Student exam questions/scenarios thread

tallaght01

I wonder if it would be a good idea for the doc/nurses/pharmacists/biologists etc who frequent the board to stick up a few short questions to help students of their discipline in the run up to exams? I ca ndo paeds and public health. But I'm probably not so useful at anything else. So would be good to have some other input. But keep it easy. Bear in mind a lot of students who read the board are very junior. It should just be a bit of fun.

If it became popular, we could have a thread for each of the disciplines.

I'll get the ball rolling, with a short paeds question?

An 18 month old boy is brought to A+E with shortness of breath. He has been coryzal for the last 2 days, and has been pyrexial for the last 18 hours, for which he has been given paracetamol.

He is normally fit and well. No previous hospital admissions, though he was in SCBU for a short while as he was born at 34 weeks gestation. No other siblings, and family history is unremarkable.

ON examination, he is not cyanosed, but is using accessory muscles of respiration, and has marked intercostal indrawing in particular. He has bilateral expiratory wheeze, though air entry is markedly reduced on both sides. there are no audible crepitations. Heart sounds and peripheral pulses are normal, and he's not oedematous. Sao2 87% on air, goes up to 92% on 2L O2. Pulse 180. Resp rate 55. Capillary refill 1 second centrally. Temp 38.8C.

What is your differential diagnosis?
What kinds of phamaceutical agents might help this child?
What would you "label" this child's condition as, when he's recovered?

Don't worry about wrong answers. The question is purposely constructed so there are a couple of potential answers.

Give it a shot

if the thread becomes in anyway popular, you don't have to wait until the previous question has been fully answered before posting a new one. Just make sure you quote the original question in your answer.

tallaght01

tallaght01 wrote: »

Pulse 180. Resp rate 55..

Do those obs freak out those of you who look after adults? :P

sam34

nah, i stopped reading when i got to "He has been coryzal for the last 2 days", cause as far as i remember coryzal means snotty, so thats when a smug, self-satisfied feeling descended on me - thank god for old age psych!!

Chunky Monkey

I have no clue about the answers but have a question...are babies supposed to have sat02 at least 98% on 02 as well as adults?

tallaght01

Depends. Some of the studies suggest newborns can dip their sats quite significantly. Some cardiac kids even run sats at 50-60%.

But decisions to deviate from the accepted norms should be left to senior paeds people. So, you should be seeking help if sats aren't in the high 90s.

In bronchiolitis I'd be happy enough with a kid whose sats are 93-94% if the kid is otherwise well.

One of my neonatal consultants hardly used sats, as they never had them while he was a reg, so he doesn't like them :P He's one of the best neonatologists ever!

Chunky Monkey

tallaght01 wrote: »

In bronchiolitis I'd be happy enough with a kid whose sats are 93-94% if the kid is otherwise well.

Is that when they're on oxygen?

One of my neonatal consultants hardly used sats, as they never had them while he was a reg, so he doesn't like them :P He's one of the best neonatologists ever!

Haha EBP fail! Then again, if he's going by his own 'EBP'

charlieroot

I'll take a stab at this, though I haven't done any paeds yet so most of this is guess work from the little I know on how to treat a "normal" patient i.e. an adult Apologies in advance if any of these answers are ridiculously off base!


What is your differential diagnosis?

URTI +/- asthma
Pneumonia (possibly atypical) +/- asthma
Allergy +/- asthma + concurrent URTI

Investigations (added this in... would like some more info please

FBC - is the child anaemic, hows the kid's WCC? and breakdown?
CXR
Sputum culture would also be useful - is it bacterial or viral? What organisms are involved.
Would also like to the know the kid's vaccine status.
ABG - that respiratory rate is a bit crazy! Does the kid have a respiratory acidosis?

What kinds of phamaceutical agents might help this child?

Paracetamol for pyrexia a bit if a gimme
Maybe steroids/beta agonist for bronchodilation
ribavirin if its RSV
Antibiotics of some shape or form if pneumonia (macrolide perhaps?)
Might also benefit from IV fluids - has he been feeding ok?
Not sure, possibly something to correct any acidosis - bicarbonate?

