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Question 1
Incorrect
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A 29-year-old female presents to the surgical intake with abdominal pain and a five day history of vomiting.
Over the last three months she has also been aware of a 6 kg weight loss.
On examination, she is pale, has a temperature of 38.5°C, blood pressure of 90/60 mmHg and pulse rate of 130 in sinus rhythm. The chest is clear on auscultation but she has a diffusely tender abdomen without guarding. Her BM reading is 2.5.
Initial biochemistry is as follows:
Sodium 124 mmol/L (137-144)
Potassium 6.0 mmol/L (3.5-4.9)
Urea 7.5 mmol/L (2.5-7.5)
Creatinine 78 µmol/L (60-110)
Glucose 2.0 mmol/L (3.0-6.0)
What is the likely diagnosis?Your Answer: Acute appendicitis
Correct Answer: Addison's disease
Explanation:Hypoadrenal Crisis and Addison’s Disease
This patient is exhibiting symptoms of hypoadrenal crisis, including abdominal pain, vomiting, shock, hypoglycemia, hyponatremia, and hyperkalemia. In the UK, this is typically caused by autoimmune destruction of the adrenal glands, known as Addison’s disease. Other less common causes include TB, HIV, adrenal hemorrhage, or anterior pituitary disease. Patients with Addison’s disease often experience weight loss, abdominal pain, lethargy, and nausea/vomiting. Additionally, they may develop oral pigmentation due to excess ACTH and other autoimmune diseases such as thyroid disease and vitiligo.
In cases like this, emergency fluid resuscitation, steroid administration, and a thorough search for underlying infections are necessary. It is important to measure cortisol levels before administering steroids. None of the other potential causes explain the patient’s biochemical findings.
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This question is part of the following fields:
- Emergency Medicine
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Question 2
Incorrect
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An 80-year-old male is brought to the Emergency department and has a witnessed seizure in the resuscitation room. His blood glucose is recorded as 1.0 mmol/L. He does not have diabetes, nor other significant medical history. He is given 50 ml of 50% dextrose and he slowly recovers over the next one hour. A serum cortisol concentration later returns as 800 nmol/L (120-600). What investigation would be most relevant for this man?
Your Answer: Chest x ray
Correct Answer: Prolonged 72 hour fast
Explanation:Diagnosis of Spontaneous Hypoglycaemia
The patient’s medical history and biochemical evidence suggest a diagnosis of spontaneous hypoglycaemia, with the most likely cause being an insulinoma. However, it is important to rule out the possibility of drug administration, and a sulphonylurea screen should be conducted. The patient has presented with symptomatic hypoglycaemia, despite not being diabetic and not having received insulin or a sulphonylurea. There is no indication of alcohol or drug misuse, nor is there any evidence of sepsis.
To confirm a diagnosis of spontaneous hypoglycaemia, a prolonged fast is necessary. If the patient experiences hypoglycaemia during the fast, insulin and C peptide levels should be measured to confirm the diagnosis. The patient’s cortisol response during the hypoglycaemic episode (cortisol 800) rules out hypoadrenalism.
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This question is part of the following fields:
- Emergency Medicine
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Question 3
Correct
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A 15-year-old girl comes to the clinic with bilateral cervical lymphadenopathy. Upon conducting a lymph node biopsy, it is revealed that she has nodular sclerosing Hodgkin's disease. What characteristic is indicative of a worse prognosis for this patient?
Your Answer: Night sweats
Explanation:Prognostic Features in Hodgkin’s Disease
Hodgkin’s disease (HD) is a type of cancer that has important prognostic features. These features include the presence of stage B symptoms, which are fever, night sweats, and weight loss. Additionally, a mass of more than 10 cm in size is also considered a poor prognostic factor. While fatigue and pruritus are common symptoms of HD, they do not have any prognostic significance. It is worth noting that EBV infection is commonly associated with HD, but it does not have any prognostic significance. Therefore, it is important to consider these prognostic features when diagnosing and treating HD. Proper management of these features can help improve the prognosis and overall outcome for patients with HD.
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This question is part of the following fields:
- Emergency Medicine
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Question 4
Incorrect
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A 57-year-old man who has been physically active throughout his life experiences a sudden onset of severe chest pain that spreads to his back, causing him to lose consciousness within minutes. He has a medical history of hypertension, but a recent treadmill test showed no signs of cardiac disease. What is the most probable diagnosis?
Your Answer: Acute myocardial infarction (MI)
Correct Answer: Tear in the aortic intima
Explanation:Aortic Dissection: A Probable Cause of Sudden Collapse with Acute Chest Pain
The given history suggests that aortic dissection is the most probable cause of sudden collapse with acute chest pain radiating to the back. Although other conditions may also lead to sudden collapse, they do not typically present with acute chest pain radiating to the back in the presence of a recent normal exercise test. While acute myocardial infarction (MI) is a possible cause, it is not the most likely in this scenario.
