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This is a 30 point quiz of ACEM Fellowship level (i.e. hard) which contains 17 MCQs and 2 EMQs..
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Question 1 of 19
1. Question
Match each cause of hyponatraemia with it’s typical features. The features may match more than one cause.
Sort elements
- Hypervolaemia and urinary Na+ < 20mmol/L
- Hypovolaemia, decreased serum cortisol, urinary Na > 20mmol/L
- Hypovolaemia, alkalosis, urinary Na < 20mmol/L
- Hypovolaemia, acidosis, urinary Na < 20mmol/L
- Alkalosis, eu- or hypovolaemia, urinary Na > 20mmol/L
- Hypovolaemia, normal pH, urinary Na < 20mmol/L
- Euvolaemia, urinary Na > 10mmol/L, normal or low serum urate
- Eu- or hypovolaemia, urinary Na > 10mmol/L, high urine output, low serum urate
- Euvolaemia, urinary Na < 10mmol/L, normal serum urate
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CCF
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Adrenocortical insufficiency
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Upper GIT losses
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Lower GIT losses
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Diuretics
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Skin losses
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SIAD
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Cerebral salt wasting syndrome
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Water intoxication
Correct 9 / 9PointsThe usual features of each condition are as follows: CCF – Intravascular overload, urinary Na < 20mmol/L; Adrenocrtical insufficiency – volume depletion, urinary Na > 20mmol/L, decreased serum cortisol; Upper GIT losses – volume depletion, alkalosis, urinary Na < 20mmol/L; Diuretics – volume depletion, urinary Na > 20 mmol/L, normal cortisol, mild alkalosis; Skin losses – volume depletion, urinary Na < 20 mmol/L, normal pH; SIADH and hypothyroidism – euvolaemia, urinary Na > 10mmol/L, normal serum urate; Cerebral salt wasting syndrome – euvolaemia, urinary Na > 10mmol/L, low serum urate; Water intoxication – euvolaemia, urinary Na < 10mmol/L. 9Link)
Incorrect / 9 PointsThe usual features of each condition are as follows: CCF – Intravascular overload, urinary Na < 20mmol/L; Adrenocrtical insufficiency – volume depletion, urinary Na > 20mmol/L, decreased serum cortisol; Upper GIT losses – volume depletion, alkalosis, urinary Na < 20mmol/L; Diuretics – volume depletion, urinary Na > 20 mmol/L, normal cortisol, mild alkalosis; Skin losses – volume depletion, urinary Na < 20 mmol/L, normal pH; SIADH and hypothyroidism – euvolaemia, urinary Na > 10mmol/L, normal serum urate; Cerebral salt wasting syndrome – euvolaemia, urinary Na > 10mmol/L, low serum urate; Water intoxication – euvolaemia, urinary Na < 10mmol/L. 9Link)
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Question 2 of 19
2. Question
Match each snake type with the features of toxicity that envenomation with that snake type causes. The features may match more than one snake type.
