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Question 1
Incorrect
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A 72-year-old man comes with his wife due to worries about his memory. After gathering information, you observe a gradual decrease in his cognitive abilities. The only significant medical history he has is a heart attack he had 8 years ago.
What is the MOST PROBABLE diagnosis?Your Answer: Dementia with Lewy bodies
Correct Answer: Vascular dementia
Explanation:Vascular dementia is the second most common form of dementia, accounting for approximately 25% of all cases. It occurs when the brain is damaged due to various factors, such as major strokes, multiple smaller strokes that go unnoticed (known as multi-infarct), or chronic changes in smaller blood vessels (referred to as subcortical dementia). The term vascular cognitive impairment (VCI) is increasingly used to encompass this range of diseases.
Unlike Alzheimer’s disease, which has a gradual and subtle onset, vascular dementia can occur suddenly and typically shows a series of stepwise increases in symptom severity. The presentation and progression of the disease can vary significantly.
There are certain features that suggest a vascular cause of dementia. These include a history of transient ischemic attacks (TIAs) or cardiovascular disease, the presence of focal neurological abnormalities, prominent memory impairment in the early stages of the disease, early onset of gait disturbance and unsteadiness, frequent unprovoked falls in the early stages, bladder symptoms (such as incontinence) without any identifiable urological condition in the early stages, and seizures.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 2
Correct
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A 65-year-old patient with advanced metastatic lung cancer is experiencing discomfort in his limbs and chest. Despite taking the maximum dosage of paracetamol, codeine phosphate, and ibuprofen regularly, his symptoms are no longer being adequately managed. You determine that it is necessary to discontinue the use of codeine phosphate and initiate stronger opioids.
What would be the most suitable initial dosage regimen in this situation?Your Answer: 20-30 mg oral morphine daily in divided doses
Explanation:When starting treatment with strong opioids for pain relief in palliative care, it is recommended to offer patients regular oral sustained-release or oral immediate-release morphine, depending on their preference. In addition, provide rescue doses of oral immediate-release morphine for breakthrough pain. For patients without renal or hepatic comorbidities, a typical total daily starting dose schedule of 20-30 mg of oral morphine is suggested, along with 5 mg of oral immediate-release morphine for rescue doses during the titration phase. It is important to adjust the dose until a good balance is achieved between pain control and side effects. If this balance is not reached after a few dose adjustments, it is advisable to seek specialist advice. Patients should be reviewed frequently, especially during the titration phase. For patients with moderate to severe renal or hepatic impairment, it is recommended to consult a specialist before prescribing strong opioids.
For maintenance therapy, oral sustained-release morphine is recommended as the first-line treatment for patients with advanced and progressive disease who require strong opioids. Transdermal patch formulations should not be routinely offered as first-line maintenance treatment unless oral opioids are not suitable. If pain remains inadequately controlled despite optimizing first-line maintenance treatment, it is important to review the analgesic strategy and consider seeking specialist advice.
When it comes to breakthrough pain, oral immediate-release morphine should be offered as the first-line rescue medication for patients on maintenance oral morphine treatment. Fast-acting fentanyl should not be offered as the first-line rescue medication. If pain continues to be inadequately controlled despite optimizing treatment, it may be necessary to seek specialist advice.
In cases where oral opioids are not suitable and analgesic requirements are stable, transdermal patches with the lowest acquisition cost can be considered. However, it is important to consult a specialist for guidance if needed. Similarly, for patients in whom oral opioids are not suitable and analgesic requirements are unstable, subcutaneous opioids with the lowest acquisition cost can be considered, with specialist advice if necessary.
For more information, please refer to the NICE Clinical Knowledge Summary: Opioids for pain relief in palliative care. https://www.nice.org.uk/guidance/cg140
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This question is part of the following fields:
- Palliative & End Of Life Care
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Question 3
Incorrect
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A 72-year-old man presents with a severe exacerbation of his COPD. He has been given a loading dose of aminophylline and you now intend to establish a maintenance infusion. He weighs 70 kg.
What is the appropriate maintenance infusion rate for him?Your Answer: 50 mg/hour
Correct Answer: 25 mg/hour
Explanation:The recommended daily oral dose for adults is 900 mg, which should be taken in 2-3 divided doses. For severe asthma or COPD, the initial intravenous dose is 5 mg/kg and should be administered over 10-20 minutes. This can be followed by a continuous infusion of 0.5 mg/kg/hour. In the case of a 50 kg individual, the appropriate infusion rate would be 25 mg/hour. It is important to note that the therapeutic range for aminophylline is narrow, ranging from 10-20 microgram/ml. Therefore, it is beneficial to estimate the plasma concentration of aminophylline during long-term treatment.
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This question is part of the following fields:
- Respiratory
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Question 4
Incorrect
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A 25-year-old type 1 diabetic arrives at the emergency department complaining of a worsening sore throat, fever, and overall feeling of illness. The patient reports that the symptoms began a week ago. During the examination, the patient's temperature is measured at 38.3ºC, bilateral posterior cervical lymphadenopathy is observed, and there is exudate on both tonsils. Additionally, tenderness is noted in the right upper quadrant. Glandular fever is suspected.
What would be the most suitable approach for conducting further investigations?Your Answer: Arrange blood test for monospot heterophile antibodies in 7 -10 days
Correct Answer: Send blood for Epstein-Barr virus (EBV) viral serology
Explanation:Glandular fever, also known as infectious mononucleosis or mono, is a clinical syndrome characterized by symptoms such as sore throat, fever, and swollen lymph nodes. It is primarily caused by the Epstein-Barr virus (EBV), with other viruses and infections accounting for the remaining cases. Glandular fever is transmitted through infected saliva and primarily affects adolescents and young adults. The incubation period is 4-8 weeks.
The majority of EBV infections are asymptomatic, with over 95% of adults worldwide having evidence of prior infection. Clinical features of glandular fever include fever, sore throat, exudative tonsillitis, lymphadenopathy, and prodromal symptoms such as fatigue and headache. Splenomegaly (enlarged spleen) and hepatomegaly (enlarged liver) may also be present, and a non-pruritic macular rash can sometimes occur.
Glandular fever can lead to complications such as splenic rupture, which increases the risk of rupture in the spleen. Approximately 50% of splenic ruptures associated with glandular fever are spontaneous, while the other 50% follow trauma. Diagnosis of glandular fever involves various investigations, including viral serology for EBV, monospot test, and liver function tests. Additional serology tests may be conducted if EBV testing is negative.
Management of glandular fever involves supportive care and symptomatic relief with simple analgesia. Antiviral medication has not been shown to be beneficial. It is important to identify patients at risk of serious complications, such as airway obstruction, splenic rupture, and dehydration, and provide appropriate management. Patients can be advised to return to normal activities as soon as possible, avoiding heavy lifting and contact sports for the first month to reduce the risk of splenic rupture.
Rare but serious complications associated with glandular fever include hepatitis, upper airway obstruction, cardiac complications, renal complications, neurological complications, haematological complications, chronic fatigue, and an increased risk of lymphoproliferative cancers and multiple sclerosis.
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This question is part of the following fields:
- Infectious Diseases
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Question 5
Incorrect
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A 57 year old male presents to the emergency department with a 24 hour history of worsening pain on the left side of the mouth and jaw. Upon examination, there is noticeable swelling of the gum around the 1st and 2nd upper left molar teeth, indicative of a dental abscess. Which of the following signs would warrant hospitalization?
Your Answer: Fever of 38.1 ºC
Correct Answer: Swelling of sublingual space
Explanation:Patients with dental abscess should be evaluated for signs of spread into deep fascial planes. Infection of the sublingual space can lead to serious complications that can be life-threatening. Swelling in this area can cause the tongue to elevate, potentially obstructing the airway. Other complications include infections such as mediastinitis, necrotizing fasciitis, cavernous sinus thrombosis, sepsis, thoracic empyema, Lemierre’s syndrome, cerebral abscess, orbital abscess, and osteomyelitis.
There are certain indications that may require admission to the hospital for dental abscess. These include evidence of significant systemic disturbance, inability to control the infection with antibiotics, rapid spread of infection, stridor or compromised airway, swelling of the sublingual space or pharynx, difficulty swallowing or speaking, immunocompromised patients, abscess requiring drainage under general anesthesia.
Fever and pain are common symptoms of dental abscess but by themselves are not enough to warrant admission. Ideally, dental abscess should be managed through urgent dental review. However, if immediate dental review is not available, the patient may be treated with antibiotics as long as there are no signs of more severe infection.
Further Reading:
Dental abscess is a condition that usually occurs as a result of dental caries or following a dental procedure or trauma. Dental caries refers to the loss of enamel caused by acids produced by bacteria in the mouth. This allows bacteria to enter the pulp, root, and local tissues, leading to infection. The infection can then spread to surrounding tissues, causing conditions such as gingivitis or dental abscess. In severe cases, the infection can spread to deep fascial planes, resulting in conditions like retropharyngeal abscess or Ludwig’s angina.
A dental abscess is typically caused by a combination of gram-positive and gram-negative bacteria, such as Streptococcus, Staphylococcus, and Prevotella. When assessing a patient with a suspected dental abscess, a thorough history and inspection of the mouth, face, and neck are necessary. This helps confirm the diagnosis and assess the risk of serious complications, such as airway compromise or deep/spreading infection.
Some concerning features on history or examination include systemic upset (e.g., fever, vomiting), sublingual or pharyngeal swelling, stridor, dysphagia, dysphonia, dyspnea, and progression of illness despite current antibiotic treatment. It’s important to consider non-dental causes of mouth and jaw pain, such as trauma, referred sinus pain, cardiac pain radiating to the jaw, trigeminal neuralgia, otalgia radiating to the jaw, and parotid gland swelling.
Management of a dental abscess typically involves providing analgesia (NSAIDs and paracetamol) and facilitating early dental review. Antibiotics may be prescribed in certain cases, such as when the patient does not have immediate access to a dentist and is systemically unwell, shows signs of severe infection, or is a high-risk individual (e.g., immunocompromised or diabetic). The choice of antibiotics includes amoxicillin, phenoxymethylpenicillin, or clarithromycin (if penicillin allergic). In severe or spreading infections, metronidazole may be added. The typical course of antibiotics is 5 days.
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This question is part of the following fields:
- Maxillofacial & Dental
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Question 6
Correct
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A 70 year old male visits the emergency department with a complaint of increasing shortness of breath. You observe that the patient had moderate aortic regurgitation on an echocardiogram conducted 12 months ago.
What is a characteristic symptom of aortic regurgitation (AR)?Your Answer: Water hammer pulse
Explanation:A collapsing pulse, also known as a water hammer pulse, is a common clinical feature associated with aortic regurgitation (AR). In AR, the pulse rises rapidly and forcefully before quickly collapsing. This pulsation pattern may also be referred to as Watson’s water hammer pulse or Corrigan’s pulse. Heart sounds in AR are typically quiet, and the second heart sound (S2) may even be absent if the valve fails to fully close. A characteristic early to mid diastolic murmur is often present. Other typical features of AR include a wide pulse pressure, a mid-diastolic Austin-Flint murmur in severe cases, a soft S1 and S2 (with S2 potentially being absent), a hyperdynamic apical pulse, and signs of heart failure such as lung creases, raised jugular venous pressure (JVP), and tachypnea.
Further Reading:
Valvular heart disease refers to conditions that affect the valves of the heart. In the case of aortic valve disease, there are two main conditions: aortic regurgitation and aortic stenosis.
Aortic regurgitation is characterized by an early diastolic murmur, a collapsing pulse (also known as a water hammer pulse), and a wide pulse pressure. In severe cases, there may be a mid-diastolic Austin-Flint murmur due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams. The first and second heart sounds (S1 and S2) may be soft, and S2 may even be absent. Additionally, there may be a hyperdynamic apical pulse. Causes of aortic regurgitation include rheumatic fever, infective endocarditis, connective tissue diseases like rheumatoid arthritis and systemic lupus erythematosus, and a bicuspid aortic valve. Aortic root diseases such as aortic dissection, spondyloarthropathies like ankylosing spondylitis, hypertension, syphilis, and genetic conditions like Marfan’s syndrome and Ehler-Danlos syndrome can also lead to aortic regurgitation.
Aortic stenosis, on the other hand, is characterized by a narrow pulse pressure, a slow rising pulse, and a delayed ESM (ejection systolic murmur). The second heart sound (S2) may be soft or absent, and there may be an S4 (atrial gallop) that occurs just before S1. A thrill may also be felt. The duration of the murmur is an important factor in determining the severity of aortic stenosis. Causes of aortic stenosis include degenerative calcification (most common in older patients), a bicuspid aortic valve (most common in younger patients), William’s syndrome (supravalvular aortic stenosis), post-rheumatic disease, and subvalvular conditions like hypertrophic obstructive cardiomyopathy (HOCM).
Management of aortic valve disease depends on the severity of symptoms. Asymptomatic patients are generally observed, while symptomatic patients may require valve replacement. Surgery may also be considered for asymptomatic patients with a valvular gradient greater than 40 mmHg and features such as left ventricular systolic dysfunction. Balloon valvuloplasty is limited to patients with critical aortic stenosis who are not fit for valve replacement.
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This question is part of the following fields:
- Cardiology
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Question 7
Incorrect
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A 42-year-old man presents sweaty and distressed, complaining of abdominal pain and nausea. On examination, he has marked abdominal tenderness that is maximal in the epigastric area. Following his blood results, you make a diagnosis of acute pancreatitis. He is a non-drinker.
His venous bloods are shown below:
Hb: 12.2 g/dL
White cell count: 16.7 x 109/L
Blood glucose 8.7 mmol/L
AST 458 IU/L
LDH 375 IU/L
Amylase: 1045 IU/L
What is the most likely underlying cause for his pancreatitis?Your Answer: Autoimmune disease
Correct Answer: Gallstones
Explanation:Acute pancreatitis is a frequently encountered and serious source of acute abdominal pain. It involves the sudden inflammation of the pancreas, leading to the release of enzymes that cause self-digestion of the organ.
The clinical manifestations of acute pancreatitis include severe epigastric pain, accompanied by feelings of nausea and vomiting. The pain may radiate to the T6-T10 dermatomes or even to the shoulder tip through the phrenic nerve if the diaphragm is irritated. Other symptoms may include fever or sepsis, tenderness in the epigastric region, jaundice, and the presence of Gray-Turner sign (bruising on the flank) or Cullen sign (bruising around the belly button).
The most common causes of acute pancreatitis are gallstones and alcohol consumption. Additionally, many cases are considered idiopathic, meaning the cause is unknown. To aid in remembering the various causes, the mnemonic ‘I GET SMASHED’ can be helpful. Each letter represents a potential cause: Idiopathic, Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion stings, Hyperlipidemia/hypercalcemia, ERCP (endoscopic retrograde cholangiopancreatography), and Drugs.
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This question is part of the following fields:
- Surgical Emergencies
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Question 8
Incorrect
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A 58-year-old woman presents with abrupt intense chest discomfort that extends to her back. She is perspiring and experiencing nausea. During the examination, her blood pressure measures 176/96 in her right arm and 143/78 in her left arm. An early diastolic murmur is audible upon auscultation.
What is the SINGLE most probable diagnosis?Your Answer: Thoracic outlet syndrome
Correct Answer: Aortic dissection
Explanation:Acute aortic dissection is characterized by the rapid formation of a false, blood-filled channel within the middle layer of the aorta. It is estimated to occur in 3 out of every 100,000 individuals per year.
Patients with aortic dissection typically experience intense chest pain that spreads to the area between the shoulder blades. The pain is often described as tearing or ripping and may also extend to the neck. Sweating, paleness, and rapid heartbeat are commonly observed at the time of presentation. Other possible symptoms include focal neurological deficits, weak pulses, fainting, and reduced blood flow to organs.
A significant difference in blood pressure between the arms, greater than 20 mmHg, is a highly sensitive indicator. If the dissection extends backward, it can involve the aortic valve, leading to the early diastolic murmur of aortic regurgitation.
Risk factors for aortic dissection include hypertension, atherosclerosis, aortic coarctation, the use of sympathomimetic drugs like cocaine, Marfan syndrome, Ehlers-Danlos syndrome, Turner’s syndrome, tertiary syphilis, and pre-existing aortic aneurysm.
Aortic dissection can be classified according to the Stanford classification system:
– Type A affects the ascending aorta and the arch, accounting for 60% of cases. These cases are typically managed surgically and may result in the blockage of coronary arteries and aortic regurgitation.
– Type B begins distal to the left subclavian artery and accounts for approximately 40% of cases. These cases are usually managed with medication to control blood pressure. -
This question is part of the following fields:
- Cardiology
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Question 9
Incorrect
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You review a 52-year-old woman who has recently been prescribed antibiotics for a urinary tract infection (UTI). She has a history of COPD and is currently taking salbutamol and Seretide inhalers and Phyllocontin Continus. Since starting the antibiotics, she has been experiencing nausea, vomiting, and abdominal pain.
Which SINGLE antibiotic is she most likely to have been prescribed for her UTI?Your Answer: Doxycycline
Correct Answer: Ciprofloxacin
Explanation:Phyllocontin Continus contains aminophylline, which is a combination of theophylline and ethylenediamine. It is a bronchodilator that is commonly used to manage COPD and asthma.
In this case, the woman is showing symptoms of theophylline toxicity, which may have been triggered by the antibiotic prescribed for her urinary tract infection. Quinolone antibiotics, like ciprofloxacin, can increase the concentration of theophyllines in the blood, leading to toxicity.
There are other medications that can also interact with theophyllines. These include macrolide antibiotics such as clarithromycin, allopurinol, antifungals like ketoconazole, and calcium-channel blockers such as amlodipine. It is important to be aware of these interactions to prevent any potential complications.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 10
Incorrect
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A 62 year old male is brought to the emergency department after experiencing difficulty breathing. You observe that he has had a tracheostomy for a long time due to being on a ventilator for an extended period following a severe car accident. You provide high flow oxygen and try to pass a suction catheter after removing the inner tracheostomy tube, but you are unable to do so. What should be the next step in managing this patient?
Your Answer: Remove outer tracheostomy tube & tracheostomy assembly
Correct Answer: Deflate the cuff
Explanation:If a patient with a tracheostomy is experiencing difficulty breathing and it is not possible to pass a suction catheter, the next step is to deflate the cuff. Deflating the cuff can help determine if the tracheostomy tube is obstructed or displaced by allowing air to flow around the tube within the airway. The following steps are followed in order: 1) Remove the inner tube and any speaking cap/valve if present. 2) Attempt to pass the suction catheter. 3) If the suction catheter cannot be passed, deflate the cuff. 4) If the patient’s condition does not stabilize or improve, the tracheostomy tube may need to be removed. This process is summarized in the green algorithm.
Further Reading:
Patients with tracheostomies may experience emergencies such as tube displacement, tube obstruction, and bleeding. Tube displacement can occur due to accidental dislodgement, migration, or erosion into tissues. Tube obstruction can be caused by secretions, lodged foreign bodies, or malfunctioning humidification devices. Bleeding from a tracheostomy can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue.
When assessing a patient with a tracheostomy, an ABCDE approach should be used, with attention to red flags indicating a tracheostomy or laryngectomy emergency. These red flags include audible air leaks or bubbles of saliva indicating gas escaping past the cuff, grunting, snoring, stridor, difficulty breathing, accessory muscle use, tachypnea, hypoxia, visibly displaced tracheostomy tube, blood or blood-stained secretions around the tube, increased discomfort or pain, increased air required to keep the cuff inflated, tachycardia, hypotension or hypertension, decreased level of consciousness, and anxiety, restlessness, agitation, and confusion.
Algorithms are available for managing tracheostomy emergencies, including obstruction or displaced tube. Oxygen should be delivered to the face and stoma or tracheostomy tube if there is uncertainty about whether the patient has had a laryngectomy. Tracheostomy bleeding can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue. Tracheo-innominate fistula (TIF) is a rare but life-threatening complication that occurs when the tracheostomy tube erodes into the innominate artery. Urgent surgical intervention is required for TIF, and management includes general resuscitation measures and specific measures such as bronchoscopy and applying direct digital pressure to the innominate artery.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 11
Correct
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A 65 year old female presents to the emergency department complaining of severe abdominal pain. You note previous attendances with alcohol related injuries. On taking the history the patient admits to being a heavy drinker and estimates her weekly alcohol consumption at 80-100 units. She tells you her abdomen feels more swollen than usual and she feels nauseated. On examination of the abdomen you note it is visibly distended, tender to palpate and shifting dullness is detected on percussion. The patient's observations are shown below:
Blood pressure 112/74 mmHg
Pulse 102 bpm
Respiration rate 22 bpm
Temperature 38.6ºC
What is the most likely diagnosis?Your Answer: Spontaneous bacterial peritonitis
Explanation:Spontaneous bacterial peritonitis (SBP) is a condition that occurs as a complication of ascites, which is the accumulation of fluid in the abdomen. SBP typically presents with various symptoms such as fevers, chills, nausea, vomiting, abdominal pain, general malaise, altered mental status, and worsening ascites. This patient is at risk of developing alcoholic liver disease and cirrhosis due to their harmful levels of alcohol consumption. Harmful drinking is defined as drinking ≥ 35 units a week for women or drinking ≥ 50 units a week for men. The presence of shifting dullness and a distended abdomen are consistent with the presence of ascites. SBP is an acute bacterial infection of the ascitic fluid that occurs without an obvious identifiable cause. It is one of the most commonly encountered bacterial infections in patients with cirrhosis. Signs and symptoms of SBP include fevers, chills, nausea, vomiting, abdominal pain and tenderness, general malaise, altered mental status, and worsening ascites.
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 12
Correct
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A 10 year old girl is brought to the emergency department by her parents after a fall while playing outside. The patient has a significant wound that needs to be cleaned and closed. You decide to examine and clean the wound under ketamine sedation as the patient is very upset. What type of sedation is typical of Ketamine?
Your Answer: Dissociative sedation
Explanation:Ketamine induces a distinct type of sedation known as dissociative sedation. This sedation state is unlike any other and is characterized by a trance-like, cataleptic condition. It provides deep pain relief and memory loss while still maintaining important protective reflexes for the airway, spontaneous breathing, and overall stability of the heart and lungs. Dissociative sedation with ketamine does not fit into the conventional categories of sedation.
Further Reading:
Procedural sedation is commonly used by emergency department (ED) doctors to minimize pain and discomfort during procedures that may be painful or distressing for patients. Effective procedural sedation requires the administration of analgesia, anxiolysis, sedation, and amnesia. This is typically achieved through the use of a combination of short-acting analgesics and sedatives.
There are different levels of sedation, ranging from minimal sedation (anxiolysis) to general anesthesia. It is important for clinicians to understand the level of sedation being used and to be able to manage any unintended deeper levels of sedation that may occur. Deeper levels of sedation are similar to general anesthesia and require the same level of care and monitoring.
Various drugs can be used for procedural sedation, including propofol, midazolam, ketamine, and fentanyl. Each of these drugs has its own mechanism of action and side effects. Propofol is commonly used for sedation, amnesia, and induction and maintenance of general anesthesia. Midazolam is a benzodiazepine that enhances the effect of GABA on the GABA A receptors. Ketamine is an NMDA receptor antagonist and is used for dissociative sedation. Fentanyl is a highly potent opioid used for analgesia and sedation.
The doses of these drugs for procedural sedation in the ED vary depending on the drug and the route of administration. It is important for clinicians to be familiar with the appropriate doses and onset and peak effect times for each drug.
Safe sedation requires certain requirements, including appropriate staffing levels, competencies of the sedating practitioner, location and facilities, and monitoring. The level of sedation being used determines the specific requirements for safe sedation.
After the procedure, patients should be monitored until they meet the criteria for safe discharge. This includes returning to their baseline level of consciousness, having vital signs within normal limits, and not experiencing compromised respiratory status. Pain and discomfort should also be addressed before discharge.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 13
Incorrect
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A 40-year-old woman with Marfan syndrome presents with a severe tearing chest pain that spreads to her back. A diagnosis of aortic dissection is suspected.
Which SINGLE statement regarding aortic dissection is FALSE?Your Answer: Focal neurological deficits can occur
Correct Answer: An inter-arm blood pressure differential of greater than 10 mmHg is a highly sensitive predictor
Explanation:Acute aortic dissection is characterized by the rapid formation of a false, blood-filled channel within the middle layer of the aorta. It is estimated to occur in 3 out of every 100,000 individuals per year.
Patients with aortic dissection typically experience intense chest pain that spreads to the area between the shoulder blades. The pain is often described as tearing or ripping and may also extend to the neck. Sweating, paleness, and rapid heartbeat are commonly observed at the time of presentation. Other possible symptoms include focal neurological deficits, weak pulses, fainting, and reduced blood flow to organs.