References such as BMJ Best Practice, BMJ Clinical Review, and eMedicine support the diagnosis and management of aortic dissection. Therefore, it is crucial to consider this condition as a potential cause of sudden collapse with acute chest pain and seek immediate medical attention. Early diagnosis and prompt treatment can significantly improve the patient’s prognosis and prevent life-threatening complications.
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This question is part of the following fields:
- Emergency Medicine
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Question 5
Incorrect
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A 60-year-old patient has been diagnosed with chronic hepatitis B through blood tests. The doctor explains that the patient is highly contagious and at a greater risk of long-term disease. Which of the following blood results is most likely to be seen in this patient?
HbSAg Anti-HBs IgM anti-HBc IgG anti-HBc HBeAg Anti-HBe
A + - + + + -
B - + - + - +
C + - - + + -
D + - - + - +
E - + - - - -Your Answer: E
Correct Answer: C
Explanation:Hepatitis B Infection and Immunity
The presence of hepatitis B surface antigen indicates the presence of the hepatitis B virus in the host cells, whether it is a chronic or acute infection. All patients infected with hepatitis B will produce antibodies to the core antigen. IgM antibodies are markers of acute infection and disappear in chronic infection, while IgG antibodies to the core antigen remain present even after the infection has been cleared. Vaccinated individuals develop antibodies to the surface antigen, which confers natural immunity after the infection has cleared.
If HBsAg persists for more than six months, the patient is a chronic carrier. HBeAg is a marker of virus replication, and HBeAg-positive carriers are highly infectious. However, over time, the HBeAg can be lost from the blood, and anti-HBe can be detected. These carriers are much less infectious.
In summary, acute HBV infection is indicated by the presence of IgM antibodies, while cleared HBV infection is indicated by the presence of IgG antibodies. Chronic HBV infection can be high or low in infectivity, depending on the presence of HBeAg or anti-HBe. Finally, individuals who respond to the HBV vaccine develop immunity to the virus. these markers and their implications can aid in the diagnosis and management of hepatitis B infection.
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This question is part of the following fields:
- Emergency Medicine
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Question 6
Correct
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A 57-year-old male presents with acute abdominal pain that has worsened over the past two hours. The pain originates in the epigastric region and radiates to the left side of his back, with colicky characteristics. He has vomited three to four times, with the vomit being greenish in color.
Upon examination, his temperature is 37.5°C, pulse is 100 beats per minute, and blood pressure is 114/80 mmHg. He has guarding of the abdomen and marked tenderness in the epigastrium. Bowel sounds are infrequent but audible.
Lab results show a neutrophilic leukocytosis, elevated glucose and urea levels, and an elevated creatinine level. Urinalysis reveals an elevated amylase level. Abdominal x-ray shows no abnormalities.
What is the likely diagnosis?Your Answer: Pancreatitis
Explanation:Acute Pancreatitis
Acute pancreatitis is a condition characterized by sudden and severe abdominal pain that radiates through to the back. It is caused by inflammation and swelling of the pancreas, which leads to the loss of enzymes into the circulation and retroperitoneally. This can result in hyperglycemia, hypocalcemia, and dehydration, which are common features of the condition.
To diagnose acute pancreatitis, a serum amylase test is usually performed. A result above 1000 mU/L is considered diagnostic. Other investigations may reveal dehydration, an elevated glucose concentration, a mild metabolic acidosis, and heavy amounts of amylase in the urine.
Treatment for acute pancreatitis involves resuscitation with IV fluids, management of hyperglycemia with sliding scale insulin, nasogastric suction, antibiotics, and analgesia. It is important to manage the condition promptly to prevent complications and improve outcomes.
In summary, acute pancreatitis is a serious condition that requires prompt diagnosis and management. It is characterized by inflammation and swelling of the pancreas, which can lead to hyperglycemia, hypocalcemia, and dehydration. Treatment involves resuscitation with IV fluids, management of hyperglycemia, and other supportive measures.
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This question is part of the following fields:
- Emergency Medicine
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Question 7
Correct
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What EEG findings are typically observed in patients with hepatic encephalopathy?
Your Answer: Delta waves
Explanation:EEG Changes in Hepatic Encephalopathy
Classic EEG changes that are commonly associated with hepatic encephalopathy include delta waves with high amplitude and low frequency, as well as triphasic waves. However, it is important to note that these findings are not specific to hepatic encephalopathy and may be present in other conditions as well. In cases where seizure activity needs to be ruled out, an EEG can be a useful tool in the initial evaluation of patients with cirrhosis and altered mental status. It is important to consider the limitations of EEG findings and to interpret them in conjunction with other clinical and laboratory data. Proper diagnosis and management of hepatic encephalopathy require a comprehensive approach that takes into account the underlying liver disease and any contributing factors.
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This question is part of the following fields:
- Emergency Medicine
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Question 8
Correct
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A 6-year-old boy is brought to the Emergency department by his mother who reports that he has put a small bead into his ear. Upon examination, you confirm the presence of a plastic bead lodged deep in the external canal of his left ear.
