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Question 1
Incorrect
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A 35-year-old male presents to the emergency department with a 72 hour history of lethargy, fever, and a sore throat. The nurse reports that his breathing is harsh and high pitched. His vital signs show a temperature of 39.4°C and an elevated respiratory and heart rate. What is the probable diagnosis?
Your Answer: Anaphylaxis
Correct Answer: Bacterial tracheitis
Explanation:Addressing Stridor and Other Airway Sounds
Added airway sounds, particularly stridor, should always be treated as a medical emergency. Stridor is a sign of a compromised upper airway and is heard predominantly on inspiration. It is important to note that stridor is not a diagnosis but a symptom, and the underlying cause must be identified urgently. The patient’s medical history is crucial in determining the correct diagnosis as all the causes listed above can present with stridor.
In children, croup caused by the parainfluenza 1 virus is the most common reason for stridor. However, stridor in adults should prompt the clinician to consider other diagnoses. If the patient appears toxic with worsening lethargy, pyrexia, and overt deterioration of the upper airway, bacterial tracheitis is the most likely cause. Diphtheria can also cause stridor, but immunization programs have reduced its incidence in the western world.
Laryngospasm is a common cause of stridor in adults, but the clinician must seek a relevant precipitant. Exposure to smoke and toxic fumes in the patient’s history should raise a high degree of suspicion and prompt the clinician to involve the anaesthetic teams in securing the patient’s airway. Foreign body aspiration and anaphylaxis are both life-threatening conditions that must be considered and excluded. The duration and onset of the stridor will be a key factor in determining the diagnosis. An abrupt onset with a history of eating nuts or chewing on a pen lid or plastic bead is often present in foreign body aspiration, while anaphylaxis may have a defined food precipitant and a more rapid onset than other conditions.
Overall, addressing stridor and other airway sounds requires urgent attention and a thorough evaluation of the patient’s medical history to determine the underlying cause.
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This question is part of the following fields:
- Emergency Medicine
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Question 2
Incorrect
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As a foundation year doctor, you have been requested by the resuscitation nurse to prescribe Tazocin in accordance with departmental policy for a 50-year-old patient with COPD who was previously seen by your colleague and is currently undergoing treatment for severe sepsis. However, ten minutes later, you receive a fast bleep to the resuscitation room where the patient is now experiencing hypotension, tachycardia, and developing a urticarial rash and wheezing. The patient's medical records indicate that they have an allergy to penicillin. What is the next therapeutic measure you will prescribe?
Your Answer: Hydrocortisone 200 mg intravenously
Correct Answer: Adrenaline 500 mcg 1:1000 intramuscularly
Explanation:Anaphylaxis: A Life-Threatening Hypersensitivity Reaction
Anaphylaxis is a severe and life-threatening hypersensitivity reaction that affects the airway, breathing, and circulation of an individual. It is crucial for clinicians to keep this diagnosis in mind as it has a lifetime prevalence ranging from 0.05-2%, and most clinicians will encounter this condition at some point in their career. The most common precipitants of anaphylaxis are antibiotics and anaesthetic drugs, followed by stings, nuts, foods, and contrast agents.
In a scenario where a patient has been prescribed a penicillin-based antibiotic despite having a documented penicillin allergy, the acute onset of life-threatening airway, breathing, and circulation issues, along with a rash, are classic symptoms of anaphylaxis. In such cases, adrenaline must be administered urgently, preferably intramuscularly, at a dose of 500 mcg 1:1000, repeated after five minutes if there is no improvement. Hydrocortisone and chlorpheniramine are also given, but their effects are seen approximately four to six hours post-administration. It is essential to note that these drugs should not delay the administration of adrenaline in suspected anaphylaxis.
It is crucial to review patient notes and drug charts carefully before prescribing drugs, especially when taking over care of patients from other clinicians. It is the responsibility of the prescriber and the nurse administering the medication to check and re-check the patient’s allergy status. Finally, the Tazocin must be stopped as soon as possible, and an alternative antibiotic prescribed according to local sepsis policies. However, this is a secondary issue to the acute anaphylaxis.
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This question is part of the following fields:
- Emergency Medicine
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Question 3
Incorrect
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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: Ecstasy
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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This question is part of the following fields:
- Emergency Medicine
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Question 4
Incorrect
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A 57-year-old woman presents to the Emergency department with increasing lethargy. She has a history of drinking a bottle of vodka daily and has been experiencing persistent vomiting for the past week.
On examination, her pulse is 96/min and blood pressure is 109/70 mmHg. The following blood results are obtained:
- pH 7.32 (7.36-7.44)
- PaO2 12.0 kPa (11.3-12.6)
- PaCO2 3.1 kPa (4.7-6.0)
- Standard bicarbonate 10 mmol/L (20-28)
- Base excess −8 mmol/L (+/−2)
- Lactate 1.2 mmol/L (0.5-2.2)
- Sodium 142 mmol/L (137-144)
- Potassium 3.4 mmol/L (3.5-4.9)
- Urea 6.5 mmol/L (2.5-7.5)
- Creatinine 72 µmol/L (60-110)
- Plasma glucose 3.4 mmol/L (3.0-6.0)
- Urine analysis Ketones +++
What is the most appropriate treatment for this patient?Your Answer: IV 5% dextrose plus 40 mmoles potassium chloride followed by thiamine
Correct Answer: IV thiamine followed by 5% dextrose plus 40 mmoles potassium chloride
Explanation:Treatment for Starvation Ketosis in Alcoholic Abuse Patients
Alcoholic abuse patients with starvation ketosis exhibit low pH, low bicarbonate, low base excess, and compensatory low PaCO2. The appropriate treatment for this condition is intravenous (IV) dextrose. However, it is important to note that glucose can trigger Wernicke’s encephalopathy, a neurological disorder that affects the brain’s ability to process information. Therefore, before administering IV dextrose, patients with alcoholic abuse and starvation ketosis require initial treatment with IV Pabrinex.
In summary, patients with alcoholic abuse and starvation ketosis require prompt medical attention to prevent further complications. The treatment involves administering IV Pabrinex before IV dextrose to avoid triggering Wernicke’s encephalopathy. This approach can help stabilize the patient’s condition and prevent further health complications.
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This question is part of the following fields:
- Emergency Medicine
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Question 5
Incorrect
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According to the Glasgow coma scale (GCS), what does a verbal score of 1 indicate?
Your Answer: Incomprehensible sounds
Correct Answer: No response
Explanation:The Glasgow coma scale is a scoring system used to assess the level of consciousness of a patient. It ranges from 3 to 15, with 3 being the worst and 15 being the best. The scale is made up of three parameters: best eye response, best verbal response, and best motor response.
The best eye response is determined by how the patient reacts to visual stimuli, such as opening their eyes spontaneously or in response to a command. The best verbal response is graded on a scale of 1 to 5, with 1 being no response and 5 being an oriented patient who can answer questions appropriately. Finally, the best motor response is assessed by observing the patient’s movements, such as their ability to follow commands or move in response to pain.
Overall, the Glasgow coma scale is an important tool for healthcare professionals to assess the level of consciousness of a patient and determine the severity of their condition. By the different parameters and scores, medical professionals can provide appropriate treatment and care for their patients.
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This question is part of the following fields:
- Emergency Medicine
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Question 6
Correct
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Which of the following is the least likely to worsen bronchospasm in severe asthma?
