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  • Question 1 - A 17-year-old boy is rushed to the Emergency department following drug use at...

    Incorrect

    • A 17-year-old boy is rushed to the Emergency department following drug use at a party.

      What signs indicate that he may have ingested Ecstasy (MDMA)?

      Your Answer: Pinpoint pupils

      Correct Answer: Pyrexia

      Explanation:

      Symptoms of Ecstasy Overdose

      Ecstasy overdose can lead to a range of symptoms, including hyperthermia, hypertension, hyponatremia, and respiratory alkalosis. Hyperthermia is characterized by an abnormally high body temperature, which can cause damage to organs and tissues. Hypertension, or high blood pressure, can lead to a range of health problems, including heart disease and stroke. Hyponatremia is caused by excessive drinking of water, which can lead to a condition known as syndrome of inappropriate antidiuretic hormone (SIADH). This can cause a range of symptoms, including confusion, seizures, and coma. Respiratory alkalosis is characterized by an increase in blood pH, which can cause a range of symptoms, including dizziness, confusion, and seizures. Pinpoint pupils may also suggest the presence of opiates.

    • This question is part of the following fields:

      • Emergency Medicine
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  • Question 2 - You are asked to assess a 75-year-old man who has a medical history...

    Incorrect

    • You are asked to assess a 75-year-old man who has a medical history of hypertension, diabetes, and congestive heart failure. He has come to the hospital with worsening paroxysmal nocturnal dyspnea and three pillow orthopnea, and is currently experiencing acute shortness of breath.

      The patient's vital signs are as follows: heart rate of 120 beats per minute, regular rhythm, blood pressure of 150/80 mmHg, and oxygen saturation of 88% on room air. The nurse has ordered a chest x-ray for the patient.

      Which of the following findings would be inconsistent with a diagnosis of congestive heart failure?

      Your Answer: Upper lobe blood diversion

      Correct Answer: Globular heart

      Explanation:

      Radiographic Signs of Congestive Cardiac Failure

      Congestive cardiac failure is a common reason for hospital admission, and it is important for all clinicians to be familiar with its presentation. One of the initial investigations is a chest radiograph, which can reveal various signs depending on the severity and acuteness of the condition.

      The earliest radiographic sign of congestive cardiac failure is the appearance of Kerley B lines, which indicate interstitial oedema and are typically found in the middle and lower zones of the lungs. Kerley A lines, on the other hand, are seen in the upper zones. As the condition progresses, alveolar oedema becomes more prominent and is distributed in a bat’s wing pattern around the hilar region. This leads to significant V/Q mismatch in the lower zones, causing upper lobe blood diversion to improve oxygenation.

      Bilateral pleural effusions, which are transudative in nature, are a common finding in congestive cardiac failure. In the long term, cardiomegaly may occur as a compensatory mechanism, but a globular heart is not typically associated with this condition. A globular heart is usually due to a pericardial effusion.

      In summary, the radiographic signs of congestive cardiac failure is crucial for clinicians in order to make an accurate diagnosis and provide appropriate treatment.

    • This question is part of the following fields:

      • Emergency Medicine
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  • Question 3 - A 78-year-old male is brought to the Emergency department by ambulance after experiencing...

    Incorrect

    • A 78-year-old male is brought to the Emergency department by ambulance after experiencing a cardiac arrest. The ambulance crew is currently performing resuscitation attempts. Upon arrival, the patient has been intubated and connected to a defibrillator monitor, which shows a slow sinus rhythm (pulseless electrical activity) at a rate of 30 complexes per minute. The patient has been administered the full drugs protocol in accordance with the latest Adult Advanced Life Support guidelines. What do these guidelines recommend regarding the use of adrenaline during cardiac arrest?

      Your Answer:

      Correct Answer: Adrenaline 1 mg should be given immediately and then two cycles whilst in this rhythm

      Explanation:

      Adrenaline is an integral part of Advanced Life Support attempts during cardiac arrest, with a recommended dose of 1 mg given immediately and then after every 2 cycles. However, there is increasing evidence that the use of adrenaline during resuscitation attempts may be detrimental to a patient’s chance of survival. Atropine, a drug used in bradycardia, was removed from the algorithm for Advanced Life Support in 2010 as there was little evidence it had any effect in cardiac arrest situations.

    • This question is part of the following fields:

      • Emergency Medicine
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  • Question 4 - The following arterial blood gases (ABGs) were taken from an unconscious 50-year-old woman...

    Incorrect

    • The following arterial blood gases (ABGs) were taken from an unconscious 50-year-old woman in the Emergency department on FiO2 of 21%:
      pH 7.36 (7.36-7.44)
      pO2 13.0 kPa (11.3-12.6)
      pCO2 3.7 kPa (4.7-6.0)
      HCO3− 15 mmol/L (20-28)

      What is the correct interpretation of the ABG result?

      Your Answer:

      Correct Answer: Compensated metabolic acidosis

      Explanation:

      Interpretation of ABG Results

      The pH and bicarbonate levels in the ABG results indicate the presence of acidosis. However, the low level of carbon dioxide suggests that it is more likely to be metabolic acidosis rather than respiratory acidosis. The body tries to compensate for the acidosis by increasing the respiratory rate, which helps to eliminate excess hydrogen ions as carbon dioxide. This compensation can also lead to high oxygen levels due to deep and rapid breathing. However, it is important to note that high oxygen levels may also be a result of oxygen therapy provided in the Emergency department. It is worth mentioning that delayed analysis of ABG samples can sometimes lead to inaccurate results, such as a falsely low pO2. However, there is no indication that this has occurred in this particular case.

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      • Emergency Medicine
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  • Question 5 - A 56-year-old woman who underwent Hartmann’s procedure six hours ago has started to...

    Incorrect

    • A 56-year-old woman who underwent Hartmann’s procedure six hours ago has started to complain of abdominal pain and light-headedness. On assessment, she has a blood pressure of 80/40 mmHg, a heart rate of 120 bpm, a respiratory rate of 22 breaths per minute, oxygen saturations of 98% and a temperature of 36.7 °C. She appears drowsy and pale, and the radial pulse is difficult to detect. Her abdomen appears rigid and is painful to palpate, and a bleed is suspected.
      What type of shock is this patient most likely to have?

