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Question 1
Correct
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A 14-year-old girl comes in with a sudden onset of a painful throat that has been bothering her for the past day. She denies having a cough or any symptoms of a cold. During the examination, her temperature is measured at 38.5°C, and there is visible exudate on her right tonsil, which also appears to be swollen. No anterior cervical lymph nodes can be felt. What is her score on the Centor Clinical Prediction Score for assessing her sore throat?
Your Answer: 3
Explanation:There are two scoring systems that NICE recommends for assessing sore throat: the Centor Clinical Prediction Score and the FeverPAIN Score.
The Centor Clinical Prediction Score was initially developed as a tool to determine the likelihood of a group A beta-haemolytic Streptococcus (GABHS) infection in adults with a sore throat. This score was created and tested in US Emergency Departments, specifically for adult patients.
The Centor score evaluates patients based on several criteria, with one point given for each positive criterion. These criteria include a history of fever (temperature above 38°C), the presence of exudate or swelling on the tonsils, tender or swollen anterior cervical lymph nodes, and the absence of cough.
According to the current NICE guidance, the Centor score can be used to guide management in the following way:
– A score of 0 to 2 indicates a 3-17% likelihood of streptococcus isolation, and antibiotics are not recommended.
– A score of 3 to 4 indicates a 32-56% likelihood of streptococcus isolation, and immediate treatment with empirical antibiotics or a backup prescription should be considered.By utilizing these scoring systems, healthcare professionals can make more informed decisions regarding the management and treatment of patients with sore throat.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 2
Incorrect
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You evaluate a 35-year-old male patient who has been diagnosed with an anal fissure. He has been undergoing treatment for the last two months, which includes lactulose, senna, topical creams with local anesthetics, and topical GTN ointment. However, his symptoms continue to persist, and he describes the pain during bowel movements as intolerable.
What would be the most suitable next step in managing this patient's condition?Your Answer: Topical diltiazem
Correct Answer: Botulinum toxin injection
Explanation:An anal fissure is a tear in the wall of the anal mucosa that exposes the circular muscle layer. The majority of these tears occur in the posterior midline. The most common cause is the passage of a large, hard stool after a period of constipation. If multiple fissures are present, it may indicate an underlying condition such as Crohn’s disease or tuberculosis.
Both men and women are equally affected by anal fissures, and they are most commonly seen in individuals in their thirties. The typical symptoms of an anal fissure include intense, sharp pain during bowel movements, which can last up to an hour after passing stool. Additionally, there may be spots of bright red blood on the toilet paper when wiping, and a history of constipation.
The initial management of an anal fissure involves non-operative measures such as using stool softeners and bulking agents. To alleviate the intense anal pain, analgesics and topical local anesthetics may be prescribed. According to a recent meta-analysis, first-line therapy should involve the use of topical GTN or diltiazem, with botulinum toxin being used as a rescue treatment if necessary (Modern perspectives in the treatment of chronic anal fissures. Ann R Coll Surg Engl. 2007 Jul;89(5):472-8.)
Sphincterotomy, a surgical procedure, should be reserved for fissures that do not heal and has a success rate of 90%. Anal dilatation, also known as Lord’s procedure, is rarely used nowadays due to the high risk of subsequent fecal incontinence.
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This question is part of the following fields:
- Surgical Emergencies
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Question 3
Incorrect
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A 32-year-old woman was involved in a car accident where her car collided with a tree at a high speed. She was not wearing a seatbelt and was thrown forward onto the steering wheel of her car. She has bruising over her anterior chest wall and is experiencing chest pain. A helical contrast-enhanced CT scan of the chest reveals a traumatic aortic injury.
Where is her injury most likely to have occurred anatomically?Your Answer: Ascending aorta
Correct Answer: Proximal descending aorta
Explanation:Traumatic aortic rupture, also known as traumatic aortic disruption or transection, occurs when the aorta is torn or ruptured due to physical trauma. This condition often leads to sudden death because of severe bleeding. Motor vehicle accidents and falls from great heights are the most common causes of this injury.
The patients with the highest chances of survival are those who have an incomplete tear near the ligamentum arteriosum of the proximal descending aorta, close to where the left subclavian artery branches off. The presence of an intact adventitial layer or contained mediastinal hematoma helps maintain continuity and prevents immediate bleeding and death. If promptly identified and treated, survivors of these injuries can recover. In cases where traumatic aortic rupture leads to sudden death, approximately 50% of patients have damage at the aortic isthmus, while around 15% have damage in either the ascending aorta or the aortic arch.
Initial chest X-rays may show signs consistent with a traumatic aortic injury. However, false-positive and false-negative results can occur, and sometimes there may be no abnormalities visible on the X-ray. Some of the possible X-ray findings include a widened mediastinum, hazy left lung field, obliteration of the aortic knob, fractures of the 1st and 2nd ribs, deviation of the trachea to the right, presence of a pleural cap, elevation and rightward shift of the right mainstem bronchus, depression of the left mainstem bronchus, obliteration of the space between the pulmonary artery and aorta, and deviation of the esophagus or NG tube to the right.
A helical contrast-enhanced CT scan of the chest is the preferred initial investigation for suspected blunt aortic injury. It has proven to be highly accurate, with close to 100% sensitivity and specificity. CT scanning should be performed liberally, as chest X-ray findings can be unreliable. However, hemodynamically unstable patients should not be placed in a CT scanner. If the CT results are inconclusive, aortography or trans-oesophageal echo can be performed for further evaluation.
Immediate surgical intervention is necessary for these injuries. Endovascular repair is the most common method used and has excellent short-term outcomes. Open repair may also be performed depending on the circumstances. It is important to control heart rate and blood pressure during stabilization to reduce the risk of rupture. Pain should be managed with appropriate analgesic
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This question is part of the following fields:
- Trauma
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Question 4
Correct
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A 12-year-old boy comes in with complaints of double vision. He is holding his head tilted to the left-hand side. During the examination of his eye movements, it is observed that both eyes can look normally to the right, but on looking to the left, his left eye cannot turn outwards past the midline. The right eye is unaffected when looking to the left.
Which muscle is the MOST likely to be involved in this case?Your Answer: Lateral rectus
Explanation:This patient is experiencing a condition called right-sided abducens nerve palsy, which means that their sixth cranial nerve is paralyzed. As a result, the lateral rectus muscle, which is responsible for moving the eye outward, is also paralyzed. This means that the patient’s right eye is unable to turn outward. This can lead to a condition called convergent strabismus, where the eyes are not aligned properly, and diplopia, which is double vision. To compensate for the double vision, patients often tilt their head towards the side of the paralyzed muscle.