Your Answer: Alfentanil
Explanation:Safe and Unsafe Medications for Asthmatics
Alfentanil is a type of painkiller that belongs to the opioid family. It is commonly used during the induction of anesthesia and is considered safe for asthmatics. Adenosine, on the other hand, is a medication that can cause wheezing and bronchospasm, making it unsuitable for asthmatics. It can also cause other unpleasant side effects and is therefore contraindicated.
Diclofenac is a non-steroidal anti-inflammatory drug (NSAID) that should not be given to patients with a history of asthma or those whose symptoms have worsened following aspirin. This is because it can trigger an asthma attack and worsen the symptoms. Labetalol, a beta-blocker, is also contraindicated for asthmatics.
Morphine is another medication that should be used with caution in asthmatics. It can release histamine, which can make bronchospasm worse.
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This question is part of the following fields:
- Emergency Medicine
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Question 7
Incorrect
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A 33-year-old male presents to the Emergency department with complaints of severe chest pain that has been ongoing for an hour. Upon examination, he is tall and slim with a blood pressure reading of 135/80 mmHg and an early diastolic murmur. The electrocardiogram reveals 1 mm ST elevation in II, III, and aVF. What is the best course of action in this situation?
Your Answer: Enoxaparin plus 300 mg of aspirin and 300 mg of clopidogrel
Correct Answer: Urgent CT scan of chest
Explanation:Differential Diagnosis for a Young Patient with Chest Pain
This patient’s presentation of chest pain may not be typical and could potentially be caused by an inferior myocardial infarction or aortic artery dissection. However, thrombolysis could be dangerous and should be avoided until a proper diagnosis is made. Due to the patient’s young age, a wide range of potential diagnoses should be considered.
The patient’s physical characteristics, including being tall and slim with an aortic diastolic murmur, suggest the possibility of Marfan’s syndrome and aortic dissection. To confirm this diagnosis, a thorough examination of all peripheral pulses should be conducted, as well as checking for discrepancies in blood pressure between limbs. Additionally, a plain chest x-ray should be scrutinized for signs of a widened mediastinum, an enlarged cardiac silhouette, or pleural effusions.
In summary, a young patient presenting with chest pain requires a thorough differential diagnosis to determine the underlying cause. Careful examination of physical characteristics and diagnostic tests can help identify potential conditions such as Marfan’s syndrome and aortic dissection, and avoid potentially harmful treatments like thrombolysis.
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This question is part of the following fields:
- Emergency Medicine
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Question 8
Incorrect
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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: Refer the patient for emergency admission
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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This question is part of the following fields:
- Emergency Medicine
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Question 9
Incorrect
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A 16-year-old boy is brought to the Emergency department by his parents. He has no past medical history of note.
In his parents' absence, he reveals that he took an overdose of paracetamol after a fight with his girlfriend, but did not intend to end his life.
What is the most reliable indicator of the extent of liver damage?Your Answer: Quantity of paracetamol ingested
Correct Answer: INR
Explanation:Management of Paracetamol Overdose
Paracetamol overdose is a common occurrence that requires prompt management. The first step is to check the paracetamol level four hours after ingestion and compare it against the Rumack-Matthew nomogram. If a large dose (more than 7.5 g) was ingested and/or the patient presents within eight hours of ingestion, gastric lavage may be necessary, and oral charcoal should be considered. N-acetylcysteine or methionine should be administered, and bowel movements should be monitored hourly.
It is crucial to check the INR 12 hourly and look out for signs of poor prognosis, which may indicate the need for transfer to a liver unit. These signs include an INR greater than 2.0 within 48 hours or greater than 3.5 within 72 hours of ingestion, creatinine greater than 200 µmol/L, blood pH less than 7.3, signs of encephalopathy, and hypotension (SBP less than 80 mmHg).
It is important to note that liver enzymes are not a reliable indicator of the degree of hepatocellular damage. Instead, synthetic function, as determined by INR or PT, is the best indicator. Proper management of paracetamol overdose can prevent severe liver damage and improve patient outcomes.
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This question is part of the following fields:
- Emergency Medicine
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Question 10
Incorrect
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What virus has a single stranded RNA genome and a 3% vertical transmission rate through blood?
Your Answer: Hepatitis D
Correct Answer: Hepatitis C
Explanation:Different Types of Hepatitis and CMV Infections
Cytomegalovirus (CMV) is a type of DNA herpes virus that infects 50-80% of adults. It is a common and widespread infection.
Hepatitis A, on the other hand, is a picornavirus that spreads through the fecal-oral route. This virus has a single-stranded, positive-sense genome.
Hepatitis B is a member of the Hepadnaviridae family and has a unique partially double-stranded circular genome. It has a high vertical transmission rate of 90%, meaning it can easily be passed from mother to child during childbirth.
Lastly, Hepatitis D is an incomplete virus with a small RNA genome. It can only infect patients who are already infected with Hepatitis B (HBV).
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This question is part of the following fields:
- Emergency Medicine
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Question 11
Incorrect
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A 40-year-old male presents to the clinic with sudden onset of headache while engaging in sexual activity. He reports no focal neurological symptoms but complains of neck stiffness. What is the best course of action for management?
Your Answer: Neurological observation and only scan if GCS is altered
Correct Answer: CT head scan
Explanation:Diagnosis of Subarachnoid Hemorrhage
When a patient is suspected of having subarachnoid hemorrhage (SAH), the initial diagnostic test should be a computerised tomography (CT) head scan. This test can identify over 93% of SAH cases within 24 hours. However, if the CT scan is normal or inconclusive and there is still a high clinical suspicion of SAH, a lumbar puncture should be performed.
During the lumbar puncture, cerebrospinal fluid (CSF) is collected in four tubes and the red blood cell (RBC) count is determined in tubes one and four. If the RBC count does not decrease between these tubes and there is an elevated opening pressure, along with the development of xanthochromia (which may take up to 12 hours from the onset of headache), SAH is suggested. It is important to note that a Glasgow coma scale score of 15 does not rule out SAH.
While magnetic resonance imaging (MRI) may be a useful diagnostic tool, it takes too long to arrange and CT head scans are an excellent first line investigation for SAH. Early diagnosis and treatment of SAH is crucial for improving patient outcomes.
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This question is part of the following fields:
- Emergency Medicine
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Question 12
Incorrect
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A 35-year-old woman presents with sudden chest pain and difficulty breathing. She recently returned from a trip to Italy with her family. She has no significant medical history but takes oral contraceptives. On examination, her pulse is 100 bpm, temperature is 37°C, oxygen saturation is 95%, respiratory rate is 28/min, and blood pressure is 116/76 mmHg. Chest examination is unremarkable and chest x-ray is normal. What is the most appropriate diagnostic test to confirm the diagnosis?
Your Answer: Troponin T concentration
Correct Answer: CTPA scan
Explanation:Diagnosis of Pulmonary Embolism in a Woman with Chest Pain and Dyspnoea
This woman is experiencing chest pain and difficulty breathing, with a rapid heart rate and breathing rate. However, there are no visible signs on chest examination and her chest x-ray appears normal. Despite having no fever, her oxygen levels are lower than expected for a healthy person. To rule out a pulmonary embolism, doctors must consider risk factors such as recent air travel and use of oral contraceptives.
