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  • Question 1 - A 25-year-old male arrives at the Emergency Department in evident distress. He woke...

    Incorrect

    • A 25-year-old male arrives at the Emergency Department in evident distress. He woke up this morning with sudden and intense pain in his right testicle. He also experiences some discomfort in his right iliac fossa. He reports feeling nauseous and has vomited twice while waiting. Upon examination, his right testicle is firm, highly sensitive, and positioned slightly higher than the left side.

      What is the MOST probable diagnosis in this case?

      Your Answer: Epididymo-orchitis

      Correct Answer: Testicular torsion

      Explanation:

      Testicular torsion is a condition where the spermatic cord twists, leading to a lack of blood flow to the testis. It is a surgical emergency and prompt action is necessary to save the testis. It is most commonly seen in individuals aged 15-30 years.

      Varicocele refers to the presence of varicose veins in the pampiniform plexus of the cord and scrotum. It is more frequently observed in the left testis and may be associated with infertility. This is believed to be due to the increased temperature caused by the varicose veins. Symptoms include a dull ache in the testis, which is often worse after exercise or at the end of the day. Standing examination can reveal the presence of Varicocele. Treatment is usually conservative, with surgery reserved for severe cases.

      Hydrocoele can occur at any age and is characterized by the accumulation of fluid in the tunica vaginalis. It presents as scrotal swelling, which can be palpated above. The surface of the hydrocoele is smooth and it can be transilluminated. The testis is contained within the swelling and cannot be felt separately. Primary or secondary causes can lead to hydrocoele, and in adults, an ultrasound is performed to rule out underlying pathology such as tumors. Conservative management is often sufficient unless the hydrocoele is large.

      Testicular cancer is the most common cancer in men aged 20-34 years. Awareness campaigns have emphasized the importance of self-examination for early detection. Risk factors include undescended testes, which increase the risk by 10-fold if bilateral. A previous history of testicular cancer carries a 4% risk of developing a second cancer. The usual presentation is a painless lump in the testis, which can also manifest as a secondary hydrocoele. Seminomas account for 60% of cases and are slow-growing, usually confined to the testis upon diagnosis. Stage 1 seminomas have a 98% 5-year survival rate. Teratomas, which can grow faster, make up 40% of cases and can occur within seminomas. Mixed type tumors are treated as teratomas due to their more aggressive nature. Surgical treatment, with or without chemotherapy and radiotherapy, is the primary approach.

      Epididymo-orchitis is inflammation of the testis and epididymis caused by infection.

    • This question is part of the following fields:

      • Urology
      3.4
      Seconds
  • Question 2 - A 15-year-old girl is prescribed prochlorperazine for symptoms of dizziness and nausea. Shortly...

    Incorrect

    • A 15-year-old girl is prescribed prochlorperazine for symptoms of dizziness and nausea. Shortly after taking the medication, she experiences an acute dystonic reaction.
      What is the most suitable treatment for this reaction? Choose ONE option only.

      Your Answer: Baclofen

      Correct Answer: Procyclidine

      Explanation:

      Drug-induced acute dystonic reactions are frequently seen in the Emergency Department. These reactions occur in approximately 0.5% to 1% of patients who have been administered metoclopramide or prochlorperazine. Procyclidine, an anticholinergic medication, has proven to be effective in treating drug-induced parkinsonism, akathisia, and acute dystonia. In emergency situations, a dose of 10 mg IV of procyclidine can be administered to promptly treat acute drug-induced dystonic reactions.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      9.9
      Seconds
  • Question 3 - A 35-year-old woman comes in with intense one-sided abdominal pain starting in the...

    Incorrect

    • A 35-year-old woman comes in with intense one-sided abdominal pain starting in the right flank and spreading to the groin. She is also experiencing severe nausea and vomiting. Her urine dipstick shows the presence of blood. A CT KUB is scheduled, and a diagnosis of ureteric colic is confirmed.
      Which of the following medications would be the LEAST appropriate choice to help manage this patient's pain?

      Your Answer: Paracetamol

      Correct Answer: Buscopan

      Explanation:

      Renal colic, also known as ureteric colic, refers to a sudden and intense pain in the loin area caused by a blockage in the ureter, which is the tube that carries urine from the kidney to the bladder. This condition is commonly associated with urinary tract stones. The pain typically starts in the flank or loin and radiates to the labia in women or to the groin or testicle in men.

      The pain experienced during renal or ureteric colic is severe and comes in spasms, with periods of no pain or a dull ache in between. It can last for minutes to hours. Nausea, vomiting, and the presence of blood in the urine (haematuria) often accompany the pain. Many individuals describe this pain as the most intense they have ever felt, with some women even comparing it to the pain of childbirth.