What would you "label" this child's condition as, when he's recovered?

A snotty nosed kid with asthma (maybe)? I really haven' t a clue on this one!

tallaght01

Not a bad effort charlieroot. A bit too much intervention than is required.

Have a bit more of a think about the diagnosis in the context of the wheeze and high temp combo. I'll add in too that the kiddy has a red throat when examined.

Chunky Monkey wrote: »

Is that when they're on oxygen?



Haha EBP fail! Then again, if he's going by his own 'EBP'

Off oxygen.

And I think the evidence actually supports him. Baby sats can dip quite a lot, especially when they're asleep. I think their importance is overrated sometimes. I think a lot of babies in hospital get 24 hour sats monitoring when it's not required.

SomeDose

I’m not sure if it’s something which comes up in exams, but I’ll throw out a typical peri-operative medication scenario which I deal with on a fairly regular basis and can sometimes be problematic for the junior docs. We also give similar questions to final year med students during prescribing workshops.

You’re the surgical house officer clerking in a 60yr old obese patient admitted for an urgent laparotomy the following morning. Relevant previous medical history as follows:
PE (2 months ago)
CVD (MI 3 years ago, managed with PCI and stenting)
AF
Crohn’s Disease
NIDDM (recent history of poor blood sugar control)

Drug History:
Metoprolol 50mg tds
Aspirin 75mg od
Simvastatin 40mg nocte
Warfarin as per INR (2.5 at last clinic visit)
Ramipril 2.5mg bd
Prednisolone 30mg od (long-term)
Metformin 500mg bd

Bearing in mind the patient will be “nil by mouth” from midnight, what drugs will you want to continue/omit on his chart, and if so are there any alternative drugs you’ll want to prescribe instead? Oh, and you're not allowed disturb the anaesthetist for advice!

tech77

tallaght01 wrote: »

I wonder if it would be a good idea for the doc/nurses/pharmacists/biologists etc who frequent the board to stick up a few short questions to help students of their discipline in the run up to exams? I ca ndo paeds and public health. But I'm probably not so useful at anything else. So would be good to have some other input. But keep it easy. Bear in mind a lot of students who read the board are very junior. It should just be a bit of fun.

If it became popular, we could have a thread for each of the disciplines.

I'll get the ball rolling, with a short paeds question?

An 18 month old boy is brought to A+E with shortness of breath. He has been coryzal for the last 2 days, and has been pyrexial for the last 18 hours, for which he has been given paracetamol.

He is normally fit and well. No previous hospital admissions, though he was in SCBU for a short while as he was born at 34 weeks gestation. No other siblings, and family history is unremarkable.

ON examination, he is not cyanosed, but is using accessory muscles of respiration, and has marked intercostal indrawing in particular. He has bilateral expiratory wheeze, though air entry is markedly reduced on both sides. there are no audible crepitations. Heart sounds and peripheral pulses are normal, and he's not oedematous. Sao2 87% on air, goes up to 92% on 2L O2. Pulse 180. Resp rate 55. Capillary refill 1 second centrally. Temp 38.8C.

What is your differential diagnosis?
What kinds of phamaceutical agents might help this child?
What would you "label" this child's condition as, when he's recovered?

Don't worry about wrong answers. The question is purposely constructed so there are a couple of potential answers.

Give it a shot

if the thread becomes in anyway popular, you don't have to wait until the previous question has been fully answered before posting a new one. Just make sure you quote the original question in your answer.

RSV infection presents with coryza -> wheeze, dyspnoea and resp distress (IIRC) and it's common so i think something like RSV would be something to think about.
It's all we ever heard of in Paeds anyway. :P
Then again no creps: just trying to recall- does that mean no bronchiolitis?

Of course URTI +/-asthma presents with wheeze, dyspnoea and resp. distress as well.

