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  • Question 1 - You are a member of the team assisting with the intubation of a...

    Correct

    • You are a member of the team assisting with the intubation of a pediatric patient. The initial intubation attempt is unsuccessful. Your attending physician instructs you to apply pressure on the larynx during the second attempt. With the patient positioned in a semi-recumbent position, which direction should pressure be applied to aid in intubation?

      Your Answer: Backwards, upwards and rightwards

      Explanation:

      The BURP maneuver is a technique used to assist with intubation. It involves applying pressure in a specific direction on the larynx. The acronym BURP stands for backwards (B), upwards (U), rightwards (R), and pressure (P). To perform the maneuver correctly, the thyroid cartilage is moved backwards, 2 cm upwards, and 0.5cm – 2 cm to the right in relation to the anatomical position.

      Further Reading:

      A difficult airway refers to a situation where factors have been identified that make airway management more challenging. These factors can include body habitus, head and neck anatomy, mouth characteristics, jaw abnormalities, and neck mobility. The LEMON criteria can be used to predict difficult intubation by assessing these factors. The criteria include looking externally at these factors, evaluating the 3-3-2 rule which assesses the space in the mouth and neck, assessing the Mallampati score which measures the distance between the tongue base and roof of the mouth, and considering any upper airway obstructions or reduced neck mobility.

      Direct laryngoscopy is a method used to visualize the larynx and assess the size of the tracheal opening. The Cormack-Lehane grading system can be used to classify the tracheal opening, with higher grades indicating more difficult access. In cases of a failed airway, where intubation attempts are unsuccessful and oxygenation cannot be maintained, the immediate priority is to oxygenate the patient and prevent hypoxic brain injury. This can be done through various measures such as using a bag-valve-mask ventilation, high flow oxygen, suctioning, and optimizing head positioning.

      If oxygenation cannot be maintained, it is important to call for help from senior medical professionals and obtain a difficult airway trolley if not already available. If basic airway management techniques do not improve oxygenation, further intubation attempts may be considered using different equipment or techniques. If oxygen saturations remain below 90%, a surgical airway such as a cricothyroidotomy may be necessary.

      Post-intubation hypoxia can occur for various reasons, and the mnemonic DOPES can be used to identify and address potential problems. DOPES stands for displacement of the endotracheal tube, obstruction, pneumothorax, equipment failure, and stacked breaths. If intubation attempts fail, a maximum of three attempts should be made before moving to an alternative plan, such as using a laryngeal mask airway or considering a cricothyroidotomy.

    • This question is part of the following fields:

      • Basic Anaesthetics
      16.8
      Seconds
  • Question 2 - A 45-year-old construction worker comes in with intense lower back pain. He has...

    Correct

    • A 45-year-old construction worker comes in with intense lower back pain. He has experienced back pain on and off for several years, but it has recently worsened significantly. He is walking with a noticeable limp, and during the examination, you observe that he has weakness in knee extension. You decide to conduct a digital rectal examination and discover that his anal sphincter tone is unexpectedly loose.

      What is the SINGLE most probable diagnosis?

      Your Answer: Cauda equina syndrome

      Explanation:

      Cauda equina syndrome (CES) is a rare but serious complication that can occur when a disc in the spine ruptures. This happens when the material from the disc is pushed into the spinal canal and puts pressure on a bundle of nerves in the lower back and sacrum. When this happens, it can lead to problems with controlling the bladder and bowels.

      There are certain signs that may indicate the presence of CES, which are known as red flags. These include experiencing sciatica on both sides of the body, having a severe or worsening neurological deficit in both legs, such as significant weakness in the muscles that extend the knee, turn the ankle outward, or lift the foot upward. Other red flags include difficulty starting to urinate or a decreased sensation of the flow of urine, a loss of feeling when the rectum is full, a loss of sensation in the perianal, perineal, or genital areas (also known as saddle anesthesia or paresthesia), and a looseness in the anal sphincter muscle.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      18
      Seconds
  • Question 3 - A 10-year-old girl is brought to the Emergency Department by her father after...

    Incorrect

    • A 10-year-old girl is brought to the Emergency Department by her father after getting injured while playing soccer. Her ankle appears to be deformed, and it is suspected that she has a fracture. The triage nurse informs you that she is experiencing moderate pain. According to RCEM guidance, which of the following analgesics is recommended for treating moderate pain in a child of this age?

      Your Answer: Oral paracetamol 10 mg/kg

      Correct Answer: Oral codeine phosphate 1 mg/kg

      Explanation:

      A recent audit conducted by the Royal College of Emergency Medicine (RCEM) in 2018 revealed a concerning decline in the standards of pain management for children with fractured limbs in Emergency Departments (EDs). The audit found that the majority of patients experienced longer waiting times for pain relief compared to previous years. Shockingly, more than 1 in 10 children who presented with significant pain due to a limb fracture did not receive any pain relief at all.

      To address this issue, the Agency for Health Care Policy and Research (AHCPR) in the USA recommends following the ABCs of pain management for all patients, including children. This approach involves regularly asking about pain, systematically assessing it, believing the patient and their family in their reports of pain and what relieves it, choosing appropriate pain control options, delivering interventions in a timely and coordinated manner, and empowering patients and their families to have control over their pain management.

      The RCEM has established standards that require a child’s pain to be assessed within 15 minutes of their arrival at the ED. This is considered a fundamental standard. Various rating scales are available for assessing pain in children, with the choice depending on the child’s age and ability to use the scale. These scales include the Wong-Baker Faces Pain Rating Scale, Numeric rating scale, and Behavioural scale.

      To ensure timely administration of analgesia to children in acute pain, the RCEM has set specific standards. These standards state that 100% of patients in severe pain should receive appropriate analgesia within 60 minutes of their arrival or triage, whichever comes first. Additionally, 75% should receive analgesia within 30 minutes, and 50% within 20 minutes.

    • This question is part of the following fields:

      • Pain & Sedation
      28.3
      Seconds
  • Question 4 - A 25 year old male with severe thoracic trauma is brought into the...

    Incorrect

    • A 25 year old male with severe thoracic trauma is brought into the emergency department. A FAST scan is conducted and cardiac tamponade is identified. The attending physician requests you to carry out a pericardiocentesis. Which of the following accurately describes the anatomical landmark utilized for inserting the needle during this procedure?

      Your Answer: Skin punctured 1-2 cm below and just to the right of the xiphisternum

      Correct Answer: Skin punctured 1-2 cm below and just to the left of the xiphisternum

      Explanation:

      During pericardiocentesis, a needle is inserted approximately 1-2 cm below and to the left of the xiphisternum. The procedure involves the following steps:
      1. Prepare the skin and administer local anesthesia, if time permits.
      2. Ensure ECG monitoring is in place.
      3. Puncture the skin using a long 16-18g catheter, 1-2 cm below and to the left of the xiphisternum.
      4. Advance the catheter towards the tip of the left scapula at a 45-degree angle to the skin.
      5. Aspirate fluid from the pericardium while monitoring the ECG for any signs of injury.
      6. Once blood from the pericardium is aspirated, leave the catheter in place with a 3-way tap until a formal thoracotomy can be performed.
      It is important to note that knowledge of pericardiocentesis is included in the CEM syllabus, although the RCEM may recommend direct thoracotomy as the preferred approach.

      Further Reading:

      Cardiac tamponade, also known as pericardial tamponade, occurs when fluid accumulates in the pericardial sac and compresses the heart, leading to compromised blood flow. Classic clinical signs of cardiac tamponade include distended neck veins, hypotension, muffled heart sounds, and pulseless electrical activity (PEA). Diagnosis is typically done through a FAST scan or an echocardiogram.

      Management of cardiac tamponade involves assessing for other injuries, administering IV fluids to reduce preload, performing pericardiocentesis (inserting a needle into the pericardial cavity to drain fluid), and potentially performing a thoracotomy. It is important to note that untreated expanding cardiac tamponade can progress to PEA cardiac arrest.

      Pericardiocentesis can be done using the subxiphoid approach or by inserting a needle between the 5th and 6th intercostal spaces at the left sternal border. Echo guidance is the gold standard for pericardiocentesis, but it may not be available in a resuscitation situation. Complications of pericardiocentesis include ST elevation or ventricular ectopics, myocardial perforation, bleeding, pneumothorax, arrhythmia, acute pulmonary edema, and acute ventricular dilatation.

      It is important to note that pericardiocentesis is typically used as a temporary measure until a thoracotomy can be performed. Recent articles published on the RCEM learning platform suggest that pericardiocentesis has a low success rate and may delay thoracotomy, so it is advised against unless there are no other options available.

    • This question is part of the following fields:

      • Resus
      24
      Seconds
  • Question 5 - A 42-year-old woman with a lengthy history of depression arrives at the Emergency...

    Correct

    • A 42-year-old woman with a lengthy history of depression arrives at the Emergency Department after intentionally overdosing on the medication she takes for her heart condition. She informs you that she consumed verapamil SR 160 mg tablets approximately 30 minutes ago. However, her spouse discovered her immediately and promptly brought her to the hospital. Currently, she shows no symptoms. Typically, how much time passes before symptoms begin to manifest in cases of this overdose?

      Your Answer: 12-16 hours

      Explanation:

      Calcium-channel blocker overdose is a serious condition that should always be taken seriously as it can be potentially life-threatening. The two most dangerous types of calcium channel blockers in overdose are verapamil and diltiazem. These medications work by binding to the alpha-1 subunit of L-type calcium channels, which prevents the entry of calcium into the cells. These channels play a crucial role in the functioning of cardiac myocytes, vascular smooth muscle cells, and islet beta-cells.

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

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

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

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      32.9
      Seconds
  • Question 6 - A 6 month old girl is brought into the emergency department with a...

    Incorrect

    • A 6 month old girl is brought into the emergency department with a history of being submerged in the pool while swimming with her parents. One of the parents explains that the child was floating on a pool noodle when a wave hit, causing the child to fall off the noodle. The child was not wearing any flotation devices and it took approximately 1 minute to find and rescue her from the water. Your consultant mentions that the child's diving reflex would have been activated. Which of the following statements accurately describes the diving reflex?

      Your Answer: Stimulated by increased pressure on the tympanic membrane during submersion

      Correct Answer: Results in peripheral vasoconstriction

      Explanation:

      The diving reflex occurs when the face comes into contact with cold water, leading to apnoea, bradycardia, and peripheral vasoconstriction. This response helps decrease the workload on the heart, lower oxygen demand in the heart muscle, and ensure adequate blood flow to the brain and vital organs. The trigeminal nerve (CN V) is responsible for transmitting sensory information, while the vagus nerve (CN X) primarily controls the motor response. This reflex is more prominent in young children and is believed to contribute to their improved survival rates in prolonged submersion in cold water.

      Further Reading:

      Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid. It can be classified as cold-water or warm-water drowning. Risk factors for drowning include young age and male sex. Drowning impairs lung function and gas exchange, leading to hypoxemia and acidosis. It also causes cardiovascular instability, which contributes to metabolic acidosis and cell death.

      When someone is submerged or immersed, they will voluntarily hold their breath to prevent aspiration of water. However, continued breath holding causes progressive hypoxia and hypercapnia, leading to acidosis. Eventually, the respiratory center sends signals to the respiratory muscles, forcing the individual to take an involuntary breath and allowing water to be aspirated into the lungs. Water entering the lungs stimulates a reflex laryngospasm that prevents further penetration of water. Aspirated water can cause significant hypoxia and damage to the alveoli, leading to acute respiratory distress syndrome (ARDS).

      Complications of drowning include cardiac ischemia and infarction, infection with waterborne pathogens, hypothermia, neurological damage, rhabdomyolysis, acute tubular necrosis, and disseminated intravascular coagulation (DIC).

      In children, the diving reflex helps reduce hypoxic injury during submersion. It causes apnea, bradycardia, and peripheral vasoconstriction, reducing cardiac output and myocardial oxygen demand while maintaining perfusion of the brain and vital organs.

      Associated injuries with drowning include head and cervical spine injuries in patients rescued from shallow water. Investigations for drowning include arterial blood gases, chest X-ray, ECG and cardiac monitoring, core temperature measurement, and blood and sputum cultures if secondary infection is suspected.

      Management of drowning involves extricating the patient from water in a horizontal position with spinal precautions if possible. Cardiovascular considerations should be taken into account when removing patients from water to prevent hypotension and circulatory collapse. Airway management, supplemental oxygen, and ventilation strategies are important in maintaining oxygenation and preventing further lung injury. Correcting hypotension, electrolyte disturbances, and hypothermia is also necessary. Attempting to drain water from the lungs is ineffective.

      Patients without associated physical injury who are asymptomatic and have no evidence of respiratory compromise after six hours can be safely discharged home. Ventilation strategies aim to maintain oxygenation while minimizing ventilator-associated lung injury.

    • This question is part of the following fields:

      • Respiratory
      18.4
      Seconds
  • Question 7 - You examine the X-ray of a 65 year old male who has tripped...

    Incorrect

    • You examine the X-ray of a 65 year old male who has tripped and landed on his extended right hand. The X-ray confirms a fracture of the distal radius with dorsal displacement. You intend to perform a reduction of the fracture using intravenous regional anesthesia (Bier's block). How many healthcare professionals should be present during the entire procedure?

      Your Answer: 4

      Correct Answer: 2

      Explanation:

      Bier’s block is a regional intravenous anesthesia technique commonly used for minor surgical procedures of the forearm or for reducing distal radius fractures in the emergency department (ED). It is recommended by NICE as the preferred anesthesia block for adults requiring manipulation of distal forearm fractures in the ED.

      Before performing the procedure, a pre-procedure checklist should be completed, including obtaining consent, recording the patient’s weight, ensuring the resuscitative equipment is available, and monitoring the patient’s vital signs throughout the procedure. The air cylinder should be checked if not using an electronic machine, and the cuff should be checked for leaks.

      During the procedure, a double cuff tourniquet is placed on the upper arm, and the arm is elevated to exsanguinate the limb. The proximal cuff is inflated to a pressure 100 mmHg above the systolic blood pressure, up to a maximum of 300 mmHg. The time of inflation and pressure should be recorded, and the absence of the radial pulse should be confirmed. 0.5% plain prilocaine is then injected slowly, and the time of injection is recorded. The patient should be warned about the potential cold/hot sensation and mottled appearance of the arm. After injection, the cannula is removed and pressure is applied to the venipuncture site to prevent bleeding. After approximately 10 minutes, the patient should have anesthesia and should not feel pain during manipulation. If anesthesia is successful, the manipulation can be performed, and a plaster can be applied by a second staff member. A check x-ray should be obtained with the arm lowered onto a pillow. The tourniquet should be monitored at all times, and the cuff should be inflated for a minimum of 20 minutes and a maximum of 45 minutes. If rotation of the cuff is required, it should be done after the manipulation and plaster application. After the post-reduction x-ray is satisfactory, the cuff can be deflated while observing the patient and monitors. Limb circulation should be checked prior to discharge, and appropriate follow-up and analgesia should be arranged.

      There are several contraindications to performing Bier’s block, including allergy to local anesthetic, hypertension over 200 mm Hg, infection in the limb, lymphedema, methemoglobinemia, morbid obesity, peripheral vascular disease, procedures needed in both arms, Raynaud’s phenomenon, scleroderma, severe hypertension and sickle cell disease.

    • This question is part of the following fields:

      • Basic Anaesthetics
      25.5
      Seconds
  • Question 8 - A 35-year-old woman with a long-standing history of heavy alcohol abuse and liver...

    Correct

    • A 35-year-old woman with a long-standing history of heavy alcohol abuse and liver cirrhosis comes in with a fever, abdominal pain, worsening ascites, and confusion.

      Which antibiotic should be administered in this case?

      Your Answer: Ceftriaxone

      Explanation:

      Spontaneous bacterial peritonitis (SBP) is a sudden bacterial infection of the fluid in the abdomen. It typically occurs in patients with high blood pressure in the portal vein, and about 70% of patients are classified as Child-Pugh class C. In any given year, around 30% of patients with ascites, a condition characterized by fluid buildup in the abdomen, will develop SBP.

      SBP can present with a wide range of symptoms, so it’s important to be vigilant when caring for patients with ascites, especially if there is a sudden decline in their condition. Some patients may not show any symptoms at all.

      Common clinical features of SBP include fever, chills, nausea, vomiting, abdominal pain, tenderness, worsening ascites, general malaise, and hepatic encephalopathy. Certain factors can increase the risk of developing SBP, such as severe liver disease, gastrointestinal bleeding, urinary tract infection, intestinal bacterial overgrowth, indwelling lines (e.g., central venous catheters or urinary catheters), previous episodes of SBP, and low levels of protein in the ascitic fluid.

      To diagnose SBP, an abdominal paracentesis, also known as an ascitic tap, is performed. This involves locating the area of dullness on the flank, next to the rectus abdominis muscle, and performing the tap about 5 cm above and towards the midline from the anterior superior iliac spines.

