00
Correct
00
Incorrect
00 : 00 : 00
Session Time
00 : 00
Average Question Time ( Secs)
  • Question 1 - A 6-week-old baby girl is brought to the Emergency Department by her parents...

    Incorrect

    • A 6-week-old baby girl is brought to the Emergency Department by her parents with projectile vomiting. She is vomiting approximately every 45 minutes after each feed but remains hungry. On examination, she appears dehydrated, and you can feel a small mass in the upper abdomen. A venous blood gas is performed.
      What is the definitive treatment for the diagnosis in this case?

      Your Answer: Billroth’s operation

      Correct Answer: Ramstedt pyloromyotomy

      Explanation:

      Infantile hypertrophic pyloric stenosis is a condition characterized by the thickening and enlargement of the smooth muscle in the antrum of the stomach, leading to the narrowing of the pyloric canal. This narrowing can easily cause obstruction. It is a relatively common condition, occurring in about 1 in 500 live births, and is more frequently seen in males than females, with a ratio of 4 to 1. It is most commonly observed in first-born male children, although it can rarely occur in adults as well.

      The main symptom of infantile hypertrophic pyloric stenosis is vomiting, which typically begins between 2 to 8 weeks of age. The vomit is usually non-bilious and forcefully expelled. It tends to occur around 30 to 60 minutes after feeding, leaving the baby hungry despite the vomiting. In some cases, there may be blood in the vomit. Other clinical features include persistent hunger, dehydration, weight loss, and constipation. An enlarged pylorus, often described as olive-shaped, can be felt in the right upper quadrant or epigastric in approximately 95% of cases. This is most noticeable at the beginning of a feed.

      The typical acid-base disturbance seen in this condition is hypochloremic metabolic alkalosis. This occurs due to the loss of hydrogen and chloride ions in the vomit, as well as decreased secretion of pancreatic bicarbonate. The increased bicarbonate ions in the distal tubule of the kidney lead to the production of alkaline urine. Hyponatremia and hypokalemia are also commonly present.

      Ultrasound scanning is the preferred diagnostic tool for infantile hypertrophic pyloric stenosis, as it is reliable and easy to perform. It has replaced barium studies as the investigation of choice.

      Initial management involves fluid resuscitation, which should be tailored to the weight and degree of dehydration. Any electrolyte imbalances should also be corrected.

      The definitive treatment for this condition is surgical intervention, with the Ramstedt pyloromyotomy being the procedure of choice. Laparoscopic pyloromyotomy is also an effective alternative if suitable facilities are available. The prognosis for infants with this condition is excellent, as long as there is no delay in diagnosis and treatment initiation.

    • This question is part of the following fields:

      • Neonatal Emergencies
      17
      Seconds
  • Question 2 - A 45-year-old immigrant from West Africa comes in with a red, papular, extremely...

    Incorrect

    • A 45-year-old immigrant from West Africa comes in with a red, papular, extremely itchy rash on his torso and limbs. Some of the lesions are darker in color and have become thickened and lichenified. Additionally, he has a few patches of skin on his lower legs that have lost their pigmentation. The areas of hyperpigmentation also seem to have lost their elasticity. He also mentions experiencing vision problems and describes everything as appearing shadowy.

      What is the MOST LIKELY diagnosis for this patient?

      Your Answer: Chagas disease

      Correct Answer: Onchocerciasis

      Explanation:

      Onchocerciasis is a parasitic disease caused by the filarial nematode Onchocerca volvulus. It is transmitted through the bites of infected blackflies of Simulium species, which carry immature larval forms of the parasite from human to human.

      In the human body, the larvae form nodules in the subcutaneous tissue, where they mature to adult worms. After mating, the female adult worm can release up to 1000 microfilariae a day.

      Onchocerciasis is currently endemic in 30 African countries, Yemen, and a few isolated regions of South America. Approximately 37 million people worldwide are currently infected.

      Symptoms start to occur around a year after the patient is infected. The earliest symptom is usually an intensely itchy rash. Various skin manifestations occur, including scattered, red, pruritic papules (acute papular onchodermatitis), larger, chronic, hyperpigmented papules (chronic papular onchodermatitis), lichenified, oedematous, hyperpigmented papules and plaques (lichenified onchodermatitis), areas of skin atrophy with loss of elasticity (‘Lizard skin’), and depigmented areas with a ‘leopard skin’ appearance, usually on the shins.

      Ocular involvement provides the common name associated with onchocerciasis, river blindness, and it can involve any part of the eye. Almost a million people worldwide have at least a partial degree of vision loss caused by onchocerciasis. Initially, there may be intense watering, a foreign body sensation, and photophobia. This can progress to conjunctivitis, iridocyclitis, and chorioretinitis. Secondary glaucoma and optic atrophy may also occur.

      In a number of countries, onchocerciasis has been controlled through the spraying of blackfly breeding sites with insecticide. The drug ivermectin is the preferred treatment for onchocerciasis.

    • This question is part of the following fields:

      • Dermatology
      41.4
      Seconds
  • Question 3 - You are asked to evaluate a 7-year-old boy who has arrived at the...

    Correct

    • You are asked to evaluate a 7-year-old boy who has arrived at the emergency department with a widespread maculopapular rash. The patient and his family have recently returned from a trip to Mexico. The mother is uncertain about the vaccinations the patient has received, and you have no access to medical records as the family relocated to the US from Mexico 8 months ago and have not yet registered with a primary care physician. You suspect Measles. What guidance should you provide to the patient's mother regarding school attendance?

      Your Answer: Exclude for 5 days from onset of rash

      Explanation:

      Children who have been diagnosed with Rubella, also known as German measles, should be advised to stay away from school for a period of 5 days from the onset of the rash. It is important to be familiar with the guidelines for excluding children from school due to infectious diseases that present with a rash.

      Further Reading:

      Rubella, also known as German measles, is a viral infection caused by the togavirus. It used to be more common before the introduction of the MMR vaccine, but now it is rare. Outbreaks of rubella are more common during the winter and spring seasons. The incubation period for rubella is 14-21 days, and individuals are infectious from 7 days before symptoms appear to 4-5 days after the onset of the rash.

      The features of rubella include a prodrome, which may include symptoms such as low-grade fever. The rash associated with rubella is maculopapular and initially appears on the face before spreading to the whole body. The rash usually fades by the 3-5 day. Lymphadenopathy, specifically suboccipital and postauricular, is also commonly seen in rubella cases.