Edit: Sorry for not giving exact ddx/investigation/tx- never was any good at Paeds.

angeldelight

SomeDose wrote: »

I’m not sure if it’s something which comes up in exams, but I’ll throw out a typical peri-operative medication scenario which I deal with on a fairly regular basis and can sometimes be problematic for the junior docs. We also give similar questions to final year med students during prescribing workshops.

You’re the surgical house officer clerking in a 60yr old obese patient admitted for an urgent laparotomy the following morning. Relevant previous medical history as follows:
PE (2 months ago)
CVD (MI 3 years ago, managed with PCI and stenting)
AF
Crohn’s Disease
NIDDM (recent history of poor blood sugar control)

Drug History:
Metoprolol 50mg tds
Aspirin 75mg od
Simvastatin 40mg nocte
Warfarin as per INR (2.5 at last clinic visit)
Ramipril 2.5mg bd
Prednisolone 30mg od (long-term)
Metformin 500mg bd

Bearing in mind the patient will be “nil by mouth” from midnight, what drugs will you want to continue/omit on his chart, and if so are there any alternative drugs you’ll want to prescribe instead? Oh, and you're not allowed disturb the anaesthetist for advice!

Discontinue the Metformin - he won't be eating so won't need it and don't want hypos. Injectable insulin may be required post-op for a short period
A few skipped doses of Simvastatin won't do him any real harm so hold off on that
As he is on long-term pred he will require cortisol supplementation NB that anaesthetist knows about this
Don't want to stop Metoprolol suddenly - convert to once daily dose and use Betaloc injection?
Aspirin and warfarin really should have been stopped by now - heparin to be used post-op to prevent DVT
Ramipril - could probably skip a day or two

Answered as a pharmacy pre-reg. Haven't looked anything up, just stumbled across the thread and gave it a whirl so apologies if I give pharmacy graduates a bad name!!

tallaght01

tallaght01 wrote: »

I wonder if it would be a good idea for the doc/nurses/pharmacists/biologists etc who frequent the board to stick up a few short questions to help students of their discipline in the run up to exams? I ca ndo paeds and public health. But I'm probably not so useful at anything else. So would be good to have some other input. But keep it easy. Bear in mind a lot of students who read the board are very junior. It should just be a bit of fun.

If it became popular, we could have a thread for each of the disciplines.

I'll get the ball rolling, with a short paeds question?

An 18 month old boy is brought to A+E with shortness of breath. He has been coryzal for the last 2 days, and has been pyrexial for the last 18 hours, for which he has been given paracetamol.

He is normally fit and well. No previous hospital admissions, though he was in SCBU for a short while as he was born at 34 weeks gestation. No other siblings, and family history is unremarkable.

ON examination, he is not cyanosed, but is using accessory muscles of respiration, and has marked intercostal indrawing in particular. He has bilateral expiratory wheeze, though air entry is markedly reduced on both sides. there are no audible crepitations. Heart sounds and peripheral pulses are normal, and he's not oedematous. Sao2 87% on air, goes up to 92% on 2L O2. Pulse 180. Resp rate 55. Capillary refill 1 second centrally. Temp 38.8C.

What is your differential diagnosis?
What kinds of phamaceutical agents might help this child?
What would you "label" this child's condition as, when he's recovered?

Don't worry about wrong answers. The question is purposely constructed so there are a couple of potential answers.

Give it a shot

if the thread becomes in anyway popular, you don't have to wait until the previous question has been fully answered before posting a new one. Just make sure you quote the original question in your answer.

I guess I should answer this one now.

This child most likely has reactive airways disease. It's like asthma in it's clinical presentation. It's also like asthma in it's treatment.

It's essentially an inflammatory response to an URTI. So, you'll see a febrile kiddy, usually with a red throat, and symptoms of asthma. I won't go into huge details, as I'm trying to make this a thread with snappy answers. But look up reactive airways. You only really label kids as asthmatic once they're older than 2. The majority of these wheezy attacks in toddlers are secondary to viral infections.

