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  • Question 1 - A 32-year-old man presents with oral and genital ulcers and a red rash,...

    Incorrect

    • A 32-year-old man presents with oral and genital ulcers and a red rash, parts of which have started to blister. On examination, he is noted to have red eyes. He had been treated with antibiotics ten days ago for a chest infection.
      What is the most probable reason behind these symptoms?

      Your Answer: Pemphigus vulgaris

      Correct Answer: Stevens-Johnson syndrome

      Explanation:

      Differential Diagnosis: Stevens-Johnson Syndrome and Other Skin Conditions

      Stevens-Johnson syndrome is a severe medical condition that requires immediate recognition and treatment. It is characterized by blistering of the skin and mucosal surfaces, leading to the loss of the skin barrier. This condition is rare and is part of a spectrum of diseases that includes toxic epidermal necrolysis. Stevens-Johnson syndrome is the milder end of this spectrum.

      The use of certain drugs can trigger the activation of cytotoxic CD8+ T-cells, which attack the skin’s keratinocytes, leading to blister formation and skin sloughing. It is important to note that mucosal involvement may precede cutaneous manifestations. Stevens-Johnson syndrome is associated with the use of non-steroidal anti-inflammatory drugs, allopurinol, antibiotics, carbamazepine, lamotrigine, phenytoin, and others.

      Prompt treatment is essential, as the condition can progress to multi-organ failure and death if left untreated. Expert clinicians and nursing staff should manage the treatment to minimize skin shearing, fluid loss, and disease progression.

      Other skin conditions that may present similarly to Stevens-Johnson syndrome include herpes simplex, bullous pemphigoid, pemphigus vulgaris, and graft-versus-host disease. Herpes simplex virus infection causes oral and genital ulceration but does not involve mucosal surfaces. Bullous pemphigoid is an autoimmune blistering condition that affects the skin but not the mucosa. Pemphigus vulgaris is an autoimmune condition that affects both the skin and mucosal surfaces. Graft-versus-host disease is unlikely in the absence of a history of transplantation.

      In conclusion, Stevens-Johnson syndrome is a severe medical condition that requires prompt recognition and treatment. It is essential to differentiate it from other skin conditions that may present similarly to ensure appropriate management.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
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  • Question 2 - A 32-year-old patient is brought in by ambulance to Accident and Emergency. He...

    Incorrect

    • A 32-year-old patient is brought in by ambulance to Accident and Emergency. He is unresponsive, and therefore obtaining a medical history is not possible. He is breathing on his own, but his respiratory rate (RR) is low at 10 breaths per minute and his oxygen saturation is at 90% on room air. His arterial blood gas (ABG) reveals respiratory acidosis, and his pupils are constricted.
      What would be the most suitable medication for initial management in this case?

      Your Answer: Atropine

      Correct Answer: Naloxone

      Explanation:

      Antidote Medications: Uses and Dosages

      Naloxone:
      Naloxone is a medication used to reverse the effects of opioid overdose. It works by blocking the opioid receptors in the brain, which can cause respiratory depression and reduced consciousness. It is administered in incremental doses every 3-5 minutes until the desired effect is achieved. However, full reversal may cause withdrawal symptoms and agitation.

      N-acetyl-L-cysteine (NAC):
      NAC is an antidote medication used to treat paracetamol overdose. Paracetamol overdose can cause liver damage and acute liver failure. NAC is administered if the serum paracetamol levels fall to the treatment level on the nomogram or if the overdose is staggered.

      Flumazenil:
      Flumazenil is a specific reversal agent for the sedative effects of benzodiazepines. It works by competing with benzodiazepines for the same receptors in the brain. However, it is not effective in treating pupillary constriction caused by benzodiazepine toxicity.

      Adrenaline:
      Adrenaline is used in the treatment of cardiac arrest and anaphylaxis. It has no role in the treatment of opiate toxicity. The dosage of adrenaline varies depending on the indication, with a stronger concentration required for anaphylaxis compared to cardiac arrest.

      Atropine:
      Atropine is a medication used to treat symptomatic bradycardia, where the patient’s slow heart rate is causing hemodynamic compromise. However, it can cause agitation in the hours following administration.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
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  • Question 3 - A 55-year-old man is admitted to the Intensive Care Unit (ICU) after acute...

    Incorrect

    • A 55-year-old man is admitted to the Intensive Care Unit (ICU) after acute haemorrhagic pancreatitis. On day 3, he develops acute respiratory distress syndrome (ARDS).
      Which of the following physiological variables is most likely to be low in this patient?

      Your Answer: Alveolar-arterial pressure difference

      Correct Answer: Lung compliance

      Explanation:

      Understanding the Pathophysiology of Acute Respiratory Distress Syndrome

      Acute respiratory distress syndrome (ARDS) is a life-threatening condition that occurs as a result of damage to the pulmonary and vascular endothelium. This damage leads to increased permeability of the vessels, causing the extravasation of neutrophils, inflammatory factors, and macrophages. The leakage of fluid into the lungs results in diffuse pulmonary edema, which disrupts the production and function of surfactant and impairs gas exchange. This, in turn, causes hypoxemia and impaired carbon dioxide excretion.

      The decrease in lung compliance, lung volumes, and the presence of a large intrapulmonary shunt are the consequences of the edema. ARDS can be caused by pneumonia, sepsis, aspiration of gastric contents, and trauma, and it has a mortality rate of 40%.

      The work of breathing is affected by pulmonary edema, which causes hypoxemia. In the initial phase, hyperventilation and an increased work of breathing compensate for the hypoxemia. However, if the underlying cause is not treated promptly, the patient tires, leading to decreased work of breathing and respiratory arrest.

      The increase in alveolar surface tension has been shown to increase lung water content by lowering interstitial hydrostatic pressure and increasing interstitial oncotic pressure. In ARDS, there is an increase in alveolar-arterial pressure difference due to a ventilation-perfusion defect. Blood is perfusing unventilated segments of the lung. ARDS is also associated with impaired production and function of surfactant, increasing the surface tension of the alveolar fluid.

      In conclusion, understanding the pathophysiology of ARDS is crucial in the management of this life-threatening condition. Early recognition and prompt treatment of the underlying cause can improve patient outcomes.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
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  • Question 4 - A 15-year-old with a known peanut allergy arrives at the Emergency Department after...

    Correct

    • A 15-year-old with a known peanut allergy arrives at the Emergency Department after consuming a peanut butter sandwich. During the examination, she displays symptoms of anaphylaxis.
      What is the initial sign that is likely to appear first in a patient experiencing anaphylaxis?

      Your Answer: Runny nose, skin rash, swelling of the lips

      Explanation:

      Understanding the Signs of Anaphylaxis: From Early Symptoms to Late Indicators of Shock

      Anaphylaxis is a severe allergic reaction that can be life-threatening if not treated promptly. The first signs of anaphylaxis may look like normal symptoms of an allergy, such as a runny nose, skin rash, and swelling of the lips. However, if left untreated, more serious signs can appear within 30 minutes, indicating compromise of circulation and end-organs.

      One of the later and more severe indicators of respiratory compromise in patients with anaphylaxis is stridor. This is a prominent wheezing sound caused by the obstruction of the airway due to swelling of the lips, tongue, and throat. If the swelling continues, complete blockage can occur, resulting in asphyxiation.

      Hypotension is another late sign of anaphylaxis when the patient goes into shock. During anaphylaxis, the body reacts and releases chemicals such as histamine, causing blood vessels to vasodilate and leading to a drop in blood pressure. This can result in episodes of syncope, or fainting, as well as other symptoms of end-organ dysfunction such as hypotonia and incontinence.

      A weak pulse is also a late sign of anaphylaxis, indicating compromised circulation. However, it is not one of the first signs to present, as the body goes through a series of reactions before reaching this stage.

      In summary, understanding the signs of anaphylaxis is crucial for prompt treatment and prevention of life-threatening complications. Early symptoms such as a runny nose, skin rash, and swelling of the lips should not be ignored, as they can progress to more severe indicators of respiratory and circulatory compromise.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
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  • Question 5 - A 68-year-old man with known long-term chronic obstructive pulmonary disease (COPD) visits his...

    Correct

    • A 68-year-old man with known long-term chronic obstructive pulmonary disease (COPD) visits his General Practitioner (GP) complaining of increasing breathlessness and wheeze. He reports that a week ago, he could walk to the store and back without getting breathless, but now he cannot even leave his house. He has been coughing up thick green sputum for the past 48 hours and is currently hypoxic - 90% on oxygen saturations, in respiratory distress, and deteriorating rapidly. An ambulance is called, and he is taken to the Emergency Department for treatment.
      What is the most appropriate next step in managing this patient?

      Your Answer: Nebulised bronchodilators

      Explanation:

      Management of Acute Exacerbation of COPD: Key Steps

      When a patient experiences an acute exacerbation of COPD, prompt and appropriate management is crucial. The following are key steps in managing this condition:

      1. Nebulised bronchodilators: Salbutamol 5 mg/4 hours and ipratropium bromide should be used as first-line treatment for immediate symptom relief.

      2. Steroids: IV hydrocortisone and oral prednisolone should be given following bronchodilator therapy ± oxygen therapy, if needed. Steroids should be continued for up to two weeks.

      3. Oxygen therapy: Care must be taken when giving oxygen due to the risk of losing the patient’s hypoxic drive to breathe. However, oxygen therapy should not be delayed while awaiting arterial blood gas results.

      4. Arterial blood gas: This test will help direct the oxygen therapy required.

      5. Physiotherapy: This can be a useful adjunct treatment in an acute infective exacerbation of COPD, but it is not the most important next step.

      Pulmonary function testing is not indicated in the management of acute COPD exacerbations. While it is useful for measuring severity of disease in patients with COPD to guide their long-term management, it is unnecessary in this acute setting. The most important next step after administering steroids is to add nebulised bronchodilators for immediate symptom relief.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
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  • Question 6 - A 35-year-old woman is brought to the Emergency Department following a fall off...

    Correct

    • A 35-year-old woman is brought to the Emergency Department following a fall off a ladder. She was witnessed to have lost consciousness at the scene and remained confused with the ambulance personnel. She is complaining of a headache and has vomited three times. Her eyes are open to voice and she is able to squeeze your hand using both hands, when asked, and wiggle her toes. She is confused about what has happened and does not remember falling. Her pupils are equal and reactive.
      How would you manage this patient?

      Your Answer: Computed tomography (CT) head scan within 1 h

      Explanation:

      Management of Head Injury: Importance of CT Scan and Neuro Observation

      Head injury is a serious medical condition that requires prompt and appropriate management. The current imaging modality used to investigate brain injury is CT. According to the National Institute for Health and Care Excellence (NICE) head injury guidelines, patients who sustained a head injury and have any of the following risk factors should be scanned within 1 hour: GCS <13 on initial assessment in the Emergency Department, GCS <15 at 2 hours after the injury on assessment in the Emergency Department, suspected open or depressed skull fracture, any sign of basal skull fracture, post-traumatic seizure, focal neurological deficit, and more than one episode of vomiting. A provisional radiology report should be given to the requesting clinician within 1 hour of the scan performed to aid immediate clinical management. While waiting for the CT scan, the patient should be monitored using a neuro observation chart, and any deterioration needs to be immediately reported to the responsible clinician for the patient’s care. Admitting the patient for neuro observation is crucial to ensure prompt management of any changes in the patient’s condition. There is no indication to discuss the patient with the neurosurgical department at present. Once the imaging has been performed and if new surgically significant intracranial pathology is detected, then discussion of the care plan should take place with the local neurosurgical team. Discussion of the care plan with a neurosurgeon is warranted, regardless of imaging, if any of the following is present: GCS 8 or less persisting despite initial resuscitation, unexplained confusion lasting >4 hours, deterioration in GCS score after admission, progressing focal neurological signs, a seizure without full recovery, CSF leak, suspected/definitive.

      In conclusion, the immediate CT scan and neuro observation are crucial steps in the management of head injury. Discharging a patient with a high-risk head injury is inappropriate and can lead to serious consequences.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
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  • Question 7 - When requesting an investigation, it is important to consider the potential benefits and...

    Incorrect

    • When requesting an investigation, it is important to consider the potential benefits and harms to the patient. Among radiographic investigations, which ones are associated with the highest radiation exposure?

      Your Answer: Dual-energy X-ray absorptiometry (DEXA) scan

      Correct Answer: Abdominal X-ray

      Explanation:

      Radiation Doses from Medical X-Rays: A Comparison

      Medical X-rays are a common diagnostic tool used to detect and diagnose various medical conditions. However, they also expose patients to ionizing radiation, which can increase the risk of cancer and other health problems. Here is a comparison of the radiation doses from different types of X-rays:

      Abdominal X-ray: The radiation dose from an abdominal X-ray is equivalent to 5 months of natural background radiation.

      Chest X-ray: The radiation dose from a chest X-ray is equivalent to 10 days of natural background radiation.

      Abdomen-Pelvis CT: The radiation dose from an abdomen-pelvis CT is equivalent to 3 years of natural background radiation.

      DEXA Scan: The radiation dose from a DEXA scan is equivalent to only a few hours of natural background radiation.

      Extremity X-rays: The radiation dose from X-rays of extremities, such as knees and ankles, is similar to that of a DEXA scan, equivalent to only a few hours of natural background radiation.

      It is important to note that while the radiation doses from medical X-rays are relatively low, they can still add up over time and increase the risk of cancer. Patients should always discuss the risks and benefits of any medical imaging procedure with their healthcare provider.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
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  • Question 8 - You are called to attend a 35-year-old man who is in cardiac arrest...

    Correct

    • You are called to attend a 35-year-old man who is in cardiac arrest on one of the wards. On arrival, the patient has defibrillator pads attached and someone is performing cardiopulmonary resuscitation (CPR). A rhythm strip displays ventricular fibrillation during a CPR pause.
      What is the most appropriate management?

      Your Answer: Safely DC shock immediately

      Explanation:

      Proper Steps for Responding to a Shockable Rhythm

      When responding to a shockable rhythm, such as ventricular fibrillation, it is important to follow the proper steps to ensure the safety and effectiveness of the resuscitation efforts. The first step is to immediately deliver a safe direct current (DC) shock, followed by one round of CPR and another safe DC shock. It is not appropriate to give drugs at this stage.

      After the second shock, continue CPR at a rate of 30 compressions to 2 breaths with interval checks. It is important to note that CPR is appropriate on both sides of the Advanced Life Support (ALS) algorithm initially, but once the pads are attached and the rhythm has been observed, the appropriate pathway should be followed.

      Under no circumstances should resuscitation be stopped if a shockable rhythm is observed. Instead, adrenaline 1:1000 IV should be administered only after the appropriate steps have been taken and the patient’s condition has been reassessed. By following these steps, responders can increase the chances of a successful resuscitation and potentially save a life.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
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  • Question 9 - A 49-year-old man with severe acute pancreatitis is transferred from the surgical ward...

    Correct

    • A 49-year-old man with severe acute pancreatitis is transferred from the surgical ward to the Intensive Care Unit with rapidly worsening shortness of breath. He has a history of heavy smoking and alcohol use.
      On examination, in the Intensive Care Unit, he is maintaining saturations of 91% only on the ‘non-rebreather’ mask. There is cyanosis around the lips; bilateral crackles are present on auscultation of the lungs.
      Investigations:
      Investigation Result Normal value
      pH 7.32 7.35–7.45
      pO2 8.1 kPa (on oxygen) 10.5–13.5 kPa
      pCO2 4.8 kPa 4.6–6.0 kPa
      Chest X-ray Bilateral pulmonary infiltrates
      Which of the following is the most likely diagnosis in this case?

      Your Answer: Acute respiratory distress syndrome (ARDS)

      Explanation:

      Understanding Acute Respiratory Distress Syndrome (ARDS) and Differential Diagnoses

      Acute respiratory distress syndrome (ARDS) is a severe condition that can be caused by various factors, including trauma, acute sepsis, and severe medical illnesses. It is characterized by a diffuse, acute inflammatory response that leads to increased vascular permeability of the lung parenchyma and loss of aerated tissue. Symptoms typically occur within 6-72 hours of the initiating event and progress rapidly, requiring high-level care. Hypoxia is difficult to manage, and pulmonary infiltrates are seen on chest X-ray. Careful fluid management and ventilation are necessary, as mortality rates can be as high as 30%. Corticosteroids may reduce late-phase damage and fibrosis.

      While secondary pneumonia may be included in the differential diagnosis, the acute deterioration and bilateral infiltrates suggest ARDS. Unilateral radiographic changes are more commonly associated with pneumonia. Viral pneumonitis is another possible diagnosis, but the rapid onset of ARDS distinguishes it from viral pneumonitis. Fibrosing alveolitis, a chronic interstitial lung disease, is unlikely to present acutely. Cardiac failure is also unlikely, as there are no cardiac abnormalities described on examination and the chest radiograph does not demonstrate cardiomegaly, pulmonary venous congestion, Kerley B lines, or pulmonary effusions that are suggestive of a cardiac cause. Echocardiography may be helpful in assessing cardiac functionality.

      In summary, ARDS is a serious condition that requires prompt and careful management. Differential diagnoses should be considered, but the acute onset and bilateral infiltrates seen on chest X-ray are suggestive of ARDS.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
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  • Question 10 - A 30-year-old man is brought by ambulance, having fallen off his motorbike. He...

    Incorrect

    • A 30-year-old man is brought by ambulance, having fallen off his motorbike. He was wearing a helmet at the time of the crash; the helmet cracked on impact. At presentation, he is haemodynamically stable and examination is unremarkable, aside from superficial abrasions on the arms and legs. Specifically, he is neurologically intact. He is nevertheless offered admission for head injury charting and observation. Two hours after admission, nurses find him unresponsive, with a unilateral fixed, dilated pupil. An emergency computed tomography (CT) scan is performed.
      What is the likely diagnosis in this case?

      Your Answer: Subarachnoid haemorrhage (SAH)

      Correct Answer: Extradural haemorrhage

      Explanation:

      Extradural Haemorrhage: Causes, Symptoms, and Treatment

      Extradural haemorrhage is a type of head injury that can lead to neurological compromise and coma if left untreated. It is typically caused by trauma to the middle meningeal artery, meningeal veins, or a dural venous sinus. The condition is most prevalent in young men involved in road traffic accidents and is characterized by a lucid interval followed by a decrease in consciousness.

