The use of feeding tubes in paediatrics: Texts Practice Book 1

Text A
Paediatric nasogastric tube use
Nasogastric is the most common route for enteral feeding. It is particularly useful in the short
term, and when it is necessary to avoid a surgical procedure to insert a gastrostomy device.
However, in the long term, gastrostomy feeding may be more suitable.
Issues associated with paediatric nasogastric tube feeding include:
• The procedure for inserting the tube is traumatic for the majority of children.
• The tube is very noticeable.
• Patients are likely to pull out the tube making regular re-insertion necessary.
• Aspiration, if the tube is incorrectly placed.
• Increased risk of gastro-esophageal reflux with prolonged use.
• Damage to the skin on the face.

Text B
Inserting the nasogastric tube
All tubes must be radio opaque throughout their length and have externally visible markings.

1. Wide bore:

- for short-term use only.

- should be changed every seven days.
- range of sizes for paediatric use is 6 Fr to 10 Fr.

2. Fine bore:

- for long-term use.

- should be changed every 30 days.
In general, tube sizes of 6 Fr are used for standard feeds, and 7-10 Fr for higher density and
fibre feeds. Tubes come in a range of lengths, usually 55cm, 75cm or 85cm.
Wash and dry hands thoroughly. Place all the equipment needed on a clean tray.
• Find the most appropriate position for the child, depending on age and/or ability to co-
operate. Older children may be able to sit upright with head support. Younger children may
sit on a parent's lap. Infants may be wrapped in a sheet or blanket.
• Check the tube is intact then stretch it to remove any shape retained from being packaged.
• Measure from the tip of the nose to the bottom of the ear lobe, then from the ear lobe to
xiphisternum. The length of tube can be marked with indelible pen or a note taken of the
measurement marks on the tube (for neonates: measure from the nose to ear and then to
the halfway point between xiphisternum and umbilicus).
• Lubricate the end of the tube using a water-based lubricant.
• Gently pass the tube into the child's nostril, advancing it along the floor of the nasopharynx
to the oropharynx. Ask the child to swallow a little water, or offer a younger child their
soother, to assist passage of the tube down the oesophagus. Never advance the tube
against resistance.
• If the child shows signs of breathlessness or severe coughing, remove the tube
immediately.
• Lightly secure the tube with tape until the position has been checked.

4
TextC

• Estimate NEX measurement (Place exit port of tube at tio of nose. Extend tube to earlobe, and then to
xiphistemum)
• Insert fully radio-opaque nasogastric tube for feeding (follow manufacturer's instructions for insertion)
• Confirm and document secured NEX measurement
• Aspirate with a syringe using gentle suction

YES NO

Try each of these techniques to help gain aspirate:

• If possible, turn child/infant onto left side
• Inject 1-5ml air into a tube using a syringe
• Wait for 15-30 minutes before aspirating again
• Advance or withdraw tube by 1-2cm
• Give mouth care to patients who are nil by mouth
(stimulates gastric secretion of acid)
• Do not use water to flush
Test aspirate on CE marked
pH indicator paper for use on
human gastric aspirate -~---------.___A=s'""'p"'"'ir=a=te'-o;;;..;;b;;;..;;t=ai=n~ed=?'-.__,
YES NO

Proceed to x-ray, ensure reason for x-ray documented

pH between pH NOT between on request form
1 and 5.5 1 and 5.5

Competent clinician (with evidence of training) to

r PROCEED TO FEED or USETUBE" ..___ ___,. document confirmation of nasogastric tube position
Record result in notes and YES in stomach
subsequently on bedside NO
documentation before each
~feed/medication/flush DO NOT FEED or USE TUBE
Consider re-siting tube or call for senior advice

A pH of between 1 and 5.5 is reliable confirmation that the tube is not in the lung, however, it does not confirm
gastric placement. If this is any concern, the patient should proceed to x-ray in order to confirm tube position.
Where pH readings fall between 5 and 6 it is recommended that a second competent person checks the
reading or retests.

Text D
Administering feeds/fluid via a feeding tube
Feeds are ordered through a referral to the dietitian.
When feeding directly into the small bowel, feeds must be delivered continuously via a
feeding pump. The small bowel cannot hold large volumes of feed.
Feed bottles must be changed every six hours, or every four hours for expressed breast
milk.
Under no circumstances should the feed be decanted from the container in which
it is sent up from the special feeds unit.
All feeds should be monitored and recorded hourly using a fluid balance chart.
If oral feeding is appropriate, this must also be recorded.
The child should be measured and weighed before feeding commences and then twice
weekly.
The use of this feeding method should be re-assessed, evaluated and recorded daily.

END OF PART A
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5
 Part A

TIME: 15 minutes

• Look at the four texts, A-0, in the separate Text Booklet.

• For each question, 1-20, look through the texts, A-0, to find the relevant information.

• Write your answers on the spaces provided in this Question Paper.

• Answer all the questions within the 15-minute time limit.

• Your answers should be correctly spelt.

The use of feeding tubes in paediatrics: Questions

Questions 1-7

For each question, 1-7, decide which text (A, B, C or D) the information comes from. You
may use any letter more than once.

In which text can you find information about

1 the risks of feeding a child via a nasogastric tube?

2 calculating the length of tube that will be required for a

patient?

3 when alternative forms of feeding may be more

appropriate than nasogastric?

4 who to consult over a patient's liquid food requirements?

5 the outward appearance of the tubes?

6 knowing when it is safe to go ahead with the use of a

tube for feeding?

7 how regularly different kinds of tubes need replacing?

7
Questions 8-15

Answer each of the questions, 8-15, with a word or short phrase from one of the texts. Each
answer may include words, numbers or both.

8 What type of tube should you use for patients who need nasogastric feeding for an
extended period?

9 What should you apply to a feeding tube to make it easier to insert?

1O What should you use to keep the tube in place temporarily?

11 What equipment should you use initially to aspirate a feeding tube?

12 If initial aspiration of the feeding tube is unsuccessful, how long should you wait
before trying again?

13 How should you position a patient during a second attempt to obtain aspirate?

14 If aspirate exceeds pH 5.5, where should you take the patient to confirm the
position of the tube?

15 What device allows for the delivery of feeds via the small bowel?

8
Questions 16-20

Complete each of the sentences, 16-20, with a word or short phrase from one of the texts. Each
answer may include words, numbers or both.

16 If a feeding tube isn't straight when you unwrap it, you should

-----------it.

17 Patients are more likely to experience _ _ _ _ _ _ _ _ _ _ _ if they need

long-term feeding via a tube.

18 If you need to give the patient a standard liquid feed, the tube to use is

_ _ _ _ _ _ _ _ _ _ _ in size.

19 You must take out the feeding tube at once if the patient is coughing badly or is

experiencing _ _ _ _ _ _ _ _ _ __

20 If a child is receiving _ _ _ _ _ _ _ _ _ _ _ via a feeding tube, you should

replace the feed bottle after four hours.

END OF PART A

THIS QUESTION PAPER WILL BE COLLECTED

9
 Test 2
Practice Book 2
Tetanus: Texts

Text A
Tetanus is a severe disease that can result in serious illness and death. Tetanus vaccination
protects against the disease.
Tetanus (sometimes called lock-jaw) is a disease caused by the bacteria Clostridium tetani.
Toxins made by the bacteria attack a person's nervous system. Although the disease is fairly
uncommon, it can be fatal.
Early symptoms of tetanus include:
• Painful muscle contractions that begin in the jaw (lock jaw)
• Rigidity in neck, shoulder and back muscles
• Difficulty swallowing
• Violent generalized muscle spasms
• Convulsions
• Breathing difficulties
A person may have a fever and sometimes develop abnormal heart rhythms. Complications
include pneumonia, broken bones (from the muscle spasms), respiratory failure and cardiac
arrest.
There is no specific diagnostic laboratory test; diagnosis is made clinically. The spatula test is
useful: touching the back of the pharynx with a spatula elicits a bite reflex in tetanus, instead
of a gag reflex.

Text B
Tetanus Risk

Tetanus is an acute disease induced by the toxin tetanus bacilli, the spores of which are
present in soil.
A TETANUS-PRONE WOUND IS:
• any wound or burn that requires surgical intervention that is delayed for> 6 hours
• any wound or burn at any interval after injury that shows one or more of the following
characteristics:
- a significant degree of tissue damage
- puncture-type wound particularly where there has been contact with soil or organic
matter which is likely to harbour tetanus organisms
• any wound from compound fractures
• any wound containing foreign bodies
• any wound or burn in patients who have systemic sepsis
• any bite wound
• any wound from tooth re-implantation
Intravenous drug users are at greater risk of tetanus. Every opportunity should be taken to
ensure that they are fully protected against tetanus. Booster doses should be given if there is
any doubt about their immunisation status.
lmmunosuppressed patients may not be adequately protected against tetanus, despite having
been fully immunised. They should be managed as if they were incompletely immunised.

28
TextC
Tetanus Immunisation following injuries

Thorough cleaning of the wound is essential irrespective of the immunisation history of the
patient, and appropriate antibiotics should be prescribed.

