Case 2: 75yr old woman admitted with hip pain and shock. BP not responding to aggressive fluid resuscitation, and patient on ITU
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Observations & Interpretations
CT: Both adrenal glands are bulky and ill-defined with significant surrounding fat stranding. There are bibasal pleural effusions with associated basal collapse/consolidation. There is some pericholecystic free fluid. There is also a fluid collection around the right hip, with no significant associated bony destruction.Principal Diagnosis
Bilateral adrenal haemorrhage (Waterhouse-Friderichsen Syndrome) possibly caussd by septic arthritis of the right hip.Differential Diagnosis
Cholecystitis causing sepsis and subsequent adrenal haemorrhage.Unidentified source of sepsis causing adrenal haemorrhage.
Management
Blood cultures, and correlate with inflammatory markers Antibiotics and Steroid Replacement Orthopaedic Referral for consideration of joint aspiration Consider ultrasound gallbladder / lumbar puncture / echocardiogram| Marking Scheme | ||
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| 3 | Nothing | Nothing Written |
| 4 | Fail | Significant Observations Missed. No Mention of Correct Diagnosis |
| 5 | Borderline | Some Observations Missed. Only 1 of the main diagnoses suggested |
| 6 | Pass | Most observations made. The main diagnoses are made (at least in differential) |
| 7 | Good Pass | Observations made. Principal Diagnoses are all correct, and there is good reasoning. |
| 8 | Perfect Answer | Clear, Concise & Confident. Good Reasoning, and no unrealistic differentials |
You should mark yourself realistically. Some cases will be hard, and just making the relevant observations and sensible observations will give you a pass. Some cases will seem easy, and it is these cases you need to be scoring 7 or 8. In the exam if you write something very incorrect, or if you put down too many obscure differentials, then half marks can be deducted from your score. Make sure you include relevant negatives. If you think there is only 1 differential then be confident, and don't put down unlikely diagnoses. Make sure your handwriting is clear, and use bullet-points to make it more readable. Timing is crucial, and don't spend too long on a single case. As you will note from the mark scheme, if you put nothing down you get a 3. So simply writing a single observation gives you a point
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