      Complications of rubella can include arthritis, thrombocytopenia, encephalitis, and myocarditis. However, these complications are rare. Rubella can be particularly dangerous if contracted during pregnancy, as it can lead to congenital rubella syndrome. The risk of fetal damage is highest during the first 8-10 weeks of pregnancy, with a risk as high as 90%. Fetal damage is rare after 16 weeks. Congenital rubella syndrome can result in various complications such as sensorineural deafness, congenital cataracts, congenital heart disease, growth retardation, hepatosplenomegaly, purpuric skin lesions, ‘salt and pepper’ chorioretinitis, microphthalmia, and cerebral palsy.

      Diagnosis of rubella can be made by testing for raised IgM antibodies in women who have recently been exposed to the virus. Serological or PCR testing is the gold standard investigation for rubella. A testing kit can be obtained from the Local Health Protection Unit (HPU).

      There is no specific treatment for rubella. Antipyretics can be used to manage fever. It is advised to exclude individuals with rubella from school for 5 days from the onset of the rash. Infection during pregnancy should prompt referral to obstetrics. Rubella is a notifiable disease, meaning that it requires notification of the local authority or UKHSA health protection team.

    • This question is part of the following fields:

      • Infectious Diseases
      26.6
      Seconds
  • Question 4 - A 35-year-old woman with a previous diagnosis of paroxysmal supraventricular tachycardia is found...

    Incorrect

    • A 35-year-old woman with a previous diagnosis of paroxysmal supraventricular tachycardia is found to have Lown-Ganong-Levine (LGL) syndrome.
      Which of the following statements about LGL syndrome is correct?

      Your Answer: It predisposes to atrial flutter

      Correct Answer: The QRS duration is typically normal

      Explanation:

      Lown-Ganong-Levine (LGL) syndrome is a condition that affects the electrical conducting system of the heart. It is classified as a pre-excitation syndrome, similar to the more well-known Wolff-Parkinson-White (WPW) syndrome. However, unlike WPW syndrome, LGL syndrome does not involve an accessory pathway for conduction. Instead, it is believed that there may be accessory fibers present that bypass all or part of the atrioventricular node.

      When looking at an electrocardiogram (ECG) of a patient with LGL syndrome in sinus rhythm, there are several characteristic features to observe. The PR interval, which represents the time it takes for the electrical signal to travel from the atria to the ventricles, is typically shortened and measures less than 120 milliseconds. The QRS duration, which represents the time it takes for the ventricles to contract, is normal. The P wave, which represents the electrical activity of the atria, may be normal or inverted. However, what distinguishes LGL syndrome from other pre-excitation syndromes is the absence of a delta wave, which is a slurring of the initial rise in the QRS complex.

      It is important to note that LGL syndrome predisposes individuals to paroxysmal supraventricular tachycardia (SVT), a rapid heart rhythm that originates above the ventricles. However, it does not increase the risk of developing atrial fibrillation or flutter, which are other types of abnormal heart rhythms.

    • This question is part of the following fields:

      • Cardiology
      15.6
      Seconds
  • Question 5 - A 42-year-old woman with a lengthy history of depression arrives at the Emergency...

    Correct

    • A 42-year-old woman with a lengthy history of depression arrives at the Emergency Department after intentionally overdosing on the medication she takes for her heart condition. She informs you that she consumed verapamil immediate-release 240 mg tablets approximately 30 minutes ago. However, her spouse promptly discovered her and brought her to the hospital. Currently, she shows no signs of symptoms. Typically, how much time passes before symptoms manifest in cases of this overdose?

      Your Answer: 1-2 hours

      Explanation:

      Calcium-channel blocker overdose is a serious condition that should always be taken seriously as it can be potentially life-threatening. The two 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 the cells. These channels play a crucial role in the functioning of cardiac myocytes, vascular smooth muscle cells, and islet beta-cells.

      Significant toxicity can occur with the ingestion of more than 10 tablets of verapamil (160 mg or 240 mg immediate or sustained-release capsules) or diltiazem (180 mg, 240 mg or 360 mg immediate or sustained-release capsules). In children, even 1-2 tablets of immediate or sustained-release verapamil or diltiazem can be harmful. Symptoms usually appear within 1-2 hours of taking standard preparations, but with slow-release versions, the onset of severe toxicity may be delayed by 12-16 hours, with peak effects occurring after 24 hours.

      The main clinical manifestations of calcium-channel blocker overdose include nausea and vomiting, low blood pressure, slow heart rate and first-degree heart block, heart muscle ischemia and stroke, kidney failure, pulmonary edema, and high blood sugar levels.

      When managing a patient with calcium-channel blocker overdose, certain bedside investigations are crucial. These include checking blood glucose levels, performing an electrocardiogram (ECG), and obtaining an arterial blood gas sample. Additional investigations that can provide helpful information include assessing urea and electrolyte levels, conducting a chest X-ray to check for pulmonary edema, and performing an echocardiography.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      12.4
      Seconds
  • Question 6 - A 35 year old male is brought to the emergency department with severe...

    Incorrect

    • A 35 year old male is brought to the emergency department with severe head and chest injuries. As his GCS continues to decline, it is determined that intubation is necessary. You begin preparing for rapid sequence induction (RSI). What is the appropriate dosage of sodium thiopentone for an adult undergoing RSI?

      Your Answer: 10-20 mg/kg

      Correct Answer: 3-5 mg/kg

      Explanation:

      To perform rapid sequence induction in adults, it is recommended to administer a dose of sodium thiopentone ranging from 3 to 5 mg per kilogram of body weight.

      Further Reading:

      There are four commonly used induction agents in the UK: propofol, ketamine, thiopentone, and etomidate.

      Propofol is a 1% solution that produces significant venodilation and myocardial depression. It can also reduce cerebral perfusion pressure. The typical dose for propofol is 1.5-2.5 mg/kg. However, it can cause side effects such as hypotension, respiratory depression, and pain at the site of injection.

      Ketamine is another induction agent that produces a dissociative state. It does not display a dose-response continuum, meaning that the effects do not necessarily increase with higher doses. Ketamine can cause bronchodilation, which is useful in patients with asthma. The initial dose for ketamine is 0.5-2 mg/kg, with a typical IV dose of 1.5 mg/kg. Side effects of ketamine include tachycardia, hypertension, laryngospasm, unpleasant hallucinations, nausea and vomiting, hypersalivation, increased intracranial and intraocular pressure, nystagmus and diplopia, abnormal movements, and skin reactions.

      Thiopentone is an ultra-short acting barbiturate that acts on the GABA receptor complex. It decreases cerebral metabolic oxygen and reduces cerebral blood flow and intracranial pressure. The adult dose for thiopentone is 3-5 mg/kg, while the child dose is 5-8 mg/kg. However, these doses should be halved in patients with hypovolemia. Side effects of thiopentone include venodilation, myocardial depression, and hypotension. It is contraindicated in patients with acute porphyrias and myotonic dystrophy.