      People with renal or ureteric colic are restless and unable to find relief by lying still, which helps distinguish this condition from peritonitis. They may have a history of previous episodes and may also present with fever and sweating if there is a concurrent urinary infection. As the stone irritates the detrusor muscle, they may complain of dysuria (painful urination), frequent urination, and straining when the stone reaches the vesicoureteric junction.

      To support the diagnosis, it is recommended to perform urine dipstick testing to check for evidence of a urinary tract infection. The presence of blood in the urine can also indicate renal or ureteric colic, although it is not a definitive diagnostic marker. Nitrite and leukocyte esterase in the urine suggest the presence of an infection.

      In terms of pain management, non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for adults, children, and young people with suspected renal colic. Intravenous paracetamol can be offered if NSAIDs are contraindicated or not providing sufficient pain relief. Opioids may be considered if both NSAIDs and intravenous paracetamol are contraindicated or not effective. Antispasmodics should not be given to individuals with suspected renal colic.

      For more detailed information, refer to the NICE guidelines on the assessment and management of renal and ureteric stones.

    • This question is part of the following fields:

      • Urology
      5.2
      Seconds
  • Question 4 - A 72 year old female is brought into the emergency department due to...

    Incorrect

    • A 72 year old female is brought into the emergency department due to near-fainting. Whilst in the department the patient loses consciousness and on examination there is no detectable pulse. You begin cardiopulmonary resuscitation (CPR). What is the ratio of chest compressions to rescue breaths used during CPR?

      Your Answer: 15:2

      Correct Answer: 30:2

      Explanation:

      The ratio of chest compressions to rescue breaths during CPR is now 30:2. Prior to 2005, the ratio used was 15:2.

      Further Reading:

      In the event of an adult experiencing cardiorespiratory arrest, it is crucial for doctors to be familiar with the Advanced Life Support (ALS) algorithm. They should also be knowledgeable about the proper technique for chest compressions, the appropriate rhythms for defibrillation, the reversible causes of arrest, and the drugs used in advanced life support.

      During chest compressions, the rate should be between 100-120 compressions per minute, with a depth of compression of 5-6 cm. The ratio of chest compressions to rescue breaths should be 30:2. It is important to change the person giving compressions regularly to prevent fatigue.

      There are two shockable ECG rhythms that doctors should be aware of: ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT). These rhythms require defibrillation.

      There are four reversible causes of cardiorespiratory arrest, known as the 4 H’s and 4 T’s. The 4 H’s include hypoxia, hypovolemia, hypo or hyperkalemia or metabolic abnormalities, and hypothermia. The 4 T’s include thrombosis (coronary or pulmonary), tension pneumothorax, tamponade, and toxins. Identifying and treating these reversible causes is crucial for successful resuscitation.

      When it comes to resus drugs, they are considered of secondary importance during CPR due to the lack of high-quality evidence for their efficacy. However, adrenaline (epinephrine) and amiodarone are the two drugs included in the ALS algorithm. Doctors should be familiar with the dosing, route, and timing of administration for both drugs.

      Adrenaline should be administered intravenously at a concentration of 1 in 10,000 (100 micrograms/mL). It should be repeated every 3-5 minutes. Amiodarone is initially given at a dose of 300 mg, either from a pre-filled syringe or diluted in 20 mL of Glucose 5%. If required, an additional dose of 150 mg can be given by intravenous injection. This is followed by an intravenous infusion of 900 mg over 24 hours. The first dose of amiodarone is given after 3 shocks.

    • This question is part of the following fields:

      • Resus
      1.8
      Seconds
  • Question 5 - You are overseeing a patient who has been administered ketamine. You have concerns...

    Incorrect

    • You are overseeing a patient who has been administered ketamine. You have concerns about restlessness and emergence phenomena during the recovery process. Which class of medication is commonly employed to manage emergence phenomena?

      Your Answer: Tricyclic antidepressants

      Correct Answer: Benzodiazepines

      Explanation:

      Benzodiazepines are medications that are utilized to address emergence phenomena, which are characterized by restlessness and distressing hallucinations experienced upon awakening from ketamine sedation or induction. These phenomena are more frequently observed in older children and adults, affecting approximately one out of every three adults. To manage emergence phenomena, benzodiazepines may be administered. It is important to note that the RCEM does not recommend preventive treatment and suggests addressing emergence phenomena as they arise.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Basic Anaesthetics
      4.1
      Seconds
  • Question 6 - A 68-year-old man presents with symptoms related to an electrolyte imbalance. It is...

