SGR Learning Hub

Date Posted: 02/11/2022

You are a GP at the UWA Medical Centre. Your next patient is Ijud, a 24 year old final year medical student living on college row who has been complaining of headaches, sore-throats and a cough that will just not go away. This is Ijud’s second time seeing you in a week – he is here to discuss findings from a chest X-ray you ordered on his initial clinic visit.

Task: Interpret Ijud’s Chest X-ray, and discuss your management plan with him.

CXR #15: Further Questions & Answers

1. What ‘special’ questions would you ask on history to distinguish between causative agents in LRTIs?
2. Differential diagnosis for chronic cough?
3. Antibiotic resistance is a growing public health crisis. What strategies, in the community and hospitals, are in place to mitigate this risk?

CXR-15: Further Questions and AnswersDownload

Date Posted: 12/10/2022

You are an intern working on the acute medical ward. John, a 65M comes in after an episode of haemoptysis this morning. This is on a background of progressive shortness of breath over the last few weeks

He has a 50 pack year smoking history.

A PA CXR was performed on admission.

Task: Interpret the CXR and provide a differential.

CXR #14: Further Questions & Answers

1. Which way is the trachea usually deviated in a pleural effusion?
2. List some causes of exudative and transudative pleural effusions.
3. What laboratory tests can be done on pleural fluid?

CXR-14: Further Questions and AnswersDownload

Date Posted: 14/09/2022

You are an intern working in ED. Amanda, a 70F is brought in by ambulance with a 3 hour history of shortness of breath.

She has a history of a previous myocardial infarction and a 40 pack year smoking history.

A PA CXR was performed on admission.

Task: Interpret the PA CXR and provide a working diagnosis.

CXR #13: Further Questions & Answers

1. What are some causes of acute heart failure in a patient with no adverse cardiac history or cardiovascular risk factors?
2. Other than a CXR, what investigations would you do to workup suspected heart failure?
3. Beta blockers are widely used in heart failure with a reduced ejection fraction (HFrEF). Are there any contraindications to their use?

CXR-13: Further Questions and AnswersDownload

Date Posted: 31/08/2022

Yinka, a 68F with a known diagnosis of colorectal cancer presented to oncology clinic to discuss starting chemotherapy.

Yinka was very against chemotherapy initially and was scared of the side effects. She presents very cachectic with night sweats, fatigue and dyspnoea. Given her recent deterioration, she has decided to reconsider chemotherapy. 

She is a non-smoker and non-drinker but eats bacon every morning. Yinka is estranged from her parents and her family history is unknown. She is not on any medications as she believes it is unnatural. 

A routine CXR was done prior to commencing chemotherapy.

Task: Interpret the PA CXR and provide a differential.

CXR #12: Further Questions & Answers

1. Outline Light’s criteria for pleural effusion and list aetiologies of a pleural effusion.
2. What are the aetiologies of a pericardial effusion.
3. List 3 factors that decrease the risk of colorectal cancer.
4. Outline the clinical presentation of colorectal cancer.
5. Explain why the most common site of metastasis of colon cancer is different to that of rectal cancer.

CXR-12: Further Questions and AnswersDownload

Date Posted: 20/07/2022

You are an intern working in the emergency department. Eliana, a 63F presents with progressively worsening shortness of breath since a myocardial infarction 1 week prior. She has been using 3 pillows to sleep and has experienced mild, retrosternal chest pain.

Eliana is an orphan and does now know of any family history. Eliana has a history of hypertension and has a 80 pack year smoking history. 

A PA CXR was performed on admission. 

Task: Interpret the PA CXR and provide a differential.

CXR #11: Further Questions & Answers

1. What 2 factors determine whether a pericardial effusion progresses to cardiac tamponade?
2. Outline the clinical presentation of cardiac tamponade
3. What are the classic ECG findings of cardiac tamponade?

CXR-11: Further Questions and AnswersDownload

Date Posted: 06/07/2022

Mina, a 68-year-old female presents to ED with right-sided chest pain and difficulty breathing following a fall off her bike whilst riding. She also says she has some right sided shoulder tip pain.

Mina appears uncomfortable and is taking fast, shallow breaths and when she coughs she winces in pain. 

Task: Interpret the Ap CXR and provide a working diagnosis.