The gold standard for diagnosing a pulmonary embolism is a CT pulmonary angiogram, as it can detect even large saddle emboli near the pulmonary arteries. While VQ scanning was previously used, it can miss these larger emboli. Additionally, doctors may perform Doppler ultrasounds of the venous system to check for deep vein thrombosis.
This presentation is not indicative of atypical pneumonia, such as Legionella, as the patient’s temperature would be expected to be high and chest signs would be present. Overall, a thorough evaluation is necessary to accurately diagnose and treat a pulmonary embolism in a patient with chest pain and dyspnoea.
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This question is part of the following fields:
- Emergency Medicine
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Question 13
Incorrect
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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: Adrenaline nebuliser 5 mg 1:1000
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.
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This question is part of the following fields:
- Emergency Medicine
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Question 14
Incorrect
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A 28-year-old accountant presents to the Emergency department with a sudden and severe headache that started six hours ago. She also reports feeling nauseous and has vomited three times. Upon examination, she has neck stiffness and photophobia, but her GCS is 15 and she has no fever. What is the most probable diagnosis?
Your Answer: Meningitis
Correct Answer: Subarachnoid haemorrhage
Explanation:Diagnosing Severe Headaches: Subarachnoid Hemorrhage and Differential Diagnosis
The sudden onset of a severe headache is a strong indication of subarachnoid hemorrhage, which can be confirmed through a head CT scan. If the scan is normal, a lumbar puncture should be performed to check for red blood cells and xanthochromia. Bacterial meningitis is also a possible diagnosis, but it typically presents with other symptoms of sepsis such as fever. Migraines, on the other hand, are usually preceded by an aura and visual disturbances, and are often associated with prior history and risk factors. Sinusitis and cluster headaches are not suggested by the patient’s history.
Overall, it is important to consider a range of potential diagnoses when evaluating severe headaches, as prompt and accurate diagnosis is crucial for effective treatment.
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This question is part of the following fields:
- Emergency Medicine
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Question 15
Correct
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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: 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.
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This question is part of the following fields:
- Emergency Medicine
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Question 16
Incorrect
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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: Renal colic
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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This question is part of the following fields:
- Emergency Medicine
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Question 17
Incorrect
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A 48-year-old woman presented to the general medical clinic with a complaint of progressive diffuse myalgia and weakness that had been ongoing for three months. She reported experiencing difficulty walking up and down stairs due to weakness in her shoulder muscles and thighs. Her medical history included hypertension and hyperlipidemia, for which she took atenolol and simvastatin regularly. On examination, there were no abnormalities in the cranial nerves or detectable neck weakness. However, there was general myalgia in the upper limbs and proximal weakness of 3/5 with preserved distal power. A similar pattern of weakness was observed in the lower limbs with preserved tone, reflexes, and sensation.
The following investigations were conducted: haemoglobin, white cell count, platelets, ESR (Westergren), serum sodium, serum potassium, serum urea, serum creatinine, plasma lactate, serum creatine kinase, fasting plasma glucose, serum cholesterol, plasma TSH, plasma T4, and plasma T3. Urinalysis was normal.
Based on these findings, what is the likely diagnosis?Your Answer: McArdle's disease
Correct Answer: Statin-induced myopathy
Explanation:Statins and Muscle Disorders
Myalgia, myositis, and myopathy are all known side effects of HMG-CoA reductase inhibitors, commonly known as statins. The risk of these muscle disorders increases when statins are taken in combination with a fibrate or with immunosuppressants. If therapy is not discontinued, rhabdomyolysis may occur, which can lead to acute renal failure due to myoglobinuria. Inclusion body myositis is a type of inflammatory myopathy that causes weakness in a distal and asymmetric pattern. On the other hand, McArdle’s disease is an autosomal recessive condition that typically presents in children with painful muscle cramps and myoglobinuria after intense exercise. This condition is caused by a deficiency in myophosphorylase, which impairs the body’s ability to utilize glucose. There are no additional neurological symptoms to suggest a mitochondrial disorder, and the plasma lactate level is normal. Finally, neuroleptic malignant syndrome is a rare but serious side effect of antipsychotic medication.
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This question is part of the following fields:
- Emergency Medicine
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Question 18
Incorrect
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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: Mycoplasma pneumoniae
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.
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This question is part of the following fields:
- Emergency Medicine
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Question 19
Correct
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As the foundation year doctor in general surgery, you are called to assess a patient who has suddenly become unresponsive at 4 am. The patient is a 45-year-old female who has been admitted for an elective cholecystectomy scheduled for 8 am.
Upon examination, the patient appears sweaty and clammy and is hypoventilating. She is only responsive to painful stimuli.
The patient's vital signs are as follows: heart rate of 115, blood pressure of 110/70 mmHg, respiratory rate of 8, oxygen saturation of 99%, and blood glucose level of 1.1.
What would be your next step in initiating drug therapy?Your Answer: Dextrose 20% 100 ml IV
Explanation:Hypoglycaemia: The Importance of Early Recognition and Management
Clinicians should always consider hypoglycaemia as a potential cause of acute unresponsiveness in patients. The diagnosis of hypoglycaemia is made when there is evidence of low blood sugar, associated symptoms, and resolution of symptoms with correction of hypoglycaemia. The management of hypoglycaemia should be prompt and involves administering 100 ml of 20% dextrose, as opposed to 50%, which can be too irritating to the veins. Repeat blood sugar measurements should be taken to ensure that levels remain above 3.0.
In patients who are fasting overnight for surgery, intravenous fluids should be prescribed with close monitoring of blood sugars to determine whether slow 5% dextrose is required to maintain an acceptable blood sugar level. Glucagon and Hypostop are alternative therapies used to increase glucose levels, but they are not rapid rescue drugs for the correction of low sugars in symptomatic patients.
To identify the cause of hypoglycaemia, the acronym EXPLAIN is used. This stands for Exogenous insulin administration, Pituitary insufficiency, Liver failure, Alcohol/Autoimmune/Addison’s, Insulinoma, and Neoplasia. All episodes of hypoglycaemia require an explanation, and further endocrine workup may be necessary if no cause is identified.
In conclusion, early recognition and management of hypoglycaemia is crucial in preventing further deterioration of the patient’s condition. Clinicians should always consider hypoglycaemia as a potential cause of acute unresponsiveness and promptly administer appropriate treatment.
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This question is part of the following fields:
- Emergency Medicine
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Question 20
Incorrect
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A 48-year-old woman is brought to the Emergency department by emergency ambulance following a deliberate overdose of an unknown drug.
She is accompanied by her husband who tells you that she has a long history of anxiety and depression and takes fluoxetine 20 mg od and lorazepam 2 mg bd.
On primary assessment, her airway is clear but she only groans when sternal rub is applied. Her chest is clear to auscultation but her respiratory rate is 6 ventilations per minute and oxygen saturations are 93% on air.
Heart sounds are normal with a rate of 80 bpm and blood pressure is 82/44 mmHg. ECG shows sinus rhythm. Capillary blood glucose is 6.3 mmol/L. Her GCS is 8/15 (E1, V2, M5) but her pupils are slowly reactive bilaterally and size 4. All limbs appear to move equally and there is no apparent injury. She smells of alcohol.