    Incorrect

    • A 68-year-old man presents with symptoms related to an electrolyte imbalance. It is believed that the electrolyte imbalance has occurred as a result of a thiazide diuretic he has been prescribed by the nephrology team.

      Which of the following electrolyte imbalances is most likely to be caused by thiazide diuretics?

      Your Answer: Hypermagnesaemia

      Correct Answer: Hyponatraemia

      Explanation:

      Thiazide diuretics, a commonly prescribed medication, can lead to two main electrolyte imbalances in patients. One of these is hyponatremia, which occurs in around 13.7% of individuals taking thiazide diuretics. The other is hypokalemia, which is observed in approximately 8.5% of patients on this medication. These electrolyte disturbances are frequently encountered in primary care settings. For more information on this topic, please refer to the article titled Thiazide diuretic prescription and electrolyte abnormalities in primary care.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      4
      Seconds
  • Question 7 - You are reviewing a middle-aged woman who came into the department with abdominal...

    Incorrect

    • You are reviewing a middle-aged woman who came into the department with abdominal pain. A diagnosis of a simple urinary tract infection has been made, and she will continue with a course of antibiotics at home. She lives at home by herself and has a neighbor who checks on her occasionally. She has mild anxiety, but has capacity and is keen to go back home. Her daughter stops you in the corridor and tells you that she doesn't want her mother to go home, but would like her to go to a rehabilitation center that specializes in mental health.

      What is the most appropriate initial response? Select ONE option only.

      Your Answer: Write to the patient’s GP requesting a referral to a nursing home

      Correct Answer:

      Explanation:

      This question delves into the challenges of managing chronic illnesses and promoting patient self-care, while also considering concerns regarding confidentiality. The patient in question is mentally capable and already has caregivers at home. It is both the patient’s preference and the most clinically sensible decision to discharge them back home. It is important to address any family concerns, ensuring that the family members have the patient’s best interests at heart rather than personal or financial motives. It is not appropriate to delegate this conversation to a nurse, as it is your responsibility as the healthcare provider. It is crucial to communicate with the patient’s general practitioner, but it is important to involve the patient in any decision regarding a referral to a nursing home.

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      4.3
      Seconds
  • Question 8 - A 25 year old third year medical student is brought into the emergency...

    Incorrect

    • A 25 year old third year medical student is brought into the emergency department for a check up after fainting while observing a prolonged delivery that required an emergency C-section. The patient complains of feeling warm and sweaty for a couple of minutes before becoming lightheaded and losing consciousness. There were no reports of loss of bladder or bowel control, and no tongue biting was observed. Physical examination reveals no focal neurological deficits and a normal cardiovascular examination. Blood pressure is 122/74 mmHg when lying down and 120/72 mmHg when standing.

      What is the probable cause of the fainting episode?

      Your Answer: Epilepsy

      Correct Answer: Vasovagal syncope

      Explanation:

      The most likely cause of the fainting episode in this 25-year-old third year medical student is vasovagal syncope. Vasovagal syncope is a common type of fainting that occurs in response to certain triggers, such as emotional stress, pain, or seeing blood. In this case, the prolonged delivery and emergency C-section likely triggered the patient’s vasovagal response.

      The patient’s symptoms of feeling warm and sweaty before fainting are consistent with vasovagal syncope. During a vasovagal episode, there is a sudden drop in blood pressure and heart rate, leading to a temporary loss of consciousness. The absence of loss of bladder or bowel control and tongue biting further support this diagnosis.

      The physical examination findings of no focal neurological deficits and a normal cardiovascular examination also align with vasovagal syncope. Additionally, the blood pressure measurements of 122/74 mmHg when lying down and 120/72 mmHg when standing suggest orthostatic hypotension, which is commonly seen in vasovagal syncope.

      Further Reading:

      Blackouts, also known as syncope, are defined as a spontaneous transient loss of consciousness with complete recovery. They are most commonly caused by transient inadequate cerebral blood flow, although epileptic seizures can also result in blackouts. There are several different causes of blackouts, including neurally-mediated reflex syncope (such as vasovagal syncope or fainting), orthostatic hypotension (a drop in blood pressure upon standing), cardiovascular abnormalities, and epilepsy.

      When evaluating a patient with blackouts, several key investigations should be performed. These include an electrocardiogram (ECG), heart auscultation, neurological examination, vital signs assessment, lying and standing blood pressure measurements, and blood tests such as a full blood count and glucose level. Additional investigations may be necessary depending on the suspected cause, such as ultrasound or CT scans for aortic dissection or other abdominal and thoracic pathology, chest X-ray for heart failure or pneumothorax, and CT pulmonary angiography for pulmonary embolism.