      Your Answer:

      Correct Answer: Hypovolaemic

      Explanation:

      Types of Shock and their Causes

      Shock is a medical emergency that occurs when the body’s organs and tissues do not receive enough oxygen and nutrients. There are different types of shock, each with its own causes and symptoms.

      Hypovolaemic shock is caused by a significant loss of blood volume, usually more than 20%. This can occur due to trauma, surgery, or internal bleeding. Symptoms include low blood pressure, rapid heartbeat, and confusion. Treatment involves urgent fluid resuscitation and surgical intervention.

      Anaphylactic shock is an allergic reaction to a substance, such as medication, food, or insect venom. Symptoms include swelling of the face and throat, hives, and difficulty breathing. Treatment involves administering epinephrine and seeking emergency medical care.

      Cardiogenic shock occurs when the heart is unable to pump enough blood to meet the body’s needs. This can occur after a heart attack or other cardiac event. Symptoms include low blood pressure, rapid heartbeat, and shortness of breath. Treatment involves addressing the underlying cardiac issue and providing supportive care.

      Neurogenic shock occurs due to damage to the central nervous system or spinal cord. Symptoms include low blood pressure, slow heartbeat, and warm skin. Treatment involves stabilizing the spine and providing supportive care.

      Septic shock occurs as a result of a severe infection that spreads throughout the body. Symptoms include fever, low blood pressure, and confusion. Treatment involves administering antibiotics and providing supportive care.

      In conclusion, recognizing the type of shock a patient is experiencing is crucial for providing appropriate and timely treatment.

    • This question is part of the following fields:

      • Emergency Medicine
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  • Question 6 - A 54-year-old female presents with a five day history of fever, cough and...

    Incorrect

    • A 54-year-old female presents with a five day history of fever, cough and malaise. She recently returned from a holiday in southern Spain and has since developed a non-productive cough with chills that have worsened. The patient has a history of smoking 10 cigarettes per day but no other medical history. On examination, she has a temperature of 40°C, blood pressure of 118/72 mmHg, and a pulse of 106 bpm. Chest examination reveals inspiratory crackles at the left base only, with a respiratory rate of 28/min. Baseline investigations show haziness at the left base on CXR, Hb 128 g/L (115-165), WCC 5.5 ×109/L (4-11), Platelets 210 ×109/L (150-400), Sodium 130 mmol/L (137-144), Potassium 3.8 mmol/L (3.5-4.9), Creatinine 100 µmol/L (60-110), Urea 5.2 mmol/L (2.5-7.5), and Glucose 5.5 mmol/L (3.0-6.0). What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Legionnaires disease

      Explanation:

      Legionnaires Disease: A Community-Acquired Pneumonia

      This patient’s medical history and symptoms suggest that they have contracted a community-acquired pneumonia. However, despite the obvious infection, their white cell count appears relatively normal, indicating that they may have an atypical pneumonia. Further investigation reveals that the patient recently traveled to Spain and is experiencing hyponatremia, which are both indicative of Legionnaires disease. This disease is caused by the Legionella pneumophila organism and is typically spread through infected water supplies, such as air conditioning systems.

      To diagnose Legionnaires disease, doctors typically look for the presence of urinary antigen before any rise in serum antibody titres. Fortunately, the organism is sensitive to macrolides and ciprofloxacin, which can be used to treat the disease. Overall, it is important for doctors to consider Legionnaire’s disease as a potential cause of community-acquired pneumonia, especially in patients with a recent history of travel and hyponatremia.

    • This question is part of the following fields:

      • Emergency Medicine
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  • Question 7 - A 27-year-old male with a history of alcohol dependence and chronic hepatitis presents...

    Incorrect

    • A 27-year-old male with a history of alcohol dependence and chronic hepatitis presents with reduced consciousness. He was discovered at home by a friend who reported that he had been depressed and threatening suicide.

      Upon examination, the patient is found to be tachycardic and hypotensive, with a blood pressure of 90/60 mmHg. His Glasgow coma scale is 13/15, and there are no signs of jaundice or hepatomegaly. A plasma-paracetamol concentration of 70 mg/litre is detected.

      What is the most appropriate course of action for this patient?

      Your Answer:

      Correct Answer: IV acetylcysteine

      Explanation:

      Treatment for Paracetamol Overdose

      This patient may have taken too much paracetamol, but it is unclear when this occurred. The paracetamol level in their blood is 70 mg/litre, which is difficult to interpret without knowing the timing of the overdose. If there is any doubt about the timing or need for treatment, the patient should receive N-acetylcysteine. In remote areas where this is not available, oral methionine can be used instead. Gastric lavage, which involves washing out the stomach, is not typically helpful for patients who have only overdosed on paracetamol. Overall, prompt treatment is essential to prevent serious liver damage and other complications.

    • This question is part of the following fields:

      • Emergency Medicine
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  • Question 8 - A 25-year-old asthmatic has been feeling unwell for the past day, experiencing a...

    Incorrect

    • A 25-year-old asthmatic has been feeling unwell for the past day, experiencing a productive cough, fever, and occasional wheezing. Despite using his regular salbutamol inhaler, his shortness of breath has been worsening, prompting him to seek medical attention at the hospital.

      After being assessed by a colleague, the patient has received four rounds of back-to-back salbutamol nebulisers, one round of ipratropium nebulisers, and intravenous hydrocortisone. However, the patient's condition is deteriorating, with increasing respiratory rate and speaking in words only. His chest is now silent, and his oxygen saturation is at 90% despite receiving 10 litres of oxygen.

      What is the next recommended therapeutic intervention for this patient?