A significant difference in blood pressure between the arms, greater than 20 mmHg, is a highly sensitive indicator. If the dissection extends backward, it can involve the aortic valve, leading to the early diastolic murmur of aortic regurgitation.
Risk factors for aortic dissection include hypertension, atherosclerosis, aortic coarctation, the use of sympathomimetic drugs like cocaine, Marfan syndrome, Ehlers-Danlos syndrome, Turner’s syndrome, tertiary syphilis, and pre-existing aortic aneurysm.
Aortic dissection can be classified according to the Stanford classification system:
– Type A affects the ascending aorta and the arch, accounting for 60% of cases. These cases are typically managed surgically and may result in the blockage of coronary arteries and aortic regurgitation.
– Type B begins distal to the left subclavian artery and accounts for approximately 40% of cases. These cases are usually managed with medication to control blood pressure. -
This question is part of the following fields:
- Cardiology
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Question 14
Incorrect
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A 72 year old male presents to the emergency department following a fall onto an outstretched hand. Following assessment you order an X-ray of the wrist which confirms a dorsally angulated extra-articular fracture of the right distal radius. You also observe cortical thinning and increased radiolucency of the bone and consider the possibility of underlying osteoporosis. What is a risk factor for osteoporosis?
Your Answer: Long term combined oral contraceptive pill use
Correct Answer: Menopause
Explanation:Osteoporosis and fragility fractures are more likely to occur in individuals with low levels of estrogen. Menopause, which causes a decrease in estrogen, can lead to estrogen deficiency. Estrogen plays a role in preventing bone breakdown by inhibiting osteoclast activity. After menopause, there is an increase in osteoclast activity, resulting in a rapid decline in bone mineral density. Osteoporosis is also associated with the long-term use of corticosteroids.
Further Reading:
Fragility fractures are fractures that occur following a fall from standing height or less, and may be atraumatic. They often occur in the presence of osteoporosis, a disease characterized by low bone mass and structural deterioration of bone tissue. Fragility fractures commonly affect the wrist, spine, hip, and arm.
Osteoporosis is defined as a bone mineral density (BMD) of 2.5 standard deviations below the mean peak mass, as measured by dual-energy X-ray absorptiometry (DXA). Osteopenia, on the other hand, refers to low bone mass between normal bone mass and osteoporosis, with a T-score between -1 to -2.5.
The pathophysiology of osteoporosis involves increased osteoclast activity relative to bone production by osteoblasts. The prevalence of osteoporosis increases with age, from approximately 2% at 50 years to almost 50% at 80 years.
There are various risk factors for fragility fractures, including endocrine diseases, GI causes of malabsorption, chronic kidney and liver diseases, menopause, immobility, low body mass index, advancing age, oral corticosteroids, smoking, alcohol consumption, previous fragility fractures, rheumatological conditions, parental history of hip fracture, certain medications, visual impairment, neuromuscular weakness, cognitive impairment, and unsafe home environment.
Assessment of a patient with a possible fragility fracture should include evaluating the risk of further falls, the risk of osteoporosis, excluding secondary causes of osteoporosis, and ruling out non-osteoporotic causes for fragility fractures such as metastatic bone disease, multiple myeloma, osteomalacia, and Paget’s disease.
Management of fragility fractures involves initial management by the emergency clinician, while treatment of low bone density is often delegated to the medical team or general practitioner. Management considerations include determining who needs formal risk assessment, who needs a DXA scan to measure BMD, providing lifestyle advice, and deciding who requires drug treatment.
Medication for osteoporosis typically includes vitamin D, calcium, and bisphosphonates. Vitamin D and calcium supplementation should be considered based on individual needs, while bisphosphonates are advised for postmenopausal women and men over 50 years with confirmed osteoporosis or those taking high doses of oral corticosteroids.
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This question is part of the following fields:
- Endocrinology
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Question 15
Incorrect
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A 35-year-old woman comes in with intense one-sided abdominal pain starting in the left flank and extending to the groin. You suspect she may have ureteric colic.
What are the two types of drugs that can be used for conservative treatment as medical expulsive therapy?Your Answer: Beta-blocker and calcium-channel blocker
Correct Answer: Alpha-blocker and calcium-channel blocker
Explanation:Conservative management of ureteric stones may involve the use of medical expulsive therapy (MET), which can be achieved through the administration of either an alpha-blocker or a calcium-channel blocker. This treatment aims to facilitate the natural passage of the stone during the observation period.
Research has shown that in adults, both alpha-blockers and calcium channel blockers have been effective in improving the passage of distal ureteric stones that are less than 10 mm in size, when compared to no treatment. Additionally, alpha-blockers have shown to be more effective than placebo in promoting stone passage. Alpha-blockers have also demonstrated more benefits than calcium channel blockers in terms of stone passage, as well as some advantages in terms of hospital stay and pain management. However, there was no significant difference in the time it took for the stone to pass or the overall quality of life.
Currently, the National Institute for Health and Care Excellence (NICE) recommends alpha-blockers as the preferred choice for medical expulsive therapy. For more detailed information, you can refer to the NICE guidelines on the assessment and management of renal and ureteric stones.
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This question is part of the following fields:
- Urology
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Question 16
Incorrect
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A 60 year old comes to the emergency department with worries of feeling nauseated and vomiting blood. The patient shows you a tissue paper with mostly coffee ground vomit and a few specks of fresh red blood. The patient mentions experiencing on-and-off abdominal pain for a few weeks. You suspect that the patient is experiencing an upper gastrointestinal bleed. What is the primary cause of upper gastrointestinal bleeding in adults?
Your Answer: Oesophagitis
Correct Answer: Peptic ulcer disease
Explanation:The primary cause of upper gastrointestinal bleeding in adults is peptic ulcer disease. Peptic ulcers are open sores that develop on the lining of the stomach or the upper part of the small intestine. These ulcers can be caused by factors such as infection with Helicobacter pylori bacteria, long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs), or excessive alcohol consumption. When a peptic ulcer bleeds, it can result in the vomiting of blood, which may appear as coffee ground vomit or have speckles of fresh red blood. Other symptoms that may accompany an upper gastrointestinal bleed include abdominal pain, nausea, and a feeling of fullness.
Further Reading:
Peptic ulcer disease (PUD) is a condition characterized by a break in the mucosal lining of the stomach or duodenum. It is caused by an imbalance between factors that promote mucosal damage, such as gastric acid, pepsin, Helicobacter pylori infection, and NSAID drug use, and factors that maintain mucosal integrity, such as prostaglandins, mucus lining, bicarbonate, and mucosal blood flow.
The most common causes of peptic ulcers are H. pylori infection and NSAID use. Other factors that can contribute to the development of ulcers include smoking, alcohol consumption, certain medications (such as steroids), stress, autoimmune conditions, and tumors.
Diagnosis of peptic ulcers involves screening for H. pylori infection through breath or stool antigen tests, as well as upper gastrointestinal endoscopy. Complications of PUD include bleeding, perforation, and obstruction. Acute massive hemorrhage has a case fatality rate of 5-10%, while perforation can lead to peritonitis with a mortality rate of up to 20%.
The symptoms of peptic ulcers vary depending on their location. Duodenal ulcers typically cause pain that is relieved by eating, occurs 2-3 hours after eating and at night, and may be accompanied by nausea and vomiting. Gastric ulcers, on the other hand, cause pain that occurs 30 minutes after eating and may be associated with nausea and vomiting.
Management of peptic ulcers depends on the underlying cause and presentation. Patients with active gastrointestinal bleeding require risk stratification, volume resuscitation, endoscopy, and proton pump inhibitor (PPI) therapy. Those with perforated ulcers require resuscitation, antibiotic treatment, analgesia, PPI therapy, and urgent surgical review.
For stable patients with peptic ulcers, lifestyle modifications such as weight loss, avoiding trigger foods, eating smaller meals, quitting smoking, reducing alcohol consumption, and managing stress and anxiety are recommended. Medication review should be done to stop causative drugs if possible. PPI therapy, with or without H. pylori eradication therapy, is also prescribed. H. pylori testing is typically done using a carbon-13 urea breath test or stool antigen test, and eradication therapy involves a 7-day triple therapy regimen of antibiotics and PPI.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 17
Incorrect
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You are participating in training for managing a significant radiation incident. Which of the following decontamination measures is expected to be the most efficient in eliminating radioactive material from an affected individual?
Your Answer: Oral activated charcoal
Correct Answer: Remove outer layer of clothing
Explanation:The first step in decontaminating radioactive material from an individual is to remove their clothing carefully, without shaking it too much to avoid spreading radioactive dust. The clothing should then be placed in a plastic bag or sealable container. Next, the person should be washed down with warm water from a clean source and scrubbed with detergent using a rinse-wipe-rinse method.
Further Reading:
Radiation exposure refers to the emission or transmission of energy in the form of waves or particles through space or a material medium. There are two types of radiation: ionizing and non-ionizing. Non-ionizing radiation, such as radio waves and visible light, has enough energy to move atoms within a molecule but not enough to remove electrons from atoms. Ionizing radiation, on the other hand, has enough energy to ionize atoms or molecules by detaching electrons from them.
There are different types of ionizing radiation, including alpha particles, beta particles, gamma rays, and X-rays. Alpha particles are positively charged and consist of 2 protons and 2 neutrons from the atom’s nucleus. They are emitted from the decay of heavy radioactive elements and do not travel far from the source atom. Beta particles are small, fast-moving particles with a negative electrical charge that are emitted from an atom’s nucleus during radioactive decay. They are more penetrating than alpha particles but less damaging to living tissue. Gamma rays and X-rays are weightless packets of energy called photons. Gamma rays are often emitted along with alpha or beta particles during radioactive decay and can easily penetrate barriers. X-rays, on the other hand, are generally lower in energy and less penetrating than gamma rays.
Exposure to ionizing radiation can damage tissue cells by dislodging orbital electrons, leading to the generation of highly reactive ion pairs. This can result in DNA damage and an increased risk of future malignant change. The extent of cell damage depends on factors such as the type of radiation, time duration of exposure, distance from the source, and extent of shielding.
The absorbed dose of radiation is directly proportional to time, so it is important to minimize the amount of time spent in the vicinity of a radioactive source. A lethal dose of radiation without medical management is 4.5 sieverts (Sv) to kill 50% of the population at 60 days. With medical management, the lethal dose is 5-6 Sv. The immediate effects of ionizing radiation can range from radiation burns to radiation sickness, which is divided into three main syndromes: hematopoietic, gastrointestinal, and neurovascular. Long-term effects can include hematopoietic cancers and solid tumor formation.
In terms of management, support is mainly supportive and includes IV fluids, antiemetics, analgesia, nutritional support, antibiotics, blood component substitution, and reduction of brain edema.
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This question is part of the following fields:
- Environmental Emergencies
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Question 18
Incorrect
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A 58 year old male comes to the emergency department complaining of palpitations, swollen legs, and excessive sweating. Thyroid function tests are requested and reveal low TSH and elevated free T4 levels. Which of the following medications is most likely responsible for these symptoms?
Your Answer: Losartan
Correct Answer: Amiodarone
Explanation:Amiodarone, a medication used to treat heart rhythm problems, can have effects on the thyroid gland. It can either cause hypothyroidism (low thyroid hormone levels) or hyperthyroidism (high thyroid hormone levels). Amiodarone is a highly fat-soluble drug that accumulates in various tissues, including the thyroid. Even after stopping the medication, its effects can still be seen due to its long elimination half-life of around 100 days.
The reason behind amiodarone impact on the thyroid is believed to be its high iodine content. In patients with sufficient iodine levels, amiodarone-induced hypothyroidism is more likely to occur. On the other hand, in populations with low iodine levels, amiodarone can lead to a condition called iodine-induced thyrotoxicosis, which is characterized by hyperthyroidism.
The mechanism of amiodarone-induced hypothyroidism involves the release of iodide from the drug, which blocks the uptake of further iodide by the thyroid gland and hampers the production of thyroid hormones. Additionally, amiodarone inhibits the conversion of the inactive thyroid hormone T4 to the active form T3.
Amiodarone-induced hyperthyroidism, on the other hand, is thought to occur in individuals with abnormal thyroid glands, such as those with nodular goiters, autonomous nodules, or latent Graves’ disease. In these cases, the excess iodine from amiodarone overwhelms the thyroid’s normal regulatory mechanisms, leading to hyperthyroidism.
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. 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 19
Incorrect
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A 60-year-old man presents with a left sided, painful groin swelling. You suspect that it is an inguinal hernia.
Which of the following examination features make it more likely to be a direct inguinal hernia?Your Answer: It appears rapidly after the patient stands
Correct Answer: It can be controlled by pressure over the deep inguinal ring
Explanation:Indirect inguinal hernias have an elliptical shape, unlike direct hernias which are round. They are not easily reducible and do not reduce spontaneously when reclining. Unlike direct hernias that appear immediately, indirect hernias take longer to appear when standing. They are reduced superiorly and then superolaterally, while direct hernias reduce superiorly and posteriorly. Pressure over the deep inguinal ring helps control indirect hernias. However, they are more prone to strangulation due to the narrow neck of the deep inguinal ring.
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This question is part of the following fields:
- Surgical Emergencies
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Question 20
Correct
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A 6-month-old infant is brought in by his parents following a brief episode where it seemed that the baby looked very pale and had ceased breathing. The infant is examined by the pediatric registrar, who declares that a 'BRUE' has taken place.
Which of the following does NOT align with a diagnosis of 'BRUE'?Your Answer: Event is explainable by an identifiable medical condition
Explanation:The term Apparent Life-Threatening Event (ALTE) has traditionally been used to describe a specific type of event. However, in 2016, the American Academy of Paediatrics (AAP) recommended replacing this term with a new one called Brief Resolved Unexplained Event (BRUE).
An ALTE is defined as an episode that is frightening to the observer and is characterized by a combination of symptoms such as apnoea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), significant change in muscle tone (usually marked limpness), choking, or gagging. In some cases, the observer may even fear that the infant has died.
On the other hand, BRUE has stricter criteria and is only applicable to episodes that occur in infants under 12 months old. A BRUE is considered brief, typically lasting 2-30 seconds but no longer than 1 minute. It must also have resolved, meaning the infant has returned to their baseline state. Additionally, it should not be explained by any identifiable medical condition and must be characterized by at least one of the following: cyanosis or pallor, absent, decreased, or irregular breathing, marked change in muscle tone (hyper- or hypotonia), or altered level of responsiveness.
To diagnose a BRUE, a full history and physical examination of the infant must be conducted, and if no explanation for the event is found, it can be classified as a BRUE. Once a BRUE is diagnosed, it can be risk-stratified to guide further management.
A BRUE is considered low risk if the infant has fully recovered, there are no concerning history or physical examination findings, and the following criteria are met: the infant is over 60 days old, born after 32 weeks gestation with a corrected gestational age over 45 weeks, no CPR was performed by a trained healthcare professional, and this was the first event that lasted less than 1 minute.
Low-risk infants can be safely discharged with early outpatient follow-up within 24 hours. However, it is important to involve the parents/caregivers in the decision-making process. They should be informed that a low-risk BRUE is unlikely to indicate a severe underlying disorder and that the event is unlikely to happen again.
Before discharge, it may be advisable to perform an ECG, observe the infant for a brief period, and conduct a pertussis swab
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This question is part of the following fields:
- Paediatric Emergencies
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Question 21
Incorrect
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You are preparing to conduct rapid sequence induction. What clinical observation, typically seen after administering suxamethonium, is not present when rocuronium is used for neuromuscular blockade?
Your Answer: Skin flushing
Correct Answer: Muscle fasciculations
Explanation:When suxamethonium is administered for neuromuscular blockade during rapid sequence induction, one of the clinical observations typically seen is muscle fasciculations. However, when rocuronium is used instead, muscle fasciculations are not present.
Further Reading:
Rapid sequence induction (RSI) is a method used to place an endotracheal tube (ETT) in the trachea while minimizing the risk of aspiration. It involves inducing loss of consciousness while applying cricoid pressure, followed by intubation without face mask ventilation. The steps of RSI can be remembered using the 7 P’s: preparation, pre-oxygenation, pre-treatment, paralysis and induction, protection and positioning, placement with proof, and post-intubation management.
Preparation involves preparing the patient, equipment, team, and anticipating any difficulties that may arise during the procedure. Pre-oxygenation is important to ensure the patient has an adequate oxygen reserve and prolongs the time before desaturation. This is typically done by breathing 100% oxygen for 3 minutes. Pre-treatment involves administering drugs to counter expected side effects of the procedure and anesthesia agents used.
Paralysis and induction involve administering a rapid-acting induction agent followed by a neuromuscular blocking agent. Commonly used induction agents include propofol, ketamine, thiopentone, and etomidate. The neuromuscular blocking agents can be depolarizing (such as suxamethonium) or non-depolarizing (such as rocuronium). Depolarizing agents bind to acetylcholine receptors and generate an action potential, while non-depolarizing agents act as competitive antagonists.
Protection and positioning involve applying cricoid pressure to prevent regurgitation of gastric contents and positioning the patient’s neck appropriately. Tube placement is confirmed by visualizing the tube passing between the vocal cords, auscultation of the chest and stomach, end-tidal CO2 measurement, and visualizing misting of the tube. Post-intubation management includes standard care such as monitoring ECG, SpO2, NIBP, capnography, and maintaining sedation and neuromuscular blockade.
Overall, RSI is a technique used to quickly and safely secure the airway in patients who may be at risk of aspiration. It involves a series of steps to ensure proper preparation, oxygenation, drug administration, and tube placement. Monitoring and post-intubation care are also important aspects of RSI.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 22
Incorrect
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A 25-year-old is brought into the emergency department after being discovered unresponsive in a neighbor's backyard. It is suspected that the patient had consumed alcohol at a nearby bar and opted to walk home in the snowy conditions. The patient's temperature is documented as 27.8ºC. The nurse connects leads to conduct a 12-lead ECG. Which of the subsequent ECG alterations is most closely linked to hypothermia?
Your Answer: Flattened P-waves
Correct Answer: Osborne Waves (J waves)
Explanation:Hypothermia can cause various changes in an electrocardiogram (ECG). These changes include a slower heart rate (bradycardia), the presence of Osborn waves (also known as J waves), a prolonged PR interval, a widened QRS complex, and a prolonged QT interval. Additionally, shivering artifact, ventricular ectopics (abnormal heartbeats originating from the ventricles), and even cardiac arrest (ventricular tachycardia, ventricular fibrillation, or asystole) may occur.
Further Reading:
Hypothermic cardiac arrest is a rare situation that requires a tailored approach. Resuscitation is typically prolonged, but the prognosis for young, previously healthy individuals can be good. Hypothermic cardiac arrest may be associated with drowning. Hypothermia is defined as a core temperature below 35ºC and can be graded as mild, moderate, severe, or profound based on the core temperature. When the core temperature drops, basal metabolic rate falls and cell signaling between neurons decreases, leading to reduced tissue perfusion. Signs and symptoms of hypothermia progress as the core temperature drops, initially presenting as compensatory increases in heart rate and shivering, but eventually ceasing as the temperature drops into moderate hypothermia territory.
ECG changes associated with hypothermia include bradyarrhythmias, Osborn waves, prolonged PR, QRS, and QT intervals, shivering artifact, ventricular ectopics, and cardiac arrest. When managing hypothermic cardiac arrest, ALS should be initiated as per the standard ALS algorithm, but with modifications. It is important to check for signs of life, re-warm the patient, consider mechanical ventilation due to chest wall stiffness, adjust dosing or withhold drugs due to slowed drug metabolism, and correct electrolyte disturbances. The resuscitation of hypothermic patients is often prolonged and may continue for a number of hours.
Pulse checks during CPR may be difficult due to low blood pressure, and the pulse check is prolonged to 1 minute for this reason. Drug metabolism is slowed in hypothermic patients, leading to a build-up of potentially toxic plasma concentrations of administered drugs. Current guidance advises withholding drugs if the core temperature is below 30ºC and doubling the drug interval at core temperatures between 30 and 35ºC. Electrolyte disturbances are common in hypothermic patients, and it is important to interpret results keeping the setting in mind. Hypoglycemia should be treated, hypokalemia will often correct as the patient re-warms, ABG analyzers may not reflect the reality of the hypothermic patient, and severe hyperkalemia is a poor prognostic indicator.
Different warming measures can be used to increase the core body temperature, including external passive measures such as removal of wet clothes and insulation with blankets, external active measures such as forced heated air or hot-water immersion, and internal active measures such as inhalation of warm air, warmed intravenous fluids, gastric, bladder, peritoneal and/or pleural lavage and high volume renal haemofilter.
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This question is part of the following fields:
- Cardiology
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Question 23
Incorrect
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A 45 year old man comes to the emergency department after intentionally overdosing on his digoxin medication. He informs you that he consumed approximately 50 tablets of digoxin shortly after discovering that his wife wants to end their marriage and file for divorce. Which of the following symptoms is commonly seen in cases of digoxin toxicity?
Your Answer: Peripheral cyanosis
Correct Answer: Yellow-green vision
Explanation:One of the signs of digoxin toxicity is yellow-green vision. Other clinical features include feeling generally unwell, lethargy, nausea and vomiting, loss of appetite, confusion, and the development of arrhythmias such as AV block and bradycardia.
Further Reading:
Digoxin is a medication used for rate control in atrial fibrillation and for improving symptoms in heart failure. It works by decreasing conduction through the atrioventricular node and increasing the force of cardiac muscle contraction. However, digoxin toxicity can occur, and plasma concentration alone does not determine if a patient has developed toxicity. Symptoms of digoxin toxicity include feeling generally unwell, lethargy, nausea and vomiting, anorexia, confusion, yellow-green vision, arrhythmias, and gynaecomastia.
ECG changes seen in digoxin toxicity include downsloping ST depression with a characteristic Salvador Dali sagging appearance, flattened, inverted, or biphasic T waves, shortened QT interval, mild PR interval prolongation, and prominent U waves. There are several precipitating factors for digoxin toxicity, including hypokalaemia, increasing age, renal failure, myocardial ischaemia, electrolyte imbalances, hypoalbuminaemia, hypothermia, hypothyroidism, and certain medications such as amiodarone, quinidine, verapamil, and diltiazem.
Management of digoxin toxicity involves the use of digoxin specific antibody fragments, also known as Digibind or digifab. Arrhythmias should be treated, and electrolyte disturbances should be corrected with close monitoring of potassium levels. It is important to note that digoxin toxicity can be precipitated by hypokalaemia, and toxicity can then lead to hyperkalaemia.
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This question is part of the following fields:
- Cardiology
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Question 24
Incorrect
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A 68-year-old woman presents with severe diarrhea one week after having a total knee replacement. The diarrhea has a foul odor and is yellow in color. A stool sample is sent to the laboratory and tests positive for Clostridium difficile toxin.
What is the MOST suitable course of action for management?Your Answer: IV teicoplanin
Correct Answer: Oral vancomycin
Explanation:Clostridium difficile is a type of bacteria that is Gram-positive, anaerobic, and capable of forming spores. It is found in the intestines of about 3% of healthy adults, according to estimates from the UK Health Protection Agency in 2012.
Clostridium difficile associated diarrhea (CDAD) often occurs after the use of broad-spectrum antibiotics, which disrupt the normal bacteria in the gut and allow Clostridium difficile to multiply. This leads to inflammation and bleeding in the lining of the large intestine, resulting in a distinct pseudomembranous appearance. The majority of Clostridium difficile infections are reported in individuals over the age of 65.
The main symptoms of CDAD include abdominal cramps, severe bloody and/or watery diarrhea, offensive-smelling diarrhea, and fever.
The gold standard for diagnosing Clostridium difficile colitis is a cytotoxin assay. However, this test can be challenging to perform and results may take up to 48 hours to obtain. The most commonly used laboratory test for diagnosing Clostridium difficile colitis is an enzyme-mediated immunoassay that detects toxins A and B. This test has a specificity of 93-100% and a sensitivity of 63-99%.
In some cases, patients may develop a condition called toxic megacolon, which can be life-threatening, especially in frail or elderly individuals.
The current recommended first-line treatment for CDAD is oral vancomycin. For more information, refer to the guidance provided by the National Institute for Health and Care Excellence (NICE) regarding the risk of Clostridium difficile infection associated with the use of broad-spectrum antibiotics.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 25
Correct
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A 32-year-old woman comes in with complaints of dysuria and frequent urination. She is currently 16 weeks pregnant. A urine dipstick test shows the presence of blood, protein, white blood cells, and nitrites. Based on this, you diagnose her with a urinary tract infection (UTI) and decide to prescribe antibiotics.
