1. Question 7
Graeme Thomson

2. Stem
An 80 year old woman from home presents with fever, cough and collapse. She has a history of chronic renal failure, hypertension and congestive heart failure. On arrival her observations are as follows:
Temp C
HR 80 /min
BP 80/70 mmHg
SaO2 89% on 6L via Hudson mask
GCS 14 (E4, M6, V4)

3. Q i
Complete the following table listing three (3) alternative methods for assessing the fluid status of this patient. For each method state two (2) pros and two (2) cons. (9 marks)

4. Fluid status assessment methods
Clinical
Ultrasound
CVP
Other more limited methods possible
CXR, laboratory tests
Could be interpreted more narrowly
Components of clinical examination

5. Pros and Cons Needed 2 for each method to get a mark.
Something more than words like: quick, easy, cheap, available, works, effective etc.
For example, pros of ultrasound could be: able to detect underhydration and overhydration, no risk of complications from an invasive procedure.

6. Q ii
Complete the following table listing three (3) alternative methods for improving oxygenation in this patient. For each method state two (2) pros and two (2) cons. (9 marks)

7. Oxygenation methods High flow nasal prongs (or higher flow via mask)
NIV (CPAP / BiPAP)
Invasive ventilation
Not just nasal prongs
Alternatives
Positioning, drug treatments

8. Pros and Cons
Highlight extra benefits of each method and their complications.
For example, pros of NIV could be: Decreased work of breathing and ability to attain high FiO2 with a closed system.

9. Q iii
List four (4) steps in establishing limitations of care for this patient. (4 marks)

10. Limitations of care Check advanced directives
Establish current diagnosis, treatments required and likely prognosis
Establish premorbid state
Discuss with likely inpatient treating team (eg ICU)
Discuss with patient (although confused)
Determine NOK and discuss with them
Find agreed position
Document the plan

11. Most common errors Leaving sections blank
Weak, uninformative or repetitive pros
Poor writing

12. Pass criteria Pass mark set at 17
Part i: 3 methods plus 2 pros and 2 cons for 2 of those
Part ii: 3 methods plus 2 pros and 2 cons for 2 of those
Part iii: 3 steps

13. Results 27 passed 15 failed Median = 18 Mode = 18 Mean = 17
Note: if the pass mark had been set at 16 then there would have been 33 passes and 9 failures.