LFT findings (2 marks)
Viral hepatitis
Drug or toxin ingestion (i.e. paracetamol, alcohol)
c) List 2 possible causes of his current state of impaired consciousness (2 marks)
Hepatic encephalopathy
Hypoglycaemia
ICH
Question 3
A 47-year-old man with a history of chronic liver disease and schizophrenia is brought to
your emergency department by ambulance with acute confusion.
His observations are:
GCS 12 E 3, V4, M 5
HR 120 /min
BP 120/60 mmHg
RR 40 /min
An arterial blood gas is taken:
His serum biochemical results are as follows
Reference Range
Arterial Blood Gas
FiO2 21 %
pH 7.30 7.35-7.45
pO2 91 mmHg 80-95
pCO2 15 mmHg 35-45
HCO3- 9 mmol/L 22-28
Lactate 14 mmol/L < 2.0
Electrolytes
Na+ 101 mmol/L 134-146
K+ 4.7 mmol/L 3.4-5
Cl- 73 mmol/L 98-106
Glucose 10.5 mmol/L 3.5-5.5
-
A. What are the processes involved and outline your reasoning
Acidaemia secondary to a High anion gap metabolic acidosis . This is seen by low
HCO3- and high lactate. PCO2 is low. PCO2 should be 21 using equation 1.5 x HCO3
+ 8. Therefore there is a concomitant respiratory alkalosis.
B. What are the likely causes for these processes
- HAGMA: Methanol/Ethylene glycol ingestions, uraemia, paraldehyde, Isoniazid,
Salicylate overdose, Infection/sepsis
- Respiratory alkalosis – Hyperventilation secondary to pain, agitation, salicylate
overdose
C. What are possible causes of hyponatraemia
Hypervolaemic – Heart failure, liver failure, CCF, renal failure
Euvolaemia – SIADH Urine Na >20 – chronic water overload, drugs, post surgery,
psychogenic, hypothyroidism. Urine Na <20 acute water overload – SIADH, drugs,
renal failure, glucocorticoid deficiency
- Hypovalaeima – Urine Na >20 - Losing water diuretics, Addison’s, salt losing
nephritis. Urine Na <20 osmotic diuresis – mannitol, urea, vomiting, excessive
seating
-
Question 5
A 5-year-old girl is referred to your emergency department by a GP, with pallor and
lethargy.
On examination she is extremely pale but appears alert and interactive.
She has the following observations:
GCS 15
HR 110 /min
BP 100/60 mmHg
RR 20 /min
O2 Saturation 98 % on room air
Temperature 36.8 0C
You perform the following blood tests
Hb 35 (101-131) g/L
WCC 9.1 (6.0-11.0) 109/L
PLT 260 (150-450) 109/L
RBC 2.18 (3.9-5.3) 1012/L
MCV 56.0 (75-85) fL
MCH 16 (23-31) pg
MCHC 286 (310-355) g/L
Retic % 3.6 (0.2-2.0)
a.
-
-
List 4 important findings on these blood tests
Anaemia Hb 35
Normal PLT, WCC indicating this is unlikely to be a whole marrow cause
MCV 56 – Microcytic
MCH (Mean corpuscular haemoglobin) – average mass of haemoglobin per red
blood cell. – Hypochromic
MCHC (mean corpuscular haemoglobin concentration) – measure of the
concentration of Hb in a given volume of packed red blood cells. Calculated by
dividing the Hb/HCT
Reticulocytosis – normal marrow reacting to the anaemic state
b. What is the most likely cause of the above findings
Microcytic hypochromic anaemia – Iron Deficiency Anameia (decreased dietary intake
due to reliance on cows milk, , poor absorption, chronic blood loss)
c. List 4 further investigations you would like to do and what would you expect the
result to be
- Iron – low
- Serum ferritin – low
- TIBC – high
- Transferrin saturation – low
- FOBT – exclude any bleeding
- LDH/Haptoglobin – haemolysis
a. What is the primary acid-base disturbance?
b. What is the compensation?
c. What is the A-a gradient?
d. Give three reasons why might this be in this context?
e. Can you summarise/explain this blood gas?
3.
a.
Metabolic alkalosis
b.
acute on chronic respiratory acidosis
c.
77 (expected = 25) = high
d.
aspiration due to vomiting
atelectasis due to hypoventilation due to diaphragmatic splinting from the
bowel obstruction
pulmonary embolus due to being sick and bedridden
im sure there are others two but I thought those were the most
likely 
e.
85 year old lady with acute metabolic hypochloraemic alkalosis most likely
secondary to vomiting, and NGT drainage. Acute on chronic respiratory
acidosis as compensation with a V/Q mismatch likely secondary to either
aspiration, atelectasis or other concomitant lung pathology (PE,
pneumonia). Dehydration as shown by raised urea and hyperglycaemia with
raised lactate – concerning given the context of bowel pathology indicating
possible bowel ischaemia and guarded prognosis
a. What are 5 findings (including calculations) in this gas?
b. List 8 differential diagnoses
c. List 6 investigations you would perform next
1. a.
Raised anion gap: 142 – (8+ 106) = 28
Severe metabolic acidosis pH 7.1, HCO3 = 8, BE -25
Respiratory compensation: 8 + 1.5x8 = 20 (+ resp alkalosis)
Renal impairment
K+ likely low = watch during correction (expected K = 6.5)
b.
Lactic acidosis: drugs such as methanol, metformin, aminoglycosides,
alcohol, ethanol, ethylene glycol, propylene glycol, paraldehyde, toluene,
iron, isoniazid, cyanide, salicylates or carbon monoxide) MUST MENTION
Lactic acidosis AND poisoning or intoxication AND TWO POSSIBLE AGENTS
The other causes of RAGMA are far less likely in this stem
c.
Toxicology screen: (salicylates, ethanol, paracetamol)
ECG
Lactate
Serum osm
CXR
Head CT
2009.1 VAQ 3
86yo female brought to ED from her nursing home (she is obviously fucking loaded
as she owns the whole nursing home. Question is why isn’t she at Greenslopes
then?) with 2 days of drowsiness and decreased oral intake. Her blood tests are as
follows.
1. What is the most likely diagnosis (2 marks)
 Ascending cholangitis (1) and likely sepsis (1)
2. What 3 clinical features would support your diagnosis (3 marks)
 RUQ pain
 Jaundice
 Fever
(Charcots’ Triad)
3. Name 3 immediate ED interventions that should occur whilst diagnosis
is confirmed. Be specific with doses and volumes. (3 marks)
 IV Antibiotics -> Amp Gent and Metro are all acceptable in the correct doses
 IV Fluids -> 250ml Normal saline boluses repeated in elderly patient.