Which antibiotic would be the most suitable to prescribe in this situation?Your Answer: Nitrofurantoin
Explanation:For the treatment of pregnant women with lower urinary tract infections (UTIs), it is recommended to provide them with an immediate prescription for antibiotics. It is important to consider their previous urine culture and susceptibility results, as well as any prior use of antibiotics that may have contributed to the development of resistant bacteria. Before starting antibiotics, it is advised to obtain a midstream urine sample from pregnant women and send it for culture and susceptibility testing.
Once the microbiological results are available, it is necessary to review the choice of antibiotic. If the bacteria are found to be resistant, it is recommended to switch to a narrow-spectrum antibiotic whenever possible. The choice of antibiotics for pregnant women aged 12 years and over is summarized below:
First-choice:
– Nitrofurantoin 100 mg modified-release taken orally twice daily for 3 days, if the estimated glomerular filtration rate (eGFR) is above 45 ml/minute.Second-choice (if there is no improvement in lower UTI symptoms with the first-choice antibiotic for at least 48 hours, or if the first-choice is not suitable):
– Amoxicillin 500 mg taken orally three times daily for 7 days (only if culture results are available and show susceptibility).
– Cefalexin 500 mg taken twice daily for 7 days.For alternative second-choice antibiotics, it is recommended to consult a local microbiologist and choose the appropriate antibiotics based on the culture and sensitivity results.
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This question is part of the following fields:
- Urology
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Question 26
Correct
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A 72 year old male with a history of COPD is brought into the emergency department due to worsening shortness of breath. You observe that the patient has been utilizing home oxygen, home salbutamol and ipratropium nebulizers, and began taking a rescue pack of antibiotics and steroids yesterday.
Which of the following factors would indicate the initiation of BiPAP ventilation?Your Answer: pH less than 7.35 on arterial blood gas
Explanation:Non-invasive ventilation is recommended for patients with hypercapnia and acidosis. Respiratory acidosis, indicated by a pH level below 7.35, is a strong indication for the use of BiPAP. However, patients with a pH level of 7.25 or lower may not respond well to non-invasive ventilation and should be considered for intensive care unit (ITU) treatment. Another criterion for the use of BiPAP is hypercapnia, which is characterized by an arterial pCO2 level greater than 6.0 KPa.
Further Reading:
Mechanical ventilation is the use of artificial means to assist or replace spontaneous breathing. It can be invasive, involving instrumentation inside the trachea, or non-invasive, where there is no instrumentation of the trachea. Non-invasive mechanical ventilation (NIV) in the emergency department typically refers to the use of CPAP or BiPAP.
CPAP, or continuous positive airways pressure, involves delivering air or oxygen through a tight-fitting face mask to maintain a continuous positive pressure throughout the patient’s respiratory cycle. This helps maintain small airway patency, improves oxygenation, decreases airway resistance, and reduces the work of breathing. CPAP is mainly used for acute cardiogenic pulmonary edema.
BiPAP, or biphasic positive airways pressure, also provides positive airway pressure but with variations during the respiratory cycle. The pressure is higher during inspiration than expiration, generating a tidal volume that assists ventilation. BiPAP is mainly indicated for type 2 respiratory failure in patients with COPD who are already on maximal medical therapy.
The pressure settings for CPAP typically start at 5 cmH2O and can be increased to a maximum of 15 cmH2O. For BiPAP, the starting pressure for expiratory pressure (EPAP) or positive end-expiratory pressure (PEEP) is 3-5 cmH2O, while the starting pressure for inspiratory pressure (IPAP) is 10-15 cmH2O. These pressures can be titrated up if there is persisting hypoxia or acidosis.
In terms of lung protective ventilation, low tidal volumes of 5-8 ml/kg are used to prevent atelectasis and reduce the risk of lung injury. Inspiratory pressures (plateau pressure) should be kept below 30 cm of water, and permissible hypercapnia may be allowed. However, there are contraindications to lung protective ventilation, such as unacceptable levels of hypercapnia, acidosis, and hypoxemia.
Overall, mechanical ventilation, whether invasive or non-invasive, is used in various respiratory and non-respiratory conditions to support or replace spontaneous breathing and improve oxygenation and ventilation.
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This question is part of the following fields:
- Respiratory
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Question 27
Incorrect
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You consult with your supervisor for a case-based discussion following a case where you treated a pediatric patient with a peritonsillar abscess. Your supervisor suggests that you take the lead in conducting a teaching session on peritonsillar abscess in children.
Which of the following statements about peritonsillar abscess in pediatric patients is accurate?Your Answer: Female sex is a risk factor
Correct Answer: Most commonly presents in adolescents and young adults aged 20-40 years
Explanation:Peritonsillar abscess, also known as quinsy, is most commonly seen in adolescents and young adults between the ages of 20 and 40. Risk factors for developing quinsy include being male and smoking. It is a relatively common condition, with studies showing an incidence rate of 10 to 30 cases per 100,000 population. When treating quinsy, it is important to use a broader range of antibiotics compared to standard treatment for pharyngotonsillitis, as the causative organisms may not be limited to Group A Streptococcus. Common antibiotic choices include intravenous amoxicillin with clindamycin or metronidazole, although the specific antibiotic used may vary depending on local antimicrobial policies.
Further Reading:
A peritonsillar abscess, also known as quinsy, is a collection of pus that forms between the palatine tonsil and the pharyngeal muscles. It is often a complication of acute tonsillitis and is most commonly seen in adolescents and young adults. The exact cause of a peritonsillar abscess is not fully understood, but it is believed to occur when infection spreads beyond the tonsillar capsule or when small salivary glands in the supratonsillar space become blocked.
The most common causative organisms for a peritonsillar abscess include Streptococcus pyogenes, Staphylococcus aureus, Haemophilus influenzae, and anaerobic organisms. Risk factors for developing a peritonsillar abscess include smoking, periodontal disease, male sex, and a previous episode of the condition.
Clinical features of a peritonsillar abscess include severe throat pain, difficulty opening the mouth (trismus), fever, headache, drooling of saliva, bad breath, painful swallowing, altered voice, ear pain on the same side, neck stiffness, and swelling of the soft palate. Diagnosis is usually made based on clinical presentation, but imaging scans such as CT or ultrasound may be used to assess for complications or determine the best site for drainage.
Treatment for a peritonsillar abscess involves pain relief, intravenous antibiotics to cover for both aerobic and anaerobic organisms, intravenous fluids if swallowing is difficult, and drainage of the abscess either through needle aspiration or incision and drainage. Tonsillectomy may be recommended to prevent recurrence. Complications of a peritonsillar abscess can include sepsis, spread to deeper neck tissues leading to necrotizing fasciitis or retropharyngeal abscess, airway compromise, recurrence of the abscess, aspiration pneumonia, erosion into major blood vessels, and complications related to the causative organism. All patients with a peritonsillar abscess should be referred to an ear, nose, and throat specialist for further management.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 28
Correct
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A 23-year-old arrives at the emergency department complaining of fatigue, a severe sore throat, and swollen neck glands that have persisted for more than a week. He visited his primary care physician yesterday and was prescribed amoxicillin. However, today he woke up with a rash all over his body and his throat has not improved. During the examination, a widespread non-blanching maculopapular rash is observed.
What is the probable underlying cause of the patient's symptoms?Your Answer: Epstein-Barr virus
Explanation:In cases of acute glandular fever, certain antibiotics like ampicillin and amoxicillin can potentially cause severe rashes that affect the entire body and specifically the extremities. The exact cause of these rashes is still unknown. If there is uncertainty in the diagnosis and the clinician wants to cover the possibility of streptococcal tonsillitis, it is recommended to use phenoxymethylpenicillin (penicillin V) as the preferred treatment.
Further Reading:
Glandular fever, also known as infectious mononucleosis or mono, is a clinical syndrome characterized by symptoms such as sore throat, fever, and swollen lymph nodes. It is primarily caused by the Epstein-Barr virus (EBV), with other viruses and infections accounting for the remaining cases. Glandular fever is transmitted through infected saliva and primarily affects adolescents and young adults. The incubation period is 4-8 weeks.
The majority of EBV infections are asymptomatic, with over 95% of adults worldwide having evidence of prior infection. Clinical features of glandular fever include fever, sore throat, exudative tonsillitis, lymphadenopathy, and prodromal symptoms such as fatigue and headache. Splenomegaly (enlarged spleen) and hepatomegaly (enlarged liver) may also be present, and a non-pruritic macular rash can sometimes occur.
Glandular fever can lead to complications such as splenic rupture, which increases the risk of rupture in the spleen. Approximately 50% of splenic ruptures associated with glandular fever are spontaneous, while the other 50% follow trauma. Diagnosis of glandular fever involves various investigations, including viral serology for EBV, monospot test, and liver function tests. Additional serology tests may be conducted if EBV testing is negative.
Management of glandular fever involves supportive care and symptomatic relief with simple analgesia. Antiviral medication has not been shown to be beneficial. It is important to identify patients at risk of serious complications, such as airway obstruction, splenic rupture, and dehydration, and provide appropriate management. Patients can be advised to return to normal activities as soon as possible, avoiding heavy lifting and contact sports for the first month to reduce the risk of splenic rupture.
Rare but serious complications associated with glandular fever include hepatitis, upper airway obstruction, cardiac complications, renal complications, neurological complications, haematological complications, chronic fatigue, and an increased risk of lymphoproliferative cancers and multiple sclerosis.
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This question is part of the following fields:
- Infectious Diseases
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Question 29
Incorrect
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You receive a needlestick injury after drawing blood from a 45-year-old patient. The patient is visiting due to experiencing frequent heart palpitations. Her only significant medical history is hypothyroidism, for which she is prescribed thyroxine.
What should be your initial course of action in this situation?Your Answer: Report the injury to the Health Protection Agency
Correct Answer: Wash the wound with soap and water and gently encourage bleeding
Explanation:First and foremost, the immediate concern is providing first aid for the wound. It is important to wash the wound with soap (or chlorhexidine) and water, while gently encouraging bleeding. It is crucial not to scrub or suck the wound. Additionally, if there are any splashes or body fluid that come into contact with the eyes or mouth, they should be thoroughly washed.
For all healthcare workers who experience a needlestick injury, it is necessary to have a baseline serum sample taken and stored. This should be arranged through occupational health. The subsequent management of the injury depends on the risk of blood-borne virus transmission. This risk is determined by factors such as the source patient’s history (e.g. IV drug use), the circumstances of the injury (e.g. visible blood on the device, use of personal protection equipment), and the healthcare worker’s own characteristics (e.g. response to hepatitis B vaccination).
If the patient consents after appropriate counseling, blood may be taken from the source patient for blood-borne virus testing. However, it is important to note that the injured healthcare worker should not be responsible for counseling and obtaining consent from the patient. Lastly, all needlestick injuries should be reported to the Health Protection Agency.
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This question is part of the following fields:
- Infectious Diseases
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Question 30
Incorrect
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A 4 week old female is brought into the emergency department by worried parents. They inform you that the patient had vomited a few times after feeds over the past week, but in the last day or two, the patient has been vomiting 30-45 minutes after every feed. The vomiting is non-bilious and projectile. You observe that the child is solely bottle fed.
What investigation would be the most helpful in confirming the suspected diagnosis?Your Answer: Venous blood gas
Correct Answer: Abdominal ultrasound
Explanation:The diagnostic criteria for hypertrophic pyloric stenosis (HPS) on ultrasound are as follows: the thickness of the pyloric muscle should be greater than 3 mm, the longitudinal length of the pylorus should be greater than 15-17 mm, the volume of the pylorus should be greater than 1.5 cm3, and the transverse diameter of the pylorus should be greater than 13 mm.
Further Reading:
Pyloric stenosis is a condition that primarily affects infants, characterized by the thickening of the muscles in the pylorus, leading to obstruction of the gastric outlet. It typically presents between the 3rd and 12th weeks of life, with recurrent projectile vomiting being the main symptom. The condition is more common in males, with a positive family history and being first-born being additional risk factors. Bottle-fed children and those delivered by c-section are also more likely to develop pyloric stenosis.
Clinical features of pyloric stenosis include projectile vomiting, usually occurring about 30 minutes after a feed, as well as constipation and dehydration. A palpable mass in the upper abdomen, often described as like an olive, may also be present. The persistent vomiting can lead to electrolyte disturbances, such as hypochloremia, alkalosis, and mild hypokalemia.
Ultrasound is the preferred diagnostic tool for confirming pyloric stenosis. It can reveal specific criteria, including a pyloric muscle thickness greater than 3 mm, a pylorus longitudinal length greater than 15-17 mm, a pyloric volume greater than 1.5 cm3, and a pyloric transverse diameter greater than 13 mm.
The definitive treatment for pyloric stenosis is pyloromyotomy, a surgical procedure that involves making an incision in the thickened pyloric muscle to relieve the obstruction. Before surgery, it is important to correct any hypovolemia and electrolyte disturbances with intravenous fluids. Overall, pyloric stenosis is a relatively common condition in infants, but with prompt diagnosis and appropriate management, it can be effectively treated.
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This question is part of the following fields:
- Paediatric Emergencies
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Question 31
Incorrect
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A 68-year-old is brought to the emergency department by his son. The patient complained of feeling sick. On checking the patient's medication, the son suspects he may have taken an excessive amount of digoxin tablets in the past few days. You are worried about digoxin toxicity. Which electrolyte imbalance is most frequently linked to triggering digoxin toxicity?
Your Answer: Hypermagnesaemia
Correct Answer: Hypokalaemia
Explanation:Digoxin toxicity can be triggered by hypokalaemia, a condition characterized by low levels of potassium in the body. This occurs because digoxin competes with potassium for binding sites, and when potassium levels are low, there is less competition for digoxin to bind to these sites. Additionally, other factors such as hypomagnesaemia, hypercalcaemia, hypernatraemia, and acidosis can also contribute to digoxin toxicity.
Further Reading:
Digoxin is a medication used for rate control in atrial fibrillation and for improving symptoms in heart failure. It works by decreasing conduction through the atrioventricular node and increasing the force of cardiac muscle contraction. However, digoxin toxicity can occur, and plasma concentration alone does not determine if a patient has developed toxicity. Symptoms of digoxin toxicity include feeling generally unwell, lethargy, nausea and vomiting, anorexia, confusion, yellow-green vision, arrhythmias, and gynaecomastia.
ECG changes seen in digoxin toxicity include downsloping ST depression with a characteristic Salvador Dali sagging appearance, flattened, inverted, or biphasic T waves, shortened QT interval, mild PR interval prolongation, and prominent U waves. There are several precipitating factors for digoxin toxicity, including hypokalaemia, increasing age, renal failure, myocardial ischaemia, electrolyte imbalances, hypoalbuminaemia, hypothermia, hypothyroidism, and certain medications such as amiodarone, quinidine, verapamil, and diltiazem.
Management of digoxin toxicity involves the use of digoxin specific antibody fragments, also known as Digibind or digifab. Arrhythmias should be treated, and electrolyte disturbances should be corrected with close monitoring of potassium levels. It is important to note that digoxin toxicity can be precipitated by hypokalaemia, and toxicity can then lead to hyperkalaemia.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 32
Incorrect
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A middle-aged individual with a history of intravenous drug use and unstable housing presents with extremely intense back pain, elevated body temperature, and weakness in the left leg. The patient has experienced multiple episodes of nighttime pain and is struggling to walk. During the examination, tenderness is noted in the lower lumbar spine, along with weakness in left knee extension and foot dorsiflexion.
What is the preferred diagnostic test to definitively confirm the diagnosis?Your Answer: CT scan spine
Correct Answer: MRI scan spine
Explanation:Discitis is an infection that affects the space between the intervertebral discs in the spine. This condition can have serious consequences, including the formation of abscesses and sepsis. The most common cause of discitis is usually Staphylococcus aureus, but other organisms like Streptococcus viridans and Pseudomonas aeruginosa may be responsible in intravenous drug users and those with weakened immune systems. Gram-negative organisms such as Escherichia coli and Mycobacterium tuberculosis can also cause discitis.
There are several risk factors that increase the likelihood of developing discitis. These include having undergone spinal surgery (which occurs in 1-2% of cases post-operatively), having an immunodeficiency, being an intravenous drug user, being under the age of eight, having diabetes mellitus, or having a malignancy.
The typical symptoms of discitis include back or neck pain (which occurs in over 90% of cases), pain that often wakes the patient from sleep, fever (present in 60-70% of cases), and neurological deficits (which can occur in up to 50% of cases). In children, refusal to walk may also be a symptom.
When diagnosing discitis, MRI is the preferred imaging modality due to its high sensitivity and specificity. It is important to image the entire spine, as discitis often affects multiple levels. Plain radiographs are not very sensitive to the early changes of discitis and may appear normal for 2-4 weeks. CT scanning is also not very sensitive in detecting discitis.
Treatment for discitis involves admission to the hospital for intravenous antibiotics. Before starting the antibiotics, it is important to send three sets of blood cultures and a full set of blood tests, including a CRP, to the lab. The choice of antibiotics depends on the specific situation. A typical antibiotic regimen for discitis may include IV flucloxacillin as the first-line treatment if there is no penicillin allergy, IV vancomycin if the infection was acquired in the hospital or there is a high risk of MRSA, and possibly IV gentamicin if there is a possibility of a Gram-negative infection. In cases where there is acute kidney injury and Gram-negative cover is required, IV piperacillin-tazobactam alone may be used.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 33
Incorrect
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A 60-year-old patient arrives at the Emergency Department with a deep cut on their leg. They have a history of alcoholism and typically consumes 10-12 drinks daily. Despite previous attempts at sobriety, they have consistently relapsed within a few days. It is currently 11 am, and they have already consumed alcohol today.
What would be the most suitable course of action to pursue?Your Answer: Arrange for their liver function to be tested
Correct Answer: Explore the reasons behind their previous relapses and the methods they have used to stop drinking in the past
Explanation:When addressing the management of long-term alcohol abuse and promoting self-care, it is important to start by exploring the reasons behind the patient’s previous relapses. This will help understand her beliefs and understanding of her condition and identify any simple, supportive measures that can aid in her efforts to stop drinking.
Referral to the Community Drug and Alcohol Team (CDAT) may be necessary at some point. Depending on the severity and duration of her alcohol abuse, she may be suitable for outpatient or community detox. However, if her drinking has been sustained and heavy for many years, she may require admission for additional support. It is important to note that there is often a long wait for available beds, so it would be more prudent to thoroughly explore her history before making this referral.
While arranging for her liver function to be tested could be part of the general work-up, it is unlikely to be necessary for a leg laceration. It is crucial to avoid suddenly abstaining or prescribing chlordiazepoxide, as these actions can be potentially dangerous. Abrupt detoxification may lead to delirium tremens, which can have catastrophic effects. Chlordiazepoxide may be used under the supervision of experienced professionals, but close monitoring and regular appointments with a GP or specialist are essential.
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This question is part of the following fields:
- Mental Health
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Question 34
Correct
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You are managing a 72-year-old male patient who has been intubated as a result of developing acute severe respiratory distress syndrome (ARDS). What is one of the four diagnostic criteria for ARDS?
Your Answer: Presence of hypoxaemia
Explanation:One of the diagnostic criteria for ARDS is the presence of hypoxemia. Other criteria include the onset of symptoms within 7 days of a clinical insult or new/worsening respiratory symptoms, bilateral opacities on chest X-ray that cannot be fully explained by other conditions, and respiratory failure that cannot be fully attributed to cardiac failure or fluid overload.
Further Reading:
ARDS is a severe form of lung injury that occurs in patients with a predisposing risk factor. It is characterized by the onset of respiratory symptoms within 7 days of a known clinical insult, bilateral opacities on chest X-ray, and respiratory failure that cannot be fully explained by cardiac failure or fluid overload. Hypoxemia is also present, as indicated by a specific threshold of the PaO2/FiO2 ratio measured with a minimum requirement of positive end-expiratory pressure (PEEP) ≥5 cm H2O. The severity of ARDS is classified based on the PaO2/FiO2 ratio, with mild, moderate, and severe categories.
Lung protective ventilation is a set of measures aimed at reducing lung damage that may occur as a result of mechanical ventilation. Mechanical ventilation can cause lung damage through various mechanisms, including high air pressure exerted on lung tissues (barotrauma), over distending the lung (volutrauma), repeated opening and closing of lung units (atelectrauma), and the release of inflammatory mediators that can induce lung injury (biotrauma). These mechanisms collectively contribute to ventilator-induced lung injury (VILI).
The key components of lung protective ventilation include using low tidal volumes (5-8 ml/kg), maintaining inspiratory pressures (plateau pressure) below 30 cm of water, and allowing for permissible hypercapnia. However, there are some contraindications to lung protective ventilation, such as an unacceptable level of hypercapnia, acidosis, and hypoxemia. These factors need to be carefully considered when implementing lung protective ventilation strategies in patients with ARDS.
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This question is part of the following fields:
- Respiratory
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Question 35
Correct
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A 25-year-old patient presents with a 48-hour history of right-sided facial weakness accompanied by pain behind the right ear. On examination, there is noticeable asymmetry in the face, with the patient unable to raise the right eyebrow or lift the right side of the mouth. There is no tenderness or swelling in the mastoid area, and the external auditory canal and tympanic membrane appear normal. Evaluation of the remaining cranial nerves shows no abnormalities, and there are no other focal neurological deficits detected. What is the most appropriate initial management for this patient?
Your Answer: Prescribe prednisolone 50 mg daily for 10 days
Explanation:The main treatment options for Bell’s palsy are oral prednisolone and proper eye care. Referral to a specialist is typically not necessary. It is recommended to start steroid treatment within 72 hours of symptom onset. Currently, NICE does not recommend the use of antiviral medications for Bell’s palsy.
Further Reading:
Bell’s palsy is a condition characterized by sudden weakness or paralysis of the facial nerve, resulting in facial muscle weakness or drooping. The exact cause is unknown, but it is believed to be related to viral infections such as herpes simplex or varicella zoster. It is more common in individuals aged 15-45 years and those with diabetes, obesity, hypertension, or upper respiratory conditions. Pregnancy is also a risk factor.
Diagnosis of Bell’s palsy is typically based on clinical symptoms and ruling out other possible causes of facial weakness. Symptoms include rapid onset of unilateral facial muscle weakness, drooping of the eyebrow and corner of the mouth, loss of the nasolabial fold, otalgia, difficulty chewing or dry mouth, taste disturbance, eye symptoms such as inability to close the eye completely, dry eye, eye pain, and excessive tearing, numbness or tingling of the cheek and mouth, speech articulation problems, and hyperacusis.
When assessing a patient with facial weakness, it is important to consider other possible differentials such as stroke, facial nerve tumors, Lyme disease, granulomatous diseases, Ramsay Hunt syndrome, mastoiditis, and chronic otitis media. Red flags for these conditions include insidious and painful onset, duration of symptoms longer than 3 months with frequent relapses, pre-existing risk factors, systemic illness or fever, vestibular or hearing abnormalities, and other cranial nerve involvement.
Management of Bell’s palsy involves the use of steroids, eye care advice, and reassurance. Steroids, such as prednisolone, are recommended for individuals presenting within 72 hours of symptom onset. Eye care includes the use of lubricating eye drops, eye ointment at night, eye taping if unable to close the eye at night, wearing sunglasses, and avoiding dusty environments. Reassurance is important as the majority of patients make a complete recovery within 3-4 months. However, some individuals may experience sequelae such as facial asymmetry, gustatory lacrimation, inadequate lid closure, brow ptosis, drooling, and hemifacial spasms.
Antiviral treatments are not currently recommended as a standalone treatment for Bell’s palsy, but they may be given in combination with corticosteroids on specialist advice. Referral to an ophthalmologist is necessary if the patient has eye symptoms such as pain, irritation, or itch.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 36
Incorrect
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A 2-week-old baby comes in with vomiting, decreased weight, and an electrolyte imbalance. After being referred to the pediatricians, they are diagnosed with congenital adrenal hyperplasia (CAH).
Which ONE statement is correct about this condition?Your Answer: Treated females are infertile
Correct Answer: Diagnosis can be made by finding elevated 17-hydroxyprogesterone levels
Explanation:Congenital adrenal hyperplasia (CAH) is a group of inherited disorders that are caused by autosomal recessive genes. The majority of affected patients, over 90%, have a deficiency of the enzyme 21-hydroxylase. This enzyme is encoded by the 21-hydroxylase gene, which is located on chromosome 6p21 within the HLA histocompatibility complex. The second most common cause of CAH is a deficiency of the enzyme 11-beta-hydroxylase. The condition is rare, with an incidence of approximately 1 in 500 births in the UK. It is more prevalent in the offspring of consanguineous marriages.
The deficiency of 21-hydroxylase leads to a deficiency of cortisol and/or aldosterone, as well as an excess of precursor steroids. As a result, there is an increased secretion of ACTH from the anterior pituitary, leading to adrenocortical hyperplasia.