      Certain features on the analysis of the peritoneal fluid strongly suggest SBP, including a total white cell count in the ascitic fluid of more than 500 cells/µL, a total neutrophil count of more than 250 cells/µL, a lactate level in the ascitic fluid of more than 25 mg/dL, a pH of less than 7.35, and the presence of bacteria on Gram-stain.

      Patients diagnosed with SBP should be admitted to the hospital and given broad-spectrum antibiotics. The preferred choice is an intravenous 3rd generation cephalosporin, such as ceftriaxone. If the patient is allergic to beta-lactam antibiotics, ciprofloxacin can be considered as an alternative. Administering intravenous albumin can help reduce the risk of kidney failure and mortality.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      88.6
      Seconds
  • Question 9 - A 45-year-old man with atrial fibrillation presents to the Emergency Department with an...

    Incorrect

    • A 45-year-old man with atrial fibrillation presents to the Emergency Department with an unrelated medical condition. Upon reviewing his medications, you discover that he is taking warfarin as part of his management.

      Which ONE of the following supplements should be avoided?

      Your Answer: Iron

      Correct Answer: St. John’s Wort

      Explanation:

      St. John’s wort can reduce the effectiveness of warfarin, an anticoagulant medication. Therefore, it is important for patients who are taking warfarin to be aware that they should avoid using St. John’s wort as a supplement. For more information on this interaction, you can refer to the BNF section on warfarin interactions.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      30
      Seconds
  • Question 10 - A 30-year-old woman with a history of schizophrenia comes in with a side...

    Incorrect

    • A 30-year-old woman with a history of schizophrenia comes in with a side effect caused by the antipsychotic medication she is currently using.

      Which ONE statement about the side effects of antipsychotic drugs is accurate?

      Your Answer: Tardive dyskinesia is always reversible on cessation of the causative drug

      Correct Answer: Haloperidol is the most common antipsychotic drug to cause extrapyramidal side effects

      Explanation:

      Extrapyramidal side effects are most commonly seen with the piperazine phenothiazines (fluphenazine, prochlorperazine, and trifluoperazine) and butyrophenones (benperidol and haloperidol). Among these, haloperidol is the most frequently implicated antipsychotic drug.

      Tardive dyskinesia, which involves rhythmic and involuntary movements of the tongue, face, and jaw, typically develops after long-term treatment or high doses. It is the most severe manifestation of extrapyramidal symptoms, as it may become irreversible even after discontinuing the causative drug, and treatment options are generally ineffective.

      Dystonia, characterized by abnormal movements of the face and body, is more commonly observed in children and young adults and tends to occur after only a few doses. Acute dystonia can be managed with intravenous administration of procyclidine (5 mg) or benzatropine (2 mg) as a bolus.

      Akathisia refers to an unpleasant sensation of restlessness, while akinesia refers to an inability to initiate movement.

      Elderly patients with dementia-related psychosis who are treated with haloperidol have an increased risk of mortality. This is believed to be due to a higher likelihood of experiencing cardiovascular events and infections such as pneumonia.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      24.4
      Seconds
  • Question 11 - A 2 year old child is brought to the emergency department by a...

    Incorrect

    • A 2 year old child is brought to the emergency department by a worried parent as the child has developed a barking cough. After conducting an examination, you diagnose croup and decide to administer corticosteroids. What is the most suitable dosage?

      Your Answer: Oral dexamethasone at a dose of 0.5 mg/kg

      Correct Answer: Oral dexamethasone at a dose of 0.15mg/kg

      Explanation:

      For patients with croup, the usual dose of oral dexamethasone is 0.15mg/kg. However, if the patient cannot take it orally, an alternative option is to administer intramuscular dexamethasone at a dose of 0.6 mg/kg as a single dose.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Paediatric Emergencies
      33.9
      Seconds
  • Question 12 - A 3-year-old child is brought in by ambulance to the resus area of...

    Incorrect

    • A 3-year-old child is brought in by ambulance to the resus area of your Emergency Department. They have been convulsing for the past 5 minutes. You have been unable to gain IV access and plan to administer a dose of buccal midazolam.
      What is the recommended dose of buccal midazolam for treating seizures in this child?

      Your Answer: 0.2 mg/kg

      Correct Answer: 0.5 mg/kg

      Explanation:

      The recommended dosage of buccal midazolam for treating a child experiencing seizures is 0.5 mg per kilogram of body weight.

    • This question is part of the following fields:

      • Neurology
      38.1
      Seconds
  • Question 13 - A 45-year-old man presents with a history of heavy menstrual bleeding and frequent...

    Incorrect

    • A 45-year-old man presents with a history of heavy menstrual bleeding and frequent nosebleeds. He is currently taking a medication but cannot remember its name or why he takes it. You have ordered a series of blood tests for him. The results are as follows:

      Hemoglobin (Hb): 12.2 g/dL (normal range: 12-15 g/dL)
      Mean Corpuscular Volume (MCV): 82 fl (normal range: 80-100 fl)
      Platelet count: 212 x 10^9/L (normal range: 150-400 x 10^9/L)
      Bleeding time: 11 minutes (normal range: 2-7 minutes)
      Prothrombin time: 12 seconds (normal range: 10-14 seconds)
      Thrombin time: 17 seconds (normal range: 15-19 seconds)
      Activated Partial Thromboplastin Time (APTT): 60 seconds (normal range: 35-45 seconds)

      Based on these results, what is the most likely diagnosis for this patient?

      Your Answer: Factor V deficiency

      Correct Answer: Von Willebrand’s disease

      Explanation:

      Von Willebrand disease (vWD) is a common hereditary coagulation disorder that affects approximately 1 in 100 people. It occurs due to a deficiency in Von Willebrand factor (vWF), which leads to reduced levels of factor VIII. vWF plays a crucial role in protecting factor VIII from breaking down quickly in the blood. Additionally, it is necessary for proper platelet adhesion, so a deficiency in vWF also results in abnormal platelet function. As a result, both the APTT and bleeding time are prolonged, while the platelet count and thrombin time remain unaffected.

      Many individuals with vWD do not experience any symptoms and are diagnosed incidentally during a routine clotting profile check. However, if symptoms do occur, the most common ones include easy bruising, nosebleeds (epistaxis), and heavy menstrual bleeding (menorrhagia). In severe cases, more significant bleeding and joint bleeding (haemarthrosis) can occur.

      For mild cases of von Willebrand disease, bleeding can be treated with desmopressin. This medication works by increasing the patient’s own levels of vWF, as it releases vWF stored in the Weibel-Palade bodies found in the endothelial cells. In more severe cases, replacement therapy is necessary, which involves cryoprecipitate infusions or Factor VIII concentrate. Replacement therapy is recommended for patients with severe von Willebrand’s disease who are undergoing moderate or major surgical procedures.

      Congenital afibrinogenaemia is a rare coagulation disorder characterized by a deficiency or malfunction of fibrinogen. This condition leads to a prolongation of the prothrombin time, bleeding time, and APTT. However, it does not affect the platelet count.

      Aspirin therapy works by inhibiting platelet cyclo-oxygenase, an essential enzyme in the generation of thromboxane A2 (TXA2). By inhibiting TXA2, aspirin reduces platelet activation and aggregation. Consequently, aspirin therapy prolongs the bleeding time but does not have an impact on the platelet count, prothrombin time, or APTT.

      Warfarin, on the other hand, inhibits the synthesis of clotting factors II, VII, IX, and X, as well as protein C and protein S, which are all dependent on vitamin K.

    • This question is part of the following fields:

      • Haematology
      12.6
      Seconds
  • Question 14 - You are tasked with organizing a teaching session for the senior residents on...

    Incorrect

    • You are tasked with organizing a teaching session for the senior residents on head injuries & increased intracranial pressure. What is the intracranial volume of a typical adult?

      Your Answer: 250ml

      Correct Answer: 1400ml

      Explanation:

      On average, the intracranial volume in adults is around 1400ml.

      Intracranial pressure (ICP) refers to the pressure within the craniospinal compartment, which includes neural tissue, blood, and cerebrospinal fluid (CSF). Normal ICP for a supine adult is 5-15 mmHg. The body maintains ICP within a narrow range through shifts in CSF production and absorption. If ICP rises, it can lead to decreased cerebral perfusion pressure, resulting in cerebral hypoperfusion, ischemia, and potentially brain herniation.

      The cranium, which houses the brain, is a closed rigid box in adults and cannot expand. It is made up of 8 bones and contains three main components: brain tissue, cerebral blood, and CSF. Brain tissue accounts for about 80% of the intracranial volume, while CSF and blood each account for about 10%. The Monro-Kellie doctrine states that the sum of intracranial volumes is constant, so an increase in one component must be offset by a decrease in the others.

      There are various causes of raised ICP, including hematomas, neoplasms, brain abscesses, edema, CSF circulation disorders, venous sinus obstruction, and accelerated hypertension. Symptoms of raised ICP include headache, vomiting, pupillary changes, reduced cognition and consciousness, neurological signs, abnormal fundoscopy, cranial nerve palsy, hemiparesis, bradycardia, high blood pressure, irregular breathing, focal neurological deficits, seizures, stupor, coma, and death.

      Measuring ICP typically requires invasive procedures, such as inserting a sensor through the skull. Management of raised ICP involves a multi-faceted approach, including antipyretics to maintain normothermia, seizure control, positioning the patient with a 30º head up tilt, maintaining normal blood pressure, providing analgesia, using drugs to lower ICP (such as mannitol or saline), and inducing hypocapnoeic vasoconstriction through hyperventilation. If these measures are ineffective, second-line therapies like barbiturate coma, optimised hyperventilation, controlled hypothermia, or decompressive craniectomy may be considered.

    • This question is part of the following fields:

      • Neurology
      29.9
      Seconds
  • Question 15 - A middle-aged individual comes in with hearing loss on one side, ringing in...

    Incorrect

    • A middle-aged individual comes in with hearing loss on one side, ringing in the ears, dizziness, and numbness in the face. An MRI scan shows the presence of an acoustic neuroma.
      Which of the following nerves is the LEAST likely to be affected?

      Your Answer: Facial nerve

      Correct Answer: Trochlear nerve

      Explanation:

      An acoustic neuroma, also referred to as a vestibular schwannoma, is a slow-growing tumor that develops from the Schwann cells of the vestibulocochlear nerve (8th cranial nerve). These growths are typically found at the cerebellopontine angle or within the internal auditory canal.

      The most commonly affected nerves are the vestibulocochlear and trigeminal nerves. Patients typically present with a gradual deterioration of hearing in one ear, along with numbness and tingling in the face, ringing in the ears, and episodes of dizziness. Additionally, some patients may have a history of headaches. In rare cases, the facial nerve, glossopharyngeal nerve, vagus nerve, or accessory nerve may also be affected.

      It is important to note that the trochlear nerve, which passes through the superior orbital fissure, is not impacted by an acoustic neuroma.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      10.3
      Seconds
  • Question 16 - A 25-year-old individual presents on a Tuesday morning after being bitten by a...

    Incorrect

    • A 25-year-old individual presents on a Tuesday morning after being bitten by a tick a few days ago while hiking in the woods. The tick was promptly removed and there have been no symptoms experienced since. After conducting some online research, the individual is extremely worried about the potential of acquiring Lyme disease.

      What is the MOST suitable course of action in this situation?

      Your Answer: Organise immunoblot test for Lyme disease

      Correct Answer: Reassurance only, no need to test or treat

      Explanation:

      According to the current NICE guidance, it is not recommended to diagnose Lyme disease in individuals who do not show any symptoms, even if they have been bitten by a tick. Therefore, there is no need to conduct tests or provide treatment in such cases. It is important to reassure these patients that the majority of ticks do not transmit Lyme disease. However, it is advised that they remain vigilant for any potential symptoms and return for re-evaluation if necessary. The ‘Be Tick Aware’ campaign by Public Health England can serve as a helpful resource for further information.

    • This question is part of the following fields:

      • Environmental Emergencies
      33.8
      Seconds
  • Question 17 - You are following up on a 62 year old patient who had been...

    Incorrect

    • You are following up on a 62 year old patient who had been referred to the medical team for investigation of electrolyte imbalances and unexplained symptoms. You observe that the patient has undergone a water deprivation test and the results are as follows:

      Serum osmolality after fluid deprivation: 348 mOSm/Kg
      Urine osmolality after fluid deprivation
      but before desmopressin: 188 mOSm/Kg
      Urine osmolality after desmopressin: 824 mOSm/Kg

      What is the probable diagnosis?

      Your Answer: Psychogenic polydipsia

      Correct Answer: Cranial diabetes insipidus

      Explanation:

      After the fluid restriction period, the urine is checked to determine if it remains relatively dilute (less than 600 mOsm/kg). If it does, desmopressin is administered and the urine is rechecked to see if it responds and becomes more concentrated.

      If the urine osmolality significantly increases after desmopressin, it indicates that the kidneys have responded appropriately to the medication and the urine has concentrated. This suggests that the patient is not producing ADH in response to water loss, indicating cranial DI.

      It is important to note that some units may use a lower cut-off of greater than 600 mOsm/kg instead of 800 mOsm/kg.

      Further Reading:

      Diabetes insipidus (DI) is a condition characterized by either a decrease in the secretion of antidiuretic hormone (cranial DI) or insensitivity to antidiuretic hormone (nephrogenic DI). Antidiuretic hormone, also known as arginine vasopressin, is produced in the hypothalamus and released from the posterior pituitary. The typical biochemical disturbances seen in DI include elevated plasma osmolality, low urine osmolality, polyuria, and hypernatraemia.

      Cranial DI can be caused by various factors such as head injury, CNS infections, pituitary tumors, and pituitary surgery. Nephrogenic DI, on the other hand, can be genetic or result from electrolyte disturbances or the use of certain drugs. Symptoms of DI include polyuria, polydipsia, nocturia, signs of dehydration, and in children, irritability, failure to thrive, and fatigue.

      To diagnose DI, a 24-hour urine collection is done to confirm polyuria, and U&Es will typically show hypernatraemia. High plasma osmolality with low urine osmolality is also observed. Imaging studies such as MRI of the pituitary, hypothalamus, and surrounding tissues may be done, as well as a fluid deprivation test to evaluate the response to desmopressin.

      Management of cranial DI involves supplementation with desmopressin, a synthetic form of arginine vasopressin. However, hyponatraemia is a common side effect that needs to be monitored. In nephrogenic DI, desmopressin supplementation is usually not effective, and management focuses on ensuring adequate fluid intake to offset water loss and monitoring electrolyte levels. Causative drugs need to be stopped, and there is a risk of developing complications such as hydroureteronephrosis and an overdistended bladder.

    • This question is part of the following fields:

      • Endocrinology
      16.5
      Seconds
  • Question 18 - A 32-year-old male presents to the emergency department with complaints of increasing lip...

    Incorrect

    • A 32-year-old male presents to the emergency department with complaints of increasing lip swelling that began 30 minutes ago. Upon reviewing his medical history, it is noted that he has a previous diagnosis of hereditary angioedema (HAE) and that his primary care physician recently prescribed him a new medication. The following vital signs have been documented:

      Blood pressure: 122/78 mmHg
      Pulse rate: 88 bpm
      Respiration rate: 15
      Temperature: 37.4 oC

      During episodes of acute hereditary angioedema, which systems are most commonly affected?

      Your Answer: Renal and integumentary systems

      Correct Answer: Respiratory, gastrointestinal and integumentary systems

      Explanation:

      Hereditary angioedema (HAE) mainly affects the respiratory, gastrointestinal, and integumentary systems. This condition primarily impacts the respiratory system, gastrointestinal system, and the skin.

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

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

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

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

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

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

    • This question is part of the following fields:

      • Allergy
      32.2
      Seconds
  • Question 19 - A 72-year-old arrives at the emergency department complaining of a nosebleed that began...

    Incorrect

    • A 72-year-old arrives at the emergency department complaining of a nosebleed that began 2 hours ago. The patient reports taking two daily tablets to manage hypertension, and their blood pressure was deemed satisfactory during their last health check 3 months ago.

      What would be the most suitable initial approach to managing this patient?

      Your Answer: Advise the patient to pinch the cartilaginous part of nose whilst leaning backwards

      Correct Answer: Advise the patient to pinch the cartilaginous part of nose whilst leaning forwards

      Explanation:

      To control nosebleeds, it is recommended to have the patient sit upright with their upper body tilted forward and their mouth open. Apply firm pressure to the cartilaginous part of the nose, just in front of the bony septum, and hold it for 10-15 minutes without releasing the pressure.

      Further Reading:

      Epistaxis, or nosebleed, is a common condition that can occur in both children and older adults. It is classified as either anterior or posterior, depending on the location of the bleeding. Anterior epistaxis usually occurs in younger individuals and arises from the nostril, most commonly from an area called Little’s area. These bleeds are usually not severe and account for the majority of nosebleeds seen in hospitals. Posterior nosebleeds, on the other hand, occur in older patients with conditions such as hypertension and atherosclerosis. The bleeding in posterior nosebleeds is likely to come from both nostrils and originates from the superior or posterior parts of the nasal cavity or nasopharynx.