      Etomidate is the most haemodynamically stable induction agent and is useful in patients with hypovolemia, anaphylaxis, and asthma. It has similar cerebral effects to thiopentone. The dose for etomidate is 0.15-0.3 mg/kg. Side effects of etomidate include injection site pain, movement disorders, adrenal insufficiency, and apnoea. It is contraindicated in patients with sepsis due to adrenal suppression.

    • This question is part of the following fields:

      • Basic Anaesthetics
      9.7
      Seconds
  • Question 7 - A 68-year-old woman presents with severe diarrhea one week after having a total...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      14.8
      Seconds
  • Question 8 - You review a child with a history of autism who is currently experiencing...

    Correct

    • You review a child with a history of autism who is currently experiencing severe communication difficulties. You attempt to engage in conversation with the child but find it challenging to comprehend their speech. Their language lacks coherence and seems to consist of random words and phrases.
      Which ONE of the following communication disorders is the child displaying?

      Your Answer: Word salad

      Explanation:

      A word salad refers to a jumbled or incomprehensible combination of seemingly arbitrary words and phrases. This phenomenon is frequently observed in individuals with schizophrenia and dementia.

    • This question is part of the following fields:

      • Mental Health
      9.9
      Seconds
  • Question 9 - A 32-year-old man that has been involved in a car crash develops symptoms...

    Incorrect

    • A 32-year-old man that has been involved in a car crash develops symptoms of acute airway blockage. You determine that he needs intubation through a rapid sequence induction. You intend to use etomidate as your induction medication.
      Etomidate functions by acting on what type of receptor?

      Your Answer: N-methyl-D-aspartate (NMDA)

      Correct Answer: Gamma-aminobutyric acid (GABA)

      Explanation:

      Etomidate is a derivative of imidazole that is commonly used to induce anesthesia due to its short-acting nature. Its main mechanism of action is believed to involve the modulation of fast inhibitory synaptic transmission within the central nervous system by acting on GABA type A receptors.

    • This question is part of the following fields:

      • Basic Anaesthetics
      35.6
      Seconds
  • Question 10 - A 60 year old female presents to the emergency department complaining of increasing...

    Correct

    • A 60 year old female presents to the emergency department complaining of increasing shortness of breath. The patient reports feeling more fatigued and breathless with minimal exertion over the past few months, but in the past few days, she has been experiencing breathlessness even at rest. She informs you that she has been taking aspirin, ramipril, bisoprolol, and rosuvastatin for the past 5 years since she had a minor heart attack. Upon examination, you observe prominent neck veins, bilateral lung crepitations that are worse at the bases, faint heart sounds, and pitting edema below the knee. The patient's vital signs are as follows:

      Blood pressure: 130/84 mmHg
      Pulse rate: 90 bpm
      Respiration rate: 23 bpm
      Temperature: 37.0ºC
      Oxygen saturation: 93% on room air

      What would be the most appropriate initial treatment for this patient?

      Your Answer: Furosemide 40 mg IV

      Explanation:

      Given the patient’s symptoms and physical findings, the most appropriate initial treatment would be to administer Furosemide 40 mg intravenously. Furosemide is a loop diuretic that helps remove excess fluid from the body, which can alleviate symptoms of fluid overload such as shortness of breath and edema. By reducing fluid volume, Furosemide can help improve the patient’s breathing and relieve the strain on the heart.

      Further Reading:

      Cardiac failure, also known as heart failure, is a clinical syndrome characterized by symptoms and signs resulting from abnormalities in the structure or function of the heart. This can lead to reduced cardiac output or high filling pressures at rest or with stress. Heart failure can be caused by various problems such as myocardial, valvular, pericardial, endocardial, or arrhythmic issues.

      The most common causes of heart failure in the UK are coronary heart disease and hypertension. However, there are many other possible causes, including valvular heart disease, structural heart disease, cardiomyopathies, certain drugs or toxins, endocrine disorders, nutritional deficiencies, infiltrative diseases, infections, and arrhythmias. Conditions that increase peripheral demand on the heart, such as anemia, pregnancy, sepsis, hyperthyroidism, Paget’s disease of bone, arteriovenous malformations, and beriberi, can also lead to high-output cardiac failure.

      Signs and symptoms of heart failure include edema, lung crepitations, tachycardia, tachypnea, hypotension, displaced apex beat, right ventricular heave, elevated jugular venous pressure, cyanosis, hepatomegaly, ascites, pleural effusions, breathlessness, fatigue, orthopnea, paroxysmal nocturnal dyspnea, nocturnal cough or wheeze, and Presyncope.

      To diagnose heart failure, NICE recommends three key tests: N-terminal pro-B-type natriuretic peptide (NT‑proBNP), transthoracic echocardiography, and ECG. Additional tests may include chest X-ray, blood tests (U&Es, thyroid function, LFT’s, lipid profile, HbA1C, FBC), urinalysis, and peak flow or spirometry.

      Management of cardiogenic pulmonary edema, a complication of heart failure, involves ensuring a patent airway, optimizing breathing with supplemental oxygen and non-invasive ventilation if necessary, and addressing circulation with loop diuretics to reduce preload, vasodilators to reduce preload and afterload, and inotropes if hypotension or signs of end organ hypoperfusion persist.

      In summary, cardiac failure is a clinical syndrome resulting from abnormalities in cardiac function. It can have various causes and is characterized by specific signs and symptoms. Diagnosis involves specific tests, and management focuses on addressing

    • This question is part of the following fields:

      • Cardiology
      30.1
      Seconds
  • Question 11 - A 7-year-old girl is brought to the Emergency Department by her father with...

    Correct

    • A 7-year-old girl is brought to the Emergency Department by her father with a high temperature and pain in her ear. During the examination, you observe that the mastoid area is red and there is a soft, painful lump in the same spot. You diagnose her with acute mastoiditis, start her on intravenous antibiotics, and refer her to the ENT team on duty.
      Which section of the temporal bone is affected in this situation?

      Your Answer: Petrous part

      Explanation:

      Mastoiditis occurs when a suppurative infection spreads from otitis media, affecting the middle ear, to the mastoid antrum. This infection causes inflammation in the mastoid and surrounding tissues, potentially leading to damage to the bone.

      The mastoid antrum, also known as the tympanic antrum, is an air space located in the petrous part of the temporal bone. It connects to the mastoid cells at the back and the epitympanic recess through the aditus to the mastoid antrum.

      The mastoid cells come in different types, varying in number and size. There are cellular cells with thin septa, diploeic cells that are marrow spaces with few air cells, and acellular cells that are neither cells nor marrow spaces.