Immunisation Clean Wound Tetanus-prone wound

Status
Vaccine Human Tetanus
Vaccine lmmunoglobulin
(HTIG)
Fully immunised 1 Not required Not required Only if high risk 2
Primary Not required Not required Only if high risk 2
immunisation
complete, boosters
incomplete but up to
date
Primary Reinforcing dose Reinforcing dose Yes (opposite limb to
immunisation and further doses and further doses vaccine)
incomplete or to complete to complete
boosters not up to recommended recommended
date schedule schedule
Not immunised or Immediate dose of Immediate dose of Yes (opposite limb to
immunisation status vaccine followed by vaccine followed by vaccine)
not known/uncertain 3 completion of full completion of full
5-dose course 5-dose course
Notes
1. has received total of 5 doses of vaccine at appropriate intervals
2. heavy contamination with material likely to contain tetanus spores and/or extensive
devitalised tissue
3. immunosuppressed patients presenting with a tetanus-prone wound should always be
managed as if they were incompletely immunised

29
Text D
Human Tetanus lmmunoglobulin (HTIG)
Indications
- treatment of clinically suspected cases of tetanus
- prevention of tetanus in high-risk, tetanus-prone wounds
Dose
Available in 1ml ampoules containing 2501U

Prevention Dose I Treatment Dose

250 IU by IM injection 1
Or
500 IU by IM injection 1 if >24 hours since injury/risk of heavy contamination/burns
5,000 - 10,000 IU by IV infusion
Or
150 IU/kg by IM injection 1 (given in multiple sites) if IV preparation unavailable
1
Due to its viscosity, HTIG should be administered slowly, using a 23 gauge needle

Contraindications
- Confirmed anaphylactic reaction to tetanus containing vaccine
- Confirmed anaphylactic reaction to neomycin, streptomycin or polymyxin B

Adverse reactions
Local - pain, erythema, induration (Arthus-type reaction)
General - pyrexia, hypotonic-hyporesponsive episode, persistent crying

END OF PART A
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30
 Tetanus: Questions

Questions 1-6

For each question, 1-6, decide which text (A, B, C or D) the information comes from.
You may use any letter more than once.

In which text can you find information about

1 the type of injuries that may lead to tetanus?

2 signs that a patient may have tetanus?

3 how to decide whether a tetanus vaccine is necessary?

4 an alternative name for tetanus?

5 possible side-effects of a particular tetanus

medication?

6 other conditions which are associated with tetanus?

Questions 7-13

Complete each of the sentences, 7-13, with a word or short phrase from one of the texts.
Each answer may include words, numbers or both.

Patients at increased risk of tetanus:

7 If a patient has been touching _ _ _ _ _ _ _ _ _ _ _ or earth, they are more

susceptible to tetanus.

8 Any _ _ _ _ _ _ _ _ _ _ _ lodged in the site of an injury will increase the

likelihood of tetanus.

9 Patients with _ _ _ _ _ _ _ _ _ _ _ fractures are prone to tetanus.

10 Delaying surgery on an injury or burn by more than _ _ _ _ _ _ _ _ _ __

increases the probability of tetanus.

11 If a burns patient has been diagnosed with _ _ _ _ _ _ _ _ _ _ _ they are

more liable to contract tetanus.

12 A patient who is _ _ _ _ _ _ _ _ _ _ _ or a regular recreational drug user

will be at greater risk of tetanus.

33
 Management of tetanus-prone injuries:

13 Clean the wound thoroughly and prescribe _ _ _ _ _ _ _ _ _ _ _ if

necessary, followed by tetanus vaccine and HTIG as appropriate.

Questions 14-20

Answer each of the questions, 14-20, with a word or short phrase from one of the texts. Each
answer may include words, numbers or both.

14 Where will a patient suffering from tetanus first experience muscle contractions?

15 What can muscle spasms in tetanus patients sometimes lead to?

16 If you test for tetanus using a spatula, what type of reaction will confirm the
condition?

17 How many times will you have to vaccinate a patient who needs a full course of
tetanus vaccine?

18 What should you give a drug user if you're uncertain of their vaccination history?

19 What size of needle should you use to inject HTIG?

20 What might a patient who experienced an adverse reaction to HTIG be unable to

stop doing?

END OF PART A
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34
 Necrotizing Fasciitis (NF): Texts

Text A
Necrotizing fasciitis (NF) is a severe, rare, potentially lethal soft tissue infection that develops
in the scrotum and perineum, the abdominal wall, or the extremities. The infection progresses
rapidly, and septic shock may ensue; hence, the mortality rate is high (median mortality
32.2%). NF is classified into four types, depending on microbiological findings.

Table 1

Classification of responsible pathogens according to type of infection

Microbiological Pathogens Site of infection Co-morbidities

type
Type 1 Obligate and facultative Trunk and perineum Diabetes mellitus
(polymicrobial) anaerobes

Type 2 Beta-hemolytic streptococcus Limbs

(monomicrobial) A

Type 3 Clostridium species Limbs, trunk and Trauma

Gram-negative bacteria perineum
Seafood
Vibrios spp. consumption (for
Aeromonas hydrophila Aeromonas)

Type4 Candida spp. Limbs, trunk, Im mu no-

perineum suppression
Zygomycetes

Text B
Antibiotic treatment for NF
Type 1
• Initial treatment includes ampicillin or ampicillin-sulbactam combined with metronidazole
or clindamycin.
• Broad gram-negative coverage is necessary as an initial empirical therapy for patients
who have recently been treated with antibiotics, or been hospitalized. In such cases,
antibiotics such as ampicillin-sulbactam, piperacillin-tazobactam, ticarcillin-clavulanate
acid, third or fourth generation cephalosporins, or carbapenems are used, and at a higher
dosage.
Type2
• First or second generation of cephalosporins are used for the coverage of methicillin-
sensitive Staphylococcus aureus (MSSA).
0 MRSA tends to be covered by vancomycin, or daptomycin and linezolid in cases where
S. aureus is resistant to vancomycin.
Type3
• NF should be managed with clindamycin and penicillin, which kill the Clostridium species.
• If Vibrio infection is suspected, the early use of tetracyclines (including doxycycline and
minocycline) and third-generation cephalosporins is crucial for the survival of the patient,
since these antibiotics have been shown to reduce the mortality rate drastically.
Type4
• Can be treated with amphotericin B or fluoroconazoles, but the results of this treatment
are generally disappointing.
Antibiotics should be administered for up to 5 days after local signs and symptoms have
resolved. The mean duration of antibiotic therapy for NF is 4-6weeks.
55
TextC
Supportive care in an ICU is critical to NF survival. This involves fluid resuscitation, cardiac
monitoring, aggressive wound care, and adequate nutritional support. Patients with NF are in a
catabolic state and require increased caloric intake to combat infection. This can be delivered
orally or via nasogastric tube, peg tube, or intravenous hyperalimentation. This should begin
immediately (within the first 24 hours of hospitalization). Prompt and aggressive support
has been shown to lower complication rates. Baseline and repeated monitoring of albumin,
prealbumin, transferrin, blood urea nitrogen, and triglycerides should be performed to ensure the
patient is receiving adequate nutrition.
Wound care is also an important concern. Advanced wound dressings have replaced wet-to-dry
dressings. These dressings promote granulation tissue formation and speed healing. Advanced
wound dressings may lend to healing or prepare the wound bed for grafting. A healthy wound
bed increases the chances of split-thickness skin graft take. Vacuum-assisted closure (VAC) was
recently reported to be effective in a patient whose cardiac status was too precarious to undergo
a long surgical reconstruction operation. With the VAC., the patient's wound decreased in size,
and the VAC was thought to aid in local management of infection and improve granulation
tissue.

Text D
Advice to give the patient before discharge
• Help arrange the patient's aftercare, including home health care and instruction regarding
wound management, social services to promote adjustment to lifestyle changes and
financial concerns, and physical therapy sessions to help rebuild strength and promote the
return to optimal physical health.
• The life-threatening nature of NF, scarring caused by the disease, and in some cases the
need for limb amputation can alter the patient's attitude and viewpoint, so be sure to take a
holistic approach when dealing with the patient and family.

Remind the diabetic patient to

• control blood glucose levels, keeping the glycated haemoglobin (HbAlc) level to 7% or less.
• keep needles capped until use and not to reuse needles.
• clean the skin thoroughly before blood glucose testing or insulin in..,jection, and to use
alcohol pads to clean the area afterward.

END OF PART A
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56
 Necrotizing Fasciitis (NF): Questions

Questions 1-7

For each question, 1-7, decide which text (A, B, C or D) the information comes from. You
may use any letter more than once.

In which text can you find information about

1 the drug treatment required?

2 which parts of the body can be affected?

3 the various ways calories can be introduced?

4 who to contact to help the patient after they leave

hospital?

5 what kind of dressing to use?

6 how long to give drug therapy to the patient?

7 what advice to give the patient regarding needle use?

Questions 8-14

Complete each of the sentences, 8-14, with a word or short phrase from one of the texts. Each
answer may include words, numbers or both.

Patients at increased risk of tetanus:

8 Which two drugs can you use to treat the clostridium species of pathogen?

9 Which common metabolic condition may occur with NF?

1O What complication can a patient suffer from if NF isn't treated quickly enough?