CXR #10: Further Questions & Answers

1. What are common risk factors for a pneumothorax?
2. What are the classic examination findings of a pneumothorax?
3. Why does Mina need to be assessed for signs of haemodynamic instability?
4. Other than a CXR, what other investigations and management would you like to do for Mina?

CXR-10: Further Questions and AnswersDownload

Date Posted: 08/06/2022

You are a GP working in Peppermint Grove. Kaiba, a 69M with a 51 pack year smoking history presents with progressive dyspnoea over the past year. He can walk 5m before onset of dyspnoea and chest tightness. Kaiba previously used to go on daily 2km walks with his wife and daughter. His wife was helping with his ADLs. He has gained 5kg over the past year and now has a BMI of 31.

Kaiba has a past history of Hepatitis C acquired from IVDU which has been cleared and has had a prostatectomy to treat prostate cancer 5 years prior. He has no other significant medical history.

A PA CXR was performed on admission.

Task: Interpret the PA CXR and provide a working diagnosis.

CXR #9: Further Questions & Answers

1. What are the spirometry findings of COPD?
2. What are the 2 morphological subtypes of emphysema and what are their most common aetiologies?
3. Outline the pathophysiology of α1-antitrypsin deficiency and describe its clinical presentation.

CXR-9: Further Questions and AnswersDownload

Date Posted: 27/04/2022

You are an intern working in the hepatology department at SCGH. Mr. Fairgood, a 63M is an inpatient who presented from home two days ago with a one week history of melaena, identified on oesophagogastroduodenoscopy (OGD) to be secondary to oesophageal varices, on a background of alcohol-related cirrhosis. His wife is a pharmacist and helps look after Mr. Fairgood, takes care of household duties and manages his medications.

He has a history of a previous episode of alcohol induced hepatic encephalopathy and has abstained from drinking for 5 years, but drank half a carton of Carlton Dry a day for 15 years prior.

Mr. Fairgood complains to you of chest pain and a dry, non-productive cough that has been going on the past three days of his admission. Mr. Fairgood is oriented to time, person and place, and shows no signs of encephalopathy. His abdomen is distended and caput medusae is present.

You decide to order a PA CXR.

Task: Interpret the CXR and provide a working diagnosis.

CXR #8: Further Questions & Answers

1. Outline the pathophysiology of ascites in a patient with cirrhosis.
2. How is ascites classified to identify its aetiology? List 5 aetiologies of ascites.
3. How is ascites managed?

CXR-8: Further Questions and AnswersDownload

Date Posted: 02/03/2022

You are on your rapid 5 minute orthopaedic ward round and to your dismay, Clive, a previously well 62 year old male, 3 days post left total hip replacement, reports feeling short of breath, feverish and sweaty overnight. He also notes a sharp pain in the lower left of his chest.

You remember, given your immense surgical prowess as a gun orthopaedic registrar, Clive’s hip replacement had no intraoperative complications. Clive appears uncomfortable and is sweating profusely, and you notice a productive cough. His breaths are shallow and rapid. He is currently on 2L of O2.

Task: Consider initial management for Clive and interpret the CXR

CXR #7: Further Questions & Answers

1. What are the most common bacterial pathogens associated with hospital acquired pneumonia?
2. What are the most commonly prescribed empirical antibiotics for hospital acquired pneumonia?
3. Clive does not respond to his empirical antibiotics and becomes acutely hypotensive, you believe he is septic. What is your immediate management?

CXR-7: Further Questions and AnswersDownload

Date Posted: 11/07/2021

You are an intern working in ED. A 21 year old female has come in after falling over at social netball, landing on her outstretched hand. She is bracing her arm and there is an obvious deformity. As part of the initial steps of management, you order an XR of her L wrist.

Task: Interpret the L wrist XR

X-Ray #6: Further Questions & Answers

1. How could you perform a neurovascular
   examination on this patient?
2. What are the indications for non-operative
   management of a Colles' fracture?

X-Ray #6: Further Questions & AnswersDownload

Date Posted: 31/07/2021

You are an intern in ED. Mrs X, a 63F presents with progressively worsening shortness of breath since an MI 1 week prior. She has been using 3 pillows to sleep and has experienced mild, retrosternal chest pain. Mrs X has a history of hypertension.

