FCEM(SA) Part I THE COLLEGES OF MEDICINE OF SOUTH AFRICA Incorporated Association not for gain Reg No 1955/000003/08 Part

I Examination for the Fellowship of the College of Emergency Medicine of South Africa 8 April 2013 Paper 1 (3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more than one is required for the one answer) 1 A 22-year-old woman presents to the emergency department complaining of a severe headache and a feeling of heaviness behind her eyes a) Draw a labeled diagram of the cavernous sinus and its contents. (7) b) List the hypothalamic and specific (anterior, pars intermedia and posterior) pituitary hormones. (6) c) Write short notes on cavernous sinus thrombosis regarding i) Clinical signs and symptoms. (3) ii) Causes. (2) d) Briefly discuss oxytocin (Syntocinon) under the following headings i) Indications. (2) ii) Side effects. (3) iii) Contraindications/precautions. (2) [25] A 34-year-old diabetic woman with severe sepsis due to pneumonia, presents to the emergency department. She is severely tachypnoeic, tachycardiac and hypotensive. You prepare to intubate and ventilate her a) List the cartilages and ligaments/membranes (extrinsic and intrinsic) of the larynx. (8) b) Draw the lung volume-time (vitalograph) curve and indicate the static volumes and capacities. (6) c) Briefly discuss the classical pathological pattern/stages of lobar pneumonia. (5) d) Write short notes on glucagon (Glucagen Novo) under the following headings i) Mechanism of action. (1) ii) Emergency use(s) and dosage. (2) iii) Adverse effects. (3) [25]

PTO/Page 2 Question 3

-23 A 32-year-old male patient is brought to the emergency department by paramedics with a history of being involved in a motorbike accident. He sustained a head injury as well as multiple limb injuries. a) Write short notes on the following i) Anatomical snuff box. (6) ii) Foramen of Munro. (2) iii) Cushings ulcer. (2) b) One of the paramedics reported that the patient has Kussmaul breathing. Write short notes on the pathophysiology of Kussmaul respiration. (4) c) Write short notes on the pharmacology of sodium bicarbonate, including the indications, dose, administration and possible side effects. (8) d) Write short notes on the blood-brain barrier. (3) [25] A 56-year-old female patient presents to the emergency department with a history of having fallen on her outstretched upper limb. She takes perindopril (Prexum) and atorvastatin (Lipitor) for hypertension and hypercholesterolaemia respectively and warfarin for a previous DVT a) List 8 potential injuries resulting from falling on an outstretched upper limb. (4) b) Describe warfarin under the following headings i) Uses and clinical indications. (2) ii) Mechanisms of actions. (1) iii) Drug interactions with respect to anticoagulation. (6) iv) Drug monitoring. (2) v) Precautions. (2) c) List potential sources of error in measuring blood pressure. (3) d) List risk factors for deep vein thrombosis. (5) [25]

FCEM(SA) Part I THE COLLEGES OF MEDICINE OF SOUTH AFRICA Incorporated Association not for gain Reg No 1955/000003/08 Part I Examination for the Fellowship of the College of Emergency Medicine of South Africa 9 April 2013 Paper 2 (3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more than one is required for the one answer) 1 A 60-year-old man presents complaining of severe pain in his left armpit, palpitations gynaecomastia a) Draw a labeled diagram (transverse section) of the axilla, its walls and contents. b) Using a flow diagram illustrate catecholamine (Adrenaline) synthesis. c) Regarding gynaecomastia, list the following i) Pathological causes. ii) Causative drugs. d) Briefly discuss paracetamol under the following headings i) Mechanism of action (general and postulated). ii) Features of paracetamol overdose. and (7) (5) (2) (5) (2) (4) [25]

A 42-year-old man with right flank pain, haematuria, nausea and vomiting presents to the emergency department a) Draw a labeled diagram of the surface anatomy of the gluteal region, its surrounding structures and indicate the safe zone for intramuscular (IMI) injections. (4) b) Briefly discuss the various neural inputs and causes of vomiting. (7) c) Regarding urolithiasis (urinary calculi) list the following i) Types and incidence. (3) ii) Precipitating factors. (4) d) Write short notes on metoclopramide under the following headings i) Mechanism of action. (1) ii) Adverse effects. (3) iii) Contraindications/precautions. (3) [25]

PTO/Page 2 Question 3

-23 A 55-year-old male patient presents to the emergency department with symptoms of dyspnoea, fatigue and confusion. He appears cyanotic a) Describe what is meant by the term cyanosis. (3) b) Write short notes on the pathophysiology of methaemoglobinaemia. Incorporate the following headings into your answer i) Aetiology and pathology. (4) ii) Oxygen dissociation curve. (2) iii) Methaemoglobin metabolism. (2) iv) Methylene blue. (2) v) Cyanide poisoning. (2) c) List the four categories of hypoxia. (4) d) His chest x-ray reveals a large pleural effusion on the right. Draw and label the anatomy involved in doing a thoracentesis. (6) [25] A 24-year-old male is injured after an altercation at a pub. He presents to the emergency department with a deep wound to the neck with a 15 cm long kitchen knife still in situ, deeply embedded in the neck, with only 4 cm protruding above the surface. He is talking, vocalising expletives and moving all his limbs normally. He threatens to pull out the knife if he is not attended to immediately a) Describe the anatomical surface landmarks for the anterior triangle of the neck. (3) b) Describe zones of penetrating trauma to the neck. (4) c) List potential complications and contraindications for central venous cannulation via the subclavian approach. (7) d) Write short notes on central venous pressure. (4) e) Describe the following under the headings indications, precautions, adverse effects, and dosing i) Protamine sulphate. (5) ii) Fresh frozen plasma. (2) [25]