      The management of epistaxis involves assessing the patient for signs of instability and implementing measures to control the bleeding. Initial measures include sitting the patient upright with their upper body tilted forward and their mouth open. Firmly pinching the cartilaginous part of the nose for 10-15 minutes without releasing the pressure can also help stop the bleeding. If these measures are successful, a cream called Naseptin or mupirocin nasal ointment can be prescribed for further treatment.

      If bleeding persists after the initial measures, nasal cautery or nasal packing may be necessary. Nasal cautery involves using a silver nitrate stick to cauterize the bleeding point, while nasal packing involves inserting nasal tampons or inflatable nasal packs to stop the bleeding. In cases of posterior bleeding, posterior nasal packing or surgery to tie off the bleeding vessel may be considered.

      Complications of epistaxis can include nasal bleeding, hypovolemia, anemia, aspiration, and even death. Complications specific to nasal packing include sinusitis, septal hematoma or abscess, pressure necrosis, toxic shock syndrome, and apneic episodes. Nasal cautery can lead to complications such as septal perforation and caustic injury to the surrounding skin.

      In children under the age of 2 presenting with epistaxis, it is important to refer them for further investigation as an underlying cause is more likely in this age group.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      5.9
      Seconds
  • Question 20 - You evaluate a child with a limp and complaints of hip discomfort. An...

    Incorrect

    • You evaluate a child with a limp and complaints of hip discomfort. An X-ray is conducted, and the diagnosis of Perthes' disease is confirmed.
      Which ONE statement about this condition is accurate?

      Your Answer: Treatment is always surgical

      Correct Answer: A positive family history is present in 10-15% of cases

      Explanation:

      Perthes’ disease is a hip disorder that occurs in childhood due to a disruption in the blood supply to the femoral head. This leads to a lack of blood flow, causing the bone to die. The condition typically affects children between the ages of 4 and 10, with boys being more commonly affected than girls. In about 10-15% of cases, there is a family history of the disease, and approximately 15% of patients have the condition in both hips.

      The progression of Perthes’ disease can be seen through characteristic changes on X-rays, which can take between 2 and 4 years to fully heal. The earliest sign is an increased density of the epiphysis (the end of the bone) and widening of the medial joint space. As the disease progresses, the epiphysis may fragment and the head of the femur may flatten. Over time, the bone gradually heals, with the dense bone being reabsorbed and replaced by new bone. This process continues until growth stops, and the bone is remodeled.

      Children with Perthes’ disease typically present with hip pain and a limp. The pain can vary in severity, and clinical signs may be minor, with only a slight restriction in hip joint movement.

      The treatment of Perthes’ disease is a topic of debate. Around 50% of patients can achieve good results with conservative management alone, without the need for surgery. Surgical intervention, such as osteotomy (reshaping the bone), is usually reserved for cases where the disease progresses unfavorably or when conservative treatment fails. Potential complications of Perthes’ disease include permanent hip deformity and secondary arthritis.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      52.4
      Seconds
  • Question 21 - A 62-year-old man presents with severe otalgia in his right ear that has...

    Incorrect

    • A 62-year-old man presents with severe otalgia in his right ear that has been gradually worsening over the past few weeks. He describes the pain as being ‘unrelenting’, and he has been unable to sleep for several nights. His family have noticed that the right side of his face appears to be ‘drooping’. His past medical history includes poorly controlled type 2 diabetes mellitus. On examination, he has a right-sided lower motor neuron facial nerve palsy. His right ear canal is very swollen and purulent exudate is visible.
      Which of the following is the MOST important investigation to perform?

      Your Answer: Blood cultures

      Correct Answer: Contrast-enhanced CT head

      Explanation:

      Malignant otitis externa (MOE), also known as necrotizing otitis externa, is a rare form of ear canal infection that primarily affects elderly diabetic patients, particularly those with poorly controlled diabetes.

      MOE initially infects the ear canal and gradually spreads to the surrounding bony structures and soft tissues. In 98% of cases, the responsible pathogen is Pseudomonas aeruginosa.

      Typically, MOE presents with severe and unrelenting ear pain, which tends to worsen at night. Even after the swelling of the ear canal subsides with topical antibiotics, the pain may persist. Other symptoms may include pus drainage from the ear and temporal headaches. Approximately 50% of patients also experience facial nerve paralysis, and cranial nerves IX to XII may be affected as well.

      To confirm the diagnosis, technetium scanning and contrast-enhanced CT scanning are usually performed to detect any extension of the infection into the surrounding bony structures.

      If left untreated, MOE can be life-threatening and may lead to serious complications such as skull base osteomyelitis, subdural empyema, and cerebral abscess.

      Treatment typically involves long-term administration of intravenous antibiotics. While surgical intervention is not effective for MOE, exploratory surgery may be necessary to obtain cultures of unusual organisms that are not responding adequately to intravenous antibiotics.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      51.7
      Seconds
  • Question 22 - A 35-year-old man receives a blood transfusion. Shortly after the transfusion is started,...

    Incorrect

    • A 35-year-old man receives a blood transfusion. Shortly after the transfusion is started, he experiences a high body temperature, shivering, and severe shaking. Blood samples are collected, and a diagnosis of bacterial infection caused by the transfusion is confirmed.
      What type of blood component is he most likely to have been given?

      Your Answer: Fresh frozen plasma

      Correct Answer: Platelets

      Explanation:

      Transfusion transmitted bacterial infection is a rare complication that can occur during blood transfusion. It is more commonly associated with platelet transfusion, as platelets are stored at room temperature. Additionally, previously frozen components that are thawed using a water bath and red cell components stored for several weeks are also at a higher risk for bacterial infection.

      Both Gram-positive and Gram-negative bacteria have been implicated in transfusion-transmitted bacterial infection, but Gram-negative bacteria are known to cause more severe illness and have higher rates of morbidity and mortality. Among the bacterial organisms, Yersinia enterocolitica is the most commonly associated with this type of infection. This particular organism is able to multiply at low temperatures and utilizes iron as a nutrient, making it well-suited for proliferation in blood stores.

      The clinical features of transfusion-transmitted bacterial infection typically manifest shortly after the transfusion begins. These features include a high fever, chills and rigors, nausea and vomiting, tachycardia, hypotension, and even circulatory collapse.

      If there is suspicion of a transfusion-transmitted bacterial infection, it is crucial to immediately stop the transfusion. Blood cultures and a Gram-stain should be requested to identify the specific bacteria causing the infection. Broad-spectrum antibiotics should be initiated promptly. Furthermore, the blood pack should be returned to the blood bank urgently for culture and Gram-stain analysis.

    • This question is part of the following fields:

      • Haematology
      25.6
      Seconds
  • Question 23 - You provide Entonox to a patient who has experienced a significant injury for...

    Incorrect

    • You provide Entonox to a patient who has experienced a significant injury for temporary pain relief.
      Which ONE statement about Entonox is NOT true?

      Your Answer: It is contraindicated in patients with bowel obstruction

      Correct Answer: It is a 50/50 mix of oxygen and nitric oxide

      Explanation:

      Entonox is a combination of oxygen and nitrous oxide, with equal parts of each. Its primary effects are pain relief and a decrease in activity within the central nervous system. The exact mechanism of action is not fully understood, but it is believed to involve the modulation of enkephalins and endorphins in the central nervous system.

      When inhaled, Entonox takes about 30 seconds to take effect and its effects last for approximately 60 seconds after inhalation is stopped. It is stored in cylinders that are either white or blue, with blue and white sections on the shoulders. Entonox has various uses, including being used alongside general anesthesia, as a pain reliever during labor, and for painful medical procedures.

      There are some known side effects of Entonox, which include nausea and vomiting in about 15% of patients, dizziness, euphoria, and inhibition of vitamin B12 synthesis. It is important to note that there are certain situations where the use of Entonox is not recommended. These contraindications include reduced consciousness, diving injuries, pneumothorax, middle ear disease, sinus disease, bowel obstruction, documented allergy to nitrous oxide, hypoxia, and violent or disabled psychiatric patients.

    • This question is part of the following fields:

      • Pain & Sedation
      18.5
      Seconds
  • Question 24 - You are requested to evaluate a 75-year-old individual who has been examined by...

    Incorrect

    • You are requested to evaluate a 75-year-old individual who has been examined by a medical student. The patient complained of swelling on one side of the face, and the medical student has tentatively diagnosed it as a salivary gland stone. Where is the most frequent location for salivary gland stones to occur?

      Your Answer: Parotid duct

      Correct Answer: Wharton's duct

      Explanation:

      This area contains stones made of stone. The parotid duct opens into the vestibule of the mouth, specifically between the cheek and gums, at a spot called the parotid papilla. This papilla is located across from the second upper molar tooth.
      The sublingual gland is drained by a series of 8-20 excretory ducts known as the ducts of Rivinus. The largest duct in this system is called Bartholin’s duct. It is worth noting that stones in the sublingual gland are extremely rare.

      Further Reading:

      Salivary gland disease refers to various conditions that affect the salivary glands, which are responsible for producing saliva. Humans have three pairs of major salivary glands, including the parotid, submandibular, and sublingual glands, as well as numerous minor salivary glands. These glands produce around 1 to 1.5 liters of saliva each day, which serves several functions such as moistening and lubricating the mouth, dissolving food, aiding in swallowing, and protecting the mucosal lining.

      There are several causes of salivary gland dysfunction, including infections (such as bacterial or viral infections like mumps), the presence of stones in the salivary ducts, benign or malignant tumors, dry mouth (xerostomia) due to medication, dehydration, or certain medical conditions like Sjögren’s syndrome, granulomatous diseases like sarcoidosis, and rare conditions like HIV-related lymphocytic infiltration. Mucoceles can also affect the minor salivary glands.

      Salivary gland stones, known as sialolithiasis, are the most common salivary gland disorder. They typically occur in adults between the ages of 30 and 60, with a higher incidence in males. These stones can develop within the salivary glands or their ducts, leading to obstruction and swelling of the affected gland. Risk factors for stones include certain medications, dehydration, gout, smoking, chronic periodontal disease, and hyperparathyroidism. Diagnosis of salivary gland stones can be made through imaging techniques such as X-ray, ultrasound, sialography, CT, or MRI. Management options include conservative measures like pain relief, antibiotics if there is evidence of infection, hydration, warm compresses, and gland massage. Invasive options may be considered if conservative management fails.

      Salivary gland infection, known as sialadenitis, can be caused by bacterial or viral pathogens. Decreased salivary flow, often due to factors like dehydration, malnutrition, immunosuppression, or certain medications, can contribute to the development of sialadenitis. Risk factors for sialadenitis include age over 40, recent dental procedures, Sjögren’s syndrome, immunosuppression, and conditions that decrease salivary flow. Staphylococcus aureus is the most common bacterial cause, while mumps is the most common viral cause. Ac

    • This question is part of the following fields:

      • Ear, Nose & Throat
      39
      Seconds
  • Question 25 - A 65 year old male is brought to the emergency department following a...

    Incorrect

    • A 65 year old male is brought to the emergency department following a fall which occurred while the patient was getting out of bed. The patient complains of feeling dizzy as he got out of bed before experiencing tunnel vision and briefly losing consciousness. The patient is certain he only blacked out for a few seconds as the time on the bedside clock had not changed. The patient informs you that he has had several similar episodes over the past few months when getting out of bed, but most of the time he only feels dizzy and doesn't faint. He denies any loss of bladder or bowel control or biting his tongue. An ECG is performed which shows normal sinus rhythm. You note the patient takes the following medication:
      Lisinopril 10 mg OD
      Fluoxetine 20 mg OD

      What is the most likely diagnosis?

      Your Answer: Vasovagal syncope

      Correct Answer: Orthostatic hypotension

      Explanation:

      Orthostatic hypotension is a condition where patients feel lightheaded and may experience tunnel vision when they stand up from a lying down position. These symptoms are often worse in the morning. The patient’s history of recurrent episodes after being in a supine position for a long time strongly suggests orthostatic hypotension. There are no signs of epilepsy, such as deja-vu or jambs vu prodrome, tongue biting, loss of bladder or bowel control, or postictal confusion. The normal ECG and consistent timing of symptoms make postural orthostatic tachycardia syndrome (PAF) less likely. There are no neurological deficits to suggest a transient ischemic attack (TIA). The prodromal symptoms, such as tunnel vision and lightheadedness, align more with orthostatic hypotension rather than vasovagal syncope, which typically occurs after long periods of standing and is characterized by feeling hot and sweaty. Although carotid sinus syndrome could be considered as a differential diagnosis, as the patient’s head turning on getting out of bed may trigger symptoms, it is not one of the options.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Cardiology
      14.9
      Seconds
  • Question 26 - A 35-year-old individual arrives at the emergency department, complaining of feeling unwell for...

    Incorrect

    • A 35-year-old individual arrives at the emergency department, complaining of feeling unwell for the past 48 hours. After obtaining the patient's medical history, you suspect carbon monoxide poisoning. What is the primary intervention in managing patients with carbon monoxide poisoning?

      Your Answer: Acetazolamide

      Correct Answer: 100% oxygen

      Explanation:

      In managing patients with carbon monoxide poisoning, the primary intervention is providing 100% oxygen. This is because carbon monoxide has a higher affinity for hemoglobin than oxygen, leading to decreased oxygen delivery to tissues. By administering 100% oxygen, the patient is able to displace carbon monoxide from hemoglobin and increase oxygen levels in the blood, which is crucial for the patient’s recovery.

      Further Reading:

      Carbon monoxide (CO) is a dangerous gas that is produced by the combustion of hydrocarbon fuels and can be found in certain chemicals. It is colorless and odorless, making it difficult to detect. In England and Wales, there are approximately 60 deaths each year due to accidental CO poisoning.

      When inhaled, carbon monoxide binds to haemoglobin in the blood, forming carboxyhaemoglobin (COHb). It has a higher affinity for haemoglobin than oxygen, causing a left-shift in the oxygen dissociation curve and resulting in tissue hypoxia. This means that even though there may be a normal level of oxygen in the blood, it is less readily released to the tissues.

      The clinical features of carbon monoxide toxicity can vary depending on the severity of the poisoning. Mild or chronic poisoning may present with symptoms such as headache, nausea, vomiting, vertigo, confusion, and weakness. More severe poisoning can lead to intoxication, personality changes, breathlessness, pink skin and mucosae, hyperpyrexia, arrhythmias, seizures, blurred vision or blindness, deafness, extrapyramidal features, coma, or even death.

      To help diagnose domestic carbon monoxide poisoning, there are four key questions that can be asked using the COMA acronym. These questions include asking about co-habitees and co-occupants in the house, whether symptoms improve outside of the house, the maintenance of boilers and cooking appliances, and the presence of a functioning CO alarm.

      Typical carboxyhaemoglobin levels can vary depending on whether the individual is a smoker or non-smoker. Non-smokers typically have levels below 3%, while smokers may have levels below 10%. Symptomatic individuals usually have levels between 10-30%, and severe toxicity is indicated by levels above 30%.

      When managing carbon monoxide poisoning, the first step is to administer 100% oxygen. Hyperbaric oxygen therapy may be considered for individuals with a COHb concentration of over 20% and additional risk factors such as loss of consciousness, neurological signs, myocardial ischemia or arrhythmia, or pregnancy. Other management strategies may include fluid resuscitation, sodium bicarbonate for metabolic acidosis, and mannitol for cerebral edema.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      16.5
      Seconds
  • Question 27 - A 65-year-old woman comes in with right-sided weakness and difficulty speaking. Her ROSIER...

    Incorrect

    • A 65-year-old woman comes in with right-sided weakness and difficulty speaking. Her ROSIER score is 3. She weighs 60 kg.
      What is the appropriate dosage of alteplase to give?

      Your Answer: 77mg

      Correct Answer: 63mg

      Explanation:

      Alteplase (rt-pA) is recommended for the treatment of acute ischaemic stroke in adults if it is administered as soon as possible within 4.5 hours of the onset of stroke symptoms. It is important to exclude intracranial haemorrhage through appropriate imaging techniques before starting the treatment. The initial dose of alteplase is 0.9 mg/kg, with a maximum dose of 90 mg. This dose should be given intravenously over a period of 60 minutes. The first 10% of the dose should be administered through intravenous injection, while the remaining dose should be given through intravenous infusion. For a patient weighing 70 kg, the recommended dose would be 63 mg. For more information, please refer to the NICE guidelines on stroke and transient ischaemic attack in individuals over 16 years old.

    • This question is part of the following fields:

      • Neurology
      8.5
      Seconds
  • Question 28 - A 30-year-old woman suffers a gunshot wound to the chest in a domestic...

    Incorrect

    • A 30-year-old woman suffers a gunshot wound to the chest in a domestic dispute. A FAST scan is performed, which shows the presence of intra-thoracic free fluid.

      Which of the following organs is most likely to be injured in this case?

      Your Answer: Liver

      Correct Answer: Small bowel

      Explanation:

      Low-velocity gunshot wounds to the abdomen result in tissue damage through laceration and cutting. On the other hand, high-velocity gunshot wounds transfer a greater amount of kinetic energy to the abdominal viscera. These types of wounds can cause more extensive damage in the surrounding area of the missile’s path due to temporary cavitation.