      Your Answer:

      Correct Answer: Magnesium sulphate 2 g

      Explanation:

      The British Thoracic Society guidelines should be followed for managing acute asthma, with patients stratified into moderate, severe, or life threatening categories. This patient has life threatening features and may require anaesthetic intervention for intubation and ventilation. Magnesium sulphate is the next important drug intervention. Adrenaline nebulisers have no role unless there are signs of upper airway obstruction. Aminophylline infusions are no longer recommended for initial stabilisation. Salbutamol inhalers can be used as a rescue measure in moderate exacerbations but have no role in severe or life threatening cases. Both prednisone and hydrocortisone are equally effective for steroid treatment.

    • This question is part of the following fields:

      • Emergency Medicine
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  • Question 9 - A 19-year-old male is admitted with acute asthma. He has been treated with...

    Incorrect

    • A 19-year-old male is admitted with acute asthma. He has been treated with steroid, bronchodilators and 15 l/min of oxygen.

      His pulse rate is 125/min, oxygen saturation 89%, respiratory rate 24/min, blood pressure 140/88 mmHg and he has a peak flow rate of 150 l/min. On auscultation of his chest, he has bilateral wheezes.

      Arterial blood gas (ABG) result taken on 15 l/min oxygen shows:

      pH 7.42 (7.36-7.44)
      PaO2 8.4 kPa (11.3-12.6)
      PaCO2 5.3 kPa (4.7-6.0)
      Standard HCO3 19 mmol/L (20-28)
      Base excess −4 (+/-2)
      Oxygen saturation 89%

      What is the most appropriate action for this man?

      Your Answer:

      Correct Answer: Call ITU to consider intubation

      Explanation:

      Urgent Need for Ventilation in Life-Threatening Asthma

      This patient is experiencing life-threatening asthma with a dangerously low oxygen saturation level of less than 92%. Despite having a normal PaCO2 level, the degree of hypoxia is inappropriate and requires immediate consideration for ventilation. The arterial blood gas (ABG) result is consistent with the clinical presentation, making a venous blood sample unnecessary. Additionally, the ABG and bedside oxygen saturation readings are identical, indicating an arterialised sample.

      It is crucial to note that in cases of acute asthma, reducing the amount of oxygen below the maximum available is not recommended. Hypoxia can be fatal and must be addressed promptly. Therefore, urgent intervention is necessary to ensure the patient’s safety and well-being.

    • This question is part of the following fields:

      • Emergency Medicine
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  • Question 10 - A 27-year-old soccer player suddenly collapses during a game. He is immediately taken...

    Incorrect

    • A 27-year-old soccer player suddenly collapses during a game. He is immediately taken to the Emergency department where he is diagnosed with ventricular tachycardia. Despite successful defibrillation, he experiences a recurrence of ventricular tachycardia and unfortunately passes away after prolonged resuscitation. The 12 lead ECG taken after resuscitation reveals left ventricular hypertrophy. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Hypertrophic cardiomyopathy

      Explanation:

      Hypertrophic Cardiomyopathy and its ECG Findings

      Hypertrophic cardiomyopathy (HCM) is a possible cause of sudden arrhythmia in a young, previously healthy individual. It is recommended that relatives of the patient be screened for the condition. Most patients with HCM have an abnormal resting electrocardiogram (ECG), which may show left ventricular hypertrophy, ST changes, T-wave inversion, right or left axis deviation, conduction abnormalities, sinus bradycardia with ectopic atrial rhythm, and atrial enlargement. Ambulatory ECG monitoring can reveal atrial and ventricular ectopics, sinus pauses, intermittent or variable atrioventricular block, and non-sustained arrhythmias. However, the ECG findings do not necessarily correlate with prognosis. Arrhythmias associated with HCM include premature ventricular complexes, non-sustained ventricular tachycardia, and supraventricular tachyarrhythmias. Atrial fibrillation occurs in about 20% of cases and is linked to an increased risk of fatal cardiac failure. Drug abuse is not a likely cause, and aortic stenosis is rare without congenital or rheumatic heart disease. Myocardial infarction and massive pulmonary embolism would have distinct ECG changes.

      In summary, HCM is a possible cause of sudden arrhythmia in young, previously healthy individuals. ECG findings may include left ventricular hypertrophy, ST changes, T-wave inversion, and various arrhythmias. Atrial fibrillation is a common complication and is associated with an increased risk of fatal cardiac failure. Relatives of the patient should be screened for the condition.

    • This question is part of the following fields:

      • Emergency Medicine
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  • Question 11 - A 20-year-old college student has ingested a mixture of over 100 paracetamol tablets...

    Incorrect

    • A 20-year-old college student has ingested a mixture of over 100 paracetamol tablets and half a bottle of vodka after a disagreement with her partner. She has since vomited and has been rushed to the Emergency department in the early hours. It has been approximately six hours since she took the tablets. Her paracetamol level is 100 mg/L, which is above the normogram treatment line. Her test results show normal levels for sodium, potassium, glucose, INR, albumin, bilirubin, and alkaline phosphatase. Her urea and creatinine levels are slightly elevated. What is the most appropriate course of action?

      Your Answer:

      Correct Answer: IV N acetylcysteine

      Explanation:

      Treatment for Paracetamol Overdose

      When a patient takes a significant overdose of paracetamol, it is important to seek treatment immediately. If the overdose is above the treatment line at six hours, the patient will require N-acetylcysteine. Even if there is uncertainty about the timing of the overdose, it is recommended to administer the antidote. Liver function tests may not show abnormalities for up to 48 hours, but the international normalised ratio (INR) is the most sensitive marker for liver damage. If the INR is normal at 48 hours, the patient may be discharged. It is crucial to seek medical attention promptly to ensure the best possible outcome for the patient.

    • This question is part of the following fields:

      • Emergency Medicine
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  • Question 12 - What EEG findings are typically observed in patients with hepatic encephalopathy? ...

    Incorrect

    • What EEG findings are typically observed in patients with hepatic encephalopathy?

      Your Answer:

      Correct Answer: Delta waves

      Explanation:

      EEG Changes in Hepatic Encephalopathy

      Classic EEG changes that are commonly associated with hepatic encephalopathy include delta waves with high amplitude and low frequency, as well as triphasic waves. However, it is important to note that these findings are not specific to hepatic encephalopathy and may be present in other conditions as well. In cases where seizure activity needs to be ruled out, an EEG can be a useful tool in the initial evaluation of patients with cirrhosis and altered mental status. It is important to consider the limitations of EEG findings and to interpret them in conjunction with other clinical and laboratory data. Proper diagnosis and management of hepatic encephalopathy require a comprehensive approach that takes into account the underlying liver disease and any contributing factors.