      CT scans typically show a high-density, lens-shaped collection of peripheral blood in the extradural space between the inner table of the skull bones and the dural surface. As the blood collects, patients may experience severe headache, vomiting, confusion, fits, hemiparesis, and ipsilateral pupil dilation.

      Treatment for extradural haemorrhage involves urgent decompression by creating a borehole above the site of the clot. Prognosis is poor if the patient is comatose or decerebrate or has a fixed pupil, but otherwise, it is excellent.

      It is important to differentiate extradural haemorrhage from other types of head injuries, such as subdural haemorrhage, subarachnoid haemorrhage, and Intraparenchymal haemorrhage. Subdural haemorrhage is not limited by cranial sutures, while subarachnoid haemorrhage is characterized by blood lining the sulci of the brain. Intraparenchymal haemorrhage, on the other hand, refers to blood within the brain parenchyma.

      In conclusion, extradural haemorrhage is a serious condition that requires urgent medical attention. Early diagnosis and treatment can significantly improve the patient’s prognosis.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
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  • Question 11 - A 28-year-old man is admitted after being found lying on the street with...

    Correct

    • A 28-year-old man is admitted after being found lying on the street with a reduced conscious level.
      On examination, he has pinpoint pupils and needle-track marks on his arms.
      What would be the most likely pattern on the arterial blood gas in this case?

      Your Answer: Hypercapnia and respiratory acidosis

      Explanation:

      Understanding the Relationship between Hypercapnia and Acid-Base Imbalances

      Opiate overdose can cause respiratory depression, leading to hypoventilation and subsequent hypercapnia. This results in respiratory acidosis, which can lead to coma and pinpoint pupils. The treatment for this condition is intravenous naloxone, with repeat dosing and infusion as necessary. It is important to note that hypercapnia always leads to an acidosis, not an alkalosis, and that hypocapnia would not cause a respiratory acidosis. Understanding the relationship between hypercapnia and acid-base imbalances is crucial in managing respiratory depression and related conditions.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
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  • Question 12 - A 50-year-old man is on the Orthopaedic Ward following a compound fracture of...

    Correct

    • A 50-year-old man is on the Orthopaedic Ward following a compound fracture of his femur. He is day three post-op and has had a relatively uncomplicated postoperative period despite a complex medical history. His past medical history includes remitting prostate cancer (responding to treatment), COPD and osteoarthritis.
      He has a body mass index (BMI) of > 30 kg/m2, hypertension and is currently using a salmeterol inhaler, enzalutamide, naproxen and the combined oral contraceptive pill. He smokes six cigarettes per day and drinks eight units of alcohol per week. He manages his activities of daily living independently.
      Blood results from yesterday:
      Investigation Result Normal value
      Haemoglobin (Hb) 130 g/l 115–155 g/l
      White cell count (WCC) 7.8 × 109/l 4–11 × 109/l
      Sodium (Na+) 141 mmol/l 135–145 mmol/l
      Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
      Chloride (Cl) 108 mmol/l 98-106 mmol/l
      Urea 7.8 mmol/l 2.5–6.5 mmol/l
      Creatinine (Cr) 85 µmol/l 50–120 µmol/l
      You are crash-paged to his bedside in response to his having a cardiac arrest.
      What is the most appropriate management?

      Your Answer: Initiate CPR, give a fibrinolytic and continue for at least 60 minutes

      Explanation:

      Management of Cardiac Arrest in a Post-Operative Patient with a History of Cancer and Oral Contraceptive Use

      In the management of a patient who experiences cardiac arrest, it is important to consider the underlying cause and initiate appropriate interventions. In the case of a post-operative patient with a history of cancer and oral contraceptive use, thrombosis is a likely cause of cardiac arrest. Therefore, CPR should be initiated and a fibrinolytic such as alteplase should be given. CPR should be continued for at least 60 minutes as per Resuscitation Council (UK) guidelines.

      Giving adrenaline without initiating CPR would not be appropriate. It is important to rule out other potential causes such as hypovolemia, hypoxia, tamponade, tension pneumothorax, and toxins. However, in this scenario, thrombosis is the most likely cause.

      Calling cardiology for pericardiocentesis is not indicated as there is no history of thoracic trauma. Informing the family is important, but initiating CPR should take priority. Prolonged resuscitation of at least 60 minutes is warranted in the case of thrombosis. Overall, prompt and appropriate management is crucial in the event of cardiac arrest.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
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  • Question 13 - A 25-year-old man is brought to the emergency room by his friends, who...

    Incorrect

    • A 25-year-old man is brought to the emergency room by his friends, who found him vomiting and surrounded by empty packets of pain medication. The patient is unable to identify which medication he took, but reports feeling dizzy and experiencing ringing in his ears. An arterial blood gas test reveals the following results:
      pH: 7.52
      paCO2: 3.1 kPa
      paO2: 15.2 kPa
      HCO3: 18 mEq/l
      Based on these findings, what is the most likely pain medication the patient ingested?

      Your Answer: Naproxen

      Correct Answer: Aspirin

      Explanation:

      Common Overdose Symptoms and Risks of Pain Medications

      Pain medications are commonly used to manage various types of pain. However, taking too much of these medications can lead to overdose and serious health complications. Here are some common overdose symptoms and risks associated with different types of pain medications:

      Aspirin: Mild aspirin overdose can cause tinnitus, nausea, and vomiting, while severe overdose can lead to confusion, hallucinations, seizures, and pulmonary edema. Aspirin can also cause ototoxicity and stimulate the respiratory center, leading to respiratory alkalosis and metabolic acidosis.

      Paracetamol: Paracetamol overdose may not show symptoms initially, but can lead to hepatic necrosis after 24 hours. Nausea and vomiting are common symptoms, and acidosis can be seen early on arterial blood gas. A paracetamol level can be sent to determine if acetylcysteine treatment is necessary.

      Ibuprofen: NSAID overdose can cause nausea, vomiting, diarrhea, and abdominal pain. Severe toxicity is rare, but large doses can lead to drowsiness, acidosis, acute kidney injury, and seizure.

      Codeine: Codeine overdose can cause opioid toxicity, leading to symptoms such as nausea, vomiting, drowsiness, and respiratory depression. Codeine is often combined with other pain medications, such as paracetamol, which can increase the risk of mixed overdose.

      Naproxen: NSAID overdose can cause nausea, vomiting, diarrhea, and abdominal pain. Severe toxicity is rare, but large doses can lead to drowsiness, acidosis, acute kidney injury, and seizure.

      It is important to be aware of the potential risks and symptoms of pain medication overdose and seek medical attention immediately if an overdose is suspected.

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      • Acute Medicine And Intensive Care
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  • Question 14 - A 65-year-old patient in the Intensive Care Unit has been on ventilatory support...

    Incorrect

    • A 65-year-old patient in the Intensive Care Unit has been on ventilatory support for the last two weeks after a significant traumatic brain injury. A decision has to be made about whether they are taken off life support and whether or not the patient has irreversible brain damage.
      In which of the following circumstances can brain death be diagnosed?

      Your Answer:

      Correct Answer: A ventilator-supported patient

      Explanation:

      Understanding the Factors that Affect Brain Death Diagnosis

      Brain death diagnosis is a critical process that determines the cessation of brain function, which is irreversible and leads to the death of an individual. However, several factors can affect the accuracy of this diagnosis, and they must be excluded before confirming brain death.

      One of the primary conditions for brain death diagnosis is the patient’s inability to maintain their own heartbeat and ventilation, requiring the support of a ventilator. However, this condition alone is not sufficient, and two other factors must be present, including unconsciousness and clear evidence of irreversible brain damage.

      Hypothermia is one of the factors that can confound the examination of cortical and brainstem function, making it difficult to diagnose brain death accurately. Similarly, encephalopathy secondary to hepatic failure and severe hypophosphataemia can also impact cortical and brainstem function, leading to inaccurate brain death diagnosis.

      Finally, sedation by anaesthetic or neuroparalytic agents can depress the neurological system, making it appear as if the patient is brain dead when they are not. Therefore, it is crucial to consider all these factors and exclude them before confirming brain death diagnosis.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
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  • Question 15 - A 25-year-old backpacker had embarked on a climbing expedition to Mount Everest. He...

    Incorrect

    • A 25-year-old backpacker had embarked on a climbing expedition to Mount Everest. He had flown from the United Kingdom the previous day. To avoid the predicted bad weather, he and his team left the base camp the following day. They reached an altitude of 6000 m on day four. He complained of occasional dull headaches and feeling light-headed, which he attributed to his dehydration. The next day, he set off alone, but was discovered by the search party ten hours later. He was found to be confused, unable to walk in a straight line, irritable, and extremely fatigued. His symptoms significantly improved after receiving dexamethasone and resting in a portable hyperbaric chamber.

      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: High-altitude cerebral oedema (HACE)

      Explanation:

      Differential Diagnosis for High-Altitude Illness in a Patient with AMS Symptoms

      High-altitude cerebral oedema (HACE) is a serious complication of acute mountain sickness (AMS) that can lead to ataxia, confusion, and even coma. In this patient, the symptoms progressed from mild AMS to HACE, as evidenced by the alleviation of symptoms following dexamethasone and hyperbaric treatment. Hypoglycaemia can mimic HACE symptoms, but the rapid ascent to high altitude and progression of symptoms point to a diagnosis of HACE. Alcohol intoxication can also mimic AMS and HAPE symptoms, but the patient’s response to treatment excludes this differential diagnosis. High-altitude pulmonary oedema (HAPE) is another potential complication, but the absence of respiratory symptoms rules it out in this case. Overall, a careful differential diagnosis is necessary to accurately diagnose and treat high-altitude illness in patients with AMS symptoms.

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      • Acute Medicine And Intensive Care
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  • Question 16 - A 17-year-old girl is brought to the Emergency Department via ambulance with reduced...

    Incorrect

    • A 17-year-old girl is brought to the Emergency Department via ambulance with reduced level of consciousness, non-blanching rash, headache, neck stiffness and fever. Her mother accompanies her and states that this confusion started several hours previously. She also states that her daughter has not passed urine since the previous day, at least 16 hours ago. On clinical examination, she appears unwell and confused, and she has a purpuric rash over her lower limbs. Her observation results are as follows:
      Temperature 39.5 °C
      Blood pressure 82/50 mmHg
      Heart rate 120 bpm
      Respiratory rate 20 breaths per minute
      Which of the following are high-risk criteria when diagnosing and risk-stratifying suspected sepsis?

      Your Answer:

      Correct Answer: Systolic blood pressure of 82 mmHg

      Explanation:

      Understanding the High-Risk Criteria for Suspected Sepsis

      Sepsis is a life-threatening condition that requires prompt medical attention. To help healthcare professionals identify and grade the severity of suspected sepsis, certain high-risk criteria are used. Here are some important points to keep in mind:

      – A systolic blood pressure of 90 mmHg or less, or a systolic blood pressure of > 40 mmHg below normal, is a high-risk criterion for grading the severity of suspected sepsis. A moderate- to high-risk criterion is a systolic blood pressure of 91–100 mmHg.
      – Not passing urine for the previous 18 hours is a high-risk criterion for grading the severity of suspected sepsis. For catheterised patients, passing < 0.5 ml/kg of urine per hour is also a high-risk criterion, as is a heart rate of > 130 bpm. Not passing urine for 12-18 hours is considered a ‘amber flag’ for sepsis.
      – Objective evidence of new altered mental state is a high-risk criteria for grading the severity of suspected sepsis. Moderate- to high-risk criteria would include: history from patient, friend or relative of new onset of altered behaviour or mental state and history of acute deterioration of functional ability.
      – Non-blanching rash of the skin, as well as a mottled or ashen appearance and cyanosis of the skin, lips or tongue, are high-risk criteria for severe sepsis.
      – A raised respiratory rate of 25 breaths per minute or more is a high-risk criterion for sepsis, as is a new need for oxygen with 40% FiO2 (fraction of inspired oxygen) or more to maintain saturation of > 92% (or > 88% in known chronic obstructive pulmonary disease). A raised respiratory rate is 21–24 breaths per minute.

      By understanding these high-risk criteria, healthcare professionals can quickly identify and treat suspected sepsis, potentially saving lives.

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  • Question 17 - A 72-year-old hospitalised man with a urinary tract infection and an indwelling bladder...

    Incorrect

    • A 72-year-old hospitalised man with a urinary tract infection and an indwelling bladder catheter (due to a bladder outlet obstruction) has developed episodic fever, chills and a fall in systemic blood pressure since yesterday. The episodes occur irregularly and last almost an hour, during which time he becomes delirious.
      Which of the following factors plays a key role in the pathogenesis of this condition?

      Your Answer:

      Correct Answer: Lipopolysaccharide

      Explanation:

      Understanding the Role of Lipopolysaccharide in Septic Shock

      Septic shock is a serious medical condition that can occur as a result of a systemic inflammatory response to an infection. In this state, the body’s immune system is activated, leading to the release of cytokines such as tumour necrosis factor and interleukins. However, the main inciting agent responsible for this activation is Gram-negative bacterial lipopolysaccharide (LPS).

      LPS plays a key role in the induction of the monocyte-macrophage system, leading to the release of cytokines and subsequent shock. Nitric oxide, also released by LPS-activated macrophages, contributes to the hypotension associated with sepsis. Additionally, tissue hypoxia can lead to increased production of lactic acid, although lactic acidosis is not the main player in shock.

      Understanding the role of LPS in septic shock is crucial for effective treatment and management of this condition. By targeting the underlying cause of the immune system activation, healthcare professionals can work to prevent the development of septic shock and improve patient outcomes.

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  • Question 18 - A 28-year-old man is brought to the Emergency Department after an episode of...

    Incorrect

    • A 28-year-old man is brought to the Emergency Department after an episode of near-drowning. He fell from a boat into a lake and was unable to swim. He was underwater for < 2 minutes before he was rescued. He did not lose consciousness. He reports swallowing lots of water and vomited twice in the ambulance. He is awake and alert; his observations are as follows: blood pressure 126/76 mmHg, pulse 94 bpm, oxygen saturations 94% on room air, and temperature 36 °C. He is coughing occasionally, and his lungs are clear to auscultation. One hour after the episode, he feels well and wishes to go home.
      What is the best management plan for this patient?

      Your Answer:

      Correct Answer: Admit overnight for observation

      Explanation:

      Management of Near-Drowning Patients: Recommendations for Observation and Treatment

      Admission for Observation:
      If a patient has experienced near-drowning but is awake and alert, it is recommended to observe them for at least six hours. This is because pulmonary oedema, a potential complication, may develop later on (usually within four hours).

      Discharge Home:
      While it may be tempting to discharge a patient after only one hour of observation, it is important to note that pulmonary oedema can occur late in near-drowning cases. Therefore, it is recommended to observe the patient for at least six hours before considering discharge.

      Admission to ICU:
      If the patient is alert and stable, there is no indication to admit them to the ICU. In cases where submersion durations are less than 10 minutes, the chances of a good outcome are very high.

      Antibiotics and IV Fluids:
      The need for antibiotics and IV fluids depends on the severity of the near-drowning incident. If the water was grossly contaminated, antibiotics may be necessary. However, if the patient is alert and able to swallow, oral antibiotics can be given. IV fluids are not necessary if the patient is haemodynamically stable and alert.

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  • Question 19 - A 32-year-old man presents to his General Practitioner (GP) with a lateral ankle...

    Incorrect

    • A 32-year-old man presents to his General Practitioner (GP) with a lateral ankle injury. This injury occurred while playing basketball the previous day. He continued playing but noted some discomfort at the time and thereafter. He is able to weight-bear with minor discomfort. On examination, there is some swelling over the ankle, a small amount of bruising and minimal tenderness on palpation. There is full range of movement in the ankle joint. He has not taken any analgesia.
      What is the best management of this man’s injury?

      Your Answer:

      Correct Answer: Advise rest, ice, compression and elevation of the ankle for one to two days, followed by early mobilisation

      Explanation:

      Managing Ankle Ligament Sprains: Rest, Ice, Compression, Elevation, and Early Mobilisation

      Ankle ligament sprains can be managed conservatively with rest, ice, compression, elevation, and analgesia. For minor sprains, pain-free stretching should be undertaken as soon as possible, followed by progressive weight-bearing and resistance exercises. Severe sprains or ruptures may require backslab immobilisation for ten days, followed by rehabilitation. Ankle X-rays are only required if there is pain in the malleolar zone and any of the Ottawa ankle rules findings. Orthopaedic referral is only necessary for dislocations or fractures. Prolonged immobilisation should be avoided, and passive stretches should be commenced as soon as possible.

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  • Question 20 - An 80-year-old man with a history of recurrent falls attends the Elderly Care...

    Incorrect

    • An 80-year-old man with a history of recurrent falls attends the Elderly Care Clinic with his daughter. He also has a history of mild dementia, congestive heart failure, coronary artery disease, hypertension and type 2 diabetes. He takes furosemide, lisinopril, amitriptyline, aspirin, metoprolol, olanzapine and simvastatin. He lives by himself in a house in which he has lived for 30 years and has help with all activities of daily living. On examination, he appears frail, has mild bruising over both knees from recent falls and has reduced proximal lower-extremity muscle strength.
      Which of the following interventions will decrease his risk of falling in the future?

      Your Answer:

      Correct Answer: Balance and gait training physical exercises

      Explanation:

      The Most Appropriate Interventions to Reduce Falls in the Elderly

      Balance and gait training exercises are effective interventions to reduce falls in the elderly. On the other hand, continuing olanzapine and commencing donepezil have not been proven to reduce the risk of falls. Diuretics, such as furosemide, can increase the likelihood of falls, so stopping them is recommended. Additionally, amitriptyline has anticholinergic side-effects that can lead to confusion and falls, so discontinuing it is a quick and potentially effective intervention. Overall, a multifactorial approach that includes balance and gait training, medication review, and fall risk assessment is the most appropriate strategy to reduce falls in the elderly.

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  • Question 21 - A 42-year-old woman arrives at Accident and Emergency with severe cellulitis in her...

    Incorrect

    • A 42-year-old woman arrives at Accident and Emergency with severe cellulitis in her left lower limb. She has no known allergies, is in good health, and is not currently experiencing fever or rapid heart rate. The medical team accepts her and starts her on IV antibiotics. However, she soon becomes hypoxic, experiencing difficulty breathing, with loud upper airway sounds and a widespread rash.
      What is the preferred treatment option in this scenario?