11 What procedure can you use with a wound if the patient can't be operated on?

59
 12 What should the patient be told to use to clean an injection site?

13 Which two drugs can be used if you can't use vancomycin?

14 What kind of infection should you use tetracyclines for?

Questions 15-20

Answer each of the questions, 15-20, with a word or short phrase from one of the texts. Each
answer may include words, numbers or both.

15 The average proportion of patients who die as a result of contracting NF is

16 Patients who have eaten _ _ _ _ _ _ _ _ _ _ _ may be infected with

Aeromonas hydrophilia.

17 Patients with Type 2 infection usually present with infected

18 Type 1 NF is also known as _ _ _ _ _ _ _ _ _ __

19 The patient needs to be aware of the need to keep glycated haemoglobin levels
lower than _ _ _ _ _ _ _ _ _ __

20 The patient will need a course of _ _ _ _ _ _ _ _ _ _ _ to regain fitness

levels after returning home.

END OF PART A
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60
 Fractures, dislocations and sprains: Texts

Text A

Fractures (buckle or break in the bone) often occur following direct or indirect injury, e.g. twisting, violence
to bones. Clinically, fractures are either:
• closed, where the skin is intact, or
• compound, where there is a break in the overlying skin
Dislocation is where a bone is completely displaced from the joint. It often results from injuries away from
the affected joint, e.g. elbow dislocation after falling on an outstretched hand.
Sprain is a partial disruption of a ligament or capsule of a joint.

Text B

E
Simple Fracture of Limbs

L
Immediate management:
• Halt any external haemorrhage by pressure bandage or direct pressure

P
• Immobilise the affected area
• Provide pain relief
Clinical assessment:
• Obtain complete patient history, including circumstances and method of injury

M
- medication history – enquire about anticoagulant use, e.g. warfarin
• Perform standard clinical observations. Examine and record:

A
- colour, warmth, movement, and sensation in hands and feet of injured limb(s)
• Perform physical examination
Examine:

S
- all places where it is painful
- any wounds or swelling
- colour of the whole limb (especially paleness or blue colour)
- the skin over the fracture
- range of movement
- joint function above and below the injury site
Check whether:
- the limb is out of shape – compare one side with the other
- the limb is warm
- the limb (if swollen) is throbbing or getting bigger
- peripheral pulses are palpable
Management:
• Splint the site of the fracture/dislocation using a plaster backslab to reduce pain
• Elevate the limb – a sling for arm injuries, a pillow for leg injuries
• If in doubt over an injury, treat as a fracture
• Administer analgesia to patients in severe pain. If not allergic, give morphine (preferable); if allergic
to morphine, use fentanyl
• Consider compartment syndrome where pain is severe and unrelieved by splinting and elevation or
two doses of analgesia
• X-ray if available

SAMPLE
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[CANDIDATE NO.] READING TEXT BOOKLET PART A 02/04
 Text C

Drug Therapy Protocol:

Authorised Indigenous Health Worker (IHW) must consult Medical Officer (MO) or Nurse Practitioner (NP).
Scheduled Medicines Rural & Isolated Practice Registered Nurse may proceed.

Drug Form Strength Route of Recommended dosage Duration

administration

Adult only:
IM/SC 0.1-0.2 mg/kg to a max. of
10 mg Stat

E
Further
Morphine Ampoule 10 mg/mL Adult only: doses on
IV Initial dose of 2 mg then MO/NP

L
(IHW may not 0.5-1 mg increments slowly, order
administer IV) repeated every 3-5

P
minutes if required to a
max. of 10 mg

Use the lower end of dose range in patients ≥70 years.

M
Provide Consumer Medicine Information: advise can cause nausea and vomiting, drowsiness.
Respiratory depression is rare – if it should occur, give naloxone.

A
Text D

S
Technique for plaster backslab for arm fractures – use same principle for leg fractures

1. Measure a length of non-compression cotton stockinette from half way up the middle finger to just
below the elbow. Width should be 2–3 cm more than the width of the distal forearm.

2. Wrap cotton padding over top for the full length of the stockinette — 2 layers, 50% overlap.

3. Measure a length of plaster of Paris 1 cm shorter than the padding/stockinette at each end. Fold the
roll in about ten layers to the same length.

4. Immerse the layered plaster in a bowl of room temperature water, holding on to each end. Gently
squeeze out the excess water.

5. Ensure any jewellery is removed from the injured limb.

6. Lightly mould the slab to the contours of the arm and hand in a neutral position.

7. Do not apply pressure over bony prominences. Extra padding can be placed over bony prominences if
applicable.

8. Wrap crepe bandage firmly around plaster backslab.

END OF PART A
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SAMPLE
81
[CANDIDATE NO.] READING TEXT BOOKLET PART A 03/04
 Part A

TIME: 15 minutes

• Look at the four texts, A-D, in the separate Text Booklet.

• For each question, 1-20, look through the texts, A-D, to find the relevant information.

• Write your answers on the spaces provided in this Question Paper.

• Answer all the questions within the 15-minute time limit.

• Your answers should be correctly spelt.

L E
Fractures, dislocations and sprains: Questions

Questions 1-7

P
For each question, 1-7, decide which text (A, B, C or D) the information comes from. You may use any
letter more than once.

M
In which text can you find information about

A
1 procedures for delivering pain relief?

2 the procedure to follow when splinting a fractured limb?

S
3 what to record when assessing a patient?

4 the terms used to describe different types of fractures?

5 the practitioners who administer analgesia?

6 what to look for when checking an injury?

7 how fractures can be caused?

Questions 8-14

Answer each of the questions, 8-14, with a word or short phrase from one of the texts. Each answer may include
words, numbers or both.

8 What should be used to elevate a patient’s fractured leg?

9 What is the maximum dose of morphine per kilo of a patient’s weight that can be given using

the intra-muscular (IM) route?

10 Which parts of a limb may need extra padding?

SAMPLE

[CANDIDATE NO.] READING QUESTION PAPER PART A 02/04

83
 11 What should be used to treat a patient who suffers respiratory depression?

12 What should be used to cover a freshly applied plaster backslab?

13 What analgesic should be given to a patient who is allergic to morphine?

E
14 What condition might a patient have if severe pain persists after splinting, elevation and

L
repeated analgesia?

P
Questions 15-20

M
Complete each of the sentences, 15-20, with a word or short phrase from one of the texts. Each answer may
include words, numbers or both.

A
15 Falling on an outstretched hand is a typical cause of a of

the elbow.

S
16 Upper limb fractures should be elevated by means of a .

17 Make sure the patient isn’t wearing any on the part of the

body where the plaster backslab is going to be placed.

18 Check to see whether swollen limbs are or increasing

in size.

19 In a plaster backslab, there is a layer of closest to the skin.

20 Patients aged and over shouldn’t be given the higher

dosages of pain relief.

END OF PART A
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SAMPLE

[CANDIDATE NO.] READING QUESTION PAPER PART A 03/04

84
 Paracetamol overdose: Texts

Text A

Paracetamol: contraindications and interactions

4.4 Special warnings and precautions for use
Where analgesics are used long-term (>3 months) with administration every two days or more frequently, headache may
develop or increase. Headache induced by overuse of analgesics (MOH medication-overuse headache) should not be
treated by dose increase. In such cases, the use of analgesics should be discontinued in consultation with the doctor.
Care is advised in the administration of paracetamol to patients with alcohol dependency, severe renal or severe hepatic
impairment. Other contraindications are: shock and acute inflammation of liver due to hepatitis C virus. The hazards of
overdose are greater in those with non-cirrhotic alcoholic liver disease.
4.5 Interaction with other medicinal products and other forms of interaction
• Anticoagulants – the effect of warfarin and other coumarins may be enhanced by prolonged regular use of paracetamol
with increased risk of bleeding. Occasional doses have no significant effect.
• Metoclopramide – may increase speed of absorption of paracetamol.
• Domperidone – may increase speed of absorption of paracetamol.
• Colestyramine – may reduce absorption if given within one hour of paracetamol.
• Imatinib – restriction or avoidance of concomitant regular paracetamol use should be taken with imatinib.
A total of 169 drugs (1042 brand and generic names) are known to interact with paracetamol.
14 major drug interactions (e.g. amyl nitrite)
62 moderate drug interactions
93 minor drug interactions
A total of 118 brand names are known to have paracetamol in their formulation, e.g. Lemsip.

Text B

Procedure for acute single overdose

Acute single overdose

Establish time since ingestion

<4 hours 4-8 hours 8-24 hours >24 hours or unable to establish

<1 hour since ingestion and >75mg/kg • Start acetylcysteine immediately • Start acetylcysteine
• Check immediate paracetamol
taken: consider activated charcoal
level. If level will not be obtained • Check paracetamol level • Check paracetamol level and measure
before 8 hours after ingestion: start AST/ALT
• If level on or above paracetamol
• Check paracetamol level at 4 hours acetylcysteine pending the result graph treatment line: continue
• Plot level against time on the • Plot level against time on the relevant acetylcysteine
relevant nomogram nomogram • If level below treatment line: stop If paracetamol level >5mg/L or AST/ALT
• Start acetylcysteine if on or above • Start acetylcysteine if on or above acetylcysteine increased or any evidence of liver or renal
treatment line treatment line dysfunction: continue acetylcysteine

Patient needs treatment with acetylcysteine?