What is the best course of action in this situation?Your Answer: Refer the patient for review in ENT clinic
Explanation:Ear foreign bodies are common and can be removed by skilled ENT staff using appropriate equipment. If unsuccessful, a general anaesthetic may be required. In cases of infection or trauma, referral as an emergency is necessary. Antibiotics are only needed if there is evidence of infection. Foreign bodies should not be left in the ear to prevent infection and ensure no associated injuries.
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This question is part of the following fields:
- Emergency Medicine
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Question 9
Correct
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What vitamin is utilized to treat confusion in individuals with chronic alcoholism?
Your Answer: Thiamine
Explanation:Wernicke-Korsakoff Syndrome
Wernicke-Korsakoff syndrome is a condition that arises due to insufficient intake of thiamine, as well as impaired absorption and storage. This condition is known to cause various symptoms, including dementia, nystagmus, paralysis of extra ocular muscles, ataxia, and retrograde amnesia, particularly in individuals who struggle with alcoholism.
The inadequate intake of thiamine is often associated with chronic alcoholism, as alcohol can interfere with the body’s ability to absorb and store thiamine. This can lead to a deficiency in the vitamin, which can cause damage to the brain and nervous system. The symptoms of Wernicke-Korsakoff syndrome can be severe and can significantly impact an individual’s quality of life.
It is essential to understand the causes and symptoms of Wernicke-Korsakoff syndrome to ensure that individuals who are at risk receive the necessary treatment and support. With proper care and management, it is possible to manage the symptoms of this condition and improve an individual’s overall health and well-being.
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This question is part of the following fields:
- Emergency Medicine
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Question 10
Correct
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What factor is linked to a higher likelihood of developing hepatocellular carcinoma?
Your Answer: Hepatitis C
Explanation:Risk of Hepatocellular Carcinoma in Cirrhosis Patients with Hepatitis C
Cirrhosis patients with hepatitis C have a 2% chance of developing hepatocellular carcinoma. This means that out of 100 people with cirrhosis caused by hepatitis C, two of them will develop liver cancer. It is important for these patients to receive regular screenings and follow-up care to detect any signs of cancer early on. Early detection can improve the chances of successful treatment and increase the likelihood of survival. Therefore, it is crucial for individuals with cirrhosis from hepatitis C to work closely with their healthcare providers to manage their condition and reduce their risk of developing hepatocellular carcinoma.
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This question is part of the following fields:
- Emergency Medicine
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Question 11
Correct
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A 35-year-old woman presents with sudden chest pain and difficulty breathing. She recently returned from a trip to Italy with her family. She has no significant medical history but takes oral contraceptives. On examination, her pulse is 100 bpm, temperature is 37°C, oxygen saturation is 95%, respiratory rate is 28/min, and blood pressure is 116/76 mmHg. Chest examination is unremarkable and chest x-ray is normal. What is the most appropriate diagnostic test to confirm the diagnosis?
Your Answer: CTPA scan
Explanation:Diagnosis of Pulmonary Embolism in a Woman with Chest Pain and Dyspnoea
This woman is experiencing chest pain and difficulty breathing, with a rapid heart rate and breathing rate. However, there are no visible signs on chest examination and her chest x-ray appears normal. Despite having no fever, her oxygen levels are lower than expected for a healthy person. To rule out a pulmonary embolism, doctors must consider risk factors such as recent air travel and use of oral contraceptives.
The gold standard for diagnosing a pulmonary embolism is a CT pulmonary angiogram, as it can detect even large saddle emboli near the pulmonary arteries. While VQ scanning was previously used, it can miss these larger emboli. Additionally, doctors may perform Doppler ultrasounds of the venous system to check for deep vein thrombosis.
This presentation is not indicative of atypical pneumonia, such as Legionella, as the patient’s temperature would be expected to be high and chest signs would be present. Overall, a thorough evaluation is necessary to accurately diagnose and treat a pulmonary embolism in a patient with chest pain and dyspnoea.
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This question is part of the following fields:
- Emergency Medicine
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Question 12
Correct
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A 28-year-old accountant presents to the Emergency department with a sudden and severe headache that started six hours ago. She also reports feeling nauseous and has vomited three times. Upon examination, she has neck stiffness and photophobia, but her GCS is 15 and she has no fever. What is the most probable diagnosis?
Your Answer: Subarachnoid haemorrhage
Explanation:Diagnosing Severe Headaches: Subarachnoid Hemorrhage and Differential Diagnosis
The sudden onset of a severe headache is a strong indication of subarachnoid hemorrhage, which can be confirmed through a head CT scan. If the scan is normal, a lumbar puncture should be performed to check for red blood cells and xanthochromia. Bacterial meningitis is also a possible diagnosis, but it typically presents with other symptoms of sepsis such as fever. Migraines, on the other hand, are usually preceded by an aura and visual disturbances, and are often associated with prior history and risk factors. Sinusitis and cluster headaches are not suggested by the patient’s history.
Overall, it is important to consider a range of potential diagnoses when evaluating severe headaches, as prompt and accurate diagnosis is crucial for effective treatment.