      Your Answer:

      Correct Answer: Adrenaline 0.5 mg, 1 in 1000 intramuscularly (IM)

      Explanation:

      Correct Dosages of Adrenaline for Anaphylaxis and Cardiac Arrest

      In cases of anaphylaxis, the recommended treatment is 1 : 1000 adrenaline 0.5 ml (0.5 mg) administered intramuscularly (IM). This dose should be given even if the patient has no known drug allergies but exhibits signs of anaphylaxis such as stridor and a rash.

      It is important to note that the correct dose of IM adrenaline for anaphylaxis is 0.5 mg, 1 in 1000. Administering a higher dose, such as 1 mg, 1 in 1000, can be dangerous and potentially harmful to the patient.

      On the other hand, during a cardiac arrest, the recommended dose of adrenaline is 1 mg, 1 in 10 000, administered intravenously (IV). This is not the recommended dose for anaphylaxis, and administering it through the wrong route can also be harmful to the patient.

      In summary, it is crucial to follow the correct dosages and routes of administration for adrenaline in different medical situations to ensure the safety and well-being of the patient.

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  • Question 22 - A 60-year-old man received a two unit blood transfusion 1 hour ago. He...

    Incorrect

    • A 60-year-old man received a two unit blood transfusion 1 hour ago. He reports feeling a strange sensation in his chest, like his heart is skipping a beat. You conduct an ECG which reveals tall tented T waves in multiple leads.
      An arterial blood gas (ABG) test shows:
      Na+: 136 mmol/l (normal 135–145 mmol/l)
      K+: 7.1 mmol/l (normal 3.5–5.0 mmol/l)
      Cl–: 96 mmol/l (normal 95–105 mmol/l).
      What immediate treatment should be administered based on these findings?

      Your Answer:

      Correct Answer: Calcium gluconate

      Explanation:

      Treatment Options for Hyperkalaemia: Calcium Gluconate, Normal Saline Bolus, Calcium Resonium, Insulin and Dextrose, Dexamethasone

      Understanding Treatment Options for Hyperkalaemia

      Hyperkalaemia is a condition where the potassium levels in the blood are higher than normal. This can lead to ECG changes, palpitations, and a high risk of arrhythmias. There are several treatment options available for hyperkalaemia, each with its own mechanism of action and benefits.

      One of the most effective treatments for hyperkalaemia is calcium gluconate. This medication works by reducing the excitability of cardiomyocytes, which stabilizes the myocardium and protects the heart from arrhythmias. However, calcium gluconate does not reduce the potassium level in the blood, so additional treatments are necessary.

      A normal saline bolus is not an effective treatment for hyperkalaemia. Similarly, calcium resonium, which removes potassium from the body via the gastrointestinal tract, is slow-acting and will not protect the patient from arrhythmias acutely.

      Insulin and dextrose are commonly used to treat hyperkalaemia. Insulin shifts potassium intracellularly, which decreases serum potassium levels. Dextrose is needed to prevent hypoglycaemia. This treatment reduces potassium levels by 0.6-1.0 mmol/L every 15 minutes and is effective in treating hyperkalaemia. However, it does not acutely protect the heart from arrhythmias and should be given following the administration of calcium gluconate.

      Dexamethasone is not a treatment for hyperkalaemia and should not be used for this purpose.

      In conclusion, calcium gluconate is an effective treatment for hyperkalaemia and should be administered first to protect the heart from arrhythmias. Additional treatments such as insulin and dextrose can be used to reduce potassium levels, but they should be given after calcium gluconate. Understanding the different treatment options for hyperkalaemia is essential for providing appropriate care to patients with this condition.

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  • Question 23 - A 55-year-old man is brought by ambulance to the Emergency Department following a...

    Incorrect

    • A 55-year-old man is brought by ambulance to the Emergency Department following a high-speed road traffic incident. He was ejected from the vehicle and sustained a severe head injury. His Glasgow Coma Scale (GCS) score is E1 V1 M2. Other injuries include an unstable pelvic fracture (secured with a binder) and bruising to his anterior chest wall. His heart rate is 100 bpm with a blood pressure of 70/40 mmHg. Additional history from a family member includes:
      Allergy – penicillin
      Past medical history – hypertension, high cholesterol
      Drug history – bisoprolol.
      Which one of the following would be the fluid of choice for supporting his blood pressure?

      Your Answer:

      Correct Answer: Packed red blood cells (through a fluid warmer)

      Explanation:

      In cases of severe high-impact trauma, the patient may experience hypotension and tachycardia due to blood loss. The most common causes of mortality following trauma are neurological injury and blood loss. In such cases, the DCR approach is used, which involves permissive hypotension and blood product-based resuscitation. Crystalloids should be avoided as they can increase haemodilution and impair coagulation and tissue perfusion. Instead, packed red blood cells should be used along with fresh frozen plasma to avoid dilutional coagulopathy. Tranexamic acid may also be used to aid haemostasis. Fluids should be warmed prior to infusion to prevent hypothermia, which is associated with worse patient outcomes.

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  • Question 24 - An 81-year-old man, who is confused and aggressive, is admitted to the Medical...

    Incorrect

    • An 81-year-old man, who is confused and aggressive, is admitted to the Medical Admission Unit. He is unable to give any history due to confusion. His wife had taken him to the general practice surgery yesterday due to increased confusion, and trimethoprim was prescribed to treat a urinary tract infection. From a previous discharge letter, you ascertain that he has a background of Alzheimer’s dementia, atrial fibrillation (AF), ischaemic heart disease and osteoarthritis. His wife reports that he is normally forgetful but is much more confused than usual.
      On examination, his pulse is 124 bpm (irregularly irregular), blood pressure 134/74 mmHg, oxygen saturation (SaO2) 95% (on 28% oxygen), respiratory rate 22 breaths per minute and temperature 38.4 °C. He has crepitations and increased vocal resonance at the right lung base, with an area of bronchial breathing above this. Neurological examination of the upper and lower limbs is normal.
      Chest X-ray (CXR): focal consolidation, right base
      Electrocardiogram (ECG): AF with rapid ventricular response
      Urine dip: protein ++, otherwise NAD
      Blood results are pending.
      What is the most likely cause of this patient's acute deterioration?

      Your Answer:

      Correct Answer: Community-acquired pneumonia

      Explanation:

      Diagnosing Acute Deterioration in Elderly Patients: Community-Acquired Pneumonia as the Likely Cause

      Elderly patients with underlying dementia often present with non-specific symptoms, making it challenging to diagnose the cause of acute deterioration. In this case, the patient presented with acute confusion, and potential causes included community-acquired pneumonia, urinary tract infection, atrial fibrillation with rapid ventricular response, and progression of Alzheimer’s disease. However, clinically and radiologically, the patient showed evidence of community-acquired pneumonia, making it the most likely diagnosis.

      Urinary tract infection and Alzheimer’s disease were ruled out based on urinalysis findings and chest findings, respectively. Atrial fibrillation with rapid ventricular response could have been a cause of the patient’s confusion, but the clinical findings suggested pneumonia as the primary cause. Myocardial infarction was also a possibility, but the chest findings made it less likely.

      In conclusion, diagnosing acute deterioration in elderly patients with underlying dementia requires a thorough evaluation of potential causes. In this case, community-acquired pneumonia was the most likely diagnosis, highlighting the importance of considering multiple pathologies that can coexist in elderly patients.

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  • Question 25 - A 28 year old patient is brought in by ambulance to the emergency...

    Incorrect

    • A 28 year old patient is brought in by ambulance to the emergency department. He is a known intravenous drug user and is currently presenting with mild respiratory depression, reduced level of consciousness, and pinpoint pupils. What would be the most appropriate medication for initial management?

      Your Answer:

      Correct Answer: Naloxone

      Explanation:

      Medication Antidotes: Understanding the Role of Naloxone, Flumazenil, N-acetyl-L-cysteine, Adrenaline, and Atropine

      Naloxone is a medication used to reverse the effects of opioid overdose. Pinpoint pupils, reduced level of consciousness, and respiratory depression are common symptoms of opioid toxicity. Naloxone should be administered in incremental doses to avoid full reversal, which can cause withdrawal symptoms and agitation.

      Flumazenil is a specific antidote for benzodiazepine sedation. However, it would not be effective in cases of pupillary constriction.

      N-acetyl-L-cysteine is the antidote for paracetamol overdose, which can cause liver damage and acute liver failure.

      Adrenaline is used in cardiac arrest and anaphylaxis, but it has no role in the treatment of opiate toxicity.

      Atropine is a muscarinic antagonist used to treat symptomatic bradycardia. However, it can cause agitation in the hours following administration.

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  • Question 26 - A 20-year-old woman arrives at the Emergency Department in Nepal. She had flown...

    Incorrect

    • A 20-year-old woman arrives at the Emergency Department in Nepal. She had flown from the United Kingdom the previous day for a hiking trip with her friends. She reports feeling light-headed and dizzy in the hotel lobby in the morning. Despite taking a short rest, she continues to feel unwell and complains of nausea and a generalised dull headache. She is overweight and has no history of migraine. Although she is well oriented, she feels that her nausea and headache are getting worse.
      What would be the most appropriate course of action for managing this patient?

      Your Answer:

      Correct Answer: Administer oxygen and acetazolamide

      Explanation:

      Treatment Options for Acute Mountain Sickness

      Acute mountain sickness (AMS) is a common condition that can occur when ascending to high altitudes without proper acclimatization. Symptoms include nausea, headache, difficulty breathing, and dizziness. Here are some treatment options for AMS:

      Administer oxygen and acetazolamide: Low-flow oxygen and acetazolamide can effectively relieve symptoms of AMS. Dexamethasone is also an alternative to acetazolamide.

      Antiemetics and a dose of prophylactic antibiotics: These can help relieve symptoms in mild cases, but are not sufficient for moderate to severe cases.

      Nifedipine: This medication may be effective in treating high-altitude pulmonary edema, but has no role in treating AMS.

      Non-steroidal anti-inflammatory drugs (NSAIDs) and bed rest: NSAIDs can provide symptomatic relief, but cannot cure the underlying cause of AMS.

      Transfer the patient immediately to a location at lower altitude: Descent is always an effective treatment for AMS, but is not necessary unless symptoms are intractable or there is suspicion of illness progression.

      Treatment Options for Acute Mountain Sickness

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  • Question 27 - A 14-year-old girl with a history of eczema and asthma suddenly experiences breathlessness,...

    Incorrect

    • A 14-year-old girl with a history of eczema and asthma suddenly experiences breathlessness, nausea, and facial swelling after eating a chicken skewer at a party. Her friends report raised red bumps all over her skin and her lips are turning blue. What is the most appropriate immediate management for this patient?

      Your Answer:

      Correct Answer: Intramuscular (IM) adrenaline 0.5 mg (1 : 1000)

      Explanation:

      For a patient experiencing an anaphylactic reaction, immediate treatment with intramuscular (IM) adrenaline 0.5 mg (1 : 1000) is necessary. This can be repeated every 5 minutes as needed, based on vital signs, until the patient stabilizes. Intravenous (IV) chlorphenamine in 0.9% saline (500 ml) may also be given, but only after adrenaline. Salbutamol may be considered after initial resuscitation, but oxygen administration, IM adrenaline, IV chlorphenamine, and hydrocortisone are the most important treatments. IV adrenaline 0.5 ml of 1 : 10 000 is only used in severe cases that do not respond to initial treatment and should be administered by experienced specialists. Reassurance and breathing exercises are not appropriate for a patient with a history of severe anaphylaxis.

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  • Question 28 - An adolescent recovering from a first-time anaphylactic reaction to shellfish is being discharged.
    What...

    Incorrect

    • An adolescent recovering from a first-time anaphylactic reaction to shellfish is being discharged.
      What should be done at discharge?

      Your Answer:

      Correct Answer: Discharge with two adrenaline autoinjectors

      Explanation:

      Discharge and Follow-Up of Anaphylactic Patients: Recommendations and Advice

      When it comes to discharging and following up with patients who have experienced anaphylaxis, there are certain recommendations and advice that healthcare professionals should keep in mind. Here are some key points to consider:

      Recommendations and Advice for Discharging and Following Up with Anaphylactic Patients

      – Give two adrenaline injectors as an interim measure after emergency treatment for anaphylaxis, before a specialist allergy service appointment. This is especially important in the event the patient has another anaphylactic attack before their specialist appointment.
      – Auto-injectors are given to patients at an increased risk of a reaction. They are not usually necessary for patients who have suffered drug-induced anaphylaxis, unless it is difficult to avoid the drug.
      – Advise that one adrenaline auto-injector will be prescribed if the patient has a further anaphylactic reaction.
      – Arrange for a blood test after one week for serum tryptase, immunoglobulin E (IgE) and histamine levels to assess biphasic reaction. Discharge and follow-up of anaphylactic patients do not involve a blood test. Tryptase sample timings, measured while the patient is in hospital, should be documented in the patient’s records.
      – Patients who have suffered from anaphylaxis should be given information about the potential of biphasic reactions (i.e. the reaction can recur hours after initial treatment) and what to do if a reaction occurs again.
      – All patients presenting with anaphylaxis should be referred to an Allergy Clinic to identify the cause, and thereby reduce the risk of further reactions and prepare the patient to manage future episodes themselves. All patients should also be given two adrenaline injectors in the event the patient has another anaphylactic attack.

      By following these recommendations and providing patients with the necessary information and resources, healthcare professionals can help ensure the best possible outcomes for those who have experienced anaphylaxis.

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  • Question 29 - A 93-year-old man is brought to the Emergency Department from a nursing home...

    Incorrect

    • A 93-year-old man is brought to the Emergency Department from a nursing home with a 4-day history of fever and lethargy. He has a background history of chronic urinary catheterisation for benign prostatic hyperplasia. On clinical examination, he is noted to be acutely confused. His temperature is 38.5 °C, and he has a heart rate of 97 bpm, blood pressure of 133/70 mmHg and a respiratory rate of 20 breaths per minute.
      Investigation Result Normal value
      White cell count 13 × 109/l 4–11 × 109/l
      Blood glucose 6 mmol/l 4–10 mmol/l
      Urinalysis
      2+ blood
      2+ leukocytes
      1+ nitrites
      NAD
      What is the diagnosis for this patient?

      Your Answer:

      Correct Answer: Sepsis

      Explanation:

      Understanding Sepsis, SIRS, Urinary Tract Infection, and Septic Shock

      Sepsis is a serious medical condition that occurs when the body’s response to an infection causes damage to its own tissues and organs. One way to diagnose sepsis is by using the Systemic Inflammatory Response Syndrome (SIRS) criteria, which include tachycardia, tachypnea, fever or hypo/hyperthermia, and leukocytosis, leukopenia, or bandemia. If a patient meets two or more of these criteria, with or without evidence of infection, they may be diagnosed with SIRS.

      A urinary tract infection (UTI) is a common type of infection that can occur in patients with a long-term catheter. However, if a patient with a UTI also meets the SIRS criteria and has a source of infection, they should be treated as sepsis.

      Septic shock is a severe complication of sepsis that occurs when blood pressure drops to dangerously low levels. In this case, there is no evidence of septic shock as the patient’s blood pressure is normal.

      In summary, this patient meets the SIRS criteria for sepsis and has a source of infection, making it a case of high-risk sepsis. It is important to understand the differences between sepsis, SIRS, UTI, and septic shock to provide appropriate treatment and prevent further complications.

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  • Question 30 - A 79-year-old woman presents with recent-onset confusion. She had been in her usual...

    Incorrect

    • A 79-year-old woman presents with recent-onset confusion. She had been in her usual state of health until she was observed to be confused and agitated during dinner yesterday. This morning, she was alert and oriented, but later in the evening, she became completely confused, agitated, and hostile. She was subsequently transported to the Emergency Department by ambulance. Additional history reveals no prior instances of confusion, but she has experienced increased frequency of urination over the past few days.
      What is the probable reason for her confusion?

      Your Answer:

      Correct Answer: Urinary tract infection (UTI)

      Explanation:

      Diagnosing Delirium in an Elderly Patient: UTI vs. Dementia vs. Pyelonephritis

      When an 89-year-old woman presents with waxing and waning consciousness, punctuated by ‘sun-downing’, it is important to consider the possible causes of delirium. In this case, the patient has normal cognitive function but is experiencing acute global cerebral dysfunction. One possible cause of delirium in the elderly is a urinary tract infection (UTI), which can present with symptoms such as frequency and confusion.

      However, it is important to rule out other potential causes of delirium, such as vascular dementia or Alzheimer’s dementia. In these conditions, cognitive decline is typically steady and progressive, whereas the patient in this case is experiencing waxing and waning consciousness. Additionally, neither of these conditions would account for the patient’s new urinary symptoms.

      Another possible cause of delirium is pyelonephritis, which can present with similar symptoms to a UTI but may also include pyrexia, renal angle tenderness, and casts on urinalysis. However, in this case, the patient does not exhibit these additional symptoms.

      Finally, pseudodementia is unlikely in this scenario as the patient does not exhibit any affective signs. Overall, it is important to consider all possible causes of delirium in an elderly patient and conduct a thorough evaluation to determine the underlying condition.

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  • Question 31 - You are on call overnight for orthogeriatrics when you receive a bleep to...

    Incorrect

    • You are on call overnight for orthogeriatrics when you receive a bleep to see a patient who is two days post-op from a left total hip replacement. You are not familiar with this patient. Upon arrival, you notice that the patient is drowsy and confused, and has a very fast heart rate. An electrocardiogram (ECG) reveals peaked T-waves, a PR interval of 230 ms, and a wide QRS. The patient's potassium level on ABG is 6.4 mmol. What is the most appropriate initial management?

      Your Answer:

      Correct Answer: Give calcium gluconate 10% 10 ml by slow iv injection

      Explanation:

      Managing Hyperkalaemia: Immediate Treatment Steps

      Hyperkalaemia is a serious condition that requires immediate treatment. The first step is to administer 10 ml of 10% calcium gluconate by slow IV injection to protect the cardiac myocytes from excess potassium. Next, 10 Units of Actrapid should be given in 100 ml of 20% glucose to draw potassium intracellularly. Salbutamol nebulisers can also be used. Finally, calcium resonium 15g orally or 30 g rectally can be given to mop up excess potassium in the gastrointestinal tract. It is important to note that this condition is life-threatening and requires immediate management, so waiting for a registrar is not an option.

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  • Question 32 - A 70-year-old known cardiopath is brought to hospital by ambulance, complaining of chest...