A PA CXR was performed on admission.

Task: Interpret the CXR and provide a differential

CXR #5: Further Questions & Answers

1. What two factors determine whether a pericardial effusion progresses to cardiac tamponade?
2. Outline the clinical presentation of cardiac tamponade
3. After pericardiocentesis, the fluid was analysed, and the fluid type was identified to be "blood'.
4. What are other aetiologies of pericardial effusion that would have this fluid type?

CXR-5: Further Questions and AnswersDownload

Date Posted: 24/06/2021

You are an intern working on a neurology ward, where a nurse informs you that one of your patient's, an 83F day 2 post-ischaemic MCA-territory stroke (initially managed with thrombolysis), is now febrile, increasingly delirious and saturating at 91% on room air.

You perform a CXR, as part of a septic screen and compare your findings with a CXR performed at admission.

Task: Interpret the CXR

CXR #4: Further Questions & Answers

1. Why are stroke patients at increased risk of aspiration pneumonia?
2. What side is aspiration pneumonia most common and why?
3. What is the empirical treatment for aspiration pneumonia in the hospital setting?

CXR-4: Further Questions and AnswersDownload

Date Posted: 22/04/2021

A 48 year old lady presents with dyspnoea on a background of recently diagnosed breast cancer.

Task: Interpret the CXR and identify any abnormalities

CXR #3: Further Questions & Answers

1. What is the criteria that can be used to differentiate between transudative and exudative pleural effusions?
2. List 3 causes of transudative effusions and 3 causes of exudative effusions.

CXR-3: Further Questions and AnswersDownload

Date Posted: 04/03/2021

A 48 year old lady presents with dyspnoea on a background of recently diagnosed breast cancer.

Task: Interpret the CXR using a systematic approach

CXR #2: Further Questions & Answers

1. How would you manage this patient?

CXR-2: Further Questions and AnswersDownload

Date Posted: 11/02/2021

A 48 year old lady presents with dyspnoea on a background of recently diagnosed breast cancer.

Task: Interpret the CXR and suggest a working differential

CXR #1: Further Questions & Answers

CXR-1: Further Questions and AnswersDownload

Date Posted: 03/08/2022

You are an RMO in the ED at a peripheral hospital. It is currently 5:00pm and Quentin, a 62M patient presents following a syncopal event in the parking lot of his local grocery store. He reports that he is currently feeling lightheaded. Mr. Q has a long-standing history of hypertension which is poorly managed. His hypertension is currently treated with ramipril and diltiazem.

On examination Quentin is responsive. He sustained some small cuts and bruises from his fall but is otherwise well. He is bradycardic and his blood pressure is 158/102 mmHg (which is normal for him), with no postural hypotension.

Task: Interpret the ECG and provide a diagnosis.

ECG #8: Further Questions & Answers

1. What are your initial investigations for Quentin?
2. How will you manage Quentin’s condition?
3. What is the pathophysiology underlying PR prolongation or PR absence in the different types of AV block?

ECG-8: Further Questions and AnswersDownload

Date Posted: 13/04/2022

You are a GP working in private practice. Jane, a 70F comes in for a routine medical. As part of her workup, you decide to perform an ECG.

Task: Interpret the ECG and provide a diagnosis.

ECG #7: Further Questions & Answers

1. What are the different types of heart block and what are their distinguishing ECG features?
2. Outline your management plan for each type of heart block.
3. What is Stokes-Adams syndrome (Stokes-Adams attacks)?

ECG-7: Further Questions and AnswersDownload

Date Posted: 16/02/2022

You are an intern in the ED. Mr. Jacobs, a 75M presents with retrosternal, crushing chest pain that radiates down his left arm. The pain was of sudden onset and has been ongoing for one hour. Mr Jacobs currently rates his pain at a 7/10 however before his GTN sublingual spray he rated the pain at an 8/10.

His father and older brother died of heart attacks in their 60s. He has a 20 pack-year history of smoking, and drinks 7 standards a night.

Mr Jacobs has a large body habitus, appears uncomfortable and is sweaty. He is currently hyperventilating.

Task: Interpret the ECG and provide a diagnosis.

