FCEM Preparation: March 2015

Wednesday 18 March 2015

Quality Checklist for Randomized Clinical Trials

The following are 11 quality checklist to go through when critically appraise RCT"s

The study population included or focused on those in the ED.

The patients were adequately randomised.

The randomisation process was concealed.

The patients were analysed in the groups to which they were randomised.

The study patients were recruited consecutively (i.e. no selection bias).

The patients in both groups were similar with respect to prognostic factors.

All participants (patients, clinicians, outcome assessors) were unaware of group allocation.

All groups were treated equally except for the intervention.

Follow-up was complete (i.e. at least 80% for both groups).

All patient-important outcomes were considered.

The treatment effect was large enough and precise enough to be clinically significant.

From SGEM

Quality Checklist for Randomized Clinical Trials

Saturday 14 March 2015

ENT - Short Answer Questions (SAQ)

Question 1:

A 45 year old female presents with vertigo and vomiting. The symptoms are worse when she sits forwards.

Give 3 features which make a central cause more likely than a peripheral cause.

You decide a peripheral cause is most likely. Give the 2 most likely diagnosis.

Which test would you use to distinguish between the 2 causes?

Explain how you would perform the test?

Give 2 classes of drugs that may be used in the chronic treatment of vertigo and examples.

Answer

1. Give 3 features which make a central cause more likely than a peripheral cause.

Associated neurological signs/symptoms eg. weakness, diplopia

Constant symptoms

Not associated with tinnitus/hearing loss

Not altered by position

2. You decide a peripheral cause is most likely. Give the 2 most likely diagnosis.

Viral labyrintitus

Benign paroxysmal positional vertigo (BPV)

3. Which test would you use to distinguish between the 2 causes?

Dix-hallpike test

4. Explain how you would perform the test?

Sit patient up on couch

Turn head 45 degrees to 1 side

Then rapidly lie down

Assessing for vertigo and nystagmus

Once settled sit up and repeat to opposite direction

5. Give 2 classes of drugs that may be used in the chronic treatment of vertigo and examples.

Antihistamines eg. cinnarizine

Phenothiazine eg. prochlorprerzine

Question 2:

A 75 year old man presents with epistaxis from the right nostril. Bleedining hasn’t settled after pressure for 20 mins. He is haemodynamically stable with BP 170/100

Which three drugs, (or classes of drugs) should you ask about?

Outline how you would insert a nasal tampon (Rapid Rhino) – you have to explain the procedure to the patient

After insertion of the tampon the patient continues to bleed. What does this imply?

How would you manage this?

Answer

1. Which three drugs, (or classes of drugs) should you ask about?

Warfarin - anti-coagulants

Aspirin, clopidogrel - antiplatelets

Cocaine

Anti-hypertensives

2. Outline how you would insert a nasal tampon(Rapid Rhino) – you have to explain the procedure to the patient

Face mask/gloves, apron.

Use a lubricated nasal tampon, 1^st check nostril to ensure no gross septal deviation/ trauma, then gently but firmly insert the tampon into the nostril, horizontally along the floor of the nose. The tampon is then inserted with 10mls N saline and taped to the patients face.

The patient is referred to ENT.

3. After insertion of the tampon the patient continues to bleed. What does this imply?

Posterior nasal bleed

4. How would you manage this?

Assess ABC, insert 2 x large bore cannula, FBC, coagulation profile, G&S

IV fluids if hypotensive.

Remove anterior tampon and insert lubricated (unflated) foley catheter into naso-pharyngeal space. Inflate ballon with 10ml saline and gentle withdraw to tamponade bleeding point. Tape to face, reinsert ant tampon and refer ENT

Question 3:

A 2 year old boy presents with a history of coin ingestion. An x-ray is performed.

Describe the x-ray

How would you manage this patient?

Answer

1. Describe the x-ray

Radio-opaque foreign body seen at level of the clavicles

2. How would you manage this patient

Assess ABC

If no acute airway compromise, urgent ENT referral.

Keep the child calm without any distress

Question 4:

A 45 year old female presents complaining of tinnitus and unilateral deafness.

What does the scan show?

What is the most likely diagnosis?

List 3 other lesions that occur in this area

Which cranial nerves may be affected by such lesions?

Answer

1. What does the scan show?

A well demarcated mass at the right cerebellopontine angle

2. What is the most likely diagnosis?

Acoustic neuroma

3. List 3 other lesions that occur in this area

Cholesteatoma

Meningioma

Neuroma V, VII, X

Basilar artery aneurysm

Medulloblastoma

4. Which cranial nerves may be affected by such lesions?

V-XI Cranial nerves.

Question 5:

21 year old presents with one week history of sore throat, fever, abdominal pain and recent travel to Spain. He is brought in suddenly after collapsing after a rugby tackle and complaining of abdominal pain.

On examination - Pulse - 110 bpm, BP 100/60, pale, c/o thirst ++, ? jaundiced

Abdomen tender and guarding LUQ

Hb 10, WBC 13, Plt 290, ESR 56, Alb 39, Alk phos 188, ALT 200, Bil 88

What is the underlying diagnosis? What complication has occurred?

What is the underlying cause and how can it be confirmed?

What is the immediate management of this patient?