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This question is part of the following fields:
- Emergency Medicine
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Question 13
Correct
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A 54-year-old female presents with a five day history of fever, cough and malaise. She recently returned from a holiday in southern Spain and has since developed a non-productive cough with chills that have worsened. The patient has a history of smoking 10 cigarettes per day but no other medical history. On examination, she has a temperature of 40°C, blood pressure of 118/72 mmHg, and a pulse of 106 bpm. Chest examination reveals inspiratory crackles at the left base only, with a respiratory rate of 28/min. Baseline investigations show haziness at the left base on CXR, Hb 128 g/L (115-165), WCC 5.5 ×109/L (4-11), Platelets 210 ×109/L (150-400), Sodium 130 mmol/L (137-144), Potassium 3.8 mmol/L (3.5-4.9), Creatinine 100 µmol/L (60-110), Urea 5.2 mmol/L (2.5-7.5), and Glucose 5.5 mmol/L (3.0-6.0). What is the most likely diagnosis?
Your Answer: Legionnaires disease
Explanation:Legionnaires Disease: A Community-Acquired Pneumonia
This patient’s medical history and symptoms suggest that they have contracted a community-acquired pneumonia. However, despite the obvious infection, their white cell count appears relatively normal, indicating that they may have an atypical pneumonia. Further investigation reveals that the patient recently traveled to Spain and is experiencing hyponatremia, which are both indicative of Legionnaires disease. This disease is caused by the Legionella pneumophila organism and is typically spread through infected water supplies, such as air conditioning systems.
To diagnose Legionnaires disease, doctors typically look for the presence of urinary antigen before any rise in serum antibody titres. Fortunately, the organism is sensitive to macrolides and ciprofloxacin, which can be used to treat the disease. Overall, it is important for doctors to consider Legionnaire’s disease as a potential cause of community-acquired pneumonia, especially in patients with a recent history of travel and hyponatremia.
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This question is part of the following fields:
- Emergency Medicine
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Question 14
Incorrect
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A 27-year-old soccer player suddenly collapses during a game. He is immediately taken to the Emergency department where he is diagnosed with ventricular tachycardia. Despite successful defibrillation, he experiences a recurrence of ventricular tachycardia and unfortunately passes away after prolonged resuscitation. The 12 lead ECG taken after resuscitation reveals left ventricular hypertrophy. What is the probable diagnosis?
Your Answer: Cocaine intoxication
Correct Answer: Hypertrophic cardiomyopathy
Explanation:Hypertrophic Cardiomyopathy and its ECG Findings
Hypertrophic cardiomyopathy (HCM) is a possible cause of sudden arrhythmia in a young, previously healthy individual. It is recommended that relatives of the patient be screened for the condition. Most patients with HCM have an abnormal resting electrocardiogram (ECG), which may show left ventricular hypertrophy, ST changes, T-wave inversion, right or left axis deviation, conduction abnormalities, sinus bradycardia with ectopic atrial rhythm, and atrial enlargement. Ambulatory ECG monitoring can reveal atrial and ventricular ectopics, sinus pauses, intermittent or variable atrioventricular block, and non-sustained arrhythmias. However, the ECG findings do not necessarily correlate with prognosis. Arrhythmias associated with HCM include premature ventricular complexes, non-sustained ventricular tachycardia, and supraventricular tachyarrhythmias. Atrial fibrillation occurs in about 20% of cases and is linked to an increased risk of fatal cardiac failure. Drug abuse is not a likely cause, and aortic stenosis is rare without congenital or rheumatic heart disease. Myocardial infarction and massive pulmonary embolism would have distinct ECG changes.
In summary, HCM is a possible cause of sudden arrhythmia in young, previously healthy individuals. ECG findings may include left ventricular hypertrophy, ST changes, T-wave inversion, and various arrhythmias. Atrial fibrillation is a common complication and is associated with an increased risk of fatal cardiac failure. Relatives of the patient should be screened for the condition.
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This question is part of the following fields:
- Emergency Medicine
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Question 15
Incorrect
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A 25-year-old homosexual male has tested positive for both IgM anti-HBc antibody and hepatitis B surface antigens. What is his current disease state?
Your Answer:
Correct Answer: Acutely infected
Explanation:Hepatitis B and its Markers
Hepatitis B surface antigen is a marker that indicates the presence of the hepatitis B virus in the cells of the host. This marker is present in both chronic and acute infections. Patients infected with hepatitis B will produce antibodies to the core antigen. IgM antibodies are indicative of acute infection and are not present in chronic infections. On the other hand, IgG antibodies to the core antigen are present even after the infection has been cleared.
Antibodies to the surface antigen are produced in individuals who have been vaccinated against hepatitis B. This confers natural immunity once the infection has been cleared. the markers of hepatitis B is crucial in diagnosing and managing the infection. It is important to note that chronic hepatitis B can lead to serious liver damage and even liver cancer if left untreated. Therefore, early detection and treatment are essential in preventing complications.