They get treated with salbutamol. Via a spacer if possible, as it freaks the kids out less than a noisy nebuliser, and is as effective in most situations. But if the kid needs oxygen you'll have to use a neb. Many people use ipratroprium bromide with the first spacer too, and you may have to move onto IV salbutamol/magnesium sulphate/aminophylline if the kiddy is deteriorating.

Then you'll need to give oral prednisolone to stifle the inflammatory response. Many of these kids actually show reduced effort of breathing with just oxygen therapy.

I would do a CXR in a kid who's having their first presentation of wheeze, as a kid with a febrile illness may still have swallowed a foreign body.

Someone above mentioned epiglottitis.....we see very little of this nowadays because of the HiB vaccine (or "The HIV vaccine" as many parents will inadvertently call it it if you do paeds Though ear in mind strep pneumoniae is the other cause of this illness). Epiglottitis will usually present as an extremely toxic child, though if they present early it can look like croup. But they have difficulty swallowing, sore throat, and drooling in many cases. Their chest shouldn't be confused with a wheezy chest.

So, no right answers above, but some good ideas.And tech77 wasn't far off.

tallaght01

Next question is very quick, and very public health-y.

You have a patient with meningococcal meningitis who lives at home with 4 more people, and has a long term girlfriend . You ring the public health registrar, who tells you they'll all need chemoprophylaxis with antibiotics.

What organism causes meningococcal meningitis?

What's the quickest lab test to identify the organism?

What is the exact rationale for offering antibiotics to household/sexual contacts of the case? Have a think about this question.

For bonus points you could talk about what antibiotics you might prescribe the contacts if they were pregnant or on the pill.

sportswear

i like this thread.

maxheadroom

SomeDose wrote: »

I’m not sure if it’s something which comes up in exams, but I’ll throw out a typical peri-operative medication scenario which I deal with on a fairly regular basis and can sometimes be problematic for the junior docs. We also give similar questions to final year med students during prescribing workshops.

You’re the surgical house officer clerking in a 60yr old obese patient admitted for an urgent laparotomy the following morning. Relevant previous medical history as follows:
PE (2 months ago)
CVD (MI 3 years ago, managed with PCI and stenting)
AF
Crohn’s Disease
NIDDM (recent history of poor blood sugar control)

Drug History:
Metoprolol 50mg tds
Aspirin 75mg od
Simvastatin 40mg nocte
Warfarin as per INR (2.5 at last clinic visit)
Ramipril 2.5mg bd
Prednisolone 30mg od (long-term)
Metformin 500mg bd

Bearing in mind the patient will be “nil by mouth” from midnight, what drugs will you want to continue/omit on his chart, and if so are there any alternative drugs you’ll want to prescribe instead? Oh, and you're not allowed disturb the anaesthetist for advice!

As a very junior anaesthetist:

Metoprolol 50mg tds

Keep. Reduces risk of perioperative coronary ischaemia

Metformin 500mg bd

Hold. Ty and arrange for op early on list. ? need for IV insulin sliding scale and dextrose / potassium infusion depending on level of insulin resistance and likely fasting time. Also hold as it is nephrotoxic and an 'urgent laparotomy' may require CT scans in the coming hours / days.

Aspirin 75mg od

Hold. Assuming an emergency admission here, and holding it wont do a huge amount of good, but is better than nothing. Consider having platelets available / on standby in case of a major bleed.

Simvastatin 40mg nocte

Keep. Won't do him any harm and he's geting it in the evening

Warfarin as per INR (2.5 at last clinic visit)

Hold. Check current INR. Contact haematology service / consult local protocol regarding reversal. Discuss this with surgical seniors / anaesthetics.

Ramipril 2.5mg bd

HOLD!!!!! Predisposes to intraop hypotension

Prednisolone 30mg od (long-term)

Keep. Will need perioperative IV hydrocortisone.