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This question is part of the following fields:
- Ophthalmology
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Question 5
Correct
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A 7-year-old girl presents with a 4-day history of blurred vision in her left eye. She is also experiencing eye pain and fatigue. On examination, her temperature is 38.0°C, but her other vital signs are normal. There is significant redness in the conjunctiva, and a collection of pus (hypopyon) is present in her left eye. Her visual acuity in that eye is reduced to counting fingers. She recently received a kitten as a pet from her parents.
What is the SINGLE most likely causative organism?Your Answer: Toxocara canis
Explanation:Toxocariasis is a rare infection caused by the parasitic roundworm Toxocara canis. The main way it spreads to humans is through contact with dog feces. However, practicing good hand hygiene can help prevent transmission. While most people who come into contact with Toxocara canis don’t show any symptoms, a small number may experience a mild flu-like illness.
The most common presentation of toxocariasis is in children, who may experience unilateral visual loss. This loss of vision is typically caused by conditions such as vitritis, macular edema, and tractional retinal detachment. It is believed that these lesions occur due to a toxic or immunoallergic reaction to the larval antigens.
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This question is part of the following fields:
- Ophthalmology
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Question 6
Incorrect
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A 65-year-old woman comes in with right-sided weakness and difficulty speaking. Her ROSIER score is 3. She weighs 60 kg.
What is the appropriate dosage of alteplase to give?Your Answer: 50 mg
Correct Answer: 63mg
Explanation:Alteplase (rt-pA) is recommended for the treatment of acute ischaemic stroke in adults if it is administered as soon as possible within 4.5 hours of the onset of stroke symptoms. It is important to exclude intracranial haemorrhage through appropriate imaging techniques before starting the treatment. The initial dose of alteplase is 0.9 mg/kg, with a maximum dose of 90 mg. This dose should be given intravenously over a period of 60 minutes. The first 10% of the dose should be administered through intravenous injection, while the remaining dose should be given through intravenous infusion. For a patient weighing 70 kg, the recommended dose would be 63 mg. For more information, please refer to the NICE guidelines on stroke and transient ischaemic attack in individuals over 16 years old.
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This question is part of the following fields:
- Neurology
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Question 7
Incorrect
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A 28-year-old woman has been involved in a physical altercation outside a bar. She has been hit multiple times in the face and has a noticeable swelling on her right cheek. Her facial X-ray shows a zygomaticomaxillary complex fracture but no other injuries.
Which of the following will NOT be visible on her X-ray?Your Answer: Fracture of the posterior maxillary sinus
Correct Answer: Fracture of the superior orbital rim
Explanation:Zygomaticomaxillary complex fractures, also known as quadramalar or tripod fractures, make up around 40% of all midface fractures and are the second most common facial bone fractures after nasal bone fractures.
These injuries typically occur when a direct blow is delivered to the malar eminence of the cheek. They consist of four components:
1. Widening of the zygomaticofrontal suture
2. Fracture of the zygomatic arch
3. Fracture of the inferior orbital rim and the walls of the anterior and posterior maxillary sinuses
4. Fracture of the lateral orbital rim. -
This question is part of the following fields:
- Maxillofacial & Dental
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Question 8
Correct
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A 45 year old male is brought into the emergency department by a family member with a 2 day history of nausea and vomiting. On initial assessment the patient appears disoriented. Observations reveal the patient to have a heart rate of 140 beats per minute and blood pressure of 90/60 mmHg. You contemplate the possibility of Addison's disease. What is the primary cause of Addison's disease in the United Kingdom?
Your Answer: Autoimmune adrenalitis
Explanation:Addison’s disease is primarily caused by tuberculosis, making it the most prevalent factor worldwide.
Further Reading:
Addison’s disease, also known as primary adrenal insufficiency or hypoadrenalism, is a rare disorder caused by the destruction of the adrenal cortex. This leads to reduced production of glucocorticoids, mineralocorticoids, and adrenal androgens. The deficiency of cortisol results in increased production of adrenocorticotropic hormone (ACTH) due to reduced negative feedback to the pituitary gland. This condition can cause metabolic disturbances such as hyperkalemia, hyponatremia, hypercalcemia, and hypoglycemia.
The symptoms of Addison’s disease can vary but commonly include fatigue, weight loss, muscle weakness, and low blood pressure. It is more common in women and typically affects individuals between the ages of 30-50. The most common cause of primary hypoadrenalism in developed countries is autoimmune destruction of the adrenal glands. Other causes include tuberculosis, adrenal metastases, meningococcal septicaemia, HIV, and genetic disorders.
The diagnosis of Addison’s disease is often suspected based on low cortisol levels and electrolyte abnormalities. The adrenocorticotropic hormone stimulation test is commonly used for confirmation. Other investigations may include adrenal autoantibodies, imaging scans, and genetic screening.
Addisonian crisis is a potentially life-threatening condition that occurs when there is an acute deficiency of cortisol and aldosterone. It can be the first presentation of undiagnosed Addison’s disease. Precipitating factors of an Addisonian crisis include infection, dehydration, surgery, trauma, physiological stress, pregnancy, hypoglycemia, and acute withdrawal of long-term steroids. Symptoms of an Addisonian crisis include malaise, fatigue, nausea or vomiting, abdominal pain, fever, muscle pains, dehydration, confusion, and loss of consciousness.
There is no fixed consensus on diagnostic criteria for an Addisonian crisis, as symptoms are non-specific. Investigations may include blood tests, blood gas analysis, and septic screens if infection is suspected. Management involves administering hydrocortisone and fluids. Hydrocortisone is given parenterally, and the dosage varies depending on the age of the patient. Fluid resuscitation with saline is necessary to correct any electrolyte disturbances and maintain blood pressure. The underlying cause of the crisis should also be identified and treated. Close monitoring of sodium levels is important to prevent complications such as osmotic demyelination syndrome.
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This question is part of the following fields:
- Endocrinology
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Question 9
Correct
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A 40-year-old man is brought to the Emergency Department by his wife following taking an overdose of one of his prescribed medications. Upon further questioning, you discover that he has taken an overdose of quetiapine. You discuss the case with your consultant, and she explains that the clinical features of this type of poisoning are due to central and peripheral acetylcholine receptor blockade.