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This question is part of the following fields:
- Emergency Medicine
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Question 16
Incorrect
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A 68-year-old man arrives at the emergency department with a 24-hour history of epigastric pain that radiates to his back and vomiting. The doctors diagnose him with pancreatitis after his serum amylase levels come back at 2000. They also run some additional blood tests and find the following results:
- WCC: 22 ×109/L (Neutrophils: 17.2)
- Hb: 155 g/L
- Urea: 18.2 mmol/L
- Creatinine: 105 μmol/L
- AST: 250 IU
- LDH: 654 IU
- Calcium: 2.3 mmol/L
- Albumin: 38 g/L
- Glucose: 7.5 mmol/L
- PaO2: 9.9 KPa
What is the Modified Glasgow score for this patient?Your Answer:
Correct Answer: 4
Explanation:Glasgow Score as a Predictor of Pancreatitis Severity
The Glasgow score is a tool used to predict the severity of pancreatitis. It is based on several factors, which can be remembered using the mnemonic PANCREAS. These factors include low PaO2 levels, age over 55 years, high neutrophil count, low calcium levels, impaired renal function, elevated enzymes such as AST and LDH, low albumin levels, and high blood sugar levels. Each factor is assigned a certain number of points, and the total score can help determine the severity of the pancreatitis.
For example, a patient who is over 55 years old, has high neutrophil count, impaired renal function, and elevated enzymes would score a total of 4 points. The higher the score, the more severe the pancreatitis is likely to be. UK guidelines recommend that a severity score be calculated for every patient with acute pancreatitis to help guide their management and treatment.
In summary, the Glasgow score is a useful tool for predicting the severity of pancreatitis based on several factors. By calculating a patient’s score, healthcare providers can better manage and treat their condition.
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This question is part of the following fields:
- Emergency Medicine
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Question 17
Incorrect
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A 65-year-old man experiences a bout of memory loss. He had a moment of confusion three days prior, during which his wife guided him inside and offered him tea. Despite being conscious and able to converse with his wife, he wandered around the house in a confused state and repeatedly asked the same questions. After three hours, he suddenly returned to his normal state and had no memory of the incident. What is the probable diagnosis?
Your Answer:
Correct Answer: Transient global amnesia
Explanation:Transient Global Amnesia: A Brief Overview
Transient global amnesia is a rare condition that typically occurs in individuals over the age of 50. It is characterized by a temporary lack of blood flow to both hippocampi, resulting in a loss of memory function. Despite this, individuals retain their personal identity and cognitive abilities. The episode typically lasts less than 24 hours and is not associated with any long-term effects.
In summary, transient global amnesia is a temporary condition that affects memory function due to a lack of blood flow to the hippocampi.
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This question is part of the following fields:
- Emergency Medicine
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Question 18
Incorrect
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A 56-year-old woman who underwent Hartmann’s procedure six hours ago has started to complain of abdominal pain and light-headedness. On assessment, she has a blood pressure of 80/40 mmHg, a heart rate of 120 bpm, a respiratory rate of 22 breaths per minute, oxygen saturations of 98% and a temperature of 36.7 °C. She appears drowsy and pale, and the radial pulse is difficult to detect. Her abdomen appears rigid and is painful to palpate, and a bleed is suspected.
What type of shock is this patient most likely to have?Your Answer:
Correct Answer: Hypovolaemic
Explanation:Types of Shock and their Causes
Shock is a medical emergency that occurs when the body’s organs and tissues do not receive enough oxygen and nutrients. There are different types of shock, each with its own causes and symptoms.
Hypovolaemic shock is caused by a significant loss of blood volume, usually more than 20%. This can occur due to trauma, surgery, or internal bleeding. Symptoms include low blood pressure, rapid heartbeat, and confusion. Treatment involves urgent fluid resuscitation and surgical intervention.
Anaphylactic shock is an allergic reaction to a substance, such as medication, food, or insect venom. Symptoms include swelling of the face and throat, hives, and difficulty breathing. Treatment involves administering epinephrine and seeking emergency medical care.
Cardiogenic shock occurs when the heart is unable to pump enough blood to meet the body’s needs. This can occur after a heart attack or other cardiac event. Symptoms include low blood pressure, rapid heartbeat, and shortness of breath. Treatment involves addressing the underlying cardiac issue and providing supportive care.
Neurogenic shock occurs due to damage to the central nervous system or spinal cord. Symptoms include low blood pressure, slow heartbeat, and warm skin. Treatment involves stabilizing the spine and providing supportive care.
Septic shock occurs as a result of a severe infection that spreads throughout the body. Symptoms include fever, low blood pressure, and confusion. Treatment involves administering antibiotics and providing supportive care.
In conclusion, recognizing the type of shock a patient is experiencing is crucial for providing appropriate and timely treatment.
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This question is part of the following fields:
- Emergency Medicine
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Question 19
Incorrect
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A 20-year old woman arrives at the Emergency department after a night out with her friends. According to her friends, she has been talking to herself about nonsensical things and appears agitated and restless. During the examination, it is noted that her reflexes are heightened and an electrocardiogram (ECG) reveals ventricular ectopics. What type of substance abuse is suspected in this case?
