Quiz Part A

Question 1

Harold 54 yom well controlled type 1 insulin dependent diabetic [IDDM]. At 1:45pm Harold injects himself with ‘little extra’ insulin to partake in Maude’s baking [pavlova]. At 3:15 Harold consumed 3 mouthfuls of pavlova. At 3:26pm Harold is GCS 8, profusely diuretic, breathing stertorously [snuffly/loud/harsh – common post seizure and comatose patients] and thrashing wildly underneath Maude’s outdoor setting.
a. Person – Object – Place
b. Go through primary survey
i. D = Nil
ii. R = Nil – sternal rub, put it recovery position
iii. A = Clear
iv. B = Present; stertorous
v. C = Central and peripheral pulse present, tachycardic
c. Go through secondary survey
i. VSS
 HR = 114bpm BP = 150/90 RR = 24
 SPO2 = 83% BGL = low GCS = 8
 Pain = Nil Temp = 37
 Cap refill = <2sec ECG = 114 sinus tach
ii. SAMPLE
 S = Very pale and diffusely sweating; pt’s clothes are soaked with perspiration
 A = Not known
 M = Atenolol; insulin
 P = Hypertension, type 1 IDDM
 L = Incident occurred during dessert stage of meal
 E = Collapsed during 3 course meal followed by whistling breathing
iii. OPQRST/AS/PN
 All NIL
iv. Neurological Assessment
 Pupils = L: 3 reactive R: 3 reactive
 Sensation = patient unresponsive
 Strength = all 4 limbs are tense and patient appears quite combative
v. Respiratory Assessment
 Stertor [heavy snoring or gasping]
vi. Head to toe
 Nil abnormalities detected

Answer 1

Patient is most likely experiencing hypoglycemia as Harold has an ALOC, change in behaviour (agitation/aggressive), diaphoretic, low BGL and atenolol medication (beta blocker - masks signs of hypoglycemia). Check for insulin delivering pump; as he is GCS 8 oral glucose can’t be consumed, and due to his thrashing IV access at this point is unattainable. 1mg of IM glucagon is advised as he is symptomatic of hypoglycemia with the inability to self-administer glucose. Provide simple face-mask at a flow rate of 10L. Re-check vital signs [BGL, GCS, SPO2, BP, HR, RR]. Transport to hospital and provide diabetes service referral.

Question 2

Bradley Evans 50yom, average weight, height, health, weekly alcohol, diet and job stress. Experienced pain in his right flank radiating into his right groin (initially dismissed but pain intensified). Query appendicitis
a. Person – Object – Place
b. Go through primary survey
i. D = Nil
ii. R = Yes patient alert and orientated
iii. C = Pale, diaphoretic, tachycardic
iv. A = Clear
v. B = Breathing; equal rise and fall of the chest; bi-lateral air entry
c. Go through secondary survey
i. VSS
 HR = 148bpm RR = 30 BP = 160/90
 SpO2 = 100% GCS = 15 Temp = 37.1
 ECG = Sinus tach Pain = 10 BGL = 5.2mmol
ii. SAMPLE
 S = Sweating, agitated, nausea, vomited 2x prior
 A = No know severe allergic reactions
 M = Nil
 P = Normally fit and well, Pt is slightly overweight
 L = Light evening meal 45min ago
 E = Sitting, sudden pain, urgent urge to void bladder
iii. OPQRST – AS – PN
 O = At rest – right flank pain radiating into groin
 P = Movement; palpation/nothing - constant
 Q = Sharp and excruciating
 R = Right flank and groin
 S = 10/10
 T = Pt states felt suboptimal all day but pain <1day
 AS = Nausea and vomiting
 PN = Nil
iv. Neurological Status Assessment
 Pupils = R & L are PEARL
 Sensation & strength are normal
v. Respiratory Status Assessment
 Tachypnoea; chest clear on auscultation; bi-lateral air entry
vi. Head to toe
 Nil abnormalities detected

Answer 2

The patient is most likely experiencing renal colic, due to the onset time of symptoms, level of pain, location and radiation, nausea, vomiting, diaphoresis and urgent urge to urinate. The fact he hasn’t lost his appetite and his age indicates the lowered chance of it being appendicitis. For treatment I would consider IV access, IV fluids, analgesia and antiemetic; specifically morphine 5mg increments every 5min max of 20mg [renal failure], and ondansetron 1 dose of 8mg [congenital long QT syndrome, current apomorphine/Parkinson therapy]. Consistent re-checking of BP, HR and pain score before every administration of fentanyl is required to ensure patient safety.

