GI, Surgery & Obstetrics – Full Test

Roger Hauge is a 49-year-old man on postoperative day 8 following deceased-donor liver transplant on tacrolimus, mycophenolate, and prednisone taper. He develops fever 38.6°C, malaise, and rising AST/ALT/bilirubin over 48 hours. Doppler ultrasound shows patent vasculature. Tacrolimus trough is 7 ng/mL (therapeutic). Blood cultures are pending. WBC is 11.2 × 10⁹/L.

a) State the two leading diagnoses that must be distinguished in this presentation. (2 marks)

b) State the single investigation required to differentiate these two diagnoses definitively. (1 mark)

c) State one histological finding that would confirm acute cellular rejection. (1 mark)

d) List two empiric investigations that should proceed in parallel while awaiting the result in (b). (2 marks)

Arthur Davis is a 55-year-old patient with Acute Respiratory Distress Syndrome.  You have decided to begin enteral feeds.  Energy expenditure is calculated using Indirect Calorimetry. The respiratory quotient (RQ) is provided in conjunction with the indirect calorimetry.

Provide the formula for respiratory quotient (1 mark)

Assuming standard diet and non-shock state, provide the normal respiratory quotient (1 mark)

For a patient receiving exclusively dextrose for calories, provide the expected RQ (1 mark)

The RQ in your patient is measured as 1.3. Identify two potential causes for this RQ  (2 marks)

Jeremiah Masterson is a 35-year-old male admitted to critical care following pelvic fracture and positive FAST four days ago. After initial partial abdominal closure, the fascia was closed with initiation of negative pressure wound therapy for the skin incision. He is sedated on propofol 1mg/kg/h and hydromorphone 3mg/h. Norepinephrine dose has increased from 0.1 to 0.5mcg/kg/m and vasopressin infusion was started to achieve MAP 65mm Hg with pulse pressure of 20mm Hg. Abdomen is distended but not rigid, bowel sounds are audible and enteral feeds are running at 30mL/h with no vomiting. Urine output has decreased over three consecutive hours from 60mL/h down to 5mL/h.

Ventilation settings are as follows: VC 500mL R20 FiO₂ 0.7 PEEP 14cm H₂O. Peak inspiratory pressure is 32cm H₂O.

List THREE possible etiologies for the decompensation (3 marks)

Provide the MOST IMPORTANT diagnostic investigation you would pursue (1 mark)

Outline the impact of a positive FAST at the current moment on your post-test probability of bleeding. Write INCREASE, DECREASE or NO DIFFERENCE (1 mark)

India Farrah is a 40-year-old male admitted with blunt traumatic injury following motor vehicle collision.

Describe four management principles following damage control laparotomy (4 marks)

Patrick Sasha is a 56-year-old man is admitted with large hematemesis.  His past medical history includes significant alcohol intake and a diagnosis of alcohol related cirrhosis, and chronic ascites.  He is on no current medications, and it is unclear as to whether he is abstinent from alcohol. Vitals are:  Heart rate: 98 sinus.  Blood pressure: 86/60.  Respiratory rate:  22

Identify the most likely cause of his upper GI bleeding (1 mark)

Provide the diagnostic procedure indicated to diagnose the bleeding etiology (1 mark)

List three medications to address the acute bleeding (3 marks)

Identify one medication indicated to prevent re-bleeding in the future (1 mark)

Marlena Noelle is a 47-year-old woman presents to the Emergency Department with severe abdominal pain for the past day.  Medical history is significant for hypertension, hyperlipidemia, obesity and diabetes mellitus. She looks unwell.  Temp 39.2^oC, HR 130, RR 32 O₂ saturation 90% on room air, BP 90/57 mm Hg.  Abdomen is distended tympanic, with severe pain on palpation in the epigastrium. Her bloodwork is as follows:

CBC WBC 26, HB 161, Plt 468.
Na 145 K 3.8 Cl 102 HCO₃ 19 BUN 15 Creat 167 umol/L, glucose 15 mmol/L
Bilirubin 25 umol/L. Alb 34 g/L, Ca 2.05 mmol/L. AST 128 U/L, ALT 88 U/L, Alk Phos 421 U/L
ABG PO₂ 62 pH 7.33 PCO₂ 35 HCO3 18
Amylase 400 U/L, lipase 200 U/L, LDH 150 U/L. Lactate 4.2 mmol/L

A CT abdomen is obtained.