      When patients experience penetrating abdominal trauma as a result of gunshot wounds, certain organs are more commonly injured. The small bowel is affected in approximately 50% of cases, followed by the colon in 40% of cases. The liver is injured in around 30% of cases, while abdominal vascular structures are affected in about 25% of cases.

      Please note that these statistics have been obtained from the most recent edition of the ATLS manual.

    • This question is part of the following fields:

      • Trauma
      19.2
      Seconds
  • Question 29 - A middle-aged man presents with homonymous hemianopia. He is brought to the hospital,...

    Correct

    • A middle-aged man presents with homonymous hemianopia. He is brought to the hospital, where a CT head scan is conducted. The CT scan confirms a diagnosis of a stroke.
      Which of the following blood vessels is most likely to be impacted?

      Your Answer: Posterior cerebral artery

      Explanation:

      The symptoms and signs of strokes can vary depending on which blood vessel is affected. Here is a summary of the main symptoms based on the territory affected:

      Anterior cerebral artery: This can cause weakness on the opposite side of the body, with the leg and shoulder being more affected than the arm, hand, and face. There may also be minimal loss of sensation on the opposite side of the body. Other symptoms can include difficulty speaking (dysarthria), language problems (aphasia), apraxia (difficulty with limb movements), urinary incontinence, and changes in behavior and personality.

      Middle cerebral artery: This can lead to weakness on the opposite side of the body, with the face and arm being more affected than the leg. There may also be a loss of sensation on the opposite side of the body. Depending on the dominant hemisphere of the brain, there may be difficulties with expressive or receptive language (dysphasia). In the non-dominant hemisphere, there may be neglect of the opposite side of the body.

      Posterior cerebral artery: This can cause a loss of vision on the opposite side of both eyes (homonymous hemianopia). There may also be defects in a specific quadrant of the visual field. In some cases, there may be a syndrome affecting the thalamus on the opposite side of the body.

      It’s important to note that these are just general summaries and individual cases may vary. If you suspect a stroke, it’s crucial to seek immediate medical attention.

    • This question is part of the following fields:

      • Neurology
      14.5
      Seconds
  • Question 30 - A 52 year old male presents to the emergency department complaining of worsening...

    Correct

    • A 52 year old male presents to the emergency department complaining of worsening chest pain associated with shortness of breath and dizziness over the past 24 hours. You note the patient has a long history of smoking and has been diagnosed with chronic obstructive pulmonary disease (COPD). On examination you note decreased breath sounds on the left side and dullness to percussion. The patient's observations are shown below:

      Blood pressure 120/80 mmHg
      Pulse 92 bpm
      Respiration rate 20 bpm
      Temperature 37.2ºC

      Which of the following is the most appropriate initial treatment for this patient?

      Your Answer: Intravenous ceftriaxone

      Explanation:

      Spontaneous bacterial peritonitis (SBP) is a condition where bacteria infect the fluid in the abdomen, known as ascites. It is commonly seen in patients with ascites. Symptoms of SBP include fever, chills, nausea, vomiting, abdominal pain, and mental confusion. To diagnose SBP, a procedure called paracentesis is done to analyze the fluid in the abdomen. If the neutrophil count in the fluid is higher than 250 cells/mm³, it confirms the diagnosis of SBP, regardless of whether bacteria are found in the culture. The initial treatment for acute community-acquired SBP is usually a 3rd generation cephalosporin antibiotic like cefotaxime or ceftriaxone. However, hospital-acquired SBP may require different antibiotics based on local resistance patterns. Patients who have had SBP in the past are at a high risk of recurrence and may need long-term antibiotic prophylaxis.

      Further Reading:

      Cirrhosis is a condition where the liver undergoes structural changes, resulting in dysfunction of its normal functions. It can be classified as either compensated or decompensated. Compensated cirrhosis refers to a stage where the liver can still function effectively with minimal symptoms, while decompensated cirrhosis is when the liver damage is severe and clinical complications are present.

      Cirrhosis develops over a period of several years due to repeated insults to the liver. Risk factors for cirrhosis include alcohol misuse, hepatitis B and C infection, obesity, type 2 diabetes, autoimmune liver disease, genetic conditions, certain medications, and other rare conditions.

      The prognosis of cirrhosis can be assessed using the Child-Pugh score, which predicts mortality based on parameters such as bilirubin levels, albumin levels, INR, ascites, and encephalopathy. The score ranges from A to C, with higher scores indicating a poorer prognosis.

      Complications of cirrhosis include portal hypertension, ascites, hepatic encephalopathy, variceal hemorrhage, increased infection risk, hepatocellular carcinoma, and cardiovascular complications.

      Diagnosis of cirrhosis is typically done through liver function tests, blood tests, viral hepatitis screening, and imaging techniques such as transient elastography or acoustic radiation force impulse imaging. Liver biopsy may also be performed in some cases.

      Management of cirrhosis involves treating the underlying cause, controlling risk factors, and monitoring for complications. Complications such as ascites, spontaneous bacterial peritonitis, oesophageal varices, and hepatic encephalopathy require specific management strategies.

      Overall, cirrhosis is a progressive condition that requires ongoing monitoring and management to prevent further complications and improve outcomes for patients.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      22.5
      Seconds
  • Question 31 - A 25-year-old man is given a medication for a medical condition during the...

    Incorrect

    • A 25-year-old man is given a medication for a medical condition during the 2nd-trimester of his partner's pregnancy. As a result, the newborn experienced delayed onset labor and premature closure of the ductus arteriosus.
      Which of the following medications is the most probable cause of these abnormalities?

      Your Answer: Heparin

      Correct Answer: Diclofenac sodium

      Explanation:

      The use of NSAIDs in the third trimester of pregnancy is linked to several risks. These risks include delayed onset of labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus, which is a condition where bilirubin causes brain dysfunction. Additionally, there is a slight increase in the risk of first-trimester abortion if NSAIDs are used early in pregnancy.

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

      ACE inhibitors (e.g. ramipril): If given in the second and third trimester, these drugs can cause hypoperfusion, renal failure, and the oligohydramnios sequence.

      Aminoglycosides (e.g. gentamicin): These drugs can cause ototoxicity and deafness.

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

      Benzodiazepines (e.g. diazepam): When given late in pregnancy, these drugs can cause respiratory depression and a neonatal withdrawal syndrome.

      Calcium-channel blockers: If given in the first trimester, these drugs can cause phalangeal abnormalities. If given in the second and third trimester, they can lead to fetal growth retardation.

      Carbamazepine: This drug can cause hemorrhagic disease of the newborn and neural tube defects.

      Chloramphenicol: Use of this drug can result in grey baby syndrome.

      Corticosteroids: If given in the first trimester, corticosteroids may cause orofacial clefts.

      Danazol: If given in the first trimester, this drug can cause masculinization of the female fetuses genitals.

      Finasteride: Pregnant women should avoid handling finasteride. Crushed or broken tablets can be absorbed through the skin and affect male sex organ development.

      Haloperidol: If given in the first trimester, this drug may cause limb malformations. If given in the third trimester, there is an increased risk of extrapyramidal symptoms in the neonate.

      Heparin: Use of heparin during pregnancy can lead to maternal bleeding and thrombocytopenia.

      Isoniazid: This drug can cause maternal liver damage

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      10.6
      Seconds
  • Question 32 - You review a child with a history of attention deficit hyperactivity disorder (ADHD)...

    Correct

    • You review a child with a history of attention deficit hyperactivity disorder (ADHD) who is currently experiencing hyperactive symptoms. During the evaluation, you observe that he is constantly repeating words. The repetitions do not appear to have any meaningful connection, but the words have similar sounds.
      Which ONE of the following symptoms is he displaying?

      Your Answer: Clang association

      Explanation:

      Clang associations refer to the grouping of words, typically rhyming words, that share similar sounds but lack any logical connection. These associations are commonly observed in individuals diagnosed with schizophrenia and bipolar disorder.

    • This question is part of the following fields:

      • Mental Health
      29.2
      Seconds
  • Question 33 - A 2-month-old baby girl is brought in by her parents with projectile vomiting....

    Incorrect

    • A 2-month-old baby girl is brought in by her parents with projectile vomiting. She is vomiting approximately every 45 minutes after each feed but remains hungry. On examination, she appears dehydrated, and you can palpate a small mass in the upper abdomen.

      What is the SINGLE most likely diagnosis?

      Your Answer: Intussusception

      Correct Answer: Infantile hypertrophic pyloric stenosis

      Explanation:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Neonatal Emergencies
      18.8
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  • Question 34 - A 25-year-old female patient arrives at the Emergency Department displaying symptoms consistent with...

    Incorrect

    • A 25-year-old female patient arrives at the Emergency Department displaying symptoms consistent with a sexually transmitted infection.
      Which of the following organisms is primarily transmitted through sexual contact?

      Your Answer: Staphylococcus aureus

      Correct Answer: Chlamydia trachomatis

      Explanation:

      Chlamydia trachomatis is a type of bacteria that is accountable for causing the infection known as chlamydia. This bacterium is mainly transmitted through sexual contact.

      There are various serological variants of C. trachomatis, and each variant is associated with different patterns of disease. Specifically, types D-K are responsible for causing genitourinary infections.

      In the United Kingdom, chlamydia is the most commonly diagnosed sexually transmitted infection (STI). It is also the leading preventable cause of infertility worldwide. Interestingly, around 50% of men infected with chlamydia do not experience any symptoms, while at least 70% of infected women are asymptomatic.

      If left untreated, chlamydia can lead to various complications. In women, these complications may include pelvic inflammatory disease (PID), ectopic pregnancy, and tubal infertility. Men, on the other hand, may experience complications such as proctitis, epididymitis, and epididymo-orchitis.

    • This question is part of the following fields:

      • Sexual Health
      26.5
      Seconds
  • Question 35 - A 60-year-old woman with a history of congestive cardiac failure is experiencing severe...

    Incorrect

    • A 60-year-old woman with a history of congestive cardiac failure is experiencing severe central chest pain when reclining. The pain is relieved by assuming an upright position. She has a documented history of severe coronary artery disease.

      What is the SINGLE most probable diagnosis?

      Your Answer: Acute myocardial infarction

      Correct Answer: Decubitus angina

      Explanation:

      Decubitus angina typically occurs in individuals who have congestive heart failure and significant coronary artery disease. When the patient assumes a lying position, the heightened volume of blood within the blood vessels puts stress on the heart, leading to episodes of chest pain.

    • This question is part of the following fields:

      • Cardiology
      53.6
      Seconds
  • Question 36 - A 32-year-old man has ingested an excessive amount of medication. He experiences nausea,...

    Incorrect

    • A 32-year-old man has ingested an excessive amount of medication. He experiences nausea, perspiration, and ringing in the ears. His arterial blood gas reveals a respiratory alkalosis, and his ECG displays an elongation of the QRS complex.
      Which drug is he most likely to have overdosed on?

      Your Answer: Paracetamol

      Correct Answer: Aspirin

      Explanation:

      Salicylate poisoning is a fairly common form of poisoning that can lead to organ damage and death if not treated promptly. Some common symptoms include nausea, vomiting, ringing in the ears, hearing loss, excessive sweating, and dehydration. Additionally, individuals may experience rapid breathing, flushed skin, and high fever, particularly in children. In severe cases, convulsions, swelling of the brain, coma, kidney failure, fluid accumulation in the lungs unrelated to heart problems, and unstable cardiovascular function may occur.

      Early on in the overdose, arterial blood gas analysis typically reveals a respiratory alkalosis due to overstimulation of the respiratory center. As the overdose progresses, especially in moderate to severe cases, a metabolic acidosis with an increased anion gap may develop as a result of elevated levels of protons in the blood.

      Electrocardiogram (ECG) abnormalities that may be observed include widening of the QRS complex, atrioventricular (AV) block, and ventricular arrhythmias.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      16.4
      Seconds
  • Question 37 - A 35-year-old individual presents with intense one-sided abdominal pain starting in the right...

    Correct

    • A 35-year-old individual presents with intense one-sided abdominal pain starting in the right flank and extending to the groin. They are also experiencing severe nausea and vomiting. The urine dipstick test shows the presence of blood. A CT KUB scan is scheduled, and a diagnosis of ureteric colic is confirmed.
      Which of the following is NOT a reason for immediate hospital admission in a patient with ureteric colic?

      Your Answer: Frank haematuria

      Explanation:

      Renal colic, also known as ureteric colic, refers to a sudden and intense pain in the lower back caused by a blockage in the ureter, which is the tube that carries urine from the kidney to the bladder. This condition is commonly associated with the presence of a urinary tract stone.

      The main symptoms of renal or ureteric colic include severe abdominal pain on one side, starting in the flank or loin area and radiating to the groin or testicle in men, or to the labia in women. The pain comes and goes in spasms, lasting for minutes to hours, with periods of no pain or a dull ache. Nausea, vomiting, and the presence of blood in the urine are often accompanying symptoms.

      The pain experienced during renal or ureteric colic is often described as the most intense pain a person has ever felt, with many women comparing it to the pain of childbirth. Restlessness and an inability to find relief by lying still are common signs, which can help differentiate renal colic from peritonitis. Previous episodes of similar pain may also be reported by the individual. In cases where there is a concomitant urinary infection, fever and sweating may be present. Additionally, the person may complain of painful urination, frequent urination, and straining when the stone reaches the junction between the ureter and the bladder, as the stone irritates the detrusor muscle.

      It is important to seek urgent medical attention if certain conditions are met. These include signs of systemic infection or sepsis, such as fever or sweating, or if the person is at a higher risk of acute kidney injury, such as having pre-existing chronic kidney disease, a solitary or transplanted kidney, or suspected bilateral obstructing stones. Hospital admission is also necessary if the person is dehydrated and unable to consume fluids orally due to nausea and/or vomiting. If there is uncertainty regarding the diagnosis, it is recommended to consult further resources, such as the NICE guidelines on the assessment and management of renal and ureteric stones.

    • This question is part of the following fields:

      • Urology
      6.2
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  • Question 38 - You are resuscitating a 38-year-old male patient with extensive burns. Your attending physician...

    Correct

    • You are resuscitating a 38-year-old male patient with extensive burns. Your attending physician requests you to insert a femoral central venous line. How should the patient be positioned for this procedure?

      Your Answer: Patient supine with slight abduction and external rotation of thigh/hip

      Explanation:

      To insert a femoral line, the patient should be lying on their back with a pillow placed under their buttocks to elevate the groin area. The thigh should be slightly moved away from the body and rotated outward.

      Further Reading:

      A central venous catheter (CVC) is a type of catheter that is inserted into a large vein in the body, typically in the neck, chest, or groin. It has several important uses, including CVP monitoring, pulmonary artery pressure monitoring, repeated blood sampling, IV access for large volumes of fluids or drugs, TPN administration, dialysis, pacing, and other procedures such as placement of IVC filters or venous stents.

      When inserting a central line, it is ideal to use ultrasound guidance to ensure accurate placement. However, there are certain contraindications to central line insertion, including infection or injury to the planned access site, coagulopathy, thrombosis or stenosis of the intended vein, a combative patient, or raised intracranial pressure for jugular venous lines.

      The most common approaches for central line insertion are the internal jugular, subclavian, femoral, and PICC (peripherally inserted central catheter) veins. The internal jugular vein is often chosen due to its proximity to the carotid artery, but variations in anatomy can occur. Ultrasound can be used to identify the vessels and guide catheter placement, with the IJV typically lying superficial and lateral to the carotid artery. Compression and Valsalva maneuvers can help distinguish between arterial and venous structures, and doppler color flow can highlight the direction of flow.

      In terms of choosing a side for central line insertion, the right side is usually preferred to avoid the risk of injury to the thoracic duct and potential chylothorax. However, the left side can also be used depending on the clinical situation.

      Femoral central lines are another option for central venous access, with the catheter being inserted into the femoral vein in the groin. Local anesthesia is typically used to establish a field block, with lidocaine being the most commonly used agent. Lidocaine works by blocking sodium channels and preventing the propagation of action potentials.

      In summary, central venous catheters have various important uses and should ideally be inserted using ultrasound guidance. There are contraindications to their insertion, and different approaches can be used depending on the clinical situation. Local anesthesia is commonly used for central line insertion, with lidocaine being the preferred agent.

    • This question is part of the following fields:

      • Resus
      4
      Seconds
  • Question 39 - A 45-year-old man presents with a history of anxiety and thoughts of self-harm....

    Incorrect

    • A 45-year-old man presents with a history of anxiety and thoughts of self-harm. You utilize the modified SAD PERSONS score to evaluate his risk.
      Which ONE of the following statements is accurate regarding this risk assessment tool?