    Incorrect

    • A 70-year-old known cardiopath is brought to hospital by ambulance, complaining of chest pain and shortness of breath. He looks pale and is very sweaty. Examination reveals a blood pressure of 80/55 mmHg, pulse of 135 bpm, SpO2 of 93% and bibasal wet crackles in the chest, as well as peripheral oedema. Peripheral pulses are palpable. A previous median sternotomy is noted. An electrocardiogram (ECG) reveals regular tachycardia, with QRS complexes of uniform amplitude, a QRS width of 164 ms and a rate of 135 bpm.
      What is the most important step in management?

      Your Answer:

      Correct Answer: DC cardioversion

      Explanation:

      Management of Ventricular Tachycardia in a Patient with Ischaemic Heart Disease

      When faced with a patient with a broad-complex tachycardia, it is important to consider ventricular tachycardia as the most common cause, particularly in patients with a history of ischaemic heart disease. In a haemodynamically unstable patient with regular ventricular tachycardia, the initial step is to evaluate for adverse signs or symptoms. If present, the patient should be sedated and synchronised DC shock should be administered, followed by amiodarone infusion and correction of electrolyte abnormalities. If there are no adverse signs or symptoms, amiodarone IV and correction of electrolyte abnormalities should begin immediately.

      Other management options, such as primary percutaneous coronary intervention (PCI), IV magnesium, aspirin and clopidogrel, IV furosemide, and oxygen, may be indicated depending on the underlying cause of the ventricular tachycardia, but DC cardioversion is the most important step in a haemodynamically unstable patient. Diuretics are not indicated in a hypotensive patient, and improving cardiac function is the key to clearing fluid from the lungs.

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  • Question 33 - A 34-year-old surgical patient develops wheeze, lip swelling, and pallor while receiving antibiotics....

    Incorrect

    • A 34-year-old surgical patient develops wheeze, lip swelling, and pallor while receiving antibiotics. Her blood pressure is 70/38 mmHg. What urgent treatment is required?

      Your Answer:

      Correct Answer: 1:1000 IM adrenaline

      Explanation:

      Understanding the Correct Treatment for Anaphylaxis

      Anaphylaxis is a severe medical emergency that requires immediate treatment. The administration of adrenaline via the intramuscular (IM) route is the first-line treatment for anaphylaxis. Adrenaline’s inotropic action provides an immediate response, making it a lifesaving treatment. Once the patient is stabilized, intravenous hydrocortisone and chlorphenamine can also be administered. However, adrenaline remains the primary treatment.

      It is crucial to conduct a full ABCDE assessment and involve an anaesthetist if there are concerns about the airway. Using 1:10,000 IM adrenaline is sub-therapeutic in the setting of anaphylaxis. This dose is only used during cardiopulmonary resuscitation. Similarly, 1:10,000 IM noradrenaline is the wrong choice of drug and dose for anaphylaxis treatment.

      Intramuscular glucagon is used to treat severe hypoglycemia when the patient is unconscious or too drowsy to administer glucose replacement therapy orally. Intravenous noradrenaline is not the correct drug or route for anaphylaxis treatment. Understanding the correct treatment for anaphylaxis is crucial in saving lives.

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  • Question 34 - An 80-year-old man is brought to the Emergency Department from a nursing home...

    Incorrect

    • An 80-year-old man is brought to the Emergency Department from a nursing home with fever and a non-healing infected ulcer in his leg. He has a history of obesity and type 2 diabetes. He reports that his leg was extremely painful but now is no longer painful. On clinical examination, his temperature is 38.6 °C, heart rate 110 bpm and blood pressure 104/69 mmHg. Peripheral pulses are palpable on examining his legs. There is tense oedema, dusky blue/purple plaques and haemorrhagic bullae on his right leg, with an underlying venous ulcer. Palpation reveals crepitus. After taking blood cultures, treatment is commenced with intravenous (IV) antibiotics and fluids.
      What is the next and most important step in management?

      Your Answer:

      Correct Answer: Surgical debridement in theatre

      Explanation:

      Treatment Options for Necrotising Fasciitis

      Necrotising fasciitis (NF) is a serious medical emergency that requires immediate surgical intervention. Antimicrobial therapy and support alone have shown to have a mortality rate of almost 100%. The primary goal of surgical intervention is to remove all necrotic tissue until healthy, viable tissue is reached. This can be done through surgical debridement in theatre or bedside wound debridement by a plastic surgeon in an aseptic environment.

      Hyperbaric oxygen (HBO) treatment is believed to increase the bactericidal effects of neutrophils and can be useful in treating synergistic infections. However, access to HBO units with appropriate staffing and chambers large enough for intensive care patients is limited.

      IV immunoglobulin (IVIG) has shown potential benefits in group A streptococcal (GAS) infections, but further studies are needed to determine its exact benefits in NF.

      While X-ray, MRI, and CT scans can aid in the diagnosis of NF, surgical treatment should never be delayed for these tests. Immediate surgical intervention is crucial in treating this life-threatening condition.

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  • Question 35 - A 25-year-old woman has been experiencing fatigue and sluggishness for the past three...

    Incorrect

    • A 25-year-old woman has been experiencing fatigue and sluggishness for the past three weeks, along with discomfort in the left upper quadrant of her abdomen. She had a UTI not long ago, which was treated with amoxicillin. However, she ceased taking the medication due to a rash that spread throughout her body. What is the probable cause of her exhaustion?

      Your Answer:

      Correct Answer: Glandular fever

      Explanation:

      Differential Diagnosis: Glandular Fever, Chronic Fatigue Syndrome, Chronic Renal Failure, Chronic Depression, Iron Deficiency

      Glandular Fever: A Possible Diagnosis
      The patient in question is likely suffering from glandular fever, also known as infectious mononucleosis. This condition is caused by the Epstein-Barr virus, which is transmitted through saliva. Symptoms typically include a sore throat, fever, and swollen lymph nodes in the neck. However, other symptoms such as fatigue, arthritis, and hepatitis may also occur. The patient’s left upper quadrant pain and tiredness are consistent with this diagnosis. A characteristic rash may also develop following treatment with certain antibiotics.

      Other Possible Diagnoses
      Chronic fatigue syndrome is a chronic condition characterized by extreme fatigue and functional impairment. However, given the short time frame of the symptoms and association with amoxicillin, this diagnosis is unlikely. Chronic renal failure is associated with fatigue and anaemia, but there is no evidence of a history of this condition. Chronic depression may cause fatigue, but the duration of symptoms would be longer than three weeks and not associated with an infection or abdominal pain. Iron deficiency is a common cause of fatigue in women of reproductive age and should also be considered.

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  • Question 36 - A 68-year-old man is admitted to the Intensive Therapy Unit after a coronary...

    Incorrect

    • A 68-year-old man is admitted to the Intensive Therapy Unit after a coronary artery bypass graft for a period of ventilation. He has a 35-pack year smoking history but successfully gave up some 2 years earlier. Unfortunately, weaning does not go as anticipated, and he cannot be weaned off the ventilator and is still in need of it 4 days later. There is evidence of right-sided bronchial breathing on auscultation. He is pyrexial with a temperature of 38.5 °C.
      Investigations:
      Investigation Result Normal value
      Sodium (Na+) 142 mmol/l 135–145 mmol/l
      Potassium (K+) 4.8 mmol/l 3.5–5.0 mmol/l
      Creatinine 170 μmol/l 50–120 µmol/l
      Haemoglobin 115 g/l 135–175 g/l
      White cell count (WCC) 12.5 × 109/l (10.0) 4–11 × 109/l
      Chest X-ray: bilateral pulmonary infiltrates, more marked on the right-hand side
      Bronchial aspirates: mixed anaerobes
      Which of the following diagnoses fits best with this clinical picture?

      Your Answer:

      Correct Answer: Ventilator acquired pneumonia

      Explanation:

      Possible Diagnoses for a Pyrexial Patient with Chest Signs

      A pyrexial patient with chest signs on the right-hand side may have ventilator-acquired pneumonia, which occurs due to contamination of the respiratory tract from oropharyngeal secretions. Diagnosis is based on clinical examination, X-ray, blood culture, and bronchial washings. Initial antibiotic therapy should cover anaerobes, MRSA, Pseudomonas, and Acinetobacter.

      If the patient has been in the hospital for more than 72 hours, any infection that develops is likely to be hospital-acquired.

      Acute respiratory distress syndrome (ARDS) presents more acutely and broncholavage samples commonly demonstrate inflammatory and necrotic cells.

      Infective pulmonary edema is unlikely if there are no indications of pleural effusions or edema on clinical examination and chest radiograph.

      Pulmonary hemorrhage is unlikely if there is no blood found in the bronchial aspirates.

      Possible Diagnoses for a Pyrexial Patient with Chest Signs

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  • Question 37 - A 65-year-old previously healthy man with a 3-day history of feeling unwell, difficulty...

    Incorrect

    • A 65-year-old previously healthy man with a 3-day history of feeling unwell, difficulty tolerating oral fluids and symptoms of a cold, is referred to the hospital by his primary care physician. The senior Accident and Emergency (A&E) nurse triages him and takes his vital signs, which are mostly normal except for a slightly elevated heart rate (102 bpm). She also performs a 12-lead electrocardiogram (ECG) and draws blood for testing, but the results are pending. The nurse suspects that the ECG shows some abnormalities and consults with the A&E senior resident, who confirms that the QRS complexes are widened, P-waves are absent, and T-waves are abnormally large.
      What is the most appropriate initial course of action?

      Your Answer:

      Correct Answer: 10 ml of 10% calcium gluconate

      Explanation:

      Managing Hyperkalaemia: The Importance of Calcium Gluconate as a Cardioprotectant

      Hyperkalaemia can lead to serious cardiac complications, including suppression of impulse generation and reduced conduction. Therefore, the priority in managing hyperkalaemia is to administer calcium gluconate as a cardioprotectant. This should be followed by the administration of salbutamol nebuliser and Actrapid® with 50% dextrose to shift potassium into the cells. If refractory hyperkalaemia occurs, senior support should be sought, potentially requiring bicarbonate or dialysis. It is important to prioritize the administration of calcium gluconate to prevent potential myocardial infarction. Once interventions have been administered, alerting senior support is recommended.

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  • Question 38 - You are with the on-call anaesthetist who has been asked to see a...

    Incorrect

    • You are with the on-call anaesthetist who has been asked to see a 30-year-old man blue-lighted into the Emergency Department. The patient complains of being stung by a wasp while running and reports his arm becoming immediately swollen and red. He kept running but, within a few minutes, began to feel very light-headed and had difficulty breathing. On examination, the patient looks flushed and has a widespread wheeze on auscultation. Blood pressure 76/55 mmHg, heart rate 150 bpm, respiratory rate 32 breaths/minute.
      Which of the following is the best initial treatment?

      Your Answer:

      Correct Answer: Intramuscular (IM) 1 : 1000 adrenaline 500 micrograms

      Explanation:

      Management of Anaphylaxis: Initial Treatment and Beyond

      Anaphylaxis is a life-threatening condition that requires prompt and appropriate management. The Resuscitation Council has established three criteria for diagnosing anaphylaxis: sudden onset and rapid progression of symptoms, life-threatening airway, breathing, and circulatory problems, and skin changes. The initial management for anaphylaxis is IM 1 : 1000 adrenaline 500 micrograms, even before equipment or IV access is available. Once expertise and equipment are available, the airway should be stabilized, high-flow oxygen given, the patient fluid-challenged, and IV hydrocortisone and chlorphenamine given. Ephedrine has no role in anaphylaxis, and IV adrenaline is not the first-line management. Prompt intubation may be necessary, but IM adrenaline must be given before a full ABCDE assessment is made. Nebulized adrenaline may help with airway swelling, but it will not treat the underlying immunological phenomenon. Proper management of anaphylaxis requires a comprehensive approach that addresses both the immediate and long-term needs of the patient.

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  • Question 39 - A 30-year-old previously healthy man is involved in an accident at home. He...

    Incorrect

    • A 30-year-old previously healthy man is involved in an accident at home. He is brought to Accident and Emergency where he is found to have superficial abrasions to the right side of his chest and upper abdomen, together with an obvious deformity of the right humerus. Radiograph of the right arm shows a displaced midshaft humerus fracture. Neurovascular examination reveals radial nerve palsy, together with absent peripheral pulses and a cool, clammy distal arm. He was given oral paracetamol at home, while waiting for the ambulance to arrive. Pain score remains 9/10. Parameters are as follows:
      Investigation Result Normal value
      Temperature 36.9 °C 36.1–37.2 °C
      Pulse 110 bpm 60–100 bpm
      Blood pressure 140/90 mmHg < 120/80 mmHg
      Oxygen saturations 98% on room air 94–98%
      Respiratory rate 22 breaths/min 12–18 breaths/min
      Which of the following is the most appropriate form of pain relief?

      Your Answer:

      Correct Answer: IV morphine

      Explanation:

      Choosing the Right Analgesic for Acute Pain: A Case-by-Case Basis

      Analgesia is typically administered in a stepwise manner, but emergency medicine requires a more individualized approach. In cases of acute pain from long bone fractures, non-opioid analgesia may not be sufficient. The two most viable options are oral and IV morphine, with IV morphine being preferred due to its rapid onset and safe side-effect profile. However, caution must be exercised due to the risk of respiratory depression and dependency. Oral NSAIDs and morphine are contraindicated as the patient must be kept nil by mouth before urgent surgical intervention. Oxycodone prolonged release is too weak for severe pain. Choosing the right analgesic for acute pain requires careful consideration of the patient’s individual needs.

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  • Question 40 - You see a 92-year-old gentleman who has been admitted following a fall. He...

    Incorrect

    • You see a 92-year-old gentleman who has been admitted following a fall. He had been discovered lying on the floor of his home by a neighbour. He has a diagnosis of dementia and cannot recall how long ago he had fallen. His observations are normal and he is apyrexial. A pelvic X-ray, including both hips, shows no evidence of bony injury. A full blood count is normal.
      His biochemistry results are as follows:
      Investigation Result Normal value
      Creatinine 210 μmol/l 50–120 µmol/l
      Urea 22.0 mmol/l 2.5–6.5 mmol/l
      Sodium 133 mmol/l 135–145 mmol/l
      Potassium 4.9 mmol/l 3.5–5.0 mmol/l
      C-reactive protein (CRP) 8 mg/l 0–10 mg/l
      What is the most appropriate investigation to request next?

      Your Answer:

      Correct Answer: Creatine kinase

      Explanation:

      Investigating the Cause of Renal Failure: Importance of Creatine Kinase

      Renal failure can have various causes, including dehydration, sepsis, and rhabdomyolysis. In this case, the patient’s normal observations and inflammatory markers suggest rhabdomyolysis as the most serious potential cause. A raised creatine kinase would confirm the diagnosis. Elderly patients are particularly at risk of rhabdomyolysis following a prolonged period of immobility. A falls screen, including routine bloods, blood glucose, resting electrocardiogram, urinalysis, and lying-standing blood pressure, would be appropriate. While a catheter urine specimen may be helpful in diagnosing sepsis, it is less likely in this case. Liver function tests and upper gastrointestinal endoscopy are unlikely to provide useful information. A plain chest X-ray is also not necessary for investigating the cause of renal failure.

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  • Question 41 - An 80-year-old woman presents with a 4-day history of right upper quadrant pain....

    Incorrect

    • An 80-year-old woman presents with a 4-day history of right upper quadrant pain. She has a past medical history of hypercholesterolaemia and obesity. On clinical examination, she is alert and has a temperature of 38.6 °C, a heart rate of 90 bpm, a respiratory rate of 14 breaths per minute, a blood pressure of 112/90 mmHg and oxygen saturations of 98% on room air. She has tenderness in her right upper quadrant. Murphy’s sign is positive.
      Her blood test results are listed below:
      Investigation Result Normal value
      White cell count 3 × 109/l 4–11 × 109/l
      Blood glucose 7.9 mmol/l 4–10 mmol/l
      C-reactive protein (CRP) 44 mg/l 0–10 mg/l
      Which of the following does this patient have?

      Your Answer:

      Correct Answer: Sepsis

      Explanation:

      Differentiating between Sepsis, Acute Pancreatitis, Appendicitis, Septic Shock, and Urosepsis

      When a patient presents with symptoms of fever, elevated heart rate, and a possible infective process, it is important to differentiate between various conditions such as sepsis, acute pancreatitis, appendicitis, septic shock, and urosepsis. In the case of sepsis, the patient may have a mild elevation in heart rate and temperature, along with a low white cell count. If there is evidence of an infective process in the biliary system, broad-spectrum antibiotics should be initiated as part of the Sepsis Six protocol activation. Acute pancreatitis is a serious diagnosis that is often associated with vomiting and a mild rise in temperature. Appendicitis typically presents with central abdominal pain that later localizes to the right iliac fossa, along with anorexia and vomiting. If a patient has sepsis with severe tachycardia, systolic blood pressure of < 90 mmHg, or life-threatening features resistant to resuscitation, they may have septic shock. Finally, urosepsis may present with symptoms of dysuria, frequency, and suprapubic tenderness, or it may be asymptomatic in elderly patients who present with confusion. It is important to rule out urosepsis in elderly patients who present unwell.

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  • Question 42 - A 35-year-old man comes to the Emergency Department (ED) with a fever of...

    Incorrect

    • A 35-year-old man comes to the Emergency Department (ED) with a fever of 40 °C, vomiting and diarrhea, and is extremely restless. He has hyperthyroidism but is known to not take his medication regularly. The ED registrar suspects that he is experiencing a thyroid storm.
      What is the most probable statement about a thyrotoxic crisis (thyroid storm)?

      Your Answer:

      Correct Answer: Fluid resuscitation, propranolol and carbimazole are used in the management of a thyroid storm

      Explanation:

      When managing a patient with a thyroid storm, it is important to first stabilize them by addressing their presenting symptoms. This may involve fluid resuscitation, a nasogastric tube if vomiting, and sedation if necessary. Beta-blockers are often used to reduce the effects of excessive thyroid hormones on end-organs, and high-dose digoxin may be used with close cardiac monitoring. Antithyroid drugs, such as carbimazole, are then used. Tepid sponging is used to manage excessive hyperthermia, and active warming may be used in cases of myxoedema coma. Men are actually more commonly affected by thyroid storms than women. Precipitants of a thyroid storm include recent thyroid surgery, radioiodine, infection, myocardial infarction, and trauma. Levothyroxine is given to replace low thyroxine levels in cases of hypothyroidism, while hydrocortisone or dexamethasone may be given to prevent peripheral conversion of T4 to T3 in managing a patient with a thyroid storm.