The severity of CAH varies depending on the degree of 21-hydroxylase deficiency. Female infants often exhibit ambiguous genitalia, such as clitoral hypertrophy and labial fusion. Male infants may have an enlarged scrotum and/or scrotal pigmentation. Hirsutism, or excessive hair growth, occurs in 10% of cases.
Boys with CAH often experience a salt-losing adrenal crisis at around 1-3 weeks of age. This crisis is characterized by symptoms such as vomiting, weight loss, floppiness, and circulatory collapse.
The diagnosis of CAH can be made by detecting markedly elevated levels of the metabolic precursor 17-hydroxyprogesterone. Neonatal screening is possible, primarily through the identification of persistently elevated 17-hydroxyprogesterone levels.
In infants presenting with a salt-losing crisis, the following biochemical abnormalities are observed: hyponatremia (low sodium levels), hyperkalemia (high potassium levels), metabolic acidosis, and hypoglycemia.
Boys experiencing a salt-losing crisis will require fluid resuscitation, intravenous dextrose, and intravenous hydrocortisone.
Affected females will require corrective surgery for their external genitalia. However, they have an intact uterus and ovaries and are capable of having children.
The long-term management of both sexes involves lifelong replacement of hydrocortisone (to suppress ACTH levels).
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This question is part of the following fields:
- Endocrinology
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Question 37
Incorrect
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A 65-year-old diabetic man presents with a gradual decrease in consciousness and confusion over the past week. He normally controls his diabetes with metformin 500 mg twice a day. He recently received treatment for a urinary tract infection from his doctor, and his family reports that he has been excessively thirsty. He has vomited multiple times today. A urine dipstick test shows a small amount of white blood cells and 1+ ketones. His arterial blood gas results are as follows:
pH: 7.29
pO2: 11.1 kPa
pCO2: 4.6 kPa
HCO3-: 22 mmol/l
Na+: 154 mmol/l
K+: 3.2 mmol/l
Cl-: 100 mmol/l
Urea: 17.6 mmol/l
Glucose: 32 mmol/l
What is the SINGLE most likely diagnosis?Your Answer: Urinary sepsis
Correct Answer: Hyperosmolar hyperglycaemic state
Explanation:In an elderly patient with a history of gradual decline accompanied by high blood sugar levels, excessive thirst, and recent infection, the most likely diagnosis is hyperosmolar hyperglycemic state (HHS). This condition can be life-threatening, with a mortality rate of approximately 50%. Common symptoms include dehydration, elevated blood sugar levels, altered mental status, and electrolyte imbalances. About half of the patients with HHS also experience hypernatremia.
To calculate the serum osmolality, the formula is 2(K+ + Na+) + urea + glucose. In this case, the serum osmolality is 364 mmol/l, indicating a high level. It is important to discontinue the use of metformin in this patient due to the risk of metformin-associated lactic acidosis (MALA). Additionally, an intravenous infusion of insulin should be initiated.
The treatment goals for HHS are to address the underlying cause and gradually and safely:
– Normalize the osmolality
– Replace fluid and electrolyte losses
– Normalize blood glucose levelsIf significant ketonaemia is present (3β-hydroxybutyrate is more than 1 mmol/L), it indicates a relative lack of insulin, and insulin should be administered immediately. However, if significant ketonaemia is not present, insulin should not be started.
Patients with HHS are at a high risk of thromboembolism, and it is recommended to routinely administer low molecular weight heparin. In cases where the serum osmolality exceeds 350 mmol/l, full heparinization should be considered.
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This question is part of the following fields:
- Endocrinology
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Question 38
Incorrect
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A 42-year-old woman comes in with lower abdominal pain and a small amount of rectal bleeding. During the examination, she has a slight fever (38.1°C) and experiences tenderness in the left iliac fossa. She has a long history of constipation.
What is the SINGLE most probable diagnosis?Your Answer: Colon cancer
Correct Answer: Acute diverticulitis
Explanation:Acute diverticulitis occurs when a diverticulum becomes inflamed or perforated. This inflammation can either stay localized, forming a pericolic abscess, or spread and cause peritonitis. The typical symptoms of acute diverticulitis include abdominal pain (most commonly felt in the lower left quadrant), fever/sepsis, tenderness in the left iliac fossa, the presence of a mass in the left iliac fossa, and rectal bleeding. About 90% of cases involve the sigmoid colon, which is why left iliac fossa pain and tenderness are commonly seen.
To diagnose acute diverticulitis, various investigations should be conducted. These include blood tests such as a full blood count, urea and electrolytes, C-reactive protein, and blood cultures. Imaging studies like abdominal X-ray, erect chest X-ray, and possibly an abdominal CT scan may also be necessary.
Complications that can arise from acute diverticulitis include perforation leading to abscess formation or peritonitis, intestinal obstruction, massive rectal bleeding, fistulae, and strictures.
In the emergency department, the treatment for diverticulitis should involve providing suitable pain relief, administering intravenous fluids, prescribing broad-spectrum antibiotics (such as intravenous co-amoxiclav), and advising the patient to refrain from eating or drinking. It is also important to refer the patient to the on-call surgical team for further management.
For more information on diverticular disease, you can refer to the NICE Clinical Knowledge Summary.
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This question is part of the following fields:
- Surgical Emergencies
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Question 39
Incorrect
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You evaluate a 45-year-old man with a history of difficult-to-control hypertension. His initial diagnosis was made after ambulatory blood pressure monitoring. He is currently taking Lisinopril 10 mg once daily and Amlodipine 10 mg once daily. Despite this treatment, his blood pressure today is 156/98. On examination, he appears normal and is otherwise in good health. A recent blood test shows the following results:
Sodium: 145 mmol/L (135-147 mmol/L)
Potassium: 3.2 mmol/L (3.5-5.5 mmol/L)
Urea: 6.3 mmol/L (2.0-6.6 mmol/L)
Creatinine: 88 mmol/L (75-125 mmol/L)
What is the MOST LIKELY diagnosis?Your Answer: Cushing’s syndrome
Correct Answer: Primary hyperaldosteronism
Explanation:The most probable diagnosis in this case is primary hyperaldosteronism, which is caused by either an adrenal adenoma (Conn’s syndrome) or bilateral idiopathic adrenal hyperplasia. Conn’s syndrome is likely in a patient who has difficult-to-control hypertension, low levels of potassium (hypokalaemia), and elevated or high normal levels of sodium. If the aldosterone:renin ratio is raised (>30), it further suggests primary hyperaldosteronism. CT scanning can be used to differentiate between an adrenal adenoma and adrenal hyperplasia. Treatment for hyperaldosteronism caused by an adenoma typically involves 4-6 weeks of spironolactone therapy followed by surgical removal of the adenoma. Adrenal hyperplasia usually responds well to potassium-sparing diuretics alone, such as spironolactone or amiloride.
Renal artery stenosis could also be suspected in a case of resistant hypertension, but it would be expected to cause a decline in renal function when taking a full dose of an ACE inhibitor like ramipril. However, in this case, the patient’s renal function is completely normal.
Phaeochromocytoma is associated with symptoms such as headaches, palpitations, tremors, and excessive sweating. The hypertension in phaeochromocytoma tends to occur in episodes. Since these symptoms are absent in this patient, a diagnosis of phaeochromocytoma is unlikely.
Cushing’s syndrome is characterized by various other clinical features, including weight gain, central obesity, a hump-like accumulation of fat on the back (buffalo hump), muscle wasting in the limbs, excessive hair growth (hirsutism), thinning of the skin, easy bruising, acne, and depression. Since this patient does not exhibit any of these features, Cushing’s syndrome is unlikely.
White coat syndrome is an unlikely diagnosis in this case because the initial diagnosis of hypertension was made based on ambulatory blood pressure monitoring.
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This question is part of the following fields:
- Endocrinology
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Question 40
Incorrect
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A 9-month-old girl comes in with a significant haemarthrosis in her left knee after falling while trying to stand up using a side table. Her mother mentions that her older sister has a bleeding disorder and has also had haemarthrosis before.
What is the MOST probable diagnosis?Your Answer: Von Willebrand disease
Correct Answer: Haemophilia A
Explanation:Haemophilia is a collection of genetic disorders that are inherited and lead to impaired blood clotting. Haemophilia A specifically occurs when there is a deficiency of factor VIII and is typically passed down as a recessive trait on the X chromosome.
The initial signs of haemophilia A usually appear around 6 months of age when infants start crawling, although it can manifest later. Bleeding can occur either spontaneously or as a result of trauma. One key indicator of haemophilia is bleeding into muscles and joints, known as haemarthrosis. While gastrointestinal and cerebral bleeding can also happen, they are less common occurrences.
Based on the symptoms described, the most likely diagnosis from the given options would be Haemophilia A, especially when there is a combination of haemarthrosis and an older brother with the same disorder.
Idiopathic thrombocytopenic purpura (ITP) is a condition where the immune system causes a decrease in platelet count. Antibodies target the glycoprotein IIb-IIIa or Ib complex. Acute ITP is more prevalent in children and affects both sexes equally. Chronic ITP, on the other hand, is more common in young to middle-aged women. Unlike haemophilia, ITP typically presents with symptoms such as nosebleeds, oral bleeding, purpura, or petechiae, rather than haemarthrosis. Additionally, ITP is not an inherited disorder.
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an inherited disorder that follows an X-linked recessive pattern. It is characterized by a defect in the G6PD enzyme, which plays a crucial role in red blood cell metabolism. Most individuals with G6PD deficiency do not experience symptoms. However, haemolytic crisis can occur in response to factors like illness (especially infection and diabetic ketoacidosis), certain medications (such as specific antibiotics, antimalarials, sulphonamides, and aspirin), or certain foods (notably fava beans).
Von Willebrand disease (vWD) is the most common hereditary coagulation disorder, affecting approximately 1 in 100 individuals. It arises from a deficiency in Von Willebrand factor (vWF), which leads to reduced levels of factor VIII. vWF is responsible for protecting factor VIII from rapid breakdown in the blood and is also necessary for platelet adhesion.
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This question is part of the following fields:
- Haematology
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Question 41
Correct
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A 45-year-old woman presents with a 6-month history of lower back pain and rib pain. She has been brought to your clinic today by her husband, who is concerned about her confusion over the past few days. She has also had difficulty passing urine today. On examination, she appears pale and has tenderness over her lumbar spine and lower ribs. Fundoscopy reveals retinal haemorrhages. Her most recent blood results are shown below:
Hb 8.4 g/dl (13-17 g/dl)
MCV 102.6 fl (80-100 fl)
Platelets 114 x 109/l (150-400 x 109/l)
WCC 3.4 x 109/l (4-11 x 109/l)
Normal differential
Sodium 140 mmol/l (135-145 mmol/l)
Potassium 4.6 mmol/l (3.5-5.0 mmol/l)
Calcium 2.94 mmol/l (2.05-2.60 mmol/l)
Creatinine 193 mmol/l (60-110 mmol/l)
Urea 11.2 mmol/l (3-7 mmol/l)
Total protein 88 g/l (60-85 g/l)
Albumin 23 g/l (36-52 g/l)
ESR 132 mm/hr (30 mm/hr)
Which is the SINGLE most likely diagnosis?Your Answer: Multiple myeloma
Explanation:Multiple myeloma is a cancerous growth of plasma cells, a type of white blood cell responsible for producing antibodies. It is more prevalent in men and typically occurs in individuals over the age of 60.
When a patient over 60 presents with an elevated ESR, unexplained anemia, hypercalcemia, renal impairment, and bone pain, the initial diagnosis is usually multiple myeloma until proven otherwise.
The most common symptoms of multiple myeloma include:
1. Anemia: This is caused by the infiltration of the bone marrow and suppression of blood cell production. It is typically normocytic and normochromic, but can also be macrocytic.
2. Bone pain: Approximately 70% of patients experience bone pain, which commonly affects the spine and ribs. Localized pain and tenderness may indicate a pathological fracture, and vertebral fractures can lead to spinal cord compression.
3. Renal failure: Acute or chronic renal failure occurs in about one-third of patients. This is generally due to the effects of light chains on the tubules.
4. Neurological symptoms: Hypercalcemia can cause weakness, lethargy, and confusion, while hyperviscosity can result in headaches and retinopathy. Amyloid infiltration can lead to peripheral neuropathies, with carpal tunnel syndrome being the most common.
5. Infection: The most common infections seen in multiple myeloma patients are pyelonephritis and pneumonia.
In addition to the routine blood tests already conducted, a suspected diagnosis of multiple myeloma should prompt further investigations, including:
– Plasma viscosity measurement
– Urinary protein electrophoresis to detect Bence-Jones proteins
– Serum electrophoresis to identify the type of paraprotein
– Quantitative immunoglobulin level testing
– Skeletal survey to look for lytic lesions
– Bone marrow aspirate and possibly biopsyA diagnosis of multiple myeloma is confirmed by the presence of a monoclonal protein in the serum or urine, lytic lesions on X-ray, and an increased number of plasma cells in the bone marrow.
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This question is part of the following fields:
- Haematology
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Question 42
Incorrect
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A 72-year-old woman presents with a painful swollen left big toe. The pain started this morning and is described as the most severe pain she has ever experienced. It has gradually worsened over the past 8 hours. She is unable to wear socks or shoes and had to come to the appointment in opened toe sandals. The overlying skin is red and shiny.
She has a history of hypertension, which has been difficult to control. She is currently taking amlodipine 10 mg and ramipril 10 mg per day for this and is awaiting a review of her antihypertensive medication. Her blood pressure today is 165/94 mmHg.
She has recently also been diagnosed with a myelodysplastic syndrome and has to have regular blood transfusions. She is being monitored in a local haematology clinic for a low white cell count and thrombocytopenia.
What is the SINGLE most appropriate next step in her management?Your Answer: Commence colchicine
Correct Answer: Commence prednisolone
Explanation:The diagnosis in this case is clearly gout. According to the guidelines from the European League Against Rheumatism (EULAR), the development of sudden joint pain accompanied by swelling, tenderness, and redness, which worsens over a period of 6-12 hours, strongly suggests crystal arthropathy.
Checking serum urate levels to confirm high levels of uric acid before starting treatment for acute gout attacks is not very beneficial and should not delay treatment. While these levels can be useful for monitoring treatment response, they often decrease during an acute attack and can even be normal. If levels are checked and found to be normal during an attack, they should be rechecked once the attack has resolved.
The first-line treatment for acute gout attacks is non-steroidal anti-inflammatory drugs (NSAIDs) like naproxen. However, caution should be exercised when using NSAIDs in patients with a history of hypertension. Since this patient has had difficulty controlling their blood pressure and remains hypertensive, it would be wise to avoid NSAIDs in this case.
Colchicine is an effective alternative for treating gout, although it may take longer to take effect. It is often used in patients who cannot take NSAIDs due to contraindications, such as hypertension or a history of peptic ulcer disease. It’s important to note that colchicine can have effects on the bone marrow, leading to an increase in neutrophils and a decrease in platelets. Therefore, it should not be used in patients with blood disorders, as is the case with this patient.
Allopurinol should not be used during an acute gout attack as it can prolong the attack and even trigger another acute attack. If a patient is already taking allopurinol, it should be continued, and the acute attack should be treated with NSAIDs, colchicine, or corticosteroids as appropriate.
Corticosteroids are an effective alternative for managing acute gout in patients who cannot take NSAIDs or colchicine. They can be administered orally, intramuscularly, intravenously, or directly into the affected joint. In this patient’s case, using corticosteroids would be the safest and most reasonable treatment option.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 43
Incorrect
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A 25-year-old man is brought to the Emergency Department by his friend following taking an overdose of one of his prescribed medications. He is agitated, confused and is experiencing visual hallucinations. His heart rate is currently 110 bpm, and his pupils are dilated. It is difficult to obtain a history from him as he is mumbling. You also note that he appears flushed and his skin is warm to the touch.
Which of the following drugs is most likely to be responsible?Your Answer: Theophylline
Correct Answer: Chlorpromazine
Explanation:This patient exhibits clinical features that are consistent with the ingestion of a drug that blocks the action of the neurotransmitter acetylcholine in the central and peripheral nervous system. There are several anticholinergic drugs commonly used in clinical practice. Some examples include antihistamines like promethazine and diphenhydramine, typical and atypical antipsychotics such as haloperidol and quetiapine, anticonvulsants like carbamazepine, antidepressants like tricyclic antidepressants, and antispasmodics like hyoscine butylbromide. Other sources of anticholinergic effects can come from plants like datura species and certain mushrooms.
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 both the central and peripheral nervous system. The central inhibition leads to 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 and seizures. The peripheral inhibition can cause dilated pupils, sinus tachycardia, dry mouth, hot and flushed skin, increased body temperature, urinary retention, and ileus.
In summary, the ingestion of an anticholinergic drug can result in a toxidrome characterized by an agitated delirium and various signs of central and peripheral acetylcholine receptor blockade. It is important to be aware of the potential effects of these drugs and to recognize the clinical features associated with their ingestion.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 44
Incorrect
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A 7-year-old boy is brought to the Emergency Department with lower abdominal pain and a high temperature. During the examination, he experiences tenderness in the right iliac fossa, leading to a preliminary diagnosis of acute appendicitis. However, he adamantly refuses to flex his thigh at the hip, and when you attempt to extend it passively, his abdominal pain intensifies.
Which muscle is most likely in contact with the inflamed structure causing these symptoms?Your Answer: Obturator internus
Correct Answer: Psoas major
Explanation:This patient is exhibiting the psoas sign, which is a medical indication of irritation in the iliopsoas group of hip flexors located in the abdomen. In this particular case, it is highly likely that the patient has acute appendicitis.
The psoas sign can be observed by extending the patient’s thigh while they are lying on their side with their knees extended, or by asking the patient to actively flex their thigh at the hip. If these movements result in abdominal pain or if the patient resists due to pain, then the psoas sign is considered positive.
The pain occurs because the psoas muscle is adjacent to the peritoneal cavity. When the muscles are stretched or contracted, they rub against the inflamed tissues nearby, causing discomfort. This strongly suggests that the appendix is positioned retrocaecal.
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This question is part of the following fields:
- Surgical Emergencies
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Question 45
Incorrect
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A 35 year old female is brought into the emergency department with chest injuries after a canister was thrown into a fire and the explosive projectile struck the patient's chest wall. On examination, there is asymmetry of the chest. You observe that the chest wall moves inward during inhalation and outward during expiration.
What is the term for this clinical sign?Your Answer: Pectus carinatum
Correct Answer: Paradoxical breathing
Explanation:The patient in this scenario is exhibiting a clinical sign known as paradoxical breathing. This is characterized by an abnormal movement of the chest wall during respiration. Normally, the chest expands during inhalation and contracts during exhalation. However, in paradoxical breathing, the opposite occurs. The chest wall moves inward during inhalation and outward during exhalation. This can be seen in cases of chest trauma or injury, where there is a disruption in the normal mechanics of breathing.
Further Reading:
Flail chest is a serious condition that occurs when multiple ribs are fractured in two or more places, causing a segment of the ribcage to no longer expand properly. This condition is typically caused by high-impact thoracic blunt trauma and is often accompanied by other significant injuries to the chest.
The main symptom of flail chest is a chest deformity, where the affected area moves in a paradoxical manner compared to the rest of the ribcage. This can cause chest pain and difficulty breathing, known as dyspnea. X-rays may also show evidence of lung contusion, indicating further damage to the chest.
In terms of management, conservative treatment is usually the first approach. This involves providing adequate pain relief and respiratory support to the patient. However, if there are associated injuries such as a pneumothorax or hemothorax, specific interventions like thoracostomy or surgery may be necessary.
Positive pressure ventilation can be used to provide internal splinting of the airways, helping to prevent atelectasis, a condition where the lungs collapse. Overall, prompt and appropriate management is crucial in order to prevent further complications and improve the patient’s outcome.
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This question is part of the following fields:
- Trauma
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Question 46
Incorrect
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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 potential terrorist act
Correct 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 47
Incorrect
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You review a 30-year-old man who presents with an acute exacerbation of asthma and consider ordering a chest X-ray.
Which of the following is NOT a reason to perform a chest X-ray in the evaluation of acute asthma?Your Answer: Suspected consolidation
Correct Answer: Acute severe asthma
Explanation:Chest X-rays are not typically recommended as a routine investigation for acute asthma. However, they may be necessary in specific situations. These situations include suspected pneumomediastinum or consolidation, as well as cases of life-threatening asthma. Additionally, if a patient fails to respond adequately to treatment or requires ventilation, a chest X-ray may be performed. It is important to note that these circumstances warrant the use of chest X-rays, but they are not routinely indicated for the investigation of acute asthma.
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This question is part of the following fields:
- Respiratory
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Question 48
Correct
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A 42-year-old woman with a long history of anxiety presents having taken a deliberate overdose of the pills she takes for insomnia. She informs you that the pill she takes for this condition is zolpidem 10 mg. She consumed the pills approximately 2 hours ago. She is currently hypotensive, with her most recent blood pressure reading being 82/56 mmHg. She weighs 70 kg. You administer a dose of calcium chloride, but there is no improvement in her condition.
Which of the following treatments is LEAST likely to be helpful in supporting her cardiovascular system?Your Answer: Magnesium sulphate
Explanation:Calcium-channel blocker overdose is a serious condition that can be life-threatening. The most dangerous types of calcium channel blockers in overdose are verapamil and diltiazem. These medications work by binding to the alpha-1 subunit of L-type calcium channels, which prevents the entry of calcium into cells. These channels are important for the functioning of cardiac myocytes, vascular smooth muscle cells, and islet beta-cells.
When managing a patient with calcium-channel blocker overdose, it is crucial to follow the standard ABC approach for resuscitation. If there is a risk of life-threatening toxicity, early intubation and ventilation should be considered. Invasive blood pressure monitoring is also necessary if hypotension and shock are developing.
The specific treatments for calcium-channel blocker overdose primarily focus on supporting the cardiovascular system. These treatments include:
1. Fluid resuscitation: Administer up to 20 mL/kg of crystalloid solution.
2. Calcium administration: This can temporarily increase blood pressure and heart rate. Options include 10% calcium gluconate (60 mL IV) or 10% calcium chloride (20 mL IV) via central venous access. Repeat boluses can be given up to three times, and a calcium infusion may be necessary to maintain serum calcium levels above 2.0 mEq/L.
3. Atropine: Consider administering 0.6 mg every 2 minutes, up to a total of 1.8 mg. However, atropine is often ineffective in these cases.
4. High dose insulin – euglycemic therapy (HIET): The use of HIET in managing cardiovascular toxicity has evolved. It used to be a last-resort measure, but early administration is now increasingly recommended. This involves giving a bolus of short-acting insulin (1 U/kg) and 50 mL of 50% glucose IV (unless there is marked hyperglycemia). Therapy should be continued with a short-acting insulin/dextrose infusion. Glucose levels should be monitored frequently, and potassium should be replaced if levels drop below 2.5 mmol/L.
5. Vasoactive infusions: Catecholamines such as dopamine, adrenaline, and/or noradrenaline can be titrated to achieve the desired inotropic and chronotropic effects.
6. Sodium bicarbonate: Consider using sodium bicarbonate in cases where a severe metabolic acidosis develops.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 49
Incorrect
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A 68-year-old patient with advanced metastatic prostate cancer is experiencing significant difficulty breathing and appears visibly distressed. Despite his discomfort, he remains mentally alert and reports moderate levels of pain. He has been informed that he has only a few days left to live. Currently, his oxygen saturation levels are at 95% when breathing regular air, and there are no specific signs of chest abnormalities.
What would be the most suitable course of action to alleviate his breathlessness in this situation?Your Answer: Salbutamol nebulisers
Correct Answer: Oral morphine
Explanation:Here are some suggestions for managing breathlessness in the final days of life, as provided by NICE:
1. It is important to identify and treat any reversible causes of breathlessness in the dying person, such as pulmonary edema or pleural effusion.
2. Non-pharmacological methods can be considered for managing breathlessness in someone nearing the end of life. It is not recommended to start oxygen therapy as a routine measure. Oxygen should only be offered to individuals who are known or suspected to have symptomatic hypoxemia.
3. Breathlessness can be managed using different medications, including opioids, benzodiazepines, or a combination of both.
For more detailed information, you can refer to the NICE guidance on the care of dying adults in the last days of life. https://www.nice.org.uk/guidance/ng31
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This question is part of the following fields:
- Palliative & End Of Life Care
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Question 50
Incorrect
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A 45 year old woman is brought into the emergency department after intentionally overdosing on a significant amount of amitriptyline following the end of a relationship. You order an ECG. What ECG changes are commonly seen in cases of amitriptyline overdose?