      During the assessment, it is important to screen for red flags and signs of any underlying serious life-threatening condition. Red flags for blackouts include ECG abnormalities, clinical signs of heart failure, a heart murmur, blackouts occurring during exertion, a family history of sudden cardiac death at a young age, an inherited cardiac condition, new or unexplained breathlessness, and blackouts in individuals over the age of 65 without a prodrome. These red flags indicate the need for urgent assessment by an appropriate specialist.

      There are several serious conditions that may be suggested by certain features. For example, myocardial infarction or ischemia may be indicated by a history of coronary artery disease, preceding chest pain, and ECG signs such as ST elevation or arrhythmia. Pulmonary embolism may be suggested by dizziness, acute shortness of breath, pleuritic chest pain, and risk factors for venous thromboembolism. Aortic dissection may be indicated by chest and back pain, abnormal ECG findings, and signs of cardiac tamponade include low systolic blood pressure, elevated jugular venous pressure, and muffled heart sounds. Other conditions that may cause blackouts include severe hypoglycemia, Addisonian crisis, and electrolyte abnormalities.

    • This question is part of the following fields:

      • Neurology
      6.5
      Seconds
  • Question 9 - You are part of the team managing a conscious patient in the emergency...

    Incorrect

    • You are part of the team managing a conscious patient in the emergency room. You decide to insert a nasopharyngeal airway adjunct. How should you determine the appropriate size of the nasopharyngeal airway?

      Your Answer: Sized according to the nostril circumference

      Correct Answer: Sized according to the distance between the nostril and the tragus of the ear

      Explanation:

      Nasopharyngeal airway adjuncts (NPAs) are selected based on their length, which should match the distance between the nostril and the tragus of the ear.

      Further Reading:

      Techniques to keep the airway open:

      1. Suction: Used to remove obstructing material such as blood, vomit, secretions, and food debris from the oral cavity.

      2. Chin lift manoeuvres: Involves lifting the head off the floor and lifting the chin to extend the head in relation to the neck. Improves alignment of the pharyngeal, laryngeal, and oral axes.

      3. Jaw thrust: Used in trauma patients with cervical spine injury concerns. Fingers are placed under the mandible and gently pushed upward.

      Airway adjuncts:

      1. Oropharyngeal airway (OPA): Prevents the tongue from occluding the airway. Sized according to the patient by measuring from the incisor teeth to the angle of the mandible. Inserted with the tip facing backwards and rotated 180 degrees once it touches the back of the palate or oropharynx.

      2. Nasopharyngeal airway (NPA): Useful when it is difficult to open the mouth or in semi-conscious patients. Sized by length (distance between nostril and tragus of the ear) and diameter (roughly that of the patient’s little finger). Contraindicated in basal skull and midface fractures.

      Laryngeal mask airway (LMA):

      – Supraglottic airway device used as a first line or rescue airway.
      – Easy to insert, sized according to patient’s bodyweight.
      – Advantages: Easy insertion, effective ventilation, some protection from aspiration.
      – Disadvantages: Risk of hypoventilation, greater gastric inflation than endotracheal tube (ETT), risk of aspiration and laryngospasm.

      Note: Proper training and assessment of the patient’s condition are essential for airway management.

    • This question is part of the following fields:

      • Basic Anaesthetics
      9.1
      Seconds
  • Question 10 - A 32-year-old traveler returns from a visit to West Africa with frequent headaches...

    Incorrect

    • A 32-year-old traveler returns from a visit to West Africa with frequent headaches and occasional fevers. Laboratory tests reveal the presence of malaria. The patient is promptly initiated on treatment, but his condition worsens, leading to the development of jaundice, renal failure, and haemoglobinuria.

      What is the MOST LIKELY organism responsible for this illness?

      Your Answer: Plasmodium ovale

      Correct Answer: Plasmodium falciparum

      Explanation:

      Malaria is a contagious illness that is spread by female mosquitoes of the Anopheles genus. It is a parasitic infection caused by the Plasmodium genus. There are five species of Plasmodium that are known to cause disease in humans: Plasmodium falciparum, Plasmodium ovale, Plasmodium vivax, Plasmodium malariae, and Plasmodium knowlesi.