    • This question is part of the following fields:

      • Emergency Medicine
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  • Question 13 - A 16-year-old girl weighing approximately 70 kg is brought to the Emergency department...

    Incorrect

    • A 16-year-old girl weighing approximately 70 kg is brought to the Emergency department in cardiac arrest. She was found collapsed at home surrounded by empty packets of amitriptyline 25 mg. The ambulance service reports that she had a weak pulse and no respiratory effort. She has been intubated and is being ventilated by bag-valve mask. The presenting rhythm is a sinusoidal supraventricular tachycardia with wide QRS complexes. Blood pressure is barely recordable but a weak carotid and femoral pulse are palpable.

      Immediate arterial bloods gases are obtained and reveal an arterial pH of 6.99 (7.35-7.45), pO2 of 11.8 kPa (11.0-14.0), pCO2 of 5.9 kPa (4.5-6.0), HCO3- of 9.6 mmol/L (16-22), base excess of −19.7 mmol/L (-2 to +2), lactate of 7.4 mmol/L (0.5-2.0), potassium of 4.9 mmol/L (3.3-5.5), and glucose of 4.8 mmol/L (5.0-7.0).

      What is the most appropriate next step?

      Your Answer:

      Correct Answer: Administer IV bicarbonate 8.4% 50 ml through a large bore cannula

      Explanation:

      Amitriptyline is a cheap and effective tricyclic antidepressant drug that is highly toxic in overdose and often lethal. Symptoms of overdose include tachycardia, hot dry skin, dilated pupils, and cardiac failure. Rapid correction of severe acidosis with intravenous 8.4% sodium bicarbonate solution is recommended, even in the absence of significant acidosis. Glucagon is given in tricyclic overdoses when the patient develops cardiac failure or profound hypotension refractory to fluids. Resuscitation attempts should continue for at least 60 minutes in the absence of significant comorbidity. Intralipid is a second line agent used to stabilize the myocardium in instances where bicarbonate has been ineffective or cardiac arrhythmias persist despite adequate alkalinisation of the blood.

    • This question is part of the following fields:

      • Emergency Medicine
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  • Question 14 - A 75-year-old male presents with haematemesis and melaena.

    His initial blood pressure is...

    Incorrect

    • A 75-year-old male presents with haematemesis and melaena.

      His initial blood pressure is 80/46 mmHg, and his heart rate is 114 bpm. He has a history of idiopathic cirrhosis and mild encephalopathy.

      You begin resuscitation with colloid, blood, FFP, and dextrose.

      What is the most suitable next medical intervention while waiting for an OGD to be arranged?

      Your Answer:

      Correct Answer: Terlipressin

      Explanation:

      Treatment Options for Acute Gastrointestinal Bleed

      Terlipressin is a medication that causes constriction of blood vessels in the splanchnic region, which can help to control bleeding from varices, a common cause of gastrointestinal bleeding. In cases of acute gastrointestinal bleeding, glypressin is the preferred treatment to help with cardiovascular resuscitation. Beta-blockers may be used later on to manage portal hypertension on a chronic basis. Lactulose is another medication that may be considered to prevent the progression of encephalopathy.

      While an OGD (oesophagogastroduodenoscopy) may be necessary to diagnose the cause of the bleeding, it is important to first focus on resuscitation and medical management. In cases where ascites is present, ciprofloxacin may be used as a prophylactic measure against spontaneous bacterial peritonitis. However, this is considered a secondary concern in the context of acute gastrointestinal bleeding. By prioritizing the appropriate treatments and interventions, healthcare providers can help to manage this potentially life-threatening condition.

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      • Emergency Medicine
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  • Question 15 - A 50-year-old man with a history of intravenous drug use presents with abnormal...

    Incorrect

    • A 50-year-old man with a history of intravenous drug use presents with abnormal blood results. His test results show Hepatitis B surface antigen positive, IgG Anti-HBc antibody positive, IgM Anti-HBc antibody negative, and Anti-Hepatitis B surface antibody negative. What is the most likely diagnosis for this patient?

      Your Answer:

      Correct Answer: Chronically infected with hepatitis B

      Explanation:

      Hepatitis B Surface Antigen and Antibodies

      The presence of hepatitis B surface antigen (HBsAg) indicates the presence of the hepatitis B virus in the host’s cells, whether it is an acute or chronic infection. All patients infected with hepatitis B will produce antibodies to the core antigen. IgM antibodies are markers of acute infection and will no longer be present in chronic infection. On the other hand, IgG antibodies to the core antigen remain present even after the infection has been cleared.

      Antibodies to the surface antigen develop in vaccinated individuals, providing natural immunity once the infection has cleared. If a patient has developed antibodies to HBsAg, they would be HBsAg negative and would not be a hepatitis B chronic carrier. the presence and absence of these antigens and antibodies is crucial in diagnosing and managing hepatitis B infections.

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      • Emergency Medicine
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  • Question 16 - A 27-year-old female is found in a confused and drowsy state. Her friend...

    Incorrect

    • A 27-year-old female is found in a confused and drowsy state. Her friend discovered her this morning after a night of drinking, but also mentions that she was upset about her recent breakup. Upon examination, she has a Glasgow coma scale rating of 10/15, a blood pressure of 138/90 mmHg, a temperature of 37.5°C, large pupils that react slowly to light, a pulse of 120 beats per minute, a respiratory rate of 32/min, and exaggerated reflexes with Downgoing plantar responses. Additionally, a palpable bladder is found during abdominal examination. What substance is she most likely to have taken?