      These air spaces serve various functions, including acting as sound receptors, providing voice resonance, offering acoustic insulation and dissipation, protecting against physical damage, and reducing the weight of the cranium.

      Overall, mastoiditis occurs when an infection from otitis media spreads to the mastoid antrum, causing inflammation and potential damage to the surrounding tissues and bone. The mastoid antrum and mastoid air cells within the temporal bone play important roles in sound reception, voice resonance, protection, and reducing cranial mass.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      47.8
      Seconds
  • Question 12 - A 72-year-old man with a history of COPD complains of a headache, dizziness,...

    Incorrect

    • A 72-year-old man with a history of COPD complains of a headache, dizziness, and palpitations. He is currently taking modified-release theophylline for his COPD. You suspect theophylline toxicity and schedule a blood test to check his levels.
      When should the blood sample be taken after his last oral dose?

      Your Answer: 12 hours

      Correct Answer: 4-6 hours

      Explanation:

      In order to achieve satisfactory bronchodilation, most individuals require a plasma theophylline concentration of 10-20 mg/litre (55-110 micromol/litre). However, it is possible for a lower concentration to still be effective. Adverse effects can occur within the range of 10-20 mg/litre, and their frequency and severity increase when concentrations exceed 20 mg/litre.

      To measure plasma theophylline concentration, a blood sample should be taken five days after starting oral treatment and at least three days after any dose adjustment. For modified-release preparations, the blood sample should typically be taken 4-6 hours after an oral dose (specific sampling times may vary, so it is advisable to consult local guidelines). If aminophylline is administered intravenously, a blood sample should be taken 4-6 hours after initiating treatment.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      7.7
      Seconds
  • Question 13 - A 7-year-old girl presents with a 4-day history of blurred vision in her...

    Incorrect

    • A 7-year-old girl presents with a 4-day history of blurred vision in her left eye. She is also experiencing eye pain and fatigue. On examination, her temperature is 38.0°C, but her other vital signs are normal. There is significant redness in the conjunctiva, and a collection of pus (hypopyon) is present in her left eye. Her visual acuity in that eye is reduced to counting fingers. She recently received a kitten as a pet from her parents.

      What is the SINGLE most likely causative organism?

      Your Answer: Ancylostoma caninum

      Correct Answer: Toxocara canis

      Explanation:

      Toxocariasis is a rare infection caused by the parasitic roundworm Toxocara canis. The main way it spreads to humans is through contact with dog feces. However, practicing good hand hygiene can help prevent transmission. While most people who come into contact with Toxocara canis don’t show any symptoms, a small number may experience a mild flu-like illness.

      The most common presentation of toxocariasis is in children, who may experience unilateral visual loss. This loss of vision is typically caused by conditions such as vitritis, macular edema, and tractional retinal detachment. It is believed that these lesions occur due to a toxic or immunoallergic reaction to the larval antigens.

    • This question is part of the following fields:

      • Ophthalmology
      21.1
      Seconds
  • Question 14 - A 35-year-old woman with bipolar disorder describes a feeling in which a voice...

    Correct

    • A 35-year-old woman with bipolar disorder describes a feeling in which a voice in her mind appears to vocalize her thoughts to her immediately after the thought has been generated.
      Which of the following psychological symptoms is she encountering?

      Your Answer: Écho de la pensée

      Explanation:

      Écho de la pensée, also known as thought echo, is a psychiatric symptom characterized by the perception of a voice in one’s mind that appears to vocalize thoughts immediately after they are generated.

      Thought withdrawal, on the other hand, is a delusional belief where individuals feel that their thoughts have been removed from their own consciousness without their control or consent.

      In contrast, thought insertion is a delusional conviction that someone else is influencing or manipulating their thoughts, causing difficulty in distinguishing between their own thoughts and those that have been inserted by another person.

      Folie à deux, also referred to as induced psychosis, is a specific type of delusional disorder that is shared by two or more individuals who have a close emotional relationship.

      Lastly, echophonia refers to the replication of the voice that can sometimes be heard when listening to the chest during auscultation.

    • This question is part of the following fields:

      • Mental Health
      9.9
      Seconds
  • Question 15 - A 35 year old man presents to the emergency department complaining of worsening...

    Correct

    • A 35 year old man presents to the emergency department complaining of worsening difficulty breathing that has been developing over the last 2 days. His partner mentioned that he looked pale. He informs you that he usually doesn't take any medications but started taking chloroquine for malaria prevention 5 days ago as he is planning to travel to Kenya next week. His oxygen saturation is 89% on room air and you observe that he appears bluish in color. Upon obtaining a blood gas, you notice that his blood has a chocolate-like hue. What is the probable diagnosis?

      Your Answer: Methaemoglobinaemia

      Explanation:

      Methaemoglobinaemia is a condition characterized by various symptoms such as headache, anxiety, acidosis, arrhythmia, seizure activity, reduced consciousness or coma. One notable feature is the presence of brown or chocolate coloured blood. It is important to note that the patient is taking chloroquine, which is a known trigger for methaemoglobinaemia. Additionally, despite the condition, the patient’s arterial blood gas analysis shows a normal partial pressure of oxygen.

      Further Reading:

      Methaemoglobinaemia is a condition where haemoglobin is oxidised from Fe2+ to Fe3+. This process is normally regulated by NADH methaemoglobin reductase, which transfers electrons from NADH to methaemoglobin, converting it back to haemoglobin. In healthy individuals, methaemoglobin levels are typically less than 1% of total haemoglobin. However, an increase in methaemoglobin can lead to tissue hypoxia as Fe3+ cannot bind oxygen effectively.

      Methaemoglobinaemia can be congenital or acquired. Congenital causes include haemoglobin chain variants (HbM, HbH) and NADH methaemoglobin reductase deficiency. Acquired causes can be due to exposure to certain drugs or chemicals, such as sulphonamides, local anaesthetics (especially prilocaine), nitrates, chloroquine, dapsone, primaquine, and phenytoin. Aniline dyes are also known to cause methaemoglobinaemia.

      Clinical features of methaemoglobinaemia include slate grey cyanosis (blue to grey skin coloration), chocolate blood or chocolate cyanosis (brown color of blood), dyspnoea, low SpO2 on pulse oximetry (which often does not improve with supplemental oxygen), and normal PaO2 on arterial blood gas (ABG) but low SaO2. Patients may tolerate hypoxia better than expected. Severe cases can present with acidosis, arrhythmias, seizures, and coma.