Provide the most likely diagnosis (1 mark)

List five possible etiologies for this presentation.  Identify the most likely diagnosis with a star (6 marks)

Outline your management by commenting on the following: Volume resuscitation, Pain, Nutrition, Antibiotic Provision (4 marks)

Ursula Zane is a 60-year-old female admitted to the intensive care unit with septic shock.  Cultures were all negative.  You suspect acalculous cholecystitis.

List three features of acalculous cholecystitis on ultrasound, not including absence of stones (3 marks)

Dee Madison is a patient under your care in the intensive care unit following liver resection for metastatic adenocarcinoma.  This has been complicated by intra-abdominal hematoma.  The patient’s ventilator pressures have increased, and urine output has decreased to < 20 mL/hour.  You are concerned about the development of abdominal compartment syndrome.

Describe the process for measurement of intra-abdominal pressure (2 marks)

Define abdominal compartment syndrome (1 mark)

List TWO approaches to medical (non-surgical) management of intra-abdominal hypertension (2 marks)

Art Audrey is a 43-year-old female with primary sclerosing cholangitis post liver transplant.  The postoperative ultrasound has been completed and the radiologist notes: resistive index in hepatic artery = 1.

Provide the equation for resistive index (1 mark)

Explain the importance of this value post-operative from liver transplantation (1 mark)

Provide two management strategies for a pathologically high resistive index (2 marks)

Provide one pharmacologic agent that may decrease risk of arterial vascular thrombosis in patients who receive liver transplants (1 mark)

Mamadou N’Diaye is a 33-year-old patient receiving invasive ventilation, continuous renal replacement therapy and vasopressors for hypotension after admission for fecal peritonitis from perforated cecum. He was admitted four days ago. Medical history is insignificant. Current medications are: pantoprazole 40mg IV daily, Dalteparin 5,000 units SQ daily, norepinephrine 0.2mcg/kg/m, hydromorphone 1mg IV q2h, propofol 2mg/kg/h and piptazo 4.5g IV q8h. Examination reveals a distended but soft abdomen, clear chest and pedal edema. Ventilator settings are: AC-VC rate 22 VC 450mL PEEP 12cm H2O FiO2 0.4 Ti 0.9s. Arterial blood gas shows the following: pH 7.33 pCO2 45mm Hg, pO2 70mm Hg HCO3- 20. After two days of enteral feeding through a nasogastric tube with tip placement confirmed in the gastric antrum, gastric residual volumes have exceeded 400mL therefore feeds have been suspended.

Provide ONE PHARMACOLOGIC and ONE MECHANICAL strategy to overcome feeding intolerance (2 marks)

Describe TWO circumstances where pro-motility agents may be INEFFECTIVE at managing feeding intolerance (2 marks)

Describe the UTILITY of routine measurement of gastric residual volumes in low risk patients with critical illness (excluding gastric surgery or history of aspiration) (1 mark)

Victor Bello is a 19-year-old male admitted to your intensive care unit for decreased level of consciousness and airway protection. There was a witnessed ingestion of 200g of acetaminophen forty hours prior, falling below the nomogram for treatment. He is invasively ventilated and sedated using propofol 5mg/kg/h, hydromorphone 2mg/h, norepinephrine 0.4mcg/kg/m, vasopressin 2.4units/h and the following ventilator settings: PCMV rate 24 PC 16cm H2O PEEP 10cm H2O FiO2 0.4 Vt 414mL.