Answer

1. What is the underlying diagnosis? What complication has occurred?

Infectious mononucleosis

Splenic rupture

2. What is the underlying cause and how can it be confirmed?

Infection with EBV

Diagnosed monospot or Paul-Bunnell test

Atypical lymphocytes on blood film.

3. What is the immediate management of this patient?

IV access and crossmatch, clotting screen, U&E, FBC

IV fluid bolus, 1-2L normal saline/hartmanns.

Refer surgeons

Consider CT scan

Infectious mononucleosis (IM) is usually a self-limiting infection, most often caused by Epstein-Barr virus (EBV), which is a human herpes virus. However, approximately 10% of those with IM are not acutely infected with EBV and many of these have symptoms attributable to cytomegalovirus (CMV) infection.

Question 6:

A 46 year old present complaining of ear ache and discharge. Otoscopy reveals the following.

What is the diagnosis?

Name 2 groups of patients at increased risk of developing this condition

Name 3 organisms implicated in this condition

How would you manage the patient?

Answer

1. What is the diagnosis?

Otitis externa

2. Name 2 groups of patients at increased risk of developing this condition

Diabetics

Swimmers

3. Name 3 organisms implicated in this condition

Pseudomonas aeuruginosa

Staphylococcus aureus

Streptococcus pyogenes

E.coli

4. How would you manage the patient?

Analgesia

Discharge on antibiotic drops eg chloramphenicol or gentisone HC, (not if ear drum perforated)

If perforated TM, oral antibiotics

Question 7:

A 6 year old female presents with fever and ear ache.

What is your diagnosis?

Name 2 common organisms implicated

Give 3 complications associated with this condition

Answer

1. What is your diagnosis?

Otitis media

2. Name 2 common organisms implicated

Bacteria - Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis

Virus - respiratory syncytial virus and rhinovirus

3. Give 3 complications associated with this condition

Cholesteatoma

Mastoiditis

Lateral sinus thrombosis

Perforated ear drum

Hearing loss

Meningitis

Facial nerve palsy

Question 8:

A 25 year old male presents with ear ache and discharge. He has a past medical history of recurrent otitis media. Otoscopy reveals the following.

What is the diagnosis?

What is the pathophysiological process associated with this condition?

Outline your management in the ED.

4. What is the diagnosis?

5. Give 3 causes of the above condition

6. How would you manage this patient in the ED?

Answer

1. What is the diagnosis?

Cholesteatoma

2. What is the pathophysiological process associated with this condition?

Erosive and expanding lesion composed of epithelium and keratin precipitate, originates from otitis media or mastoiditis.

3. Outline your management in the ED.

Analgesia

Refer ENT for antibiotics and surgical debridement

4. What is the diagnosis?

Perforated tympanic membrane

5. Give 3 causes of the above condition

Acute otitis media

Barotraumas

Explosion

6. How would you manage this patient in the ED?

Analgesia, refer ENT for outpatient follow up and audiography. Antibiotics as per local protocol.

Advice not to swim or get water in ear.

Further read: Patient.co.uk

Question 9:

36 year old female presents complaining of spilling liquids when she tries to drink.

Give 4 causes of this presentation

Describe the anatomy and how this impacts on presentation of this condition.

Answer

1. Give 4 causes of this presentation

Bell’s palsy

Ramsey hunt syndrome

Otitis media

Munps

Trauma/inflammation parotid gland

2. Describe the anatomy and how this impacts on presentation of this condition.

Facial nerve originates in facial nucleus in pons, lesions above this are UMN lesions and appears clinically with sparing of forehead on affected side due to bilateral innervation.

Then crosses cerebellopontine angle to enter internal auditory canal and geniculate ganglion. Lesions at this point are associated with weakness of facial muscles, abnormal lacrimation, reduced taste sensation to ant 2/3 tongue, hyperaccusis.

Branch arises from geniculate ganglion, greater superficial petrosal nerve to supply lacrimal glands.

Rest of nerve passes through petrosal temporal bone giving off branches ant 2/3 tongue and submandibular and sub-lingual salivary glands –chorda typmani. Further branch, nerve to stapedius also arises here.

The nerve exists at the stylomastoid foramen and enters parotid gland before giving nerves off to muscles of facial expression. Lesions of nerve in parotid gland are associated with facial muscle weakness but normal taste/ hearing.

Question 10:

45 year old man presents complaining of ear ache and a “lopsided face”.

What is the diagnosis?

How would you manage this patient?

Answer

1. What is the diagnosis?

Ramsey hunt syndrome – infection of geniculate ganglion by varicella zoster virus

The Ramsay Hunt syndrome occurs when the varicella zoster virus (chickenpox) becomes reactivated in the geniculate ganglion of the VIIth cranial nerve (facial nerve).

2. How would you manage this patient?

Analgesia

Acyclovir 800mg 5X/day for 7/7

Prednisolone 60mg daily 7/7 then reduced dose.

Check eye for dendritic ulcer

Refer ENT for review and follow up.

ENT - Short Answer Questions (SAQ)

Monday 2 March 2015

RCEM Guidelines

This page contains guidelines and statements produced by the Royal College of Emergency Medicine"s Quality in Emergency Care (QEC) committee. All links take you to college site or specific download page.