      The main symptom of malaria is the malarial paroxysm, which is a recurring pattern of symptoms. It begins with a cold phase, during which the patient experiences intense chills. This is followed by a hot stage, where the patient feels extremely hot. Finally, there is a sweating stage, during which the fever subsides and the patient sweats profusely. Upon examination, the patient may exhibit signs of anemia, jaundice, and have an enlarged liver and spleen, but there is no evidence of swollen lymph nodes.

      If a patient develops haemoglobinuria (the presence of hemoglobin in the urine) and renal failure after treatment, it may indicate a condition called blackwater fever, which is caused by Plasmodium falciparum. In this condition, an autoimmune reaction occurs between the parasite and quinine, leading to the destruction of red blood cells, hemoglobinuria, jaundice, and renal failure. Blackwater fever can be life-threatening.

    • This question is part of the following fields:

      • Infectious Diseases
      9.8
      Seconds
  • Question 11 - A 32-year-old woman who is 39-weeks pregnant is brought to the Emergency Department...

    Incorrect

    • A 32-year-old woman who is 39-weeks pregnant is brought to the Emergency Department due to severe headaches, visual disturbances, and abdominal pain. Shortly after arrival, she experiences a seizure and collapses. Her husband mentions that she has been receiving treatment for hypertension during the pregnancy.

      What is the most suitable initial treatment in this case?

      Your Answer: IV lorazepam

      Correct Answer: IV magnesium sulphate

      Explanation:

      Eclampsia is the most likely diagnosis in this case. It is characterized by the occurrence of one or more convulsions on top of pre-eclampsia. To control seizures in eclampsia, the recommended treatment is magnesium sulphate. The Collaborative Eclampsia Trial regimen should be followed for administering magnesium sulphate. Initially, a loading dose of 4 g should be given intravenously over 5 to 15 minutes. This should be followed by a continuous infusion of 1 g per hour for 24 hours. If the woman experiences another eclamptic seizure, the infusion should be continued for an additional 24 hours after the last seizure. In case of recurrent seizures, a further dose of 2-4 g should be administered intravenously over 5 to 15 minutes. It is important to note that the only cure for eclampsia is the delivery of the fetus and placenta. Once the patient is stabilized, she should be prepared for an emergency caesarean section.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      10.1
      Seconds
  • Question 12 - You review a 72-year-old man who is currently on the Clinical Decision Unit...

    Incorrect

    • You review a 72-year-old man who is currently on the Clinical Decision Unit (CDU) after undergoing surgery for a hip fracture that occurred as a result of a fall. He informs you that he experienced the onset of menopause in his early 50s. His primary care physician recently arranged for a DEXA scan, and you have obtained the results from the CDU computer. The scan reveals a T-score of -3.0 standard deviations. Upon reviewing his medical history and family history, you discover that his father suffered a hip fracture in his early 60s, and the patient himself has a body mass index of 21 kg/m2.

      Which SINGLE statement regarding this case is true?

      Your Answer: She has normal bone density

      Correct Answer: She has osteoporosis and ideally should be started on a combination of treatment such as alendronate and calcichew D3 forte

      Explanation:

      Fragility fractures occur when a person experiences a fracture from a force that would not typically cause a fracture, such as a fall from a standing height or less. The most common areas for fragility fractures are the vertebrae, hip, and wrist. Osteoporosis is diagnosed when a patient’s bone mineral density, measured by a T-score on a DEXA scan, is -2.5 standard deviations or below. This T-score compares the patient’s bone density to the peak bone density of a population. In women over 75 years old, osteoporosis can be assumed without a DEXA scan. Osteopenia is diagnosed when a patient’s T-score is between -1 and -2.5 standard deviations below peak bone density. Risk factors for fractures include a family history of hip fractures, excessive alcohol consumption, and rheumatoid arthritis. Low bone mineral density can be indicated by a BMI below 22 kg/m2, untreated menopause, and conditions causing prolonged immobility or certain medical conditions. Medications used to prevent osteoporotic fractures in postmenopausal women include alendronate, risedronate, etidronate, and strontium ranelate. Raloxifene is not used for primary prevention. Alendronate is typically the first-choice medication and is recommended for women over 70 years old with confirmed osteoporosis and either a risk factor for fracture or low bone mineral density. Women over 75 years old with two risk factors or two indicators of low bone mineral density may be assumed to have osteoporosis without a DEXA scan. Other pharmacological interventions can be tried if alendronate is not tolerated.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      9.6
      Seconds
  • Question 13 - A 25-year-old individual complains of persistent and bothersome urticaria after being exposed to...

    Incorrect

    • A 25-year-old individual complains of persistent and bothersome urticaria after being exposed to latex. Despite taking an antihistamine, the itch remains severe and greatly affects their well-being.
      What is the most suitable treatment to prescribe alongside the antihistamine for this patient?