Which of the following clinical effects occurs as a result of peripheral acetylcholine receptor blockade?Your Answer: Mydriasis
Explanation:Anticholinergic drugs work by blocking the effects of acetylcholine, a neurotransmitter, in both the central and peripheral nervous systems. These drugs are commonly used in clinical practice and include antihistamines, typical and atypical antipsychotics, anticonvulsants, antidepressants, antispasmodics, antiemetics, antiparkinsonian agents, antimuscarinics, and certain plants. When someone ingests an anticholinergic drug, they may experience a toxidrome, which is characterized by an agitated delirium and various signs of acetylcholine receptor blockade in the central and peripheral systems.
The central effects of anticholinergic drugs result in an agitated delirium, which is marked by fluctuating mental status, confusion, restlessness, visual hallucinations, picking at objects in the air, mumbling, slurred speech, disruptive behavior, tremor, myoclonus, and in rare cases, coma or seizures. On the other hand, the peripheral effects can vary and may include dilated pupils, sinus tachycardia, dry mouth, hot and flushed skin, increased body temperature, urinary retention, and ileus.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 10
Correct
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You assess a 48-year-old woman who has experienced an anaphylactic reaction after mistakenly consuming peanuts in a dish at a Thai eatery. She has a history of hypertension, but her blood pressure is effectively managed with a daily dose of atenolol 50 mg and amlodipine 5 mg. You have given her two injections of IM adrenaline, but her condition continues to worsen.
Which of the following interventions is most likely to quickly improve her condition?Your Answer: IM glucagon
Explanation:Patients who are on beta-blockers may not respond effectively to adrenaline during anaphylaxis. Research conducted on animals and reported cases have indicated that glucagon can be utilized to counteract the effects of beta-blockade if initial adrenaline doses prove ineffective.
Although prednisolone and hydrocortisone can be beneficial later on, it typically takes 6-8 hours for them to take full effect. Therefore, they are unlikely to have any impact on the patient during the brief period it will take for the ambulance to arrive.
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This question is part of the following fields:
- Allergy
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Question 11
Correct
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A 65-year-old patient presents with nausea and vomiting and decreased urine output. He has only passed a small amount of urine in the last day, and he has noticeable swelling in his ankles. His blood tests show a sudden increase in his creatinine levels in the last 48 hours, leading to a diagnosis of acute kidney injury (AKI).
What is a potential cause of post-renal AKI?Your Answer: Papillary necrosis
Explanation:Acute kidney injury (AKI), previously known as acute renal failure, is a sudden decline in kidney function. This results in the accumulation of urea and other waste products in the body and disrupts the balance of fluids and electrolytes. AKI can occur in individuals with previously normal kidney function or those with pre-existing kidney disease, known as acute-on-chronic kidney disease. It is a relatively common condition, with approximately 15% of adults admitted to hospitals in the UK developing AKI.
The causes of AKI can be categorized into pre-renal, intrinsic renal, and post-renal factors. The majority of AKI cases that develop outside of healthcare settings are due to pre-renal causes, accounting for 90% of cases. These causes typically involve low blood pressure associated with conditions like sepsis and fluid depletion. Medications, particularly ACE inhibitors and NSAIDs, are also frequently implicated.
Pre-renal:
– Volume depletion (e.g., severe bleeding, excessive vomiting or diarrhea, burns)
– Oedematous states (e.g., heart failure, liver cirrhosis, nephrotic syndrome)
– Low blood pressure (e.g., cardiogenic shock, sepsis, anaphylaxis)
– Cardiovascular conditions (e.g., severe heart failure, arrhythmias)
– Renal hypoperfusion: NSAIDs, COX-2 inhibitors, ACE inhibitors or ARBs, abdominal aortic aneurysm
– Renal artery stenosis
– Hepatorenal syndromeIntrinsic renal:
– Glomerular diseases (e.g., glomerulonephritis, thrombosis, hemolytic-uremic syndrome)
– Tubular injury: acute tubular necrosis (ATN) following prolonged lack of blood supply
– Acute interstitial nephritis due to drugs (e.g., NSAIDs), infection, or autoimmune diseases
– Vascular diseases (e.g., vasculitis, polyarteritis nodosa, thrombotic microangiopathy, cholesterol emboli, renal vein thrombosis, malignant hypertension)
– EclampsiaPost-renal:
– Kidney stones
– Blood clot
– Papillary necrosis
– Urethral stricture
– Prostatic hypertrophy or malignancy
– Bladder tumor
– Radiation fibrosis
– Pelvic malignancy
– Retroperitoneal -
This question is part of the following fields:
- Nephrology
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Question 12
Correct
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A 42-year-old woman comes in with dysuria, fevers, rigors, and pain in her left loin. During the examination, she experiences tenderness over the left renal angle, and her temperature is 38.6°C. The triage nurse has already inserted a cannula, and a complete set of blood tests has been sent to the lab.
What is the SINGLE most probable diagnosis?Your Answer: Pyelonephritis
Explanation:This patient is displaying symptoms and signs that are consistent with a diagnosis of acute pyelonephritis. Additionally, they are showing signs of sepsis, which indicates a more serious illness or condition. Therefore, it would be advisable to admit the patient for inpatient treatment.
According to the recommendations from the National Institute for Health and Care Excellence (NICE), patients with pyelonephritis should be admitted if it is severe or if they exhibit any signs or symptoms that suggest a more serious condition, such as sepsis. Signs of sepsis include significant tachycardia, hypotension, or breathlessness, as well as marked signs of illness like impaired level of consciousness, profuse sweating, rigors, pallor, or significantly reduced mobility. A temperature greater than 38°C or less than 36°C is also indicative of sepsis.
NICE also advises considering referral or seeking specialist advice for individuals with acute pyelonephritis if they are significantly dehydrated or unable to take oral fluids and medicines, if they are pregnant, if they have a higher risk of developing complications due to known or suspected abnormalities of the genitourinary tract or underlying diseases like diabetes mellitus or immunosuppression, or if they have recurrent episodes of urinary tract infections (UTIs).
For non-pregnant women and men, the recommended choice of antibacterial therapy is as follows: oral first-line options include cefalexin, ciprofloxacin, or co-amoxiclav (taking into account local microbial resistance data), and trimethoprim if sensitivity is known. Intravenous first-line options are amikacin, ceftriaxone, cefuroxime, ciprofloxacin, or gentamicin if the patient is severely unwell or unable to take oral treatment. Co-amoxiclav may be used if given in combination or if sensitivity is known. Antibacterials may be combined if there are concerns about susceptibility or sepsis. For intravenous second-line options, it is recommended to consult a local microbiologist.