What is the first most appropriate step in the immediate management of this patient?Your Answer: Administer intravenous naloxone 400 mcg then further doses of 200 mcg dependent on response
Correct Answer: Insert a nasopharyngeal airway and commence high flow oxygen
Explanation:The ABCDE approach is important for assessing acutely unwell patients. Protecting the airway is paramount in this case, as the patient’s level of consciousness threatens it. Oxygen and a nasopharyngeal airway are the first steps. Flumazenil and naloxone are not indicated, as the drug taken is unknown and opioid overdose is unlikely. Activated charcoal may not be effective if the time of ingestion is unknown. Prophylactic intubation is reasonable but not mandatory. Arterial blood gases can help determine ventilation, but supplemental oxygen and airway adjuncts are reasonable first steps.
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This question is part of the following fields:
- Emergency Medicine
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Question 21
Correct
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A 25-year-old homosexual male has tested positive for both IgM anti-HBc antibody and hepatitis B surface antigens. What is his current disease state?
Your Answer: Acutely infected
Explanation:Hepatitis B and its Markers
Hepatitis B surface antigen is a marker that indicates the presence of the hepatitis B virus in the cells of the host. This marker is present in both chronic and acute infections. Patients infected with hepatitis B will produce antibodies to the core antigen. IgM antibodies are indicative of acute infection and are not present in chronic infections. On the other hand, IgG antibodies to the core antigen are present even after the infection has been cleared.
Antibodies to the surface antigen are produced in individuals who have been vaccinated against hepatitis B. This confers natural immunity once the infection has been cleared. the markers of hepatitis B is crucial in diagnosing and managing the infection. It is important to note that chronic hepatitis B can lead to serious liver damage and even liver cancer if left untreated. Therefore, early detection and treatment are essential in preventing complications.
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This question is part of the following fields:
- Emergency Medicine
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Question 22
Incorrect
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A 65-year-old man with lung cancer was admitted to the Emergency department due to respiratory distress. Upon examination, his ECG revealed electrical alternans. What is the most probable diagnosis for this patient?
Your Answer: Pleural effusion
Correct Answer: Cardiac tamponade
Explanation:Pericardial Tamponade: Commonly Caused by Malignant Diseases
Pericardial tamponade is a condition where the pericardium, the sac surrounding the heart, becomes filled with fluid or blood, putting pressure on the heart and preventing it from functioning properly. Malignant diseases are the most common cause of pericardial tamponade, often resulting from malignant infiltration associated with a large effusion. However, tamponade can also occur as a result of any type of pericarditis.
When pericardial tamponade occurs, the heart is unable to pump blood effectively, leading to symptoms such as shortness of breath, chest pain, and low blood pressure. Diagnosis is typically made through imaging tests such as echocardiography or CT scans.
On an electrocardiogram (ECG), sinus tachycardia, low volume, and electrical alternans – variability of the complexes – are often observed. Treatment for pericardial tamponade typically involves draining the fluid or blood from the pericardium, either through a needle or a surgical procedure. In severe cases, emergency surgery may be necessary to prevent further damage to the heart.
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This question is part of the following fields:
- Emergency Medicine
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Question 23
Incorrect
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A 50-year-old runner experiences chest pain and collapses while jogging. He is brought to the Emergency department within an hour. Upon arrival, he is conscious and given a sublingual nitrate which provides some relief. His heart rate is 90 beats per minute and his blood pressure is 120/85 mmHg. An ECG reveals 3 mm of ST segment elevation in leads II, III, AVF, V5 and V6. What is the most appropriate next step in managing this patient?
Your Answer: An exercise stress test to rule out ischaemia as the cause of his symptoms
Correct Answer: Admission for cardiac catheterisation and percutaneous transluminal coronary angioplasty
Explanation:Initial and Long-Term Treatment for Inferolateral ST-Elevation MI
The patient’s history and ECG findings suggest that they are experiencing an Inferolateral ST-elevation MI. The best initial treatment for this condition would be percutaneous coronary intervention. It is likely that the patient would have already received aspirin in the ambulance.
For long-term treatment, the patient will require dual antiplatelet therapy, such as aspirin and clopidogrel, a statin, a beta blocker, and an ACE-inhibitor. These medications will help manage the patient’s condition and prevent future cardiac events.
It is important to follow the NICE guideline for Acute Coronary Syndrome to ensure that the patient receives the appropriate treatment and care. By following these guidelines, healthcare professionals can help improve the patient’s prognosis and quality of life.
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This question is part of the following fields:
- Emergency Medicine
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Question 24
Correct
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A 22-year-old woman is discovered by her roommates in a confused, drowsy, and sweaty state in her bedroom. She is unable to provide a clear medical history. Upon examination, she has a fever of 38.3°C, a heart rate of 110 bpm, a blood pressure of 110/60 mmHg, and appears to be short of breath with a respiratory rate of 30. There is no stiffness in her neck, and her chest sounds clear upon auscultation. An arterial blood gas test taken with 15 l/min oxygen shows a pH of 7.29 (7.35-7.45), Pa O2 of 37 kPa (11-14), PaCO2 of 2.1 kPa (4.5-6), and lactate of 2.4 mmol/L (0.1-2.5). What is the most probable diagnosis?
Your Answer: Aspirin overdose
Explanation:Signs of Aspirin Toxicity
Aspirin toxicity can be identified through several symptoms such as fever, sweating, tachypnoea, and acidosis. These signs indicate that the body is experiencing an overdose of aspirin. The presence of confusion is a clear indication of severe overdose. On the other hand, hypoxia is expected in severe asthma and Legionella pneumonia.
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This question is part of the following fields:
- Emergency Medicine
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Question 25
Correct
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A 57-year-old male presents to the cardiology clinic with complaints of weight loss, lethargy, and diarrhea. Upon examination, he is found to be tremulous, tachycardic, and has a palpable goiter. His thyroid function tests reveal a TSH level of <0.02 mU/L (normal range: 0.5-5), a free T4 level of 45 pmol/L (normal range: 9-23), and a free T3 level of 6.0 pmol/L (normal range: 3.5-5.5). Which medication is most likely responsible for his symptoms?
Your Answer: Amiodarone
Explanation:Thyroid Disorders Caused by Amiodarone
Amiodarone is a medication that contains iodine and can lead to thyroid function disorders. These disorders can manifest as either hypothyroidism or hyperthyroidism. Hypothyroidism is more common in areas where iodine intake is normal, while hyperthyroidism is more common in areas where iodine intake is low. Hyperthyroidism can be classified as type 1 when it is associated with an underlying thyroid abnormality or type 2 when it presents as a thyroiditis. Unfortunately, the condition can be refractory, and the drug often has to be discontinued. Treatment with carbimazole or propylthiouracil is often necessary to manage the symptoms.
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This question is part of the following fields:
- Emergency Medicine
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Question 26
Correct
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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: 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.
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This question is part of the following fields:
- Emergency Medicine
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Question 27
Correct
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A 29-year-old female presents to the surgical intake with abdominal pain and a five day history of vomiting.
Over the last three months she has also been aware of a 6 kg weight loss.
On examination, she is pale, has a temperature of 38.5°C, blood pressure of 90/60 mmHg and pulse rate of 130 in sinus rhythm. The chest is clear on auscultation but she has a diffusely tender abdomen without guarding. Her BM reading is 2.5.