Labs are below:
Chemistry: Na 138 K 4 Cl 110 HCO3 20 Mg 0.9 P 1.4 Ca 2.2.
Hematology Hb 130g/L WBC 11 Plt 200 INR 2.1 PTT 26s
Blood gas: Arterial. pH 7.33 PaCO2 38 PaO2 80 HCO3 19
AST 1840mmol/L ALT 3038mmol/L Bilirubin 45mmol/L

List THREE management options for this acetaminophen toxicity (3 marks)

List THREE indications for transplantation, per the King’s College Criteria. Be specific (3 marks)

List ONE additional biochemical investigation to guide management of encephalopathy (1 mark)

Your centre has continuous renal replacement therapy and invasive intracranial pressure monitoring. You are 300km from the nearest liver transplantation centre. State whether you would transfer this patient now (write yes/no) and provide a brief rationale (2 marks)

Louis Parsons is a 65-year-old man is admitted to the ICU post bowel resection for gastric carcinoma causing acute perforation. His ideal body weight and actual body weight are 70 kg. It is the weekend and you have to write a complete TPN order for him.

a) State his estimated daily caloric requirement in kcal. (1 mark)

b) State his estimated total daily protein requirement in grams. (1 mark)

c) State his estimated total daily non-protein calories. (1 mark)

d) State the amount of total daily calories supplied by fat. (1 mark)

e) State the amount of total daily calories supplied by carbohydrates. (1 mark)

Dante Galtieri is a 26 year old male admitted with anoxic brain injury following neck trauma. He was admitted two days ago. Gastric residual volumes have been 300mL consistently resulting in feeding restriction since admission. You are mechanisms of improving nutrition.

Choose gastric or post-pyloric as the preferred INITIAL option for enteral nutrition in the general critically ill patient (without luminal gastrointestinal issue) (1 mark)

Describe the role of measuring gastric residual volumes and ONE reason they may be unreliable (2 marks)

Provide TWO indications for post-pyloric feeding tube insertion (2 marks)

List TWO prokinetic agents you would consider to improve feeding tolerance (2 marks)

Provide TWO reasons why prokinetics may be insufficient or contraindicated (2 marks)

Crystal Marchand is a 24-year-old female developed significant soft tissue injury 5 days ago after playing soccer and started taking large doses of acetaminophen for discomfort. She presents with confusion and feeling unwell. Markedly elevated transaminases (several thousands), INR 2.5, bilirubin 42 μmol/L, creatinine 100 μmol/L.

a) List EXACTLY TWO ways acetaminophen overdose causes toxicity. (2 marks)

b) List EXACTLY THREE situations which may result in acetaminophen toxicity despite consuming less than the listed toxic dose. (3 marks)

c) Explain why patients develop acute renal failure in acetaminophen overdose. (1 mark)

d) State the stage of acute liver failure when cerebral edema presents and the usual timeframe for this stage. (2 marks)

e) State EXACTLY TWO Kings College Criteria for transplantation following acute liver failure from acetaminophen ingestion. (2 marks)

Josefine Afi is a 63-year-old woman presenting with severe acute pancreatitis, acute kidney injury, respiratory failure, metabolic acidosis, and refractory shock requiring intubation, high PEEP, vasopressors, and aggressive fluid resuscitation. Contrast-enhanced CT shows inflammation of approximately 60% of the pancreas with no evidence of necrosis, hemorrhage, or abscess. No gallstones are identified.

a) State the indication for prophylactic antibiotic therapy in acute pancreatitis and whether it applies in this case. (2 marks)

b) State the optimal route and timing of nutrition and the recommended position of the feeding tube. (2 marks)

Pearl Emma is a 52-year-old woman with decompensated cirrhosis and portal hypertension admitted to the ICU with an acute upper gastrointestinal bleed from esophageal varices. She has been resuscitated and undergone urgent endoscopy confirming active variceal hemorrhage. The team is planning strategies to reduce rebleeding risk.

a) List THREE evidence-based interventions to decrease rebleeding in variceal upper GI hemorrhage. (3 marks)

A 34-year-old woman with anorexia nervosa and severe malnutrition is admitted to the ICU and enteral nutrition is initiated. On day 2 of feeding she develops confusion and a new cardiac dysrhythmia. The team suspects refeeding syndrome.

a) List FOUR clinical criteria or manifestations of refeeding syndrome. (4 marks)