      Your Answer:

      Correct Answer: Tricyclic antidepressants

      Explanation:

      Anticholinergic Overdose and Treatment

      Anticholinergic overdose can be identified by symptoms such as drowsiness, irritability, large pupils, pyrexia, and tachycardia. Tricyclics, commonly used as antidepressants, can be lethal in overdose. Patients with anticholinergic overdose should be closely monitored for ventricular arrhythmias and seizures, which can be treated with phenytoin and lidocaine, respectively. Additionally, metabolic acidosis should be corrected with bicarbonate.

      Paracetamol overdose may not present with many symptoms or signs initially, but can later lead to fulminant hepatic failure. Opiates typically cause small pupils and depressed respirations, while benzodiazepines usually only result in marked drowsiness. Ecstasy, on the other hand, often causes excitability, tachycardia, and hypertension, except in cases of severe hyponatremia associated with excessive water consumption.

      In summary, anticholinergic overdose requires close monitoring and prompt treatment to prevent potentially lethal complications. Other types of overdose may present with different symptoms and require different interventions.

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      • Emergency Medicine
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  • Question 17 - You are summoned to the assessment unit to evaluate a 65-year-old man who...

    Incorrect

    • You are summoned to the assessment unit to evaluate a 65-year-old man who has been experiencing fevers and purulent green sputum for the past three days. He has no significant medical history and is not taking any regular medications. He is eager to return home as he is the primary caregiver for his ailing father.

      During the examination, you observe that the patient is alert and oriented, but has bronchial breathing at the right base and a respiratory rate of 32 breaths per minute. His vital signs are as follows: HR 115 regular, BP 88/58 mmHg, O2 92% room air.

      Initial blood tests reveal a WCC of 13.2 ×109/L (4-11) and urea of 8.5 mmol/L (2.5-7.5).

      What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Admit to HDU

      Explanation:

      The CURB-65 Criteria for Pneumonia Assessment

      Assessing patients for pneumonia is a common task for healthcare professionals. To determine whether hospitalization is necessary, the CURB-65 criteria is a useful tool. The criteria include confusion, urea levels greater than 7, respiratory rate greater than 30, blood pressure less than 90 systolic or less than 60 diastolic, and age greater than 65. Patients who score 0-1 are suitable for home treatment, while those with scores of 2-3 should be considered for admission on a general ward. Patients with scores of 4-5 are likely to require HDU level interventions.

      In this scenario, the patient does not exhibit confusion but scores 4 on the other criteria, indicating the need for hospitalization and at least an HDU review. The CURB-65 criteria provides a clear and concise method for clinicians to assess the severity of pneumonia and make informed decisions about patient care.

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      • Emergency Medicine
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  • Question 18 - A 55-year-old woman is scheduled for a routine blood pressure check. As she...

    Incorrect

    • A 55-year-old woman is scheduled for a routine blood pressure check. As she waits in the reception area, she suddenly experiences severe breathlessness with stridor. She had mentioned to someone else in the room that she was stung by an insect on her way to the clinic. Based on your assessment, you determine that she is having an anaphylactic reaction to the sting. What would be the appropriate dose and route of administration for adrenaline in this scenario?

      Your Answer:

      Correct Answer: Intramuscular 1:1000 (500 micrograms)

      Explanation:

      Recommended Injection Route for Anaphylactic Reactions

      Anaphylactic reactions require immediate treatment, and one of the most effective ways to administer medication is through injection. The recommended route of injection is intramuscular, which involves injecting the medication into the muscle tissue. While the subcutaneous route can also be used, it is not as effective as the intramuscular route. In some cases, intravenous adrenaline 1:10000 may be used, but only under the supervision of a specialist. It is important to follow the guidelines provided by the Resuscitation Council (UK) for the emergency treatment of anaphylactic reactions. By administering medication through the recommended injection route, healthcare providers can effectively manage anaphylactic reactions and potentially save lives.

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      • Emergency Medicine
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  • Question 19 - A 55-year-old accountant presents with weight loss and excessive sweating. Upon examination, she...

    Incorrect

    • A 55-year-old accountant presents with weight loss and excessive sweating. Upon examination, she is found to be clinically thyrotoxic with a diffuse goitre. The following investigations were conducted: Free T4 levels were found to be 40 pmol/L (normal range: 9-23), Free T3 levels were 9.8 nmol/L (normal range: 3.5-6), and TSH levels were 6.1 mU/L (normal range: 0.5-5). What would be the most appropriate next step in the diagnostic process?

      Your Answer:

      Correct Answer: MRI scan pituitary gland

      Explanation:

      Possible Thyrotroph Adenoma in a Thyrotoxic Patient

      This patient is experiencing thyrotoxicosis, but the non-suppressed thyroid-stimulating hormone (TSH) indicates that the cause may be excessive TSH production by the pituitary gland. This suggests the possibility of a thyrotroph adenoma, which is a rare type of tumor that affects the cells in the pituitary gland responsible for producing TSH. In cases of primary hyperthyroidism, the TSH should be suppressed due to negative feedback, which is not the case here. Therefore, further investigation is necessary to determine if a thyrotroph adenoma is the underlying cause of the patient’s thyrotoxicosis. A normal or elevated TSH level in the presence of thyrotoxicosis would be a strong indication of a thyrotroph adenoma.

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      • Emergency Medicine
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  • Question 20 - A 75-year-old man is referred following a collapse at home. He is currently...

    Incorrect

    • A 75-year-old man is referred following a collapse at home. He is currently taking diclofenac for persistent low back pain. Upon examination, he appears pale and has a pulse of 110 beats per minute. His blood pressure is 110/74 mmHg while sitting and drops to 85/40 mmHg when standing. What is the most appropriate next step?

      Your Answer:

      Correct Answer: Digital rectal examination

      Explanation:

      Syncopal Collapse and Possible Upper GI Bleed

      This patient experienced a syncopal collapse, which is likely due to hypovolemia, as evidenced by her postural drop in blood pressure. It is possible that she had an upper gastrointestinal (GI) bleed caused by gastric irritation from her non-steroidal anti-inflammatory drug (NSAID) use. A rectal examination that shows melaena would confirm this suspicion.