No Yes
Supportive treatment only Check AST/ALT, INR/PT, serum electrolytes, urea, creatinine, lactate, and
arterial pH and repeat every 24 hours

SAMPLE

[CANDIDATE NO.] READING TEXT BOOKLET PART A 02/04

103
 Text C
Paracetamol poisoning – Emergency treatment of poisoning
Patients whose plasma-paracetamol
200
200 concentrations are above the normal
1.3
190 1.3 treatment line should be treated with
190
180
1.2
1.2 acetylcysteine by intravenous infusion
180
170 (or, if acetylcysteine cannot be used,
170 1.1
160 1.1 with methionine by mouth, provided the

Plasma-paracetamol concentration (mmol/litre)

160
Plasma-paracetamol concentration (mg/litre)

Plasma-paracetamol concentration (mmol/litre)

overdose has been taken within 10-12
Plasma-paracetamol concentration (mg/litre)

150 1
150 Normal treatment line 1
140 Normal treatment line hours and the patient is not vomiting).
140 0.9
130 0.9
130
120 0.8 Patients on enzyme-inducing drugs
120 0.8
110 (e.g. carbamazepine, phenobarbital,
110 0.7
100 0.7 phenytoin, primidone, rifampicin and St
100
90 0.6 John’s wort) or who are malnourished
90 0.6
80
(e.g. in anorexia, in alcoholism, or those
80
70 0.5
0.5 who are HIV positive) should be treated
70
with acetylcysteine if their plasma-
60 0.4
60 0.4 paracetamol concentration is above the
50
50
0.3
0.3 high-risk treatment line.
40
40
30 0.2
30 0.2
20
20 High-risk treatment line 0.1
10 High-risk treatment line 0.1
10
0 0
0 0
0 2 4 6 8 10 12 14 16 18 20 22 24
0 2 4 6 8 10 Time
12 14(hours)
16 18 20 22 24

Text D

Clinical Assessment
• Commonly, patients who have taken a paracetamol overdose are asymptomatic for the first 24 hours or just have
nausea and vomiting
• Hepatic necrosis (elevated transaminases, right upper quadrant pain and jaundice) begins to develop after 24
hours and can progress to acute liver failure (ALF)
• Patients may also develop:
• Encephalopathy • Renal failure – usually occurs around day three
• Oliguria • Lactic acidosis
• Hypoglycaemia
History
• Number of tablets, formulation, any concomitant tablets
• Time of overdose
• Suicide risk – was a note left?
• Any alcohol taken (acute alcohol ingestion will inhibit liver enzymes and may reduce the production of the toxin
NAPQI, whereas chronic alcoholism may increase it)

END OF PART A
THIS TEXT BOOKLET WILL BE COLLECTED

SAMPLE

[CANDIDATE NO.] READING TEXT BOOKLET PART A 03/04

104
 Sedation: Iron deficiencies

Text A

Iron deficiency and iron deficiency anaemia are common. The serum ferritin level is the most useful
indicator of iron deficiency, but interpretation can be complex. Identifying the cause of iron
deficiency is crucial. Oral iron supplements are effective first-line treatment. Intravenous iron
infusions, if required, are safe, effective and practical.

Key Points
• Measurement of the serum ferritin level is the most useful diagnostic assay for detecting iron
deficiency, but interpretation may be difficult in patients with comorbidities.
• Identifying the cause of iron deficiency is crucial; referral to a gastroenterologist is often
required.
• Faecal occult blood testing is not recommended in the evaluation of iron deficiency; a
negative result does not impact on the diagnostic evaluation.
• Oral iron is an effective first-line treatment, and simple strategies can facilitate patient
tolerance.
• For patients who cannot tolerate oral therapy or require more rapid correction of iron
deficiency, intravenous iron infusions are safe, effective and practical, given the short
infusion times of available formulations.
• Intramuscular iron is no longer recommended for patients of any age.

Text B

Treatment of infants and children

Although iron deficiency in children cannot be corrected solely by dietary change, dietary advice
should be given to parents and carers. Cows’ milk is low in iron compared with breast milk and
infant formula, and enteropathy caused by hypersensitivity to cows’ milk protein can lead to
occult gastrointestinal blood loss. Excess cows’ milk intake (in lieu of iron-rich solid foods) is the
most common cause of iron deficiency in young children. Other risk factors for dietary iron
deficiency include late introduction of or insufficient iron-rich foods, prolonged exclusive
breastfeeding and early introduction of cows’ milk.

Adult doses of iron can be toxic to children, and paediatric-specific protocols on iron
supplementation should be followed. The usual paediatric oral iron dosage is 3 to 6mg/kg
elemental iron daily. If oral iron is ineffective or not tolerated then consider other causes of
anaemia, referral to a specialist paediatrician and use of IV iron.

126
Text C
AN ALGORITHM FOR THE IDENTIFICATION AND MANAGEMENT OF ADULTS WITH IRON DEFICIENCY

Patient presents with clinically suspected iron deficiency

• member of high-risk population (infants, children, menstruating or pregnant
women, vegetarians)
• clinical or laboratory evidence of iron deficiency or anaemia
• micocytosis or hypochromasia (MCV or MCH below laboratory lower limit of
normal)

• Evaluate clinically for

- potential contributors and risk factors for iron deficiency
- inflammatory states or other disorders that may influence interpretation of FBC or iron studies
• Measure serum ferritin level if not already measured

Serum ferritin <30mcg/L Serum ferritin 30-100 mcg/L Serum ferritin >100 mcg/L

Iron deficiency • Borderline iron stores • Iron deficiency unlikely

• Iron deficiency not excluded as serum • If anaemia present then consider
ferritin level may be raised because of functional iron deficiency; specialist input
inflammation may be required

Evaluate for cause (see If iron deficiency felt If inflammatory state

Box 2) to be contributory identified

• Replace iron • Correct inflammatory state

- give oral iron preparation • Selected patients may still
- if rapid correction required (poorly tolerated anaemia) benefit from iron replacement;
or oral therapy unsuccessful then give intravenous iron specialist input advised

• Re-evaluate 1 to 2 weeks after therapy to ensure iron stores are replete and anaemia improving
• Re-evaluate 3 to 6 months after therapy to ensure iron repletion is maintained and anaemia resolved

If iron deficiency recurs If anaemia identified

• repeat evaluation for additional or recurrent source of blood loss; with normal iron stores
consider all diagnoses in Box 2 • evaluate for other
• refer men aged over 40 years and women over 50 years for causes of anaemia
endoscopy and colonoscopy regardless of gastrointestinal symptoms

127
Text D

END OF PART A
THIS TEXT BOOKLET WILL BE COLLECTED

128
E2 Language Reading Part A.1

• Look at the four texts, A-D, in the (printable) Text Booklet.

• For each question, 1-20, look through the texts, A-D, to find the relevant information.
• Write your answers on the spaces provided in the ANSWER SHEET.
• Answer all the questions within the 15-minute time limit.

Iron Deficiency: Questions

Questions 1-7
For each of the questions, 1-7, decide which text (A, B, C or D) the information comes from.
You may use any letter more than once.
In which text can you find information about
1 considerations when treating children with iron deficiency?
2 essential steps for identifying iron deficiency?
3 evaluating iron deficiency by testing for blood in stool?
4 risk factors associated with dietary iron deficiency?
5 different types of iron solutions?
6 a treatment for iron deficiency that is no longer supported?
7 appropriate dosage when administering IV iron infusions?

Questions 8-14
Answer each of the questions, 8-14, with a word or short phrase from one of the texts. Each
answer may include words, numbers or both.
Your answers should be correctly spelled.
8 What level of serum ferritin leads to a diagnosis of iron deficiency?
9 What is the most likely cause of iron deficiency in children?
10 Which form of iron can also be injected into the muscle?
11 What should a clinician do if iron stores are normal and anaemia is still present?
12 How long after iron replacement therapy should a patient be re-tested?
13 Which form of iron is presented in a vial?
14 What is the first type of treatment iron deficient patients are typically given?

Questions 15-20
Complete each of the sentences, 15-20, with a word or short phrase from one of the texts.
Each answer may include words, numbers or both.
Your answers should be correctly spelled.
In comparison to breast milk and infant formula, cows’ milk is (15).........................
Special procedures should be used because (16)........................ may be poisonous for children
.

129
Men over 40 and women over 50 with a recurring iron deficiency should have an (17)
.........................
Iron sucrose can be given to a patient no more than (18).........................
Although serum ferritin level is a good indication of deficiency, interpreting the results is
sometimes difficult (19).........................
IV iron infusions are a safe alternative when patients are unable to (20).........................