Miguel Hernnadez is a 59-year-old man is admitted to the ICU with septic shock requiring mechanical ventilation and vasopressors. The team is assessing his risk for stress-related gastrointestinal bleeding and discussing indications for prophylaxis.

a) List FIVE risk factors associated with high risk for GI bleeding in critically ill patients. (5 marks)

Arnold Sing is a 58-year-old man with decompensated cirrhosis and recurrent variceal hemorrhage refractory to endoscopic and pharmacologic therapy being considered for transjugular intrahepatic portosystemic shunt (TIPS) insertion. The hepatology team asks you to review contraindications.

a) List SIX contraindications to TIPS. (6 marks)

Diego Adichie is a 54-year-old man with cirrhosis and severe hepatopulmonary syndrome (pre-transplant PaO2 52 mmHg on room air, shunt fraction 38%) who underwent deceased-donor liver transplant. The operative report describes prolonged hypoxemia requiring intraoperative VV-ECMO cannulation, a TEG-guided massive transfusion protocol for coagulopathic bleeding, and a complex hepatic artery reconstruction using an iliac artery conduit due to recipient artery dissection. He arrives in the ICU on VV-ECMO, tacrolimus and mycophenolate.

a) State the expected postoperative trajectory of oxygenation in hepatopulmonary syndrome after a technically successful transplant (1 mark)

b) Abdominal drain output is 500mL in the first 30 minutes of ICU treatment.  TEG is normal. State the MOST APPROPRIATE next step. (1 mark)

c) Ultrasound is performed post-operative day 1 with high resistive index (peak systolic – end-diastolic/peak systolic velocities). List TWO non-concerning potential explanations for elevated resistive index and TWO pathological concerns. (4 marks)

Khalida Lindholm is a 47-year-old woman on postoperative day 3 following deceased-donor liver transplant with duct-to-duct biliary reconstruction. She develops increasing abdominal distension, new ascites on exam, and her abdominal drain output increases from 30 mL/hr serosanguineous to 180 mL/hr of discoloured serous fluid. Her AST and ALT, previously trending down, have risen sharply, and bilirubin is rising. Doppler ultrasound shows patent hepatic artery and portal vein but reduced hepatic vein flow with a monophasic waveform.

a) State the drain fluid test that would confirm a biliary leak and the result that would be diagnostic. (2 marks)

b) State the imaging finding described that suggests a separate process, and name that process. (2 marks)

c) State the most likely structural cause of the hepatic vein finding in the early postoperative period. (1 mark)

Yelena Verbeek is a 36-year-old woman on postoperative day 5 following allogeneic stem cell transplant on tacrolimus for graft-versus-host prophylaxis. She has a witnessed generalized tonic-clonic seizure. BP is 168/98 mmHg, and she has new visual disturbance reported prior to the seizure. Tacrolimus trough is 22 ng/mL (target 5–10 ng/mL). CT head is unremarkable.

a) State the most likely diagnosis. (1 mark)

b) State the imaging modality most sensitive for confirming this diagnosis and the characteristic finding. (2 marks)

c) List two immediate management steps specific to this diagnosis. (2 marks)

Johan Matthews is a 76-year-old male receiving total parenteral nutrition seven days following small bowel resection for perforated viscus secondary to mesenteric ischemia.  The formulation is 7% amino acid/17% dextrose.

Calculate the calories per litre from dextrose. (1 mark)

Calculate the calories per litre contributed by protein (1 mark)

List the components of SMOF and describe how SMOF differs from intralipid (5 marks)

Farrukh Adebimpe is a 54-year-old man with decompensated alcoholic cirrhosis. He has ascites, hepatic encephalopathy, and a variceal bleed requiring banding. His bilirubin is 180 µmol/L, INR 2.4, creatinine 210 µmol/L (he has known CKD from hypertension), sodium 128 mmol/L, and albumin 22 g/L. He is being assessed for liver transplant listing and for TIPS to manage refractory ascites.

a) State what the MELD score predicts in this patient’s clinical context and identify the specific time point of mortality it estimates. (2 marks)

b) Name one disease category that receives automatic MELD score exception points regardless of calculated score. (1 mark)

c) State two limitations of MELD score interpretation specific to this patient’s clinical features. (2 marks)

d) State the additional role of MELD score assessment at the time of TIPS planning. (1 mark)