SomeDose

Good effort angeldelight, especially for a pre-reg! Strictly speaking, "nil by mouth" still permits the patient to have oral meds with a sip of water up to 1-2hrs pre-op. Max seems to have covered most of the important points, and I'd add (based on our local practices):

Warfarin & Aspirin:

Most definitely omit. Since this is an emergency procedure (and assuming an INR ~2.5), FFP is usually required to get the INR down to <1.5. May also need IV vitamin K if this isn't successful. In view of his history, a recent PE means he's at high risk of another thromboembolic event and would almost certainly need full anticoagulation peri-op. Sliding-scale heparin infusion with APTT monitoring probably preferred (as opposed to full-dose LMWH) since it can be stopped a few hours pre-op and re-started ~12hrs assuming no bleeds/excessive drain output. The point about him being obese was a hint that the heparin dose should be based on ideal body weight.

Metoprolol:

Definitely continue, for the reason Max gave, plus risks of rebound tachys if it were suddenly withdrawn. Could convert to 5mg IV Betaloc tds.

Metformin:

We'll assume he's on the morning list due to the urgency, so omit and commence on sliding-scale IV insulin (with K+) as it'll be major surgery and he'll most likely end up in critical care post-op. Correct about CT and risks of renal damage and lactic acidosis.

Simvastatin:

Can have it the night before, but no big deal if it's omitted for a few days anyway.

Prednisolone:

Give pre-op, then follow with hydrocortisone 50mg IV tds after 6-8hrs for extra adrenal cover for a day or two post-op. If his oral route is kibosh then 30mg preds can be replaced with 120mg IV hydrocortisone.

Ramipril:

Now this can go either way. I should've specified an indication here...if it's for hypertension then it should be omitted, especially if there'll be big fluid loss intra-op. If it's for HF or previous MI then I think the anaesthetist will usually give it (not 100% on this, any thoughts Max??). It gets even more tricky if the patient has a low BP post-op, which may be due to cardiogenic shock and omitting the ACEI can actually cause the BP to drop further. This is always a head-scratcher for me!

PhysiologyRocks

tallaght01 wrote: »

Next question is very quick, and very public health-y.

You have a patient with meningococcal meningitis who lives at home with 4 more people, and has a long term girlfriend . You ring the public health registrar, who tells you they'll all need chemoprophylaxis with antibiotics.

What organism causes meningococcal meningitis?

What's the quickest lab test to identify the organism?

What is the exact rationale for offering antibiotics to household/sexual contacts of the case? Have a think about this question.

For bonus points you could talk about what antibiotics you might prescribe the contacts if they were pregnant or on the pill.

I'm not sure if I know enough to even try, but I'll give it a go.

1)

Neisseria Meningitidis (sp?)

2)

I know the Thayer-Martin VCN method can be used, not sure if it's speedy, though.

3)

I'm not sure. It's possible that a close contact is a carrier and they are how the patient got ill. Also, they may have been exposed to the same medium through which the patient got ill. If there is continued contact with the patient, antibiotics may prevent the contact from becoming ill, or passing the disease on to others.

4)

Can rifampicin be given? I must admit, I consulted the MIMS about this one. It says nothing against it. I know minocycline can't be given in pregnancy, though, and it interferes with the pill.

sportswear

Next question is very quick, and very public health-y.

You have a patient with meningococcal meningitis who lives at home with 4 more people, and has a long term girlfriend . You ring the public health registrar, who tells you they'll all need chemoprophylaxis with antibiotics.

What organism causes meningococcal meningitis?

What's the quickest lab test to identify the organism?

What is the exact rationale for offering antibiotics to household/sexual contacts of the case? Have a think about this question.

For bonus points you could talk about what antibiotics you might prescribe the contacts if they were pregnant or on the pill.

neiserria meningitidis (sp!) - meningococcus

rapid antigen screen

not really sure what is meant by the next question, i think its to start treatment in case they have already been colonised(nasopharyngeal), and also limit the spread of the bacterium.

ceftriaxone in pregnancy?

tallaght01

tallaght01 wrote: »

Next question is very quick, and very public health-y.

You have a patient with meningococcal meningitis who lives at home with 4 more people, and has a long term girlfriend . You ring the public health registrar, who tells you they'll all need chemoprophylaxis with antibiotics.

What organism causes meningococcal meningitis?

What's the quickest lab test to identify the organism?

