A 72-year-old woman is brought to the Emergency Department from a nursing home with confusion, fever and flank pain. Her temperature is 38.5 °C, blood pressure 82/48 mmHg, pulse rate 123 bpm and respiration rate 27 breaths per minute. Physical examination reveals dry mucous membranes and flank tenderness. Urinalysis shows 50–100 leukocytes and many bacteria per high-powered field.
Which of the following is most likely to improve survival for this patient?
A 25-year-old backpacker had embarked on a climbing expedition to Mount Everest. He had flown from the United Kingdom the previous day. To avoid the predicted bad weather, he and his team left the base camp the following day. They reached an altitude of 6000 m on day four. He complained of occasional dull headaches and feeling light-headed, which he attributed to his dehydration. The next day, he set off alone, but was discovered by the search party ten hours later. He was found to be confused, unable to walk in a straight line, irritable, and extremely fatigued. His symptoms significantly improved after receiving dexamethasone and resting in a portable hyperbaric chamber.
What is the most probable diagnosis?
A 32-year-old nurse suddenly falls ill in the break room during her lunch break. She has a known severe shellfish allergy. She appears pale and agitated, with a respiratory rate of 60 breaths/minute, audible wheezing, a pulse rate of 130 bpm, and a blood pressure of 80/50 mmHg. Some of her coworkers are present. Anaphylaxis is suspected.
What is the initial emergency intervention that should be given by her colleagues?
A 28-year-old man is admitted after being found lying on the street with a reduced conscious level.
On examination, he has pinpoint pupils and needle-track marks on his arms.
What would be the most likely pattern on the arterial blood gas in this case?
A 65-year-old patient in the Intensive Care Unit has been on ventilatory support for the last two weeks after a significant traumatic brain injury. A decision has to be made about whether they are taken off life support and whether or not the patient has irreversible brain damage.
In which of the following circumstances can brain death be diagnosed?
A 55-year-old woman is admitted unresponsive to the Emergency Department. She is not breathing and has no pulse. The ambulance crew had initiated cardiopulmonary resuscitation before arrival. She is known to have hypertension and takes ramipril.
She had routine bloods at the General Practice surgery three days ago:
Investigation Result Normal value
Haemoglobin (Hb) 134 g/l 115–155 g/l
White cell count (WCC) 3.5 × 109/l 4–11 × 109/l
Sodium (Na+) 134 mmol/l 135–145 mmol/l
Potassium (K+) 6.1 mmol/l 3.5–5.0 mmol/l
Urea 9.3 mmol/l 2.5–6.5 mmol/l
Creatinine (Cr) 83 µmol/l 50–120 µmol/l
Estimated glomerular filtration rate (eGFR) > 60
The Ambulance Crew hand you an electrocardiogram (ECG) strip which shows ventricular fibrillation (VF).
What is the most likely cause of her cardiac arrest?
A 25-year-old man is brought to the emergency room by his friends, who found him vomiting and surrounded by empty packets of pain medication. The patient is unable to identify which medication he took, but reports feeling dizzy and experiencing ringing in his ears. An arterial blood gas test reveals the following results:
pH: 7.52
paCO2: 3.1 kPa
paO2: 15.2 kPa
HCO3: 18 mEq/l
Based on these findings, what is the most likely pain medication the patient ingested?
A 68-year-old man is admitted to the Intensive Therapy Unit after a coronary artery bypass graft for a period of ventilation. He has a 35-pack year smoking history but successfully gave up some 2 years earlier. Unfortunately, weaning does not go as anticipated, and he cannot be weaned off the ventilator and is still in need of it 4 days later. There is evidence of right-sided bronchial breathing on auscultation. He is pyrexial with a temperature of 38.5 °C.
Investigations:
Investigation Result Normal value
Sodium (Na+) 142 mmol/l 135–145 mmol/l
Potassium (K+) 4.8 mmol/l 3.5–5.0 mmol/l
Creatinine 170 μmol/l 50–120 µmol/l
Haemoglobin 115 g/l 135–175 g/l
White cell count (WCC) 12.5 × 109/l (10.0) 4–11 × 109/l
Chest X-ray: bilateral pulmonary infiltrates, more marked on the right-hand side
Bronchial aspirates: mixed anaerobes
Which of the following diagnoses fits best with this clinical picture?
A 50-year-old man is on the Orthopaedic Ward following a compound fracture of his femur. He is day three post-op and has had a relatively uncomplicated postoperative period despite a complex medical history. His past medical history includes remitting prostate cancer (responding to treatment), COPD and osteoarthritis.
He has a body mass index (BMI) of > 30 kg/m2, hypertension and is currently using a salmeterol inhaler, enzalutamide, naproxen and the combined oral contraceptive pill. He smokes six cigarettes per day and drinks eight units of alcohol per week. He manages his activities of daily living independently.
Blood results from yesterday:
Investigation Result Normal value
Haemoglobin (Hb) 130 g/l 115–155 g/l
White cell count (WCC) 7.8 × 109/l 4–11 × 109/l
Sodium (Na+) 141 mmol/l 135–145 mmol/l
Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
Chloride (Cl) 108 mmol/l 98-106 mmol/l
Urea 7.8 mmol/l 2.5–6.5 mmol/l
Creatinine (Cr) 85 µmol/l 50–120 µmol/l
You are crash-paged to his bedside in response to his having a cardiac arrest.
What is the most appropriate management?
A 75-year-old is brought to the Emergency Department after being found at home on the floor by her daughter. Her daughter tried to rouse her but had no response. She has a laceration to her head and her daughter believes she may have had a fall. You notice she has a sudden decrease in consciousness in the department. You are unable to get the patient to make any vocalisation. When you apply supraorbital pressure, she briefly opens her eyes and withdraws from the pain.
Which one of the following is the best immediate management option for this patient?