Question 3

Hannah Bianna is a 24yof accountant; under 5wks after returning from holiday and for the last 5days, Hannah has experienced early morning vomiting. Colleague suggested possibility of pregnancy, following morning Hannah vomits more violently and copiously, with apparent fresh blood. She experiences a sharp stabbing pain in the left side of her groin, with a heavy fresh per virginal bleed. Query appendicitis
a.	Person – Object – Place 
b.	Go through primary survey
i.	D = Nil
ii.	R = Yes
iii.	C = Present / tachycardic
iv.	A = Clear – vomitus around mouth
v.	B = Present, shallow, quick
c.	Go through secondary survey
i.	VSS
	HR = 104	RR = 22	GCS = 15
	BP = 108/80	Pain = 	7/10	Temp = 36.5
	SpO2 = 97%	ECG = Sinus tachycardia
ii.	SAMPLE
	S = Pale, sweating, dry, violent retching
	A = Nil
	M = Promethazine/Phenergan (taken 12min prior)
	P = Nil (might be pregnant)
	L = Dry toast prior to commencement of vomiting
	E = Pt states vomiting every morning for past 6 days
iii.	OPQRST-AS-PN
	O & P = 6/7wks Pt’s last period, recurrent morning V
	Q = Vomiting / Nil
	R = Tearing; burning
	S = Thoracic and left lower quadrant
	T = 7/10
	AS = 1/24
	PN = Haematemesis/PV bleed, pregnant [not confirmed]
iv.	Neurological Assessment
	Pupils = PEARL
v.	Head to Toe
	Nil abnormalities detected.

Answer 3

The patient is most likely experiencing an ectopic pregnancy, due to age, amenorrhea [missed period], early morning nausea/vomiting, the left lower quadrant pain, haematemesis [extreme cases of morning sickness during 1st trimester] and abnormal sudden heavy PV bleed. It can’t be appendicitis as that would be right lower quadrant pain. For treatment I would provide IV fluid due to early signs of hypovolaemia specifically the heavy PV bleed, patient being pale, tachycardic and elevated BP; analgesia specifically morphine 2.5mg repeat as required to max of 20mg; in regards to providing an antiemetic I would refrain from administering ondansetron due to the promethazine but if active nausea and vomiting occur I would administer 4mg [congenital long QT syndrome, current apomorphine/Parkinson therapy].

Question 4

Mitchell Smithson is a 26yom recidivist, he injected himself with heroin in the toilets of a bar with an ‘old friend’, wanted to say farewell to an old friend. Query cardiac arrest
a.	Person – Object – Place 
b.	Go through primary survey
i.	D = Drug paraphernalia; Kelpie cross [not aggressive or protective of Mitchell and is obedient to being tethered]
ii.	R = Nil
iii.	C = Present / bradycardic / cyanosed appearance
iv.	A = Clear
v.	B = Present, shallow, bradypnoea
c.	Go through secondary survey
vi.	VSS
	HR = 42	RR = 6		GCS = 3
	BP = 100/80	Pain = 	N/A	Temp = 35.5
	SpO2 = 85%	ECG = Sinus bradycardia
vii.	SAMPLE
	S = Cyanosed; patient is unresponsive
	A = Unable to determine [N/A]
	M = N/A
	P = N/A
	L = N/A
	E = Bystander confirms Mitchel injected himself with heroin then leaves the scene
viii.	OPQRST-AS-PN
	O = N/A
	P = N/A
	Q = N/A
	R = N/A
	S = N/A
	T = N/A
	AS = N/A
	PN = N/A
ix.	Neurological Assessment
	Pupils = 2mm 	Sensation & Strength = N/A
x.	Respiratory Assessment
	Chest clear on auscultation
xi.	Head to Toe
	Nil abnormalities detected.

Answer 4

The patient has overdosed on heroin; position Mitchell sitting up, administer oxygen [IPPB -BVM 15L 2 breaths between his], consider administering naloxone [IM 1.6mg] after oxygen administration, place blanket on patient, gain IV access for IV fluids and prophylactic ondansetron 8mg, use midazolam [IM 5mg repeat every 10min max 20mg] if seizure occurs; monitor airway, breathing and vital signs whilst transport to hospital.

Question 5

Gilbert Perry 21yom, collapsed after kissing Jennifer [who had peanut brownie on her lips] under the mistletoe of a Christmas party. Query allergic reaction / anaphylaxis
a.	Person – Object – Place 
b.	Go through primary survey
i.	D = Nil
ii.	R = Yes
iii.	C = Radial and carotid pulse present
iv.	A = Stridor, wheeze
v.	B = Present, tachypnoea
c.	Go through secondary survey
i.	VSS
	HR = 127	RR = 26	GCS = 14
	BP = 94/70	Pain = 	Nil	Temp = 36.8
	SpO2 = 81%	ECG = Sinus tachycardia
ii.	SAMPLE
	S = Erythema; urticarial; light headed; sweating; swelling to the lips and mouth
	A = Peanuts
	M = Epipen
	P = Patient is extremely reactive to peanuts
	L = Midday
	E = Pt at Christmas party and kissed colleague
iii.	OPQRST-AS-PN
	O = Nil
	P = Nil
	Q = Nil
	R = Nil
	S = Nil
	T = 5min ago
	AS = Nausea
	PN = Nil
iv.	Neurological Assessment
	Pupils = PEARL
	Sensation = altered sensation in extremities
	Strength = generalized weakness
v.	Head to Toe
	Generalized facial swelling and erythema