      Your Answer: A score of 4 would indicate the patient requires hospital admission

      Correct Answer: A history of divorce indicates increased risk

      Explanation:

      The modified SAD PERSONS scoring system is a valuable tool used to evaluate a patient’s risk of suicide. This scoring system consists of ten yes/no questions, and points are assigned for each affirmative answer. The points are distributed as follows: 1 point for being male, 1 point for being younger than 19 or older than 45 years, 2 points for experiencing depression or hopelessness, 1 point for having a history of previous suicidal attempts or psychiatric care, 1 point for excessive alcohol or drug use, 2 points for exhibiting a loss of rational thinking due to psychotic or organic illness, 1 point for being single, widowed, or divorced, 2 points for an organized or serious suicide attempt, 1 point for lacking social support, and 2 points for expressing future intent to repeat or being ambivalent about suicide.

      Based on the total score, the patient’s risk level can be determined. A score of 0-5 suggests that it may be safe to discharge the patient or provide outpatient management, depending on the circumstances. A score of 6-8 indicates that the patient probably requires psychiatric consultation. Finally, a score higher than 8 suggests that the patient likely requires hospital admission for further evaluation and care. This scoring system helps healthcare professionals make informed decisions regarding the appropriate level of intervention and support needed for patients at risk of suicide.

    • This question is part of the following fields:

      • Mental Health
      43.4
      Seconds
  • Question 40 - A 14-month-old boy presents with a history of occasional wheezing and cough, which...

    Correct

    • A 14-month-old boy presents with a history of occasional wheezing and cough, which worsens at night. He recently had a cold and appears congested today. His mother reports that he often wheezes after a cold, and this can persist for several weeks after the infection has resolved. Both parents smoke, but his mother is trying to reduce her smoking, and neither parent smokes inside the house. There is no family history of asthma or allergies. Another doctor recently prescribed inhalers, but they have had little effect. On examination, he has a slight fever of 37.8°C, and there are scattered audible wheezes heard during chest examination.

      What is the SINGLE most likely diagnosis?

      Your Answer: Viral induced wheeze

      Explanation:

      Viral induced wheeze is a common condition in childhood that is triggered by a viral infection, typically a cold. The wheezing occurs during the infection and can persist for several weeks after the infection has cleared. This condition is most commonly seen in children under the age of three, as their airways are smaller. It is also more prevalent in babies who were small for their gestational age and in children whose parents smoke. It is important to note that viral induced wheeze does not necessarily mean that the child has asthma, although a small percentage of children with this condition may go on to develop asthma. Asthma is more commonly seen in children with a family history of asthma or allergies. Inhalers are often prescribed for the management of viral induced wheeze, but they may not always be effective.

    • This question is part of the following fields:

      • Respiratory
      11.4
      Seconds
  • Question 41 - A 32-year-old woman comes to the Emergency Department complaining of dizziness and palpitations....

    Incorrect

    • A 32-year-old woman comes to the Emergency Department complaining of dizziness and palpitations. She informs you that she was recently diagnosed with Wolff-Parkinson-White syndrome. She is connected to an ECG monitor, and you observe the presence of an arrhythmia.
      What is the most frequently encountered type of arrhythmia in Wolff-Parkinson-White syndrome?

      Your Answer: Ventricular fibrillation

      Correct Answer: Atrioventricular re-entrant tachycardia

      Explanation:

      Wolff-Parkinson-White (WPW) syndrome is a condition that affects the electrical system of the heart. It occurs when there is an abnormal pathway, known as the bundle of Kent, between the atria and the ventricles. This pathway can cause premature contractions of the ventricles, leading to a type of rapid heartbeat called atrioventricular re-entrant tachycardia (AVRT).

      In a normal heart rhythm, the electrical signals travel through the bundle of Kent and stimulate the ventricles. However, in WPW syndrome, these signals can cause the ventricles to contract prematurely. This can be seen on an electrocardiogram (ECG) as a shortened PR interval, a slurring of the initial rise in the QRS complex (known as a delta wave), and a widening of the QRS complex.

      There are two distinct types of WPW syndrome that can be identified on an ECG. Type A is characterized by predominantly positive delta waves and QRS complexes in the praecordial leads, with a dominant R wave in V1. This can sometimes be mistaken for right bundle branch block (RBBB). Type B, on the other hand, shows predominantly negative delta waves and QRS complexes in leads V1 and V2, and positive in the other praecordial leads, resembling left bundle branch block (LBBB).

      Overall, WPW syndrome is a condition that affects the electrical conduction system of the heart, leading to abnormal heart rhythms. It can be identified on an ECG by specific features such as shortened PR interval, delta waves, and widened QRS complex.

    • This question is part of the following fields:

      • Cardiology
      15.2
      Seconds
  • Question 42 - A 35-year-old man is brought into the emergency room by an ambulance with...

    Incorrect

    • A 35-year-old man is brought into the emergency room by an ambulance with sirens blaring. He has been in a building fire and has sustained severe burns. Upon assessing his airway, you have concerns about potential airway blockage. You decide to proceed with intubation and begin preparing the required equipment.
      What is one reason for performing early intubation in a burn patient?

      Your Answer: Circumferential superficial neck burns

      Correct Answer: Hoarseness of voice

      Explanation:

      Early assessment of the airway is a critical aspect of managing a burned patient. Airway obstruction can occur rapidly due to direct injury or swelling from the burn. If there is a history of trauma, the airway should be evaluated while maintaining cervical spine control.

      There are several risk factors for airway obstruction in burned patients, including inhalation injury, soot in the mouth or nostrils, singed nasal hairs, burns to the head, face, and neck, burns inside the mouth, large burn area and increasing burn depth, associated trauma, and a carboxyhemoglobin level above 10%.

      In cases where significant swelling is anticipated, it may be necessary to urgently secure the airway with an uncut endotracheal tube before the swelling becomes severe. Delaying recognition of impending airway obstruction can make intubation difficult, and a surgical airway may be required.

      The American Burn Life Support (ABLS) guidelines recommend early intubation in certain situations. These include signs of airway obstruction, extensive burns, deep facial burns, burns inside the mouth, significant swelling or risk of swelling, difficulty swallowing, respiratory compromise, decreased level of consciousness, and anticipated transfer of a patient with a large burn and airway issues without qualified personnel to intubate during transport.

      Circumferential burns of the neck can cause tissue swelling around the airway, making early intubation necessary in these cases as well.

    • This question is part of the following fields:

      • Trauma
      24.1
      Seconds
  • Question 43 - A 25-year-old man has had discoloured teeth since taking a medication in his...

    Incorrect

    • A 25-year-old man has had discoloured teeth since taking a medication in his youth. Upon examination, visible greyish-brown horizontal stripes can be observed across all of his teeth.
      Which SINGLE medication is most likely responsible for this?

      Your Answer: Metronidazole

      Correct Answer: Doxycycline

      Explanation:

      Tetracycline antibiotics, such as tetracycline and doxycycline, have the potential to cause staining on permanent teeth while they are still forming beneath the gum line. This staining occurs when the drug becomes calcified within the tooth during its development. It is important to note that children are vulnerable to tetracycline-related tooth staining until approximately the age of 8. Additionally, pregnant women should avoid taking tetracycline as it can affect the development of teeth in the unborn child.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      11.5
      Seconds
  • Question 44 - A 45 year old female patient has been brought to the emergency department...

    Incorrect

    • A 45 year old female patient has been brought to the emergency department with multiple injuries following a fall while hiking in the mountains. You observe significant injuries to the face. There is also bruising to the chest wall and a fracture dislocation to the ankle. The patient has undergone rapid sequence induction with Propofol and Suxamethonium. A chest X-ray shows multiple rib fractures but no pneumothorax or visible pulmonary contusion. You notice that the patient's end tidal CO2 has steadily increased since being intubated from 4.5 KPa to 7.4 KPa. You observe esophageal temperature is 39.3ºC. What is the likely cause of these readings?

      Your Answer: Tracheal perforation

      Correct Answer: Malignant hyperthermia

      Explanation:

      The earliest and most frequent clinical indication of malignant hyperthermia is typically an increase in end tidal CO2. An unexplained elevation in end tidal CO2 is often the initial and most reliable sign of this condition.

      Further Reading:

      Malignant hyperthermia is a rare and life-threatening syndrome that can be triggered by certain medications in individuals who are genetically susceptible. The most common triggers are suxamethonium and inhalational anaesthetic agents. The syndrome is caused by the release of stored calcium ions from skeletal muscle cells, leading to uncontrolled muscle contraction and excessive heat production. This results in symptoms such as high fever, sweating, flushed skin, rapid heartbeat, and muscle rigidity. It can also lead to complications such as acute kidney injury, rhabdomyolysis, and metabolic acidosis. Treatment involves discontinuing the trigger medication, administering dantrolene to inhibit calcium release and promote muscle relaxation, and managing any associated complications such as hyperkalemia and acidosis. Referral to a malignant hyperthermia center for further investigation is also recommended.

    • This question is part of the following fields:

      • Basic Anaesthetics
      15.4
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  • Question 45 - A 40-year-old male with schizophrenia is brought to the emergency department by the...

    Correct

    • A 40-year-old male with schizophrenia is brought to the emergency department by the CPN after admitting to ingesting approximately 100 aspirin tablets one hour ago. He is now experiencing tinnitus. When would you initially measure salicylate levels in this patient?

      Your Answer: 2 hours post ingestion

      Explanation:

      If a person shows symptoms after ingesting salicylate, their salicylate levels should be measured 2 hours after ingestion. However, if the person does not show any symptoms, the levels should be measured 4 hours after ingestion. It is important to note that if enteric coated preparations are taken, salicylate levels may continue to increase for up to 12 hours. Therefore, it is necessary to regularly check the levels every 2-3 hours until they start to decrease.

      Further Reading:

      Salicylate poisoning, particularly from aspirin overdose, is a common cause of poisoning in the UK. One important concept to understand is that salicylate overdose leads to a combination of respiratory alkalosis and metabolic acidosis. Initially, the overdose stimulates the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the effects of salicylate on lactic acid production, breakdown into acidic metabolites, and acute renal injury occur, it can result in high anion gap metabolic acidosis.

      The clinical features of salicylate poisoning include hyperventilation, tinnitus, lethargy, sweating, pyrexia (fever), nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.

      When investigating salicylate poisoning, it is important to measure salicylate levels in the blood. The sample should be taken at least 2 hours after ingestion for symptomatic patients or 4 hours for asymptomatic patients. The measurement should be repeated every 2-3 hours until the levels start to decrease. Other investigations include arterial blood gas analysis, electrolyte levels (U&Es), complete blood count (FBC), coagulation studies (raised INR/PTR), urinary pH, and blood glucose levels.

      To manage salicylate poisoning, an ABC approach should be followed to ensure a patent airway and adequate ventilation. Activated charcoal can be administered if the patient presents within 1 hour of ingestion. Oral or intravenous fluids should be given to optimize intravascular volume. Hypokalemia and hypoglycemia should be corrected. Urinary alkalinization with intravenous sodium bicarbonate can enhance the elimination of aspirin in the urine. In severe cases, hemodialysis may be necessary.

      Urinary alkalinization involves targeting a urinary pH of 7.5-8.5 and checking it hourly. It is important to monitor for hypokalemia as alkalinization can cause potassium to shift from plasma into cells. Potassium levels should be checked every 1-2 hours.

      In cases where the salicylate concentration is high (above 500 mg/L in adults or 350 mg/L in children), sodium bicarbonate can be administered intravenously. Hemodialysis is the treatment of choice for severe poisoning and may be indicated in cases of high salicylate levels, resistant metabolic acidosis, acute kidney injury, pulmonary edema, seizures and coma.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      37.5
      Seconds
  • Question 46 - You assess a patient who is currently undergoing systemic anticancer treatment. She has...

    Incorrect

    • You assess a patient who is currently undergoing systemic anticancer treatment. She has been experiencing chills and feeling unwell and is worried about the potential of having an infection. She informs you that she is currently prescribed an antibiotic as a preventive measure against neutropenic sepsis.
      Which of the subsequent antibiotic classes is utilized for this specific purpose?

      Your Answer: Penicillins

      Correct Answer: Fluoroquinolones

      Explanation:

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

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

    • This question is part of the following fields:

      • Oncological Emergencies
      23.6
      Seconds
  • Question 47 - A 25-year-old patient visits your clinic with concerns about a recent alteration in...

    Incorrect

    • A 25-year-old patient visits your clinic with concerns about a recent alteration in her usual vaginal discharge. She is not sexually active at the moment and has no other health issues. She does not report any itching symptoms but has observed a strong fishy odor and a greyish-white appearance in the discharge.
      What is the most suitable treatment for this patient?

      Your Answer: Oral doxycycline

      Correct Answer: Oral metronidazole

      Explanation:

      Bacterial vaginosis (BV) is a common condition that affects up to a third of women during their childbearing years. It occurs when there is an overgrowth of bacteria, specifically Gardnerella vaginalis. This bacterium is anaerobic, meaning it thrives in environments without oxygen. As it multiplies, it disrupts the balance of bacteria in the vagina, leading to a rise in pH levels and a decrease in lactic acid-producing lactobacilli. It’s important to note that BV is not a sexually transmitted infection.

      The main symptom of BV is a greyish discharge with a distinct fishy odor. However, it’s worth mentioning that around 50% of affected women may not experience any symptoms at all.

      To diagnose BV, healthcare providers often use Amsel’s criteria. This involves looking for the presence of three out of four specific criteria: a vaginal pH greater than 4.5, a positive fishy smell test when potassium hydroxide is added, the presence of clue cells on microscopy, and a thin, white, homogeneous discharge.

      The primary treatment for BV is oral metronidazole, typically taken for 5-7 days. This medication has an initial cure rate of about 75%. It’s crucial to provide special care to pregnant patients diagnosed with BV, as it has been linked to an increased risk of late miscarriage, early labor, and chorioamnionitis. Therefore, prompt treatment for these patients is of utmost importance.

    • This question is part of the following fields:

      • Sexual Health
      7.2
      Seconds
  • Question 48 - You are present for the unexpected delivery of a baby in one of...

    Incorrect

    • You are present for the unexpected delivery of a baby in one of the cubicles in the Emergency Department. Your consultant evaluates the newborn one minute after birth and informs you that:
      The hands and feet appear bluish in color
      The heart rate is 110 beats per minute
      There is no response to stimulation
      There is slight bending of the limbs
      The cry is feeble, and the baby is gasping for breath
      What is the Apgar score of the newborn at one minute?

      Your Answer: 3

      Correct Answer: 5

      Explanation:

      The Apgar score is a straightforward way to evaluate the well-being of a newborn baby right after birth. It consists of five criteria, each assigned a score ranging from zero to two. Typically, the assessment is conducted at one and five minutes after delivery, with the possibility of repeating it later if the score remains low. A score of 7 or higher is considered normal, while a score of 4-6 is considered fairly low, and a score of 3 or below is regarded as critically low. To remember the five criteria, you can use the acronym APGAR:

      Appearance
      Pulse rate
      Grimace
      Activity
      Respiratory effort

      The Apgar score criteria are as follows:

      Score of 0:
      Appearance (skin color): Blue or pale all over
      Pulse rate: Absent
      Reflex irritability (grimace): No response to stimulation
      Activity: None
      Respiratory effort: Absent

      Score of 1:
      Appearance (skin color): Blue at extremities (acrocyanosis)
      Pulse rate: Less than 100 per minute
      Reflex irritability (grimace): Grimace on suction or aggressive stimulation
      Activity: Some flexion
      Respiratory effort: Weak, irregular, gasping

      Score of 2:
      Appearance (skin color): No cyanosis, body and extremities pink
      Pulse rate: More than 100 per minute
      Reflex irritability (grimace): Cry on stimulation
      Activity: Flexed arms and legs that resist extension
      Respiratory effort: Strong, robust cry

    • This question is part of the following fields:

      • Neonatal Emergencies
      14.6
      Seconds
  • Question 49 - A toddler develops a palsy of his left leg following a fall. On...

    Correct

    • A toddler develops a palsy of his left leg following a fall. On examination, there is a loss of hip abduction, external rotation and knee flexion. The leg is noticeably dragging with the knee extended and the foot turned inward.
      What is the SINGLE most likely diagnosis?

      Your Answer: Erb’s palsy

      Explanation:

      Erb’s palsy, also known as Erb-Duchenne palsy, is a condition where the arm becomes paralyzed due to an injury to the upper roots of the brachial plexus. The primary root affected is usually C5, although C6 may also be involved in some cases. The main cause of Erb’s palsy is when the arm experiences excessive force during a difficult childbirth, but it can also occur in adults as a result of shoulder trauma.

      Clinically, the affected arm will hang by the side with the elbow extended and the forearm turned inward (known as the waiter’s tip sign). Upon examination, there will be a loss of certain movements:

      – Shoulder abduction (involving the deltoid and supraspinatus muscles)
      – Shoulder external rotation (infraspinatus muscle)
      – Elbow flexion (biceps and brachialis muscles)

      It is important to differentiate Erb’s palsy from Klumpke’s palsy, which affects the lower roots of the brachial plexus (C8 and T1). Klumpke’s palsy presents with a claw hand due to paralysis of the intrinsic hand muscles, along with sensory loss along the ulnar side of the forearm and hand. If T1 is affected, there may also be the presence of Horner’s syndrome.