4.


Anti-emetics
Analgesia if required
Monitor Potassium
What is her disposition (2 marks)
Surgical team
Adhere to advanced healthcare directives and patient wishes.
Question 4
Question 4
A 72 year old man presents from a nursing home with 4 days of increasing confusion. His GP
letter notes that he has a history of dementia, hypertension and ischaemic heart disease.
The following laboratory results were obtain on his arrival in the emergency department.
Sodium
114
mmol/L (135-145)
Potassium
3.8
mmol/L (3.5-5.2)
Chloride
105
mmol/L (95-110)
Urea
6.2
mmol/L (3.2-7.7)
Creatinine
98
umol/L (60-105)
Glucose
7.6
mmol/L (3.4-5.4 fasting)
Calcium
2.15
mmol/L (2.10-2.55)
Albumin
40
g/L
His vital signs are
GCS
13
(E3, M6, V4)
HR
70
/min
BP
150/85 mmHg
RR
16
/min
O2 Sats
99
%
(36-50)
a) Please fill out the following table by listing the 3 main categories of hyponatreamia
and 3 causes for each category. (9 Marks)
Category
Causes
b) List up to 5 clinical findings you would expect in patients with hyponatreamia. (5
marks)
Question 4 Answers
a) Please fill out the following table by listing the 3 main categories of
hyponatreamia and 2 causes for each category.
Category
Causes
Hypovolaemic Hyponatraemia
Renal Losses: Diuretics, Mineralocorticoid
deficiency, Salt losing nephropathy,
Osmotic diuresis (Glucose, Mannitol, Urea),
Ketouria,
Bicarbonaturia with metabolic alkalosis
Extrarenal Losses: Vomiting, Diarrhoea,
Excessive sweating, Blood loss, Burns,
Pancreatitis, Trauma
Euvolaemic Hyponatraemia
Psychogenic Polydipsia
SIADH
Inatrogenic water intoxication
Postoperative hyponatreamia
Non-Osmotic ADH secretion
Drugs: NSAIDs, Carbamazepine, Oxytocin,
Psychoactive agents, Anticancer agents
Hypervolaemic Hyponatraemia
CCF
Hepatic failure and cirrhosis
Nephrotic syndrome and chronic renal
failure
b) List up to 5 clinical findings you would expect in patients with hyponatreamia.
 Anorexia
 Nausea and vomiting
 Lethargy
 Muscle cramps and weakness
 Headache
 Altered LOC / confusion
 Coma
 Seizures
References
ACEM Examiner’s Report 2011.2
Cameron’s page 537 – Electrolyte disturbances (Read the tables of causes)
5. A 54 year old woman with a history of bipolar affective disorder presents with an
altered conscious state.
Her observations are:
GCS 11 (E3, V3, M5)
HR 100 beats/min
BP 110/60 mmHg
RR 18 /min
Temperature 37 oC
O2 Saturation 96 % on room air
Serum urea and electrolytes are taken.
a) List three key features seen in this biochemical panel
- hypernatraemia (likely cause for ALOC)
- renal impairment
- hyperglycaemia
- RAGMA
b) What is the most likely diagnosis?
Lithium toxicity
c) What are key features of treatment of the above diagnosis?
1.
Fluid resuscitation
a. 10-20mL/kg IV N/Saline and re-assess
b. Aim UO > 1mL/kg/hr
2. Dialysis
a. Indications:
i. Severe clinical symptoms
ii. Li > 4mmol/L in acute ingestion; >3.5mmol/L chronic
iii. Li > 2.5mmol/L in renal impairment
b. Must be prolonged to compensate for slow equilibration time between
compartments (6-12hrs)
(Tox handbook, Cameron p919-920; Dunn p1414)
VAQs 2003.2
VAQ 1
You are the Consultant on a busy evening shift when a 45 year old male presents following
melena and hematemesis. In the process of his work up he has the following bloods done.
Question1
What are the 4 salient positives in this result panel.
Question 2
What are 4 further investigations that are indicated in this case?
VAQ1 Answers
Question1
What are the 4 salient positives in this result panel.
Hyponatraemia
If oedema may be assoc with cirrhosis with liver failure.
May be secondary to vomiting
Mild elevated urea. Possible secondary to an acute bleed and it’s metabolism
Elevation Creatinine
(Ratio 83. Can be normal ratio or indicate post renal disease.)
Hypoalbuminaemic – secondary to decreased synthetic function in the setting of possible
hepatic disease given elevated LFTs
LFTS
Marked elevated Bilirubin
Elevated LFTS moderately – apart from normal ALT
Mixed hepatocellular and obstructive picture – Secondary to long term alcohol use, unclear
at what stage of hepatic failure this could be.
Normal anion Gap
Normal osm
No pH supplied.
Slight hyperglycaemia but if not if a non fasting sample.
Question 2
What are 4 further investigations that are indicated in this case?
Bloods
FBC – Hb to assess for level of anaemia, Wcc to asses for acute phase reaction +/- infective
etiology.
INR – Coagulopathic, synthetic function
Group and Crossmatch – Will likely require transfusion and
Ammonia – Assoc with hepatic dysfunction and possible encepholapthy.
Paired urine and blood sodium, electrolytes and osmolality
Radiology
CXR – aspiration, LRTI, Features suggestive of Boerhaves including pleural effusion,
pneumomediastinum.
OGD and colonoscopy with sclerotherapy, banding
References – Scarce from exam report on LITFL. This question may require further synthesis
of results.
VAQ 3
An 8 year old girl is brought to your mixed ED by her mother with general malaise. Her
mother brought her in today because she was difficult to rouse and very lethargic this
morning.
Her initial obs are GCS 9, P 110 b/min, Bp 85/50, RR 18, T 36.
Question 1
What are the relevant positive on the results outlined above.
Question 2
List 4 important differential diagnosis for this condition
VAQ 3 Answers
Question 1
What are the relevant positive and negatives on the results outlined below.