      Your Answer: Chlorpheniramine

      Correct Answer: Prednisolone

      Explanation:

      Urticaria is a skin condition characterized by red, raised, and itchy rashes that can appear in specific areas or all over the body. It is a common issue, affecting around 15% of individuals at some point in their lives. Urticaria can be either acute or chronic, with the acute form being more prevalent.

      According to the current guidelines from the National Institute for Health and Care Excellence (NICE), individuals seeking treatment for urticaria should be offered a non-sedating antihistamine from the second-generation category. Examples of second-generation antihistamines include cetirizine, loratadine, fexofenadine, desloratadine, and levocetirizine.

      It is no longer recommended to use conventional first-generation antihistamines like promethazine and chlorpheniramine for urticaria. These medications have short-lasting effects, can cause sedation and anticholinergic side effects, and may interfere with sleep, learning, and performance. They can also interact negatively with alcohol and other medications. Additionally, there have been reports of lethal overdoses with first-generation antihistamines. Terfenadine and astemizole should also be avoided as they can have harmful effects on the heart when combined with certain drugs like erythromycin and ketoconazole.

      In cases where symptoms are severe, a short course of oral corticosteroids such as prednisolone (40 mg for up to seven days) may be prescribed alongside the second-generation antihistamine.

    • This question is part of the following fields:

      • Allergy
      15.8
      Seconds
  • Question 14 - A 35-year-old woman is brought in by ambulance following a car accident where...

    Incorrect

    • A 35-year-old woman is brought in by ambulance following a car accident where her car was hit by a truck. She has sustained severe facial injuries and shows signs of airway obstruction. Her cervical spine is immobilized. She has suffered significant midface trauma, and the anesthesiologist decides to secure a definitive airway by intubating the patient.

      Which of the following does NOT indicate proper placement of the endotracheal tube?

      Your Answer: Auscultation of bilateral equal breath sounds

      Correct Answer: Presence of borborygmi in the epigastrium

      Explanation:

      The presence of borborygmi in the epigastrium can indicate that the endotracheal tube (ETT) is incorrectly placed in the esophagus. There are several ways to verify the correct placement of the endotracheal tube (ETT).

      One method is through direct visualization, where the ETT is observed passing through the vocal cords. Another method is by checking for fogging in the ETT, which can indicate proper placement. Auscultation of bilateral equal breath sounds is also a reliable way to confirm correct ETT placement.

      Additionally, the absence of borborygmi in the epigastrium is a positive sign that the ETT is in the correct position. Capnography or using a CO2 detector can provide further confirmation of proper ETT placement. Finally, chest radiography can be used to visually assess the placement of the endotracheal tube.

    • This question is part of the following fields:

      • Basic Anaesthetics
      8.9
      Seconds
  • Question 15 - You evaluate a 60-year-old man with a previous diagnosis of hearing impairment.
    Which tuning...

    Incorrect

    • You evaluate a 60-year-old man with a previous diagnosis of hearing impairment.
      Which tuning fork should be utilized to conduct a Weber's test on this individual?

      Your Answer: 256 Hz

      Correct Answer: 512 Hz

      Explanation:

      A 512 Hz tuning fork is recommended for conducting both the Rinne’s and Weber’s tests. However, a lower-pitched 128 Hz tuning fork is commonly used to assess vibration sense during a peripheral nervous system examination. Although a 256 Hz tuning fork can be used for both tests, it is considered less reliable.

      To perform the Weber’s test, the 512 Hz tuning fork should be set in motion and then placed on the center of the patient’s forehead. The patient should be asked if they perceive the sound in the middle of their forehead or if it is heard more on one side.

      If the sound is heard more on one side, it may indicate either ipsilateral conductive hearing loss or contralateral sensorineural hearing loss.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      8.9
      Seconds
  • Question 16 - A 45-year-old man comes to the Emergency Department with a painful rash that...

    Incorrect

    • A 45-year-old man comes to the Emergency Department with a painful rash that seems to be indicative of shingles. The rash is vesicular in nature and affects a single dermatome.

      What is the most frequent location of reactivation of the varicella zoster virus in individuals with a healthy immune system?

      Your Answer: Mandibular division of the trigeminal nerve

      Correct Answer: Thoracic nerves

      Explanation:

      Shingles is caused by the varicella-zoster virus (VZV), which primarily infects individuals during childhood as chickenpox. However, the initial infection can also be subclinical. After the primary infection, the virus remains dormant in the sensory nervous system, specifically in the geniculate, trigeminal, or dorsal root ganglia.