      Diagnosis of methaemoglobinaemia is made by directly measuring the level of methaemoglobin using a co-oximeter, which is present in most modern blood gas analysers. Other investigations, such as a full blood count (FBC), electrocardiogram (ECG), chest X-ray (CXR), and beta-human chorionic gonadotropin (bHCG) levels (in pregnancy), may be done to assess the extent of the condition and rule out other contributing factors.

      Active treatment is required if the methaemoglobin level is above 30% or if it is below 30% but the patient is symptomatic or shows evidence of tissue hypoxia. Treatment involves maintaining the airway and delivering high-flow oxygen, removing the causative agents, treating toxidromes and consider giving IV dextrose 5%.

    • This question is part of the following fields:

      • Haematology
      345.8
      Seconds
  • Question 16 - You review a child with hypocalcaemia with your consultant. She performs an examination...

    Incorrect

    • You review a child with hypocalcaemia with your consultant. She performs an examination and taps along the course of the facial nerve as part of this. This causes contraction of the muscles of the eye, mouth, and nose on the same side.

      Which SINGLE sign has the consultant demonstrated?

      Your Answer: Trousseau’s sign

      Correct Answer: Chvostek’s sign

      Explanation:

      Chvostek’s sign is an indication of latent tetany and is observed in individuals with hypocalcaemia. When the angle of the jaw is tapped, the facial muscles on the same side of the face will momentarily contract.

      Trousseau’s sign is another indication of latent tetany seen in hypocalcaemia. To test for this sign, a blood pressure cuff is placed around the subject’s arm and inflated to 20 mmHg above systolic blood pressure. This occludes arterial blood flow to the hand for a period of 3 to 5 minutes. In the presence of hypocalcaemia, carpopedal spasm will occur, characterized by flexion at the wrist and MCP joints, extension of the IP joints, and adduction of the thumb and fingers.

      Blumberg’s sign is a diagnostic tool for peritonitis. It is considered positive when rebound tenderness is felt in the abdominal wall upon slow compression and rapid release.

      Froment’s sign is a test used to assess ulnar nerve palsy, specifically evaluating the action of the adductor pollicis muscle. The patient is instructed to hold a piece of paper between their thumb and index finger. The examiner then attempts to pull the paper from between the thumb and index finger. A patient with ulnar nerve palsy will struggle to maintain a grip and may compensate by flexing the flexor pollicis longus muscle to sustain the pinching effect.

      Gower’s sign is observed in children with Duchenne’s muscular dystrophy. When attempting to stand up from the ground, these children will start with both hands and feet on the floor and gradually use their hands to work up their legs until they achieve an upright posture.

    • This question is part of the following fields:

      • Nephrology
      10.9
      Seconds
  • Question 17 - A 25-year-old woman arrives at the emergency department with complaints of lip swelling...

    Correct

    • A 25-year-old woman arrives at the emergency department with complaints of lip swelling that began 30 minutes ago. During her medical history, she mentions that her sister experienced a similar episode and was recently diagnosed with hereditary angioedema (HAE). What is the main treatment for this condition?

      Your Answer: C1 Esterase Inhibitor Replacement Protein

      Explanation:

      The explanation states that the increased activity of the enzyme kininogenase is caused by hormonal factors, specifically oestrogen, as well as genetic factors.

      Further Reading:

      Angioedema and urticaria are related conditions that involve swelling in different layers of tissue. Angioedema refers to swelling in the deeper layers of tissue, such as the lips and eyelids, while urticaria, also known as hives, refers to swelling in the epidermal skin layers, resulting in raised red areas of skin with itching. These conditions often coexist and may have a common underlying cause.

      Angioedema can be classified into allergic and non-allergic types. Allergic angioedema is the most common type and is usually triggered by an allergic reaction, such as to certain medications like penicillins and NSAIDs. Non-allergic angioedema has multiple subtypes and can be caused by factors such as certain medications, including ACE inhibitors, or underlying conditions like hereditary angioedema (HAE) or acquired angioedema.

      HAE is an autosomal dominant disease characterized by a deficiency of C1 esterase inhibitor. It typically presents in childhood and can be inherited or acquired as a result of certain disorders like lymphoma or systemic lupus erythematosus. Acquired angioedema may have similar clinical features to HAE but is caused by acquired deficiencies of C1 esterase inhibitor due to autoimmune or lymphoproliferative disorders.

      The management of urticaria and allergic angioedema focuses on ensuring the airway remains open and addressing any identifiable triggers. In mild cases without airway compromise, patients may be advised that symptoms will resolve without treatment. Non-sedating antihistamines can be used for up to 6 weeks to relieve symptoms. Severe cases of urticaria may require systemic corticosteroids in addition to antihistamines. In moderate to severe attacks of allergic angioedema, intramuscular epinephrine may be considered.

      The management of HAE involves treating the underlying deficiency of C1 esterase inhibitor. This can be done through the administration of C1 esterase inhibitor, bradykinin receptor antagonists, or fresh frozen plasma transfusion, which contains C1 inhibitor.

      In summary, angioedema and urticaria are related conditions involving swelling in different layers of tissue. They can coexist and may have a common underlying cause. Management involves addressing triggers, using antihistamines, and in severe cases, systemic corticosteroids or other specific treatments for HAE.

    • This question is part of the following fields:

      • Dermatology
      9.7
      Seconds
  • Question 18 - A 22-year-old individual comes in with a painful, itchy, red left eye. During...

    Correct

    • A 22-year-old individual comes in with a painful, itchy, red left eye. During the examination, there is noticeable redness in the conjunctiva, and follicles are observed on the inner eyelid when it is turned inside out. The patient recently had a mild and brief upper respiratory tract infection, but there are no other significant medical history details.

      What is the MOST LIKELY organism responsible for this condition?

      Your Answer: Adenovirus

      Explanation:

      Conjunctivitis is the most common reason for red eyes, accounting for about 35% of all eye problems seen in general practice. It occurs when the conjunctiva, the thin layer covering the white part of the eye, becomes inflamed. Conjunctivitis can be caused by an infection or an allergic reaction.

      Infective conjunctivitis is inflammation of the conjunctiva caused by a viral, bacterial, or parasitic infection. The most common type of infective conjunctivitis is viral, with adenoviruses being the main culprits. Bacterial conjunctivitis is also common and is usually caused by Streptococcus pneumoniae, Staphylococcus aureus, or Haemophilus influenzae.

      The symptoms of infective conjunctivitis include sudden redness of the conjunctiva, discomfort described as a gritty or burning sensation, watering of the eyes, and discharge that may temporarily blurry vision. It can be challenging to differentiate between viral and bacterial conjunctivitis based on symptoms alone.