Nkechi Shirazi is a 48-year-old woman on postoperative day 2 following liver transplant from a donation after circulatory death (DCD) donor with a total warm ischemic time of 28 minutes. Her pre-transplant diagnosis included cirrhosis and hepatopulmonary syndrome (pre-operative PaO2 58 mmHg on room air). Postoperatively her AST is 2,840 U/L and ALT 1,960 U/L, trending down from peak values on day 1. Her SpO2 is 88% on FiO2 0.50 and she remains intubated. The team is concerned about primary graft non-function.

a) State why the transaminase values on day 2, while markedly elevated, may not indicate primary graft non-function in this specific donor context. (1 mark)

b) State the expected trajectory of transaminases in ischemic reperfusion injury from DCD donation, and identify the finding that would indicate true graft dysfunction rather than expected ischemia-reperfusion. (2 marks)

c) State why persistent hypoxemia requiring high FiO2 on postoperative day 2 is not necessarily a sign of graft failure or pulmonary complication in this patient. (1 mark)

d) State the expected trajectory of oxygenation in hepatopulmonary syndrome following technically successful transplant. (1 mark)

e) List two findings that would indicate this patient’s hypoxemia is pathological rather than expected. (2 marks)

Javad Holm is a 31-year-old man presenting 5 days after acetaminophen overdose with acute liver failure, INR 7.2, bilirubin 290 µmol/L, creatinine 388 µmol/L, and lactate 5.8 mmol/L. He is progressively obtunded with GCS 9, and CT head shows early cerebral edema without herniation. Ammonia is 188 µmol/L. The transplant team is assessing candidacy.

a) Identify one bedside or monitoring finding that would distinguish cerebral edema from hepatic encephalopathy as the primary etiology for depressed level of consciousness. (1 mark)

b) State the two King’s College Criteria thresholds met in this patient that indicate poor prognosis without transplant. (2 marks)

c) State one contraindication to liver transplant related to his intracranial status, as listed in transplant guidelines. (1 mark)

d) State the role of intraoperative renal replacement therapy in this patient if he proceeds to transplant, and identify the specific metabolic target it is used to address. (2 marks)

Megan Connolly is a 68-year-old female admitted with pneumonia.  You are writing enteral feeding orders. Height 150cm weight 170kg. BMI 60.  Estimated energy expenditure using indirect calorimetry is 2600kcal/day.

Provide the daily caloric requirement (1 mark).

Provide the daily protein requirement (1 mark)

Oleksa Dragomir is a 27-year-old woman admitted to the medicine floor with dehydration.  She has a history of anorexia with admission weight of 42kg.  She was started on isosource HN at 40mL/h enterally via nasogastric tube.  She is also receiving intravenous fluid in the form of D5W 0 .9%saline at 100mL/h.  The floor team consults ICU for weakness and pulmonary edema.

Provide the most likely diagnosis (1 mark)

Identify the biochemical disturbance most likely to be causing muscle weakness (1 mark)

List three other clinical manifestations of the biochemical disturbance (3 marks)

Gary Childress is a 64-year-old patient with Crohn’s pan-colitis managed on outpatient biologic therapy who is admitted to hospital for large volume diarrhea.  This has caused dehydration, acute on chronic renal failure and distributive shock. The gastroenterology team initiated the patient on intravenous steroids in the form of hydrocortisone 100 mg IV q8h for a presumed Crohn’s flare and replaced his intravascular fluids aggressively with a total of 7 liters of isotonic crystalloid during his first 24 hours in hospital.

At morning shift change on the patient’s second post admission day he is found to be obtunded with a blood pressure of 70/40 in spite of his aggressive fluid resuscitation. His lactate has climbed to 4.2 and his renal failure has reached a critical threshold for urgent dialysis with a K of 6.8 and a pH of 7.17. The patient is transferred to the intensive care unit and vasopressors are initiated via a left subclavian line central venous catheter, invasive arterial monitoring is obtained, and a right IJ dialysis line is placed for the planned initiation of continuous renal replacement therapy. The patient remains extubated and his diarrhea comes to a somewhat abrupt halt.