      During the dormant phase, the virus is kept under control by the immune system for many years. However, it can later become active and cause a flare-up in a specific dermatomal segment. This reactivation occurs when the virus travels down the affected nerve over a period of 3 to 5 days, leading to inflammation within and around the nerve. The decline in cell-mediated immunity is believed to trigger the virus’s reactivation.

      Several factors can trigger the reactivation of the varicella-zoster virus, including advancing age (with most patients being older than 50), immunosuppressive illnesses, physical trauma, and psychological stress. In immunocompetent patients, the most common site of reactivation is the thoracic nerves, followed by the ophthalmic division of the trigeminal nerve.

      Diagnosing shingles can usually be done based on the patient’s history and clinical examination alone, as it has a distinct history and appearance. While various techniques can be used to detect the virus or antibodies, they are often unnecessary. Microscopy and culture tests using scrapings and smears typically yield negative results.

    • This question is part of the following fields:

      • Dermatology
      7.6
      Seconds
  • Question 17 - A 3-year-old boy has been brought into the Emergency Department having seizures that...

    Incorrect

    • A 3-year-old boy has been brought into the Emergency Department having seizures that have lasted for 25 minutes prior to his arrival. On arrival, he is continuing to have a tonic-clonic seizure.
      What dose of phenytoin is recommended in the treatment of the convulsing child that reaches that stage of the APLS algorithm?

      Your Answer: 100 mg/kg over 20 minutes

      Correct Answer: 20 mg/kg over 20 minutes

      Explanation:

      If a child who is experiencing convulsions reaches step 3 of the APLS algorithm, it is recommended to prepare a phenytoin infusion. This infusion should be administered at a dosage of 20 mg/kg over a period of 20 minutes.

    • This question is part of the following fields:

      • Neurology
      10.5
      Seconds
  • Question 18 - A 60-year-old woman comes in with severe left eye pain and loss of...

    Incorrect

    • A 60-year-old woman comes in with severe left eye pain and loss of vision in the left eye. After conducting a comprehensive examination and measuring the intraocular pressure, you diagnose her with acute closed-angle glaucoma.
      Which of the following statements about acute closed-angle glaucoma is correct?

      Your Answer: The mainstay of treatment is topical acetazolamide applied to the affected eye

      Correct Answer: intraocular pressures are often greater than 30 mmHg

      Explanation:

      This patient has presented with acute closed-angle glaucoma, which is a medical emergency in the field of ophthalmology. It occurs when the iris bows forward and blocks the fluid access to the trabecular meshwork, which is located at the entrance to Schlemm’s canal. As a result, the intraocular pressure rises and leads to glaucomatous optic neuropathy.

      The main clinical features of acute closed-angle glaucoma include severe eye pain, loss of vision or decreased visual acuity, congestion and redness around the cornea, corneal swelling, a fixed semi-dilated oval-shaped pupil, nausea and vomiting, and preceding episodes of blurred vision or seeing haloes.

      The diagnosis can be confirmed by tonometry, which measures the pressure inside the eye. The normal range of intraocular pressure is 10-21 mmHg, but in acute closed-angle glaucoma, it is often higher than 30 mmHg. Goldmann’s applanation tonometer is commonly used in hospitals for this purpose.

      Management of acute closed-angle glaucoma should include providing pain relief, such as morphine, and antiemetics if the patient is experiencing vomiting. Intravenous administration of acetazolamide 500 mg is recommended to reduce intraocular pressure. Treatment with a topical miotic, like pilocarpine 1% or 2%, should be initiated approximately one hour after starting other measures, as the pupil may initially be paralyzed and unresponsive.

      On the other hand, chronic open-angle glaucoma is a more common presentation than acute closed-angle glaucoma. It affects approximately 1 in 50 people over the age of 40 and 1 in 10 people over the age of 75. In this condition, there is a partial blockage within the trabecular meshwork, which hinders the drainage of aqueous humor and gradually increases intraocular pressure, leading to optic neuropathy. Unlike acute closed-angle glaucoma, chronic open-angle glaucoma does not cause eye pain or redness. It presents gradually with a progressive loss of peripheral vision, while central vision is relatively preserved.

    • This question is part of the following fields:

      • Ophthalmology
      11.3
      Seconds
  • Question 19 - A 35-year-old traveler returns from a vacation in India with a high temperature...

    Incorrect

    • A 35-year-old traveler returns from a vacation in India with a high temperature and stomach issues. After medical examination, he is confirmed to have typhoid fever.