    • This question is part of the following fields:

      • Neurology
      13.5
      Seconds
  • Question 50 - A 28-year-old woman comes in seeking contraceptive advice. She forgot to take her...

    Incorrect

    • A 28-year-old woman comes in seeking contraceptive advice. She forgot to take her last Microgynon 30 pill and it has been 48 hours since her last dose. She has been taking the rest of the pills in the packet consistently. She had unprotected sex last night and wants to know the best course of action.
      What is the MOST suitable advice to provide her?

      Your Answer: She should take both of the missed pills today and emergency contraception should be considered

      Correct Answer: She should take the most recent missed pill, the remaining pills should be continued at the usual time, but no emergency contraception is required

      Explanation:

      If you have missed one pill, which means it has been 48-72 hours since you took the last pill in your current packet or you started the first pill in a new packet 24-48 hours late, you need to take the missed pill as soon as you remember. Make sure to continue taking the remaining pills at your usual time. Emergency contraception is generally not necessary in this situation, but it may be worth considering if you have missed pills earlier in the packet or during the last week of the previous packet.

    • This question is part of the following fields:

      • Sexual Health
      7.8
      Seconds
  • Question 51 - A 45 year old female comes to the emergency department with abrupt onset...

    Incorrect

    • A 45 year old female comes to the emergency department with abrupt onset tearing chest pain that spreads to the throat and back. You contemplate the likelihood of aortic dissection. What is the predominant risk factor observed in individuals with aortic dissection?

      Your Answer: Down syndrome

      Correct Answer: Hypertension

      Explanation:

      Aortic dissection is a condition that occurs when the middle layer of the aorta, known as the tunica media, becomes weakened. This weakening leads to the development of cases of aortic dissection.

      Further Reading:

      Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.

      The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.

      Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.

      Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.

    • This question is part of the following fields:

      • Cardiology
      13.7
      Seconds
  • Question 52 - A 45-year-old patient has been diagnosed with gonorrhea. You are preparing to initiate...

    Correct

    • A 45-year-old patient has been diagnosed with gonorrhea. You are preparing to initiate antibiotic treatment.
      Which of the following antibiotic combinations would be the most suitable?

      Your Answer: Ceftriaxone and azithromycin

      Explanation:

      Ceftriaxone is currently one of the limited antibiotics that effectively treats gonorrhoea. It is typically administered alongside azithromycin or doxycycline to enhance its effectiveness.

    • This question is part of the following fields:

      • Sexual Health
      13
      Seconds
  • Question 53 - A 60-year-old woman with uncontrolled hypertension experiences a sudden loss of vision in...

    Incorrect

    • A 60-year-old woman with uncontrolled hypertension experiences a sudden loss of vision in her left eye. The visual acuity in her left eye is reduced to hand movements only, while her right eye has a visual acuity of 6/6. Upon examining her fundi, you observe engorged retinal veins, disc edema, numerous flame-shaped hemorrhages, and cotton wool spots scattered throughout the entire retina.

      What is the SINGLE most probable diagnosis?

      Your Answer: Vitreous haemorrhage

      Correct Answer: Central retinal vein occlusion

      Explanation:

      Central retinal vein occlusion (CRVO) typically results in painless, one-sided vision loss. On fundoscopic examination, the retina displays a distinct appearance resembling a ‘pizza thrown against a wall’. This includes engorged retinal veins, swelling of the optic disc, multiple flame-shaped hemorrhages, and cotton wool spots. Hypertension is present in about 65% of CRVO patients, and it is more common in individuals over 65 years old.

      In contrast, central retinal artery occlusion (CRAO) also causes sudden, painless, one-sided vision loss. However, the retina’s appearance in CRAO is different from CRVO. It appears pale, with narrowed blood vessels. A notable feature is the presence of a ‘cherry-red spot’ at the center of the macula, which is supplied by the underlying choroid. Examination often reveals an afferent pupillary defect.

      Vitreous hemorrhage occurs when there is bleeding into the middle chamber of the eye, known as the vitreous. This can be caused by conditions such as proliferative diabetic retinopathy, trauma, or retinal detachment. The appearance of vitreous hemorrhage is described as ‘blood within a bloodless gel’, resulting in a diffuse red appearance of the retina. Unlike CRVO, there are no focal flame-shaped hemorrhages.

      Diabetic maculopathy refers to the presence of diabetic eye disease within a one-disc diameter of the macula.

      Wet age-related macular degeneration (ARMD) causes vision loss due to choroidal neovascularization, which leads to leakage of blood and protein beneath the macula. While there may be hemorrhages visible on the retina, the overall appearance does not match the description provided in the question.

    • This question is part of the following fields:

      • Ophthalmology
      13.6
      Seconds
  • Question 54 - A 72-year-old woman with a history of hypertension and kidney disease is prescribed...

    Incorrect

    • A 72-year-old woman with a history of hypertension and kidney disease is prescribed spironolactone. Upon reviewing her blood test results, you observe a notable electrolyte imbalance.
      Which of the following electrolyte imbalances is most likely to have occurred?

      Your Answer: Hypocalcaemia

      Correct Answer: Hyperkalaemia

      Explanation:

      Spironolactone is a medication used to treat conditions such as congestive cardiac failure, hypertension, hepatic cirrhosis with ascites and edema, and Conn’s syndrome. It functions as a competitive aldosterone receptor antagonist, primarily working in the distal convoluted tubule. In this area, it hinders the reabsorption of sodium ions and enhances the reabsorption of potassium ions. Spironolactone is commonly known as a potassium-sparing diuretic.

      The main side effect of spironolactone is hyperkalemia, particularly when renal impairment is present. In severe cases, hyperkalemia can be life-threatening. Additionally, there is a notable occurrence of gastrointestinal disturbances, with nausea and vomiting being the most common. Women may experience menstrual disturbances, while men may develop gynecomastia, both of which are attributed to the antiandrogenic effects of spironolactone.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      14.6
      Seconds
  • Question 55 - You are summoned to a cardiac arrest in the resuscitation area of your...

    Incorrect

    • You are summoned to a cardiac arrest in the resuscitation area of your Emergency Department.
      Which ONE statement about the utilization of amiodarone in cardiac arrest is accurate?

      Your Answer: It is indicated in PEA arrests

      Correct Answer: It increases the duration of the action potential

      Explanation:

      Amiodarone is a medication that is recommended to be administered after the third shock in a shockable cardiac arrest (Vf/pVT) while chest compressions are being performed. The prescribed dose is 300 mg, given as an intravenous bolus that is diluted in 5% dextrose to a volume of 20 mL. It is important to note that amiodarone is not suitable for treating PEA or asystole.

      In cases where VF/pVT persists after five defibrillation attempts, an additional dose of 150 mg of amiodarone should be given. However, if amiodarone is not available, lidocaine can be used as an alternative. The recommended dose of lidocaine is 1 mg/kg. It is crucial to avoid administering lidocaine if amiodarone has already been given.

      Amiodarone is classified as a membrane-stabilizing antiarrhythmic drug. It works by prolonging the duration of the action potential and the refractory period in both the atrial and ventricular myocardium. This medication also slows down atrioventricular conduction and has a similar effect on accessory pathways.

      Additionally, amiodarone has a mild negative inotropic action, meaning it weakens the force of heart contractions. It also causes peripheral vasodilation through non-competitive alpha-blocking effects.

      It is important to note that while there is no evidence of long-term benefits from using amiodarone, it may improve short-term survival rates, which justifies its continued use.

    • This question is part of the following fields:

      • Cardiology
      4.1
      Seconds
  • Question 56 - You are preparing to conduct rapid sequence induction. What clinical observation, typically seen...

    Incorrect

    • You are preparing to conduct rapid sequence induction. What clinical observation, typically seen after administering suxamethonium, is not present when rocuronium is used for neuromuscular blockade?

      Your Answer: Skin flushing

      Correct Answer: Muscle fasciculations

      Explanation:

      When suxamethonium is administered for neuromuscular blockade during rapid sequence induction, one of the clinical observations typically seen is muscle fasciculations. However, when rocuronium is used instead, muscle fasciculations are not present.

      Further Reading:

      Rapid sequence induction (RSI) is a method used to place an endotracheal tube (ETT) in the trachea while minimizing the risk of aspiration. It involves inducing loss of consciousness while applying cricoid pressure, followed by intubation without face mask ventilation. The steps of RSI can be remembered using the 7 P’s: preparation, pre-oxygenation, pre-treatment, paralysis and induction, protection and positioning, placement with proof, and post-intubation management.

      Preparation involves preparing the patient, equipment, team, and anticipating any difficulties that may arise during the procedure. Pre-oxygenation is important to ensure the patient has an adequate oxygen reserve and prolongs the time before desaturation. This is typically done by breathing 100% oxygen for 3 minutes. Pre-treatment involves administering drugs to counter expected side effects of the procedure and anesthesia agents used.

      Paralysis and induction involve administering a rapid-acting induction agent followed by a neuromuscular blocking agent. Commonly used induction agents include propofol, ketamine, thiopentone, and etomidate. The neuromuscular blocking agents can be depolarizing (such as suxamethonium) or non-depolarizing (such as rocuronium). Depolarizing agents bind to acetylcholine receptors and generate an action potential, while non-depolarizing agents act as competitive antagonists.

      Protection and positioning involve applying cricoid pressure to prevent regurgitation of gastric contents and positioning the patient’s neck appropriately. Tube placement is confirmed by visualizing the tube passing between the vocal cords, auscultation of the chest and stomach, end-tidal CO2 measurement, and visualizing misting of the tube. Post-intubation management includes standard care such as monitoring ECG, SpO2, NIBP, capnography, and maintaining sedation and neuromuscular blockade.

      Overall, RSI is a technique used to quickly and safely secure the airway in patients who may be at risk of aspiration. It involves a series of steps to ensure proper preparation, oxygenation, drug administration, and tube placement. Monitoring and post-intubation care are also important aspects of RSI.

    • This question is part of the following fields:

      • Basic Anaesthetics
      18.3
      Seconds
  • Question 57 - You review a 30-year-old woman with a known diagnosis of HIV. She asks...

    Incorrect

    • You review a 30-year-old woman with a known diagnosis of HIV. She asks you some questions about her diagnosis.
      What is the median incubation period from HIV infection until the development of advanced HIV disease (also referred to as AIDS)?

      Your Answer: 6 months

      Correct Answer: 10 years

      Explanation:

      The estimated median incubation period from HIV infection to the onset of advanced HIV disease, also known as AIDS, is around ten years.

    • This question is part of the following fields:

      • Infectious Diseases
      21
      Seconds
  • Question 58 - A middle-aged woman presents with symptoms that can be associated with sexually transmitted...

    Incorrect

    • A middle-aged woman presents with symptoms that can be associated with sexually transmitted infection. Following her investigations, she is diagnosed with gonorrhoea.

      Which of the following is the most common presenting clinical feature of gonorrhoea in women?

      Your Answer: Pelvic pain

      Correct Answer: Vaginal discharge

      Explanation:

      Neisseria gonorrhoeae is a type of bacteria that is shaped like two spheres and stains pink when tested. It is responsible for causing the sexually transmitted infection known as gonorrhoea. This infection is most commonly seen in individuals between the ages of 15 and 35, and it is primarily transmitted through sexual contact. One important thing to note is that the gonococcal pili, which are hair-like structures on the bacteria, can change their appearance. This means that even if someone has recovered from a previous infection, they can still be reinfected due to the bacteria’s ability to alter its antigens.

      In men, the most common symptoms of gonorrhoea include inflammation of the urethra, which is the tube that carries urine out of the body. This is seen in approximately 80% of cases. Other symptoms may include painful urination, as well as the presence of a discharge that is a combination of mucus and pus. In some cases, the infection can also affect the rectum, leading to anal discharge. It is worth noting that pharyngitis, which is inflammation of the throat, is usually asymptomatic in men.

      On the other hand, women with gonorrhoea often experience a vaginal discharge as the main symptom, which is seen in about 50% of cases. Lower abdominal pain is another common symptom, occurring in approximately 25% of cases. Dysuria, or painful urination, is seen in about 10-15% of women with the infection. Some women may also experience tenderness in the pelvic or lower abdominal area. Additionally, there may be a discharge or bleeding from the endocervix, which is the opening of the cervix. Similar to men, rectal infection is usually asymptomatic in women, but it can cause anal discharge. Pharyngitis, or inflammation of the throat, is typically not accompanied by any noticeable symptoms in women.

      Overall, it is important to be aware of the various clinical features of gonorrhoea in both men and women in order to recognize and seek appropriate treatment for this sexually transmitted infection.

    • This question is part of the following fields:

      • Sexual Health
      20.5
      Seconds
  • Question 59 - A 4-year-old girl is brought in by an emergency ambulance after being involved...

    Incorrect

    • A 4-year-old girl is brought in by an emergency ambulance after being involved in a car accident. A trauma alert is activated, and you are tasked with obtaining intravenous access and administering a fluid bolus. However, you are unable to successfully establish intravenous access and decide to prepare for intraosseous access instead.

      Which of the following anatomical sites would be the most appropriate for insertion?

      Your Answer: Scapula

      Correct Answer: Proximal humerus

      Explanation:

      Intraosseous access is recommended in trauma, burns, or resuscitation situations when other attempts at venous access fail or would take longer than one minute. It is particularly recommended for circulatory access in pediatric cardiac arrest cases. This technique can also be used when urgent blood sampling or intravenous access is needed and traditional cannulation is difficult and time-consuming. It serves as a temporary measure to stabilize the patient and facilitate long-term intravenous access.

      Potential complications of intraosseous access include compartment syndrome, infection, and fracture. Therefore, it is contraindicated to use this method on the side of definitively fractured bones or limbs with possible proximal fractures. It should also not be used at sites of previous attempts or in patients with conditions such as osteogenesis imperfecta or osteopetrosis.

      There are several possible sites for intraosseous access insertion. These include the proximal humerus, approximately 1 cm above the surgical neck; the proximal tibia, on the anterior surface, 2-3 cm below the tibial tuberosity; the distal tibia, 3 cm proximal to the most prominent aspect of the medial malleolus; the femoral region, on the anterolateral surface, 3 cm above the lateral condyle; the iliac crest; and the sternum.

    • This question is part of the following fields:

      • Trauma
      29.3
      Seconds
  • Question 60 - You review a 25 year old male who presented to the emergency department...

    Incorrect

    • You review a 25 year old male who presented to the emergency department after developing a raised red itchy rash to the arms, legs, and abdomen shortly after going for a hike. The patient informs you that he had eaten some trail mix and drank some water during the hike, but he had not had a reaction to these in the past. On examination, the mouth and throat are normal, the patient is speaking without difficulty, and there is no wheezing. The patient's vital signs are as follows:

      Respiratory rate: 16 bpm
      Blood pressure: 120/70 mmHg
      Pulse rate: 75 bpm
      Oxygen saturations: 98% on room air
      Temperature: 37.0ºC

      You diagnose urticaria. What is the most appropriate treatment to administer?

      Your Answer: Prednisolone 40 mg PO

      Correct Answer: chlorpheniramine 10 mg PO

      Explanation:

      Most histamine receptors in the skin are of the H1 type. Therefore, when treating urticaria without airway compromise, it is appropriate to use an H1 blocking antihistamine such as chlorpheniramine, fexofenadine, or loratadine. However, if the case is mild and the trigger is easily identifiable and avoidable, NICE advises that no treatment may be necessary. In the given case, the trigger is not obvious. For more severe cases, an oral systemic steroid course like prednisolone 40 mg for 5 days may be used in addition to antihistamines. Topical steroids do not have a role in this treatment.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Dermatology
      13.7
      Seconds
  • Question 61 - A 67 year old female attends the emergency department complaining of palpitations. The...

    Incorrect

    • A 67 year old female attends the emergency department complaining of palpitations. The patient reports experiencing brief episodes of palpitations over the past few weeks, but they usually resolve themselves after 5-10 minutes. However, today's episode has been ongoing for 30 minutes. The patient denies any chest pain or shortness of breath. She is currently taking aspirin 75mg once daily as her only medication. Blood tests are conducted, and the results are as follows:

      Hemoglobin (Hb): 115 g/l
      Platelets: 155 * 109/l
      White blood cells (WBC): 6.4 * 109/l
      Sodium: 138 mmol/l
      Potassium: 3.8 mmol/l
      Urea: 4.1 mmol/l
      Creatinine: 74 µmol/l
      Glomerular filtration rate (GFR): 68 mL/min/1.73m2

      An electrocardiogram (ECG) is performed, revealing atrial fibrillation. You decide to assess the patient's bleeding risk using the ORBIT tool. What is this patient's ORBIT score?

      Your Answer: 6

      Correct Answer: 3

      Explanation:

      Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting around 5% of patients over the age of 70-75 years and 10% of patients aged 80-85 years. While AF can cause palpitations and inefficient cardiac function, the most important aspect of managing patients with AF is reducing the increased risk of stroke.