      To determine the cause of her condition, a full blood count is necessary. Afterward, appropriate fluid resuscitation, correction of anemia, and an upper GI endoscopy should be performed instead of further cardiological or neurological evaluation.

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      • Emergency Medicine
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  • Question 21 - As the orthopaedic foundation year doctor, you have been requested by the nurse...

    Incorrect

    • As the orthopaedic foundation year doctor, you have been requested by the nurse in charge to assess a patient who is experiencing acute shortness of breath and right-sided chest pain 8 days after undergoing total knee replacement surgery. The patient is a 66-year-old builder with a medical history of COPD and high cholesterol. He has a BMI of 35 and currently smokes 30 cigarettes per day. His vital signs are as follows: regular heart rate of 115 beats per minute, blood pressure of 135/60 mmHg, and oxygen saturation of 91% on room air. What is the most effective diagnostic test to perform on this patient?

      Your Answer:

      Correct Answer: CT pulmonary angiogram

      Explanation:

      Diagnosing Pulmonary Embolism in Postoperative Patients

      In postoperative patients who become acutely unwell, pulmonary embolism (PE) must be considered and excluded as a crucial diagnosis. After initial resuscitation, diagnostic tests such as arterial blood gas sampling, full blood count, and C-reactive protein count are likely to be performed. However, these tests cannot confirm a specific diagnosis and may be abnormal in various conditions such as PE, pneumonia, acute respiratory distress syndrome (ARDS), pneumothorax, or cardiac events.

      D-dimer is often used to assess the risk of PE, but in patients with major risk factors such as surgery and minor risk factors such as obesity, a negative D-dimer cannot rule out PE. Chest X-ray can reveal underlying chest pathology, but it is rarely diagnostic for PE. The wedge-shaped infarcts that are often associated with PE are not common. However, a chest X-ray can determine whether a ventilation-perfusion (V/Q) scan is possible or whether a computed tomography pulmonary angiography (CTPA) is required.

      In patients with chronic obstructive pulmonary disease (COPD), there is already an underlying V/Q mismatch, making it difficult to diagnose PE with a low probability result. Therefore, a CTPA is necessary to confirm or exclude the diagnosis of PE. Patients with suspected PE should be placed on a direct oral anticoagulant (DOAC) until a definitive diagnosis is made. In conclusion, clinicians must have a high degree of suspicion for PE in postoperative patients and use a diagnostic rationale to exclude other potential diagnoses.

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  • Question 22 - A 25-year-old male presents to the Emergency department after being assaulted. He states...

    Incorrect

    • A 25-year-old male presents to the Emergency department after being assaulted. He states that he was hit in the nose, resulting in swelling, deformity, and a small nosebleed. He also reports difficulty breathing through his left nostril. Upon examination, there is no active bleeding, but there is some deviation of the nasal bones to the left and no septal haematoma. What is the best course of action in this situation?

      Your Answer:

      Correct Answer: Arrange an ENT follow up appointment for within the next one week

      Explanation:

      Emergency Admission for Isolated Nasal Injuries

      Isolated nasal injuries are a common occurrence that often presents in the Emergency department. However, emergency admission is rarely necessary for these cases. There are only three exceptions to this rule, which are patients with a septal haematoma, a compound nasal fracture, or associated epistaxis.

      It is important to note that nasal bone x-rays are not required for diagnosis, as it can be determined entirely through clinical examination. For uncomplicated cases, patients are best reviewed after five days in the ENT clinic when associated swelling has subsided. This allows for a better assessment of whether manipulation of the fracture is necessary.

      Traumatic epistaxis can be a serious complication and may require packing if there is active bleeding. It is crucial to monitor patients with this condition closely and provide appropriate treatment to prevent further complications. Overall, while isolated nasal injuries are common, emergency admission is only necessary in specific cases, and proper diagnosis and management are essential for optimal patient outcomes.

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  • Question 23 - An 80-year-old male is brought to the Emergency department and has a witnessed...

    Incorrect

    • An 80-year-old male is brought to the Emergency department and has a witnessed seizure in the resuscitation room. His blood glucose is recorded as 1.0 mmol/L. He does not have diabetes, nor other significant medical history. He is given 50 ml of 50% dextrose and he slowly recovers over the next one hour. A serum cortisol concentration later returns as 800 nmol/L (120-600). What investigation would be most relevant for this man?

      Your Answer:

      Correct Answer: Prolonged 72 hour fast

      Explanation:

      Diagnosis of Spontaneous Hypoglycaemia

      The patient’s medical history and biochemical evidence suggest a diagnosis of spontaneous hypoglycaemia, with the most likely cause being an insulinoma. However, it is important to rule out the possibility of drug administration, and a sulphonylurea screen should be conducted. The patient has presented with symptomatic hypoglycaemia, despite not being diabetic and not having received insulin or a sulphonylurea. There is no indication of alcohol or drug misuse, nor is there any evidence of sepsis.

      To confirm a diagnosis of spontaneous hypoglycaemia, a prolonged fast is necessary. If the patient experiences hypoglycaemia during the fast, insulin and C peptide levels should be measured to confirm the diagnosis. The patient’s cortisol response during the hypoglycaemic episode (cortisol 800) rules out hypoadrenalism.

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  • Question 24 - A 26-year-old man with a history of asthma is admitted to the hospital...

    Incorrect

    • A 26-year-old man with a history of asthma is admitted to the hospital for a left lower lobe pneumonia. He is prescribed amoxicillin, but within two minutes of taking the antibiotic, he complains of feeling unwell. A rapidly developing, erythematosus, macular rash appears on his trunk and limbs, along with large wheals on his torso. He also experiences lip and tongue swelling and a harsh wheeze is heard when his chest is auscultated. His blood pressure is 84/39 mmHg, and his heart rate is 167 bpm, which is determined to be a sinus tachycardia when connected to cardiac monitoring. His oxygen saturation levels are at 90% on air, so he is put on high flow oxygen.

      What is the most appropriate drug to administer next?