Your Answer: Absent P-waves
Correct Answer: Prolongation of QRS
Explanation:TCA toxicity can be identified through specific changes seen on an electrocardiogram (ECG). Sinus tachycardia, which is a faster than normal heart rate, and widening of the QRS complex are key features of TCA toxicity. These ECG changes occur due to the blocking of sodium channels and muscarinic receptors (M1) by the medication. In the case of an amitriptyline overdose, additional ECG changes may include prolongation of the QT interval, an R/S ratio greater than 0.7 in lead aVR, and the presence of ventricular arrhythmias such as torsades de pointes. The severity of the QRS prolongation on the ECG is associated with the likelihood of adverse events. A QRS duration greater than 100 ms is predictive of seizures, while a QRS duration greater than 160 ms is predictive of ventricular arrhythmias like ventricular tachycardia or torsades de pointes.
Further Reading:
Tricyclic antidepressant (TCA) overdose is a common occurrence in emergency departments, with drugs like amitriptyline and dosulepin being particularly dangerous. TCAs work by inhibiting the reuptake of norepinephrine and serotonin in the central nervous system. In cases of toxicity, TCAs block various receptors, including alpha-adrenergic, histaminic, muscarinic, and serotonin receptors. This can lead to symptoms such as hypotension, altered mental state, signs of anticholinergic toxicity, and serotonin receptor effects.
TCAs primarily cause cardiac toxicity by blocking sodium and potassium channels. This can result in a slowing of the action potential, prolongation of the QRS complex, and bradycardia. However, the blockade of muscarinic receptors also leads to tachycardia in TCA overdose. QT prolongation and Torsades de Pointes can occur due to potassium channel blockade. TCAs can also have a toxic effect on the myocardium, causing decreased cardiac contractility and hypotension.
Early symptoms of TCA overdose are related to their anticholinergic properties and may include dry mouth, pyrexia, dilated pupils, agitation, sinus tachycardia, blurred vision, flushed skin, tremor, and confusion. Severe poisoning can lead to arrhythmias, seizures, metabolic acidosis, and coma. ECG changes commonly seen in TCA overdose include sinus tachycardia, widening of the QRS complex, prolongation of the QT interval, and an R/S ratio >0.7 in lead aVR.
Management of TCA overdose involves ensuring a patent airway, administering activated charcoal if ingestion occurred within 1 hour and the airway is intact, and considering gastric lavage for life-threatening cases within 1 hour of ingestion. Serial ECGs and blood gas analysis are important for monitoring. Intravenous fluids and correction of hypoxia are the first-line therapies. IV sodium bicarbonate is used to treat haemodynamic instability caused by TCA overdose, and benzodiazepines are the treatment of choice for seizure control. Other treatments that may be considered include glucagon, magnesium sulfate, and intravenous lipid emulsion.
There are certain things to avoid in TCA overdose, such as anti-arrhythmics like quinidine and flecainide, as they can prolonged depolarization. Amiodarone should
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 51
Correct
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A 75-year-old is brought to the emergency department by her daughter. The patient has been feeling sick for the past day. The patient's daughter suspects she may have taken an excessive amount of digoxin tablets in the past few days. You are worried about digoxin toxicity. What antidote should be readily accessible in the emergency department for the treatment of digoxin toxicity?
Your Answer: Digoxin specific antibody fragments
Explanation:Digoxin-specific antibody fragments, known as Digibind or Digifab, are utilized for the treatment of digoxin toxicity. These antibody fragments should be readily available in all hospital pharmacies across the UK and accessible within a maximum of one hour.
Further Reading:
Digoxin is a medication used for rate control in atrial fibrillation and for improving symptoms in heart failure. It works by decreasing conduction through the atrioventricular node and increasing the force of cardiac muscle contraction. However, digoxin toxicity can occur, and plasma concentration alone does not determine if a patient has developed toxicity. Symptoms of digoxin toxicity include feeling generally unwell, lethargy, nausea and vomiting, anorexia, confusion, yellow-green vision, arrhythmias, and gynaecomastia.
ECG changes seen in digoxin toxicity include downsloping ST depression with a characteristic Salvador Dali sagging appearance, flattened, inverted, or biphasic T waves, shortened QT interval, mild PR interval prolongation, and prominent U waves. There are several precipitating factors for digoxin toxicity, including hypokalaemia, increasing age, renal failure, myocardial ischaemia, electrolyte imbalances, hypoalbuminaemia, hypothermia, hypothyroidism, and certain medications such as amiodarone, quinidine, verapamil, and diltiazem.
Management of digoxin toxicity involves the use of digoxin specific antibody fragments, also known as Digibind or digifab. Arrhythmias should be treated, and electrolyte disturbances should be corrected with close monitoring of potassium levels. It is important to note that digoxin toxicity can be precipitated by hypokalaemia, and toxicity can then lead to hyperkalaemia.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 52
Correct
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A 27 year old male presents to the emergency department with noticeable swelling and bruising on his face. He reports being attacked and punched in the face repeatedly. A zygomatic fracture is suspected, prompting you to request facial X-rays. What are the two standard X-ray views included in the facial X-ray series?
Your Answer: Occipitomental and occipitomental 30º
Explanation:The standard facial X-ray series consists of two occipitomental x-rays: the Occipitomental (or Occipitomental 15º) and the Occipitomental 30º. The Occipitomental view captures the upper and middle thirds of the face, showing important structures such as the orbital margins, frontal sinuses, zygomatic arches, and maxillary antra. On the other hand, the Occipitomental 30º view uses a 30º caudal angulation, resulting in a less clear visualization of the orbits but a clearer view of the zygomatic arches and the walls of the maxillary antra.
Further Reading:
Zygomatic injuries, also known as zygomatic complex fractures, involve fractures of the zygoma bone and often affect surrounding bones such as the maxilla and temporal bones. These fractures can be classified into four positions: the lateral and inferior orbital rim, the zygomaticomaxillary buttress, and the zygomatic arch. The full extent of these injuries may not be visible on plain X-rays and may require a CT scan for accurate diagnosis.
Zygomatic fractures can pose risks to various structures in the face. The temporalis muscle and coronoid process of the mandible may become trapped in depressed fractures of the zygomatic arch. The infraorbital nerve, which passes through the infraorbital foramen, can be injured in zygomaticomaxillary complex fractures. In orbital floor fractures, the inferior rectus muscle may herniate into the maxillary sinus.
Clinical assessment of zygomatic injuries involves observing facial asymmetry, depressed facial bones, contusion, and signs of eye injury. Visual acuity must be assessed, and any persistent bleeding from the nose or mouth should be noted. Nasal injuries, including septal hematoma, and intra-oral abnormalities should also be evaluated. Tenderness of facial bones and the temporomandibular joint should be assessed, along with any step deformities or crepitus. Eye and jaw movements must also be evaluated.
Imaging for zygomatic injuries typically includes facial X-rays, such as occipitomental views, and CT scans for a more detailed assessment. It is important to consider the possibility of intracranial hemorrhage and cervical spine injury in patients with facial fractures.
Management of most zygomatic fractures can be done on an outpatient basis with maxillofacial follow-up, assuming the patient is stable and there is no evidence of eye injury. However, orbital floor fractures should be referred immediately to ophthalmologists or maxillofacial surgeons. Zygomatic arch injuries that restrict mouth opening or closing due to entrapment of the temporalis muscle or mandibular condyle also require urgent referral. Nasal fractures, often seen in conjunction with other facial fractures, can be managed by outpatient ENT follow-up but should be referred urgently if there is uncontrolled epistaxis, CSF rhinorrhea, or septal hematoma.
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This question is part of the following fields:
- Maxillofacial & Dental
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Question 53
Incorrect
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A 3 year old is brought to the emergency department due to concern that the patient has developed a fever, symptoms of a cold, and a widespread rash with blisters. You diagnose the child with chickenpox and advise the mother on how to manage the condition. The mother informs you that she is 12 weeks pregnant and is worried about the potential consequences of contracting chickenpox during pregnancy.
What is the most significant complication of chickenpox infection for the mother during pregnancy?Your Answer: Myocarditis
Correct Answer: Pneumonitis
Explanation:Pregnant women who contract chickenpox for the first time are more likely to develop pneumonitis, a condition characterized by inflammation of the lungs. Additionally, these women face a five-fold increased risk of pneumonitis compared to non-pregnant individuals. Furthermore, the fetus is at risk of developing fetal varicella syndrome, a condition associated with chickenpox infection during pregnancy.
Further Reading:
Chickenpox exposure during pregnancy poses risks to both the mother and the fetus. The mother has a 5 times greater risk of developing pneumonitis, a potentially serious complication. The fetus is at risk of developing fetal varicella syndrome (FVS) if the maternal exposure occurs before 20 weeks gestation. The risk of FVS is around 1% in these cases and includes features such as skin scarring, eye defects, limb hypoplasia, microcephaly, and learning disabilities. There have been very few cases of FVS reported between 20-28 weeks gestation and none following 28 weeks.
Other risks to the fetus include the development of shingles in infancy, which has a 1-2% risk if the maternal exposure occurs in the second or third trimester. There is also a risk of severe neonatal varicella if the mother develops a rash between 5 days before and 2 days after birth. This condition can be fatal to the newborn child in around 20% of cases.
In the management of chickenpox exposure during pregnancy, it is important to determine if the mother is immune to varicella. If there is any doubt, maternal blood should be urgently checked for varicella antibodies. If the pregnant woman is not immune, she should be given varicella zoster immunoglobulin (VZIG) as soon as possible. VZIG is considered effective up to 10 days post-exposure. Consensus guidelines also recommend the use of oral aciclovir if the pregnant woman presents with chickenpox within 24 hours of the rash onset.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 54
Incorrect
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A 17 year old female presents to the emergency department with a guardian, complaining of feeling unwell. She reports experiencing pain in her pelvic and lower abdominal area. The guardian reveals that they suspect she may have a tampon stuck inside her. You request permission to conduct a vaginal examination. In the event that this patient is determined to be incapable of giving consent, who among the following individuals has the authority to provide consent on her behalf?
Your Answer: Patient's carer(s)
Correct Answer: Court Appointed Deputy
Explanation:Consent for individuals who lack capacity can be given by the person with lasting power of attorney, a court-appointed deputy, or doctors. Since the patient is an adult (>18), parental consent is not applicable. However, parents or family members can consent on behalf of an adult if they have been granted lasting power of attorney (LPA). The authorized individuals who can provide consent are the person with lasting power of attorney, court-appointed deputies, and doctors in cases involving treatment under best interests or mental health legislation. It is important to note that parental consent is only appropriate if they have LPA.
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 55
Incorrect
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A 35-year-old woman is brought into the emergency department after being hit by a car while riding her bike. The patient was not wearing a helmet and suffered a head injury from hitting the pavement. She has a significant scalp contusion and appears drowsy. There is a suspicion of increased intracranial pressure. How does intracranial pressure affect cerebral perfusion pressure?
Your Answer: Cerebral perfusion pressure (CPP) = systolic blood pressure (SBP) - intracranial pressure (ICP)
Correct Answer: Cerebral perfusion pressure (CPP) = mean arterial pressure (MAP) - intracranial pressure (ICP)
Explanation:Cerebral perfusion pressure (CPP) is calculated by adding the intracranial pressure (ICP) to the diastolic blood pressure (DBP).
Further Reading:
Intracranial pressure (ICP) refers to the pressure within the craniospinal compartment, which includes neural tissue, blood, and cerebrospinal fluid (CSF). Normal ICP for a supine adult is 5-15 mmHg. The body maintains ICP within a narrow range through shifts in CSF production and absorption. If ICP rises, it can lead to decreased cerebral perfusion pressure, resulting in cerebral hypoperfusion, ischemia, and potentially brain herniation.
The cranium, which houses the brain, is a closed rigid box in adults and cannot expand. It is made up of 8 bones and contains three main components: brain tissue, cerebral blood, and CSF. Brain tissue accounts for about 80% of the intracranial volume, while CSF and blood each account for about 10%. The Monro-Kellie doctrine states that the sum of intracranial volumes is constant, so an increase in one component must be offset by a decrease in the others.
There are various causes of raised ICP, including hematomas, neoplasms, brain abscesses, edema, CSF circulation disorders, venous sinus obstruction, and accelerated hypertension. Symptoms of raised ICP include headache, vomiting, pupillary changes, reduced cognition and consciousness, neurological signs, abnormal fundoscopy, cranial nerve palsy, hemiparesis, bradycardia, high blood pressure, irregular breathing, focal neurological deficits, seizures, stupor, coma, and death.
Measuring ICP typically requires invasive procedures, such as inserting a sensor through the skull. Management of raised ICP involves a multi-faceted approach, including antipyretics to maintain normothermia, seizure control, positioning the patient with a 30º head up tilt, maintaining normal blood pressure, providing analgesia, using drugs to lower ICP (such as mannitol or saline), and inducing hypocapnoeic vasoconstriction through hyperventilation. If these measures are ineffective, second-line therapies like barbiturate coma, optimised hyperventilation, controlled hypothermia, or decompressive craniectomy may be considered.
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This question is part of the following fields:
- Neurology
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Question 56
Incorrect
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A 45-year-old hiker is brought in by helicopter after being stranded on a hillside overnight. The rescue team informs you that according to the Swiss Staging system, he is at stage III.
What is the most accurate description of his current medical condition?Your Answer: Clearly conscious and shivering
Correct Answer: Unconscious
Explanation:Hypothermia occurs when the core body temperature drops below 35°C. It is categorized as mild (32-35°C), moderate (28-32°C), or severe (<28°C). Rescuers at the scene can use the Swiss staging system to describe the condition of victims. The stages range from clearly conscious and shivering to unconscious and not breathing, with death due to irreversible hypothermia being the most severe stage. There are several risk factors for hypothermia, including environmental exposure, unsatisfactory housing, poverty, lack of cold awareness, drugs, alcohol, acute confusion, hypothyroidism, and sepsis. The clinical features of hypothermia vary depending on the severity. At 32-35°C, symptoms may include apathy, amnesia, ataxia, and dysarthria. At 30-32°C, there may be a decreased level of consciousness, hypotension, arrhythmias, respiratory depression, and muscular rigidity. Below 30°C, ventricular fibrillation may occur, especially with excessive movement or invasive procedures. Diagnosing hypothermia involves checking the core temperature using an oesophageal, rectal, or tympanic probe with a low reading thermometer. Rectal and tympanic temperatures may lag behind core temperature and are unreliable in hypothermia. Various investigations should be carried out, including blood tests, blood glucose, amylase, blood cultures, arterial blood gas, ECG, chest X-ray, and CT head if there is suspicion of head injury or CVA. The management of hypothermia involves supporting the ABCs, treating the patient in a warm room, removing wet clothes and drying the skin, monitoring the ECG, providing warmed, humidified oxygen, correcting hypoglycemia with IV glucose, and handling the patient gently to avoid VF arrest. Rewarming methods include passive Rewarming with warm blankets or Bair hugger/polythene sheets, surface Rewarming with a water bath, core Rewarming with heated, humidified oxygen or peritoneal lavage, and extracorporeal Rewarming via cardiopulmonary bypass for severe hypothermia/cardiac arrest. In the case of hypothermic cardiac arrest, CPR should be performed with chest compressions and ventilations at standard rates.
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This question is part of the following fields:
- Environmental Emergencies
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Question 57
Incorrect
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A 68 year old is brought into the emergency department after being bitten on the leg by a patient with Alzheimer's disease at a nearby nursing home. The bite wound seems to have only punctured the skin without any ongoing bleeding or signs of infection such as redness, swelling, or discharge. Despite the absence of current infection, you decide to administer prophylactic antibiotics. What is the recommended length of time for prophylactic antibiotics in a non-infected human bite wound?
Your Answer: 7 days
Correct Answer: 3 days
Explanation:In cases of human bite wounds where the skin is broken but no blood is drawn, it is recommended to consider antibiotic prophylaxis, especially if the bite occurs in a high-risk area like the hands. According to NICE guidelines, a 3-day course of antibiotics is usually sufficient for prophylaxis in bite wounds. However, if the bite wound becomes infected, a 5-day course of antibiotics is advised for treatment.
Further Reading:
Bite wounds from animals and humans can cause significant injury and infection. It is important to properly assess and manage these wounds to prevent complications. In human bites, both the biter and the injured person are at risk of infection transmission, although the risk is generally low.
Bite wounds can take various forms, including lacerations, abrasions, puncture wounds, avulsions, and crush or degloving injuries. The most common mammalian bites are associated with dogs, cats, and humans.
When assessing a human bite, it is important to gather information about how and when the bite occurred, who was involved, whether the skin was broken or blood was involved, and the nature of the bite. The examination should include vital sign monitoring if the bite is particularly traumatic or sepsis is suspected. The location, size, and depth of the wound should be documented, along with any functional loss or signs of infection. It is also important to check for the presence of foreign bodies in the wound.
Factors that increase the risk of infection in bite wounds include the nature of the bite, high-risk sites of injury (such as the hands, feet, face, genitals, or areas of poor perfusion), wounds penetrating bone or joints, delayed presentation, immunocompromised patients, and extremes of age.
The management of bite wounds involves wound care, assessment and administration of prophylactic antibiotics if indicated, assessment and administration of tetanus prophylaxis if indicated, and assessment and administration of antiviral prophylaxis if indicated. For initial wound management, any foreign bodies should be removed, the wound should be encouraged to bleed if fresh, and thorough irrigation with warm, running water or normal saline should be performed. Debridement of necrotic tissue may be necessary. Bite wounds are usually not appropriate for primary closure.
Prophylactic antibiotics should be considered for human bites that have broken the skin and drawn blood, especially if they involve high-risk areas or the patient is immunocompromised. Co-amoxiclav is the first-line choice for prophylaxis, but alternative antibiotics may be used in penicillin-allergic patients. Antibiotics for wound infection should be based on wound swab culture and sensitivities.
Tetanus prophylaxis should be administered based on the cleanliness and risk level of the wound, as well as the patient’s vaccination status. Blood-borne virus risk should also be assessed, and testing for hepatitis B, hepatitis C, and HIV should be done.
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This question is part of the following fields:
- Infectious Diseases
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Question 58
Incorrect
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A 68 year old female is brought into the emergency department by her son due to a two day history of increased confusion and restlessness. The son informs you that the patient had a similar episode 8 months ago that was caused by a urinary tract infection. The son also mentions that the patient is generally in good health but was diagnosed with Parkinson's disease approximately 4 months ago after experiencing a tremor and difficulties with balance. While in the ED, the patient becomes verbally aggressive towards staff and other patients. You decide to administer medication to manage her acute behavior. What is the most suitable choice?
Your Answer: Amisulpride
Correct Answer: Lorazepam
Explanation:Haloperidol should not be used in patients with Parkinson’s, Lewy body dementia, or prolonged QT syndrome. It is the first choice for controlling aggressive behavior in most patients with delirium, but lorazepam is preferred for patients with Parkinson’s, Lewy body dementia, prolonged QT syndrome, extrapyramidal side effects, or delirium due to alcohol withdrawal. Haloperidol can reduce the effectiveness of levodopa in Parkinson’s disease by blocking dopamine receptors in the corpus striatum, which can lead to worsened motor function, psychosis, or a combination of both.
Further Reading:
Delirium is an acute syndrome that causes disturbances in consciousness, attention, cognition, and perception. It is also known as an acute confusional state. The DSM-IV criteria for diagnosing delirium include recent onset of fluctuating awareness, impairment of memory and attention, and disorganized thinking. Delirium typically develops over hours to days and may be accompanied by behavioral changes, personality changes, and psychotic features. It often occurs in individuals with predisposing factors, such as advanced age or multiple comorbidities, when exposed to new precipitating factors, such as medications or infection. Symptoms of delirium fluctuate throughout the day, with lucid intervals occurring during the day and worse disturbances at night. Falling and loss of appetite are often warning signs of delirium.
Delirium can be classified into three subtypes based on the person’s symptoms. Hyperactive delirium is characterized by inappropriate behavior, hallucinations, and agitation. Restlessness and wandering are common in this subtype. Hypoactive delirium is characterized by lethargy, reduced concentration, and appetite. The person may appear quiet or withdrawn. Mixed delirium presents with signs and symptoms of both hyperactive and hypoactive subtypes.
The exact pathophysiology of delirium is not fully understood, but it is believed to involve multiple mechanisms, including cholinergic deficiency, dopaminergic excess, and inflammation. The cause of delirium is usually multifactorial, with predisposing factors and precipitating factors playing a role. Predisposing factors include older age, cognitive impairment, frailty, significant injuries, and iatrogenic events. Precipitating factors include infection, metabolic or electrolyte disturbances, cardiovascular disorders, respiratory disorders, neurological disorders, endocrine disorders, urological disorders, gastrointestinal disorders, severe uncontrolled pain, alcohol intoxication or withdrawal, medication use, and psychosocial factors.
Delirium is highly prevalent in hospital settings, affecting up to 50% of inpatients aged over 65 and occurring in 30% of people aged over 65 presenting to the emergency department. Complications of delirium include increased risk of death, high in-hospital mortality rates, higher mortality rates following hospital discharge, increased length of stay in hospital, nosocomial infections, increased risk of admission to long-term care or re-admission to hospital, increased incidence of dementia, increased risk of falls and associated injuries and pressure sores.
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This question is part of the following fields:
- Neurology
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Question 59
Incorrect
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You are treating a 68 year old male who has been brought into the resuscitation bay by the ambulance crew. The patient was at home when he suddenly experienced dizziness and difficulty breathing. The ambulance crew presents the patient's ECG to you. You plan on administering atropine to address the patient's bradyarrhythmia.
According to the resuscitation council, what is the maximum recommended total dose of atropine that should be administered?Your Answer: 5 mg
Correct Answer: 3mg
Explanation:When treating adults with bradycardia, a maximum of 6 doses of atropine 500 mcg can be administered. Each dose is given intravenously every 3-5 minutes. The total dose should not exceed 3mg.
Further Reading:
Causes of Bradycardia:
– Physiological: Athletes, sleeping
– Cardiac conduction dysfunction: Atrioventricular block, sinus node disease
– Vasovagal & autonomic mediated: Vasovagal episodes, carotid sinus hypersensitivity
– Hypothermia
– Metabolic & electrolyte disturbances: Hypothyroidism, hyperkalaemia, hypermagnesemia
– Drugs: Beta-blockers, calcium channel blockers, digoxin, amiodarone
– Head injury: Cushing’s response
– Infections: Endocarditis
– Other: Sarcoidosis, amyloidosisPresenting symptoms of Bradycardia:
– Presyncope (dizziness, lightheadedness)
– Syncope
– Breathlessness
– Weakness
– Chest pain
– NauseaManagement of Bradycardia:
– Assess and monitor for adverse features (shock, syncope, myocardial ischaemia, heart failure)
– Treat reversible causes of bradycardia
– Pharmacological treatment: Atropine is first-line, adrenaline and isoprenaline are second-line
– Transcutaneous pacing if atropine is ineffective
– Other drugs that may be used: Aminophylline, dopamine, glucagon, glycopyrrolateBradycardia Algorithm:
– Follow the algorithm for management of bradycardia, which includes assessing and monitoring for adverse features, treating reversible causes, and using appropriate medications or pacing as needed.
https://acls-algorithms.com/wp-content/uploads/2020/12/Website-Bradycardia-Algorithm-Diagram.pdf -
This question is part of the following fields:
- Cardiology
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Question 60
Incorrect
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A 21-year-old student comes in with a sore throat, low-grade fever, and feeling unwell for the past week. She mentions having a faint rash all over her body that disappeared quickly. During the examination, you observe mild splenomegaly. The heterophile antibody test comes back positive.
What is the most probable organism responsible for this case?Your Answer: HIV
Correct Answer: Epstein-Barr virus
Explanation:Infectious mononucleosis is typically a self-limiting infection that is primarily caused by the Epstein-Barr virus (EBV), a member of the human herpesvirus family. About 10% of cases are caused by cytomegalovirus (CMV) infection.
This clinical infection is most commonly observed in populations with a large number of young adults, such as university students and active-duty military personnel.
The main clinical features of infectious mononucleosis include a low-grade fever, fatigue, prolonged malaise, sore throat (often accompanied by tonsillar enlargement and exudate), a transient, fine, non-itchy rash, lymphadenopathy (most commonly in the cervical region), arthralgia and myalgia, mild enlargement of the liver and spleen, and jaundice (which is less common in young adults but more prevalent in the elderly).
To diagnose EBV infectious mononucleosis, a variety of unrelated non-EBV heterophile antibodies and specific EBV antibodies can be used.