Answer Sheet
1) correct answer: b
2) correct answer: c
3) correct answer: a
4) correct answer: b
5) correct answer: d
6) correct answer: a
7) correct answer: d
8) correct answer: <30 mcg/L / less than 30 mcg/L / < 30 mcg / L / <30mcg/L
9) correct answer: excess cow's milk / excess cow milk / excess cows' milk /
excessive cow's milk / excessive cow milk / excessive cows' milk / excess cow's milk intake /

130
excess cow milk intake / excess cows' milk intake / excessive cow's milk intake / excessive cow
milk intake / excessive cows' milk intake
10) correct answer: iron polymaltose
11) correct answer: consider other cases / evaluate other causes / evaluate for
other causes
12) correct answer: 1 to 2 weeks / one to two weeks / 1-2 weeks / 1 - 2 weeks
13) correct answer: ferric carboxymaltose
14) correct answer: oral iron / oral iron supplements
15) correct answer: low in iron
16) correct answer: adult doses of iron / adult iron doses
17) correct answer: endoscopy and colonoscopy / colonoscopy and endoscopy
18) correct answer: 3 times per week / three times per week / 3 times a week /
three times a week / 3 times weekly / three times weekly
19) correct answer: in patients with comorbidities
20) correct answer: tolerate oral iron / tolerate oral iron therapies / tolerate
oral iron therapy

131
 Opioid dependence

Text A

Identifying opioid dependence

The International Classification of Disease, Tenth Edition [​ICD-10]​ is a coding system created
by the World Health Organization (WHO) to catalogue and name diseases, conditions, signs
and symptoms.

The ​ICD-10​ includes criteria to identify dependence. According to the ​ICD-10,​ opioid
dependence is defined by the presence of three or more of the following features at any one
time in the preceding year:

● a strong desire or sense of compulsion to take opioids

● difficulties in controlling opioid use
● a physiological withdrawal state
● tolerance of opioids
● progressive neglect of alternative interests or pleasures because of opioid use
● persisting with opioid use despite clear evidence of overtly harmful consequences.

There are other definitions of opioid dependence or ‘use disorder’ (e.g. the ​Diagnostic and
Statistical Manual of Mental Disorders​, 5th edition, [​DSM-5​]), but the central features are the
same. Loss of control over use, continuing use despite harm, craving, compulsive use, physical
tolerance and dependence remain key in identifying problems.

151
Text B
WHY NOT JUST PRESCRIBE CODEINE OR ANOTHER OPIOID?
Now that analgesics containing codeine are no longer available OTC (over the counter), patients may
request a prescription for codeine. It is important for GPs to explain that there is a lack of evidence
demonstrating the long-term analgesic efficacy of codeine in treating chronic non-cancer pain. Long-term
use of opioids has not been associated with sustained improvement in function or quality of life, and there
are increasing concerns about the risk of harm.

GPs should explain that the risks associated with opioids include tolerance leading to dose escalation,
overdose, falls, accidents and death. It should be emphasised that OTC codeine-containing analgesics
were only intended for short-term use (one to three days) and that longer-term pain management requires
a more detailed assessment of the patient's medical condition as well as clinical management.

New trials have shown that for acute pain, nonopioid combinations can be as effective as combination
analgesics containing opioids such as codeine and oxycodone. If pain isn’t managed with nonopioid
medications then consider referring the patient to a pain specialist or pain clinic.

Patient resources for pain management are freely available online to all clinicians at websites such as:
• Pain Management Network in NSW - www.aci.health.nsw.gov.au/networks/pain-management
• Australian and New Zealand College of Anaesthetists Faculty of Pain Medicine -
www.fpm.anzca.edu.au

152
Text C

153
Text D

Preparation for tapering

As soon as a valid indication for tapering of opioid analgesics is established, it is important to have a
conversation with the patient to explain the process and develop a treatment agreement. This agreement
could include:
• time frame for the agreement
• objectives of the taper
• frequency of dose reduction
• requirement for obtaining the prescriptions from a designated clinician
• scheduled appointments for regular review
• anticipated effects of the taper
• consent for urine drug screening
• possible consequences of failure to comply.

Before starting tapering, it needs to be clearly emphasised to the patient that reducing the dose of opioid
analgesia will not necessarily equate to increased pain and that it will, in effect, lead to improved mood
and functioning as well as a reduction in pain intensity. The prescriber should establish a therapeutic
alliance with the patient and develop a shared and specific goal.

END OF PART A
THIS TEXT BOOKLET WILL BE COLLECTED
154
 Test 8

E2 Language Part A.2

• Look at the four texts, A-D, in the (printable) Text Booklet.
• For each question, 1-20, look through the texts, A-D, to find the relevant information.
• Write your answers on the spaces provided in the ANSWER SHEET.
• Answer all the questions within the 15-minute time limit.

Managing Opioid Dependence

Questions 1-7
For each of the questions, 1-7, decide which text (A, B, C or D) the information comes from.
You may use any letter more than once.
In which text can you find information about...
1 what GPs should say to patients requesting codeine?
2 basic indications of an opioid problem?
3 different medications used for weaning patients off opioids?
4 decisions to make before beginning treatment of dependence?
5 defining features of a use disorder?
6 the development of a common goal for both prescriber and patient?
7 sources of further information on pain management?

Questions 8-14
Answer each of the questions, 8-14, with a word or short phrase from one of the texts. Each
answer may include words, numbers or both. Your answers should be correctly spelled.
8 What will reduced doses of opioids lead to a reduction of?
9 What is the most effective medication for tapering opioid dependence?
10 How long should over the counter codeine analgesics be used for?
11 When should doctors consider referring a patient to a pain expert or clinic?
12 What might a patient give permission to before starting treatment?
13 What might be increasingly neglected as a result of opioid use?
14 How many Buprenorphine patches are needed to taper from codeine tablets?

Questions 15-20
Complete each of the sentences, 15-20, with a word or short phrase from one of the texts.
Each answer may include words, numbers or both. Your answers should be correctly spelled.
The use of Buprenorphine-naxolone requires a (15)........ before treatment.
The use of symptomatic medications for the treatment of opioid dependence has been found
to have (16)........ than tramadol.
Different definitions of opioid dependence share the same (17).........
Once it is decided that opioid taper is a suitable treatment the doctor and patient should create
a (18).........

155
Recent research indicates that (19)........ can work as well as combination analgesics including
codeine and oxycodone.
The ICD-10 defines a patient as dependent if they have (20)........ key symptoms
simultaneously.

Answer Sheet
1) correct answer: b
2) correct answer: a
3) correct answer: c
4) correct answer: d
5) correct answer: a
6) correct answer: d
7) correct answer: b
8) correct answer: pain intensity

156
9) correct answer: buprenorphine-naloxone / buprenorphine - naloxone /
buprenorphine-naloxone (sublingual) / buprenorphine - naloxone (sublingual)
10) correct answer: one to three days / 1 to 3 days / 1-3 days / 1 - 3 days
11) correct answer: if pain isn't managed with nonopioid medications / if pain
isn't managed / if pain isn't managed with non-opioid medications
12) correct answer: urine drug screening
13) correct answer: alternative interests or pleasures / alternative interests
and pleasures / interests or pleasures / interests and pleasures
14) correct answer: a single patch / one patch / 1 patch
15) correct answer: permit
16) correct answer: poorer outcomes
17) correct answer: central features / features
18) correct answer: treatment agreement
19) correct answer: nonopioid combinations / non-opioid combinations
20) correct answer: three or more / at least three / 3 or more / at least 3

157
 ADHD

Text A

The GP’s role in the management of ADHD

It helps to remind patients that ADHD is not all bad. ADHD is associated with positive attributes
such as being more spontaneous and adventurous. Some studies have indicated that people
with ADHD may be better equipped for lateral thinking. It has been suggested that explorers or
entrepreneurs are more likely to have ADHD.

In addition, GPs can reinforce the importance of developing healthy sleep–wake behaviours,
obtaining adequate exercise and good nutrition. These are the building blocks on which other
treatment is based. For patients who are taking stimulant medication, it is helpful if the GP
continues to monitor their blood pressure, given that stimulant medication may cause elevation.
Once a patient has been stabilised on medication for ADHD, the psychiatrist may refer the
patient back to the GP for ongoing prescribing in line with state-based guidelines. However, in
most states and territories, the GP is not granted permission to alter the dose.

Text B

ADHD: Overview

Contrary to common belief, ADHD is not just a disorder of childhood. At least 40 to 50% of
children with ADHD will continue to meet criteria in adulthood, with ADHD affecting about one in
20 adults. ADHD can be masked by many comorbid disorders that GPs are typically good at
recognising such as depression, anxiety and substance use. In patients with underlying ADHD,
the attentional, hyperactive or organisational problems pre-date the comorbid disorders and are
not episodic as the comorbid disorders may be. GPs are encouraged to ask whether the
complaints are of recent onset or longstanding. Collateral history can be helpful for developing a
timeline of symptoms (e.g. parent or partner interview). Diagnosis of underlying ADHD in these
patients will significantly improve their treatment outcomes, general health and quality of life.

169
Text C

170
Text D

Treatment of ADHD

It is very important that the dosage of medication is individually optimised. An analogy may be made
with getting the right pair of glasses – you need the right prescription for your particular
presentation with not too much correction and not too little. The optimal dose typically requires
careful titration by a psychiatrist with ADHD expertise. Multiple follow-up appointments are usually
required to maximise the treatment outcome. It is essential that the benefits of treatment outweigh
any negative effects. Common side effects of stimulant medication may include:
• appetite suppression
• insomnia
• palpitations and increased heart rate
• feelings of anxiety
• dry mouth and sweating

END OF PART A
THIS TEXT BOOKLET WILL BE COLLECTED

171
E2 Language Reading Part A.3

• Look at the four texts, A-D, in the (printable) Text Booklet.