Initial biochemistry is as follows:
Sodium 124 mmol/L (137-144)
Potassium 6.0 mmol/L (3.5-4.9)
Urea 7.5 mmol/L (2.5-7.5)
Creatinine 78 µmol/L (60-110)
Glucose 2.0 mmol/L (3.0-6.0)
What is the likely diagnosis?Your Answer: Addison's disease
Explanation:Hypoadrenal Crisis and Addison’s Disease
This patient is exhibiting symptoms of hypoadrenal crisis, including abdominal pain, vomiting, shock, hypoglycemia, hyponatremia, and hyperkalemia. In the UK, this is typically caused by autoimmune destruction of the adrenal glands, known as Addison’s disease. Other less common causes include TB, HIV, adrenal hemorrhage, or anterior pituitary disease. Patients with Addison’s disease often experience weight loss, abdominal pain, lethargy, and nausea/vomiting. Additionally, they may develop oral pigmentation due to excess ACTH and other autoimmune diseases such as thyroid disease and vitiligo.
In cases like this, emergency fluid resuscitation, steroid administration, and a thorough search for underlying infections are necessary. It is important to measure cortisol levels before administering steroids. None of the other potential causes explain the patient’s biochemical findings.
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This question is part of the following fields:
- Emergency Medicine
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Question 28
Incorrect
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A 63-year-old male presents with a sudden onset of double vision that has been ongoing for eight hours. He has a medical history of hypertension, which is managed with amlodipine and atenolol, and type 2 diabetes that is controlled through diet. Upon examination, the patient displays watering of the right eye, a slight droop of the eyelid, and displacement of the eye to the right. The left eye appears to have a full range of movements, and the pupil size is the same as on the left. What is the probable cause of his symptoms?
Your Answer: Vasculitis
Correct Answer: Diabetes
Explanation:Causes of Painless Partial Third Nerve Palsy
A painless partial third nerve palsy with pupil sparing is most likely caused by diabetes mononeuropathy. This condition is thought to be due to a microangiopathy that leads to the occlusion of the vasa nervorum. On the other hand, an aneurysm of the posterior communicating artery is associated with a painful third nerve palsy, and pupillary dilation is typical. Cerebral infarction, on the other hand, does not usually cause pain. Hypertension, which is a common condition, would normally cause signs of CVA or TIA. Lastly, cerebral vasculitis can cause symptoms of CVA/TIA, but they usually cause more global neurological symptoms.
In summary, a painless partial third nerve palsy with pupil sparing is most likely caused by diabetes mononeuropathy. Other conditions such as aneurysm of the posterior communicating artery, cerebral infarction, hypertension, and cerebral vasculitis can also cause similar symptoms, but they have different characteristics and causes. It is important to identify the underlying cause of the condition to provide appropriate treatment and management.
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This question is part of the following fields:
- Emergency Medicine
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Question 29
Incorrect
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What EEG findings are typically observed in patients with hepatic encephalopathy?
Your Answer: Theta waves
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.
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This question is part of the following fields:
- Emergency Medicine
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Question 30
Correct
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A 40-year-old asthmatic has been admitted to the hospital with a worsening wheeze that has persisted for 24 hours. You are urgently called as the patient has become acutely short of breath despite receiving three sets of salbutamol nebulisers. The patient is now hypotensive and desaturating. Upon examination, you notice reduced air entry with a resonant percussion note in the left lung field and a trachea deviated to the right. Based on these symptoms, what is the most likely diagnosis?
Your Answer: Tension pneumothorax
Explanation:Urgent Treatment for Evolving Pneumothorax
This patient is showing clinical signs of a developing pneumothorax, which requires urgent treatment. While a tension pneumothorax is typically associated with a deviated trachea and hyper-resonance, these signs may not appear until later stages. It is possible that the patient has a simple pneumothorax, but given their hypotension, urgent needle decompression is necessary to treat a potential tension pneumothorax. In such cases, chest imaging should not be prioritized over immediate intervention. The procedure involves inserting a large bore needle in the second intercostal space in the mid-clavicular line, followed by a chest drain.
Pneumonia can often trigger asthma exacerbations, which can lead to severe chest sepsis and SIRS criteria evolving into severe sepsis. In such cases, ARDS may be the predominant clinical picture with wet lung fields. While massive pulmonary embolism can also cause desaturation and hypotension, there are no other apparent risk factors in this patient’s case. It is important to note that while acute asthma exacerbations can cause anxiety, the diagnosis of panic attacks should only be made after excluding other potential causes.
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This question is part of the following fields:
- Emergency Medicine
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Question 31
Incorrect
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A 14-year-old boy is brought to the Emergency department by his parents. He has a two day history of general malaise, vomiting and vague abdominal discomfort. Over the past twelve hours he has become increasingly drowsy.
On examination, he was unresponsive to verbal commands. His temperature was 36.5°C and his blood pressure was 74/48 mmHg. The following investigations were done:
- Sodium: 121 mmol/L (137-144)
- Potassium: 6.2 mmol/L (3.5-4.9)
- Urea: 11.6 mmol/L (2.5-7.5)
- Creatinine: 162 µmol/L (60-110)
- Glucose: 1.1 mmol/L (3.0-6.0)
- Chloride: 91 mmol/L (95-107)
- Bicarbonate: 14 mmol/L (20-28)
After giving emergency treatment, what single investigation would be most valuable in confirming the diagnosis?Your Answer: Insulin + C peptide levels
Correct Answer: Tetracosactrin (Synacthen) test
Explanation:Addisonian Crisis and Diagnosis with Synacthen Test
The patient is experiencing an Addisonian crisis, which is a life-threatening condition caused by a severe deficiency of cortisol and aldosterone hormones. To confirm the diagnosis of Addison’s disease, a Synacthen test is performed. This test involves injecting a synthetic hormone called Synacthen, which stimulates the adrenal glands to produce cortisol. Blood samples are taken before and after the injection to measure the levels of cortisol in the blood. If the adrenal glands are functioning properly, the cortisol levels will increase significantly after the injection. However, if the adrenal glands are not producing enough cortisol, the levels will remain low. The Synacthen test is a reliable and accurate way to diagnose Addison’s disease and determine the appropriate treatment plan. It is important to diagnose and treat Addison’s disease promptly to prevent complications and improve the patient’s quality of life.
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This question is part of the following fields:
- Emergency Medicine
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Question 32
Correct
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A 50-year-old man is brought to the hospital by the police after being found unconscious on the street. He appears disheveled and smells strongly of alcohol. Despite attempts to gather information about his medical history, none is available. Upon examination, his temperature is 35°C, blood pressure is 106/72 mmHg, and pulse is 52 bpm. He does not respond to commands, but when a venflon is attempted, he tries to grab the arm of the medical professional and makes incomprehensible sounds while keeping his eyes closed. What is his Glasgow coma scale score?
Your Answer: 8
Explanation:The Glasgow Coma Scale: A Simple and Reliable Tool for Assessing Brain Injury
The Glasgow Coma Scale (GCS) is a widely used tool for assessing the severity of brain injury. It is simple to use, has a high degree of interobserver reliability, and is strongly correlated with patient outcomes. The GCS consists of three components: Eye Opening (E), Verbal Response (V), and Motor Response (M). Each component is scored on a scale of 1 to 6, with higher scores indicating better function.