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  • Question 43 - A 71-year-old man attends the Emergency Department with a 3-day history of a...

    Incorrect

    • A 71-year-old man attends the Emergency Department with a 3-day history of a warm, red, tender right lower leg. He thinks it is the result of banging his leg against a wooden stool at home. He has a past medical history of diabetes. He is unable to recall his drug history and is unsure of his allergies, although he recalls having ‘a serious reaction’ to an antibiotic as a child.
      You diagnose cellulitis and prescribe an initial dose of flucloxacillin, which is shortly administered. Several minutes later, the nurse asks for an urgent review of the patient since the patient has become very anxious and has developed a hoarse voice. You attend the patient and note swelling of the tongue and lips. As you take the patient’s wrist to feel the rapid pulse, you also note cool fingers. A wheeze is audible on auscultation of the chest and patchy erythema is visible. You ask the nurse for observations and she informs you the respiratory rate is 29 and systolic blood pressure 90 mmHg. You treat the patient for an anaphylactic reaction, administering high-flow oxygen, intravenous (iv) fluid, adrenaline, hydrocortisone and chlorpheniramine.
      What is the dose of adrenaline you would use?

      Your Answer:

      Correct Answer: 0.5 ml of 1 in 1000 intramuscular (im)

      Explanation:

      Anaphylaxis and the ABCDE Approach

      Anaphylaxis is a severe and life-threatening allergic reaction that requires immediate medical attention. It is characterized by respiratory and circulatory compromise, skin and mucosal changes, and can be triggered by various agents such as foods and drugs. In the case of anaphylaxis, the ABCDE approach should be used to assess the patient. Adrenaline is the most important drug in the treatment of anaphylaxis and should be administered at a dose of 0.5 mg (0.5 ml of 1 in 1000) intramuscularly. The response to adrenaline should be monitored, and further boluses may be required depending on the patient’s response. Other medications that should be given include chlorpheniramine and hydrocortisone, as well as intravenous fluids. It is crucial to recognize and treat anaphylaxis promptly to prevent severe complications.

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  • Question 44 - An 85-year-old woman has been brought to Accident and Emergency from her residential...

    Incorrect

    • An 85-year-old woman has been brought to Accident and Emergency from her residential home due to increasing concern from staff there. She has been experiencing increasing confusion over the past few days, which staff initially attributed to her Alzheimer's dementia. She has a known history of chronic obstructive pulmonary disease (COPD), but no other long-term medical conditions. During the ambulance ride to the hospital, she was given intravenous (IV) paracetamol. Unfortunately, you are unable to obtain any useful medical history from her. However, she is responding to voice only, with some minor abdominal tenderness found on examination and little else. She appears to be in shock, and her vital signs are as follows:
      Temperature 37.6 °C
      Blood pressure 88/52 mmHg
      Heart rate 112 bpm
      Saturations 92% on room air
      An electrocardiogram (ECG) is performed, which shows first-degree heart block and nothing else.
      What type of shock is this woman likely experiencing?

      Your Answer:

      Correct Answer: Septic

      Explanation:

      Differentiating Shock Types: A Case Vignette

      An elderly woman presents with a change in mental state, indicating delirium. Abdominal tenderness suggests a urinary tract infection (UTI), which may have progressed to sepsis. Although there is no pyrexia, the patient has received IV paracetamol, which could mask a fever. Anaphylactic shock is unlikely as there is no mention of new medication administration. Hypovolaemic shock is also unlikely as there is no evidence of blood loss or volume depletion. Cardiogenic shock is improbable due to the absence of cardiac symptoms. Neurogenic shock is not a consideration as there is no indication of spinal pathology. Urgent intervention is necessary to treat the sepsis according to sepsis guidelines.

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  • Question 45 - A 75-year-old woman, who is a nursing home resident, presents to the Emergency...

    Incorrect

    • A 75-year-old woman, who is a nursing home resident, presents to the Emergency Department, complaining of a one-week history of a red swollen calf, nausea and ‘ants on her arm’. She is noted to be unsteady on her feet and cannot remember what medications she is on. Observations find her temperature is 38.6 °C, oxygen saturation 98%, blood pressure 90/60 mmHg, heart rate 90 bpm and respiratory rate 20 breaths per minute.
      What is the most likely cause of her hypotension?

      Your Answer:

      Correct Answer: Sepsis

      Explanation:

      Possible Diagnoses for a Patient with Red Swollen Calf and Signs of Infection

      This patient is presenting with a red swollen calf, which is most likely caused by cellulitis. However, there are other possible diagnoses to consider based on the patient’s symptoms.

      One possible diagnosis is sepsis, which is a life-threatening condition. The patient should be treated immediately using the Sepsis Six protocol.

      Another possible diagnosis is pulmonary embolus with an underlying deep vein thrombosis (DVT), but this should be considered after ruling out sepsis and starting antibiotics.

      Hypovolaemia is also a consideration due to the patient’s hypotension, but there is no history of blood or fluid loss.

      Myocardial infarction is unlikely as the patient has no history of cardiac disease and did not present with any chest symptoms.

      Anaphylaxis is not a possible cause given the lack of a causative agent and other features associated with anaphylaxis.

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  • Question 46 - A 65-year-old woman presents to Accident and Emergency with chest pain.
    For which of...

    Incorrect

    • A 65-year-old woman presents to Accident and Emergency with chest pain.
      For which of the following is a chest X-ray the least appropriate as an investigation to best manage the patient?

      Your Answer:

      Correct Answer: Suspected rib fracture without respiratory compromise

      Explanation:

      Indications for Chest X-Ray: When to Perform a CXR

      Chest X-rays (CXRs) are a common imaging modality used to diagnose various conditions affecting the chest. However, it is important to use CXRs judiciously and only when they are likely to provide useful information. Here are some indications for performing a CXR:

      Suspected rib fracture without respiratory compromise: In patients with musculoskeletal chest pain, a CXR should not be the first-line investigation. Instead, a CT scan of the chest, abdomen, and pelvis is more useful. However, if the patient is unstable, has respiratory compromise, or is a child with concerns for radiation exposure, a CXR can be considered.

      Suspected pleural effusion: A CXR is useful in diagnosing pleural effusions, which appear as an opacity with a meniscal superior edge.

      Suspected pneumonia: A CXR is useful in diagnosing pneumonia, which appears as consolidation in the affected lobe of the lung.

      Suspected sepsis: A CXR can be used as part of a septic screen, alongside cultures and urinalysis.

      Suspected pneumothorax: A CXR is diagnostic of a pneumothorax, which appears as air within the pleural space. Treatment modalities can be directed based on the size of the pneumothorax.

      In summary, CXRs should be used judiciously and only when they are likely to provide useful information. In some cases, a CT scan may be more useful as a first-line investigation.

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  • Question 47 - A 32-year-old nurse suddenly falls ill in the break room during her lunch...

    Incorrect

    • A 32-year-old nurse suddenly falls ill in the break room during her lunch break. She has a known severe shellfish allergy. She appears pale and agitated, with a respiratory rate of 60 breaths/minute, audible wheezing, a pulse rate of 130 bpm, and a blood pressure of 80/50 mmHg. Some of her coworkers are present. Anaphylaxis is suspected.

      What is the initial emergency intervention that should be given by her colleagues?

      Your Answer:

      Correct Answer: 0.5 mg of 1 in 1000 adrenaline intramuscular (IM) injection

      Explanation:

      Treatment Algorithm for Anaphylaxis: Medications and IV Fluids

      Anaphylaxis is a severe and potentially life-threatening allergic reaction that requires immediate treatment. The following medications and IV fluids are part of the treatment algorithm for anaphylaxis:

      1. 0.5 mg of 1 in 1000 adrenaline intramuscular (IM) injection: This should be given to treat anaphylaxis, repeated after five minutes if the patient is no better. An IV injection should only be used by experienced practitioners.

      2. Hydrocortisone 200 mg intravenous (IV): Once adrenaline has been administered, IV access should be obtained to administer steroids, fluids and antihistamines.

      3. 1 mg of 1 in 10 000 adrenaline im injection: The recommended initial dose of adrenaline is 0.5 mg im of 1 in 1000 strength.

      4. IV fluids through a wide-bore cannula: Once adrenaline has been administered, IV access should be obtained to administer steroids, fluids and antihistamines.

      5. Promethazine 50 mg IV: Once adrenaline has been administered, IV access should be obtained to administer steroids, fluids and antihistamines.

      It is important to note that administration of adrenaline should not be delayed and the patient’s airway, breathing, and circulation should be assessed before administering any medication. IV access should also be obtained as soon as possible to administer the necessary medications and fluids.

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  • Question 48 - A 65-year-old male inpatient with an infective exacerbation of chronic obstructive pulmonary disease...

    Incorrect

    • A 65-year-old male inpatient with an infective exacerbation of chronic obstructive pulmonary disease (COPD) has suddenly become very unwell in the space of 10–15 minutes and is struggling to breathe. The nurse tells you he is on intravenous (IV) antibiotics for this exacerbation and has been on the ward for a few days.
      Which one of the following would be the most concerning observation after assessing this patient?

      Your Answer:

      Correct Answer: Left-sided pleuritic chest pain

      Explanation:

      Assessing Symptoms and Vital Signs in a Patient with COPD Exacerbation

      When evaluating a patient with chronic obstructive pulmonary disease (COPD) who is experiencing an infective exacerbation, it is important to consider their symptoms and vital signs. Left-sided pleuritic chest pain is a concerning symptom that may indicate pneumothorax, which requires urgent attention. However, it is common for COPD patients with exacerbations to be on non-invasive ventilation (NIV), which is not necessarily alarming. A slightly elevated heart rate and respiratory rate may also be expected in this context. An increased antero-posterior (AP) diameter on X-ray is a typical finding in COPD patients due to hyperinflated lungs. A borderline fever is also common in patients with infective exacerbations of COPD. Overall, a comprehensive assessment of symptoms and vital signs is crucial in managing COPD exacerbations.

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  • Question 49 - A 65-year-old man, with a history of hypertension and atrial fibrillation being treated...

    Incorrect

    • A 65-year-old man, with a history of hypertension and atrial fibrillation being treated with warfarin, experiences a catastrophic intracranial hemorrhage. Despite receiving the highest level of organ support in the ICU, he fails to show any signs of improvement. Before deciding to withdraw organ support, he is evaluated for brain death.
      What healthcare professionals are necessary to diagnose brain death?

      Your Answer:

      Correct Answer: Two doctors, one of whom must be a consultant, both fully registered for at least five years and both competent in the assessment, conduct and interpretation of brainstem examinations

      Explanation:

      Requirements for Diagnosis of Death by Neurological Criteria

      To diagnose death by neurological criteria, at least two medical practitioners must be involved. They should be fully registered for at least five years and competent in the assessment, conduct, and interpretation of brainstem examinations. At least one of the doctors must be a consultant, but not both.

      It is important to note that a nurse cannot be one of the medical practitioners involved in the diagnosis. Additionally, the number of doctors required for the diagnosis does not need to be three, as two competent doctors are sufficient.

      Overall, the diagnosis of death by neurological criteria should be taken seriously and conducted by qualified medical professionals to ensure accuracy and ethical considerations.

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  • Question 50 - You have just received a 70-year-old woman into the resus room who had...

    Incorrect

    • You have just received a 70-year-old woman into the resus room who had a witnessed collapse after complaining of chest pain. There was no pulse and CPR was performed at the scene. CPR is ongoing upon patient arrival in the Emergency Department. Pulse check demonstrates no palpable central pulse and there is no respiratory effort. A 3-lead ECG demonstrates no coordinated electrical activity or recognisable complexes, looking very much like a wandering flat line.
      What is the most appropriate management of this patient?

      Your Answer:

      Correct Answer: 1 mg of adrenaline 1 : 10 000 intravenously (iv), and continue CPR

      Explanation:

      Correct Management of Cardiac Arrest: Understanding the Appropriate Interventions

      When faced with a patient in cardiac arrest, it is crucial to understand the appropriate interventions for the specific situation. In the case of a patient in asystole, the non-shockable side of the Advanced Life Support algorithm should be followed, with CPR 30 : 2 and 1 mg of adrenaline 10 ml of 1 : 10 000 iv every other cycle of CPR. It is important to note that a shock is not indicated for asystole.

      Adrenaline 1 : 1000 im should not be given in cardiac arrest situations, as it is used for anaphylaxis. External pacing is unlikely to be successful in the absence of P-wave asystole. Atropine is no longer recommended for use in Advanced Life Support.

      By understanding the appropriate interventions for different cardiac arrest situations, healthcare professionals can provide the best possible care for their patients.

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  • Question 51 - A 42-year-old man is brought to the Intensive Care Unit after accidental drowning...

    Incorrect

    • A 42-year-old man is brought to the Intensive Care Unit after accidental drowning in a lake. He was a swimmer who got into trouble and was underwater for approximately 10 minutes before being rescued. He was found unresponsive and not breathing, and bystanders immediately started performing CPR while waiting for emergency services. Upon arrival at the ICU, he is intubated and ventilated, and his vital signs are as follows: blood pressure 90/60 mmHg, pulse 130 bpm, oxygen saturations 85%, and temperature 33.2 °C.
      Under what circumstances is extracorporeal membrane oxygenation (ECMO) considered as a treatment option for drowning patients?

      Your Answer:

      Correct Answer: Persistent hypothermia from cold water drowning

      Explanation:

      When to Consider Extracorporeal Membrane Oxygenation (ECMO) for Drowning Patients

      Drowning can lead to respiratory compromise and persistent hypothermia, which may require advanced medical intervention. Extracorporeal membrane oxygenation (ECMO) is a treatment option that can be considered for selected patients who have drowned. However, it is important to understand the indications for ECMO and when it may not be appropriate.

      ECMO may be considered in cases where conventional mechanical ventilation or high-frequency ventilation have failed to improve respiratory function. Additionally, there should be a reasonable probability of the patient recovering neurological function. Persistent hypothermia from cold water drowning is another indication for ECMO.

      On the other hand, altered level of consciousness alone is not an indication for ECMO. Patients who respond well to conventional mechanical ventilation or high-frequency ventilation may not require ECMO. Similarly, haemodynamic instability can be managed with inotropes and fluids, and ECMO should only be considered for patients who are resistant to conventional organ support.

      It is important to note that ECMO has a high complication rate, with a 15% risk of bleeding. Therefore, it should only be used in selected cases where the potential benefits outweigh the risks.

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  • Question 52 - You are alone walking in the countryside when an elderly man collapses in...

    Incorrect

    • You are alone walking in the countryside when an elderly man collapses in front of you. There is nobody else around. You look, listen and feel, ensuring his airway is open. He is not breathing and is unresponsive. You phone for an ambulance.
      What is the next step that you would take while waiting for the ambulance to arrive?

      Your Answer:

      Correct Answer: Begin chest compressions at a rate of 100–120 per minute, giving two rescue breaths after every 30 compressions

      Explanation:

      How to Perform Chest Compressions and Rescue Breaths in Basic Life Support

      When faced with a non-responsive person who is not breathing, it is important to act quickly and perform basic life support. Begin by confirming that the person is not breathing and calling for an ambulance. Then, kneel by the person’s side and place the heel of one hand in the centre of their chest, with the other hand on top, interlocking fingers. Apply pressure to the sternum to a depth of 5-6 cm at a rate of 100-120 compressions per minute. After 30 compressions, open the airway and give two rescue breaths. Pinch the nose closed and blow steadily into the mouth, watching for the chest to rise. Repeat chest compressions and rescue breaths until help arrives.

      Note: The previous recommendation of two rescue breaths before chest compressions has been replaced with immediate chest compressions. Do not delay potentially life saving resuscitation.

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  • Question 53 - A 38-year-old man is brought in by ambulance as a trauma call following...

    Incorrect

    • A 38-year-old man is brought in by ambulance as a trauma call following a road traffic collision. On admission, he has a GCS score of 10 and a primary survey reveals asymmetric pupils, an open right forearm fracture, absent breath sounds on the right side, extensive RUQ pain, a painful abdomen, and a systolic blood pressure of 90 mmHg. When prioritizing intervention and stabilization of the patient, which injury should be given priority?

      Your Answer:

      Correct Answer: Absent breath sounds on the right side

      Explanation:

      Prioritizing Management in a Trauma Patient: An ABCDE Approach

      When managing a trauma patient, it is important to prioritize interventions based on the severity of their injuries. Using an ABCDE approach, we can assess and address each issue in order of priority.

      In the case of absent breath sounds on the right side, the priority would be to assess for a potential tension pneumothorax and treat it with needle decompression and chest drain insertion if necessary. Asymmetric pupils suggest an intracranial pathology, which would require confirmation via a CT head, but addressing the potential tension pneumothorax would still take priority.

      RUQ pain and abdominal tenderness would fall under ‘E’, but if there is suspicion of abdominal bleeding, then this would be elevated into the ‘C’ category. Regardless, addressing the breathing abnormality would be the priority here.

      An open forearm fracture would also fall under ‘E’, with the breathing issue needing to be addressed beforehand.

      Finally, the underlying hypotension, potentially caused by abdominal bleeding, falls under ‘C’, and therefore the breathing abnormality should be prioritized.

      In summary, using an ABCDE approach allows for a systematic and prioritized management of trauma patients, ensuring that the most life-threatening issues are addressed first.

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  • Question 54 - A 72-year-old man presents to the Emergency Department with fever, rigors, breathlessness and...

    Incorrect

    • A 72-year-old man presents to the Emergency Department with fever, rigors, breathlessness and a cough. He is producing a frothy pink/green sputum spotted with blood. On examination, you find that he is very confused, with a respiratory rate (RR) of 33 breaths per minute and blood pressure (BP) of 100/70 mmHg. Bloods reveal his urea is 3.2 mmol/l. On auscultation of the chest, you hear a pleural rub. Chest X-ray reveals multilobar consolidation.
      Which one of the following statements regarding his management is most appropriate?