For pregnant women, the recommended choice of antibacterial therapy is cefalexin for oral first-line treatment. If the patient is severely unwell or unable to take oral treatment, cefuroxime is the recommended intravenous first-line option.
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This question is part of the following fields:
- Urology
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Question 13
Correct
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A 16 year old female arrives at the emergency department after falling off a skateboard. X-ray confirms a dislocated shoulder. She doesn't want her parents notified about the injury. You inform the patient that the shoulder will need to be reduced under sedation. After conversing with the patient, you are confident that she has comprehended the information provided and possesses the capacity to consent to treatment. What is the term used to describe a young person's ability to give consent for medical treatment?
Your Answer: Gillick competence
Explanation:Gillick competence is a legal concept that determines whether a child under the age of 16 has the ability to give consent for their own medical treatment, even without parental consent or knowledge. This term originated in England and Wales and is commonly used in medical law. On the other hand, Fraser guidelines are specifically applied to situations involving advice and treatment related to a young person’s sexual health and contraception.
Further Reading:
Patients have the right to determine what happens to their own bodies, and for consent to be valid, certain criteria must be met. These criteria include the person being informed about the intervention, having the capacity to consent, and giving consent voluntarily and freely without any pressure or undue influence.
In order for a person to be deemed to have capacity to make a decision on a medical intervention, they must be able to understand the decision and the information provided, retain that information, weigh up the pros and cons, and communicate their decision.
Valid consent can only be provided by adults, either by the patient themselves, a person authorized under a Lasting Power of Attorney, or someone with the authority to make treatment decisions, such as a court-appointed deputy or a guardian with welfare powers.
In the UK, patients aged 16 and over are assumed to have the capacity to consent. If a patient is under 18 and appears to lack capacity, parental consent may be accepted. However, a young person of any age may consent to treatment if they are considered competent to make the decision, known as Gillick competence. Parental consent may also be given by those with parental responsibility.
The Fraser guidelines apply to the prescription of contraception to under 16’s without parental involvement. These guidelines allow doctors to provide contraceptive advice and treatment without parental consent if certain criteria are met, including the young person understanding the advice, being unable to be persuaded to inform their parents, and their best interests requiring them to receive contraceptive advice or treatment.
Competent adults have the right to refuse consent, even if it is deemed unwise or likely to result in harm. However, there are exceptions to this, such as compulsory treatment authorized by the mental health act or if the patient is under 18 and refusing treatment would put their health at serious risk.
In emergency situations where a patient is unable to give consent, treatment may be provided without consent if it is immediately necessary to save their life or prevent a serious deterioration of their condition. Any treatment decision made without consent must be in the patient’s best interests, and if a decision is time-critical and the patient is unlikely to regain capacity in time, a best interest decision should be made. The treatment provided should be the least restrictive on the patient’s future choices.
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This question is part of the following fields:
- Safeguarding & Psychosocial Emergencies
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Question 14
Correct
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A 62 year old male is brought into the emergency department by concerned bystanders who witnessed the patient vomit blood outside a local bar. The patient is familiar to the department due to multiple alcohol-related visits in the past and has a previous diagnosis of alcohol-related liver cirrhosis. The patient experiences another episode of large volume bright red hematemesis shortly after arriving in the emergency department and is transferred to resus. The patient's initial vital signs are as follows:
Blood pressure: 98/70 mmHg
Pulse: 126 bpm
Respiration rate: 24 bpm
Temperature: 36.4ºC
Which of the following treatments should be administered as a priority?Your Answer: Terlipressin
Explanation:When a variceal bleed is suspected, it is important to start treatment with either terlipressin or somatostatin as soon as possible. These medications help control the bleeding and are typically continued for 3-5 days if variceal haemorrhage is confirmed. Additionally, an upper GI endoscopy may be performed to either band the varices or inject a sclerosing agent to stop the bleeding. If the bleeding is difficult to control, a Sengstaken-Blakemore tube may be inserted until further treatment can be administered. Once the bleeding is under control and the patient has been resuscitated, antibiotic prophylaxis should be prescribed. Ceftriaxone or fluoroquinolones are commonly used for this purpose. Proton pump inhibitors are not recommended unless there is a specific need for treating peptic ulcer disease. Beta blockers like carvedilol are used to prevent variceal bleeding but are not effective in treating active bleeding. Vitamin K is typically not used in the acute setting of variceal bleeding.
Further Reading:
Cirrhosis is a condition where the liver undergoes structural changes, resulting in dysfunction of its normal functions. It can be classified as either compensated or decompensated. Compensated cirrhosis refers to a stage where the liver can still function effectively with minimal symptoms, while decompensated cirrhosis is when the liver damage is severe and clinical complications are present.
Cirrhosis develops over a period of several years due to repeated insults to the liver. Risk factors for cirrhosis include alcohol misuse, hepatitis B and C infection, obesity, type 2 diabetes, autoimmune liver disease, genetic conditions, certain medications, and other rare conditions.
The prognosis of cirrhosis can be assessed using the Child-Pugh score, which predicts mortality based on parameters such as bilirubin levels, albumin levels, INR, ascites, and encephalopathy. The score ranges from A to C, with higher scores indicating a poorer prognosis.
Complications of cirrhosis include portal hypertension, ascites, hepatic encephalopathy, variceal hemorrhage, increased infection risk, hepatocellular carcinoma, and cardiovascular complications.
Diagnosis of cirrhosis is typically done through liver function tests, blood tests, viral hepatitis screening, and imaging techniques such as transient elastography or acoustic radiation force impulse imaging. Liver biopsy may also be performed in some cases.
Management of cirrhosis involves treating the underlying cause, controlling risk factors, and monitoring for complications. Complications such as ascites, spontaneous bacterial peritonitis, oesophageal varices, and hepatic encephalopathy require specific management strategies.
Overall, cirrhosis is a progressive condition that requires ongoing monitoring and management to prevent further complications and improve outcomes for patients.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 15
Correct
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A 35-year-old woman is brought in by ambulance following a car accident where her car was hit by a truck. She has sustained severe facial injuries and shows signs of airway obstruction. Her cervical spine is immobilized. The anesthesiologist has attempted to intubate her but is unsuccessful and decides to perform a surgical cricothyroidotomy.