Your Answer:
Correct Answer: Ecstasy
Explanation:Ecstasy Overdose
Ecstasy, also known as MDMA, is a drug that stimulates the central nervous system. It can cause increased alertness, euphoria, extroverted behavior, and rapid speech. People who take ecstasy may also experience a lack of desire to eat or sleep, tremors, dilated pupils, tachycardia, and hypertension. However, more severe intoxication can lead to excitability, agitation, paranoid delusions, hallucinations, hypertonia, and hyperreflexia. In some cases, convulsions, rhabdomyolysis, hyperthermia, and cardiac arrhythmias may also develop.
Severe cases of MDMA poisoning can result in hyperthermia, disseminated intravascular coagulation, rhabdomyolysis, acute renal failure, hyponatremia, and even hepatic damage. In rare cases, amphetamine poisoning may lead to intracerebral and subarachnoid hemorrhage and acute cardiomyopathy, which can be fatal. Chronic amphetamine users may also experience hyperthyroxinemia.
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This question is part of the following fields:
- Emergency Medicine
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Question 20
Incorrect
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Which of the following is the least likely to worsen bronchospasm in severe asthma?
Your Answer:
Correct Answer: Alfentanil
Explanation:Safe and Unsafe Medications for Asthmatics
Alfentanil is a type of painkiller that belongs to the opioid family. It is commonly used during the induction of anesthesia and is considered safe for asthmatics. Adenosine, on the other hand, is a medication that can cause wheezing and bronchospasm, making it unsuitable for asthmatics. It can also cause other unpleasant side effects and is therefore contraindicated.
Diclofenac is a non-steroidal anti-inflammatory drug (NSAID) that should not be given to patients with a history of asthma or those whose symptoms have worsened following aspirin. This is because it can trigger an asthma attack and worsen the symptoms. Labetalol, a beta-blocker, is also contraindicated for asthmatics.
Morphine is another medication that should be used with caution in asthmatics. It can release histamine, which can make bronchospasm worse.
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This question is part of the following fields:
- Emergency Medicine
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Question 21
Incorrect
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A known case of chronic obstructive pulmonary disease (COPD) presents to the Emergency department, distressed and cyanosed. Arterial blood gases reveal pH 7.2 (7.36-7.44), PaO2 8.3 kPa (11.3-12.6 kPa), PaCO2 10 kPa (4.7-6.0 kPa). The patient, who is in his 60s, is given high concentration oxygen together with a salbutamol nebuliser and intravenous hydrocortisone. Despite these interventions, the patient's breathing effort worsens, although pulse oximetry showed SaO2 of 93%. What could be the reason for the patient's deterioration?
Your Answer:
Correct Answer: High concentration oxygen administration
Explanation:The Dangers of High Concentration Oxygen for COPD Patients
The patient’s acute exacerbation of COPD had led to hypoxia and hypercapnia. Due to the nature of his condition, his respiratory centre was only stimulated by hypoxia. As a result, when he was given high concentration oxygen, his respiratory effort decreased and his condition worsened. This is because the high concentration of oxygen deprived him of the hypoxic drive that was necessary to stimulate his respiratory centre. Therefore, it is important to be cautious when administering oxygen to COPD patients, as high concentrations can have dangerous consequences. Proper monitoring and management of oxygen levels can help prevent exacerbations and improve patient outcomes.
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This question is part of the following fields:
- Emergency Medicine
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Question 22
Incorrect
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A 35-year-old female smoker presents with acute severe asthma.
The patient's SaO2 levels are at 91% even with 15 L of oxygen, and her pO2 is at 8.2 kPa (10.5-13). There is widespread expiratory wheezing throughout her chest.
The medical team administers IV hydrocortisone, 100% oxygen, and 5 mg of nebulised salbutamol and 500 micrograms of nebulised ipratropium, but there is little response. Nebulisers are repeated 'back-to-back,' but the patient remains tachypnoeic with wheezing, although there is good air entry.
What should be the next step in the patient's management?Your Answer:
Correct Answer: IV Magnesium
Explanation:Acute Treatment of Asthma
When dealing with acute asthma, the initial approach should be SOS, which stands for Salbutamol, Oxygen, and Steroids (IV). It is also important to organize a CXR to rule out pneumothorax. If the patient is experiencing bronchoconstriction, further efforts to treat it should be considered. If the patient is tiring or has a silent chest, ITU review may be necessary. Magnesium is recommended at a dose of 2 g over 30 minutes to promote bronchodilation, as low magnesium levels in bronchial smooth muscle can favor bronchoconstriction. IV theophylline may also be considered, but magnesium is typically preferred. While IV antibiotics may be necessary, promoting bronchodilation should be the initial focus. IV potassium may also be required as beta agonists can push down potassium levels. Oral prednisolone can wait, as IV hydrocortisone is already part of the SOS approach. Non-invasive ventilation is not recommended for the acute management of asthma.