1. Heterophile antibodies:
Around 70-90% of patients with EBV infectious mononucleosis produce heterophile antibodies, which are antibodies that react against antigens from other species. False positives can occur with hepatitis, malaria, toxoplasmosis, rubella, systemic lupus erythematosus (SLE), lymphoma, and leukemia. Two main screening tests can detect these antibodies and provide rapid results within a day:
– Paul-Bunnell test: Sheep red blood cells agglutinate in the presence of heterophile antibodies.
– Monospot test: Horse red blood cells agglutinate in the presence of heterophile antibodies.2. EBV-specific antibodies:
Patients who remain heterophile-negative after six weeks are considered heterophile-negative and should be tested for EBV-specific antibodies. These antibodies are also useful in cases where a false positive heterophile antibody test is suspected.Other useful investigations include a full blood count, which often shows a raised white cell count with lymphocytosis and atypical lymphocytes in more than 20% of cases, an elevated erythrocyte sedimentation rate (ESR) in most patients, liver function tests (LFTs) that may show mild elevation of serum transaminases, throat swabs to rule out group A streptococci pharyngitis as a differential diagnosis, and abdominal ultrasound if splenomegaly is present.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 61
Correct
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A middle-aged man is brought to the hospital with slurred speech and unusual behavior. He has been experiencing urinary incontinence and has also noticed weakness in his right arm. A CT scan is conducted, which confirms the diagnosis of a stroke.
Which of the following blood vessels is most likely to be affected?Your Answer: Anterior cerebral artery
Explanation:The symptoms and signs of strokes can vary depending on which blood vessel is affected. Here is a summary of the main symptoms based on the territory affected:
Anterior cerebral artery: This can cause weakness on the opposite side of the body, with the leg and shoulder being more affected than the arm, hand, and face. There may also be minimal loss of sensation on the opposite side of the body. Other symptoms can include difficulty speaking (dysarthria), language problems (aphasia), apraxia (difficulty with limb movements), urinary incontinence, and changes in behavior and personality.
Middle cerebral artery: This can lead to weakness on the opposite side of the body, with the face and arm being more affected than the leg. There may also be a loss of sensation on the opposite side of the body. Depending on the dominant hemisphere of the brain, there may be difficulties with expressive or receptive language (dysphasia). In the non-dominant hemisphere, there may be neglect of the opposite side of the body.
Posterior cerebral artery: This can cause a loss of vision on the opposite side of both eyes (homonymous hemianopia). There may also be defects in a specific quadrant of the visual field. In some cases, there may be a syndrome affecting the thalamus on the opposite side of the body.
It’s important to note that these are just general summaries and individual cases may vary. If you suspect a stroke, it’s crucial to seek immediate medical attention.
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This question is part of the following fields:
- Neurology
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Question 62
Incorrect
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You are requested to evaluate a 6-year-old child who has arrived at the emergency department displaying irritability, conjunctivitis, fever, and a widespread rash. Upon further investigation, you discover that the patient is a refugee and has not received several vaccinations. The diagnosis of measles is confirmed.
What guidance should you provide regarding the exclusion of this child from school due to measles?Your Answer: No exclusion once rash appears
Correct Answer: 4 days from onset of rash
Explanation:The current school exclusion advice for certain infectious diseases with a rash is as follows:
– For chickenpox, children should be excluded for at least 5 days from the onset of the rash and until all blisters have crusted over.
– In the case of measles, children should be excluded for 4 days from the onset of the rash, provided they are well enough to attend.
– Mumps requires a 5-day exclusion after the onset of swelling.
– Rubella, also known as German measles, requires a 5-day exclusion from the onset of the rash.
– Scarlet fever necessitates exclusion until 24 hours after starting antibiotic treatment.It is important to note that school exclusion advice has undergone changes in recent years, and the information provided above reflects the updated advice as of May 2022.
Further Reading:
Measles is a highly contagious viral infection caused by an RNA paramyxovirus. It is primarily spread through aerosol transmission, specifically through droplets in the air. The incubation period for measles is typically 10-14 days, during which patients are infectious from 4 days before the appearance of the rash to 4 days after.
Common complications of measles include pneumonia, otitis media (middle ear infection), and encephalopathy (brain inflammation). However, a rare but fatal complication called subacute sclerosing panencephalitis (SSPE) can also occur, typically presenting 5-10 years after the initial illness.
The onset of measles is characterized by a prodrome, which includes symptoms such as irritability, malaise, conjunctivitis, and fever. Before the appearance of the rash, white spots known as Koplik spots can be seen on the buccal mucosa. The rash itself starts behind the ears and then spreads to the entire body, presenting as a discrete maculopapular rash that becomes blotchy and confluent.
In terms of complications, encephalitis typically occurs 1-2 weeks after the onset of the illness. Febrile convulsions, giant cell pneumonia, keratoconjunctivitis, corneal ulceration, diarrhea, increased incidence of appendicitis, and myocarditis are also possible complications of measles.
When managing contacts of individuals with measles, it is important to offer the MMR vaccine to children who have not been immunized against measles. The vaccine-induced measles antibody develops more rapidly than that following natural infection, so it should be administered within 72 hours of contact.
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This question is part of the following fields:
- Infectious Diseases
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Question 63
Incorrect
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A 35 year old male presents to the emergency department after twisting his right ankle while playing basketball. He reports pain on the outer side of his ankle and foot, and experiences discomfort when putting weight on it.
After conducting a physical examination, the healthcare provider decides to order ankle and foot X-rays based on the Ottawa foot & ankle rules. According to these guidelines, which of the following scenarios would warrant a foot X-ray?Your Answer: Tenderness over calcaneus
Correct Answer: Tenderness over navicular
Explanation:An X-ray of the foot is recommended when there is pain in the base of the fifth metatarsal or the navicular bone, as well as an inability to bear weight immediately after an injury or in the emergency department. The Ottawa ankle rules can also be used to determine if an X-ray is necessary for ankle injuries. These rules focus on two specific areas (the malleolar and midfoot zones) to determine if an X-ray of the ankle or foot is needed. More information on these rules can be found in the notes below.
Further Reading:
Ankle fractures are traumatic lower limb and joint injuries that involve the articulation between the tibia, fibula, and talus bones. The ankle joint allows for plantar and dorsiflexion of the foot. The key bony prominences of the ankle are called malleoli, with the medial and posterior malleolus being prominences of the distal tibia and the lateral malleolus being a prominence of the distal fibula. The distal fibula and tibia are joined together by the distal tibiofibular joint or syndesmosis, which is comprised of three key ligaments. An ankle X-ray series is often used to guide clinical decision making in patients with ankle injuries, using the Ottawa ankle rules to determine if an X-ray is necessary. Ankle fractures are commonly described by the anatomical fracture pattern seen on X-ray relative to the malleoli involved, such as isolated malleolus fractures, bimalleolar fractures, and trimalleolar fractures. The Weber classification is a commonly used system for distal fibula fractures, categorizing them as Weber A, B, or C based on the level and extent of the fracture.
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This question is part of the following fields:
- Trauma
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Question 64
Correct
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A 3-year-old toddler comes in with a high temperature, trouble swallowing, and drooling. Speaking is difficult for the child. The medical team calls for an experienced anesthesiologist and ear, nose, and throat surgeon. The child is intubated, and a diagnosis of acute epiglottitis is confirmed.
Which antibiotic would be the best choice for treatment in this case?Your Answer: Ceftriaxone
Explanation:Acute epiglottitis is inflammation of the epiglottis, which can be life-threatening if not treated promptly. When the soft tissues surrounding the epiglottis are also affected, it is called acute supraglottitis. This condition is most commonly seen in children between the ages of 3 and 5, but it can occur at any age, with adults typically presenting in their 40s and 50s.
In the past, Haemophilus influenzae type B was the main cause of acute epiglottitis, but with the introduction of the Hib vaccination, it has become rare in children. Streptococcus spp. is now the most common causative organism. Other potential culprits include Staphylococcus aureus, Pseudomonas spp., Moraxella catarrhalis, Mycobacterium tuberculosis, and the herpes simplex virus. In immunocompromised patients, Candida spp. and Aspergillus spp. infections can occur.
The typical symptoms of acute epiglottitis include fever, sore throat, painful swallowing, difficulty swallowing secretions (especially in children who may drool), muffled voice, stridor, respiratory distress, rapid heartbeat, tenderness in the front of the neck over the hyoid bone, ear pain, and swollen lymph nodes in the neck. Some patients may also exhibit the tripod sign, where they lean forward on outstretched arms to relieve upper airway obstruction.
To diagnose acute epiglottitis, fibre-optic laryngoscopy is considered the gold standard investigation. However, this procedure should only be performed by an anaesthetist in a setting prepared for intubation or tracheostomy in case of airway obstruction. Other useful tests include a lateral neck X-ray to look for the thumbprint sign, throat swabs, blood cultures, and a CT scan of the neck if an abscess is suspected.
When dealing with a case of acute epiglottitis, it is crucial not to panic or distress the patient, especially in pediatric cases. Avoid attempting to examine the throat with a tongue depressor, as this can trigger spasm and worsen airway obstruction. Instead, keep the patient as calm as possible and immediately call a senior anaesthetist, a senior paediatrician, and an ENT surgeon. Nebulized adrenaline can be used as a temporary measure if there is critical airway obstruction.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 65
Incorrect
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A 35 year old is admitted to the emergency department after a severe assault resulting in facial and head trauma. The patient presents with continuous nasal discharge, and a fellow healthcare provider expresses concern about potential cerebrospinal fluid (CSF) rhinorrhea. What is the most suitable test to confirm this diagnosis?
Your Answer: Nasal discharge sent for protein electrophoresis
Correct Answer: Nasal discharge tested for beta-2 transferrin
Explanation:If someone is suspected to have CSF rhinorrhoea, their nasal discharge should be tested for beta-2 transferrin. This test is considered the most accurate diagnostic method to confirm the presence of CSF rhinorrhoea and has replaced glucose testing.
Further Reading:
Zygomatic injuries, also known as zygomatic complex fractures, involve fractures of the zygoma bone and often affect surrounding bones such as the maxilla and temporal bones. These fractures can be classified into four positions: the lateral and inferior orbital rim, the zygomaticomaxillary buttress, and the zygomatic arch. The full extent of these injuries may not be visible on plain X-rays and may require a CT scan for accurate diagnosis.
Zygomatic fractures can pose risks to various structures in the face. The temporalis muscle and coronoid process of the mandible may become trapped in depressed fractures of the zygomatic arch. The infraorbital nerve, which passes through the infraorbital foramen, can be injured in zygomaticomaxillary complex fractures. In orbital floor fractures, the inferior rectus muscle may herniate into the maxillary sinus.
Clinical assessment of zygomatic injuries involves observing facial asymmetry, depressed facial bones, contusion, and signs of eye injury. Visual acuity must be assessed, and any persistent bleeding from the nose or mouth should be noted. Nasal injuries, including septal hematoma, and intra-oral abnormalities should also be evaluated. Tenderness of facial bones and the temporomandibular joint should be assessed, along with any step deformities or crepitus. Eye and jaw movements must also be evaluated.
Imaging for zygomatic injuries typically includes facial X-rays, such as occipitomental views, and CT scans for a more detailed assessment. It is important to consider the possibility of intracranial hemorrhage and cervical spine injury in patients with facial fractures.
Management of most zygomatic fractures can be done on an outpatient basis with maxillofacial follow-up, assuming the patient is stable and there is no evidence of eye injury. However, orbital floor fractures should be referred immediately to ophthalmologists or maxillofacial surgeons. Zygomatic arch injuries that restrict mouth opening or closing due to entrapment of the temporalis muscle or mandibular condyle also require urgent referral. Nasal fractures, often seen in conjunction with other facial fractures, can be managed by outpatient ENT follow-up but should be referred urgently if there is uncontrolled epistaxis, CSF rhinorrhea, or septal hematoma.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 66
Correct
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A 32-year-old man with a long-standing history of ulcerative colitis presents with a complication of his illness.
What is the SINGLE least likely complication that he has developed?Your Answer: Perianal fistula
Explanation:Ulcerative colitis can lead to various complications, although the development of fistulae is rare and less likely compared to other complications. Perianal complications associated with ulcerative colitis are uncommon and typically occur in cases with more extensive inflammation and a severe disease course.
The complications of ulcerative colitis can be categorized into localized and systemic complications. Localized complications include bleeding, electrolyte imbalance, toxic megacolon, perforation, an increased risk of colonic carcinoma, an increased risk of lymphoma, and the rare occurrence of stricture and fistula formation.
On the other hand, systemic complications of ulcerative colitis involve malnutrition and weight loss, iron-deficiency anemia, vitamin B12 deficiency, hypoproteinaemia, primary sclerosing cholangitis, primary biliary cirrhosis, chronic active hepatitis, joint pain or arthropathy, ankylosing spondylitis, pyoderma gangrenosum, and erythema nodosum. Additionally, ulcerative colitis can also lead to complications affecting the eyes, such as iritis, episcleritis, and uveitis.
Overall, while ulcerative colitis can present with various complications, the development of fistulae is rare and less likely compared to other complications. Perianal complications are infrequent and typically associated with more extensive inflammation and a severe disease course.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 67
Incorrect
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You evaluate a 45-year-old woman who presents with lower abdominal and pelvic pain. During a bimanual vaginal examination, you detect a significant pelvic mass. She has no significant medical history or gynecological issues, such as uterine fibroids.
What would be the MOST suitable next step in managing this patient?Your Answer: Arrange an urgent ultrasound scan and review with results
Correct Answer: Urgent referral to gynaecology service (for an appointment within 2 weeks)
Explanation:Women who are 18 years or older and have a pelvic mass that is not clearly uterine fibroids should be promptly referred for assessment. In this case, an abdominal X-ray would not provide much useful information, and it is not advisable to take no action at this point. For more information, please refer to the NICE referral guidelines for suspected cancer.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 68
Incorrect
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A 35-year-old woman presents with a swollen, red, and warm right knee. She has recently returned from a trip to Tokyo. During examination, her temperature is 38.6°C, and she has a rash with small blisters on her chest. The knee feels warm to touch and is immobile. Attempts to bend or straighten the knee are unsuccessful. A joint fluid sample is taken, revealing the presence of Gram-negative diplococci.
What is the most likely organism responsible for this condition?Your Answer: Streptococcus pyogenes
Correct Answer: Neisseria gonorrhoea
Explanation:The most probable diagnosis in this case is septic arthritis, which occurs when an infectious agent invades a joint and causes pus formation. The patient’s recent travel to Bangkok, presence of a vesicular rash on the trunk, and the identification of Gram-negative diplococci support this diagnosis.
Septic arthritis is characterized by several clinical features. These include pain in the affected joint, redness, warmth, and swelling of the joint, and difficulty in moving the joint. Patients may also experience fever and systemic symptoms.
The most common cause of septic arthritis is Staphylococcus aureus. Other bacteria that can lead to this condition include Streptococcus spp., Haemophilus influenzae, Neisseria gonorrhoea (typically seen in sexually active young adults with macules or vesicles on the trunk), and Escherichia coli (common in intravenous drug users, the elderly, and seriously ill individuals).
According to the current recommendations by NICE (National Institute for Health and Care Excellence) and the BNF (British National Formulary), the treatment for septic arthritis involves the following approaches. Flucloxacillin is the first-line antibiotic. In cases of penicillin allergy, clindamycin is recommended. If there is suspicion of MRSA infection, vancomycin should be used. For gonococcal arthritis or Gram-negative infection, cefotaxime is the preferred choice. The suggested duration of treatment is 4-6 weeks, although it may be longer if the infection is complicated.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 69
Incorrect
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A 70 year old male who underwent aortic valve replacement 2 months ago presents to the emergency department with a 4 day history of fever, fatigue, and overall malaise. The initial observations are as follows:
Temperature: 38.7ºC
Pulse rate: 126 bpm
Blood pressure: 132/76 mmHg
Respiration rate: 24 bpm
Oxygen saturation: 96% on room air
During the examination, splinter hemorrhages are observed on the patient's fingernails, leading to a suspicion of infective endocarditis. What is the most likely causative organism in this particular case?Your Answer: Pseudomonas
Correct Answer: Staphylococcus
Explanation:In this case, a 70-year-old male who recently underwent aortic valve replacement is presenting with symptoms of fever, fatigue, and overall malaise. Upon examination, splinter hemorrhages are observed on the patient’s fingernails, which raises suspicion of infective endocarditis. Given the patient’s history and symptoms, the most likely causative organism in this particular case is Staphylococcus.
Further Reading:
Infective endocarditis (IE) is an infection that affects the innermost layer of the heart, known as the endocardium. It is most commonly caused by bacteria, although it can also be caused by fungi or viruses. IE can be classified as acute, subacute, or chronic depending on the duration of illness. Risk factors for IE include IV drug use, valvular heart disease, prosthetic valves, structural congenital heart disease, previous episodes of IE, hypertrophic cardiomyopathy, immune suppression, chronic inflammatory conditions, and poor dental hygiene.
The epidemiology of IE has changed in recent years, with Staphylococcus aureus now being the most common causative organism in most industrialized countries. Other common organisms include coagulase-negative staphylococci, streptococci, and enterococci. The distribution of causative organisms varies depending on whether the patient has a native valve, prosthetic valve, or is an IV drug user.
Clinical features of IE include fever, heart murmurs (most commonly aortic regurgitation), non-specific constitutional symptoms, petechiae, splinter hemorrhages, Osler’s nodes, Janeway’s lesions, Roth’s spots, arthritis, splenomegaly, meningism/meningitis, stroke symptoms, and pleuritic pain.
The diagnosis of IE is based on the modified Duke criteria, which require the presence of certain major and minor criteria. Major criteria include positive blood cultures with typical microorganisms and positive echocardiogram findings. Minor criteria include fever, vascular phenomena, immunological phenomena, and microbiological phenomena. Blood culture and echocardiography are key tests for diagnosing IE.
In summary, infective endocarditis is an infection of the innermost layer of the heart that is most commonly caused by bacteria. It can be classified as acute, subacute, or chronic and can be caused by a variety of risk factors. Staphylococcus aureus is now the most common causative organism in most industrialized countries. Clinical features include fever, heart murmurs, and various other symptoms. The diagnosis is based on the modified Duke criteria, which require the presence of certain major and minor criteria. Blood culture and echocardiography are important tests for diagnosing IE.
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This question is part of the following fields:
- Infectious Diseases
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Question 70
Incorrect
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A 65 year old female is brought into the emergency department with a one week history of worsening nausea, muscle cramps, fatigue, and weakness. You send urine and blood samples for analysis. The patient's observations and investigation results are shown below:
Na+ 120 mmol/l
K+ 5.3 mmol/l
Urea 6.5 mmol/l
Creatinine 87 µmol/l
Glucose 5.5 mmol/l
Urine osmolality 365 mosmol/kg
Blood pressure 138/78 mmHg
Pulse 82 bpm
Respiration rate 18 bpm
Oxygen saturations 97% on air
What is the most likely diagnosis?Your Answer: Nephrogenic diabetes insipidus
Correct Answer: SIADH
Explanation:The patient’s symptoms of nausea, muscle cramps, fatigue, and weakness are consistent with hyponatremia, which is a low sodium level in the blood. The blood test results show a low sodium level (Na+ 120 mmol/l) and normal potassium level (K+ 5.3 mmol/l), which is commonly seen in SIADH.
Additionally, the urine osmolality of 365 mosmol/kg indicates concentrated urine, which is contrary to what would be expected in diabetes insipidus. In diabetes insipidus, the urine would be dilute due to the inability to concentrate urine properly.
The patient’s blood pressure, pulse, respiration rate, and oxygen saturations are within normal range, which does not suggest a diagnosis of Addison’s disease or Conn’s syndrome.
Therefore, based on the symptoms, laboratory results, and urine osmolality, the most likely diagnosis for this patient is SIADH.
Further Reading:
Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition characterized by low sodium levels in the blood due to excessive secretion of antidiuretic hormone (ADH). ADH, also known as arginine vasopressin (AVP), is responsible for promoting water and sodium reabsorption in the body. SIADH occurs when there is impaired free water excretion, leading to euvolemic (normal fluid volume) hypotonic hyponatremia.
There are various causes of SIADH, including malignancies such as small cell lung cancer, stomach cancer, and prostate cancer, as well as neurological conditions like stroke, subarachnoid hemorrhage, and meningitis. Infections such as tuberculosis and pneumonia, as well as certain medications like thiazide diuretics and selective serotonin reuptake inhibitors (SSRIs), can also contribute to SIADH.
The diagnostic features of SIADH include low plasma osmolality, inappropriately elevated urine osmolality, urinary sodium levels above 30 mmol/L, and euvolemic. Symptoms of hyponatremia, which is a common consequence of SIADH, include nausea, vomiting, headache, confusion, lethargy, muscle weakness, seizures, and coma.
Management of SIADH involves correcting hyponatremia slowly to avoid complications such as central pontine myelinolysis. The underlying cause of SIADH should be treated if possible, such as discontinuing causative medications. Fluid restriction is typically recommended, with a daily limit of around 1000 ml for adults. In severe cases with neurological symptoms, intravenous hypertonic saline may be used. Medications like demeclocycline, which blocks ADH receptors, or ADH receptor antagonists like tolvaptan may also be considered.
It is important to monitor serum sodium levels closely during treatment, especially if using hypertonic saline, to prevent rapid correction that can lead to central pontine myelinolysis. Osmolality abnormalities can help determine the underlying cause of hyponatremia, with increased urine osmolality indicating dehydration or renal disease, and decreased urine osmolality suggesting SIADH or overhydration.
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This question is part of the following fields:
- Endocrinology
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Question 71
Incorrect
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A 32-year-old man receives a blood transfusion and experiences a severe transfusion reaction. His condition quickly worsens, and he ultimately succumbs to this reaction. His death is reported to Serious Hazards of Transfusion (SHOT).
Which of the following is the SECOND most common cause of transfusion-related fatalities in the UK?Your Answer: Acute haemolytic reaction
Correct Answer: TACO
Explanation:Transfusion-related lung injury (TRALI) is responsible for about one-third of all transfusion-related deaths, making it the leading cause. On the other hand, transfusion-associated circulatory overload (TACO) accounts for approximately 20% of these fatalities, making it the second leading cause. TACO occurs when a large volume of blood is rapidly infused, particularly in patients with limited cardiac reserve or chronic anemia. Elderly individuals, infants, and severely anemic patients are especially vulnerable to this reaction.
The typical signs of TACO include acute respiratory distress, rapid heart rate, high blood pressure, the appearance of acute or worsening pulmonary edema on a chest X-ray, and evidence of excessive fluid accumulation. In many cases, simply reducing the transfusion rate, positioning the patient upright, and administering diuretics will be sufficient to manage the condition. However, in more severe cases, it is necessary to halt the transfusion and consider non-invasive ventilation.
Transfusion-related acute lung injury (TRALI) is defined as new acute lung injury (ALI) that occurs during or within six hours of transfusion, not explained by another ALI risk factor. Transfusion of part of one unit of any blood product can cause TRALI.
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This question is part of the following fields:
- Haematology
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Question 72
Correct
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A 15 year old male is brought to the emergency department by his parents and admits to taking 32 paracetamol tablets 6 hours ago. Blood tests are conducted, including paracetamol levels. What is the paracetamol level threshold above which the ingestion is deemed 'significant'?
Your Answer: 75 mg/kg/24 hours
Explanation:If someone consumes at least 75 mg of paracetamol per kilogram of body weight within a 24-hour period, it is considered to be a significant ingestion. Ingesting more than 150 mg of paracetamol per kilogram of body weight within 24 hours poses a serious risk of harm.
Further Reading:
Paracetamol poisoning occurs when the liver is unable to metabolize paracetamol properly, leading to the production of a toxic metabolite called N-acetyl-p-benzoquinone imine (NAPQI). Normally, NAPQI is conjugated by glutathione into a non-toxic form. However, during an overdose, the liver’s conjugation systems become overwhelmed, resulting in increased production of NAPQI and depletion of glutathione stores. This leads to the formation of covalent bonds between NAPQI and cell proteins, causing cell death in the liver and kidneys.
Symptoms of paracetamol poisoning may not appear for the first 24 hours or may include abdominal symptoms such as nausea and vomiting. After 24 hours, hepatic necrosis may develop, leading to elevated liver enzymes, right upper quadrant pain, and jaundice. Other complications can include encephalopathy, oliguria, hypoglycemia, renal failure, and lactic acidosis.
The management of paracetamol overdose depends on the timing and amount of ingestion. Activated charcoal may be given if the patient presents within 1 hour of ingesting a significant amount of paracetamol. N-acetylcysteine (NAC) is used to increase hepatic glutathione production and is given to patients who meet specific criteria. Blood tests are taken to assess paracetamol levels, liver function, and other parameters. Referral to a medical or liver unit may be necessary, and psychiatric follow-up should be considered for deliberate overdoses.