Which of the following statements regarding surgical cricothyroidotomy is FALSE?Your Answer: It is the surgical airway of choice in patients under the age of 12
Explanation:A surgical cricothyroidotomy is a procedure performed in emergency situations to secure the airway by making an incision in the cricothyroid membrane. It is also known as an emergency surgical airway (ESA) and is typically done when intubation and oxygenation are not possible.
There are certain conditions in which a surgical cricothyroidotomy should not be performed. These include patients who are under 12 years old, those with laryngeal fractures or pre-existing or acute laryngeal pathology, individuals with tracheal transection and retraction of the trachea into the mediastinum, and cases where the anatomical landmarks are obscured due to trauma.
The procedure is carried out in the following steps:
1. Gathering and preparing the necessary equipment.
2. Positioning the patient on their back with the neck in a neutral position.
3. Sterilizing the patient’s neck using antiseptic swabs.
4. Administering local anesthesia, if time permits.
5. Locating the cricothyroid membrane, which is situated between the thyroid and cricoid cartilage.
6. Stabilizing the trachea with the left hand until it can be intubated.
7. Making a transverse incision through the cricothyroid membrane.
8. Inserting the scalpel handle into the incision and rotating it 90°. Alternatively, a haemostat can be used to open the airway.
9. Placing a properly-sized, cuffed endotracheal tube (usually a size 5 or 6) into the incision, directing it into the trachea.
10. Inflating the cuff and providing ventilation.
11. Monitoring for chest rise and auscultating the chest to ensure adequate ventilation.
12. Securing the airway to prevent displacement.Potential complications of a surgical cricothyroidotomy include aspiration of blood, creation of a false passage into the tissues, subglottic stenosis or edema, laryngeal stenosis, hemorrhage or hematoma formation, laceration of the esophagus or trachea, mediastinal emphysema, and vocal cord paralysis or hoarseness.
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This question is part of the following fields:
- Trauma
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Question 16
Correct
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A 50-year-old patient with a history of exhaustion and weariness has a complete blood count scheduled. The complete blood count reveals the presence of macrocytic anemia.
What is the most probable underlying diagnosis?Your Answer: Myeloproliferative disease
Explanation:Anaemia can be categorized based on the size of red blood cells. Microcytic anaemia, characterized by a mean corpuscular volume (MCV) of less than 80 fl, can be caused by various factors such as iron deficiency, thalassaemia, anaemia of chronic disease (which can also be normocytic), sideroblastic anaemia (which can also be normocytic), lead poisoning, and aluminium toxicity (although this is now rare and mainly affects haemodialysis patients).
On the other hand, normocytic anaemia, with an MCV ranging from 80 to 100 fl, can be attributed to conditions like haemolysis, acute haemorrhage, bone marrow failure, anaemia of chronic disease (which can also be microcytic), mixed iron and folate deficiency, pregnancy, chronic renal failure, and sickle-cell disease.
Lastly, macrocytic anaemia, characterized by an MCV greater than 100 fl, can be caused by factors such as B12 deficiency, folate deficiency, hypothyroidism, reticulocytosis, liver disease, alcohol abuse, myeloproliferative disease, myelodysplastic disease, and certain drugs like methotrexate, hydroxyurea, and azathioprine.
It is important to understand the different causes of anaemia based on red cell size as this knowledge can aid in the diagnosis and management of this condition.
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This question is part of the following fields:
- Haematology
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Question 17
Incorrect
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A 65-year-old patient comes in after a chronic overdose of digoxin. She complains of nausea, extreme fatigue, and overall feeling unwell.
What is the indication for using DigiFab in this patient?Your Answer: Recurrent seizures
Correct Answer: Significant gastrointestinal symptoms
Explanation:Digoxin-specific antibody (DigiFab) is an antidote used to counteract digoxin overdose. It is a purified and sterile preparation of digoxin-immune ovine Fab immunoglobulin fragments. These fragments are derived from healthy sheep that have been immunized with a digoxin derivative called digoxin-dicarboxymethoxylamine (DDMA). DDMA is a digoxin analogue that contains the essential cyclopentanoperhydrophenanthrene: lactone ring moiety coupled to keyhole limpet hemocyanin (KLH).
DigiFab has a higher affinity for digoxin compared to the affinity of digoxin for its sodium pump receptor, which is believed to be the receptor responsible for its therapeutic and toxic effects. When administered to a patient who has overdosed on digoxin, DigiFab binds to digoxin molecules, reducing the levels of free digoxin in the body. This shift in equilibrium away from binding to the receptors helps to reduce the cardiotoxic effects of digoxin. The Fab-digoxin complexes are then eliminated from the body through the kidney and reticuloendothelial system.
The indications for using DigiFab in cases of acute and chronic digoxin toxicity are summarized below:
Acute digoxin toxicity:
– Cardiac arrest
– Life-threatening arrhythmia
– Potassium level >5 mmol/l
– Ingestion of >10 mg of digoxin (in adults)
– Ingestion of >4 mg of digoxin (in children)
– Digoxin level >12 ng/mlChronic digoxin toxicity:
– Cardiac arrest
– Life-threatening arrhythmia
– Significant gastrointestinal symptoms
– Symptoms of digoxin toxicity in the presence of renal failure -
This question is part of the following fields:
- Pharmacology & Poisoning
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Question 18
Correct
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A 70-year-old male smoker presents with intense chest discomfort. His electrocardiogram (ECG) indicates an acute myocardial infarction, and he is immediately taken to the catheterization laboratory. Angiography reveals a blockage in the left anterior descending artery.
Which area of the heart is most likely affected in this scenario?Your Answer: Anteroseptal
Explanation:A summary of the vessels involved in different types of myocardial infarction, along with the corresponding ECG leads and the location of the infarction.
For instance, an anteroseptal infarction involving the left anterior descending artery is indicated by ECG leads V1-V3. Similarly, an anterior infarction involving the left anterior descending artery is indicated by leads V3-V4.
In cases of anterolateral infarctions, both the left anterior descending artery and the left circumflex artery are involved, and this is reflected in ECG leads V5-V6. An extensive anterior infarction involving the left anterior descending artery is indicated by leads V1-V6.
Lateral infarcts involving the left circumflex artery are indicated by leads I, II, aVL, and V6. Inferior infarctions, on the other hand, involve either the right coronary artery (in 80% of cases) or the left circumflex artery (in 20% of cases), and this is shown by leads II, III, and aVF.