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This question is part of the following fields:
- Emergency Medicine
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Question 23
Incorrect
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A 50-year-old man with a history of intravenous drug use presents with abnormal blood results. His test results show Hepatitis B surface antigen positive, IgG Anti-HBc antibody positive, IgM Anti-HBc antibody negative, and Anti-Hepatitis B surface antibody negative. What is the most likely diagnosis for this patient?
Your Answer:
Correct Answer: Chronically infected with hepatitis B
Explanation:Hepatitis B Surface Antigen and Antibodies
The presence of hepatitis B surface antigen (HBsAg) indicates the presence of the hepatitis B virus in the host’s cells, whether it is an acute or chronic infection. All patients infected with hepatitis B will produce antibodies to the core antigen. IgM antibodies are markers of acute infection and will no longer be present in chronic infection. On the other hand, IgG antibodies to the core antigen remain present even after the infection has been cleared.
Antibodies to the surface antigen develop in vaccinated individuals, providing natural immunity once the infection has cleared. If a patient has developed antibodies to HBsAg, they would be HBsAg negative and would not be a hepatitis B chronic carrier. the presence and absence of these antigens and antibodies is crucial in diagnosing and managing hepatitis B infections.
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This question is part of the following fields:
- Emergency Medicine
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Question 24
Incorrect
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A 47-year-old man with HIV and a CD4 count of 46 is found to have 'owl's eye' inclusion bodies on histological tissue staining. Which virus is this finding suggestive of?
Your Answer:
Correct Answer: Cytomegalovirus
Explanation:CMV and Hodgkin’s Lymphoma
CMV is a virus that typically affects individuals with a weakened immune system. While a CD4 count of less than 400 is often used as a threshold for diagnosis, CMV disease is rare in HIV-positive patients unless their CD4 count drops below 50. A positive PCR result can confirm a diagnosis of CMV, which should be treated with ganciclovir. On the other hand, Hodgkin’s lymphoma is a type of cancer that is characterized by the presence of Reed-Sternberg cells, which have a distinct owl’s eye appearance.
In summary, CMV and Hodgkin’s lymphoma are two distinct medical conditions that require different approaches to diagnosis and treatment. While CMV is an opportunistic virus that affects immunocompromised individuals, Hodgkin’s lymphoma is a type of cancer that can affect anyone. By the key differences between these two conditions, healthcare professionals can provide more effective care to their patients.
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This question is part of the following fields:
- Emergency Medicine
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Question 25
Incorrect
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You are summoned to an emergency on the orthopaedic ward where a 75-year-old male has been discovered unconscious by nursing staff. He has recently undergone surgery for a fractured hip.
Upon examination, he is tachycardic with a blood pressure of 100/60 mmHg. His oxygen saturation was 90% on air, and the nursing staff have administered oxygen at 15 litres/minute. His respiratory rate is 5 breaths per minute, and his chest is clear. The abdomen is soft, and his Glasgow coma scale is 10/15. Pupils are equal, small, and unreactive, and he has flaccid limbs bilaterally.
What is the appropriate course of action?Your Answer:
Correct Answer: Urgent review of the drug chart
Explanation:Managing Opioid Toxicity in Post-Surgical Patients
When a patient exhibits symptoms of opioid toxicity, such as reduced consciousness, respiratory depression, and pinpoint pupils, it is important to review their treatment chart to confirm if they have received opiate analgesia following recent surgery. If confirmed, the patient should be prescribed naloxone to reverse the effects of the opioid and may require ventilatory support.
Opioid toxicity can be a serious complication in post-surgical patients, and prompt management is crucial to prevent further harm. It is important for healthcare providers to monitor patients closely for signs of opioid toxicity and to have a plan in place for managing it if it occurs. By being vigilant and prepared, healthcare providers can help ensure the safety and well-being of their patients.
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This question is part of the following fields:
- Emergency Medicine
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Question 26
Incorrect
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A 50-year-old runner experiences chest pain and collapses while jogging. He is brought to the Emergency department within an hour. Upon arrival, he is conscious and given a sublingual nitrate which provides some relief. His heart rate is 90 beats per minute and his blood pressure is 120/85 mmHg. An ECG reveals 3 mm of ST segment elevation in leads II, III, AVF, V5 and V6. What is the most appropriate next step in managing this patient?
Your Answer:
Correct Answer: Admission for cardiac catheterisation and percutaneous transluminal coronary angioplasty
Explanation:Initial and Long-Term Treatment for Inferolateral ST-Elevation MI
The patient’s history and ECG findings suggest that they are experiencing an Inferolateral ST-elevation MI. The best initial treatment for this condition would be percutaneous coronary intervention. It is likely that the patient would have already received aspirin in the ambulance.
For long-term treatment, the patient will require dual antiplatelet therapy, such as aspirin and clopidogrel, a statin, a beta blocker, and an ACE-inhibitor. These medications will help manage the patient’s condition and prevent future cardiac events.