      Here are some key features that can help distinguish between viral and bacterial conjunctivitis:

      Features suggestive of viral conjunctivitis:
      – Mild to moderate redness of the conjunctiva
      – Presence of follicles on the inner surface of the eyelids
      – Swelling of the eyelids
      – Small, pinpoint bleeding under the conjunctiva
      – Pseudomembranes (thin layers of tissue) may form on the inner surface of the eyelids in severe cases, often caused by adenovirus
      – Less discharge (usually watery) compared to bacterial conjunctivitis
      – Mild to moderate itching
      – Symptoms of upper respiratory tract infection and swollen lymph nodes in front of the ears

      Features suggestive of bacterial conjunctivitis:
      – Purulent or mucopurulent discharge with crusting of the eyelids, which may cause them to stick together upon waking
      – Mild or no itching
      – Swollen lymph nodes in front of the ears, which are often present in severe bacterial conjunctivitis
      – If the discharge is copious and mucopurulent, infection with Neisseria gonorrhoeae should be considered.

      By considering these distinguishing features, healthcare professionals can better diagnose and manage cases of conjunctivitis.

    • This question is part of the following fields:

      • Ophthalmology
      16.2
      Seconds
  • Question 19 - In which age group does Addison's disease typically first manifest? ...

    Incorrect

    • In which age group does Addison's disease typically first manifest?

      Your Answer: Adults aged 18-30 years of age

      Correct Answer: Adults aged 30-50 years of age

      Explanation:

      Adrenal insufficiency, also known as Addison’s disease, is a condition that is more frequently observed in women and typically manifests in individuals aged 30-50 years. In the UK alone, nearly 9000 individuals have received a diagnosis for this disorder. While it can affect people of all ages, it predominantly occurs in women and those within the 30-50 age range.

      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.

    • This question is part of the following fields:

      • Endocrinology
      11.9
      Seconds
  • Question 20 - A 2-year-old toddler is brought to the emergency department by worried parents. The...

    Correct

    • A 2-year-old toddler is brought to the emergency department by worried parents. The parents inform you that the child had a slight fever and a runny nose for 48 hours before developing a barking cough last night. During the examination, the child's temperature is recorded as 38.1ºC and you observe a high-pitched wheeze during inspiration.

      What is the most suitable initial treatment option?

      Your Answer: Oral dexamethasone

      Explanation:

      Corticosteroids are the primary treatment for croup. In this case, the child’s symptoms align with croup. The recommended initial medication for croup is a one-time oral dose of dexamethasone, regardless of the severity of the condition. The dosage is typically 0.15mg per kilogram of the child’s weight.

      Further Reading:

      Croup, also known as laryngotracheobronchitis, is a respiratory infection that primarily affects infants and toddlers. It is characterized by a barking cough and can cause stridor (a high-pitched sound during breathing) and respiratory distress due to swelling of the larynx and excessive secretions. The majority of cases are caused by parainfluenza viruses 1 and 3. Croup is most common in children between 6 months and 3 years of age and tends to occur more frequently in the autumn.

      The clinical features of croup include a barking cough that is worse at night, preceded by symptoms of an upper respiratory tract infection such as cough, runny nose, and congestion. Stridor, respiratory distress, and fever may also be present. The severity of croup can be graded using the NICE system, which categorizes it as mild, moderate, severe, or impending respiratory failure based on the presence of symptoms such as cough, stridor, sternal/intercostal recession, agitation, lethargy, and decreased level of consciousness. The Westley croup score is another commonly used tool to assess the severity of croup based on the presence of stridor, retractions, air entry, oxygen saturation levels, and level of consciousness.

      In cases of severe croup with significant airway obstruction and impending respiratory failure, symptoms may include a minimal barking cough, harder-to-hear stridor, chest wall recession, fatigue, pallor or cyanosis, decreased level of consciousness, and tachycardia. A respiratory rate over 70 breaths per minute is also indicative of severe respiratory distress.

      Children with moderate or severe croup, as well as those with certain risk factors such as chronic lung disease, congenital heart disease, neuromuscular disorders, immunodeficiency, age under 3 months, inadequate fluid intake, concerns about care at home, or high fever or a toxic appearance, should be admitted to the hospital. The mainstay of treatment for croup is corticosteroids, which are typically given orally. If the child is too unwell to take oral medication, inhaled budesonide or intramuscular dexamethasone may be used as alternatives. Severe cases may require high-flow oxygen and nebulized adrenaline.

      When considering the differential diagnosis for acute stridor and breathing difficulty, non-infective causes such as inhaled foreign bodies.

    • This question is part of the following fields:

      • Paediatric Emergencies
      8.8
      Seconds
  • Question 21 - A 65-year-old man presents with a 10-week history of loose stools and occasional...

    Correct

    • A 65-year-old man presents with a 10-week history of loose stools and occasional blood in his stool. He has experienced a weight loss of 5 kg over the past eight months. During the examination, you detect a mass in his lower right quadrant.

      What is the SINGLE most probable diagnosis?

      Your Answer: Colorectal cancer

      Explanation:

      In patients of this age who have experienced a change in bowel habit, rectal bleeding, and weight loss, the most probable diagnosis is colorectal carcinoma. Considering the patient’s history and examination findings, the other options in this question are significantly less likely. It is crucial to refer this patient promptly to a specialized team that focuses on the treatment of lower gastrointestinal cancer.

    • This question is part of the following fields:

      • Surgical Emergencies
      8.8
      Seconds
  • Question 22 - You assess a patient who is currently undergoing systemic anticancer treatment. She has...

    Correct

    • You assess a patient who is currently undergoing systemic anticancer treatment. She has been experiencing chills and feeling unwell and is worried about the potential of having an infection. She informs you that she is currently prescribed a medication to prevent neutropenic sepsis.
      Which of the following medications is she most likely taking for this purpose?

      Your Answer: Ciprofloxacin

      Explanation:

      According to the latest guidelines from NICE, it is recommended that adult patients who are undergoing treatment for acute leukaemia, stem cell transplants, or solid tumours and are expected to experience significant neutropenia as a result of chemotherapy, should be offered prophylaxis with a fluoroquinolone such as ciprofloxacin (500 mg taken orally twice daily) during the period when neutropenia is expected. This is to help prevent the occurrence of neutropenic sepsis, a serious infection that can occur in cancer patients with low levels of neutrophils.

      Reference:
      NICE guidance: ‘Neutropenic sepsis: prevention and management of neutropenic sepsis in cancer patients’

    • This question is part of the following fields:

      • Oncological Emergencies
      10.7
      Seconds
  • Question 23 - A 10 year old girl is brought into the emergency department by worried...

    Incorrect

    • A 10 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 6.98
      Bicarbonate 9 mmol/l
      Glucose 28 mmol/l

      The girl weighs 35kg. What is the calculated fluid deficit for this patient?