      Your Answer: Diarrhoea is the most common bowel disturbance in the early stages

      Correct Answer: The incubation period is between 7 and 21 days

      Explanation:

      Typhoid fever is a bacterial infection caused by Salmonella typhi. Paratyphoid fever, on the other hand, is a similar illness caused by Salmonella paratyphi. Together, these two conditions are collectively known as the enteric fevers.

      Typhoid fever is prevalent in India and many other parts of Asia, Africa, Central America, and South America. It is primarily transmitted through the consumption of contaminated food or water that has been infected by the feces of an acutely infected or recovering person, or a chronic carrier. About 1-6% of individuals infected with S. typhi become chronic carriers. The incubation period for this illness ranges from 7 to 21 days.

      During the first week of the illness, patients experience weakness and lethargy, accompanied by a gradually increasing fever. The onset of the illness is usually subtle, and constipation is more common than diarrhea in the early stages. Other early symptoms include headaches, abdominal pain, and nosebleeds. In cases of typhoid fever, the fever can occur with a relatively slow heart rate, known as Faget’s sign.

      As the illness progresses into the second week, patients often become too fatigued to get out of bed. Diarrhea becomes more prominent, the fever intensifies, and patients may become agitated and delirious. The abdomen may become tender and swollen, and approximately 75% of patients develop an enlarged spleen. In up to a third of patients, red macules known as Rose spots may appear.

      In the third week, the illness can lead to various complications. Intestinal bleeding may occur due to bleeding in congested Peyer’s patches. Other potential complications include intestinal perforation, secondary pneumonia, encephalitis, myocarditis, metastatic abscesses, and septic shock.

      After the third week, surviving patients begin to show signs of improvement, with the fever and symptoms gradually subsiding over the course of 7-14 days. Untreated patients have a mortality rate of 15-30%. Traditionally, drugs like ampicillin and trimethoprim have been used for treatment. However, due to the emergence of multidrug resistant cases, azithromycin or fluoroquinolones are now the primary treatment options.

    • This question is part of the following fields:

      • Infectious Diseases
      9.6
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  • Question 20 - A 65-year-old woman with a history of chronic alcohol abuse is diagnosed with...

    Incorrect

    • A 65-year-old woman with a history of chronic alcohol abuse is diagnosed with Wernicke's encephalopathy. You have been requested to assess the patient and initiate her treatment.
      What condition will she develop if she goes untreated?

      Your Answer:

      Correct Answer: Korsakoff psychosis

      Explanation:

      Wernicke’s encephalopathy is a condition that is commonly associated with alcohol abuse and other causes of thiamine deficiency. It is characterized by a triad of symptoms, including acute confusion, ophthalmoplegia (paralysis or weakness of the eye muscles), and ataxia (loss of coordination). Additional features may include papilloedema (swelling of the optic disc), hearing loss, apathy, dysphagia (difficulty swallowing), memory impairment, and hypothermia. Most cases also involve peripheral neuropathy, which typically affects the legs.

      The condition is caused by capillary hemorrhages, astrocytosis (abnormal increase in astrocytes, a type of brain cell), and neuronal death in the upper brainstem and diencephalon. These changes can be visualized using MRI scanning, although CT scanning is not very useful for diagnosis.

      If left untreated, most patients with Wernicke’s encephalopathy will develop Korsakoff psychosis. This condition is characterized by retrograde amnesia (loss of memory for events that occurred before the onset of amnesia), an inability to form new memories, disordered time perception, and confabulation (fabrication of false memories).

      Patients suspected of having Wernicke’s encephalopathy should receive parenteral thiamine (such as Pabrinex) for at least 5 days. Oral thiamine should be administered after the parenteral therapy.

      It is important to note that in patients with chronic thiamine deficiency, the infusion of glucose-containing intravenous fluids without thiamine can trigger the development of Wernicke’s encephalopathy.

    • This question is part of the following fields:

      • Neurology
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SESSION STATS - PERFORMANCE PER SPECIALTY

Pharmacology & Poisoning (2/2) 100%
Urology (1/1) 100%
Resus (1/1) 100%
Basic Anaesthetics (3/3) 100%
Safeguarding & Psychosocial Emergencies (0/1) 0%
Neurology (2/3) 67%
Infectious Diseases (1/2) 50%
Obstetrics & Gynaecology (1/1) 100%
Elderly Care / Frailty (1/1) 100%
Allergy (1/1) 100%
Ear, Nose & Throat (0/1) 0%
Dermatology (1/1) 100%
Ophthalmology (1/1) 100%
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