      Your Answer:

      Correct Answer: He needs an ABC approach with fluid resuscitation

      Explanation:

      Managing Severe Pneumonia: Key Considerations and Treatment Approaches

      Severe pneumonia requires prompt and effective management to prevent complications and improve outcomes. The following points highlight important considerations and treatment approaches for managing patients with severe pneumonia:

      – ABC approach with fluid resuscitation: The initial step in managing severe pneumonia involves assessing and addressing the patient’s airway, breathing, and circulation. This may include providing oxygen therapy, administering fluids to correct hypovolemia or dehydration, and monitoring vital signs.
      – CURB 65 score: This scoring system helps to assess the severity of pneumonia and guide treatment decisions. Patients with a score of 3 or higher may require ICU referral.
      – Oxygen saturation: Low oxygen saturation levels (<95%) at presentation increase the risk of death and should be promptly addressed with oxygen therapy.
      – Analgesia for pleuritic chest pain: While analgesia may be offered to manage pleuritic chest pain, it may not be effective in all cases. Paracetamol or NSAIDs are recommended as first-line options.
      – Antibiotic therapy: Empirical antibiotics should be started promptly after appropriate resuscitation. Culture results should be obtained to confirm the causative organism and guide further treatment.

      In summary, managing severe pneumonia requires a comprehensive approach that addresses the patient’s clinical status, severity of illness, and potential complications. By following these key considerations and treatment approaches, healthcare providers can improve outcomes and reduce the risk of adverse events.

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  • Question 55 - Mrs Johnson is a 79-year-old lady who has been admitted with a urinary...

    Incorrect

    • Mrs Johnson is a 79-year-old lady who has been admitted with a urinary tract infection. She has a past medical history of chronic obstructive pulmonary disease (COPD), for which she takes inhalers. Her abbreviated mental test score (AMTS) was 8/10 on admission. A midstream urine sample was sent for microbiology and the report indicates a pure growth of Escherichia coli sensitive to trimethoprim and co-amoxiclav. After receiving 48 hours of intravenous co-amoxiclav, she is now on appropriate oral antibiotic therapy.
      You are called to the ward at 0100 h as Mrs Johnson is increasingly agitated and confused. She now has an AMTS of 2/10 and is refusing to stay in bed. Her vital signs are normal, and respiratory, cardiovascular, abdominal and neurological examinations reveal some fine crepitations at both lung bases, but no other abnormality. Her Glasgow Coma Score (GCS) is 14.
      What is the most appropriate next management option?

      Your Answer:

      Correct Answer: Advise nursing in a well-lit environment with frequent reassurance and reorientation

      Explanation:

      Managing Acute Delirium in Mrs Smith: Nursing in a Well-Lit Environment with Frequent Reassurance and Reorientation

      Acute delirium is a common condition that can be caused by various factors, including sepsis, metabolic problems, hypoxia, intracranial vascular insults, and toxins. When assessing a patient with acute delirium, it is crucial to exclude life-threatening or reversible causes through a thorough history, clinical examination, and appropriate investigations.

      In the case of Mrs Smith, who has new confusion with preserved consciousness, there is no evidence of acute clinical illness, and she is receiving appropriate treatment for a urinary tract infection. Therefore, the most appropriate management is to nurse her in a well-lit environment with frequent reassurance and reorientation. Sedating medication, such as lorazepam or haloperidol, should only be considered as a last resort if the patient is at risk of harm due to delirium.

      It is not necessary to arrange an urgent CT head or a full septic screen unless there are specific indications. Instead, optimizing the patient’s environment can help resolve delirium and improve outcomes. By following these guidelines, healthcare professionals can effectively manage acute delirium in patients like Mrs Smith.

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  • Question 56 - A 57-year-old man is admitted to the Intensive Care Unit (ICU) with acute...

    Incorrect

    • A 57-year-old man is admitted to the Intensive Care Unit (ICU) with acute pancreatitis caused by excessive alcohol consumption. His abdominal sepsis is complicated by multi-organ failure. He is currently receiving mechanical ventilation, inotropic support, and continuous haemodialysis in the ICU. What evidence-based strategies have been shown to decrease mortality in cases of sepsis?

      Your Answer:

      Correct Answer: Maintenance of the patient’s blood sugar level between 4.4 and 6 mmol/l

      Explanation:

      Critical Care Management Strategies

      Maintaining the patient’s blood sugar level between 4.4 and 6 mmol/l is crucial in critical care management. Stress and severe illness can reduce insulin secretion, leading to hyperglycemia. Intravenous infusion of short-acting insulin is recommended to achieve this goal. However, in some cases, a range of 5-9 mmol/l may be necessary.

      Blood transfusion to maintain a haemoglobin level above 100 g/l is not recommended in critically ill patients. Studies show that it does not improve patient outcomes and may lead to potential complications. A haemoglobin level of 70-90 g/l is considered acceptable in the absence of ischaemic heart disease.

      High-dose steroids are not routinely recommended in septic shock management. However, they may be considered in patients with increasing vasopressor requirements and failure of other therapeutic strategies. Low-dose steroids have also not shown significant reduction in mortality rates.

      Nursing the patient semi-recumbent (sitting at 30-45 degrees) instead of completely flat is recommended to reduce the risk of ventilator-associated pneumonia. This position helps to prevent aspiration and promotes better lung function.

      Critical Care Management Strategies for Patients in ICU

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  • Question 57 - A 75-year-old is brought to the Emergency Department after being found at home...

    Incorrect

    • A 75-year-old is brought to the Emergency Department after being found at home on the floor by her daughter. Her daughter tried to rouse her but had no response. She has a laceration to her head and her daughter believes she may have had a fall. You notice she has a sudden decrease in consciousness in the department. You are unable to get the patient to make any vocalisation. When you apply supraorbital pressure, she briefly opens her eyes and withdraws from the pain.
      Which one of the following is the best immediate management option for this patient?

      Your Answer:

      Correct Answer: Insert Guedel airway

      Explanation:

      Management of a Patient with Low Glasgow Coma Scale Score

      The Glasgow Coma Scale (GCS) is a tool used to assess the level of consciousness in patients. A patient with a GCS score below 8 requires urgent referral to critical care or the anaesthetist on-call for appropriate management. In this case, the patient has a GCS score of 7 (E2, V1, M4) and needs immediate attention.

      Airway management is the top priority in patients with a low GCS score. The patient may need invasive ventilation if they lose the capacity to maintain their own airway. Once the airway is secured, a referral to the neurosurgical registrar may be necessary, and investigations such as a CT brain scan should be carried out to determine the cause of the low GCS score.

      A neurological observation chart is also needed to detect any deteriorating central nervous system function. A medication review can be done once the patient is stabilised and an intracranial bleed has been ruled out. This will help identify medications that could cause a fall and stop unnecessary medication.

      In summary, a patient with a low GCS score requires urgent attention to secure their airway, determine the cause of the low score, and monitor for any neurological deterioration. A medication review can be done once the patient is stable.

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  • Question 58 - A 31-year-old man presents to the Emergency Department, appearing ill at 2300 after...

    Incorrect

    • A 31-year-old man presents to the Emergency Department, appearing ill at 2300 after consuming 'a few handfuls' of paracetamol tablets. Upon further inquiry, it is revealed that this occurred at approximately 1400 and the patient weighs 80 kgs.
      What is the initial step that should be taken?

      Your Answer:

      Correct Answer: Intravenous (IV) N-acetylcysteine (NAC) STAT

      Explanation:

      Treatment for Paracetamol Overdose: NAC, Naloxone, and Activated Charcoal

      Paracetamol overdose is a serious medical emergency that requires immediate treatment. The mainstay of treatment is intravenous (IV) N-acetylcysteine (NAC), which replenishes depleted glutathione reserves in the liver and protects liver cells from NAPQI toxicity. NAC should be started if the overdose occurred less than 10-12 hours ago, there is no vomiting, and the plasma paracetamol level is above the concentration on the treatment line. If the overdose occurred more than 8-24 hours ago and there is suspicion of a large overdose, it is best to start NAC and stop if plasma paracetamol levels fall below the treatment line and if INR/ALT return to normal. Naloxone is the mainstay of treatment for opioid overdose, while activated charcoal may play a role in gastrointestinal decontamination in a patient presenting less than 4 hours since an overdose. It is important to monitor observations and treat if deterioration occurs. A plasma paracetamol measurement should be taken to direct treatment, with NAC treatment started immediately if the time of ingestion is more than 8 hours ago and the amount ingested is likely to be more than 75 mg/kg. If the time of ingestion is within 8 hours, the paracetamol level should be checked first and treatment guided accordingly.

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  • Question 59 - A 55-year-old woman is admitted unresponsive to the Emergency Department. She is not...

    Incorrect

    • A 55-year-old woman is admitted unresponsive to the Emergency Department. She is not breathing and has no pulse. The ambulance crew had initiated cardiopulmonary resuscitation before arrival. She is known to have hypertension and takes ramipril.
      She had routine bloods at the General Practice surgery three days ago:
      Investigation Result Normal value
      Haemoglobin (Hb) 134 g/l 115–155 g/l
      White cell count (WCC) 3.5 × 109/l 4–11 × 109/l
      Sodium (Na+) 134 mmol/l 135–145 mmol/l
      Potassium (K+) 6.1 mmol/l 3.5–5.0 mmol/l
      Urea 9.3 mmol/l 2.5–6.5 mmol/l
      Creatinine (Cr) 83 µmol/l 50–120 µmol/l
      Estimated glomerular filtration rate (eGFR) > 60
      The Ambulance Crew hand you an electrocardiogram (ECG) strip which shows ventricular fibrillation (VF).
      What is the most likely cause of her cardiac arrest?

      Your Answer:

      Correct Answer: Hyperkalaemia

      Explanation:

      Differential Diagnosis for Cardiac Arrest: Hyperkalaemia as the Most Likely Cause

      The patient’s rhythm strip shows ventricular fibrillation (VF), which suggests hyperkalaemia as the most likely cause of cardiac arrest. The blood results from three days ago and the patient’s medication (ramipril) support this diagnosis. Ramipril can increase potassium levels, and the patient’s K+ level was already high. Therefore, it is recommended to suspend ramipril until the K+ level comes down.

      Other potential causes of cardiac arrest were considered and ruled out. There is no evidence of hypernatraemia, hypovolaemia, or hypoxia in the patient’s history or blood results. While pulmonary thrombus cannot be excluded, it is unlikely to result in VF arrest and usually presents as pulseless electrical activity (PEA).

      In summary, hyperkalaemia is the most likely cause of the patient’s cardiac arrest, and appropriate measures should be taken to manage potassium levels.

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  • Question 60 - A 19-year-old man is brought to the Emergency Department with a swollen face...

    Incorrect

    • A 19-year-old man is brought to the Emergency Department with a swollen face and lips, accompanied by wheeze after being stung by a bee. He is experiencing breathing difficulties and has a blood pressure reading of 83/45 mmHg from a manual reading. What is the next course of action?

      Your Answer:

      Correct Answer: Give 1 : 1000 intramuscular (im) adrenaline and repeat after 5 min if no improvement

      Explanation:

      Treatment for Anaphylaxis

      Anaphylaxis is a severe and life-threatening medical emergency that requires immediate treatment. The following are the appropriate steps to take when dealing with anaphylaxis:

      Administer 1 : 1000 intramuscular (IM) adrenaline and repeat after 5 minutes if there is no improvement. Adrenaline should not be given intravenously unless the person administering it is skilled and experienced in its use. Routine use of IV adrenaline is not recommended.

      Administer IV fluids if anaphylactic shock occurs to maintain the circulatory volume. Salbutamol nebulizers may help manage associated wheezing.

      Do not give IV hydrocortisone as it takes several hours to work and anaphylaxis is rapidly life-threatening.

      Do not observe the person as anaphylaxis may progress quickly.

      Do not give 1 : 10 000 IV adrenaline as this concentration is only given during a cardiac arrest.

      In summary, the immediate administration of 1 : 1000 IM adrenaline is the most critical step in treating anaphylaxis. IV adrenaline and hydrocortisone should only be given by skilled and experienced individuals. IV fluids and salbutamol nebulizers may also be used to manage symptoms.

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  • Question 61 - A 54-year-old woman presents to her General Practitioner (GP) with a 1-week history...

    Incorrect

    • A 54-year-old woman presents to her General Practitioner (GP) with a 1-week history of productive cough and fever. She has had no sick contacts or foreign travel. She has a background history of mild intermittent asthma and is a non-smoker. She has been taking paracetamol and salbutamol. On clinical examination, her respiratory rate is 16 breaths per minute, oxygen saturations 96% (on room air), blood pressure 136/82 mmHg and temperature 38.2 °C. On chest auscultation, there is mild expiratory wheeze and coarse crackles in the right lung base.
      What is the most appropriate management of this woman?

      Your Answer:

      Correct Answer: Prescribe amoxicillin 500 mg three times daily for five days

      Explanation:

      Management of Community-Acquired Pneumonia in a Woman with a CRB-65 Score of 0

      When managing a woman with community-acquired pneumonia (CAP) and a CRB-65 score of 0, the recommended treatment is amoxicillin 500 mg three times daily for five days. If there is no improvement after three days, the duration of treatment should be extended to seven to ten days.

      If the CRB-65 score is 1 or 2, dual therapy with amoxicillin 500 mg three times daily and clarithromycin 500 mg twice daily for 7-10 days, or monotherapy with doxycycline for 7-10 days, should be considered. However, in this case, the CRB-65 score is 0, so this is not necessary.

      Admission for intravenous (IV) antibiotics and steroids is not required for this woman, as she is relatively well with mild wheeze and a CRB-65 score of 0. A chest X-ray is also not necessary, as she is younger and a non-smoker.

      Symptomatic management should be continued, and the woman should be advised to return in three days if there is no improvement. It is important to prescribe antibiotics for people with suspected CAP, unless this is not appropriate, such as in end-of-life care.

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  • Question 62 - A 68 year old homeless man is brought into the Emergency Department with...

    Incorrect

    • A 68 year old homeless man is brought into the Emergency Department with acute confusion. The patient is unable to provide a history and is shivering profusely. Physical examination reveals a body temperature of 34.5oC.
      Regarding thermoregulation, which of the following statements is accurate?

      Your Answer:

      Correct Answer: Acclimatisation of the sweating mechanism occurs in response to heat

      Explanation:

      Understanding Heat Adaptation and Thermoregulation in Humans

      Humans have the unique ability to actively acclimatize to heat stress through adaptations in the sweating mechanism. This process involves an increase in the sweating capability of the glands, which helps to lower body core temperatures. Heat adaptation begins on the first day of exposure and typically takes 4-7 days to develop in most individuals, with complete adaptation taking around 14 days.

      While brown fat plays a significant role in non-shivering thermogenesis in newborns and infants, there are very few remnants of brown fat in adults. Instead, thermoregulation is mainly controlled by the hypothalamus, which is responsible for regulating body temperature and other vital functions.

      Although apocrine sweat glands have little role in thermoregulation, they still play an important role in heat loss by evaporation. Overall, understanding heat adaptation and thermoregulation in humans is crucial for maintaining optimal health and preventing heat-related illnesses.

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  • Question 63 - Your consultant asks you to monitor a 93-year-old woman on a General Medical...

    Incorrect

    • Your consultant asks you to monitor a 93-year-old woman on a General Medical Ward admitted with a lower respiratory tract infection who the nurses say becomes really confused at night. She scores 28/30 on Mini-Mental State Examination (MMSE) on two occasions in the daytime. Between these two results, on a night when you are on call, you completed the examination and found she scored only 18/30. She also complained of animals running around the room.
      What is the most likely reason for her cognitive impairment?

      Your Answer:

      Correct Answer: Delirium

      Explanation:

      Interpreting MMSE Scores and Differential Diagnosis for Confusion in an Elderly Patient

      A MMSE score of 28/30 suggests no significant cognitive impairment, while a score of 18/30 indicates impairment. However, educational attainment can affect results, and the MMSE is not recommended for those with learning disabilities. Fluctuating confusion with increased impairment at night and visual hallucinations in an elderly person with an infection suggests delirium. Mild or moderate dementia is suggested if the MMSE score is over 26 in the daytime on two occasions, but confusion is at night, suggestive of delirium over dementia. Normal pressure hydrocephalus is unlikely without ataxic gait or urinary incontinence, and cerebral abscess is unlikely without persistent confusion or temperature.

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  • Question 64 - A 7-year-old girl was brought to the Emergency Department by her parents. Her...

    Incorrect

    • A 7-year-old girl was brought to the Emergency Department by her parents. Her lips were swollen; she had stridor and was short of breath, and she was sweaty and clammy. She has a known allergy to shellfish and had eaten some seafood at a family gathering.
      What is the appropriate course of action?

      Your Answer:

      Correct Answer: 300 mcg of 1 : 1000 adrenaline im

      Explanation:

      Correct Doses and Administration of Adrenaline for Anaphylaxis

      Adrenaline is a crucial medication for treating anaphylaxis, and it is always administered intramuscularly (im) at a concentration of 1:1000. However, it is essential to know the correct doses and volumes for different age groups, as vials can vary.

      For adults and children over 12 years old, the appropriate dose is 500 mcg or 0.5 ml. For children aged 6-12 years, the correct dose is 300 mcg or 0.3 ml. For children under 6 years old, the recommended dose is 150 mcg or 0.15 ml.

      It is crucial to administer the correct dose for the patient’s age and weight to avoid adverse effects. Additionally, it is essential to administer adrenaline im and not intravenously (iv) to prevent complications. By following these guidelines, healthcare providers can ensure safe and effective treatment of anaphylaxis with adrenaline.

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  • Question 65 - A 35-year-old patient arrives by ambulance after developing breathing difficulties. She is otherwise...

    Incorrect

    • A 35-year-old patient arrives by ambulance after developing breathing difficulties. She is otherwise healthy but had recently been prescribed amoxicillin by her doctor for a lower respiratory tract infection.
      During examination, she is unable to speak and has harsh upper airway sounds on inspiration. She also has a noticeable rash. Her pulse is 160 bpm and her blood pressure is 80/40. Her oxygen saturation is 90% on high-flow oxygen.
      What is the initial step in managing this patient?

      Your Answer:

      Correct Answer: Administer 0.5 ml of 1 : 1000 adrenaline solution intramuscularly (im)

      Explanation:

      Management of Anaphylaxis: Initial Steps and Common Mistakes

      Anaphylaxis is a life-threatening emergency that requires prompt and appropriate management. The initial steps in managing anaphylaxis follow the ABCDE approach, which includes securing the airway, administering high-flow oxygen, and giving adrenaline intramuscularly (IM). The recommended dose of adrenaline is 0.5 ml of 1 : 1000 solution, which can be repeated after 5 minutes if necessary. However, administering adrenaline via the intravenous (IV) route should only be done during cardiac arrest or by a specialist experienced in its use for circulatory support.