      AF can be classified as first detected episode, paroxysmal, persistent, or permanent. First detected episode refers to the initial occurrence of AF, regardless of symptoms or duration. Paroxysmal AF occurs when a patient has 2 or more self-terminating episodes lasting less than 7 days. Persistent AF refers to episodes lasting more than 7 days that do not self-terminate. Permanent AF is continuous atrial fibrillation that cannot be cardioverted or if attempts to do so are deemed inappropriate. The treatment goals for permanent AF are rate control and anticoagulation if appropriate.

      Symptoms of AF include palpitations, dyspnea, and chest pain. The most common sign is an irregularly irregular pulse. An electrocardiogram (ECG) is essential for diagnosing AF, as other conditions can also cause an irregular pulse.

      Managing patients with AF involves two key parts: rate/rhythm control and reducing stroke risk. Rate control involves slowing down the irregular pulse to avoid negative effects on cardiac function. This is typically achieved using beta-blockers or rate-limiting calcium channel blockers. If one drug is not effective, combination therapy may be used. Rhythm control aims to restore and maintain normal sinus rhythm through pharmacological or electrical cardioversion. However, the majority of patients are managed with a rate control strategy.

      Reducing stroke risk in patients with AF is crucial. Risk stratifying tools, such as the CHA2DS2-VASc score, are used to determine the most appropriate anticoagulation strategy. Anticoagulation is recommended for patients with a score of 2 or more. Clinicians can choose between warfarin and novel oral anticoagulants (NOACs) for anticoagulation.

      Before starting anticoagulation, the patient’s bleeding risk should be assessed using tools like the HAS-BLED score or the ORBIT tool. These tools evaluate factors such as hypertension, abnormal renal or liver function, history of bleeding, age, and use of drugs that predispose to bleeding.

    • This question is part of the following fields:

      • Cardiology
      14.4
      Seconds
  • Question 62 - A 35-year-old woman is involved in a car accident. Her observations are taken...

    Incorrect

    • A 35-year-old woman is involved in a car accident. Her observations are taken one hour after arriving in the Emergency Department. Her pulse rate is 125 bpm, BP is 92/46 mmHg, respiratory rate 35 breaths/minute, and her urine output over the past hour has been 10 ml. She is anxious and slightly confused. The patient weighs approximately 70 kg.
      How would you classify her hemorrhage according to the ATLS hemorrhagic shock classification?

      Your Answer: Class II

      Correct Answer: Class III

      Explanation:

      This patient is experiencing an increased heart rate and respiratory rate, as well as a decrease in urine output. Additionally, they are feeling anxious and confused. These symptoms indicate that the patient has suffered a class III haemorrhage at this point in time.

      Recognizing the extent of blood loss based on vital signs and mental status abnormalities is a crucial skill. The Advanced Trauma Life Support (ATLS) haemorrhagic shock classification connects the amount of blood loss to expected physiological responses in a healthy 70 kg patient. In a 70 kg male patient, the total circulating blood volume is approximately five liters, which accounts for about 7% of their total body weight.

      The ATLS haemorrhagic shock classification is summarized as follows:

      CLASS I:
      – Blood loss: Up to 750 mL
      – Blood loss (% blood volume): Up to 15%
      – Pulse rate: Less than 100 bpm
      – Systolic BP: Normal
      – Pulse pressure: Normal (or increased)
      – Respiratory rate: 14-20 breaths per minute
      – Urine output: Greater than 30 mL/hr
      – CNS/mental status: Slightly anxious

      CLASS II:
      – Blood loss: 750-1500 mL
      – Blood loss (% blood volume): 15-30%
      – Pulse rate: 100-120 bpm
      – Systolic BP: Normal
      – Pulse pressure: Decreased
      – Respiratory rate: 20-30 breaths per minute
      – Urine output: 20-30 mL/hr
      – CNS/mental status: Mildly anxious

      CLASS III:
      – Blood loss: 1500-2000 mL
      – Blood loss (% blood volume): 30-40%
      – Pulse rate: 120-140 bpm
      – Systolic BP: Decreased
      – Pulse pressure: Decreased
      – Respiratory rate: 30-40 breaths per minute
      – Urine output: 5-15 mL/hr
      – CNS/mental status: Anxious, confused

      CLASS IV:
      – Blood loss: More than 2000 mL
      – Blood loss (% blood volume): More than 40%
      – Pulse rate: More than 140 bpm
      – Systolic BP: Decreased
      – Pulse pressure: Decreased
      – Respiratory rate: More than 40 breaths per minute
      – Urine output: Negligible
      – CNS/mental status: Confused, leth

    • This question is part of the following fields:

      • Trauma
      20.7
      Seconds
  • Question 63 - A young man arrives at the Emergency Department with symptoms of acute alcohol...

    Incorrect

    • A young man arrives at the Emergency Department with symptoms of acute alcohol withdrawal. He is seeking admission for 'inpatient detox' and expresses a desire for medication to alleviate his discomfort.
      Which ONE of the following medications will you administer to alleviate his symptoms during his stay in the Emergency Department?

      Your Answer: Acamprosate

      Correct Answer: Diazepam

      Explanation:

      Benzodiazepines are commonly prescribed in the UK to help manage symptoms of alcohol withdrawal. Currently, only diazepam and chlordiazepoxide have been approved for this purpose. If you would like to learn more about the NICE pathway for acute alcohol withdrawal or the RCEM syllabus reference, please refer to the provided links. Additionally, information on alcohol and substance misuse can be found in the MHC1 section.

    • This question is part of the following fields:

      • Mental Health
      16.9
      Seconds
  • Question 64 - A 72-year-old woman is evaluated in the cardiac care unit 2 days after...

    Incorrect

    • A 72-year-old woman is evaluated in the cardiac care unit 2 days after experiencing a heart attack. She complains of significant shortness of breath. During the physical examination, a pansystolic murmur is audible and is most prominent at the lower left sternal border.

      What is the SINGLE most probable diagnosis?

      Your Answer: Mitral regurgitation

      Correct Answer: Ventricular septal defect

      Explanation:

      Post myocardial infarction ventricular septal defect (VSD) is a rare but serious complication that occurs when the cardiac wall ruptures. It typically develops 2-3 days after a heart attack, and if left untreated, 85% of patients will die within two months. The murmur associated with VSD is a continuous sound throughout systole, and it is loudest at the lower left sternal edge. A palpable vibration, known as a thrill, is often felt along with the murmur.

      Dressler’s syndrome, on the other hand, is a type of pericarditis that occurs 2-10 weeks after a heart attack or cardiac surgery. It is characterized by sharp chest pain that is relieved by sitting forwards. Other signs of Dressler’s syndrome include a rubbing sound heard when listening to the heart, pulsus paradoxus (an abnormal drop in blood pressure during inspiration), and signs of right ventricular failure.

      Mitral regurgitation also causes a continuous murmur throughout systole, but it is best heard at the apex of the heart and may radiate to the axilla (armpit).

      Tricuspid stenosis, on the other hand, causes an early diastolic murmur that is best heard at the lower left sternal edge during inspiration.

      Lastly, mitral stenosis causes a rumbling mid-diastolic murmur that is best heard at the apex of the heart. To listen for this murmur, the patient should be in the left lateral position, and the stethoscope bell should be used during expiration.

    • This question is part of the following fields:

      • Cardiology
      29
      Seconds
  • Question 65 - A 32-year-old woman comes in with a history of urgency, bloody diarrhea, and...

    Correct

    • A 32-year-old woman comes in with a history of urgency, bloody diarrhea, and crampy abdominal pain for the past 8 weeks. She occasionally experiences pain before having a bowel movement, but it is relieved once the stool is passed. A sigmoidoscopy is conducted, and a rectal biopsy reveals the presence of inflammatory cell infiltrate and crypt abscesses.

      What is the SINGLE most probable diagnosis?

      Your Answer: Ulcerative colitis

      Explanation:

      In a young patient who has been experiencing bloody diarrhea for more than 6 weeks, it is important to consider inflammatory bowel disease as a possible diagnosis. The challenge lies in distinguishing between ulcerative colitis and Crohn’s disease. In this case, a biopsy was performed and the results showed the presence of inflammatory cell infiltrate and crypt abscesses, which strongly suggests a diagnosis of ulcerative colitis.

      Ulcerative colitis:
      – Typically affects only the rectum and colon
      – The terminal ileum may be affected if backwash ileitis occurs
      – Does not have skip lesions (areas of normal mucosa between affected areas)
      – Decreased incidence in smokers
      – Common associations include liver conditions such as primary biliary cirrhosis, chronic active hepatitis, and primary sclerosing cholangitis
      – Other systemic manifestations are less common compared to Crohn’s disease
      – Pathological features include primarily affecting the mucosa and submucosa, presence of mucosal ulcers, inflammatory cell infiltrate, and crypt abscesses
      – Clinical features include less prominent abdominal pain, bloody diarrhea in 90% of cases, passage of mucus, and possible fever
      – Barium studies may show a granular appearance, button-shaped ulcers, and loss of normal haustral markings
      – Complications include a 20-fold increase in the 20-year risk of colonic carcinoma, iron deficiency anemia, and rare occurrence of fistulae

      Crohn’s disease:
      – Can affect any part of the gastrointestinal tract from the mouth to the anus
      – May have skip lesions of normal mucosa between affected areas
      – Increased incidence in smokers
      – Systemic manifestations are more common compared to ulcerative colitis, including erythema nodosum, pyoderma gangrenosum, iritis/uveitis, cholelithiasis, and joint pain/arthropathy
      – Pathological features include transmural inflammation, presence of lymphoid aggregates and neutrophil infiltrates, and non-caseating granulomas seen in 30% of cases
      – Clinical features include more prominent abdominal pain, common occurrence of diarrhea (which can also be bloody), frequent and oral lesions, and possible fever
      – Barium studies may show severe mucosal ulcers

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      16.3
      Seconds
  • Question 66 - You assess a client with a history of schizophrenia who is currently experiencing...

    Incorrect

    • You assess a client with a history of schizophrenia who is currently experiencing acute psychosis. He reports a sensation in which he believes that individuals in close proximity to him are inserting their thoughts into his mind.
      Which ONE of the following thought disorders is he exhibiting?

      Your Answer: Thought broadcast

      Correct Answer: Thought insertion

      Explanation:

      Thought insertion is one of the primary symptoms identified by Schneider in schizophrenia. This symptom refers to the patient’s belief that their thoughts are being controlled or influenced by external sources, such as other individuals or entities. In some cases, they may even experience auditory hallucinations, hearing distinct voices.

    • This question is part of the following fields:

      • Mental Health
      9.4
      Seconds
  • Question 67 - A 28-year-old woman comes to the GP complaining of a painful lump in...

    Incorrect

    • A 28-year-old woman comes to the GP complaining of a painful lump in her breast that she noticed two days ago. She also mentions feeling tired all the time. She recently had her first baby four weeks ago and is currently breastfeeding without any issues. During the examination, a poorly defined lump measuring approximately 5 cm in diameter is found just below the left nipple in the outer lower quadrant of the left breast. The skin above the lump is red, and it feels soft and tender when touched.

      What is the MOST likely diagnosis for this patient?

      Your Answer: Breast cancer

      Correct Answer: Breast abscess

      Explanation:

      A breast abscess is a localized accumulation of pus in the breast tissue. It often occurs in women who are breastfeeding and is typically caused by bacteria entering through a crack in the nipple. However, it can also develop in non-lactating women after breast trauma or in individuals with a weakened immune system.

      The common presentation of a breast abscess includes a tender lump in a specific area of the breast, which may be accompanied by redness of the skin. Additionally, the patient may experience fever and overall feelings of illness.

      Diagnosis of a breast abscess is usually made based on clinical examination. However, an ultrasound scan can be utilized to assist in confirming the diagnosis. Treatment involves draining the abscess through incision and then administering antibiotics to prevent further infection.

    • This question is part of the following fields:

      • Surgical Emergencies
      27.3
      Seconds
  • Question 68 - A 55 year old female patient is brought into the emergency department with...

    Incorrect

    • A 55 year old female patient is brought into the emergency department with urosepsis. It is decided to intubate her pending transfer to ITU. Your consultant requests you prepare propofol and suxamethonium for rapid sequence intubation (RSI). What is the recommended dose of suxamethonium for RSI in adults?

      Your Answer: 2.5 mg/kg

      Correct Answer: 1.5 mg/kg

      Explanation:

      The appropriate dosage of suxamethonium for rapid sequence intubation (RSI) in adults is between 1 and 1.5 milligrams per kilogram of body weight.

      Further Reading:

      Rapid sequence induction (RSI) is a method used to place an endotracheal tube (ETT) in the trachea while minimizing the risk of aspiration. It involves inducing loss of consciousness while applying cricoid pressure, followed by intubation without face mask ventilation. The steps of RSI can be remembered using the 7 P’s: preparation, pre-oxygenation, pre-treatment, paralysis and induction, protection and positioning, placement with proof, and post-intubation management.

      Preparation involves preparing the patient, equipment, team, and anticipating any difficulties that may arise during the procedure. Pre-oxygenation is important to ensure the patient has an adequate oxygen reserve and prolongs the time before desaturation. This is typically done by breathing 100% oxygen for 3 minutes. Pre-treatment involves administering drugs to counter expected side effects of the procedure and anesthesia agents used.

      Paralysis and induction involve administering a rapid-acting induction agent followed by a neuromuscular blocking agent. Commonly used induction agents include propofol, ketamine, thiopentone, and etomidate. The neuromuscular blocking agents can be depolarizing (such as suxamethonium) or non-depolarizing (such as rocuronium). Depolarizing agents bind to acetylcholine receptors and generate an action potential, while non-depolarizing agents act as competitive antagonists.

      Protection and positioning involve applying cricoid pressure to prevent regurgitation of gastric contents and positioning the patient’s neck appropriately. Tube placement is confirmed by visualizing the tube passing between the vocal cords, auscultation of the chest and stomach, end-tidal CO2 measurement, and visualizing misting of the tube. Post-intubation management includes standard care such as monitoring ECG, SpO2, NIBP, capnography, and maintaining sedation and neuromuscular blockade.

      Overall, RSI is a technique used to quickly and safely secure the airway in patients who may be at risk of aspiration. It involves a series of steps to ensure proper preparation, oxygenation, drug administration, and tube placement. Monitoring and post-intubation care are also important aspects of RSI.

    • This question is part of the following fields:

      • Basic Anaesthetics
      57.7
      Seconds
  • Question 69 - A 45-year-old individual is preparing to board a flight for a business conference...

    Incorrect

    • A 45-year-old individual is preparing to board a flight for a business conference and has concerns regarding the potential risk of developing DVT. They would like to inquire about the minimum duration of travel that is considered to pose an elevated risk of DVT during air travel.

      Your Answer: 5 hours

      Correct Answer: 4 hours

      Explanation:

      The World Health Organisation Research into Global Hazards of Travel (Wright) Project found that the main factor contributing to deep venous thrombosis is being immobile, and the risk of developing a blood clot is higher when traveling for more than 4 hours. According to the Wright Study, the absolute risk of experiencing deep venous thrombosis during flights lasting over 4 hours was found to be one in 4656. For more information on this topic, you can refer to the guidance provided by the Civil Aviation Authority for medical professionals.

    • This question is part of the following fields:

      • Vascular
      25.6
      Seconds
  • Question 70 - A 23-year-old arrives at the emergency department complaining of fatigue, a severe sore...

    Incorrect

    • A 23-year-old arrives at the emergency department complaining of fatigue, a severe sore throat, and swollen neck glands that have persisted for more than a week. He visited his primary care physician yesterday and was prescribed amoxicillin. However, today he woke up with a rash all over his body and his throat has not improved. During the examination, a widespread non-blanching maculopapular rash is observed.

      What is the probable underlying cause of the patient's symptoms?

      Your Answer: Respiratory syncytial virus

      Correct Answer: Epstein-Barr virus

      Explanation:

      In cases of acute glandular fever, certain antibiotics like ampicillin and amoxicillin can potentially cause severe rashes that affect the entire body and specifically the extremities. The exact cause of these rashes is still unknown. If there is uncertainty in the diagnosis and the clinician wants to cover the possibility of streptococcal tonsillitis, it is recommended to use phenoxymethylpenicillin (penicillin V) as the preferred treatment.

      Further Reading:

      Glandular fever, also known as infectious mononucleosis or mono, is a clinical syndrome characterized by symptoms such as sore throat, fever, and swollen lymph nodes. It is primarily caused by the Epstein-Barr virus (EBV), with other viruses and infections accounting for the remaining cases. Glandular fever is transmitted through infected saliva and primarily affects adolescents and young adults. The incubation period is 4-8 weeks.

      The majority of EBV infections are asymptomatic, with over 95% of adults worldwide having evidence of prior infection. Clinical features of glandular fever include fever, sore throat, exudative tonsillitis, lymphadenopathy, and prodromal symptoms such as fatigue and headache. Splenomegaly (enlarged spleen) and hepatomegaly (enlarged liver) may also be present, and a non-pruritic macular rash can sometimes occur.