• For each question, 1-20, look through the texts, A-D, to find the relevant information.
• Write your answers on the spaces provided in the ANSWER SHEET.
• Answer all the questions within the 15-minute time limit.

ADHD

Questions 1-7
For each of the questions, 1-7, decide which text (A, B, C or D) the information comes from.
You may use any letter more than once.
In which text can you find information about...

1 different types of ADHD medication?

2 possible side effects of medication?
3 conditions which may be present alongside ADHD?
4 a doctor’s control over a patient’s medication?
5 positive perspectives on having ADHD?
6 when patients should take their ADHD medicine?
7 figuring out a patient’s optimal dosage of medication?

Questions 8-14
Answer each of the questions, 8-14, with a word or short phrase from one of the texts. Each
answer may include words, numbers or both. Your answers should be correctly spelled.
8 What is the maximum recommended dose of Dexamfetamine?
9 What is typically needed to get the best results from ADHD treatment?
10 How can GP’s collect information about their patient’s collateral history?
11 What causes symptoms such as palpitations and anxiety in some patients?
12 What proportion of children with ADHD will carry symptoms into adulthood?
13 What positive personality traits are sometimes associated with ADHD?
14 Which medication has dose recommendations related to patient weight?

Questions 15-20
Complete each of the sentences, 15-20, with a word or short phrase from one of the texts.
Each answer may include words, numbers or both. Your answers should be correctly spelled.
Sleep, exercise and nutrition comprise the (15)......... of further ADHD treatment.
When diagnosing ADHD, it is important to ask if the issues arose recently or are (16)..........
It is possible to move to (17)......... after one month of immediate-release methylphenidate.
Signs of ADHD can be disguised by (18)......... which GPs are more likely to recognise.

172
GPs should regularly check the (19)......... of patients prescribed stimulant medication.
Establishing the ideal dose of ADHD medication needs (20)......... by an expert psychiatrist.

Answer Sheet
1) correct answer: c
2) correct answer: d
3) correct answer: b
4) correct answer: a
5) correct answer: a
6) correct answer: c
7) correct answer: d
8) correct answer: 60 mg/day
9) correct answer: multiple follow-up appointments / multiple follow up
appointments / follow up appointments

173
10) correct answer: parent or partner interview / partner or parent interview
11) correct answer: side effects of stimulant medication / stimulant medication
12) correct answer: at least 40-50% / at least 40 - 50% / at least 40 to 50
percent / 40-50% / 40 to 50% / 40 - 50%
13) correct answer: being more spontaneous and adventurous / spontaneous
and adventurous
14) correct answer: atomoxetine
15) correct answer: building blocks
16) correct answer: longstanding / underlying
17) correct answer: longer-acting formulations of methylphenidate / longer
acting formulations of methylphenidate / longer-acting formulations / longer acting
formulations
18) correct answer: comorbid disorders
19) correct answer: blood pressure
20) correct answer: careful titration / titration

174
 Test 9

1 Premium reading
Dengue Fever: Texts OETonline

Text A

Dengue: virus, fever and mosquitoes

Dengue fever is a viral disease spread only by certain mosquitoes – mostly Aedes aegypti or
“dengue mosquitoes” which are common in tropical areas around the world.

There are four types of the dengue virus that cause dengue fever – Dengue Type 1, 2, 3 and 4. People
become immune to a particular type of dengue virus once they’ve had it, but can still get sick from the
other types of dengue if exposed. Catching different types of dengue, even years apart, increases the
risk of developing severe dengue. Severe dengue causes bleeding and shock, and can be life
threatening.

Dengue mosquitoes only live and breed around humans and buildings, and not in bush or rural areas.
They bite during the day – mainly mornings and evenings. Dengue mosquitoes are not born with
dengue virus in them, but if one bites a sick person having the virus in their blood, that mosquito can
pass it on to another human after about a week. This time gap for the virus to multiply in the mosquito
means that only elderly female mosquitoes transmit dengue fever. The mosquitoes remain infectious for
life, and can infect several people. Dengue does not spread directly from person to person.

Text B

Signs and Symptoms

Classic dengue fever, or “break bone fever,” is characterised by acute onset of high fever 3–14 days after
the bite of an infected mosquito. Symptoms include frontal headache, retro-orbital pain, myalgias,
arthralgias, hemorrhagic manifestations, rash, and low white blood cell count. The patient also may
complain of weight loss and nausea. Acute symptoms, when present, usually last about 1 week, but
weakness, malaise, and weight loss may persist for several weeks. A high proportion of dengue infections
produce no symptoms or minimal symptoms, especially in children and those with no previous history of
having a dengue infection.

186
Text C

Steps to take when seeing a suspected case of dengue fever

Step 1: Notify your nearest Public Health Unit immediately upon clinical suspicion.

Step 2: Take a comprehensive travel history and determine whether the case was acquired
overseas or locally.

Step 3: Note the date of onset of symptoms to identify the correct diagnostic test, as
suitable laboratory tests depend on when the blood sample is collected during the illness.

• Another useful test is full blood count. Cases often have leukopenia and/or
thrombocytopenia.

The table below shows which test to order at which stage of illness:

Test Type PCR NS1 ELISA IgM IgG

Days after onset 0-5 days 0-9 days From day 5 From day 8
of symptoms onwards onwards

Step 4: Provide personal protection advice.

• The patient should stay in screened accommodation and have someone stay home to
look after them.

• The patient should use personal insect repellent particularly during daylight hours to
avoid mosquito bites.

• All household members should use personal insect repellent during daylight hours.

• Advise family members or associates of the case who develop a fever to present
immediately for diagnosis.

187
 Dengue Fever: Texts

Text D

Prior to discharge:

• Tell patients to drink plenty of fluids and get plenty of rest.

• Tell patients to take antipyretics to control their temperature. Children with dengue are at risk for
febrile seizures during the febrile phase of illness.

• Warn patients to avoid aspirin and anti-inflammatory medications because they increase the risk of
haemorrhage.

• Monitor your patients’ hydration status during the febrile phase of illness. Educate patients and parents
about the signs of dehydration and have them monitor their urine output.

• Assess hemodynamic status frequently by checking the patient’s heart rate, capillary refill,
pulse pressure, blood pressure, and urine output. If patients cannot tolerate fluids orally, they may need
IV fluids.

• Perform hemodynamic assessments, baseline hematocrit testing, and platelet counts.

• Continue to monitor your patients closely during defervescence. The critical phase of dengue begins
with defervescence and lasts 24–48 hours.

END OF PART A

188
Part A:Questions
Reading test 3

Type all your answers in the Answer box provided.

One mark will be granted for each correct answer.
Answer ALL questions. Marks are NOT deducted for incorrect answers.
Part A
TIME: 15 minutes

• Look at the four texts, A-D, in the separate Reading Part A: Text
Booklet.
• For each question, 1-20, look through the texts A-D, to find the relevant
information.
• Type your answers in the Answer box provided.
• Answer all the questions within the 15-minute time limit.
• Your answers should be spelled correctly.
•
• Questions 1 - 7
• For each of the questions, 1 - 7, decide which text (A, B, C, or D) the
information comes from. You may use any letter more than once.
•
• In which text can you find information about

1. In which text can you find information about the different types of dengue virus?
2. In which text can you find information about how fever presents in patients?
3. In which text can you find information about how dengue fever is transmitted?
4. In which text can you find information about the stages at which to conduct tests for
dengue fever?
5. In which text can you find information about monitoring and assessing a patient’s
condition?
6. In which text can you find information about what advice to give patients to avoid
mosquito bites?
7. In which text can you find information about advice for patients regarding medication?

189
 Questions 8 - 14
Complete each of the sentences, 8 - 14, with a word or short phrase
from one of the texts.
Each answer may include words, numbers, or both.

8. How long after being bitten by an infected mosquito does high fever occur?
9. What might patients with dengue fever complain of?
10. Which test should only be ordered 5 days after symptoms appear?
11. What other test is also useful when checking for dengue fever?
12. Who is at risk of seizures during the febrile stage of dengue?
13. What takes places in the most lethal cases of dengue?
14. How long does the most serious stage of dengue last?

Questions 15 - 20
Answer each of the questions, 15 - 20, with a word or short phrase
from one of the texts.
Each answer may include words, numbers or both.

15. Dengue fever does not spread _______________

16. In many ______________ dengue infections cause almost no symptoms.

17. Within three days of symptoms beginning a PCR or ____________ can be ordered.

18. To avoid haemorrhage patients mustn’t take anti-inflammatory medications

or ________________.

19. Advise patients be cared for by someone at home in ________________ accommodation.

20. Patients must be made aware of the need to check their ______________________.

190
 Test 10

KAPLAN READING TEST

Practice set 1

Part A

TIME: 15 minutes

Anaemia Texts

Text A

Anaemia is defined as an overall decrease in red blood cell mass. There are many varying
causes of anaemia, which all present with some general symptoms. Anaemia results in a
lack of red blood cells in the blood. Because it is the haemoglobin in red blood cells that
carries oxygen from the lungs to the rest of the body, a decrease in red blood cells results
in less oxygen going into the tissues. This causes a state known as hypoxia, or reduced
oxygen in body tissues.