Sort elements
- Defibrinating coagulopathy, early cardiovascular collapse
- Post synaptic neuromuscular paralysis, local pain at the bite site
- Marked bruising and redness at the bite site after 3 hours, non defibrinating coagulopathy
- Elevated CK, minimal local pain, paralysis, no coagulopathy
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Brown snake
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Death adder
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Mulga snake
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Seasnake
Correct 4 / 4PointsThe typical features of toxicity of each of the snakes is as follows: Death adder – post synaptic paralysis, local pain, no coagulopathy; Brown snake – early hypotension/cardiovascular collapse, defibrinating coagulopathy, direct renal toxicity; Mulga and Colletts – local pain and swelling, non defibrinating coagulopathy, myotoxicity; Seasnake – no coagulopathy, myopathy, neuropathy. (Link)
Incorrect / 4 PointsThe typical features of toxicity of each of the snakes is as follows: Death adder – post synaptic paralysis, local pain, no coagulopathy; Brown snake – early hypotension/cardiovascular collapse, defibrinating coagulopathy, direct renal toxicity; Mulga and Colletts – local pain and swelling, non defibrinating coagulopathy, myotoxicity; Seasnake – no coagulopathy, myopathy, neuropathy. (Link)
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Question 3 of 19
3. Question
A 61 year old man of medium build presents with pleuritic chest pain and has an inspiratory CXR that demonstrates a pneumothorax that is approximately 2cm from the chest wall at the lung apex. The approximate size of the pneumothorax is
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Question 4 of 19
4. Question
A 35 year old woman presents with diplopia and a letter from her GP concerned she may have a partial lesion of cranial nerve IV (Trochlear) on the right hand side. Which one of the following eye movements would you expect to be most impaired
Correct
A partial CN IV lesion would be expected to produce the greatest difficulty in depressing the eye when it is slightly adducted. When it is slightly abducted, the action of the inferior rectus (CN III) would predominate. (link)
Incorrect
A partial CN IV lesion would be expected to produce the greatest difficulty in depressing the eye when it is slightly adducted. When it is slightly abducted, the action of the inferior rectus (CN III) would predominate. (link)
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Question 5 of 19
5. Question
A 54 year old man is brought to your hospital by the retrieval team after a dirt bike crash. The initially assessed him at a regional hospital where a finger thoracostomy was performed through the 4th ICS in the anterior axillary line due to a suspected pneumothorax. He now has a large pneumothorax on CXR with a moderate haemothorax so you decide to insert a 28F ICC. Your preferred insertion site would be
Correct
Insertion of the ICC through the correctly positioned finger thoracostomy site would be preferred, if the site was not contaminated (it should not be as it was performed in another hospital, not at the crash site). Insertion above would be difficult and risks injury to axillary contents. Insertion posteriorly would risk the thoracodorsal nerve, and an anterior approach is not ideal if a haemothorax is present. (link)
Incorrect
Insertion of the ICC through the correctly positioned finger thoracostomy site would be preferred, if the site was not contaminated (it should not be as it was performed in another hospital, not at the crash site). Insertion above would be difficult and risks injury to axillary contents. Insertion posteriorly would risk the thoracodorsal nerve, and an anterior approach is not ideal if a haemothorax is present. (link)
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Question 6 of 19
6. Question
Key functions of the chair of a committee include all of the following except
Correct
The chair of the committee has responsibility for; setting the agenda; determining the order that members speak to an item; ensuring all members have the opportunity to participate (even if disruptive); determining the priorities of items for discussion; informing the committee if the nature of the item is confidential; ensuring the minutes of the meeting are accurate. (link)
Incorrect
The chair of the committee has responsibility for; setting the agenda; determining the order that members speak to an item; ensuring all members have the opportunity to participate (even if disruptive); determining the priorities of items for discussion; informing the committee if the nature of the item is confidential; ensuring the minutes of the meeting are accurate. (link)
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Question 7 of 19
7. Question
Operative intervention following elbow dislocation is usually required in which one of the following circumstances
Correct
Operative management is performed to try to prevent recurrent dislocation or arthritis. Usual indications include: coronoid process fractures > 50% of of the process; any displaced, intra-articular fracture; medial epicondyle fractures displaced > 10mm or associated with ulna nerve injury; a comminuted radial head fracture. (link)
Incorrect
Operative management is performed to try to prevent recurrent dislocation or arthritis. Usual indications include: coronoid process fractures > 50% of of the process; any displaced, intra-articular fracture; medial epicondyle fractures displaced > 10mm or associated with ulna nerve injury; a comminuted radial head fracture. (link)
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Question 8 of 19
8. Question
When using the delta gap to assess acid base disorders, which one of the following statements is correct
Correct
The delta gap is the change in the anion gap – the change in the HCO3- concentration. It is calculated by the following formula: Delta gap = Na – (Cl+HCO3)-12- (24-HCO3), using arterial values. This results in the formula of Delta gap = Na – Cl – 36. Values > +6 indicate the presence of a metabolic alkalosis and values < -6 indicate a hyperchloraemic acidosis. The delta gap is of little practical use but appears in exams disproportionally frequently to it’s actual usefulness, so that’s why there is a question on it! (link).