      Your Answer:

      Correct Answer: Adrenaline 1:1000 0.5 ml (500 mcg equivalent) intramuscular

      Explanation:

      The vignette describes a classical anaphylactic reaction, possibly caused by recent administration of penicillin. Anaphylaxis is characterized by massive mast cell degranulation and cytokine release, leading to rash, swelling, mucous membrane swelling, airway obstruction, hypotension, tachycardia, and wheezing. Treatment includes hydrocortisone, chlorphenamine, and adrenaline, which acts as an agonist at all subtypes of the adrenergic receptor to maintain blood pressure and alleviate wheezing. Intravenous adrenaline is not recommended outside of the intensive care setting, but may be used in life-threatening situations such as cardiac arrest. Intravenous fluids should also be considered. Metoprolol, a β-1 antagonist drug, is not part of the anaphylaxis algorithm and is contraindicated in asthmatic patients.

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  • Question 25 - A 57-year-old male presents with acute abdominal pain that has worsened over the...

    Incorrect

    • A 57-year-old male presents with acute abdominal pain that has worsened over the past two hours. The pain originates in the epigastric region and radiates to the left side of his back, with colicky characteristics. He has vomited three to four times, with the vomit being greenish in color.

      Upon examination, his temperature is 37.5°C, pulse is 100 beats per minute, and blood pressure is 114/80 mmHg. He has guarding of the abdomen and marked tenderness in the epigastrium. Bowel sounds are infrequent but audible.

      Lab results show a neutrophilic leukocytosis, elevated glucose and urea levels, and an elevated creatinine level. Urinalysis reveals an elevated amylase level. Abdominal x-ray shows no abnormalities.

      What is the likely diagnosis?

      Your Answer:

      Correct Answer: Pancreatitis

      Explanation:

      Acute Pancreatitis

      Acute pancreatitis is a condition characterized by sudden and severe abdominal pain that radiates through to the back. It is caused by inflammation and swelling of the pancreas, which leads to the loss of enzymes into the circulation and retroperitoneally. This can result in hyperglycemia, hypocalcemia, and dehydration, which are common features of the condition.

      To diagnose acute pancreatitis, a serum amylase test is usually performed. A result above 1000 mU/L is considered diagnostic. Other investigations may reveal dehydration, an elevated glucose concentration, a mild metabolic acidosis, and heavy amounts of amylase in the urine.

      Treatment for acute pancreatitis involves resuscitation with IV fluids, management of hyperglycemia with sliding scale insulin, nasogastric suction, antibiotics, and analgesia. It is important to manage the condition promptly to prevent complications and improve outcomes.

      In summary, acute pancreatitis is a serious condition that requires prompt diagnosis and management. It is characterized by inflammation and swelling of the pancreas, which can lead to hyperglycemia, hypocalcemia, and dehydration. Treatment involves resuscitation with IV fluids, management of hyperglycemia, and other supportive measures.

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  • Question 26 - A 25-year-old law student presents with visual loss in the right eye, accompanied...

    Incorrect

    • A 25-year-old law student presents with visual loss in the right eye, accompanied by a constant headache for the past three months. She also reports not having had her menstrual cycle for six months. Upon examination, her visual acuity in the affected eye is 6/24, with slight constriction of both temporal visual fields. However, there are no other neurological deficits present. The patient is stable, without fever or hemodynamic abnormalities. What is the likely diagnosis?

      Your Answer:

      Correct Answer: Pituitary tumour

      Explanation:

      Pituitary Lesion and Visual Pathway Involvement

      This patient is presenting with symptoms of headache and amenorrhoea, which are suggestive of a pituitary lesion. The lesion could either be a prolactinoma or a non-functioning tumour. Unfortunately, the involvement of the visual pathway has led to visual loss, which has further complicated the situation.

      To determine the extent of the pituitary lesion, the patient needs to undergo an urgent assessment of her pituitary function. Additionally, an MRI scan of the pituitary gland is necessary to determine the extent of the lesion. One of the most important investigations to perform would be a serum prolactin test.

      It is unlikely that the patient is suffering from retrobulbar neuritis associated with MS, as the amenorrhoea would argue against this. Similarly, the peripheral visual field constriction would be unusual, as a central scotoma and fluctuating visual loss would be more typical.

      In conclusion, the patient’s symptoms suggest a pituitary lesion, which has been complicated by involvement of the visual pathway. Urgent assessment and imaging are necessary to determine the extent of the lesion and appropriate treatment.

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  • Question 27 - A 32-year-old man is brought to the Emergency department from the local psychiatric...

    Incorrect

    • A 32-year-old man is brought to the Emergency department from the local psychiatric hospital where he is being treated for resistant schizophrenia.

      His medical history is otherwise significant only for depression, asthma and occasional cannabis use.

      He is extremely agitated and confused and unable to deliver a coherent history. Examination is difficult as he is unable to lie on the bed due to extreme muscle rigidity and his limbs are fixed in partial contractures and there is mild tremor. Chest and heart sounds are normal although he is tachycardic at 115 bpm. He is sweating profusely and his temperature is measured at 40.2°C. Blood pressure is 85/42 mmHg.

      Blood tests reveal:

      Haemoglobin 149 g/L (130-180)

      White cells 21.7 ×109/L (4-11)

      Neutrophils 17.4 ×109/L (1.5-7)

      Lymphocytes 3.6 ×109/L (1.5-4)

      Platelets 323 ×109/L (150-400)

      Sodium 138 mmol/L (137-144)

      Potassium 5.7 mmol/L (3.5-4.9)

      Urea 10.3 mmol/L (2.5-7.5)

      Creatinine 145 μmol/L (60-110)

      CRP 45 g/L -

      Bilirubin 14 μmol/L (0-3.4)

      ALP 64 U/L (45-405)

      ALT 38 U/L (5-35)

      Calcium (corrected) 2.93 mmol/L (2.2-2.6)

      CK 14398 U/L -

      The registered psychiatric nurse who accompanies him tells you he has been worsening over the previous 48 hours and his regular dose of risperidone was increased a few days ago. Other than risperidone 10 mg daily, he is also taking salbutamol four times a day.

      What is the likely diagnosis?