The common symptoms of all anaemias are those of hypoxia:

⚫ Weakness, fatigue, difficult or laboured breathing

⚫ Pale skin

⚫ Headache and light-headedness

⚫ Chest pain (if the patient already has a disease of the arteries supplying the
heart)

Text B

There are many classification systems to differentiate anaemias. The most commonly used
is based on the size of the red blood cell. Anaemias with red blood cells that are smaller
than normal are known as microcytic anaemias. If the anaemia has normally sized red
blood cells, it is referred to as a normocytic anaemia. Finally, if the red blood cells are too
big, it is known as a macrocytic anaemia. Normocytic anaemias are further broken up into
whether or not there is an increased number of young red blood cells (a.k.a. reticulocytes),
which is an indication if the bone marrow is working properly—for example, if the red
blood cells are being destroyed (haemolysis), there should be higher reticulocytes because
there is no effect on the bone marrow’s ability to produce new cells.

204
 Microcytic

Anaemia

Normal/ Low reticulocyte

Macrocytic
Normocytic

High reticulocyte

205
Text C

While there are many different causes of anaemia, laboratory studies and unique features
of the patient can be used to help differentiate between various aetiologies.

Laboratory studies used to diagnose anaemia include:

⚫ Haemoglobin (Hb)—a measure of the protein that transports oxygen in the

red blood cell

⚫ Haematocrit (Hct)—a measure of the percentage of red blood cells in the

blood

⚫ Red blood cell amount (erythrocyte count)—a measure of the number of red
blood cells in the blood

A general diagnosis of anaemia can be determined by the following values:

⚫ Haemoglobin level

⭘ Males: less than 13.5 g/dL

⭘ Females: less than 12.5 g/dL (women have a generally lower haemoglobin because
of blood loss during the monthly menstrual cycle)

⚫ Haematocrit

⭘ Males: less than 45% red blood cells

⭘ Females: less than 37% red blood cells (women have a generally lower
haematocrit because of blood loss during the monthly menstrual cycle)

⚫ Red blood cell amount

⭘ Male: less than 4.7 million cells/mL

⭘ Female: less than 4.2 million cells/mL (women have a generally lower red
blood cell amount because of blood loss during the monthly menstrual cycle)

While these laboratory tests are good estimates of the red blood cell mass, they are not
perfect. Red blood cell mass is very difficult to measure, and therefore these laboratory
tests are used together to assess whether or not someone has anaemia.

206
Text D

The treatment of anaemia depends heavily on the type of anaemia that the patient is
experiencing. However, there are several overarching goals of treatment. If possible, treat
the underlying cause of the red blood cell loss. For example, if the patient has anaemia
because of blood loss, give a blood transfusion.

Identify and treat any complications that have occurred because of the anaemia. Educate
the patient on how to manage their anaemia. For example, a patient with anaemia
because of iron deficiency can supplement their treatment with iron rich foods, such as
leafy green vegetables. Alternatively, a patient with anaemia caused by vitamin deficiency
should be advised to increase their intake of folic acid and B-12. Note that patients who
follow vegetarian or vegan diets may struggle to meet B-12 requirements, so eating
fortified foods and using supplements should be advised.

207
Part A

Question paper

⚫ Look at the four texts, A – D

⚫ For each question, 1 – 20, look through the texts, A – D, to find the relevant
information.

⚫ Write your answers in the spaces provided in this Question Paper.

⚫ Answer all the questions within the 15-minute time limit.

Questions 1 – 6

For each question below, decide which text (A, B, C or D) the information comes from. You
may use any letter more than once. In which text can you find information about . . .

1. treating patients with anaemia?

2. the symptoms of hypoxia?

3. methods used to identify anaemic patients?

4. the different types of anaemia?

5. the levels of haemoglobin in a woman with anaemia?

6. how red blood cell size affects anaemia?

Questions 7 – 14

Answer the questions below. For each answer, use a word or short phrase from the text. Each answer
may include words, numbers or both.

7. What should vegan patients with vitamin deficiency anaemia be encouraged to add to their diets?

8. If there is a decreased number of young red blood cells, what type of anaemia is being dealt with?

208
9. How will a patient’s breathing sound when experiencing a significant reduction of oxygen in the
body’s tissues?

10. A male with anaemia must have less than what percentage of red blood cells?

11. What is an increase in the number of reticulocytes an indication of?

12. What reduces the amount of red blood cells in some patients?

13. What should be treated in anaemic patients, after identifying the cause?

14. How are the different types of anaemia most commonly distinguished?

Questions 15 – 20

Complete the sentences below by using a word or short phrase from the text. Each answer may include
words, numbers or both.

15. Anaemia caused by (15) should be treated with a blood transfusion.

16. Patients suffering from hypoxia and chest pain are likely to also have a (16)

17. If (17) is functioning properly, high reticulocyte anaemia is likely to be

present.

18. A number of tests may be necessary to diagnose anaemia, due to the difficulties involved in
measuring (18)

19. Patients with anaemia caused by (19) should be instructed to adjust

their diet.

209
20. When identifying the type of aetiology, (20) of the patient should be
considered, in addition to laboratory studies.

210
Part A: Answer Keys

1.D

2. A

3. C

4. B

5. C

6. B

7. fortified foods (and supplements)

8. low reticulocytes

9. laboured

10. 45

11. reticulocytes

12. menstrual cycle

13. complications

14. size of the red blood cell

15. blood loss

16. disease of the arteries

17. bone marrow

18. iron deficiency

19. chest pain

20. unique features

211
 Test 11

KAPLAN READING TEST 2

Part A

Time : 15 minutes

⚫ Look at the four texts, A – D, in the Text Booklet.

⚫ For each question, 1 – 20, look through the texts, A – D, to find the relevant
information.

⚫ Write your answers in the spaces provided in this Question Paper.

⚫ Answer all the questions within the 15-minute time limit.

Asthma : Texts

Text A

227
Asthma sufferers of any severity may also experience the following:

⚫ shortness of breath

⚫ coughing

⚫ tightness or pain in the chest

⚫ a whistling sound when exhaling

Text B

Lung Function Tests in Asthma

Asthma tests should be undertaken to diagnose and aid management of the condition.
This is particularly important in asthma, because it presents slightly differently with each
patient. Spirometry is the most important test, however several different types of test are
available:

⚫ Peak expiratory flow rate (PEFR): this is the maximum flow rate during
exhalation, after full lung inflation. Diurnal variation in PEFR is a good measure of
asthma and useful to the long-term management of patients and the response to
treatment. Monitor PEFR over 2-4 weeks in adults if there is uncertainty about
diagnosis. It is measured with a peak flow meter - a small, handheld device - into
which the patient blows, giving a reading in l/min.

⚫ Spirometry: measures volume and flow of air that can be exhaled or inhaled
during normal breathing. Asthma can be diagnosed with a >15% improvement in
FEV1 or PEFT following bronchodilator inhalation. Alternatively, consider FEV1/FVC
< 70% as a positive result for obstructive airway disease. A spirometry test usually
takes less than 10 minutes, but will last about 30 minutes if it includes reversibility
testing.

⭘ Direct bronchial challenge test with histamine or methacholine: in this

test, patients breathe in a bronchoconstrictor. The degree of narrowing can be
quantified by spirometry. Asthmatics will react to lower doses, due to existing
airway hyperactivity.

228
 ⭘ Exercise tests: these are often used for the diagnosis of asthma in children.
The child should run 6 minutes (on a treadmill or other) at a workload sufficient to
increase their heart rate > 160/min. Spirometry is used before and after the
exercise - an FEV1 decrease > 10% indicates exercise-induced asthma.

⚫ Allergy testing: can be useful if year-round allergies trigger a patient’s

asthma. This will be recommended if inhaled corticosteroids are not controlling
symptoms. Three different tests are used to measure the patient’s reaction to
allergens: nitric oxide testing, sputum eosinophils and blood eosinophils.

Text C

Patients with asthma of any severity may find their attacks panic-inducing. Remember that
the patient’s struggle to breathe can cause stress, panic and a feeling of helplessness.
There is a strong link between people who suffer from asthma and those who experience
panic attacks. Staff must keep this in mind when treating patients with asthma, as some
sufferers will require additional emotional support.

Patients may find breathing exercises beneficial. Advise patients to practice daily, to allow
these exercises to become habitual. When experiencing an attack, patients should make a
conscious effort to relax their muscles and maintain steady breathing. Advise patients to
breathe deeply in through the nose and out through the mouth.

Smokers are at a higher risk of developing both panic attacks and asthma. In addition,
smoking can irritate the airways in patients with asthma, causing neutrophilic
inflammation, and exacerbating breathing problems in those with asthma. Ensure that
patients who smoke are fully aware of the risks of smoking with asthma.

Text D

Management of Acute Asthma

Rapid treatment and reassessment is of paramount importance. It is sometimes difficult to

assess severity. Maintaining a calm atmosphere is helpful to resolving an acute asthmatic
attack.