List three additional tests to clarify the diagnosis for this patient’s colitis. (3 marks)

Two hours after initiating CRRT the patient begins to manifest signs of respiratory failure with tachypnea, air hunger and pleuritic chest pain. Following intubation the patient is placed on controlled mechanical ventilation at a rate of 18 breaths per minute with a distending pressure of 18 and a PEEP of 10. With these settings the patient’s tidal volumes are 180cc and plateau airway pressure is measured at 32 cmH₂O. Despite increasing FiO₂ to 80% the patient remains hypoxic.  There is no pneumothorax on chest imaging.

Provide one bedside investigation to guide management (1 mark)

List two procedures indicated to improve ventilation. Briefly justify your answer (3 marks)

Wesley Theodore is a 33-year-old male with primary sclerosing cholangitis in the context of ulcerative colitis.  The MELD (Model for End-stage Liver Disease) score is used to prioritize patients for liver transplant.

Explain the outcome predicted by MELD (2 marks)

List four components included in the MELD score

List two conditions for which patients may receive high priority for liver transplantation without consideration of the MELD score. Exclude fulminant hepatic failure

George Mason is an 80-year-old male admitted to critical care with Ogilvie’s syndrome (acute colonic pseudo-obstruction).  The patient has a nasogastric tube at low intermittent suction and a rectal tube.  The surgery team suggests a trial of pharmacologic therapy.

Identify your pharmacologic therapy (1 mark)

Describe the mechanism of action for your therapy (1 mark)

Identify cardiovascular adverse effects of your therapy (1 mark)

Hebe Chou is a 60-year-old woman admitted with lactic acidosis refractory to intravenous fluid and antibiotics.  Mesenteric ischemia is raised as a possible etiology for shock.

List THREE CT findings suggestive of mesenteric ischemia (3 marks)

Aside from prompt recognition, fluid resuscitation and surgical resection of infarcted bowel, list three principles of management in acute intestinal ischemia (3 marks)

Marian Fyshe is a 32-year-old female G2P1 at 35+2 weeks gestation who presents with refractory hypoxemia fulfilling criteria for acute respiratory distress syndrome.

List FOUR obstetrical conditions associated with ARDS (4 marks)

Comment on whether the physiologic variable would be INCREASED, DECREASED or UNCHANGED at this stage of gestation in a NORMAL pregnancy (6 marks)

Functional Residual Capacity, PaCO2, Static lung compliance, Chest wall resistance, Minute Ventilation, VO2

Femi Kurala is a 35 year old female at 30 weeks gestation presenting to the Intensive Care Unit with depressed level of consciousness requiring intubation and invasive mechanical ventilation for airway protection. She was admitted 6 hours ago. Medical history is significant for anxiety and she takes no medications. This is her first pregnancy, it was planned with pre-natal vitamin supplementation including folic acid and uncomplicated antenatal care. Vitals show: BP 129/79mm Hg HR 105 bpm (sinus) SpO2 96% on PSV PEEP 8 FiO2 0.25 Vt 400mL rate 16. Neurologic examination reveals normal reflexes and no focal deficits. Laboratory investigations show: Platelets 105, D-dimer 400, Na 134 K 4.2 Glucose 7 Lactate 2.2. Arterial blood gas: pH 7.35 paCO2 40 PaO2 70. CT head is negative for hemorrhage or stroke on admission. POCUS reveals normal ventricular function.