Answer 5

The patient is most likely experiencing an anaphylactic response to peanuts. I would position him supine or the most comfortable and I would administer oxygen [6L simple face mask], adrenaline [IM 300mic, 5min intervals, no max dose], IV fluid, and if required salbutamol [NEB 5mg, no max dose]; then transport to hospital.

Question 6

Hans Valmont, 68yom Belgian immigrant, was diagnosed 5yrs ago with follicular lymphoma. He initially received radiotherapy and 3yrs later the cancer returned and he received CHOP and Rituximab treatment. 2months ago numerous lumps appeared and were diagnosed with an aggressive type of lymphoma. In last 7days received one complete dose of chemotherapy. Tonight Hans woke with a fever.
a.	Person – Object – Place 
b.	Go through primary survey
i.	D = Nil
ii.	R = Yes
iii.	C = Radial and carotid pule present, tachycardic
iv.	A = Clear
v.	B = Present
c.	Go through secondary survey
i.	VSS
	HR = 115	RR = 20 	GCS = 15
	BP = 100/70	Pain = 	Nil	Temp = 38.3
	SpO2 = 95%	ECG = Sinus Tachycardia
ii.	SAMPLE
	S = Pale and generally unwell looking
	A = Nil
	M = Chlorpromazine; paracetamol; carbenicillin; Zolpidem; metformin; omeprazole; oxycodone
	P = Diagnosed with indolent follicular lymphoma; osteo arthritis and type 2 NIDDM
	L = 1800
	E = Pt fine all day, flu like symptoms just before bed
iii.	OPQRST-AS-PN
	O = Nil
	P = Nil
	Q = Nil
	R = Nil
	S = Nil
	T = Nil
	AS = Nil
	PN = Nil
iv.	Neurological Assessment
	Pupils = PEARL 	Sensation & Strength = normal
v.	Respiratory Assessment
	Chest clear on auscultation
vi.	Head to Toe
	Nil abnormalities detected.

Answer 6

The patient is most likely just experiencing symptoms related to his follicular lymphoma; provide rest and reassurance, administer paracetamol if not already taken, get IV access, provide fluids and remove any excess clothing to bring temperature down slightly, monitor vital signs whilst transporting to hospital.

Question 7

Florence Diamond, 18yof school leaver, partying for previous 7days, when she wakes she can barely lift her head off the pillow.
a.	Person – Object – Place 
b.	Go through primary survey
i.	D = Nil
ii.	R = Alert
iii.	C = Radial [weak] and carotid pulse present
iv.	A = Clear
v.	B = Present; rapid; shallow
c.	Go through secondary survey
i.	VSS
	HR = 144	RR = 25	GCS = 14
	BP = 100/76	Pain = 	7	Temp = 39.9
	SpO2 = 91%	ECG = Sinus tachycardia
ii.	SAMPLE
	S = Pale, lethargic, general malaise; nil rash; dry mucosal membrane, headache and nuchal rigidity
	A = House dust
	M = Seretide; salbutamol
	P = Asthma [well controlled – causative agents: exercise, induced and exposure to house dust]
	L = Unknown
	E = Barely slept or eaten in last 7 days = partying
iii.	OPQRST-AS-PN
	O = 20min ago
	P = Movement; bright light
	Q = Throbbing
	R = Nil
	S = 7/10
	T = 21hrs ago
	AS = Nausea, vomiting, headache, neck pain
	PN = Rash
iv.	Neurological Assessment
	Pupils = PEARL
	Sensation = Generalized paraesthesia in all 4 limbs
	Strength = Weak
v.	Respiratory Assessment
	Chest clear on auscultation
vi.	Head to Toe
	Nil abnormalities detected.

Answer 7

The patient most likely has meningitis or meningococcal septicaemia, the only difference in our treatment plan for both is administering ceftriaxone for meningococcal septicaemia due to lack of rash treatment path will remain the same; treatment includes passively cooling her down, gaining IV access for fluid administration, provide 1g paracetamol, administer methoxyflurane 3mL [Hx liver/renal disease or malignant hyperthermia], if further pain relief is required than IV fentanyl [25mic increments max 200mics], then transport to hospital.