In the case of a right ventricular infarction, the right coronary artery is involved, and this is indicated by leads V1 and V4R. Lastly, a posterior infarction involving the right coronary artery is shown by leads V7-V9.
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This question is part of the following fields:
- Cardiology
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Question 19
Incorrect
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A 45-year-old man comes to the clinic complaining of sudden pain in his left scrotum and fever for the past 5 days. Upon examination, the epididymis is swollen and tender, and the skin over the scrotum is red and warm. The pain is relieved when the scrotum is elevated. The patient has no known allergies to medications.
What is the most suitable treatment for this patient?Your Answer: Ceftriaxone plus doxycycline
Correct Answer: Ofloxacin
Explanation:Epididymo-orchitis refers to the inflammation of the epididymis and/or testicle. It typically presents with sudden pain, swelling, and inflammation in the affected area. This condition can also occur chronically, which means that the pain and inflammation last for more than six months.
The causes of epididymo-orchitis vary depending on the age of the patient. In men under 35 years old, the infection is usually sexually transmitted and caused by Chlamydia trachomatis or Neisseria gonorrhoeae. In men over 35 years old, the infection is usually non-sexually transmitted and occurs as a result of enteric organisms that cause urinary tract infections, with Escherichia coli being the most common. However, there can be some overlap between these groups, so it is important to obtain a thorough sexual history in all age groups.
Mumps should also be considered as a potential cause of epididymo-orchitis in the 15 to 30 age group, as mumps orchitis occurs in around 40% of post-pubertal boys with mumps.
While most cases of epididymo-orchitis are infective, non-infectious causes can also occur. These include genito-urinary surgery, vasectomy, urinary catheterization, Behcet’s disease, sarcoidosis, and drug-induced cases such as those caused by amiodarone.
Patients with epididymo-orchitis typically present with unilateral scrotal pain and swelling that develops relatively quickly. The affected testis will be tender to touch, and there is usually a palpable swelling of the epididymis that starts at the lower pole of the testis and spreads towards the upper pole. The testis itself may also be involved, and there may be redness and/or swelling of the scrotum on the affected side. Patients may experience fever and urethral discharge as well.
The most important differential diagnosis to consider is testicular torsion, which requires immediate medical attention within 6 hours of onset to save the testicle. Testicular torsion is more likely in men under the age of 20, especially if the pain is very severe and sudden. It typically presents around four hours after onset. In this case, the patient’s age, longer history of symptoms, and the presence of fever are more indicative of epididymo-orchitis.
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This question is part of the following fields:
- Urology
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Question 20
Incorrect
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Your hospital’s neurology department is currently evaluating the utility of a triple marker test for use in diagnosing patients with suspected stroke. The test will use brain natriuretic peptide (BNP), neuron-specific enolase (NSE), and S100B protein.
How long after a stroke do levels of glial fibrillary acidic protein (GFAP) start to increase?Your Answer: 8-12 hours
Correct Answer: 4-8 hours
Explanation:The timing of the initial rise, peak, and return to normality of various cardiac enzymes can serve as a helpful guide. Creatine kinase, the main cardiac isoenzyme, typically experiences an initial rise within 4-8 hours, reaches its peak at 18 hours, and returns to normal within 2-3 days. Myoglobin, which lacks specificity due to its association with skeletal muscle damage, shows an initial rise within 1-4 hours, peaks at 6-7 hours, and returns to normal within 24 hours. Troponin I, known for its sensitivity and specificity, exhibits an initial rise within 3-12 hours, reaches its peak at 24 hours, and returns to normal within 3-10 days. HFABP, or heart fatty acid binding protein, experiences an initial rise within 1.5 hours, peaks at 5-10 hours, and returns to normal within 24 hours. Lastly, LDH, predominantly found in cardiac muscle, shows an initial rise at 10 hours, peaks at 24-48 hours, and returns to normal within 14 days.
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This question is part of the following fields:
- Cardiology
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Question 21
Correct
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While handling a difficult case, you come across a situation where you believe you may have to violate patient confidentiality. You discuss the scenario with your supervisor.
Which ONE of the following is NOT an illustration of a circumstance where patient confidentiality can be breached?Your Answer: Informing the police of a patient’s prior cannabis usage
Explanation:Instances where confidentiality may be breached include situations where there is a legal obligation, such as informing the Health Protection Agency (HPA) about a notifiable disease. Another example is in legal cases where a judge requests information. Additionally, confidentiality may be breached when there is a risk to the public, such as potential terrorism or serious criminal activity. It may also be breached when there is a risk to others, such as when a patient expresses homicidal intent towards a specific individual. Cases relevant to statutory regulatory bodies, like informing the Driver and Vehicle Licensing Agency (DVLA) about a patient who continues to drive despite a restriction, may also require breaching confidentiality.
However, it is important to note that there are examples where confidentiality should not be breached. It is inappropriate to disclose a patient’s diagnosis to third parties without their consent, including the police, unless there is a serious threat to the public or an individual.
If you are considering breaching patient confidentiality, it is crucial to seek the patient’s consent first. If consent is refused, it is advisable to seek guidance from your local trust and your medical defense union.
For more information, you can refer to the General Medical Council (GMC) guidance on patient confidentiality.
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This question is part of the following fields:
- Safeguarding & Psychosocial Emergencies
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Question 22
Correct
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A 28-year-old woman is given an antibiotic while pregnant. As a result, the newborn is born with deafness in both ears.
Which antibiotic is most likely responsible for these abnormalities?Your Answer: Gentamicin
Explanation:Aminoglycosides have the ability to pass through the placenta and can lead to damage to the 8th cranial nerve in the fetus, resulting in permanent bilateral deafness.
ACE inhibitors, such as ramipril, can cause hypoperfusion, renal failure, and the oligohydramnios sequence if given in the 2nd and 3rd trimesters.
Aminoglycosides, like gentamicin, can cause ototoxicity and deafness in the fetus.
High doses of aspirin can lead to 1st trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) do not pose significant risks.
Benzodiazepines, including diazepam, when administered late in pregnancy, can result in respiratory depression and a neonatal withdrawal syndrome.
Calcium-channel blockers, if given in the 1st trimester, can cause phalangeal abnormalities. If given in the 2nd and 3rd trimesters, they can lead to fetal growth retardation.
Carbamazepine can cause hemorrhagic disease of the newborn and neural tube defects.
Chloramphenicol is associated with grey baby syndrome.
Corticosteroids, if given in the 1st trimester, may cause orofacial clefts.