In cases of staggered ingestion, all patients should be treated with NAC without delay. Blood tests are also taken, and if certain criteria are met, NAC can be discontinued. Adverse reactions to NAC are common and may include anaphylactoid reactions, rash, hypotension, and nausea. Treatment for adverse reactions involves medications such as chlorpheniramine and salbutamol, and the infusion may be stopped if necessary.
The prognosis for paracetamol poisoning can be poor, especially in cases of severe liver injury. Fulminant liver failure may occur, and liver transplant may be necessary. Poor prognostic indicators include low arterial pH, prolonged prothrombin time, high plasma creatinine, and hepatic encephalopathy.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 73
Incorrect
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You are requested to evaluate a 6 year old girl. She was playing in the backyard when she suddenly burst into tears. Her mother suspects she stepped on a bee. Shortly after, her face began to swell and her breathing became rapid and noisy. Your diagnosis is anaphylaxis. What is the appropriate dosage of adrenaline to administer?
Your Answer: 250 micrograms by IM injection
Correct Answer: 150 micrograms by IM injection
Explanation:The appropriate dose of adrenaline for treating anaphylaxis in children under 6 years old is 150 micrograms, which is equivalent to 0.15 ml of a 1 in 1,000 solution.
Further Reading:
Anaphylaxis is a severe and life-threatening allergic reaction that affects the entire body. It is characterized by a rapid onset and can lead to difficulty breathing, low blood pressure, and loss of consciousness. In paediatrics, anaphylaxis is often caused by food allergies, with nuts being the most common trigger. Other causes include drugs and insect venom, such as from a wasp sting.
When treating anaphylaxis, time is of the essence and there may not be enough time to look up medication doses. Adrenaline is the most important drug in managing anaphylaxis and should be administered as soon as possible. The recommended doses of adrenaline vary based on the age of the child. For children under 6 months, the dose is 150 micrograms, while for children between 6 months and 6 years, the dose remains the same. For children between 6 and 12 years, the dose is increased to 300 micrograms, and for adults and children over 12 years, the dose is 500 micrograms. Adrenaline can be repeated every 5 minutes if necessary.
The preferred site for administering adrenaline is the anterolateral aspect of the middle third of the thigh. This ensures quick absorption and effectiveness of the medication. It is important to follow the Resuscitation Council guidelines for anaphylaxis management, as they have recently been updated.
In some cases, it can be challenging to determine if a patient had a true episode of anaphylaxis. In such cases, serum tryptase levels may be measured, as they remain elevated for up to 12 hours following an acute episode of anaphylaxis. This can help confirm the diagnosis and guide further management.
Overall, prompt recognition and administration of adrenaline are crucial in managing anaphylaxis in paediatrics. Following the recommended doses and guidelines can help ensure the best outcomes for patients experiencing this severe allergic reaction.
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This question is part of the following fields:
- Paediatric Emergencies
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Question 74
Incorrect
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A 35-year-old woman with a long-standing history of heavy alcohol abuse and liver cirrhosis presents with a fever, abdominal pain, worsening ascites, and confusion.
What is the SINGLE most appropriate initial investigation?Your Answer: Colonoscopy
Correct Answer: Abdominal paracentesis
Explanation:Spontaneous bacterial peritonitis (SBP) is a sudden bacterial infection of the fluid in the abdomen. It typically occurs in patients with high blood pressure in the portal vein, and about 70% of patients are classified as Child-Pugh class C. In any given year, around 30% of patients with ascites, a condition characterized by fluid buildup in the abdomen, will develop SBP.
SBP can present with a wide range of symptoms, so it’s important to be vigilant when caring for patients with ascites, especially if there is a sudden decline in their condition. Some patients may not show any symptoms at all.
Common clinical features of SBP include fever, chills, nausea, vomiting, abdominal pain, tenderness, worsening ascites, general malaise, and hepatic encephalopathy. Certain factors can increase the risk of developing SBP, such as severe liver disease, gastrointestinal bleeding, urinary tract infection, intestinal bacterial overgrowth, indwelling lines (e.g., central venous catheters or urinary catheters), previous episodes of SBP, and low levels of protein in the ascitic fluid.
To diagnose SBP, an abdominal paracentesis, also known as an ascitic tap, is performed. This involves locating the area of dullness on the flank, next to the rectus abdominis muscle, and performing the tap about 5 cm above and towards the midline from the anterior superior iliac spines.
Certain features on the analysis of the peritoneal fluid strongly suggest SBP, including a total white cell count in the ascitic fluid of more than 500 cells/µL, a total neutrophil count of more than 250 cells/µL, a lactate level in the ascitic fluid of more than 25 mg/dL, a pH of less than 7.35, and the presence of bacteria on Gram-stain.
Patients diagnosed with SBP should be admitted to the hospital and given broad-spectrum antibiotics. The preferred choice is an intravenous 3rd generation cephalosporin, such as ceftriaxone. If the patient is allergic to beta-lactam antibiotics, ciprofloxacin can be considered as an alternative. Administering intravenous albumin can help reduce the risk of kidney failure and mortality.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 75
Correct
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A 45-year-old woman presents with several recent episodes of significant haemoptysis. She has been feeling extremely tired and has been experiencing worsening nausea over the past few days. She also complains of intermittent chest pain. The patient mentions that her urine has been dark in color. She has no significant medical history and smokes 10 cigarettes per day. On examination, she appears pale and has inspiratory crackles at both bases. Her blood pressure is elevated at 175/94 mmHg. Urinalysis reveals proteinuria and microscopic haematuria.
Her blood results today are as follows:
Hb 8.4 g/dl (13-17 g/dl)
MCV 69 fl (76-96 fl)
WCC 21.5 x 109/l (4-11 x 109/l)
Neutrophils 17.2 x 109/l (2.5-7.5 x 109/l)
Na 134 mmol/l (133-147 mmol/l)
K 4.2 mmol/l (3.5-5.0 mmol/l)
Creat 232 micromol/l (60-120 micromol/l)
Urea 12.8 mmol/l (2.5-7.5 mmol/l)
Which SINGLE investigation will confirm the diagnosis in this case?Your Answer: Renal biopsy
Explanation:The most probable diagnosis in this situation is Goodpasture’s syndrome, a rare autoimmune vasculitic disorder characterized by three main symptoms: pulmonary hemorrhage, glomerulonephritis, and the presence of anti-glomerular basement membrane (Anti-GBM) antibodies. Goodpasture’s syndrome is more prevalent in men, particularly in smokers. It is also associated with HLA-B7 and HLA-DRw2.
The clinical manifestations of Goodpasture’s syndrome include constitutional symptoms like fever, fatigue, nausea, and weight loss. Patients may also experience hemoptysis or pulmonary hemorrhage, chest pain, breathlessness, and inspiratory crackles at the lung bases. Anemia due to bleeding within the lungs, arthralgia, rapidly progressive glomerulonephritis, hematuria, hypertension, and rarely hepatosplenomegaly may also be present.
Blood tests will reveal iron deficiency anemia, an elevated white cell count, and renal impairment. Elisa for Anti-GBM antibodies is highly sensitive and specific, but it is not widely available. Approximately 30% of patients may also have circulating antineutrophilic cytoplasmic antibodies (ANCAs), although these are not specific for Goodpasture’s syndrome and can be found in other conditions such as Wegener’s granulomatosis, which also cause renal impairment and pulmonary hemorrhage.
Diagnosis is typically confirmed through a renal biopsy, which can detect the presence of anti-GBM antibodies. This would be the most appropriate investigation to confirm the diagnosis in this case.
The management of Goodpasture’s syndrome involves a combination of plasmapheresis to remove circulating antibodies and the use of corticosteroids or cyclophosphamide.
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This question is part of the following fields:
- Respiratory
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Question 76
Incorrect
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A 35-year-old woman who has been involved in a car accident is estimated to have suffered a class I haemorrhage according to the Advanced Trauma Life Support (ATLS) haemorrhagic shock classification. The patient weighs approximately 60 kg.
Which of the following physiological parameters is consistent with a diagnosis of class I haemorrhage?Your Answer: Urine output of 10 ml/hr
Correct Answer: Increased pulse pressure
Explanation:Recognizing the extent of blood loss based on vital sign and mental status abnormalities is a crucial skill. The Advanced Trauma Life Support (ATLS) classification for hemorrhagic shock correlates the amount of blood loss with expected physiological responses in a healthy individual weighing 70 kg. In terms of body weight, the total circulating blood volume accounts for approximately 7%, which is roughly equivalent to five liters in an average 70 kg male patient.
The ATLS classification for hemorrhagic shock is as follows:
CLASS I:
– Blood loss: Up to 750 mL
– Blood loss (% blood volume): Up to 15%
– Pulse rate: Less than 100 beats per minute (bpm)
– Systolic blood pressure: Normal
– Pulse pressure: Normal (or increased)
– Respiratory rate: 14-20 breaths per minute
– Urine output: Greater than 30 mL/hr
– CNS/mental status: Slightly anxiousCLASS II:
– Blood loss: 750-1500 mL
– Blood loss (% blood volume): 15-30%
– Pulse rate: 100-120 bpm
– Systolic blood pressure: Normal
– Pulse pressure: Decreased
– Respiratory rate: 20-30 breaths per minute
– Urine output: 20-30 mL/hr
– CNS/mental status: Mildly anxiousCLASS III:
– Blood loss: 1500-2000 mL
– Blood loss (% blood volume): 30-40%
– Pulse rate: 120-140 bpm
– Systolic blood pressure: Decreased
– Pulse pressure: Decreased
– Respiratory rate: 30-40 breaths per minute
– Urine output: 5-15 mL/hr
– CNS/mental status: Anxious, confusedCLASS IV:
– Blood loss: More than 2000 mL
– Blood loss (% blood volume): More than 40%
– Pulse rate: More than 140 bpm
– Systolic blood pressure: Decreased
– Pulse pressure: Decreased
– Respiratory rate: More than 40 breaths per minute
– Urine output: Negligible
– CNS/mental status: Confused, lethargic -
This question is part of the following fields:
- Trauma
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Question 77
Incorrect
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A 45-year-old man develops corneal microdeposits as a side effect of a gastrointestinal drug that he has been prescribed.
Which of the following drugs is MOST likely to be causing this?Your Answer: Sotalol
Correct Answer: Amiodarone
Explanation:Corneal microdeposits are found in almost all individuals (over 90%) who have been taking amiodarone for more than six months, particularly at doses higher than 400 mg/day. These deposits generally do not cause any symptoms, although approximately 10% of patients may experience a perception of a ‘bluish halo’ around objects they see.
Amiodarone can also have other effects on the eye, but these are much less common, occurring in only 1-2% of patients. These effects include optic neuropathy, nonarteritic anterior ischemic optic neuropathy (N-AION), optic disc swelling, and visual field defects.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 78
Incorrect
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You evaluate a 42-year-old woman with a long-standing history of alcohol abuse. She is determined to quit drinking and has the complete backing of her family. Currently, she consumes 20-30 units of alcohol daily. You opt to utilize a screening questionnaire to evaluate the extent of her dependency before referring her to specialized alcohol services.
Which of the subsequent screening tests is endorsed by the current NICE guidance for this situation?Your Answer: AUDIT
Correct Answer: SADQ
Explanation:The Severity of Alcohol Dependence Questionnaire (SADQ) is a brief, self-administered questionnaire consisting of 20 items. It was developed by the World Health Organisation with the aim of assessing the severity of alcohol dependence. Another assessment tool recommended by NICE is the Leeds Dependence Questionnaire (LDQ), which is a self-completion questionnaire comprising of 10 items. The LDQ is designed to measure dependence on various substances. Both the SADQ and LDQ are considered useful in evaluating the severity of alcohol misuse.
NICE suggests the use of specific assessment tools to effectively evaluate the nature and severity of alcohol misuse. The AUDIT is recommended for identification purposes and as a routine outcome measure. For assessing the severity of dependence, the SADQ or LDQ are recommended. To evaluate the severity of withdrawal symptoms, the Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar) is recommended. Lastly, the APQ is recommended for assessing the nature and extent of problems arising from alcohol misuse.
to the NICE guidance on the diagnosis, assessment, and management of harmful drinking and alcohol dependence.
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This question is part of the following fields:
- Mental Health
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Question 79
Correct
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A 65-year-old woman with a history of chronic alcohol abuse is diagnosed with Korsakoff's psychosis. You have been requested to assess the patient and report your observations.
Which of the following symptoms is typically observed in individuals with Korsakoff's psychosis?Your Answer: Disordered time appreciation
Explanation:Wernicke’s encephalopathy is a condition that is commonly associated with alcohol abuse and other causes of thiamine deficiency. It is characterized by a classic triad of symptoms, which include acute confusion, ophthalmoplegia (paralysis or weakness of the eye muscles), and ataxia (loss of coordination and balance). Additional possible features of this condition may include papilloedema (swelling of the optic disc), hearing loss, apathy, dysphagia (difficulty swallowing), memory impairment, and hypothermia. In the majority of cases, peripheral neuropathy (nerve damage) is also observed, typically affecting the legs.
The condition is marked by the presence of acute capillary haemorrhages, astrocytosis (abnormal increase in astrocytes, a type of brain cell), and neuronal death in the upper brainstem and diencephalon. These abnormalities can be visualized using MRI scanning, while CT scanning is not very useful for diagnosis.
If left untreated, most patients with Wernicke’s encephalopathy will go on to develop a Korsakoff psychosis. This condition is characterized by retrograde amnesia (difficulty remembering past events), an inability to memorize new information, disordered time appreciation, and confabulation (fabrication of false memories).
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This question is part of the following fields:
- Mental Health
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Question 80
Incorrect
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You assess a patient with airway obstruction in the resuscitation area of the Emergency Department at your hospital.
Which of the following is the LEAST probable cause?Your Answer: Laryngospasm
Correct Answer: GCS score of 9
Explanation:The airway is deemed at risk when the Glasgow Coma Scale (GCS) falls below 8. There are various factors that can lead to airway obstruction, including the presence of blood or vomit in the airway, a foreign object such as a tooth or food blocking the passage, direct injury to the face or throat, inflammation of the epiglottis (epiglottitis), involuntary closure of the larynx (laryngospasm), constriction of the bronchial tubes (bronchospasm), swelling in the pharynx due to infection or fluid accumulation (oedema), excessive bronchial secretions, and blockage of a tracheostomy tube.
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This question is part of the following fields:
- Trauma
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Question 81
Incorrect
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A 72 year old male comes to the emergency department complaining of sudden difficulty breathing, heart palpitations, and a cough that produces pink frothy sputum. During the examination, you observe an irregular heart rhythm, crackling sounds in the lower parts of the lungs, a loud first heart sound, and a mid-late diastolic murmur. What is the probable diagnosis?
Your Answer: Tricuspid regurgitation
Correct Answer: Mitral stenosis
Explanation:Mitral stenosis is a condition characterized by a narrowing of the mitral valve, which can lead to various symptoms. One common symptom is a mid-late diastolic murmur, which can be heard during a physical examination. This murmur may also be described as mid-diastolic, late-diastolic, or mid-late diastolic. Additionally, patients with chronic mitral stenosis may not experience any symptoms, and the murmur may only be detected incidentally.
A significant risk associated with mitral stenosis is the development of atrial fibrillation (AF). When AF occurs in patients with mitral stenosis, it can trigger acute pulmonary edema. This happens because the left atrium, which is responsible for pumping blood across the narrowed mitral valve into the left ventricle, needs to generate higher pressure. However, when AF occurs, the atrial contraction becomes inefficient, leading to impaired emptying of the left atrium. This, in turn, causes increased back pressure in the pulmonary circulation.
The elevated pressure in the left atrium and pulmonary circulation can result in the rupture of bronchial veins, leading to the production of pink frothy sputum. This symptom is often observed in patients with mitral stenosis who develop acute pulmonary edema.
Further Reading:
Mitral Stenosis:
– Causes: Rheumatic fever, Mucopolysaccharidoses, Carcinoid, Endocardial fibroelastosis
– Features: Mid-late diastolic murmur, loud S1, opening snap, low volume pulse, malar flush, atrial fibrillation, signs of pulmonary edema, tapping apex beat
– Features of severe mitral stenosis: Length of murmur increases, opening snap becomes closer to S2
– Investigation findings: CXR may show left atrial enlargement, echocardiography may show reduced cross-sectional area of the mitral valveMitral Regurgitation:
– Causes: Mitral valve prolapse, Myxomatous degeneration, Ischemic heart disease, Rheumatic fever, Connective tissue disorders, Endocarditis, Dilated cardiomyopathy
– Features: pansystolic murmur radiating to left axilla, soft S1, S3, laterally displaced apex beat with heave
– Signs of acute MR: Decompensated congestive heart failure symptoms
– Signs of chronic MR: Leg edema, fatigue, arrhythmia (atrial fibrillation)
– Investigation findings: Doppler echocardiography to detect regurgitant flow and pulmonary hypertension, ECG may show signs of LA enlargement and LV hypertrophy, CXR may show LA and LV enlargement in chronic MR and pulmonary edema in acute MR. -
This question is part of the following fields:
- Cardiology
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Question 82
Correct
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A 25-year-old woman with a previous diagnosis of depression is admitted to the emergency department following an unintentional ingestion of amitriptyline tablets. Which toxidrome is commonly associated with an overdose of amitriptyline?
Your Answer: Anticholinergic
Explanation:An overdose of Amitriptyline, a tricyclic antidepressant, leads to a toxic effect known as anticholinergic toxidrome. This occurs when the muscarinic acetylcholine receptors are blocked, causing the characteristic signs and symptoms associated with this condition.
Further Reading:
Tricyclic antidepressant (TCA) overdose is a common occurrence in emergency departments, with drugs like amitriptyline and dosulepin being particularly dangerous. TCAs work by inhibiting the reuptake of norepinephrine and serotonin in the central nervous system. In cases of toxicity, TCAs block various receptors, including alpha-adrenergic, histaminic, muscarinic, and serotonin receptors. This can lead to symptoms such as hypotension, altered mental state, signs of anticholinergic toxicity, and serotonin receptor effects.
TCAs primarily cause cardiac toxicity by blocking sodium and potassium channels. This can result in a slowing of the action potential, prolongation of the QRS complex, and bradycardia. However, the blockade of muscarinic receptors also leads to tachycardia in TCA overdose. QT prolongation and Torsades de Pointes can occur due to potassium channel blockade. TCAs can also have a toxic effect on the myocardium, causing decreased cardiac contractility and hypotension.
Early symptoms of TCA overdose are related to their anticholinergic properties and may include dry mouth, pyrexia, dilated pupils, agitation, sinus tachycardia, blurred vision, flushed skin, tremor, and confusion. Severe poisoning can lead to arrhythmias, seizures, metabolic acidosis, and coma. ECG changes commonly seen in TCA overdose include sinus tachycardia, widening of the QRS complex, prolongation of the QT interval, and an R/S ratio >0.7 in lead aVR.
Management of TCA overdose involves ensuring a patent airway, administering activated charcoal if ingestion occurred within 1 hour and the airway is intact, and considering gastric lavage for life-threatening cases within 1 hour of ingestion. Serial ECGs and blood gas analysis are important for monitoring. Intravenous fluids and correction of hypoxia are the first-line therapies. IV sodium bicarbonate is used to treat haemodynamic instability caused by TCA overdose, and benzodiazepines are the treatment of choice for seizure control. Other treatments that may be considered include glucagon, magnesium sulfate, and intravenous lipid emulsion.
There are certain things to avoid in TCA overdose, such as anti-arrhythmics like quinidine and flecainide, as they can prolonged depolarization.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 83
Incorrect
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A 5 year old girl is brought into the emergency department by worried parents. The child mentioned having stomach pain and feeling nauseous yesterday but began vomiting this morning and now appears sleepy. After evaluating her, you examine the results of the venous blood gas and glucose (provided below):
pH 7.25
Bicarbonate 13 mmol/l
Glucose 28 mmol/l
The girl weighs 20kg. What is the calculated fluid deficit for this patient?Your Answer: 700ml
Correct Answer: 1000ml
Explanation:Fluid deficit in children and young people with severe diabetic ketoacidosis (DKA) is determined by measuring their blood pH and bicarbonate levels. If the blood pH is below 7.1 and/or the bicarbonate level is below 5, it indicates a fluid deficit. This simplified explanation uses a cutoff value of 5 to determine the severity of the fluid deficit in DKA.
Further Reading:
Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs due to a lack of insulin in the body. It is most commonly seen in individuals with type 1 diabetes but can also occur in type 2 diabetes. DKA is characterized by hyperglycemia, acidosis, and ketonaemia.
The pathophysiology of DKA involves insulin deficiency, which leads to increased glucose production and decreased glucose uptake by cells. This results in hyperglycemia and osmotic diuresis, leading to dehydration. Insulin deficiency also leads to increased lipolysis and the production of ketone bodies, which are acidic. The body attempts to buffer the pH change through metabolic and respiratory compensation, resulting in metabolic acidosis.
DKA can be precipitated by factors such as infection, physiological stress, non-compliance with insulin therapy, acute medical conditions, and certain medications. The clinical features of DKA include polydipsia, polyuria, signs of dehydration, ketotic breath smell, tachypnea, confusion, headache, nausea, vomiting, lethargy, and abdominal pain.
The diagnosis of DKA is based on the presence of ketonaemia or ketonuria, blood glucose levels above 11 mmol/L or known diabetes mellitus, and a blood pH below 7.3 or bicarbonate levels below 15 mmol/L. Initial investigations include blood gas analysis, urine dipstick for glucose and ketones, blood glucose measurement, and electrolyte levels.
Management of DKA involves fluid replacement, electrolyte correction, insulin therapy, and treatment of any underlying cause. Fluid replacement is typically done with isotonic saline, and potassium may need to be added depending on the patient’s levels. Insulin therapy is initiated with an intravenous infusion, and the rate is adjusted based on blood glucose levels. Monitoring of blood glucose, ketones, bicarbonate, and electrolytes is essential, and the insulin infusion is discontinued once ketones are below 0.3 mmol/L, pH is above 7.3, and bicarbonate is above 18 mmol/L.
Complications of DKA and its treatment include gastric stasis, thromboembolism, electrolyte disturbances, cerebral edema, hypoglycemia, acute respiratory distress syndrome, and acute kidney injury. Prompt medical intervention is crucial in managing DKA to prevent potentially fatal outcomes.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 84
Incorrect
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A 68-year-old woman with a history of chronic anemia receives a blood transfusion as part of her treatment protocol. She has a known history of heart failure, for which she takes metoprolol and hydrochlorothiazide. She becomes short of breath, volume overloaded, and edematous during the transfusion.
Which of the following tests will be most useful in confirming the diagnosis?Your Answer: D-dimer
Correct Answer: BNP
Explanation:Transfusion-associated circulatory overload (TACO) is a reaction that occurs when a large volume of blood is infused rapidly. It is the second leading cause of deaths related to transfusions, accounting for about 20% of all fatalities.
TACO typically happens in patients with limited cardiac reserve or chronic anemia who receive a fast blood transfusion. Elderly individuals, infants, and severely anemic patients are particularly vulnerable.
The common signs of TACO include acute respiratory distress, rapid heartbeat, high blood pressure, the appearance of acute or worsening fluid accumulation in the lungs on a chest X-ray, and evidence of excessive fluid retention.
The B-type natriuretic peptide (BNP) can be a helpful diagnostic tool for TACO. Usually, the BNP level is elevated to at least 1.5 times the baseline before the transfusion.
In many cases, simply slowing down the rate of transfusion, positioning the patient upright, and administering diuretics will be sufficient. In more severe cases, the transfusion should be stopped, and non-invasive ventilation may be considered.
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This question is part of the following fields:
- Haematology
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Question 85
Incorrect
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You evaluate a 14-year-old with Down syndrome. The reason for the visit is the caregiver's worry about recent occurrences of nosebleeds and bleeding gums. During the examination, the patient appears pale, but there are no other notable findings.
What is the PRIMARY diagnosis that should raise the most concern at this point?Your Answer: G6PD deficiency
Correct Answer: Acute leukaemia
Explanation:There is a known connection between trisomy 21 and acute lymphoblastic leukemia. Therefore, it is important to investigate and rule out this possibility as the first step in this case.