ECG #6: Further Questions & Answers

1. How can we see a posterior MI on an ECG?
2. Other than ST elevation, what other finding on an ECG can be used to diagnose a STEMI?
3. What is your management plan for this patient?
4. List 5 complications of an MI

ECG-6: Further Questions and AnswersDownload

Date Posted: 11/05/2021

You are a MO in ED. Mr X, a 72 year old male is BIBA post collapse with a 2/7 hx of worsening confusion, on a background of end stage kidney failure on peritoneal dialysis, chronic heart failure and hypertension managed with ramipril, bisoprolol and spironolactone. On further questioning, Mr X has not been adhering to his renal diet and fluid restriction.

Task: Interpret the first ECG and provide a diagnosis.

ECG #5: Further Questions & Answers

1. Outline your approach to initial management
   of this condition.
2. The second ECG shows a life-threatening
   consequence of this condition. Describe and
   interpret the second ECG.

ECG-5: Further Questions and AnswersDownload

Date Posted: 15/04/2021

You are a GP you are assessing John an 80 yo M, you have never seen him before. He is new to town, and you are doing a general checkup. The nurse hands you his "abnormal ECG'.

Task: Interpret the first ECG and identify the abnormalities.

ECG #4: Further Questions & Answers

1. What are the causes of RBBB?
2. What is done about an asymptomatic 1st
   degree heart block?

ECG-4: Further Questions and AnswersDownload

Date Posted: 01/04/2021

Trigger 2: The same 29 yo M from ECG #2 presents to ED with a 1-day history of acute chest pain described as 9/10 chest tightness that does not radiate to his jaw or shoulder, associated with SOB. The pain is worse when he leans forward. Relevant history is a previous diagnosis of pericarditis 2 weeks prior.

Task: Interpret the ECG and provide a diagnosis.

ECG #3: Further Questions & Answers

1. Outline the staging system of your diagnosis

ECG-3: Further Questions and AnswersDownload

Date Posted: 01/04/2021

29 yo M presents with a 3-day history of worsening, acute onset central chest pain. Today he describes the pain as an 8/10, tight in character, without radiation to the jaw or shoulder, with no associated symptoms.

Task: Interpret the ECG and provide a diagnosis.

ECG #2: Further Questions & Answers

1. Provide the initial management of this patient

ECG-2: Further Questions and AnswersDownload

Date Posted: 18/02/2021

You are a junior medical officer working at a tertiary ED when Mr X, a 40M, presents with a 1- hour history of severe central chest pain. However, on initial assessment he was pain free.

Four minutes later he developed further intense chest pain and a repeat ECG was performed.

Task: Interpret both ECGs and identify the abnormalities.

ECG #1: Further Questions & Answers

1. Outline your initial management as the JMO for this patient.

ECG-1: Further Questions and AnswersDownload

Date Posted: 22/06/2022

You are an intern working on the medical ward. Alfred, a 63M presented 3 days ago with severe chest pain and was taken for a coronary angiogram. His past medical history is unknown.

His vitals are stable however his urine output has decreased overnight.

He has been having routine bloods done each morning on the phleb round. Today’s results are listed.

Task: Interpret the bloods and give your working diagnosis.

Blood Tests #4: Further Questions & Answers

1. What investigation result might we look for in his previous bloodwork?
2. His renal function continues to deteriorate and he starts to develop electrolyte abnormalities. What diagnosis is shown on this ECG?
3. Other than kidney disease, what else might cause a raised urea?

Blood Test-4: Further Questions & AnswersDownload

Date Posted: 11/05/2022

You are a GP seeing your first patient of the day. Alex is a 45M who comes in for a skin check. On further questioning, Alex complains that he is constantly fatigued regardless of the amount of sleep he gets and reports ongoing shortness of breath over the last few months.

When you probe his social history, you discover Alex lives by himself at home, drinks a slab of emu exports (24 pack) each day and his diet consists entirely of 2 minute noodles.

The examination findings were:

- Vitals: HR 94, BP 110/90, RR 18, Spo2 96%, Temp WNL

- On general inspection Alex appears pale

- On inspection of the face Alex’s tongue appears smooth

Routine bloods are performed.

Task: Interpret the blood results, provide a working diagnosis and list other investigations/things you would like to do.