The Eye Opening component assesses the patient’s ability to open their eyes spontaneously or in response to verbal or painful stimuli. The Verbal Response component evaluates the patient’s ability to speak and communicate appropriately. The Motor Response component assesses the patient’s ability to move their limbs in response to verbal or painful stimuli.
The GCS score is calculated by adding the scores for each component.
When providers use the GCS in connection with a head injury, they tend to apply scoring ranges to describe how severe the injury is. The ranges are:
- 13 to 15: Mild traumatic brain injury (mTBI). Also known as a concussion.
- 9 to 12: Moderate TBI.
- 3 to 8: Severe TBI.
The GCS score is an important prognostic indicator, as it can help predict patient outcomes and guide treatment decisions.
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This question is part of the following fields:
- Emergency Medicine
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Question 33
Incorrect
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A 6-year-old boy is brought to the Emergency department by his mother who reports that he has put a small bead into his ear. Upon examination, you confirm the presence of a plastic bead lodged deep in the external canal of his left ear.
What is the best course of action in this situation?Your Answer: Attempt to remove the bead under direct vision
Correct Answer: Refer the patient for review in ENT clinic
Explanation:Ear foreign bodies are common and can be removed by skilled ENT staff using appropriate equipment. If unsuccessful, a general anaesthetic may be required. In cases of infection or trauma, referral as an emergency is necessary. Antibiotics are only needed if there is evidence of infection. Foreign bodies should not be left in the ear to prevent infection and ensure no associated injuries.
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This question is part of the following fields:
- Emergency Medicine
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Question 34
Incorrect
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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.
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This question is part of the following fields:
- Emergency Medicine
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Question 35
Incorrect
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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: Topical ethyl chloride
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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This question is part of the following fields:
- Emergency Medicine
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Question 36
Incorrect
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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: Short Synacthen test
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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This question is part of the following fields:
- Emergency Medicine
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Question 37
Correct
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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: 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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This question is part of the following fields:
- Emergency Medicine
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Question 38
Incorrect
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A 50-year-old male with a history of paroxysmal atrial fibrillation is experiencing uncontrolled tachycardia despite treatment with digoxin and bisoprolol, leading to acute left ventricular dysfunction. The patient has been prescribed amiodarone. What investigation must be done before starting amiodarone?
Your Answer: eGFR
Correct Answer: Thyroid function test
Explanation:Amiodarone and Thyroid Function
Amiodarone, a medication used to treat heart rhythm disorders, can have adverse effects on thyroid function. Both hypothyroidism and hyperthyroidism can occur as a result of amiodarone use. Clinical assessment alone may not be reliable in detecting these disorders, so the British National Formulary (BNF) recommends laboratory testing before treatment and every six months during therapy.
It is important to note that amiodarone can cause an elevation in thyroxine (T4) levels, even in the absence of hyperthyroidism. This is due to the medication’s inhibition of the conversion of T4 to triiodothyronine (T3). Therefore, it is crucial to test for both thyroid-stimulating hormone (TSH) and T3 in addition to T4.
In addition to thyroid dysfunction, amiodarone can also be hepatotoxic, meaning it can cause liver damage. If evidence of liver dysfunction develops, treatment with amiodarone should be discontinued. Regular monitoring and testing can help detect and manage these potential adverse effects of amiodarone therapy.
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This question is part of the following fields:
- Emergency Medicine
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Question 39
Correct
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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: 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.
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This question is part of the following fields:
- Emergency Medicine
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Question 40
Incorrect
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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: Adrenaline 1:10000 10 ml (1 mg equivalent) intramuscular
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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This question is part of the following fields:
- Emergency Medicine
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Question 41
Incorrect
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A nervous 23-year-old man with a rapid breathing rate presents with the following arterial blood gas findings:
pH 7.27 (7.36-7.44)
PCO2 2.6 KPa (4.7-6.0)
Base excess −12 mmol/L
What is his acid-base status?Your Answer: Combined metabolic and respiratory acidosis
Correct Answer: Metabolic acidosis with some compensatory respiratory alkalosis
Explanation:Metabolic Acidosis
Metabolic acidosis is a condition characterized by a low pH level and base deficit, indicating an excess of acid in the body. This can be caused by a variety of factors, including lactic acidosis, ketoacidosis, poisoning, and renal tubular acidosis. Additionally, loss of bicarbonate due to conditions such as diarrhea, biliary/pancreatic/small bowel fistulae, urinary diversion surgery, and cholestyramine can also contribute to metabolic acidosis.
One of the physiological responses to metabolic acidosis is respiratory compensation, which involves the body attempting to normalize pH by clearing out the acidic gas CO2. This can result in a low CO2 level. It is important to identify the underlying cause of metabolic acidosis in order to provide appropriate treatment and prevent further complications.
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This question is part of the following fields:
- Emergency Medicine
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Question 42
Correct
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A 15-year-old girl comes to the clinic with bilateral cervical lymphadenopathy. Upon conducting a lymph node biopsy, it is revealed that she has nodular sclerosing Hodgkin's disease. What characteristic is indicative of a worse prognosis for this patient?
Your Answer: Night sweats
Explanation:Prognostic Features in Hodgkin’s Disease
Hodgkin’s disease (HD) is a type of cancer that has important prognostic features. These features include the presence of stage B symptoms, which are fever, night sweats, and weight loss. Additionally, a mass of more than 10 cm in size is also considered a poor prognostic factor. While fatigue and pruritus are common symptoms of HD, they do not have any prognostic significance. It is worth noting that EBV infection is commonly associated with HD, but it does not have any prognostic significance. Therefore, it is important to consider these prognostic features when diagnosing and treating HD. Proper management of these features can help improve the prognosis and overall outcome for patients with HD.
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This question is part of the following fields:
- Emergency Medicine
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Question 43
Incorrect
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A 4-year-old girl is brought to the Emergency department by her mother.
The girl is experiencing elbow pain and is refusing to use her arm. Her mother reports that she was lifted up by her outstretched arms earlier in the day.
What is the probable diagnosis for this case?Your Answer: Fracture of the lateral epicondyle
Correct Answer: Subluxation of the radial head
Explanation:Subluxation of the Radial Head in Children
Subluxation of the radial head, also known as pulled elbow, is a frequent injury in young children. It occurs when the arm is pulled directly, causing the radial head to dislocate from its ligament. The child may experience pain in the elbow and have limited movement in supination and extension. They may also refuse to use their arm.
Fortunately, a diagnosis can often be made without the need for an x-ray if the history is typical. Treatment involves providing pain relief and manipulating the elbow by supination while it is flexed at a 90° angle. With proper care, most children recover quickly from this injury.
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This question is part of the following fields:
- Emergency Medicine
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Question 44
Correct
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What vitamin is utilized to treat confusion in individuals with chronic alcoholism?
Your 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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This question is part of the following fields:
- Emergency Medicine
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Question 45
Correct
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Which of the following indicates a verbal response score of 1 on the Glasgow Coma Scale?
Your Answer: No response
Explanation:The Glasgow coma scale is a widely used tool to assess the severity of brain injuries. It is scored between 3 and 15, with 3 being the worst and 15 the best. The scale comprises three parameters: best eye response, best verbal response, and best motor response. The verbal response is scored from 1 to 5, with 1 indicating no response and 5 indicating orientation.
A score of 13 or higher on the Glasgow coma scale indicates a mild brain injury, while a score of 9 to 12 indicates a moderate injury. A score of 8 or less indicates a severe brain injury.