      Your Answer:

      Correct Answer: Neuroleptic malignant syndrome

      Explanation:

      Neuroleptic Malignant Syndrome

      Neuroleptic malignant syndrome (NMS) is a serious condition that can occur with the long-term use of certain antipsychotic drugs. It is important to consider NMS as a potential cause of deterioration in patients taking these drugs, especially if there has been a recent increase in dosage. Unfortunately, NMS is often misdiagnosed as it can mimic other conditions, including the underlying psychiatric disorder. NMS is caused by changes in dopamine levels in the brain and the release of calcium from muscle cells. This occurs due to activation of the ryanodine receptor, which causes high metabolic activity in muscles, leading to hyperpyrexia and rhabdomyolysis.

      Symptoms of NMS include extreme muscle rigidity, parkinsonism, and high fever. Patients may also experience confusion, fluctuations in consciousness, and autonomic instability. Treatment for NMS involves IV fluid rehydration, dantrolene, and bromocriptine. It is important to differentiate NMS from other conditions, such as sepsis or asthma exacerbation, through careful examination and testing. Discontinuation of the offending drug is mandatory, and patients may require prolonged ITU admissions.

      In conclusion, NMS is a potentially life-threatening condition that can occur with the use of certain antipsychotic drugs. It is important to consider NMS as a potential cause of deterioration in patients taking these drugs and to differentiate it from other conditions through careful examination and testing. Treatment for NMS involves supportive care and discontinuation of the offending drug.

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  • Question 28 - A 50-year-old plumber presents to the Emergency department with a saw injury to...

    Incorrect

    • A 50-year-old plumber presents to the Emergency department with a saw injury to his right thumb. On examination, there is a 1.5 cm laceration on the ulnar aspect of the thumb. The neurovascular supply is intact, and there is no evidence of injury to other structures. What is the suitable local anaesthetic to use for exploring the wound and suturing the laceration?

      Your Answer:

      Correct Answer: Lidocaine 1% - 20 ml

      Explanation:

      Anaesthetics for Wound Management in the Emergency Department

      For wound management in the Emergency department, 1% lidocaine is the most commonly used anaesthetic for cleaning, exploring, and suturing wounds. However, adrenaline should not be used in areas supplied by end arteries, such as fingers and toes.

      The maximum dose of plain lidocaine in a healthy adult is 3 mg/kg or 200 mg (20 ml of 1%). It is important to note that 1% lidocaine is equivalent to 10 mg/ml. On the other hand, if lidocaine with adrenaline is used, the maximum dose is 7 mg/kg or 500 mg (50 ml of 1%). The duration of action for plain lidocaine is 30-60 minutes, while lidocaine with adrenaline lasts approximately 90 minutes.

      Another topical anaesthetic that can be used is ethyl chloride, which is sprayed onto the skin and causes rapid cooling. However, it is very short-acting and lasts less than 60 seconds, making it inadequate for providing sufficient analgesia in most cases.

      In summary, the choice of anaesthetic for wound management in the Emergency department depends on the location and severity of the wound, as well as the patient’s overall health. It is important to follow the recommended maximum doses and duration of action to ensure safe and effective pain management.

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  • Question 29 - A 68-year-old man arrives at the emergency department with a 24-hour history of...

    Incorrect

    • A 68-year-old man arrives at the emergency department with a 24-hour history of epigastric pain that radiates to his back and vomiting. The doctors diagnose him with pancreatitis after his serum amylase levels come back at 2000. They also run some additional blood tests and find the following results:

      - WCC: 22 ×109/L (Neutrophils: 17.2)
      - Hb: 155 g/L
      - Urea: 18.2 mmol/L
      - Creatinine: 105 μmol/L
      - AST: 250 IU
      - LDH: 654 IU
      - Calcium: 2.3 mmol/L
      - Albumin: 38 g/L
      - Glucose: 7.5 mmol/L
      - PaO2: 9.9 KPa

      What is the Modified Glasgow score for this patient?

      Your Answer:

      Correct Answer: 4

      Explanation:

      Glasgow Score as a Predictor of Pancreatitis Severity

      The Glasgow score is a tool used to predict the severity of pancreatitis. It is based on several factors, which can be remembered using the mnemonic PANCREAS. These factors include low PaO2 levels, age over 55 years, high neutrophil count, low calcium levels, impaired renal function, elevated enzymes such as AST and LDH, low albumin levels, and high blood sugar levels. Each factor is assigned a certain number of points, and the total score can help determine the severity of the pancreatitis.

      For example, a patient who is over 55 years old, has high neutrophil count, impaired renal function, and elevated enzymes would score a total of 4 points. The higher the score, the more severe the pancreatitis is likely to be. UK guidelines recommend that a severity score be calculated for every patient with acute pancreatitis to help guide their management and treatment.

      In summary, the Glasgow score is a useful tool for predicting the severity of pancreatitis based on several factors. By calculating a patient’s score, healthcare providers can better manage and treat their condition.

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  • Question 30 - What vitamin is utilized to treat confusion in individuals with chronic alcoholism? ...

    Incorrect

    • What vitamin is utilized to treat confusion in individuals with chronic alcoholism?

      Your Answer:

      Correct Answer: Thiamine

      Explanation:

      Wernicke-Korsakoff Syndrome

      Wernicke-Korsakoff syndrome is a condition that arises due to insufficient intake of thiamine, as well as impaired absorption and storage. This condition is known to cause various symptoms, including dementia, nystagmus, paralysis of extra ocular muscles, ataxia, and retrograde amnesia, particularly in individuals who struggle with alcoholism.

      The inadequate intake of thiamine is often associated with chronic alcoholism, as alcohol can interfere with the body’s ability to absorb and store thiamine. This can lead to a deficiency in the vitamin, which can cause damage to the brain and nervous system. The symptoms of Wernicke-Korsakoff syndrome can be severe and can significantly impact an individual’s quality of life.

      It is essential to understand the causes and symptoms of Wernicke-Korsakoff syndrome to ensure that individuals who are at risk receive the necessary treatment and support. With proper care and management, it is possible to manage the symptoms of this condition and improve an individual’s overall health and well-being.

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