It is important to follow the NICE guideline for Acute Coronary Syndrome to ensure that the patient receives the appropriate treatment and care. By following these guidelines, healthcare professionals can help improve the patient’s prognosis and quality of life.
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This question is part of the following fields:
- Emergency Medicine
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Question 27
Incorrect
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The following arterial blood gases (ABGs) were taken from an unconscious 50-year-old woman in the Emergency department on FiO2 of 21%:
pH 7.36 (7.36-7.44)
pO2 13.0 kPa (11.3-12.6)
pCO2 3.7 kPa (4.7-6.0)
HCO3− 15 mmol/L (20-28)
What is the correct interpretation of the ABG result?Your Answer:
Correct Answer: Compensated metabolic acidosis
Explanation:Interpretation of ABG Results
The pH and bicarbonate levels in the ABG results indicate the presence of acidosis. However, the low level of carbon dioxide suggests that it is more likely to be metabolic acidosis rather than respiratory acidosis. The body tries to compensate for the acidosis by increasing the respiratory rate, which helps to eliminate excess hydrogen ions as carbon dioxide. This compensation can also lead to high oxygen levels due to deep and rapid breathing. However, it is important to note that high oxygen levels may also be a result of oxygen therapy provided in the Emergency department. It is worth mentioning that delayed analysis of ABG samples can sometimes lead to inaccurate results, such as a falsely low pO2. However, there is no indication that this has occurred in this particular case.
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This question is part of the following fields:
- Emergency Medicine
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Question 28
Incorrect
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A 23-year-old gardener experiences a sudden onset of breathlessness and right-sided chest pain while tending to the plants. He is quickly taken to the hospital, but his condition deteriorates during the examination conducted by a junior doctor.
The doctor notes a deviated trachea to the left and very faint breath sounds over the right lung. However, with the assistance of a senior doctor, the patient's condition improves rapidly.
What is the likely diagnosis for this patient?Your Answer:
Correct Answer: Tension pneumothorax
Explanation:Recognizing and Treating Tension Pneumothorax
Sudden chest pain and difficulty breathing in a previously healthy young man may indicate the presence of pneumothorax. It is important to be able to recognize and treat a tension pneumothorax if it occurs during a physical examination. There are many stories of patients developing tension pneumothorax while in the hospital, so it is crucial to be prepared.
The treatment for tension pneumothorax involves needle thoracocentesis in the second intercostal space. It is not necessary to obtain a chest X-ray before performing this procedure.
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This question is part of the following fields:
- Emergency Medicine
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Question 29
Incorrect
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A 65-year-old man with lung cancer was admitted to the Emergency department due to respiratory distress. Upon examination, his ECG revealed electrical alternans. What is the most probable diagnosis for this patient?
Your Answer:
Correct Answer: Cardiac tamponade
Explanation:Pericardial Tamponade: Commonly Caused by Malignant Diseases
Pericardial tamponade is a condition where the pericardium, the sac surrounding the heart, becomes filled with fluid or blood, putting pressure on the heart and preventing it from functioning properly. Malignant diseases are the most common cause of pericardial tamponade, often resulting from malignant infiltration associated with a large effusion. However, tamponade can also occur as a result of any type of pericarditis.
When pericardial tamponade occurs, the heart is unable to pump blood effectively, leading to symptoms such as shortness of breath, chest pain, and low blood pressure. Diagnosis is typically made through imaging tests such as echocardiography or CT scans.
On an electrocardiogram (ECG), sinus tachycardia, low volume, and electrical alternans – variability of the complexes – are often observed. Treatment for pericardial tamponade typically involves draining the fluid or blood from the pericardium, either through a needle or a surgical procedure. In severe cases, emergency surgery may be necessary to prevent further damage to the heart.
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This question is part of the following fields:
- Emergency Medicine
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Question 30
Incorrect
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A 75-year-old widower is brought to the Emergency department after being found collapsed at home. His wife passed away recently and he has been struggling with depression. He has a history of stable angina and takes atenolol for it.
During the examination, his blood pressure is 80/35 mmHg and he is bradycardic. His first and second heart sounds are audible, his oxygen saturation is 95%, and his chest is clear. The cardiac monitor shows a heart rate of 20 beats per minute, and the ECG shows a junctional escape rhythm without changes of ischaemia.
What would be the most appropriate initial intervention?Your Answer:
Correct Answer: 0.5 mg intravenous atropine
Explanation:Management of Beta-Blocker Overdose
In cases of beta-blocker overdose, a profound bradycardia may occur. The initial intervention should be intravenous atropine. If this proves ineffective, intravenous glucagon can be administered, followed by an infusion of 50 mcg/kg/hour. If glucagon is unavailable, IV isoprenaline can be used as an alternative. In refractory cases, a transvenous temporary cardiac pacemaker may be necessary. However, intravenous insulin is not recommended in this situation. It is important to promptly manage beta-blocker overdose to prevent potentially life-threatening complications.
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This question is part of the following fields:
- Emergency Medicine
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