Incorrect
The delta gap is the change in the anion gap – the change in the HCO3- concentration. It is calculated by the following formula: Delta gap = Na – (Cl+HCO3)-12- (24-HCO3), using arterial values. This results in the formula of Delta gap = Na – Cl – 36. Values > +6 indicate the presence of a metabolic alkalosis and values < -6 indicate a hyperchloraemic acidosis. The delta gap is of little practical use but appears in exams disproportionally frequently to it’s actual usefulness, so that’s why there is a question on it! (link).
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Question 9 of 19
9. Question
Which one of the following would be the weakest indication for immediate PTCA in a patient with suspected ACS but without STEMI criteria
Correct
Indications for immediate PTCA include: ST elevation in aVR with deeply inverted T waves in V1-4 (indicates L main occlusion and probably the strongest indication); cardiogenic shock; post cardiac arrest with ROSC; failure of ST elevation to improve by 50% within 90 min. of commencement of thrombolytic therapy; haemodynamically significant ventricular arrhythmias resistant to treatment; ongoing pain uncontrolled by all standard therapies.(link)
Incorrect
Indications for immediate PTCA include: ST elevation in aVR with deeply inverted T waves in V1-4 (indicates L main occlusion and probably the strongest indication); cardiogenic shock; post cardiac arrest with ROSC; failure of ST elevation to improve by 50% within 90 min. of commencement of thrombolytic therapy; haemodynamically significant ventricular arrhythmias resistant to treatment; ongoing pain uncontrolled by all standard therapies.(link)
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Question 10 of 19
10. Question
A 43 year old indigenous man presents with chest pain of 50 minutes duration and features of an anterior STEMI on ECG. The best management of his acute coronary ischaemia from the choices available is
Correct
Current (2013) indications for throumbolytic therapy for STEMI are for: patients presenting < 1 hour from symptom onset and PTCA is unavailable within 60 min.; patient presenting 1-3 hours of symptom onset and PTCA unavailable within 90 min.; and patient presenting 3-12 hours of symptom onset and PTCA unavailable within 2 hours. Streptokinase is contra-indicated in indigenous Australians due to the high prevalence of anti-streptococcal antibodies and potentially higher allergic reaction rate. (link)
Incorrect
Current (2013) indications for throumbolytic therapy for STEMI are for: patients presenting < 1 hour from symptom onset and PTCA is unavailable within 60 min.; patient presenting 1-3 hours of symptom onset and PTCA unavailable within 90 min.; and patient presenting 3-12 hours of symptom onset and PTCA unavailable within 2 hours. Streptokinase is contra-indicated in indigenous Australians due to the high prevalence of anti-streptococcal antibodies and potentially higher allergic reaction rate. (link)
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Question 11 of 19
11. Question
The proportion of normal people who would be expected to have at least one abnormal result if 20 different parameters are measured is aproximately
Correct
The proportion of normal people who would be expected to have at least one abnormal result if 20 different parameters are measured is approximately 66%.The probability of an abnormal test increases exponentially with each extra test ordered. (link)
Incorrect
The proportion of normal people who would be expected to have at least one abnormal result if 20 different parameters are measured is approximately 66%.The probability of an abnormal test increases exponentially with each extra test ordered. (link)
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Question 12 of 19
12. Question
Indications for corticosteroid therapy in patients with TB include all of the following except
Correct
Indications for corticosteroid therapy in patients with TB include: lobar collapse secondary to lymphadenopathy; meningitis; renal TB; adrenal TB; moribund patients. Haemoptysis alone is not an indication for steroid therapy. (link)
Incorrect
Indications for corticosteroid therapy in patients with TB include: lobar collapse secondary to lymphadenopathy; meningitis; renal TB; adrenal TB; moribund patients. Haemoptysis alone is not an indication for steroid therapy. (link)
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Question 13 of 19
13. Question
Which one of the following central venous approaches would be likely to have the highest risk of arterial puncture in an adult when a blind technique is used.