What is the exact rationale for offering antibiotics to household/sexual contacts of the case? Have a think about this question.

For bonus points you could talk about what antibiotics you might prescribe the contacts if they were pregnant or on the pill.

The organism is neisseria meningitidis.

The quickest lab test is a PCR. Most labs will do microscopy on the CSF (though sometimes the patient is too ill to do a lumbar puncture). The lab scientist will usually tell you it's a gram negative diplococcus, which is pretty suggestive of meningococcal disease.

You can do a PCR on spinal fluid or blood. Occasionally it gets done on a punch biopsy of a petechial spot.

You give antibiotics to household and sexual contacts

Rifampicin is most commonly used. But it interferes with the oral contraceptive pill.

We use cipro locally if they're on the pill and definitely not pregnant.

We use ceftriaxone if they're pregnant.

The rationale for giving chemoprophylaxis is often (almost always, in fact) misunderstood. People usually think it's to stop people developing meningococcal from the affected person.

But the reality is that affected meningococcal patients are not paticularly contagious. BUt they've usually caught the bug from a household or sexual contact. That person is usually an asymptomatic carrier. So, you give the antibiotic to those people to stop them carrying it in their nasopharynx, which will usually stop them from passing it onto others. Does that make sense?

tallaght01

Next scenario:

You're the neonatal intern and you're asked to go to the post natal war to see a new baby who's an hour old. The midwife there thinks he's breathing very quickly.

He was a normal delivery, on time, and no complications.

When you get there he's tachypnoiec, but otherwise well.

Physical examination is normal, except for the fast rate.

He needs a little bit of oxygen via nasal prongs.

What are the big differential diagnoses here? It's neonatalogy, so it's not hugely important for you to be expert in this area as med students. But this is the kind of question you could get.

Dr Galen

Do we have enough nursing students here to bother with a nuring version of this thread?

Hats off though, this has been very interesting reading. Surprising myself with the stuff i know!

tallaght01

I dunno if we have any nurses these days on the forum. ut we sure as hell have a good few medics...and the educational sub-forums were Indy's idea....so I'm waiting for some cutting edge gen medicine questions from him :P

It's time to let your geekiness shine, DrIndy

me2gud4u

just wanted to say that I have been following and reading this thread and It's great!I'm only going into 2nd med though so I wont embarrass myself with guesses yet but i do understand a lot of things which is such a confidence booster (after doing two yrs of college it would seem i've been learning something!!) so here's hoping i will be able to hazard an intelligent guess or two in a few months time!!
Thanks to the contributors!

tallaght01

me2gud4u wrote: »

just wanted to say that I have been following and reading this thread and It's great!I'm only going into 2nd med though so I wont embarrass myself with guesses yet but i do understand a lot of things which is such a confidence booster (after doing two yrs of college it would seem i've been learning something!!) so here's hoping i will be able to hazard an intelligent guess or two in a few months time!!
Thanks to the contributors!

Fair enough in 2nd year I wouldn't have known the answers to any of those questions either. they're more final year stuff. BUt feel free to have a guess, or even a guess at sections of the questions. No one will expect much clinical knowledge from you at this stage, so don't feel embarrassed. It's just a it of fun.

I'm glad you're at least understanding some of the stuff though

There's a "test your sexual health knowledge" thread on the mens health forum that you might find useful, as the questions there are pretty basic ones that you might be ale to hazard a guess at from your pre-clinical reading

tallaght01

A quick question for the med students. It's based on a question i was asked today.

So, you're working in a public health unit. The statistician approaches you, and tells you there's been a rise in the number of reported cases of pertussis in the database.

That's not unusual, as there's a widespread epidemic currently in the region.

But she's just done a database search, and found that quite a lot (about 30%) of these cases are in people who have been previously vaccinated.

She's concerned that there might be something wrong with the vaccines.

Is there something wrong with the vaccines? How would you explain the above?

Could one of the mods move this to the health sciences education forum please?

Please use spoilers if you post an answer, so as people can try the question without seeing your answers.