      While other interventions such as giving a 500-ml bolus of 0.9% sodium chloride IV, administering 10 mg of chlorphenamine IV, and administering 200 mg of hydrocortisone IV are important parts of overall management, they should not be the first steps. Giving steroids, such as hydrocortisone, may take several hours to take effect, and anaphylaxis can progress rapidly. Similarly, administering IV fluids and antihistamines may be necessary to treat hypotension and relieve symptoms, but they should not delay the administration of adrenaline.

      One common mistake in managing anaphylaxis is administering IV adrenaline in the wrong dose and route. This can lead to fatal complications and should be avoided. Therefore, it is crucial to follow the recommended initial steps and seek expert help if necessary to ensure the best possible outcome for the patient.

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  • Question 66 - A 21-year-old woman is referred to the Emergency Department by her General Practitioner...

    Incorrect

    • A 21-year-old woman is referred to the Emergency Department by her General Practitioner (GP) with a 4-day history of right flank pain, dysuria and fever. Urosepsis is suspected, and the Sepsis Six Pathway is implemented in the Emergency Department.
      Which of the following is part of the ‘Sepsis Six’, the six key components to managing sepsis?

      Your Answer:

      Correct Answer: Intravenous (IV) fluids

      Explanation:

      Treatment Options for Sepsis: IV Fluids, Corticosteroids, Antipyretics, and More

      Sepsis is a life-threatening condition that requires immediate treatment. The following are some of the treatment options available for sepsis:

      IV Fluids: The National Institute for Health and Care Excellence (NICE) recommends giving an IV fluid bolus without delay for suspected sepsis. Reassess the patient after completion of the IV fluid bolus, and if no improvement is observed, give a second bolus.

      Corticosteroids: In patients with septic shock, corticosteroid therapy appears to be safe but does not reduce 28-day all-cause mortality rates. It does, however, significantly reduce the incidence of vasopressor-dependent shock. Low-quality evidence indicates that steroids reduce mortality among patients with sepsis.

      Antipyretics: Treating sepsis is the most important immediate treatment plan. This will also reduce fever, although Antipyretics can be given in conjunction with this treatment, it will not reduce mortality.

      Maintain Blood Glucose 8–12 mmol/l: Measuring blood glucose on venous blood gas is important, as sepsis may cause hypo- or hyperglycaemia, which may require treatment. However, maintaining blood glucose between 8 and 12 mmol/l is not an evidence-based intervention and could cause iatrogenic hypo- and hyperglycaemia.

      Avoid Oxygen Therapy Unless Severe Hypoxia: Give oxygen to achieve a target saturation of 94−98% for adult patients or 88−92% for those at risk of hypercapnic respiratory failure.

      Treatment Options for Sepsis: What You Need to Know

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  • Question 67 - A 25-year-old woman arrives at the Emergency Department in a very unwell state....

    Incorrect

    • A 25-year-old woman arrives at the Emergency Department in a very unwell state. She reports having had the flu for the past few days and is having difficulty keeping anything down. She feels weak, drowsy, and disoriented, and experiences dizziness upon standing. Upon observation, you note that she is tachycardic and hypotensive and has a fever. She informs you that she only takes hydrocortisone 20 mg orally (PO) once daily for Addison's disease. What is the most crucial management step in this case?

      Your Answer:

      Correct Answer: Give 100 mg hydrocortisone IM STAT

      Explanation:

      When a patient experiences an Addisonian crisis, the first-line treatment is to administer 100 mg of hydrocortisone intramuscularly. It is important for patients with Addison’s disease to carry an autoinjector in case of emergencies. After administering hydrocortisone, fluid resuscitation should be carried out, and glucose may be added if the patient is hypoglycemic. Fludrocortisone may be used if the crisis is caused by adrenal disease. Oral hydrocortisone should not be given if the patient is vomiting. In cases of hypoglycemia, hydrocortisone should be given before glucose gel. Blood tests should be carried out urgently, and IV fluids may be necessary. Fludrocortisone may be given after hydrocortisone if the cause is adrenal disease.

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  • Question 68 - A 5-year-old boy is brought to the Emergency Department with symptoms of lethargy,...

    Incorrect

    • A 5-year-old boy is brought to the Emergency Department with symptoms of lethargy, high fever, and headache. During examination, he presents with neck stiffness and a rash. When should the communicable disease consultant (CDC) be notified?

      Your Answer:

      Correct Answer: Clinical diagnosis

      Explanation:

      Management of Suspected Meningococcal Meningitis: Importance of Early Diagnosis and Treatment

      This article discusses the management of suspected meningococcal meningitis, a serious and potentially life-threatening condition caused by Neisseria meningitidis. Early diagnosis and treatment are crucial to prevent complications and contain the spread of the disease.

      Clinical Diagnosis
      The classic triad of symptoms associated with meningococcal meningitis includes fever, headache, and meningeal signs, usually in the form of neck stiffness. A non-blanching rash is also a common feature. Medical practitioners have a statutory obligation to notify Public Health England on clinical suspicion of meningococcal meningitis and septicaemia, without waiting for microbiological confirmation.

      Upon Microbiological Diagnosis
      Delay in notifying the communicable disease consultant of a suspected case of meningococcal meningitis can lead to a delay in contact tracing and outbreak management. Upon culture and isolation, the patient should be administered a stat dose of intramuscular or intravenous benzylpenicillin. Samples should be obtained before administration of antibiotics, including blood for cultures and PCR, CSF for microscopy, culture, and PCR, and nasopharyngeal swab for culture. The patient should be kept in isolation, Public Health England notified, and contacts traced.

      Upon Treatment
      Early treatment with intramuscular or intravenous benzylpenicillin is essential to prevent complications and reduce mortality. Treatment should be administered at the earliest opportunity, either in primary or secondary care.

      After Discharge
      Alerting the communicable disease consultant after discharge is too late to track and treat other individuals at risk. Therefore, it is crucial to notify Public Health England and trace contacts as soon as a suspected case of meningococcal meningitis is identified.

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  • Question 69 - A 42-year-old man is pulled from the water onto the shore by lifeguards...

    Incorrect

    • A 42-year-old man is pulled from the water onto the shore by lifeguards after being seen struggling in strong currents. He was underwater for six minutes before being rescued. As a bystander on the beach, you assist in the resuscitation efforts while waiting for the ambulance. The man is unconscious and not breathing. You open his airway.
      What is the next best course of action in attempting to revive this individual?

      Your Answer:

      Correct Answer: Give five rescue breaths before commencing chest compressions

      Explanation:

      The Importance of Bystander CPR in Drowning Patients

      Drowning patients are at high risk of hypoxia and require immediate intervention. Bystander CPR is crucial in these cases, and it is recommended to give five initial rescue breaths, supplemented with oxygen if available. If the victim does not respond, chest compressions should be started at a rate of 100-120 per minute, with two rescue breaths given for every 30 compressions. Continuous chest compressions are essential for cerebral circulation during cardiac arrest, and rescue breaths should be given until the ambulance arrives. Compression-only CPR is likely to be ineffective in drowning patients and should be avoided. Remember, early intervention can save lives in drowning cases.

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      • Acute Medicine And Intensive Care
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  • Question 70 - You are the on-call general practitioner and are called urgently to the nurses’...

    Incorrect

    • You are the on-call general practitioner and are called urgently to the nurses’ room where a 6-year-old boy receiving his school vaccinations has developed breathing difficulties. The child has swollen lips and is covered in a blotchy rash; respiratory rate is 40, heart rate is 140 and there is a wheeze audible without using a stethoscope.
      After lying the patient flat and raising his legs, what immediate action is required?

      Your Answer:

      Correct Answer: Administer 150 micrograms of adrenaline intramuscularly (im)

      Explanation:

      Anaphylaxis Management: Administering Adrenaline

      Anaphylaxis is a severe and life-threatening hypersensitivity reaction that requires immediate management. The Resuscitation Council guidelines outline three essential criteria for recognizing anaphylaxis: sudden-onset, rapidly progressive symptoms, life-threatening Airway/Breathing/Circulation problems, and skin and mucosal changes.

      The first step in anaphylaxis management is to administer adrenaline intramuscularly (im) at a dilution of 1:1000. The appropriate dosage for adrenaline administration varies based on the patient’s age. For a 4-year-old patient, the recommended dose is 150 micrograms im. However, adrenaline iv should only be administered by experienced specialists and is given at a dose of 50 micrograms in adults and 1 microgram/kg in children and titrated accordingly.

      Adrenaline administration is only the first step in the treatment of anaphylaxis. It is crucial to follow the anaphylaxis algorithm, which includes establishing the airway and giving high-flow oxygen, iv fluid challenge, and chlorphenamine.

      It is essential to note that administering an incorrect dose of adrenaline can be dangerous. For instance, administering 1 mg of adrenaline im is inappropriate for the management of anaphylaxis. Therefore, it is crucial to follow the Resuscitation Council guidelines and administer the appropriate dose of adrenaline based on the patient’s age.

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  • Question 71 - A 65-year-old patient presents with acute severe abdominal pain and the following blood...

    Incorrect

    • A 65-year-old patient presents with acute severe abdominal pain and the following blood results:
      Investigation Result Normal value
      Haemoglobin 130 g/l
      Female: 115–155 g/l
      Male: 135–175 g/l
      White cell count (WCC) 18 × 109/l 4–11 × 109/l
      Sodium (Na+) 142 mmol/l 135–145 mmol/l
      Potassium (K+) 4.2 mmol/l 3.5–5.0 mmol/l
      Urea 22 mmol/l 2.5–6.5 mmol/l
      Creatinine 95 μmol/l 50–120 μmol/l
      Calcium 1.9 mmol/l 2.20–2.60 mmol/l
      Lactate Dehydrogenase (LDH) 800 IU/l 50–120 IU/l
      Albumin 30 g/l 35–50 g/l
      Amylase 1600 U/l < 200 U/l
      What is the most appropriate transfer location for ongoing care?

      Your Answer:

      Correct Answer: Intensive care as an inpatient

      Explanation:

      Appropriate Management of Acute Pancreatitis: A Case Study

      A patient presents with acutely raised amylase, high white cell count (WCC), and high lactate dehydrogenase (LDH), indicating acute pancreatitis or organ rupture. The Glasgow system suggests severe pancreatitis with a poor outcome. In this case study, we explore the appropriate management options for this patient.

      Intensive care as an inpatient is the most appropriate response, as the patient is at high risk for developing multi-organ failure. The modified Glasgow score is used to assess the severity of acute pancreatitis, and this patient meets the criteria for severe pancreatitis. Aggressive support in an intensive care environment is necessary.

      Discharge into the community and general practitioner review in 1 week would be a dangerous response, as the patient needs inpatient treatment and acute assessment and treatment. The same applies to general surgical outpatient review in 1 week.

      Operating theatre would be inappropriate, as no operable problem has been identified. Supportive management is the most likely course of action. If organ rupture is suspected, stabilisation of shock and imaging would likely be done first.

      General medical ward as an inpatient is not the best option, as acute pancreatitis is a surgical problem and should be admitted under a surgical team. Additionally, the patient’s deranged blood tests, especially the low calcium and high WCC, indicate a high risk of developing multi-organ failure, requiring intensive monitoring.

      In conclusion, appropriate management of acute pancreatitis requires prompt and aggressive support in an intensive care environment, with close monitoring of the patient’s condition.

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  • Question 72 - A 70-year-old man with a history of hypertension, coronary artery disease and depression...

    Incorrect

    • A 70-year-old man with a history of hypertension, coronary artery disease and depression underwent bypass surgery last night. His depression has responded well to selective serotonin reuptake inhibitors (SSRIs) and there is no past history of psychosis. His blood pressure is also well controlled with medications. The following morning, he develops confusion, agitation and irritability, tries to remove his intravenous (iv) lines and wants to run away from hospital. His level of consciousness fluctuates, and at times he forgets who he is. He is given a neuroleptic drug and appears much improved.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Delirium

      Explanation:

      Differentiating Delirium from Other Psychiatric Disorders in Postoperative Patients

      Delirium is a common complication that can occur after surgery and general anesthesia. It is characterized by acute changes in mental status, including waxing and waning levels of consciousness, agitation, irritability, and psychosis. While delirium is self-limited and can be managed with low-dose neuroleptics, it is important to differentiate it from other psychiatric disorders that may present with similar symptoms.

      Schizophrenia, for example, typically presents with delusions, hallucinations, and bizarre behavior, and tends to start at a younger age than the acute symptoms seen in postoperative patients. It is also characterized by a progressive deterioration in functioning. Adjustment disorder, on the other hand, can result from any psychosocial or biological stressor, and may present with anxiety, irritability, and depressive mood. However, fluctuating levels of consciousness are not typically seen in this disorder.

      Dementia can also present with irritability, confusion, and agitation, but it follows an insidious course and does not have a fluctuating course like delirium. Finally, severe depression can present with psychotic features, suicidal ideation, and irritability, but the patient’s history of good response to SSRIs and lack of prior history of psychosis can help differentiate it from delirium.

      In summary, while delirium is a common complication of surgery and anesthesia, it is important to consider other psychiatric disorders that may present with similar symptoms in order to provide appropriate management and treatment.

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  • Question 73 - A 25-year-old woman is admitted to the Emergency Department with vomiting. She has...

    Incorrect

    • A 25-year-old woman is admitted to the Emergency Department with vomiting. She has vague abdominal pain, and a particularly keen junior surgeon takes her to theatre for an appendectomy; the appendix is removed and is normal. In recovery, she becomes hypotensive and tachycardic and does not respond as expected to fluid replacement. On examination, she is very well tanned and slim; her blood pressure is 90/65 mmHg, with a pulse rate of 100 bpm.
      Investigations:
      Investigation Result Normal value
      Potassium (K+) 6.2 mmol/l 3.5–5.0 mmol/l
      Sodium (Na+) 127 mmol/l 135–145 mmol/l
      Urea 9.1 mmol/l 2.5–6.5 mmol/l
      Creatinine 165 μmol/l 50–120 µmol/l
      Haemoglobin 98 g/l (normochromic normocytic) 115–155 g/l
      Free T4 6.2 pmol/l (low) 11–22 pmol/l
      Which of the following fits best with this clinical scenario?

      Your Answer:

      Correct Answer: iv hydrocortisone is the initial treatment of choice

      Explanation:

      The recommended initial treatment for patients experiencing an adrenal crisis is intravenous hydrocortisone. This is because the adrenal glands are not producing enough cortisol, which can lead to severe adrenal insufficiency. The most common causes of an adrenal crisis include undiagnosed adrenal insufficiency with associated major stress, abrupt cessation of glucocorticoid therapy, and bilateral infarction of the adrenal glands. Symptoms of an adrenal crisis can include hyperkalemia, hyponatremia, renal impairment, and normochromic normocytic anemia, as well as non-specific symptoms such as vomiting, abdominal pain, weakness, fever, and lethargy. The patient’s tan may be due to increased melanocyte activity caused by raised levels of adrenocorticotrophic hormone. Intravenous T3 replacement may be effective in treating the patient’s low free T4 levels, which are likely a result of adrenal insufficiency. Fluid replacement alone will not be sufficient to treat the patient’s shock, which is the main manifestation of an adrenal crisis. Normochromic normocytic anemia can be treated with corticosteroid replacement, and the patient’s deranged renal function is likely a result of sepsis.

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  • Question 74 - A 65-year-old woman, whose children called for an ambulance due to concerns about...

    Incorrect

    • A 65-year-old woman, whose children called for an ambulance due to concerns about her breathing, has an arterial blood gas (ABG) test done. She is a frequent visitor to the Accident and Emergency department and has been experiencing a cough and producing green sputum for the past 6 days. She is currently receiving long-term oxygen therapy (LTOT) at home. While on controlled oxygen therapy through a Venturi system, her ABG results are as follows:
      Investigation Result Normal value
      pH 7.232 7.35–7.45
      CO2 8.9 kPa 3.5–4.5 kPa
      O2 9.4 kPa 8.0–10.0 kPa
      HCO3– 33 mmol/l 22.0–28.0 mmol/l
      SaO2 89%
      Lactate 2.1 0.1–2.2
      Which of the following statements best describes this ABG?

      Your Answer:

      Correct Answer: Respiratory acidosis with partial metabolic compensation

      Explanation:

      Interpreting ABGs: Examples of Acid-Base Imbalances

      Acid-base imbalances can be identified through arterial blood gas (ABG) analysis. Here are some examples of ABGs and their corresponding acid-base imbalances:

      Respiratory acidosis with partial metabolic compensation
      This ABG indicates a patient with long-term chronic obstructive pulmonary disease (COPD) who has chronic carbon dioxide (CO2) retention and partial metabolic compensation (elevated bicarbonate (HCO3)). However, during an infective exacerbation of COPD, the patient’s hypoxia and hypercapnia worsened, resulting in a more severe acidaemia. The metabolic compensation is therefore only partial.

      Respiratory acidosis with complete metabolic compensation
      This ABG shows respiratory acidosis with a low pH due to CO2 retention. Despite some metabolic compensation, this is an acute-on-chronic change that has led to a worsening of the acidaemia.

      Metabolic acidosis with partial respiratory compensation
      In this ABG, a patient with chronic COPD who has presented with an infective exacerbation shows respiratory acidosis with partial metabolic compensation.

      Metabolic alkalosis with respiratory compensation
      This ABG indicates acidaemia due to a chronic respiratory disease.

      Respiratory acidosis without compensation
      Although this ABG shows respiratory acidosis, there is an element of metabolic compensation, as evidenced by the rise in HCO3.

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  • Question 75 - A 72-year-old woman is brought to the Emergency Department from a nursing home...

    Incorrect

    • A 72-year-old woman is brought to the Emergency Department from a nursing home with confusion, fever and flank pain. Her temperature is 38.5 °C, blood pressure 82/48 mmHg, pulse rate 123 bpm and respiration rate 27 breaths per minute. Physical examination reveals dry mucous membranes and flank tenderness. Urinalysis shows 50–100 leukocytes and many bacteria per high-powered field.
      Which of the following is most likely to improve survival for this patient?