Correct
The left sided femoral approach would be expected to have the greatest risk of arterial puncture as the left femoral vein usually overlaps the artery to a greater extent than the right. Internal jugular approaches on either side have a lower incidence of arterial puncture than femoral approaches, when a blind technique is used. (link)
Incorrect
The left sided femoral approach would be expected to have the greatest risk of arterial puncture as the left femoral vein usually overlaps the artery to a greater extent than the right. Internal jugular approaches on either side have a lower incidence of arterial puncture than femoral approaches, when a blind technique is used. (link)
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Question 14 of 19
14. Question
Which one of the following phrases is the least likely to be misunderstood when spoken
Correct
The phrase least likely to be misunderstood is the one in which the numbers are spelled out individually. Numbers from 14-19 can be misunderstood as 40 – 90 so pose a particular risk to patients. (link)
Incorrect
The phrase least likely to be misunderstood is the one in which the numbers are spelled out individually. Numbers from 14-19 can be misunderstood as 40 – 90 so pose a particular risk to patients. (link)
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Question 15 of 19
15. Question
Which one of the following statements best describes the current role of hypothermia following out of hospital cardiac arrest in adults.
Correct
Although active cooling to 33C was previously thought to possibly be of benefit in patients with out of hospital cardiac arrest, this is no longer the case. Prevention of hyperthermia (by keeping temperatures < 37.5C) and not actively rewarming if the temperature is > 34C is the current standard. Cooling is not specifically contra-indicated in pregnancy and should be used if the patient is hyperthermic following arrest. (link)
Incorrect
Although active cooling to 33C was previously thought to possibly be of benefit in patients with out of hospital cardiac arrest, this is no longer the case. Prevention of hyperthermia (by keeping temperatures < 37.5C) and not actively rewarming if the temperature is > 34C is the current standard. Cooling is not specifically contra-indicated in pregnancy and should be used if the patient is hyperthermic following arrest. (link)
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Question 16 of 19
16. Question
The peripheral IV access site most likely to result in inadvertent arterial cannulation in a severely shocked patient is
Correct
Attempts to access the Cephalic vein in the proximal forearm is the most likely to inadvertently cannulate an artery as approximately 10% of people have a superficial radial artery at this site.
Incorrect
Attempts to access the Cephalic vein in the proximal forearm is the most likely to inadvertently cannulate an artery as approximately 10% of people have a superficial radial artery at this site.
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Question 17 of 19
17. Question
The most likely effect of a 200J biphasic defibrillation delivered through adhesive pads on a staff member who only has contact with the patients chest with their gloved hands is
Correct
‘Hands on’ defibrillation is associated with only mild symptoms with some authors suggesting that chest compressions should not be stopped during defibrillation. (link)
Incorrect
‘Hands on’ defibrillation is associated with only mild symptoms with some authors suggesting that chest compressions should not be stopped during defibrillation. (link)
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Question 18 of 19
18. Question
The average flow rate you would expect for an infusion of crystalloid through a 16G cannula using gravity alone in an adult is
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Question 19 of 19
19. Question
For US guided IV access, orienting the US probe position longitudinal to the cannula (in line, or in axis technique) has the advantage over transverse probe orientation (off axis technique) of
Correct
The longitudinal approach has the advantage of being able to directly visualise the angle of approach of the needle and ability to watch it penetrate the vessel wall without needing to move the probe. However this orientation requires a more steady hand (as the US beam is very narrow) and more space for the probe footprint (especially if a small vascular access probe is not available). The depth of the vessel from the skin can be determined using either probe orientation. (link)
Incorrect
The longitudinal approach has the advantage of being able to directly visualise the angle of approach of the needle and ability to watch it penetrate the vessel wall without needing to move the probe. However this orientation requires a more steady hand (as the US beam is very narrow) and more space for the probe footprint (especially if a small vascular access probe is not available). The depth of the vessel from the skin can be determined using either probe orientation. (link)