229
230
Questions 1 – 6

⚫ For each question below, 1 – 6, decide which text (A, B, C or D) the

information comes from.

⚫ You may use any letter more than once.

⚫ In which text can you find information about......

1. relaxation techniques for those suffering from an asthma attack?

2. measuring the respiration abilities in patients with asthma?

3. identifying the intensity of asthma attacks in patients?

4. the procedure to follow when treating an asthma attack?

5. symptoms of asthma in patients?

6. how to diagnose asthma in patients?

Questions 7 – 12

Complete each of the sentences, 7 – 12, with a word or short phrase from one of the texts.
Each answer may include words, numbers or both. Your answers should be correctly
spelled.

231
7. To understand how severe an asthma attack is, (7) ) must be measured,
in addition to PEF.

8. For patients who do not respond to therapy, an IV of (8) can

be used to treat severe asthma attacks.

9. Nitric oxide testing can be used to determine (9) in patients.

10. A patient suffering from arrhythmia and a peak expiratory flow of greater than 33%
would be diagnosed with (10) asthma attacks.

11. Spirometry tests that contain (11) typically last for

half an hour.

12. (12) can cause neutrophilic inflammation in patients

with asthma.

Questions 13 – 20

⚫ Answer each of the questions, 13 – 20, with a word or short phrase from one
of the texts.

⚫ Each answer may include words, numbers or both.

⚫ Your answers should be correctly spelled.

13. How often should patients be advised to practice breathing exercises?

232
14. How often should patients with a peak expiratory flow of less than 75% be given 10 mg
of salbutamol?

15. When should patients be given 2mg of magnesium sulfate?

16. Which patients will typically need to run when completing spirometry tests?

17. What should staff do when assessing a patient suffering from a lifethreatening panic
attack?

18. Which lung function test is helpful for understanding how the patient responds to
treatment?

19. What sort of noise might patients with asthma make when breathing?

20. What is used to measure peak expiratory flow rate?

233
 Sedation: Texts

Text A
Procedural sedation and analgesia for adults in the emergency department
Patients in the emergency department often need to undergo painful, distressing or unpleasant
diagnostic and therapeutic procedures as part of their care. Various combinations of analgesic,
sedative and anaesthetic agents are commonly used for the procedural sedation of adults in the
emergency department.

Although combinations of benzodiazepines and opioids have generally been used for procedural
sedation, evidence for the use of other sedatives is emerging and is supported by guidelines
based on randomised trials and observational studies. Patients in pain should be provided with
analgesia before proceeding to more general sedation. The intravenous route is generally the
most predictable and reliable method of administration for most agents.

Local factors, including availability, familiarity, and clinical experience will affect drug choice, as
will safety, effectiveness, and cost factors. There may also be cost savings associated with
providing sedation in the emergency department for procedures that can be performed safely in
either the emergency department or the operating theatre.

Text B

Levels of sedation as described by the American Society of Anesthesiologists

Non-dissociative sedation
• Minimal sedation and analgesia: essentially mild anxiolysis or pain control. Patients respond
normally to verbal commands. Example of appropriate use: changing burns dressings
• Moderate sedation and analgesia: patients are sleepy but also aroused by voice or light
touch. Example of appropriate use: direct current cardioversion
• Deep sedation and analgesia: patients require painful stimuli to evoke a purposeful response.
Airway or ventilator support may be needed. Example of appropriate use: major joint
reduction
• General anesthesia: patient has no purposeful response to even repeated painful stimuli.
Airway and ventilator support is usually required. Cardiovascular function may also be
impaired. Example of appropriate use: not appropriate for general use in the emergency
department except during emergency intubation.

Dissociative sedation
Dissociative sedation is described as a trance-like cataleptic state characterised by profound
analgesia and amnesia, with retention of protective airway reflexes, spontaneous respirations,
and cardiopulmonary stability. Example of appropriate use: fracture reduction.

[CANDIDATE NO.] READING TEXT BOOKLET PART A 02/04

254
Text C

Drug administration: General principles

International consensus guidelines recommend that minimal sedation – for example, with 50% nitrous oxide-
oxygen blend – can be administered by a single physician or nurse practitioner with current life support
certification anywhere in the emergency department. Guidelines recommend that for moderate and
dissociative sedation using intravenous agents, a physician should be present to administer the sedative, in
addition to the practitioner carrying out the procedure.
For moderate sedation, resuscitation room facilities are recommended, with continuous cardiac and oxygen
saturation monitoring, non-invasive blood-pressure monitoring, and consideration of capnography (monitoring
of the concentration or partial pressure of carbon dioxide in the respiratory gases).
During deep sedation, capnography is recommended, and competent personnel should be present to provide
cardiopulmonary rescue in terms of advanced airway management and advanced life support.

Text D
Drugs used for procedural sedation and analgesia in adults in the emergency department
Class Drug Dosage Advantages Cautions

Opioids Fentanyl 0.5-1 µg/kg over 2 Short acting analgesic; May cause apnoea,
mins reversal agent (naloxone) respiratory depression,
available bradycardia, dysphoria,
muscle rigidity, nausea and
vomiting
Morphine 50-100 µg/kg then Reversal agent (naloxone); Slow onset and peak effect
0.8-1 mg/h prolonged analgesic time; less reliable
Remifentanil 0.025-0.1 µg/kg/ Ultra-short acting; no solid Difficult to use without an
min organ involved in infusion pump
metabolic clearance
Benzodiazepines Midazolam Small doses of Minimal effect on No analgesic effect; may
0.02-0.03 mg/kg respiration; reversal agent cause hypotension
until clinical effect (flumazenil)
achieved; repeat
dosing of 0.5-1 mg
with total dose ≤
5mg
Volatile agents Nitrous oxide 50% nitrous oxide - Rapid onset and recovery; Acute tolerance may
50% oxygen cardiovascular and develop; specialised
mixture respiratory stability equipment needed
Propofol Propofol Infusion of 100 Rapid onset; short-acting; May cause rapidly
µg/kg/min for 3-5 anticonvulsant properties deepening sedation, airway
min then reduce obstruction, hypotension
to~50 µg/kg/min
Phencyclidines Ketamine 0.2-0.5 mg/kg Rapid onset; short-acting; Avoid in patients with
over 2-3 min potent analgesic even at history of psychosis; may
low doses; cardiovascular cause nausea and vomiting
stability
Etomidate Etomidate 0.1-0.15 mg/kg Rapid onset; short-acting; May cause pain on
may re-administer cardiovascular stability injection, nausea, vomiting;
caution when using in
patients with seizure
disorders/epilepsy – may
induce seizures
END OF PART A
THIS TEXT BOOKLET WILL BE COLLECTED

[CANDIDATE NO.] READING TEXT BOOKLET PART A 03/04

 Part A

TIME: 15 minutes

• Look at the four texts, A-D, in the separate Text Booklet.

• For each question, 1-20, look through the texts, A-D, to find the relevant information.

• Write your answers on the spaces provided in this Question Paper.

• Answer all the questions within the 15-minute time limit.

• Your answers should be correctly spelt.

Sedation: Questions

Questions 1-7

For each question, 1-7, decide which text (A, B, C or D) the information comes from. You may use
any letter more than once.

In which text can you find information about

1 the point at which any necessary pain relief should be given? ____________________

2 the benefits and drawbacks of specific classes of drugs? ____________________

3 financial considerations when making decisions about sedation? ____________________

4 typical procedures carried out under various sedation levels? ____________________

5 measures to be taken to ensure a patient’s stability under sedation? ____________________

6 reference to research into alternative sedative agents? ____________________

7 patients’ levels of sensory awareness when sedated? ____________________

Questions 8-14

Answer each of the questions, 8-14, with a word or short phrase from one of the texts. Each answer
may include words, numbers or both.

8 What class of drug is traditionally administered together with opioids for the purpose of
procedural sedation?

____________________________________________________________________

9 What level of sedation is appropriate for changing burns dressings?

____________________________________________________________________

[CANDIDATE NO.] READING QUESTION PAPER PART A 02/04

10 What is the only emergency department procedure for which it is appropriate to use
general anaesthesia?

____________________________________________________________________

11 What procedure may be carried out under dissociative sedation?

____________________________________________________________________

12 What class of drugs is unsuitable for patients who have a history of psychosis?

____________________________________________________________________

13 What opioid drug should be administered using specific equipment?

____________________________________________________________________

14 What is the maximum overall dose of Midazolam which should be given?

____________________________________________________________________

Questions 15-20

Complete each of the sentences, 15-20, with a word or short phrase from one of the texts. Each
answer may include words, numbers or both.

15 The majority of sedative drugs are administered via the _________________________.

16 General anaesthesia is the one form of sedation under which patients may have reduced

_________________________.

17 Patients under minimal sedation will react if they are given ___________________________.

18 Care should be taken when administering Etomidate to patients who are likely to have

_______________________.

19 It may be helpful to use capnography to keep track of patients’ ________________________

levels during moderate sedation.

20 Fentanyl, Morphine and Midozolam each have a ________________________, which is used to

cancel out the effects of the drug.

END OF PART A
THIS QUESTION PAPER WILL BE COLLECTED

[CANDIDATE NO.] READING QUESTION PAPER PART A 03/04