      Your Answer:

      Correct Answer: Aggressive fluid resuscitation

      Explanation:

      The Importance of Timing in Fluid Resuscitation for Severe Sepsis: Debunking Myths about Haemodynamic Monitoring, Albumin Infusion, and Haemoglobin Levels

      When it comes to treating severe sepsis, timing is crucial. Aggressive fluid resuscitation within the first six hours can significantly improve a patient’s chances of survival. This was demonstrated in a landmark study by Rivers and colleagues, which found that early goal-directed therapy resulted in higher survival rates than delayed resuscitation attempts.

      However, not all interventions are equally effective. Haemodynamic monitoring with a pulmonary artery catheter, for example, has not been shown to increase survival in septic patients. Similarly, there is no evidence that albumin infusion reduces mortality, and in fact, some studies have shown increased mortality rates in patients who received albumin solutions.

      Maintaining a haemoglobin level above 120 g/l is also not supported by evidence. While giving blood may be part of resuscitation for anaemic patients in shock, aiming for a specific haemoglobin level is not necessary.

      Finally, there is no data to support the idea that maintaining a lower Pa(CO2) would increase survival in septic patients. In summary, aggressive fluid resuscitation within the first six hours is crucial for treating severe sepsis, but not all interventions are equally effective or supported by evidence.

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  • Question 76 - You are on call overnight on orthopaedics when you receive a bleep to...

    Incorrect

    • You are on call overnight on orthopaedics when you receive a bleep to see a patient you are not familiar with. The patient had a left total hip replacement procedure 2 days ago and is now exhibiting signs of drowsiness and confusion. Upon examination, you observe that the patient is tachycardic, and an electrocardiogram (ECG) shows peaked T-waves and a wide QRS complex. You decide to take an arterial blood gas (ABG) which reveals a potassium level of 6.4 mmol (normal 5–5.0 mmol/l). What would be the most appropriate initial management action for this patient?

      Your Answer:

      Correct Answer: Give 10 ml of 10% calcium gluconate by slow intravenous (IV) injection

      Explanation:

      Managing Hyperkalaemia: Treatment Options and Considerations

      Hyperkalaemia is a life-threatening condition that requires immediate management. The first step is to administer 10 ml of 10% calcium gluconate by slow IV injection to protect the cardiac myocytes from excess potassium. Following this, 10 units of Actrapid® in 100 ml of 20% glucose can be given to draw potassium intracellularly. Salbutamol nebulisers may also be helpful. Calcium resonium 15g orally or 30 g rectally can be used to mop up excess potassium in the gastrointestinal tract, but it is not effective in the acute setting.

      It is important to note that this condition requires urgent attention and cannot wait for a registrar to arrive. Once the patient is stabilised, senior support may be called for.

      It is crucial to administer the correct dosage and concentration of medications. Giving 50 ml of 15% calcium gluconate by slow IV injection is not the correct volume and concentration. Careful consideration and attention to detail are necessary in managing hyperkalaemia.

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  • Question 77 - An 83-year-old man is brought to the Emergency Department after being discovered in...

    Incorrect

    • An 83-year-old man is brought to the Emergency Department after being discovered in an acute state of confusion. He was lethargic and combative, attempting to strike his caregiver when she visited his home earlier that day. He has a history of chronic obstructive pulmonary disease (COPD) and continues to smoke 20 cigarettes per day, and is currently undergoing testing for prostatism. Upon examination, he has a fever of 38.2 °C and exhibits coarse crackles and wheezing in both lungs upon auscultation.

      Investigations:
      Investigation Result Normal value
      Haemoglobin 121 g/l 135–175 g/l
      White cell count (WCC) 14.2 × 109/l 4–11 × 109/l
      Platelets 231 × 109/l 150–400 × 109/l
      Sodium (Na+) 128 mmol/l 135–145 mmol/l
      Potassium (K+) 4.4 mmol/l 3.5–5.0 mmol/l
      Creatinine 120 μmol/l 50–120 µmol/l
      Urine Blood +

      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Lower respiratory tract infection

      Explanation:

      Possible Infections and Conditions in an Elderly Man: Symptoms and Management

      An elderly man is showing signs of confusion and has a fever, which could indicate an infection. Upon chest examination, crackles are heard, suggesting a lower respiratory tract infection. A high white blood cell count also supports an immune response to an infection. A chest X-ray may confirm the diagnosis. Antibiotic therapy is the main treatment, and fluid restriction may be necessary if the patient has low sodium levels.

      If an elderly man’s dementia worsens, a fever and high white blood cell count may suggest an infection as the cause. Diabetes insipidus, characterized by excessive thirst and urination, typically leads to high sodium levels due to dehydration. A urinary tract infection may cause confusion, but it often presents with urinary symptoms. Viral encephalitis may cause confusion and fever, but the presence of crackles and wheezing suggests a respiratory infection.

      In summary, an elderly man with confusion and fever may have a lower respiratory tract infection, which requires antibiotic therapy and fluid management. Other conditions, such as worsening dementia, diabetes insipidus, urinary tract infection, or viral encephalitis, may have similar symptoms but different diagnostic features and treatments.

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  • Question 78 - You are asked by nursing staff to review a pediatric patient in recovery...

    Incorrect

    • You are asked by nursing staff to review a pediatric patient in recovery overnight. As you arrive, the nurse looking after the patient informs you that she is just going to get a bag of fluid for him. On examination, the patient is unresponsive with an obstructed airway (snoring). You notice on the monitor that his heart rate is 33 bpm and blood pressure 89/60 mmHg. His saturation probe has fallen off.
      What is your first priority?

      Your Answer:

      Correct Answer: Call for help and maintain the airway with a jaw thrust and deliver 15 l of high-flow oxygen

      Explanation:

      Managing a Patient with Bradycardia and Airway Obstruction: Priorities and Interventions

      When faced with a patient who is unresponsive and has both an obstructed airway and bradycardia, the first priority is to address the airway obstruction. After calling for help, the airway can be maintained with a jaw thrust and delivery of 15 l of high-flow oxygen via a non-rebreather mask. Monitoring the patient’s oxygen saturation is important to assess their response. If bradycardia persists despite maximal atropine treatment, second-line drugs such as an isoprenaline infusion or an adrenaline infusion can be considered. Atropine is the first-line medication for reversing the arrhythmia, given in 500-micrograms boluses iv and repeated every 3-5 minutes as needed. While a second iv access line may be beneficial, it is not a priority compared to maintaining the airway and controlling the bradycardia. Re-intubation may be necessary if simpler measures and non-definitive airway interventions have failed to ventilate the patient.

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  • Question 79 - An 82-year-old man is brought to the Emergency Department, having suffered from a...

    Incorrect

    • An 82-year-old man is brought to the Emergency Department, having suffered from a fall in his home. He has bruising to his face and legs and a ‘dinner fork’ deformity of his left wrist. His pulse is 70 bpm, blood pressure (BP) 110/90 mmHg, temperature 37.2 °C and oxygen saturations 98%. His plan includes an occupational therapy and risk assessment for falls, with a view to modification of his home and lifestyle to prevent future recurrence.
      Approximately what percentage of people aged over 80 suffer from falls?

      Your Answer:

      Correct Answer: 50%

      Explanation:

      Falls in Older Adults: Prevalence and Risk Factors

      Falls are a common occurrence in older adults, with approximately 30% of those over 65 and 50% of those over 80 experiencing a fall each year. These falls can lead to serious consequences, such as neck of femur fractures, loss of confidence, and increased anxiety.

      There are several risk factors for falls, including muscle weakness, gait abnormalities, use of a walking aid, visual impairment, postural hypotension, cluttered environment, arthritis, impaired activities of daily living, depression, cognitive impairment, and certain medications.

      To prevent falls, interventions such as balance and exercise training, medication rationalization, correction of visual impairments, and home assessments can be implemented. Additionally, underlying medical conditions should be treated, and osteoporosis prophylaxis should be considered for those with recurrent falls.

      Overall, falls in older adults are a significant concern, but with proper prevention and management strategies, their impact can be minimized.

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  • Question 80 - A middle-aged woman is brought to the Emergency Department (ED), after being found...

    Incorrect

    • A middle-aged woman is brought to the Emergency Department (ED), after being found unconscious in the town centre by members of the police. She is poorly kept, and a police handover reports that she has no fixed abode. She is well known to various members of ED. On arrival in ED, she is still unconscious. Her airway is patent; she is saturating at 94% on room air, with a respiratory rate of 10 breaths/min. She is haemodynamically stable, with a temperature of 35.6 °C and small, constricted pupils. There appears to be an area of minor external bleeding and a scalp haematoma on the back of her head.
      What is the most appropriate initial course of action?

      Your Answer:

      Correct Answer: Naloxone 400 μg intramuscularly (IM)

      Explanation:

      Treatment Priorities for Opioid Overdose: A Case Vignette

      In cases of suspected opioid overdose, the priority is to address respiratory compromise with the administration of naloxone. The British National Formulary recommends an initial dose of 400 μg, with subsequent doses of 800 μg at 1-minute intervals if necessary, and a final dose of 2 mg if there is still no response. Naloxone acts as a non-selective and competitive opioid receptor antagonist, and is a relatively safe drug.

      In the case of an unkempt man with a low respiratory rate and pinpoint pupils, the priority is to administer naloxone. High-flow oxygen is not necessary if the patient is maintaining saturations of 94%. A CT head scan or neurosurgical referral may be necessary in cases of head injury, but in this case, the priority is to address the opioid overdose.

      Flumazenil, a benzodiazepine receptor antagonist, is not the correct choice for opioid overdose. Benzodiazepine overdose presents with CNS depression, ataxia, and slurred speech, but not pupillary constriction. Naloxone is the appropriate antidote for opioid overdose.

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  • Question 81 - A 35-year-old man is brought to the Emergency Department following a car accident....

    Incorrect

    • A 35-year-old man is brought to the Emergency Department following a car accident. He has a head injury and has vomited twice within the ambulance. His eyes are open to voice; he is able to squeeze your hand with both hands, when asked, and wiggle his toes. He is confused about what has happened and does not remember the accident. He cannot remember his age and tells you that he does not know where he is currently. Other injuries include a broken collarbone (immobilized). His sats are 98% on 10 l high-flow oxygen, with a heart rate of 100 bpm and a blood pressure of 120/80 mmHg.
      What is his Glasgow Coma Scale (GCS) score?

      Your Answer:

      Correct Answer: 13

      Explanation:

      Understanding the Glasgow Coma Scale

      The Glasgow Coma Scale (GCS) is a tool used to assess a patient’s level of consciousness based on three components: eye opening, verbal response, and motor response. The score ranges from 3 (lowest) to 15 (highest). Each component has a range of scores, with higher scores indicating better function.

      The breakdown of scores for each component is as follows:

      – Eye opening: spontaneous (4), to speech (3), to pain (2), none (1)
      – Verbal response: oriented response (5), confused speech (4), inappropriate words (3), incomprehensible sounds (2), none (1)
      – Best motor response: obeys commands (6), movement localized to stimulus (5), withdraws (4), abnormal muscle bending and flexing (3), involuntary muscle straightening and extending (2), none (1)

      To calculate the GCS score, the scores for each component are added together. For example, a patient who opens their eyes to speech (3), is confused (4), and obeys commands (6) would have a GCS score of 13 (E3 V4 M6 = GCS 13).

      It is important to note that a reduced GCS score may indicate the need for intubation, particularly if the score is 8 or less. Understanding the GCS can help healthcare providers quickly assess a patient’s level of consciousness and determine appropriate interventions.

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  • Question 82 - A 35-year-old man arrives at the Emergency Department after smoking excessive amounts of...

    Incorrect

    • A 35-year-old man arrives at the Emergency Department after smoking excessive amounts of heroin. He is unresponsive and exhibits pinpoint pupils and symptoms of respiratory depression.
      What is the most suitable antidote for this patient?

      Your Answer:

      Correct Answer: Naloxone

      Explanation:

      Antidotes for Overdose: Understanding the Correct Treatment for Different Types of Overdose

      Overdose can be a life-threatening situation that requires immediate medical attention. Different types of overdose require different antidotes for effective treatment. Here is a breakdown of some common antidotes and their uses:

      Naloxone: This is the first-line treatment for opioid overdose. It works by binding to opioid receptors in the brain and reversing the effects of opioids. Naloxone can be given intravenously, intramuscularly, subcutaneously, or intranasally.

      Vitamin K: This antidote is used for patients with severe bleeding on anticoagulation therapy or those who are vitamin K-deficient. Vitamin K takes time to take effect, with the maximum effect occurring 6-24 hours after administration.

      Lithium: This medication is not used as an antidote for overdose. It is commonly used for mania and bipolar disorder.

      Flumazenil: This is the first-line treatment for benzodiazepine overdose. It works by competing with benzodiazepines for receptor binding sites. Flumazenil should only be given in cases of known benzodiazepine overdose.

      N-acetylcysteine (NAC): This is the first-line antidote for paracetamol overdose. It works by replenishing depleted glutathione reserves in the liver and enhancing non-toxic metabolism of acetaminophen.

      In conclusion, understanding the correct antidote for different types of overdose is crucial for effective treatment. Naloxone for opioid overdose, vitamin K for severe bleeding, flumazenil for benzodiazepine overdose, and NAC for paracetamol overdose are some common examples of antidotes used in clinical practice.

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  • Question 83 - A 21-year-old man is brought to the Emergency Department after near-drowning. This occurred...

    Incorrect

    • A 21-year-old man is brought to the Emergency Department after near-drowning. This occurred after he fell from a boat into a lake, while intoxicated with alcohol. He has no medical history. He is drowsy, with a Glasgow Coma Scale (GCS) score of 9; his oxygen saturations are 80% on an inspired fraction of oxygen (FiO2) of 1.0 via a non-rebreather face mask.
      Which of the following is part of the treatment algorithm for drowning?

      Your Answer:

      Correct Answer: Warming strategies for hypothermia

      Explanation:

      Warming and Treatment Strategies for Hypothermia and Drowning

      Hypothermia and drowning are serious medical emergencies that require prompt intervention to prevent further complications. In cases of hypothermia, the severity of the condition will determine the appropriate intervention. For mild cases, passive rewarming through heated blankets and warm fluids may be sufficient. However, for more severe cases, blood rewarming through the use of a haemodialysis machine or warm intravenous fluids may be necessary. Airway rewarming using humidified oxygen may also be used.

      In cases of drowning, support for shock is crucial, and patients should be managed with warming, IV fluids, and airway support. Diuresis should be avoided in shocked patients. Oxygenation is critical in treating post-drowning patients, and intubation and mechanical ventilation may be required in cases of moderate to severe hypoxia. Prophylactic antibiotics are unproven, but may be given if fever develops or there is grossly contaminated aspirated water. Treatment should be targeted towards likely pathogens, with route of administration depending on the patient’s condition. Pneumonia can be a major complication, and atypical organisms should be considered.

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  • Question 84 - A 50-year-old publican presents with severe epigastric pain and vomiting for the past...

    Incorrect

    • A 50-year-old publican presents with severe epigastric pain and vomiting for the past 8 hours. He is becoming dehydrated and confused. Shortly after admission, he develops increasing shortness of breath. On examination, he has a blood pressure of 128/75 mmHg, a pulse of 92 bpm, and bilateral crackles on chest auscultation. The jugular venous pressure is not elevated. Laboratory investigations reveal a haemoglobin level of 118 g/l, a WCC of 14.8 × 109/l, a platelet count of 162 × 109/l, a sodium level of 140 mmol/l, a potassium level of 4.8 mmol/l, a creatinine level of 195 μmol/l, and an amylase level of 1330 U/l. Arterial blood gas analysis shows a pH of 7.31, a pO2 of 8.2 kPa, and a pCO2 of 5.5 kPa. Chest X-ray reveals bilateral pulmonary infiltrates. Pulmonary artery wedge pressure is normal. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Acute (adult) respiratory distress syndrome (ARDS)

      Explanation:

      Mucopolysacchirodosis

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  • Question 85 - A 65-year-old woman presents to the Emergency Department with severe bilateral pneumonia, which...

    Incorrect

    • A 65-year-old woman presents to the Emergency Department with severe bilateral pneumonia, which is found to be secondary to Legionella. She is hypoxic and drowsy and has an acute kidney injury. She is intubated and ventilated and transferred to the Intensive Care Unit. Despite optimal organ support, her respiratory system continues to deteriorate, requiring high fraction of inspired oxygen (FiO2) (0.8) to maintain oxygen saturations of 88–92%. A chest X-ray shows diffuse bilateral infiltrates. A diagnosis of acute respiratory distress syndrome (ARDS) is made.
      Which of the following is a recognised component of the management strategy for ARDS?

      Your Answer:

      Correct Answer: Lung-protective ventilation

      Explanation:

      Best Practices for Mechanical Ventilation in ARDS Patients

      Mechanical ventilation is a crucial intervention for patients with acute respiratory distress syndrome (ARDS). However, there are specific strategies that should be employed to ensure the best outcomes for these patients.

      Lung-protective ventilation with lower tidal volume (≤ 6 ml/kg predicted body weight) and a plateau pressure of ≤ 30 cmH2O is associated with a reduced risk of hospital mortality and barotrauma. In contrast, mechanical ventilation with high tidal volume is associated with an increased incidence of ventilator-induced lung injury.

      In 2000, a large randomized controlled trial demonstrated the benefits of ventilation with low tidal volumes in patients with ARDS. Therefore, it is essential to use lower tidal volumes to prevent further lung damage.

      While low positive end-expiratory pressure (PEEP) is not a recognized management strategy, higher levels of PEEP can benefit patients with more severe ARDS. High PEEP aims to keep the lung open during the entire respiratory cycle, improving alveolar recruitment, reducing lung stress and strain, and preventing atelectrauma. However, a combination of individual PEEP titration following an alveolar recruitment maneuver could lead to better outcomes in more severe ARDS patients.

      Finally, prone positioning for at least 12 hours per day can be used in patients with moderate/severe ARDS and is associated with a reduction in mortality when combined with lung-protective ventilation. Therefore, patients should be maintained supine or prone, and prone positioning should be considered in appropriate cases.

      In conclusion, the best practices for mechanical ventilation in ARDS patients include lung-protective ventilation with lower tidal volume, higher levels of PEEP in severe cases, and prone positioning when appropriate. These strategies can help improve outcomes and reduce the risk of complications.

    • This question is part of the following fields:

      • Acute Medicine And Intensive Care
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