      Your Answer: 1500ml

      Correct Answer: 3000ml

      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.

    • This question is part of the following fields:

      • Paediatric Emergencies
      25.2
      Seconds
  • Question 24 - You assess a patient who has been brought into the resuscitation room in...

    Correct

    • You assess a patient who has been brought into the resuscitation room in an obtunded state. The patient is wearing a MedicAlert bracelet, indicating a diagnosis of Addison's disease.
      Which ONE statement accurately describes this condition?

      Your Answer: ACTH levels are usually elevated

      Explanation:

      Addison’s disease occurs when the adrenal glands do not produce enough steroid hormones. This includes glucocorticoids, mineralocorticoids, and sex steroids. The most common cause is autoimmune adrenalitis, which accounts for about 70-80% of cases. It is more prevalent in women and typically occurs between the ages of 30 and 50.

      The clinical symptoms of Addison’s disease include weakness, lethargy, low blood pressure (especially when standing up), nausea, vomiting, weight loss, reduced hair in the armpits and pubic area, depression, and hyperpigmentation (darkening of the skin in certain areas like the palms, mouth, and exposed skin).

      Biochemically, Addison’s disease is characterized by increased levels of ACTH (a hormone that tries to stimulate the adrenal glands), low sodium levels, high potassium levels, high calcium levels, low blood sugar, and metabolic acidosis.

      People with Addison’s disease have a higher risk of developing type 1 diabetes, Hashimoto’s thyroiditis, Grave’s disease, premature ovarian failure, pernicious anemia, vitiligo, and alopecia.

      Management of Addison’s disease should be overseen by an Endocrinologist. Treatment typically involves taking 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 in case of an Addisonian crisis.

    • This question is part of the following fields:

      • Endocrinology
      13
      Seconds
  • Question 25 - You review a patient with a history of schizophrenia who is currently experiencing...

    Correct

    • You review a patient with a history of schizophrenia who is currently experiencing acute psychosis. During the consultation, you observe that it is challenging to engage in effective communication with her as she frequently repeats words and statements. Additionally, you notice that everything she says appears to be excessively verbose.
      Which ONE of the following thought disorders is she exhibiting?

      Your Answer: Logorrhoea

      Explanation:

      Logorrhoea is a form of communication disorder characterized by an excessive use of words and repetitive speech patterns. This condition can result in challenges when it comes to effective communication and may lead to incoherent conversations. Logorrhoea is commonly observed in individuals with frontal lobe disorders and thalamic lesions.

    • This question is part of the following fields:

      • Mental Health
      6.4
      Seconds
  • Question 26 - A 68-year-old woman with a history of chronic anemia receives a blood transfusion...

    Correct

    • A 68-year-old woman with a history of chronic anemia receives a blood transfusion as part of her treatment plan. She has a known history of heart failure and takes bisoprolol and furosemide. Her most recent BNP level was measured at 123 pmol/l. Five hours after starting the transfusion, she experiences shortness of breath and her existing peripheral edema worsens. Her blood pressure increases to 170/105 mmHg and her BNP level is rechecked, now measuring 192 pmol/l.

      Which of the following treatment options is the most appropriate?

      Your Answer: Slow the transfusion rate and administer diuretics

      Explanation:

      Blood transfusion is a potentially life-saving treatment that can provide great clinical benefits. However, it also carries several risks and potential problems. These include immunological complications, administration errors, infections, and immune dilution. While there has been an increased awareness of these risks and improved reporting systems, transfusion errors and serious adverse reactions still occur and may go unreported.

      One specific transfusion reaction is transfusion-associated circulatory overload (TACO), which occurs when a large volume of blood is rapidly infused. It is the second leading cause of transfusion-related deaths, accounting for about 20% of fatalities. TACO is more likely to occur in patients with diminished cardiac reserve or chronic anemia, particularly in the elderly, infants, and severely anemic patients.

      The typical clinical features of TACO include acute respiratory distress, tachycardia, hypertension, acute or worsening pulmonary edema on chest X-ray, and evidence of positive fluid balance. The B-type natriuretic peptide (BNP) can be a useful diagnostic tool for TACO, with levels usually elevated to at least 1.5 times the pre-transfusion baseline.

      In many cases, simply slowing the transfusion rate, placing the patient in an upright position, and administering diuretics can be sufficient for managing TACO. In more severe cases, the transfusion should be stopped, and non-invasive ventilation may be considered.

    • This question is part of the following fields:

      • Haematology
      12.2
      Seconds
  • Question 27 - A 28-year-old woman is diagnosed with tuberculosis during her pregnancy and given isoniazid...

    Correct

    • A 28-year-old woman is diagnosed with tuberculosis during her pregnancy and given isoniazid as part of her medication. As a result of this treatment, the newborn develops a defect.

      Which of the following defects is the most probable outcome due to the use of this medication during pregnancy?

      Your Answer: Neuropathy

      Explanation:

      The standard drug regimen for tuberculosis is generally safe to use during pregnancy, with the exception of streptomycin which should be avoided. However, the use of isoniazid during pregnancy has been associated with potential risks such as liver damage in the mother and the possibility of neuropathy and seizures in the newborn.

      Here is a list outlining some commonly encountered drugs that have adverse effects during pregnancy:

      ACE inhibitors (e.g. ramipril): If taken during the second and third trimesters, these medications can lead to reduced blood flow, kidney failure, and a condition called oligohydramnios.

      Aminoglycosides (e.g. gentamicin): These drugs can cause ototoxicity, resulting in hearing loss in the baby.

      Aspirin: High doses of aspirin can increase the risk of first trimester abortions, delayed labor, premature closure of the fetal ductus arteriosus, and a condition called fetal kernicterus. However, low doses (e.g. 75 mg) do not pose significant risks.

      Benzodiazepines (e.g. diazepam): When taken late in pregnancy, these medications can cause respiratory depression in the baby and lead to a withdrawal syndrome.

      Calcium-channel blockers: If taken during the first trimester, these drugs can cause abnormalities in the fingers and toes. If taken during the second and third trimesters, they may result in fetal growth retardation.

      Carbamazepine: This medication can increase the risk of hemorrhagic disease in the newborn and neural tube defects.

      Chloramphenicol: Use of this drug in newborns can lead to a condition known as grey baby syndrome.

      Corticosteroids: If taken during the first trimester, corticosteroids may increase the risk of orofacial clefts in the baby.

      Danazol: When taken during the first trimester, this medication can cause masculinization of the female fetuses genitals.

      Finasteride: Pregnant women should avoid handling crushed or broken tablets of finasteride as it can be absorbed through the skin and affect the development of male sex organs in the baby.

