Dip PEC(SA)

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain
Reg No 1955/000003/08

Examination for the Diploma in Primary Emergency Care of the

College of Emergency Medicine of South Africa

9 February 2017

Paper 1 (3 hours)

All questions 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) List the potential signs and symptoms of intussusception in a 6-week-old infant. (5)
b) List the potential signs and symptoms of infantile hypertrophic pyloric stenosis in a
4-week-old infant. (5)
c) List the indications for admission of a 1-year-old child with bronchiolitis. (5)
d) When evaluating the neurological response in an infant (< 1-year), the AVPU scale or
the Glasgow Coma Score (GCS) may be used. If the GCS is to be used, list the
components (scoring 1-5) of the verbal score, when applied to an infant. (5)
e) List the common modifiable risk factors that parents may be warned about, to prevent
Sudden Infant Death Syndrome (SIDS)? (5)
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2 a) A 23-year-old primipara presents to the emergency department (ED) at 10 weeks

gestation with severe vomiting. She has suffered with early morning vomiting from 6
weeks gestation, but over the last 5 days it has become continuous. She complains of
weakness and light-headedness. She has a blood pressure of 100/65mmHg, heart
rate of 105 beats per minute, and a temperature of 37.2C.
i) List 3 urinary investigations and 3 blood investigations that should be performed
in the emergency department on this patient. (6)
ii) Describe the emergency department management of this patient, listing the
pharmacological agents of choice for this condition. (6)
iii) List 2 conditions associated with hyperemesis gravidarum that may be
identified on ultrasound examination. (2)
b) A 22-year-old female patient presents with severe right iliac fossa pain, with guarding
and tenderness on abdominal palpation. She has had normal recent menses but
complains of a vaginal discharge and rigors. Her temperature is 38.3C and heart rate
is 110 beats per minute.
i) What is the most likely diagnosis? (1)
ii) List the clinical features associated with the most likely diagnosis. (3)
iii) List the 2 most common pathogens implicated in this condition. (2)
iv) List 2 outpatient treatment regimens appropriate for this patient. (2)
v) List the complications of this condition. (3)
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PTO/Page 2 Question 3...

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3 A 22-year-old man is brought into your emergency department. He climbed up an electric

pole, touched the transformer, was electrocuted, and fell. He has oxygen saturations of 82%
on room air and requires intubation and ventilation.
a) List the factors determining the severity of high voltage electrical burn injuries. (3)
b) List the potential causes of poor lung compliance in a patient who is receiving invasive
mechanical ventilation post high-voltage electrical injury. (6)
c) This patient is noted to have dark coloured urine and a creatine kinase (CK) that is
elevated at 32000U/L. What is the most likely cause and how will you manage this
clinical condition? (9)
d) Describe the evaluation and management of short sustained exposure to household
electrical current in a 3-year-old child. (4)
e) Describe the typical patterns of burn wounds caused by electrical injuries. (3)
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4 A 21-year-old man, currently on tuberculosis (TB) and antiretroviral (ARV) treatment, is

transported by ambulance to the emergency department (ED). He presents with a history of
seizures. Upon examination, generalised tonic-clonic convulsions and a depressed level of
consciousness are confirmed. His vital signs include a blood pressure of 95/65 mmHg, heart
rate of 119 beats per minute, oxygen saturation of 95% on supplemental oxygen (40% face
mask oxygen), temperature 37.8C, and respiratory rate 31 breaths per minute.
Regarding suspected isoniazid (INH) toxicity:
a) What is the antidote? (1)
b) What dose(s) of antidote would one prescribe? (2)
c) What acid-base disturbance would you expect? (2)
d) Which class of ARV drugs may also commonly cause this acid-base disturbance? List
one specific example. (2)

The family arrives in the emergency department and provides collateral history of ethylene
glycol ingestion.
e) What is the mechanism of ethylene glycol toxicity? (2)
f) Which electrolyte disturbance subsequently occurs? (1)
g) Which enzyme is primarily involved in ethylene glycol toxicity? (1)
h) Which antagonist(s)/antidote(s) are available for use? (2)
i) Which metabolic disturbance must one anticipate post-antidote/antagonist
administration and how would one treat it? (3)

The patient’s seizures are treated with anticonvulsants.