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This question is part of the following fields:
- Haematology
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Question 86
Incorrect
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A 62-year-old woman presents, confused and trembling. She has a strong smell of alcohol and her appearance is unkempt. She informs you that she typically consumes large amounts of alcohol (>1 L vodka per day) but has not had any since yesterday. Upon examination, you observe that she has jaundice and abdominal distension. There are numerous spider naevi on her abdomen. Her initial blood results are as follows:
AST: 492 IU/L (5-40)
ALT: 398 IU/L (5-40)
ALP: 320 IU/L (20-140)
Gamma GT: 712 IU/L (5-40)
Bilirubin: 104 mmol (3-20)
What is the SINGLE most likely diagnosis?Your Answer: Autoimmune hepatitis
Correct Answer: Alcohol-induced hepatitis
Explanation:This patient presents with elevated transaminases and gamma GT, along with mildly elevated ALP and hyperbilirubinemia. These findings strongly indicate a diagnosis of alcohol-induced hepatitis. Additionally, the patient’s history and examination features strongly suggest a history of chronic alcohol abuse and withdrawal, further supporting this diagnosis.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 87
Incorrect
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A 22-year-old presents to the emergency department with a nosebleed. You observe that they have blood-soaked tissue paper held against the nose, blocking the opening of the left nostril, and blood stains on the front of their shirt. What is the most appropriate initial management for this patient?
Your Answer: Insert adrenaline soaked cotton wool into the nostrils and leave for 3-5 minutes before performing rhinoscopy
Correct Answer: Advise the patient to sit forward and pinch just in front of the bony septum firmly and hold it for 15 minutes
Explanation:To control epistaxis, it is recommended to have the patient sit upright with their upper body tilted forward and their mouth open. Firmly pinch the cartilaginous part of the nose, specifically in front of the bony septum, and maintain pressure for 10-15 minutes without releasing it.
Further Reading:
Epistaxis, or nosebleed, is a common condition that can occur in both children and older adults. It is classified as either anterior or posterior, depending on the location of the bleeding. Anterior epistaxis usually occurs in younger individuals and arises from the nostril, most commonly from an area called Little’s area. These bleeds are usually not severe and account for the majority of nosebleeds seen in hospitals. Posterior nosebleeds, on the other hand, occur in older patients with conditions such as hypertension and atherosclerosis. The bleeding in posterior nosebleeds is likely to come from both nostrils and originates from the superior or posterior parts of the nasal cavity or nasopharynx.
The management of epistaxis involves assessing the patient for signs of instability and implementing measures to control the bleeding. Initial measures include sitting the patient upright with their upper body tilted forward and their mouth open. Firmly pinching the cartilaginous part of the nose for 10-15 minutes without releasing the pressure can also help stop the bleeding. If these measures are successful, a cream called Naseptin or mupirocin nasal ointment can be prescribed for further treatment.
If bleeding persists after the initial measures, nasal cautery or nasal packing may be necessary. Nasal cautery involves using a silver nitrate stick to cauterize the bleeding point, while nasal packing involves inserting nasal tampons or inflatable nasal packs to stop the bleeding. In cases of posterior bleeding, posterior nasal packing or surgery to tie off the bleeding vessel may be considered.
Complications of epistaxis can include nasal bleeding, hypovolemia, anemia, aspiration, and even death. Complications specific to nasal packing include sinusitis, septal hematoma or abscess, pressure necrosis, toxic shock syndrome, and apneic episodes. Nasal cautery can lead to complications such as septal perforation and caustic injury to the surrounding skin.
In children under the age of 2 presenting with epistaxis, it is important to refer them for further investigation as an underlying cause is more likely in this age group.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 88
Correct
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A 4-year-old child is brought in by ambulance. He has been experiencing seizures for the past 20 minutes. He has already received one dose of rectal diazepam from the ambulance crew while on the way. Intravenous access has been established, his bowel movement is 4.5, and he weighs 25 kg.
Based on the current APLS guidelines, what would be the most suitable next course of action in managing his condition?Your Answer: IV lorazepam 2.5 mg
Explanation:The current algorithm for treating a convulsing child, known as APLS, is as follows:
Step 1 (5 minutes after the start of convulsion):
If a child has been convulsing for 5 minutes or more, they should be given an initial dose of benzodiazepine. This can be administered intravenously (IV) or intraosseously (IO) if vascular access is available. Alternatively, buccal midazolam or rectal diazepam can be given if vascular access is not available.Step 2 (10 minutes after the start of step 1):
If the convulsion continues for another 10 minutes, a second dose of benzodiazepine should be given. It is also important to seek senior help at this point.Step 3 (10 minutes after the start of step 2):
At this stage, it is necessary to involve senior medical personnel to reassess the child and provide guidance on further management. The recommended approach is as follows:
– If the child is not already receiving phenytoin, a phenytoin infusion should be initiated. This involves administering 20 mg/kg of phenytoin intravenously over a period of 20 minutes.
– If the child is already taking phenytoin, phenobarbitone can be used instead. The recommended dosage is 20 mg/kg administered intravenously over 20 minutes.
– In the meantime, rectal paraldehyde can be considered at a dose of 0.8 ml/kg of the 50:50 mixture while preparing the infusion.Step 4 (20 minutes after the start of step 3):
If the child is still experiencing convulsions at this stage, it is crucial to have an anaesthetist present. A rapid sequence induction with thiopental is recommended for further management.In the case of this specific child who weighs 25 kg and has already received a dose of lorazepam, they should receive a second dose of 0.1 mg/kg, which amounts to 2.5 mg.
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This question is part of the following fields:
- Neurology
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Question 89
Correct
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A 7-year-old child experiences an anaphylactic reaction after being stung by a bee. How much IM adrenaline should be administered in this situation?
Your Answer: 300 mcg
Explanation:The management of anaphylaxis involves several important steps. First and foremost, it is crucial to ensure proper airway management. Additionally, early administration of adrenaline is essential, preferably in the anterolateral aspect of the middle third of the thigh. Aggressive fluid resuscitation is also necessary. In severe cases, intubation may be required. However, it is important to note that the administration of chlorpheniramine and hydrocortisone should only be considered after early resuscitation has taken place.
Adrenaline is the most vital medication for treating anaphylactic reactions. It acts as an alpha-adrenergic receptor agonist, which helps reverse peripheral vasodilatation and reduce oedema. Furthermore, its beta-adrenergic effects aid in dilating the bronchial airways, increasing the force of myocardial contraction, and suppressing histamine and leukotriene release. Administering adrenaline as the first drug is crucial, and the intramuscular (IM) route is generally the most effective for most individuals.
The recommended doses of IM adrenaline for different age groups during anaphylaxis are as follows:
– Children under 6 years: 150 mcg (0.15 mL of 1:1000)
– Children aged 6-12 years: 300 mcg (0.3 mL of 1:1000)
– Children older than 12 years: 500 mcg (0.5 mL of 1:1000)
– Adults: 500 mcg (0.5 mL of 1:1000) -
This question is part of the following fields:
- Allergy
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Question 90
Incorrect
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A 35-year-old woman comes in with a painful swelling on the left side of her face. The pain and swelling appear to get worse before meals and then gradually improve after eating. During the examination, a solid lump can be felt in the submandibular region. There is no redness, and the patient has no fever and is in good overall health.
What is the SINGLE most probable diagnosis?Your Answer: Sjögrens syndrome
Correct Answer: Sialolithiasis
Explanation:Sialolithiasis is a condition in which a calcified stone (sialolith) forms inside a salivary gland. The submandibular gland (Wharton’s duct) is the most common site, accounting for about 90% of cases, while the parotid gland is the second most affected. In rare instances, sialoliths can also develop in the sublingual gland or minor salivary glands.
The presence of a sialolith obstructs the flow of saliva, leading to pain and swelling in the affected gland during eating. The pain is most intense when salivary flow is high, such as before and during meals, and gradually subsides within an hour after eating. By palpating the floor of the mouth with both hands, a stone may be detected, and sometimes it can even be seen at the opening of the duct. If there is an accompanying infection, pus may be expressed from the gland.
To assess salivary flow, acidic foods like lemon juice can be used as a simple test. X-rays of the mouth’s floor can reveal the presence of a stone. Patients should be referred to an ear, nose, and throat specialist (ENT) for the removal of the stone.
Sialadenitis refers to inflammation of the salivary glands and can be either acute or chronic. Acute sialadenitis is most commonly caused by a bacterial infection, usually ascending from Staphylococcus aureus or Streptococcus viridans. It can occur as a result of sialolithiasis or poor oral hygiene. Clinically, there will be a painful swelling in the affected gland area, with redness of the overlying skin and potential swelling of the cheek and nearby regions. Patients often experience general malaise, with a low-grade fever and elevated inflammatory markers.
Parotitis, on the other hand, refers to inflammation of one or both parotid glands. This inflammation can be caused by bacteria (particularly Staphylococcus aureus), viruses (such as mumps), or tuberculosis.
Sjögren’s syndrome is an autoimmune disorder characterized by dry eyes and dry mouth.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 91
Incorrect
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A middle-aged man who lives alone is brought in by ambulance; he is drowsy, slightly disoriented, vomiting, and complaining of a headache. His skin is dry and hot, he is hyperventilating, and his core temperature is currently 41.2°C. There is currently a summer heatwave, and he has been at home alone in a poorly ventilated apartment. He currently takes ibuprofen and atorvastatin daily and has no known drug allergies.
What is the SINGLE most likely diagnosis?Your Answer: Heat exhaustion
Correct Answer: Heat stroke
Explanation:Heat stroke is a condition characterized by a core temperature greater than 40.6°C, accompanied by changes in mental state and varying levels of organ dysfunction. There are two forms of heat stroke: classic non-exertional heat stroke, which occurs during high environmental temperatures and typically affects elderly patients during heat waves, and exertional heat stroke, which occurs during strenuous physical exercise in high environmental temperatures, such as endurance athletes competing in hot conditions.
Heat stroke happens when the body’s ability to regulate temperature is overwhelmed by a combination of excessive environmental heat, excessive production of heat from exertion, and inadequate heat loss. Several risk factors increase the likelihood of developing heat stroke, including hot and humid environmental conditions, age (particularly the elderly and infants), physical factors like obesity and excessive exertion, medical conditions like anorexia and cardiovascular disease, and certain medications such as alcohol, amphetamines, and diuretics.
The typical clinical features of heat stroke include a core temperature above 40.6°C, early symptoms like extreme fatigue, headache, syncope, facial flushing, vomiting, and diarrhea. The skin is usually hot and dry, although sweating may occur in around 50% of cases of exertional heat stroke. The loss of the ability to sweat is a late and concerning sign. Hyperventilation is almost always present. Heat stroke can also lead to cardiovascular dysfunction, respiratory dysfunction, central nervous system dysfunction, and potentially multi-organ failure, coagulopathy, and rhabdomyolysis if the temperature rises above 41.5°C.
Heat cramps, on the other hand, are characterized by intense thirst and muscle cramps. Body temperature is often elevated but typically remains below 40°C. Sweating, heat dissipation mechanisms, and cognition are preserved, and there is no neurological impairment. Heat exhaustion usually precedes heat stroke and if left untreated, can progress to heat stroke. Heat dissipation is still functioning, and the body temperature is usually below 41°C. Symptoms of heat exhaustion include nausea, oliguria, weakness, headache, thirst, and sinus tachycardia. Central nervous system functioning is usually largely preserved, and patients may complain of feeling hot and appear flushed and sweaty.
It is important to note that malignant hyperthermia and neuroleptic malignant syndrome are highly unlikely in this scenario as the patient has no recent history of a general anesthetic or taking phenothiazines or other antipsychotics, respectively.
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This question is part of the following fields:
- Environmental Emergencies
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Question 92
Incorrect
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A 25-year-old individual comes in with a fever and symptoms resembling the flu. They also complain of muscle pain, diarrhea, and a dry cough. During the examination, their temperature is measured at 38.3°C and they exhibit tenderness in the upper right quadrant of their abdomen. Upon further inquiry, it is revealed that they recently returned from a backpacking trip to Malawi, where they recall developing blisters on their ankles after swimming in a lake. Blood tests indicate a significant increase in eosinophils.
What is the SINGLE most likely diagnosis?Your Answer: West Nile fever
Correct Answer: Schistosomiasis
Explanation:Schistosomiasis, also known as bilharzia, is a tropical disease caused by parasitic trematodes (flukes) of the Schistosoma type. The transmission of this disease occurs when water becomes contaminated with faeces or urine containing eggs, and a specific freshwater snail serves as the intermediate host. Human contact with water inhabited by the intermediate host snail is necessary for transmission to occur.
There are five species of Schistosoma that can cause human disease, namely S. japonicum, S. mansoni, S. haematobium, S. intercalatum, and S. mekongi. Schistosomiasis is the second most impactful tropical disease in terms of public health, following malaria, with over 200 million people worldwide being infected. It is prevalent in the Middle East, Africa, and parts of South America and the Caribbean. Infection can manifest as either acute or chronic.
Acute schistosomiasis is characterized by the early clinical sign of swimmers itch, which involves the development of blisters and an urticarial response at the site where the Schistosoma parasite enters the skin. This typically occurs a few days after the parasite has penetrated the skin. While most acute infections are asymptomatic, some individuals may experience an acute syndrome.
The most common acute syndrome is known as Katayama fever, which primarily affects children or young adults with no previous exposure to the disease. It is caused by an allergic reaction to the sudden release of highly antigenic eggs and usually occurs a few weeks after initial exposure to S. japonicum. Symptoms of Katayama fever include fever, flu-like illness, arthralgia, myalgia, abdominal pain, diarrhea, and cough. Patients may also exhibit right upper quadrant tenderness and hepatosplenomegaly. An extremely high eosinophil count is often present.
Chronic schistosomiasis can manifest in two major forms: intestinal and urogenital. Intestinal schistosomiasis is primarily caused by S. japonicum and S. mansoni, while S. haematobium is the main cause of urogenital schistosomiasis. In intestinal schistosomiasis, adult worms migrate from the liver to the mesenteric venules, where female worms continuously lay eggs. Common symptoms include abdominal pain and bloody diarrhea.
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This question is part of the following fields:
- Infectious Diseases
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Question 93
Incorrect
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A 72-year-old individual presents to the emergency department with complaints of nausea, muscle cramps, and severe fatigue that have been progressively worsening over the past 1-2 weeks. The initial blood test results are as follows:
Na+ 117 mmol/l
K+ 3.9 mmol/l
Urea 8.4 mmol/l
Creatinine 101 µmol/l
Based on these findings, the most probable underlying cause is suspected to be SIADH.Your Answer: Renal artery stenosis
Correct Answer: Small cell lung cancer
Explanation:SIADH, also known as syndrome of inappropriate antidiuretic hormone secretion, is frequently observed in individuals diagnosed with small cell lung cancer. The condition can also be caused by malignancy, pulmonary disorders, and certain medications.
Further Reading:
Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition characterized by low sodium levels in the blood due to excessive secretion of antidiuretic hormone (ADH). ADH, also known as arginine vasopressin (AVP), is responsible for promoting water and sodium reabsorption in the body. SIADH occurs when there is impaired free water excretion, leading to euvolemic (normal fluid volume) hypotonic hyponatremia.
There are various causes of SIADH, including malignancies such as small cell lung cancer, stomach cancer, and prostate cancer, as well as neurological conditions like stroke, subarachnoid hemorrhage, and meningitis. Infections such as tuberculosis and pneumonia, as well as certain medications like thiazide diuretics and selective serotonin reuptake inhibitors (SSRIs), can also contribute to SIADH.
The diagnostic features of SIADH include low plasma osmolality, inappropriately elevated urine osmolality, urinary sodium levels above 30 mmol/L, and euvolemic. Symptoms of hyponatremia, which is a common consequence of SIADH, include nausea, vomiting, headache, confusion, lethargy, muscle weakness, seizures, and coma.
Management of SIADH involves correcting hyponatremia slowly to avoid complications such as central pontine myelinolysis. The underlying cause of SIADH should be treated if possible, such as discontinuing causative medications. Fluid restriction is typically recommended, with a daily limit of around 1000 ml for adults. In severe cases with neurological symptoms, intravenous hypertonic saline may be used. Medications like demeclocycline, which blocks ADH receptors, or ADH receptor antagonists like tolvaptan may also be considered.
It is important to monitor serum sodium levels closely during treatment, especially if using hypertonic saline, to prevent rapid correction that can lead to central pontine myelinolysis. Osmolality abnormalities can help determine the underlying cause of hyponatremia, with increased urine osmolality indicating dehydration or renal disease, and decreased urine osmolality suggesting SIADH or overhydration.
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This question is part of the following fields:
- Nephrology
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Question 94
Incorrect
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A toddler is brought in with a non-blanching rash and a high fever. You suspect a potential diagnosis of meningococcal disease.
Based on the current NICE guidelines, which of the following features is MOST indicative of this diagnosis?Your Answer: Convulsive status epilepticus
Correct Answer: Capillary refill time >3 seconds or longer
Explanation:NICE has emphasized that certain symptoms and signs can indicate specific diseases as the underlying cause of a fever. In the case of meningococcal disease, the presence of a rash that does not fade when pressed upon (non-blanching rash) is particularly suggestive, especially if the child appears unwell, the lesions are larger than 2 mm in diameter (purpura), the capillary refill time is 3 seconds or longer, or there is neck stiffness. For more information, you can refer to the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.
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This question is part of the following fields:
- Neurology
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Question 95
Correct
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A 72-year-old man is brought to the resuscitation area of your Emergency Department by ambulance. He has become increasingly unwell over the past few days with vomiting and diarrhea. His wife tells you that he was started on a medication by his GP six months ago for pain and stiffness around his shoulders, upper arms, and hips. She describes this medication as being '6 small blue tablets.' He has been unable to take these tablets for the past few days. On examination, he is pale and sweaty and appears confused. His observations are as follows: temperature 37.2°C, HR 130 bpm, BP 90/50, RR 22, SaO2 97% on 2 L oxygen, GCS 13. He has intravenous access in situ, and his BM stick glucose is 2.5.
Which of the following medications are the 'small blue tablets' most likely to be?Your Answer: Prednisolone
Explanation:This patient has presented with an Addisonian crisis, which is a rare but potentially catastrophic condition if not diagnosed promptly. The most likely underlying rheumatological diagnosis in this case is polymyalgia rheumatica, and it is likely that the GP started the patient on prednisolone medication.
Addison’s disease occurs when the adrenal glands underproduce steroid hormones, affecting the production of glucocorticoids, mineralocorticoids, and sex steroids. The main causes of Addison’s disease include autoimmune adrenalitis (accounting for 80% of cases), bilateral adrenalectomy, Waterhouse-Friderichsen syndrome (hemorrhage into the adrenal glands), and tuberculosis.
An Addisonian crisis is most commonly triggered by the deliberate or accidental withdrawal of steroid therapy in patients with Addison’s disease. Other factors that can precipitate a crisis include infection, trauma, myocardial infarction, cerebral infarction, asthma, hypothermia, and alcohol abuse.
The clinical features of Addison’s disease include weakness, lethargy, hypotension (especially orthostatic hypotension), nausea, vomiting, weight loss, reduced axillary and pubic hair, depression, and hyperpigmentation (particularly in palmar creases, buccal mucosa, and exposed areas). In an Addisonian crisis, the main features are usually hypoglycemia and shock, characterized by tachycardia, peripheral vasoconstriction, hypotension, altered consciousness, and coma.
Biochemically, Addison’s disease is characterized by increased ACTH levels (as a compensatory response to stimulate the adrenal glands), elevated serum renin levels, hyponatremia, hyperkalemia, hypercalcemia, hypoglycemia, and metabolic acidosis. Diagnostic investigations may include the Synacthen test, plasma ACTH level, plasma renin level, and adrenocortical antibodies.
Management of Addison’s disease should be overseen by an Endocrinologist. Typically, patients require hydrocortisone, fludrocortisone, and dehydroepiandrosterone. Some patients may also need thyroxine if there is hypothalamic-pituitary disease present. Treatment is lifelong, and patients should carry a steroid card and a MedicAlert bracelet, being aware of the possibility of an Addisonian crisis.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 96
Correct
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A 40-year-old woman undergoes a blood transfusion after giving birth. Soon after starting the transfusion, she experiences hives and itching all over her body. She is in good health otherwise and shows no signs of any problems with her airway or breathing.
What is the most probable cause of this reaction to the blood transfusion?Your Answer: Presence of foreign plasma proteins
Explanation:Blood transfusion is a crucial treatment that can save lives, but it also comes with various risks and potential problems. These include immunological complications, administration errors, infections, and immune dilution. While there has been an improvement in safety procedures and a reduction in transfusion use, errors and serious adverse reactions still occur and often go unreported.
Mild allergic reactions during blood transfusion are relatively common and typically occur within a few minutes of starting the transfusion. These reactions happen when patients have antibodies that react with foreign plasma proteins in the transfused blood components. Symptoms of mild allergic reactions include urticaria, Pruritus, and hives.
Anaphylaxis, on the other hand, is much rarer and occurs when an individual has previously been sensitized to an allergen present in the blood. When re-exposed to the allergen, the body releases IgE or IgG antibodies, leading to severe symptoms such as bronchospasm, laryngospasm, abdominal pain, nausea, vomiting, hypotension, shock, and loss of consciousness. Anaphylaxis can be fatal.
Mild allergic reactions can be managed by slowing down the transfusion rate and administering antihistamines. If there is no progression after 30 minutes, the transfusion may continue. Patients who have experienced repeated allergic reactions to transfusion should be given pre-treatment with chlorpheniramine. In cases of anaphylaxis, the transfusion should be stopped immediately, and the patient should receive oxygen, adrenaline, corticosteroids, and antihistamines following the ALS protocol.
The table below summarizes the main transfusion reactions and complications, along with their features and management:
Complication | Features | Management
Febrile transfusion reaction | 1 degree rise in temperature, chills, malaise | Supportive care, paracetamol
Acute haemolytic reaction | Fever, chills, pain at transfusion site, nausea, vomiting, dark urine | STOP THE TRANSFUSION, administer IV fluids, diuretics if necessary
Delayed haemolytic reaction | Fever, anaemia, jaundice, haemoglobinuria | Monitor anaemia and renal function, treat as required
Allergic reaction | Urticaria, Pruritus, hives | Symptomatic treatment with ant -
This question is part of the following fields:
- Haematology
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Question 97
Incorrect
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A 42 year old male patient is brought into resus with a two day history of nausea and vomiting. He has reduced GCS, is hypotensive and tachycardic. His wife tells you he has Addison's but frequently neglects to take his medication. Concerning Addison's, which electrolyte imbalance is most frequently linked to the condition?
Your Answer: Hypokalaemia
Correct Answer: Hyponatraemia
Explanation:The electrolyte imbalances that are commonly observed in individuals with Addison’s disease are decreased sodium levels, increased potassium levels, increased calcium levels, and decreased glucose levels. In cases of Addisonian crisis, which is a severe form of Addison’s disease, patients may also experience hyponatremia (low sodium levels), hyperkalemia (high potassium levels), hypercalcemia (high calcium levels), and hypoglycemia (low glucose levels). Additionally, these patients may often develop acidosis.
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 98
Incorrect
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A child presents with a headache, high temperature, and a very itchy rash on their face and body that has been there for 3 days. The doctor suspects the child has chickenpox. When should aciclovir be considered for this patient?
Your Answer: Patient aged 18 years
Correct Answer: Immunocompromised
Explanation:Chickenpox is a highly contagious illness caused by the varicella-zoster virus, a DNA virus from the Herpesviridae family. Most cases are mild to moderate, and the infection usually resolves on its own. Severe complications are rare but can occur, especially in individuals with weakened immune systems or underlying health conditions.
The incubation period for chickenpox is typically between 14 to 21 days. It is contagious from a few days before the rash appears until about a week after the first lesions show up.
The common clinical features of chickenpox include:
– Fever, which lasts for approximately 3-5 days.
– The initial rash starts as flat red spots and progresses into raised bumps.
– These bumps then turn into fluid-filled blisters and eventually form pustules surrounded by redness.
– The lesions are extremely itchy.
– The rash reaches its peak around 48 hours in individuals with a healthy immune system.
– The rash tends to be more concentrated on the face and trunk, with fewer lesions on the limbs.
– The blisters eventually dry up and form crusts, which can lead to scarring if scratched.
– Headache, fatigue, and abdominal pain may also occur.Chickenpox tends to be more severe in teenagers and adults compared to children. Antiviral treatment should be considered for these individuals if they seek medical attention within 24 hours of rash onset. The recommended oral dose of aciclovir is 800 mg taken five times a day for seven days.
Immunocompromised patients and those at higher risk, such as individuals with severe cardiovascular or respiratory disease or chronic skin disorders, should receive antiviral treatment for ten days, with at least seven days of intravenous administration.
Although most cases are relatively mild, if serious complications like pneumonia, encephalitis, or dehydration are suspected, it is important to refer the patient for hospital admission.
For more information, you can refer to the NICE Clinical Knowledge Summary on Chickenpox.
https://cks.nice.org.uk/topics/chickenpox/ -
This question is part of the following fields:
- Dermatology
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