      Haloperidol: If taken during the first trimester, this medication may increase the risk of limb malformations. If taken during the third trimester, it can lead to an increased risk of extrapyramidal symptoms in the newborn.

      Heparin: Use of heparin during pregnancy is associated with an acceptable bleeding rate and a low rate of thrombotic recurrence in the mother.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      11.2
      Seconds
  • Question 28 - You assess a 65-year-old woman with a history of progressively increasing shortness of...

    Correct

    • You assess a 65-year-old woman with a history of progressively increasing shortness of breath. As part of the patient's treatment plan, your supervisor requests that you carry out a pleural aspiration.
      Based on the BTS guidelines, what is one of the indications for performing a pleural aspiration?

      Your Answer: Unilateral exudative pleural effusion

      Explanation:

      A pleural effusion refers to an excess accumulation of fluid in the pleural cavity, which is the space between the parietal and visceral pleura. Normally, this cavity contains a small amount of lubricating fluid, around 5-10 ml, that allows the pleurae to slide smoothly over each other. This fluid also creates surface tension, bringing the two membranes together and ensuring that as the thorax expands, the lungs expand and fill with air. However, when there is too much fluid in the pleural cavity, it hinders breathing by limiting lung expansion.

      Percutaneous pleural aspiration is commonly performed for two main reasons. Firstly, it is used to investigate pleural effusion, particularly when it is unilateral and exudative in nature. Secondly, it provides symptomatic relief for breathlessness caused by pleural effusion. However, the British Thoracic Society (BTS) guidelines recommend that pleural aspiration should not be carried out if there is suspicion of unilateral or bilateral transudative effusion, unless there are atypical features or failure of response to therapy. In urgent cases where respiratory distress is caused by pleural effusion, pleural aspiration can also be used to quickly decompress the pleural space.

      During the procedure, the patient is typically seated upright with a pillow supporting their arms and head. It is important for the patient not to lean too far forward, as this increases the risk of injury to the liver and spleen. The conventional site for aspiration is in the mid-scapular line, about 10 cm lateral to the spine, and one or two spaces below the upper level of the fluid. To avoid damaging the intercostal nerves and vessels that run just below the rib, the needle should be inserted just above the upper border of the chosen rib.

    • This question is part of the following fields:

      • Respiratory
      7.1
      Seconds
  • Question 29 - A 40-year-old teacher presents with a red itchy urticarial rash on her arms...

    Correct

    • A 40-year-old teacher presents with a red itchy urticarial rash on her arms 20 minutes after wearing a pair of latex gloves.
      Which of the following mediates the allergic reaction in this case?

      Your Answer: IgE

      Explanation:

      Type I hypersensitivity reactions are allergic reactions that occur when a person is exposed again to a particular antigen, known as an allergen. These reactions are triggered by IgE and typically happen within 15 to 30 minutes after exposure to the allergen.

      A rapid onset of an urticarial rash, which occurs shortly after being exposed to an allergen (such as latex), is highly likely to be caused by a type I hypersensitivity reaction.

    • This question is part of the following fields:

      • Allergy
      4
      Seconds
  • Question 30 - A 70 year old type 2 diabetic visits the emergency department with a...

    Incorrect

    • A 70 year old type 2 diabetic visits the emergency department with a foot injury. You suspect neuropathy and conduct sensory testing. Which of the following senses is usually the first to be lost in diabetic neuropathy?

      Your Answer: Proprioception

      Correct Answer: Vibration

      Explanation:

      The initial noticeable abnormality in sensory testing for diabetic neuropathy is often the loss of vibration sense. Reduced sensation, particularly in vibration sense, is typically the first symptom to be observed in diabetic neuropathy.

      Further Reading:

      Diabetic foot is a complication that can occur in individuals with diabetes due to long-standing high blood sugar levels. This leads to a process called glycation or glycosylation, where glucose binds to proteins and lipids in the body. Abnormal protein glycation can cause cellular dysfunction and various complications.

      One of the main problems in diabetic foot is peripheral vascular disease and peripheral neuropathy. These conditions can result in significant foot issues, as trauma to the feet may go unnoticed and untreated. Vascular disease also impairs wound healing and increases the risk of developing ulcers.

      Clinical features of diabetic foot include reduced sensation, especially to vibration, non-dermatomal sensory loss, foot deformities such as pes cavus and claw toes, and weak or absent foot pulses. It is important for diabetic patients to have their feet assessed regularly, at least annually, to identify any potential problems. Additional foot assessments should also be conducted during hospital admissions.

      During a diabetic foot assessment, the healthcare provider should remove shoes, socks, and any bandages or dressings to examine both feet. They should assess for neuropathy using a 10 g monofilament to test foot sensation and check for limb ischemia by examining pulses and performing ankle brachial pressure index (ABPI) measurements. Any abnormal tissue, such as ulcers, calluses, infections, inflammation, deformities, or gangrene, should be documented. The risk of Charcot arthropathy should also be assessed.

      The severity of foot ulcers in diabetic patients can be documented using standardized systems such as SINBAD or the University of Texas classification. The presence and severity of diabetic foot infection can be determined based on criteria such as local swelling, induration, erythema, tenderness, pain, warmth, and purulent discharge.

      Management of foot ulcers involves offloading, control of foot infection, control of ischemia, wound debridement, and appropriate wound dressings. Antibiotics may be necessary depending on the severity of the infection. Diabetic patients with foot ulcers should undergo initial investigations including blood tests, wound swabs, and imaging to assess for possible osteomyelitis.

      Charcot foot is a serious complication of diabetic peripheral neuropathy that results in progressive destructive arthropathy and foot deformity. Signs of Charcot foot include redness, swelling, warm skin, pain, and deformity. The hallmark deformity is midfoot collapse, known as the rocker-bottom foot.

    • This question is part of the following fields:

      • Endocrinology
      9.2
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Neonatal Emergencies (0/1) 0%
Dermatology (1/2) 50%
Infectious Diseases (1/1) 100%
Cardiology (1/2) 50%
Pharmacology & Poisoning (2/3) 67%
Basic Anaesthetics (0/2) 0%
Gastroenterology & Hepatology (1/1) 100%
Mental Health (3/3) 100%
Ear, Nose & Throat (1/1) 100%
Ophthalmology (1/2) 50%
Haematology (2/2) 100%
Nephrology (0/1) 0%
Endocrinology (1/3) 33%
Paediatric Emergencies (1/2) 50%
Surgical Emergencies (1/1) 100%
Oncological Emergencies (1/1) 100%
Respiratory (1/1) 100%
Allergy (1/1) 100%
Passmed