Danazol, if given in the 1st trimester, can cause masculinization of the female fetuses genitals.
Finasteride should not be handled by pregnant women as crushed or broken tablets can be absorbed through the skin and affect male sex organ development.
Haloperidol, if given in the 1st trimester, may cause limb malformations. If given in the 3rd trimester, there is an increased risk of extrapyramidal symptoms in the neonate.
Heparin can lead to maternal bleeding and thrombocytopenia.
Isoniazid can cause maternal liver damage and neuropathy and seizures in the neonate.
Isotretinoin carries a high risk of teratogenicity, including multiple congenital malformations, spontaneous abortion, and intellectual disability.
Lithium, if given in the 1st trimester, poses a risk of fetal cardiac malformations.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 23
Correct
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A 52-year-old businessman returns from a visit to Los Angeles with difficulty breathing and chest pain that worsens with deep breaths. The results of his arterial blood gas (ABG) on room air are as follows:
pH: 7.48
pO2: 7.4 kPa
PCO2: 3.1 kPa
HCO3-: 24.5 mmol/l
Which ONE statement about his ABG is correct?Your Answer: He has a respiratory alkalosis
Explanation:Arterial blood gas (ABG) interpretation is crucial in evaluating a patient’s respiratory gas exchange and acid-base balance. While the normal values on an ABG may slightly vary between analysers, they generally fall within the following ranges: pH of 7.35 – 7.45, pO2 of 10 – 14 kPa, PCO2 of 4.5 – 6 kPa, HCO3- of 22 – 26 mmol/l, and base excess of -2 – 2 mmol/l.
In this particular case, the patient’s medical history raises concerns about a potential diagnosis of pulmonary embolism. The relevant ABG findings are as follows: significant hypoxia (indicating type 1 respiratory failure), elevated pH (alkalaemia), low PCO2, and normal bicarbonate levels. These findings suggest that the patient is experiencing primary respiratory alkalosis.
By analyzing the ABG results, healthcare professionals can gain valuable insights into a patient’s respiratory function and acid-base status, aiding in the diagnosis and management of various conditions.
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This question is part of the following fields:
- Respiratory
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Question 24
Correct
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A 28-year-old woman has been involved in a physical altercation outside a bar. She has been hit multiple times in the face and has a noticeable swelling on her right cheek. Her facial X-ray shows a zygomaticomaxillary complex fracture but no other injuries.
Which of the following will be visible on her X-ray?Your Answer: Fracture of the zygomatic arch
Explanation:Zygomaticomaxillary complex fractures, also known as quadramalar or tripod fractures, make up around 40% of all midface fractures and are the second most common facial bone fractures after nasal bone fractures.
These injuries typically occur when a direct blow is delivered to the malar eminence of the cheek. They consist of four components:
1. Widening of the zygomaticofrontal suture
2. Fracture of the zygomatic arch
3. Fracture of the inferior orbital rim and the walls of the anterior and posterior maxillary sinuses
4. Fracture of the lateral orbital rim. -
This question is part of the following fields:
- Maxillofacial & Dental
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Question 25
Correct
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You review a child with a history of autism who is currently experiencing severe communication difficulties. You attempt to engage in conversation with the child but find it challenging to comprehend their speech. Their language lacks coherence and seems to consist of random words and phrases.
Which ONE of the following communication disorders is the child displaying?Your Answer: Word salad
Explanation:A word salad refers to a jumbled or incomprehensible combination of seemingly arbitrary words and phrases. This phenomenon is frequently observed in individuals with schizophrenia and dementia.
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This question is part of the following fields:
- Mental Health
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Question 26
Incorrect
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A 70-year-old female smoker presents with intense chest discomfort. Her ECG indicates an acute myocardial infarction and she is immediately taken to the cath lab. Angiography reveals a blockage in the left anterior descending artery.
Which area of the heart is most likely affected in this scenario?Your Answer: Anteroseptal
Correct Answer: Right ventricle
Explanation:A summary of the vessels involved in different types of myocardial infarction, along with the corresponding ECG leads and the location of the infarction.
For instance, an anteroseptal infarction involving the left anterior descending artery is indicated by ECG leads V1-V3. Similarly, an anterior infarction involving the left anterior descending artery is indicated by leads V3-V4.
In cases of anterolateral infarctions, both the left anterior descending artery and the left circumflex artery are involved, and this is reflected in ECG leads V5-V6. An extensive anterior infarction involving the left anterior descending artery is indicated by leads V1-V6.
Lateral infarcts involving the left circumflex artery are indicated by leads I, II, aVL, and V6. Inferior infarctions, on the other hand, involve either the right coronary artery (in 80% of cases) or the left circumflex artery (in 20% of cases), and this is shown by leads II, III, and aVF.
In the case of a right ventricular infarction, the right coronary artery is involved, and this is indicated by leads V1 and V4R. Lastly, a posterior infarction involving the right coronary artery is shown by leads V7-V9.
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This question is part of the following fields:
- Cardiology
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Question 27
Correct
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A 52 year old female presents to the emergency department due to increasing confusion and restlessness over the past 48 hours. The patient's family inform you that she had complained of feeling anxious and having loose stools yesterday but had attributed it to the antibiotics prescribed by her dentist for a tooth infection a few days ago. It is important to note that the patient has a history of Graves disease. The patient's vital signs are as follows:
Blood pressure: 152/78 mmHg
Pulse: 128 bpm
Respiration rate: 24 bpm
Temperature: 39.8ºC
What is the most likely diagnosis?Your Answer: Thyroid storm
Explanation:Thyroid storm, also known as thyrotoxic crisis, is a rare and potentially life-threatening complication of hyperthyroidism. The most common cause of thyroid storm is infection. Please refer to the yellow box at the bottom of the notes for additional information on thyroid storm.
Further Reading:
The thyroid gland is an endocrine organ located in the anterior neck. It consists of two lobes connected by an isthmus. The gland produces hormones called thyroxine (T4) and triiodothyronine (T3), which regulate energy use, protein synthesis, and the body’s sensitivity to other hormones. The production of T4 and T3 is stimulated by thyroid-stimulating hormone (TSH) secreted by the pituitary gland, which is in turn stimulated by thyrotropin-releasing hormone (TRH) from the hypothalamus.