Provide TWO etiologies on your differential diagnosis (2 marks)

Identify the MOST appropriate investigation. Be specific (2 marks)

If anticoagulation is required, provide the BEST class or agent and ONE class or agent to avoid (2 marks)

Lee Jini is a 32-year-old female at 36 weeks gestation, presents to the ICU with fatigue, jaundice, and confusion over the past 24 hours. Medical and antenatal histories are unremarkable with uneventful pregnancy, routine screening and pre-natal optimization. She has not been diagnosed with preeclampsia. She has been hypertensive (BP 150/95 mmHg) for the last week but without a formal diagnosis of preeclampsia. On admission vitals show: HR 110 bpm BP 150/95 (labetalol 1mg/m) SpO2 97% R/A RR 20 T 36.3.  Urine output  is under 10 mL/hour. Labs reveal: ALT: 180 U/L, AST: 200 U/L, Bilirubin: 89 mg/dL, Platelets: 90 × 10³/μL, Fibrinogen 2, Glucose: 2.5mmol/L INR 2.8.  Arterial pH 7.28 HCO3 15 Lactate 6.

Identify the MOST LIKELY diagnosis (1 mark)

Provide TWO immediate management principles (2 marks)

Describe the DEFINITIVE management intervention (1 mark)

List TWO complications of the most likely diagnosis (2 marks)

Mika Benson is a 36-year-old female, G2P2, 36 hours post-partum, presents with nausea, vomiting and headache, with GCS 13. She had a C-section for late decelerations. She complains of 8/10 abdominal pain. Blood pressure 175/100; papilledema present but no focal neurological deficits; upper abdomen diffusely tender; C-section incision looks good. Pregnancy was otherwise uncomplicated. Labs show: transaminases in 300s, hemoglobin 85 g/L, platelets 75 × 10⁹/L, LDH 750 U/L, protein in urine, INR 2.2, oozing from IV sites.

a) List EXACTLY FIVE things on your differential diagnosis. (5 marks)

b) State the top TWO diagnoses on your differential. (2 marks)

a) List the TWO MOST ESSENTIAL additional bloodwork tests you would order now  (2 marks)

d) Explain what is happening given INR 2.2 and oozing from IV sites. (1 mark)

e) List EXACTLY THREE treatment priorities. (3 marks)

Ina Harmonmy is a 32-year-old woman at 38 weeks gestation presenting with two weeks of progressive dyspnea, cough, and increased puffer use without improvement. Vital signs: SpO2 91% on room air, RR 32, HR 130, BP 135/70. She deteriorates rapidly requiring intubation; cultures are negative, CXR shows bilateral infiltrates, and pulmonary artery catheter shows wedge pressure of 24 mmHg.

a) List FIVE diagnoses in the initial differential. (5 marks)

b) State the most likely diagnosis given the investigation results. (1 mark)

c) List THREE initial management steps addressing both mother and fetus. (3 marks)

d) State TWO classes of heart failure medication contraindicated in pregnancy. (2 marks)

e) State the next escalation option if she continues to deteriorate. (1 mark)

f) List TWO risk factors for peripartum cardiomyopathy. (2 marks)

Deepa Raghunathan is a 28-year-old woman at 22 weeks gestation with no prior hypertension presenting post-ictal after a 2-minute generalized tonic-clonic seizure. BP 178/112 mmHg, GCS 11, 2+ proteinuria. Platelets 210 × 10⁹/L, LFTs normal, creatinine normal. Fetal heart rate tracing shows a prolonged deceleration. MgSO4 has been started.

a) List two diagnoses aside from eclampsia that must be excluded. (2 marks)

b) State the mechanism of action of magnesium sulfate in eclampsia, name the toxic serum level with its first clinical sign, and state the antidote. (3 marks)

c) List two pregnancy-related physiologic changes that alter drug pharmacokinetics in this patient. (2 marks)

Marcelina Wojciechowska is a 31-year-old woman at 29 weeks gestation with progressive hypoxemic respiratory failure over 48 hours. SpO2 88% on FiO2 1.0, RR 36, visibly fatigued. CXR shows bilateral alveolar infiltrates. No fever, no hypertension, no proteinuria, echo shows normal biventricular function. The obstetrics team asks whether to deliver now and whether to give corticosteroids.

a) List three physiologic changes of pregnancy that increase the risk of rapid oxygen desaturation during intubation. (3 marks)

b) State the dual indication for corticosteroids, name the agent and dose for each indication (2 marks)

c) State the two determinants guiding delivery versus expectant management, and name the fetal monitoring finding mandating immediate delivery. (2 marks)