Hyponatraemia
Hypoglycaemia
Hyperkalaemia
Raised anion Gap acidosis.
 Question 2
List 4 important differential diagnosis for this condition
Primary




Adrenal crisis
Primary – Addisons
Congenital adrenal hyperplasia
Adrenal infarction - secondary to haemorrhage or sepsis.
Secondary




Suppression of HPA over time
Exogenous steroids.
CNS tumour
Idiopathic


Any adrenal crisis can occur in
Concurrent illness - sepsis, surgery and failure to take regular meds
References - LITFL, Cameron Paeds Second Ed Page 246, FACEM Exam report.
VAQ 5
A 30 year old female is sitting in a chair awaiting assessment with a two day history of
nausea and RUQ pain. The medical student has already taken bloods. The nurse is doing her
obs awaiting a bed. They are Gcs15, HR 95 b/min, Bp 150/100mmHg, Temp 36.5, O2 97.
Question 1
What are 4 relevant positives and 2 relevant negatives in the blood test outline below
Question 2
What 2 differential diagnosis are important in this case
VAQ 5 Answers
Question 1
What are 4 relevant positives and 2 relevant negatives in the blood test outline below.
FBC



Hb – lower limit of normal.
Wcc normal.
Platelet low - < 100 may indicate DIC, < 50 may indicate need for platelet
transfusion. If haemolytic anaemia and thrombocytopaenia may indicate HELLP.
Check LFTs
LFTs



Elevated Bilirubin, alt and AST++
Transanimase > 70 is consistence with hepatic parenchymal damage
Raised bilirubin from haemolysis
U+E


Creatinine- Not elevated. Though it can be in preeclampsia.
Urea slightly elevated.
Co ags

Normal Coags – synthetic function intact.
Question 2
What 2 differential diagnosis are important in this case?




HELLP
Fatty liver of pregnancy
Drugs – unknown what she is on but paracetamol is possible.
Haematological – haemolytic anaemia, thrmobocytopaenia – idiopathic, Thrombotic
thrombocytopenia purpura.
Reference – Cameron, 4th Ed, page 653, FACEM Exam report.