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This question is part of the following fields:
- Emergency Medicine
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Question 46
Correct
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A 25-year-old male presents with wheezing and a respiratory rate of 35/min, a pulse of 120 beats per min, blood pressure 110/70 mmHg, and a peak expiratory flow rate of less than 50% predicted. He has received back-to-back nebulisers of salbutamol 5 mg and ipratropium 0.5 mg for the past 45 minutes and is currently on face mask oxygen. Additionally, he has been given hydrocortisone 100 mg IV, and the intensive care team has been notified.
An arterial blood gas test was performed on high-flow oxygen, revealing a pH of 7.42 (7.36-7.44), PaCO2 of 5.0 kPa (4.7-6.0), PaO2 of 22 kPa (11.3-12.6), base excess of -2 mmol/L (+/-2), and SpO2 of 98.
What is the recommended next step in therapy for this patient?Your Answer: Magnesium 1-2 g IV
Explanation:Treatment for Life Threatening Asthma
This patient is experiencing life threatening asthma, which requires immediate treatment. A normal PaCO2 in an asthmatic can indicate impending respiratory failure. The initial treatment involves administering β2-agonists, preferably nebuliser with oxygen, and repeating doses every 15-30 minutes. Nebulised ipratropium bromide should also be added for patients with acute severe or life threatening asthma. Oxygen should be given to maintain saturations at 94-98%, and patients with saturations less than 92% on air should have an ABG to exclude hypercapnia. Intravenous magnesium sulphate can be used if the patient fails to respond to initial treatment. Intensive care is indicated for patients with severe acute or life threatening asthma who are failing to respond to therapy. Steroids should also be given early in the attack to reduce mortality and improve outcomes.
It is important to note that chest radiographs are not necessary unless there is suspicion of pneumothorax or consolidation, or if the patient is experiencing life threatening asthma, a failure to respond to treatment, or a need for ventilation. Additionally, all patients who are transferred to an intensive care unit should be accompanied by a doctor who can intubate if necessary. In this case, if the patient fails to respond to magnesium, intubation and ventilation may be necessary. It is crucial to discuss the patient’s condition with ITU colleagues during treatment.
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This question is part of the following fields:
- Emergency Medicine
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Question 47
Correct
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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: 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.
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This question is part of the following fields:
- Emergency Medicine
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Question 48
Incorrect
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A 70-year-old patient with type 2 diabetes and stable ischaemic heart disease presents with palpitations lasting for 4 days. The patient is currently taking metformin 500 mg tds, aspirin 75 mg daily, ramipril 2.5 mg daily, and simvastatin 40 mg daily. Upon examination, the patient's pulse rate is 140/minute and blood pressure is 128/98 mmHg. There is no chest pain or evidence of acute heart failure, but the ECG confirms atrial fibrillation. What is the most appropriate treatment for managing the patient's atrial fibrillation?
Your Answer: IV amiodarone
Correct Answer: Oral bisoprolol
Explanation:Management of Acute Onset Symptomatic Atrial Fibrillation
In cases of acute onset symptomatic atrial fibrillation (AF), the most appropriate chemical agent for rate control is beta blockers. However, if the patient has ischaemic heart disease, rate control is the initial management strategy. If beta blockers are contraindicated, rate-limiting calcium channel blockers can be used instead. In the event that the patient is hypotensive, IV digoxin is the preferred rate control medication. If the patient cannot tolerate beta blockers, calcium channel blockers, or digoxin, amiodarone is given.
Long-term anticoagulation is necessary after an appropriate risk assessment. Chemical cardioversion can be performed with amiodarone or flecainide, but the latter is contraindicated in patients with ischaemic heart disease. Although AF is generally well tolerated, patients with haemodynamic instability that is considered life-threatening require DC cardioversion. If there is a delay in DC cardioversion, amiodarone is recommended.
Overall, the management of acute onset symptomatic AF involves careful consideration of the patient’s medical history and current condition to determine the most appropriate treatment strategy.
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This question is part of the following fields:
- Emergency Medicine
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Question 49
Incorrect
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A 16-year-old girl and her mother rush to the Emergency department due to the girl's sudden onset of breathlessness and facial puffiness. The girl has a history of eczema and is currently taking oral contraceptives. Despite being well prior to this incident, she is now visibly distressed and experiencing laboured breathing with stridor but no wheezing. What is the most probable reason for her breathlessness?
Your Answer: Pulmonary embolism
Correct Answer: Angio-oedema
Explanation:Noisy Breathing and Atopy in Adolescents
The presence of noisy breathing in an adolescent may indicate the possibility of stridor, which can be caused by an allergic reaction even in an otherwise healthy individual. The history of atopy, or a tendency to develop allergic reactions, further supports the diagnosis of angio-oedema. The sudden onset of symptoms also adds to the likelihood of this diagnosis.
While asthma is a possible differential diagnosis, it typically presents with expiratory wheezing. However, if the chest is silent, it may indicate a severe and life-threatening form of asthma. Therefore, it is important to consider all possible causes of noisy breathing and atopy in adolescents to ensure prompt and appropriate treatment.
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This question is part of the following fields:
- Emergency Medicine
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Question 50
Incorrect
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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: Noradrenaline
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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This question is part of the following fields:
- Emergency Medicine
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Question 51
Incorrect
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A 65-year-old man experiences a bout of memory loss. He had a moment of confusion three days prior, during which his wife guided him inside and offered him tea. Despite being conscious and able to converse with his wife, he wandered around the house in a confused state and repeatedly asked the same questions. After three hours, he suddenly returned to his normal state and had no memory of the incident. What is the probable diagnosis?
Your Answer: Alcohol related amnesia
Correct Answer: Transient global amnesia
Explanation:Transient Global Amnesia: A Brief Overview
Transient global amnesia is a rare condition that typically occurs in individuals over the age of 50. It is characterized by a temporary lack of blood flow to both hippocampi, resulting in a loss of memory function. Despite this, individuals retain their personal identity and cognitive abilities. The episode typically lasts less than 24 hours and is not associated with any long-term effects.
In summary, transient global amnesia is a temporary condition that affects memory function due to a lack of blood flow to the hippocampi.
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This question is part of the following fields:
- Emergency Medicine
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Question 52
Incorrect
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A 47-year-old female collapses at home and is referred to the medical team. She has had two episodes of haematemesis in the emergency department, but no melaena. Her family denies any history of alcohol excess, and she has been otherwise healthy.
Upon examination, the patient appears pale and sweaty with a pulse of 110 bpm. Her lying blood pressure is 95/60 mmHg, which drops by 30 mmHg systolic upon standing. Palmar erythema, purpura, and spider naevi are noted. There is no hepatomegaly, but a fullness is present in the left hypochondrium.
What is the appropriate course of action for this patient?Your Answer: Referral to surgical team on call
Correct Answer: Emergency upper GI endoscopy
Explanation:Upper Gastrointestinal Bleeding with Haemodynamic Compromise
This patient is experiencing upper gastrointestinal bleeding and is showing signs of significant haemodynamic compromise, as indicated by her hypotension and postural drop. The most likely cause of this bleeding is variceal bleeding, which is often associated with chronic liver disease and portal hypertension. Urgent endoscopy is necessary in this case, as over 50% of patients with variceal bleeding require intervention such as banding or sclerotherapy, and the condition is associated with a high mortality rate. The underlying cause of the portal hypertension is unknown, so there is no need for vitamin supplementation unless alcohol excess is suspected.