Thyroid disorders can occur when there is an imbalance in the production or regulation of thyroid hormones. Hypothyroidism is characterized by a deficiency of thyroid hormones, while hyperthyroidism is characterized by an excess. The most common cause of hypothyroidism is autoimmune thyroiditis, also known as Hashimoto’s thyroiditis. It is more common in women and is often associated with goiter. Other causes include subacute thyroiditis, atrophic thyroiditis, and iodine deficiency. On the other hand, the most common cause of hyperthyroidism is Graves’ disease, which is also an autoimmune disorder. Other causes include toxic multinodular goiter and subacute thyroiditis.
The symptoms and signs of thyroid disorders can vary depending on whether the thyroid gland is underactive or overactive. In hypothyroidism, common symptoms include weight gain, lethargy, cold intolerance, and dry skin. In hyperthyroidism, common symptoms include weight loss, restlessness, heat intolerance, and increased sweating. Both hypothyroidism and hyperthyroidism can also affect other systems in the body, such as the cardiovascular, gastrointestinal, and neurological systems.
Complications of thyroid disorders can include dyslipidemia, metabolic syndrome, coronary heart disease, heart failure, subfertility and infertility, impaired special senses, and myxedema coma in severe cases of hypothyroidism. In hyperthyroidism, complications can include Graves’ orbitopathy, compression of the esophagus or trachea by goiter, thyrotoxic periodic paralysis, arrhythmias, osteoporosis, mood disorders, and increased obstetric complications.
Myxedema coma is a rare and life-threatening complication of severe hypothyroidism. It can be triggered by factors such as infection or physiological insult and presents with lethargy, bradycardia, hypothermia, hypotension, hypoventilation, altered mental state, seizures and/or coma.
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This question is part of the following fields:
- Endocrinology
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Question 28
Correct
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A 45-year-old man with a long-standing history of type 2 diabetes mellitus complains of pain in his left buttock, hip, and thigh. The pain began abruptly a couple of months ago, and he cannot recall any previous injury. During the examination, you observe muscle wasting in his left quadriceps, struggles in standing up from a seated position, and an absent knee jerk on the left side. Additionally, you notice muscle fasciculations in his left thigh.
What is the SINGLE most probable diagnosis?Your Answer: Diabetic amyotrophy
Explanation:Diabetic amyotrophy, also referred to as proximal diabetic neuropathy, is the second most prevalent form of diabetic neuropathy. It typically begins with discomfort in the buttocks, hips, or thighs and is often initially experienced on one side. The pain may start off as mild and gradually progress or it can suddenly manifest, as seen in this case. Subsequently, weakness and wasting of the proximal muscles in the lower limbs occur, making it difficult for the patient to transition from sitting to standing without assistance. Reflexes in the affected areas can also be impacted. Good control of blood sugar levels, physiotherapy, and lifestyle adjustments can reverse diabetic amyotrophy.
Peripheral neuropathy is the most common type of diabetic neuropathy and typically manifests as pain or loss of sensation in the feet or hands.
Autonomic neuropathy leads to changes in digestion, bowel and bladder function, sexual response, and perspiration. It can also affect the cardiovascular system, resulting in rapid heart rates and orthostatic hypotension.
Focal neuropathy causes sudden weakness in a single nerve or group of nerves, resulting in pain, sensory loss, or muscle weakness. Any nerve in the body can be affected.
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This question is part of the following fields:
- Endocrinology
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Question 29
Incorrect
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A 5-year-old girl is brought to the Emergency Department by her parents. For the past two days, she has had severe diarrhea and vomiting. She has not passed urine so far today. She normally weighs 20 kg. On examination, she has sunken eyes and dry mucous membranes. She is tachycardic and tachypneic and has cool peripheries. Her capillary refill time is prolonged.
What is her estimated fluid loss?Your Answer: 2000 ml
Correct Answer: 3000 ml
Explanation:Generally speaking, if a child shows clinical signs of dehydration but does not exhibit shock, it can be assumed that they are 5% dehydrated. On the other hand, if shock is also present, it can be assumed that the child is 10% dehydrated or more. When a child is 5% dehydrated, it means that their body has lost 5 grams of fluid per 100 grams of body weight, which is equivalent to 50 ml of fluid per kilogram. In the case of 10% dehydration, the body has lost 100 ml of fluid per kilogram.
For example, if a child is 10% dehydrated and weighs 30 kilograms, their estimated fluid loss would be 100 ml/kg x 30 kg = 3000 ml.
The clinical features of dehydration and shock are summarized below:
Dehydration (5%):
– The child appears unwell
– Their heart rate may be normal or increased (tachycardia)
– Their respiratory rate may be normal or increased (tachypnea)
– Peripheral pulses are normal
– Capillary refill time (CRT) is normal or slightly prolonged
– Blood pressure is normal
– Extremities feel warm
– Urine output is decreased
– Skin turgor is reduced
– Eyes may appear sunken
– The fontanelle (soft spot on the baby’s head) may be depressed
– Mucous membranes are dryClinical shock (10%):
– The child appears pale, lethargic, and mottled
– Heart rate is increased (tachycardia)
– Respiratory rate is increased (tachypnea)
– Peripheral pulses are weak
– Capillary refill time (CRT) is prolonged
– Blood pressure is low (hypotension)
– Extremities feel cold
– Urine output is decreased
– Level of consciousness is decreased -
This question is part of the following fields:
- Nephrology
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Question 30
Incorrect
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You are reviewing a middle-aged woman who came into the department with abdominal pain. A diagnosis of a simple urinary tract infection has been made, and she will continue with a course of antibiotics at home. She lives at home by herself and has a neighbor who checks on her occasionally. She has mild anxiety, but has capacity and is keen to go back home. Her daughter stops you in the corridor and tells you that she doesn't want her mother to go home, but would like her to go to a rehabilitation center that specializes in mental health.
What is the most appropriate initial response? Select ONE option only.Your Answer: The patient has capacity and therefore their interests and wishes must be prioritised
Correct Answer:
Explanation:This question delves into the challenges of managing chronic illnesses and promoting patient self-care, while also considering concerns regarding confidentiality. The patient in question is mentally capable and already has caregivers at home. It is both the patient’s preference and the most clinically sensible decision to discharge them back home. It is important to address any family concerns, ensuring that the family members have the patient’s best interests at heart rather than personal or financial motives. It is not appropriate to delegate this conversation to a nurse, as it is your responsibility as the healthcare provider. It is crucial to communicate with the patient’s general practitioner, but it is important to involve the patient in any decision regarding a referral to a nursing home.
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This question is part of the following fields:
- Safeguarding & Psychosocial Emergencies
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