Blood Tests #3: Further Questions & Answers

1. What is the classic description of neutrophils in megaloblastic anaemia?
2. What neurological condition can result from prolonged B12 deficiency?
3. Is folate or B12 deficiency more common? Why?

Blood Test-3: Further Questions & AnswersDownload

Date Posted: 30/03/2022

You are a GP working in the community. Charles, a 65M complains of feeling increasingly tired and fatigued over the last 3 months.

Though he does not have any significant past medical history, he has not been to a doctor in 10 years, and has never done any sort of preventative health screening.

The examination findings were:

- Vitals WNL

- HSDNA

- Chest NAD

- Abdomen NAD

The GP ordered some blood tests to further investigate.

Task: Interpret the blood results, provide a working diagnosis and list other investigations/things you would like to do.

Blood Tests #2: Further Questions & Answers

1. The best measure we have of total body iron stores is a serum ferritin level. When conducting iron studies, why might a CRP be ordered alongside the ferritin level?
2. Charles wants to know some side effects of oral iron supplementation. List 4.
3. Haemolytic anaemia is a cause of normocytic anaemia. What investigations are part of the workup of haemolysis?

Blood Test-2: Further Questions & AnswersDownload

Date Posted: 16/03/2022

You are an intern working in ED. Bethanie, a 45F with a BMI of 34 presents with a 3 day history of constant RUQ pain which is worse postprandially, radiates to her right shoulder and is associated with vomiting.

Beth describes her urine as tea coloured and her stool as clay coloured. She has sleeve tattoos, a history of IVDU and poorly managed T2DM.

On examination she has scleral jaundice and scratch marks on both of her arms. All vital signs are within normal limits.

Task: Interpret the blood results, provide a working diagnosis and list other investigations/things you would like to do.

Blood Tests #1: Further Questions & Answers

1. Label the following diagram of the biliary tree
2. What conditions resulting from gallstones can occur in each part of the biliary tree?
3. List 5 aetiologies of pancreatitis.
4. How is a diagnosis of acute pancreatitis made?

Blood Test-1: Further Questions & AnswersDownload

Date Posted: 17/08/2022

Archibald, a 74-year-old man with a long history of COPD presents with 4 days of worsening shortness of breath, productive cough, and increased sputum production. Archie has a 120 pack-year history. He can normally walk 150m on level ground but this morning he was struggling to make it to the door. He is also having difficulty sitting up.

On examination:

- Vitals: RR 32, HR 102, BP 136/88, SpO2 92% → 88%, temp 37.9ºC

- Visible intercostal recession, tracheal tug and paradoxical abdominal movements

- Cyanosed

- Polyphonic wheeze throughout

The registrar asks you to take an ABG.

Task: Interpret the results, provide a working diagnosis and list other investigations/things you would like to do.

ABG #2: Further Questions & Answers

1. What is the general management of COPD?
2. What is the management of a COPD exacerbation?
3. What are common causes of respiratory failure?

Advanced:

4. What are the indications for home O2 therapy in COPD?
5. The registrar looks at the ABG and tells you that the patient’s respiratory failure is acute - how do they know this?

ABG-2 Further Questions and AnswersDownload

Date Posted: 25/05/2022

A priority 1 call has come in to ED. A young woman has been found unconscious at home and is currently en route to ED via ambulance. The registrar is organising his team for the resuscitation and as everyone else will be wearing PPE, you, the resident, have been asked to run the ABG.

Task: Interpret the results, provide a working diagnosis and list other investigations/things you would like to do.

ABG #1: Further Questions & Answers

1. What are common causes of high and normal anion gap metabolic acidosis (HAGMA/NAGMA)?
2. Explain your immediate and continued management of the patient.
3. List 4 potential triggers for DKA in this patient. 

ABG-1 Further Questions and AnswersDownload

Date Posted: 11/07/2021

You are an intern working in ED. A 21 year old female has come in after falling over at social netball, landing on her outstretched hand. She is bracing her arm and there is an obvious deformity. As part of the initial steps of management, you order an XR of her L wrist.

Task: Interpret the L wrist XR

TXR #1: Further Questions & Answers

1. How could you perform a neurovascular
   examination on this patient?
2. What are the indications for non-operative
   management of a Colles' fracture?

TXR#1: Further Questions & AnswersDownload