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This question is part of the following fields:
- Emergency Medicine
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Question 53
Incorrect
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An 80-year-old woman presents to the Emergency department with a Pretibial laceration and skin flap after injuring her leg on furniture at home. She is currently taking prednisolone for polymyalgia rheumatica. What is the optimal approach to managing this injury?
Your Answer: Clean then suture the laceration with an absorbable suture
Correct Answer: Clean then steristrip the laceration
Explanation:Management of Pretibial Lacerations in Different Patient Populations
In managing Pretibial lacerations, the approach may vary depending on the patient’s age and skin condition. For young patients with good skin, suturing with non-absorbable sutures is usually done and removed after seven to 10 days. However, for elderly patients with thin skin or those taking warfarin or steroids, suturing may not be possible due to fragile skin. In this case, the wound is cleaned thoroughly and steristripped meticulously to promote skin healing. A non-adherent dressing and light bandage are applied, and the patient is advised to elevate the leg.
After a week, patients should be reviewed to monitor the wound’s progress. It is important to note that Pretibial lacerations may take several months to heal, and some may require skin grafting procedures. By tailoring the management approach to the patient’s specific needs, optimal wound healing can be achieved.
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This question is part of the following fields:
- Emergency Medicine
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Question 54
Incorrect
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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.
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This question is part of the following fields:
- Emergency Medicine
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Question 55
Incorrect
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What factor is linked to a higher likelihood of developing hepatocellular carcinoma?
Your Answer: Cytomegalovirus
Correct Answer: Hepatitis C
Explanation:Risk of Hepatocellular Carcinoma in Cirrhosis Patients with Hepatitis C
Cirrhosis patients with hepatitis C have a 2% chance of developing hepatocellular carcinoma. This means that out of 100 people with cirrhosis caused by hepatitis C, two of them will develop liver cancer. It is important for these patients to receive regular screenings and follow-up care to detect any signs of cancer early on. Early detection can improve the chances of successful treatment and increase the likelihood of survival. Therefore, it is crucial for individuals with cirrhosis from hepatitis C to work closely with their healthcare providers to manage their condition and reduce their risk of developing hepatocellular carcinoma.
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This question is part of the following fields:
- Emergency Medicine
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Question 56
Incorrect
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A 20-year old woman arrives at the Emergency department after a night out with her friends. According to her friends, she has been talking to herself about nonsensical things and appears agitated and restless. During the examination, it is noted that her reflexes are heightened and an electrocardiogram (ECG) reveals ventricular ectopics. What type of substance abuse is suspected in this case?
Your Answer:
Correct Answer: Ecstasy
Explanation:Ecstasy Overdose
Ecstasy, also known as MDMA, is a drug that stimulates the central nervous system. It can cause increased alertness, euphoria, extroverted behavior, and rapid speech. People who take ecstasy may also experience a lack of desire to eat or sleep, tremors, dilated pupils, tachycardia, and hypertension. However, more severe intoxication can lead to excitability, agitation, paranoid delusions, hallucinations, hypertonia, and hyperreflexia. In some cases, convulsions, rhabdomyolysis, hyperthermia, and cardiac arrhythmias may also develop.
Severe cases of MDMA poisoning can result in hyperthermia, disseminated intravascular coagulation, rhabdomyolysis, acute renal failure, hyponatremia, and even hepatic damage. In rare cases, amphetamine poisoning may lead to intracerebral and subarachnoid hemorrhage and acute cardiomyopathy, which can be fatal. Chronic amphetamine users may also experience hyperthyroxinemia.
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This question is part of the following fields:
- Emergency Medicine
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Question 57
Incorrect
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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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This question is part of the following fields:
- Emergency Medicine
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Question 58
Incorrect
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A 16-year-old boy comes to the emergency department after taking 60 of his father's fluoxetine tablets about four hours ago.
Which of the following symptoms is consistent with his reported ingestion?Your Answer:
Correct Answer: Vomiting
Explanation:Safety and Adverse Effects of Fluoxetine Overdose
Fluoxetine, an SSRI, is considered safe in overdose and has minimal adverse effects compared to tricyclic antidepressants. However, there have been rare reports of tachycardia occurring alongside symptoms such as tremors, drowsiness, nausea, and vomiting. If pupillary constriction or respiratory suppression is present, it may suggest an opiate overdose. On the other hand, a prolonged QRS complex is consistent with a tricyclic antidepressant overdose. Despite these potential symptoms, fluoxetine remains a relatively safe option for treating depression and anxiety disorders.
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This question is part of the following fields:
- Emergency Medicine
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Question 59
Incorrect
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You are the foundation year doctor on the medical admissions unit and have been asked to review a 60-year-old female who has been referred to the unit for palpitations.
The venous gas has been performed by the nurse and has revealed a potassium of 6.5 mmol/L. The patient's ECG shows tented T waves.
What is the most important first drug intervention?Your Answer:
Correct Answer: Calcium gluconate 10% 10 ml
Explanation:Hyperkalaemia is a potentially life-threatening condition with a strict definition of K+ > 5.5 mmol/L. The underlying causes can be divided into renal, intracellular shift out, increased circulatory K+, and false positives. In severe cases with symptomatic and ECG changes, calcium chloride should be given first to stabilise the myocardium. The conventional treatment is a combination of insulin and dextrose infusions, with salbutamol nebulisers and sodium bicarbonate as additional options. Sodium bicarbonate should be used in discussion with a renal physician.
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This question is part of the following fields:
- Emergency Medicine
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Question 60
Incorrect
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A 60-year-old patient has been diagnosed with chronic hepatitis B through blood tests. The doctor explains that the patient is highly contagious and at a greater risk of long-term disease. Which of the following blood results is most likely to be seen in this patient?
HbSAg Anti-HBs IgM anti-HBc IgG anti-HBc HBeAg Anti-HBe
A + - + + + -
B - + - + - +
C + - - + + -
D + - - + - +
E - + - - - -Your Answer:
Correct Answer: C
Explanation:Hepatitis B Infection and Immunity
The presence of hepatitis B surface antigen indicates the presence of the hepatitis B virus in the host cells, whether it is a chronic or acute infection. All patients infected with hepatitis B will produce antibodies to the core antigen. IgM antibodies are markers of acute infection and disappear in chronic infection, while IgG antibodies to the core antigen remain present even after the infection has been cleared. Vaccinated individuals develop antibodies to the surface antigen, which confers natural immunity after the infection has cleared.
If HBsAg persists for more than six months, the patient is a chronic carrier. HBeAg is a marker of virus replication, and HBeAg-positive carriers are highly infectious. However, over time, the HBeAg can be lost from the blood, and anti-HBe can be detected. These carriers are much less infectious.
In summary, acute HBV infection is indicated by the presence of IgM antibodies, while cleared HBV infection is indicated by the presence of IgG antibodies. Chronic HBV infection can be high or low in infectivity, depending on the presence of HBeAg or anti-HBe. Finally, individuals who respond to the HBV vaccine develop immunity to the virus. these markers and their implications can aid in the diagnosis and management of hepatitis B infection.
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This question is part of the following fields:
- Emergency Medicine
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