j) List the metabolic adverse effects of sodium valproate (valproic acid) toxicity. (6)
k) What is a common adverse effect if phenytoin is rapidly administered intravenously
and what is the main causative agent responsible for this effect? (2)
l) What dose (mg/kg) of sodium valproate and phenytoin is/are used in the treatment of
status epilepticus. (1)
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Dip PEC(SA)

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain
Reg No 1955/000003/08

Examination for the Diploma in Primary Emergency Care of the

College of Emergency Medicine of South Africa

10 February 2017

Paper 2 (3 hours)

All questions 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) You are called to assist with decision making and emergency ventilation of two trauma
patients that are currently in the resuscitation area. Describe how you would go about
mechanical ventilation of these patients, including mode of ventilation, all ventilator
settings, and target end points as determined by arterial blood gas sampling:
i) A 36-year-old male patient with a history of traumatic brain injury who has just
returned from CT scan with a diagnosis of an acute subdural haematoma and is
awaiting neurosurgical intervention. His initial Glasgow Coma Score was 7/15
and he was intubated on scene by the ALS paramedic. (7)
ii) A 65-year-old male patient with multiple rib fractures on the right-hand side,
following a fall from a ladder. He is currently not intubated and is cooperative, but
is tachypnoeic and has poor oxygenation. (5)
b) A young female has sustained a gunshot wound to the right lower limb, just proximal
to the knee. Clinically there is a distal femur fracture. The dorsalis pedis pulse is
palpable on the right foot but you are concerned about a possible vascular injury. List,
in a step wise approach, how you would go about excluding such an injury. (5)
c) You are designing a protocol for massive transfusion for your emergency department.
Define the following
i) The clinical parameters that a patient should meet to be initiated on the massive
transfusion protocol. (2)
ii) The type and ratios of blood products to be administered. (2)
iii) The targets to be reached before stopping transfusion. (4)
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2 A 30-year-old HIV positive male patient who is not yet on treatment presents to the
emergency department with a swollen jaw and neck two days post tooth extraction.
a) List four differential diagnoses for this acute presentation. (4)
b) Write short notes on Ludwig’s angina using the following headings
i) Clinical presentation (3)
ii) Diagnostic strategies (2)
iii) Management (4)
c) Define the following terms
i) Stridor (2)
ii) Wheezes (2)
iii) Grunting (2)
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d) i) What is the differential diagnosis for a 2-year-old child with stridor? (4)
ii) What x-ray is commonly requested in a patient with suspected epiglottitis? (1)
iii) What is the classical x-ray finding expected with epiglottitis? (1)
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3 The police bring a 28-year-old male known with bipolar mood disorder to your emergency
department suffering from grandiose delusions and an acute psychosis. He is very agitated
and is at high risk of harming himself and the public. He refuses any medical assistance and
states that he will sue if his wishes are not heeded. He demands to sign a refusal of hospital
treatment form and leave.
a) In terms of the Mental Health Care Act (Act 17 of 2002), what is the purpose of the
following forms and who should complete them?
i) MCHA Form 01. (2)
ii) MCHA Form 02. (2)
iii) MCHA Form 04. (2)
iv) MHCA Form 05. (2)
v) MHCA Form 07. (2)
vi) MHCA Form 22. (2)
b) In general, under which circumstances or conditions may a patient not refuse hospital
treatment? (3)
c) While attempting to restrain the patient and administer intramuscular medication, your
colleague sustains a needle-stick injury.
i) What ethical principles should you consider when performing a rapid HIV test on
this patient and how would you obtain consent? (4)
ii) He tests positive and his wife would like to know his results. In general, under
which circumstances are you as a health practitioner allowed to break doctor-
patient confidentiality? (6)
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4 A 56-year-old male is brought to the emergency department by his son after he had a
“fainting” spell at home and is now complaining of pain in the upper chest, radiating to his
back and into his upper abdomen. He has a blood pressure of 150/90 mmHg in both upper
limbs and 130/75 mmHg in both lower limbs. He is mildly dyspnoeic. There is no history of
trauma or history of ischaemic heart disease, and the patient has had no previous surgery.
a) What is the differential diagnosis for life threatening chest pain and what is the most
likely diagnosis? (5)
b) Describe the emergency care and the diagnostic work-up you will follow when
managing this patient. (10)
c) How may ultrasound assist in the diagnosis of this pathology? (5)
d) List the acute complications of this pathology. (5)
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