      Glandular fever can lead to complications such as splenic rupture, which increases the risk of rupture in the spleen. Approximately 50% of splenic ruptures associated with glandular fever are spontaneous, while the other 50% follow trauma. Diagnosis of glandular fever involves various investigations, including viral serology for EBV, monospot test, and liver function tests. Additional serology tests may be conducted if EBV testing is negative.

      Management of glandular fever involves supportive care and symptomatic relief with simple analgesia. Antiviral medication has not been shown to be beneficial. It is important to identify patients at risk of serious complications, such as airway obstruction, splenic rupture, and dehydration, and provide appropriate management. Patients can be advised to return to normal activities as soon as possible, avoiding heavy lifting and contact sports for the first month to reduce the risk of splenic rupture.

      Rare but serious complications associated with glandular fever include hepatitis, upper airway obstruction, cardiac complications, renal complications, neurological complications, haematological complications, chronic fatigue, and an increased risk of lymphoproliferative cancers and multiple sclerosis.

    • This question is part of the following fields:

      • Infectious Diseases
      26.6
      Seconds
  • Question 71 - You assess a patient with a confirmed diagnosis of von Willebrand’s disease (vWD)...

    Incorrect

    • You assess a patient with a confirmed diagnosis of von Willebrand’s disease (vWD) who is scheduled for a surgical procedure. He wishes to have a conversation about how his condition will affect his surgery.
      Which ONE statement about vWD is accurate?

      Your Answer: It causes a reduction in Factor VII levels

      Correct Answer: It causes a prolongation of the APTT

      Explanation:

      Von Willebrand disease (vWD) is a common hereditary coagulation disorder that affects approximately 1 in 100 individuals. It occurs due to a deficiency in Von Willebrand factor (vWF), which plays a crucial role in blood clotting. vWF not only binds to factor VIII to protect it from rapid breakdown, but it is also necessary for proper platelet adhesion. When vWF is lacking, both factor VIII levels and platelet function are affected, leading to prolonged APTT and bleeding time. However, the platelet count and thrombin time remain unaffected.

      While some individuals with vWD may not experience any symptoms and are diagnosed incidentally during a clotting profile check, others may present with easy bruising, nosebleeds (epistaxis), and heavy menstrual bleeding (menorrhagia). In severe cases, more significant bleeding and joint bleeding (haemarthrosis) can occur.

      For mild cases of von Willebrand disease, bleeding can be managed with desmopressin. This medication works by stimulating the release of vWF stored in the Weibel-Palade bodies, which are storage granules found in the endothelial cells lining the blood vessels and heart. By increasing the patient’s own levels of vWF, desmopressin helps improve clotting. In more severe cases, replacement therapy is necessary. This involves infusing cryoprecipitate or Factor VIII concentrate to provide the missing vWF. Replacement therapy is particularly recommended for patients with severe von Willebrand’s disease who are undergoing moderate or major surgical procedures.

    • This question is part of the following fields:

      • Haematology
      6.3
      Seconds
  • Question 72 - A 45-year-old teacher complains of a red and itchy urticarial rash on her...

    Incorrect

    • A 45-year-old teacher complains of a red and itchy urticarial rash on her hands that appeared 15 minutes after she wore a pair of latex gloves. What is the most probable cause for the development of this rash?

      Your Answer: Type II hypersensitivity reaction

      Correct Answer: Type I hypersensitivity reaction

      Explanation:

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

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

    • This question is part of the following fields:

      • Allergy
      11.8
      Seconds
  • Question 73 - A 40 year old male has been brought into the ED during the...

    Incorrect

    • A 40 year old male has been brought into the ED during the late hours of the evening after being discovered unresponsive lying on the sidewalk. The paramedics initiated Cardiopulmonary resuscitation which has been ongoing since the patient's arrival in the ED. The patient's core temperature is documented at 28ºC. How frequently would you administer adrenaline to a patient with this core temperature during CPR?

      Your Answer:

      Correct Answer: Withhold adrenaline

      Explanation:

      During CPR of a hypothermic patient, it is important to follow specific guidelines. If the patient’s core temperature is below 30ºC, resuscitation drugs, such as adrenaline, should be withheld. Once the core temperature rises above 30ºC, cardiac arrest drugs can be administered. However, if the patient’s temperature is between 30-35ºC, the interval for administering cardiac arrest drugs should be doubled. For example, adrenaline should be given every 6-10 minutes instead of the usual 3-5 minutes for a normothermic patient.

      Further Reading:

      Hypothermic cardiac arrest is a rare situation that requires a tailored approach. Resuscitation is typically prolonged, but the prognosis for young, previously healthy individuals can be good. Hypothermic cardiac arrest may be associated with drowning. Hypothermia is defined as a core temperature below 35ºC and can be graded as mild, moderate, severe, or profound based on the core temperature. When the core temperature drops, basal metabolic rate falls and cell signaling between neurons decreases, leading to reduced tissue perfusion. Signs and symptoms of hypothermia progress as the core temperature drops, initially presenting as compensatory increases in heart rate and shivering, but eventually ceasing as the temperature drops into moderate hypothermia territory.

      ECG changes associated with hypothermia include bradyarrhythmias, Osborn waves, prolonged PR, QRS, and QT intervals, shivering artifact, ventricular ectopics, and cardiac arrest. When managing hypothermic cardiac arrest, ALS should be initiated as per the standard ALS algorithm, but with modifications. It is important to check for signs of life, re-warm the patient, consider mechanical ventilation due to chest wall stiffness, adjust dosing or withhold drugs due to slowed drug metabolism, and correct electrolyte disturbances. The resuscitation of hypothermic patients is often prolonged and may continue for a number of hours.

      Pulse checks during CPR may be difficult due to low blood pressure, and the pulse check is prolonged to 1 minute for this reason. Drug metabolism is slowed in hypothermic patients, leading to a build-up of potentially toxic plasma concentrations of administered drugs. Current guidance advises withholding drugs if the core temperature is below 30ºC and doubling the drug interval at core temperatures between 30 and 35ºC. Electrolyte disturbances are common in hypothermic patients, and it is important to interpret results keeping the setting in mind. Hypoglycemia should be treated, hypokalemia will often correct as the patient re-warms, ABG analyzers may not reflect the reality of the hypothermic patient, and severe hyperkalemia is a poor prognostic indicator.

      Different warming measures can be used to increase the core body temperature, including external passive measures such as removal of wet clothes and insulation with blankets, external active measures such as forced heated air or hot-water immersion, and internal active measures such as inhalation of warm air, warmed intravenous fluids, gastric, bladder, peritoneal and/or pleural lavage and high volume renal haemofilter.

    • This question is part of the following fields:

      • Environmental Emergencies
      0
      Seconds
  • Question 74 - A 42-year-old woman comes in with back pain and a fever. After a...

    Incorrect

    • A 42-year-old woman comes in with back pain and a fever. After a thorough evaluation and tests, the patient is diagnosed with discitis. She has no significant medical history and does not take any medications regularly.
      What is the most probable organism responsible for this patient's condition?

      Your Answer:

      Correct Answer: Staphylococcus aureus

      Explanation:

      Discitis is an infection that affects the space between the intervertebral discs in the spine. This condition can have serious consequences, including the formation of abscesses and sepsis. The most common cause of discitis is usually Staphylococcus aureus, but other organisms like Streptococcus viridans and Pseudomonas aeruginosa may be responsible in certain cases, especially in immunocompromised individuals and intravenous drug users. Gram-negative organisms like Escherichia coli and Mycobacterium tuberculosis can also cause discitis, particularly in cases of Pott’s disease.

      There are several risk factors that increase the likelihood of developing discitis. These include having undergone spinal surgery (which occurs in about 1-2% of patients post-operatively), having an immunodeficiency, being an intravenous drug user, being under the age of eight, having diabetes mellitus, or having a malignancy.

      The typical symptoms of discitis include back or neck pain (which occurs in over 90% of cases), pain that often wakes the patient from sleep, fever (present in 60-70% of cases), and neurological deficits (which can occur in up to 50% of cases). In children, a refusal to walk may also be a symptom.

      When diagnosing discitis, magnetic resonance imaging (MRI) is the preferred imaging modality due to its high sensitivity and specificity. It is important to image the entire spine, as discitis often affects multiple levels. Plain radiographs are not very sensitive to the early changes of discitis and may appear normal for 2-4 weeks. Computed tomography (CT) scanning is also not very sensitive in detecting discitis.

      Treatment for discitis involves hospital admission for intravenous antibiotics. Before starting the antibiotics, it is recommended to send three sets of blood cultures and a full set of blood tests, including a C-reactive protein (CRP) test, to the laboratory.

      A typical antibiotic regimen for discitis would include intravenous flucloxacillin 2 g every 6 hours as the first-line treatment if there is no penicillin allergy. Intravenous vancomycin may be used if the infection was acquired in the hospital, if there is a high risk of methicillin-resistant Staphylococcus aureus (MRSA) infection, or if there is a documented penicillin allergy.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      0
      Seconds
  • Question 75 - A child presents with a severe acute asthma attack. After a poor response...

    Incorrect

    • A child presents with a severe acute asthma attack. After a poor response to their initial salbutamol nebulizer, you administer a second nebulizer that also contains ipratropium bromide. How long would it take for the ipratropium bromide to have its maximum effect?

      Your Answer:

      Correct Answer: 30-60 minutes

      Explanation:

      Ipratropium bromide is a medication that falls under the category of antimuscarinic drugs. It is commonly used to manage acute asthma and chronic obstructive pulmonary disease (COPD). While it can provide short-term relief for chronic asthma, it is generally recommended to use short-acting β2 agonists as they act more quickly and are preferred.

      According to the guidelines set by the British Thoracic Society (BTS), nebulized ipratropium bromide (0.5 mg every 4-6 hours) can be added to β2 agonist treatment for patients with acute severe or life-threatening asthma, or those who do not respond well to initial β2 agonist therapy.

      For mild cases of chronic obstructive pulmonary disease, aerosol inhalation of ipratropium can be used for short-term relief, as long as the patient is not already using a long-acting antimuscarinic drug like tiotropium. The maximum effect of ipratropium occurs within 30-60 minutes after use, and its bronchodilating effects can last for 3-6 hours. Typically, treatment with ipratropium is recommended three times a day to maintain bronchodilation.

      The most common side effect of ipratropium bromide is dry mouth. Other potential side effects include constipation, cough, paroxysmal bronchospasm, headache, nausea, and palpitations. It is important to note that ipratropium can cause urinary retention in patients with prostatic hyperplasia and bladder outflow obstruction. Additionally, it can trigger acute closed-angle glaucoma in susceptible patients.

      For more information on the management of asthma, it is recommended to refer to the BTS/SIGN Guideline on the Management of Asthma.

    • This question is part of the following fields:

      • Respiratory
      0
      Seconds
  • Question 76 - A 42-year-old male is brought into the ED by ambulance following a car...

    Incorrect

    • A 42-year-old male is brought into the ED by ambulance following a car accident with suspected internal abdominal injury. Upon arrival in the ED, his blood pressure was recorded as 102/68 mmHg and his pulse rate was 114 bpm. Initial resuscitation measures have been initiated, and a fluid bolus of 500 ml of 0.9% saline has been administered. The patient's vital signs are reassessed after the bolus and are as follows:

      Blood pressure: 92/66 mmHg
      Pulse rate: 124 bpm
      Respiration rate: 29 bpm
      SpO2: 98% on 15 liters of oxygen
      Temperature: 36.1 ºC

      What percentage of the patient's circulating blood volume would you estimate has been lost?

      Your Answer:

      Correct Answer: 30-40%

      Explanation:

      Shock is a condition characterized by inadequate tissue perfusion due to circulatory insufficiency. It can be caused by fluid loss or redistribution, as well as impaired cardiac output. The main causes of shock include haemorrhage, diarrhoea and vomiting, burns, diuresis, sepsis, neurogenic shock, anaphylaxis, massive pulmonary embolism, tension pneumothorax, cardiac tamponade, myocardial infarction, and myocarditis.

      One common cause of shock is haemorrhage, which is frequently encountered in the emergency department. Haemorrhagic shock can be classified into different types based on the amount of blood loss. Type 1 haemorrhagic shock involves a blood loss of 15% or less, with less than 750 ml of blood loss. Patients with type 1 shock may have normal blood pressure and heart rate, with a respiratory rate of 12 to 20 breaths per minute.

      Type 2 haemorrhagic shock involves a blood loss of 15 to 30%, with 750 to 1500 ml of blood loss. Patients with type 2 shock may have a pulse rate of 100 to 120 beats per minute and a respiratory rate of 20 to 30 breaths per minute. Blood pressure is typically normal in type 2 shock.

      Type 3 haemorrhagic shock involves a blood loss of 30 to 40%, with 1.5 to 2 litres of blood loss. Patients with type 3 shock may have a pulse rate of 120 to 140 beats per minute and a respiratory rate of more than 30 breaths per minute. Urine output is decreased to 5-15 mls per hour.

      Type 4 haemorrhagic shock involves a blood loss of more than 40%, with more than 2 litres of blood loss. Patients with type 4 shock may have a pulse rate of more than 140 beats per minute and a respiratory rate of more than 35 breaths per minute. They may also be drowsy, confused, and possibly experience loss of consciousness. Urine output may be minimal or absent.

      In summary, shock is a condition characterized by inadequate tissue perfusion. Haemorrhage is a common cause of shock, and it can be classified into different types based on the amount of blood loss. Prompt recognition and management of shock are crucial in order to prevent further complications and improve patient outcomes

    • This question is part of the following fields:

      • Trauma
      0
      Seconds
  • Question 77 - A 45 year old male patient is brought into the emergency department with...

    Incorrect

    • A 45 year old male patient is brought into the emergency department with a suspected massive pulmonary embolism. It is decided to intubate him pending transfer to ITU. Your consultant requests you prepare the patient for rapid sequence intubation. You start pre-oxygenating the patient. What is the gold standard evaluation for ensuring sufficient pre-oxygenation?

      Your Answer:

      Correct Answer: End tidal O2 > 85%

      Explanation:

      The blood gas measurement of pO2 should be equal to or greater than 18 kilopascals (kPa) at a level of 10.

      Further Reading:

      Rapid sequence induction (RSI) is a method used to place an endotracheal tube (ETT) in the trachea while minimizing the risk of aspiration. It involves inducing loss of consciousness while applying cricoid pressure, followed by intubation without face mask ventilation. The steps of RSI can be remembered using the 7 P’s: preparation, pre-oxygenation, pre-treatment, paralysis and induction, protection and positioning, placement with proof, and post-intubation management.

      Preparation involves preparing the patient, equipment, team, and anticipating any difficulties that may arise during the procedure. Pre-oxygenation is important to ensure the patient has an adequate oxygen reserve and prolongs the time before desaturation. This is typically done by breathing 100% oxygen for 3 minutes. Pre-treatment involves administering drugs to counter expected side effects of the procedure and anesthesia agents used.

      Paralysis and induction involve administering a rapid-acting induction agent followed by a neuromuscular blocking agent. Commonly used induction agents include propofol, ketamine, thiopentone, and etomidate. The neuromuscular blocking agents can be depolarizing (such as suxamethonium) or non-depolarizing (such as rocuronium). Depolarizing agents bind to acetylcholine receptors and generate an action potential, while non-depolarizing agents act as competitive antagonists.

      Protection and positioning involve applying cricoid pressure to prevent regurgitation of gastric contents and positioning the patient’s neck appropriately. Tube placement is confirmed by visualizing the tube passing between the vocal cords, auscultation of the chest and stomach, end-tidal CO2 measurement, and visualizing misting of the tube. Post-intubation management includes standard care such as monitoring ECG, SpO2, NIBP, capnography, and maintaining sedation and neuromuscular blockade.

      Overall, RSI is a technique used to quickly and safely secure the airway in patients who may be at risk of aspiration. It involves a series of steps to ensure proper preparation, oxygenation, drug administration, and tube placement. Monitoring and post-intubation care are also important aspects of RSI.

    • This question is part of the following fields:

      • Basic Anaesthetics
      0
      Seconds
  • Question 78 - A 42-year-old man presents with central chest pain that has been present for...

    Incorrect

    • A 42-year-old man presents with central chest pain that has been present for the past three days. The pain is worsened by deep inspiration and lying flat and relieved by sitting forwards. He recently returned from a vacation in Spain, which involved a short flight. He has no significant medical history but smokes 15 cigarettes per day. His father died from a heart attack at the age of 58. His vital signs are as follows: HR 102, BP 128/72, temperature 37.1oC, SaO2 96% on room air. His ECG shows widespread concave ST elevation and PR depression.
      What is the SINGLE most likely diagnosis?

      Your Answer:

      Correct Answer: Pericarditis

      Explanation:

      Pericarditis refers to the inflammation of the pericardium, which can be caused by various factors such as infections (typically viral, like coxsackie virus), drug-induced reactions (e.g. isoniazid, cyclosporine), trauma, autoimmune conditions (e.g. SLE), paraneoplastic syndromes, uremia, post myocardial infarction (known as Dressler’s syndrome), post radiotherapy, and post cardiac surgery.

      The clinical presentation of pericarditis often includes retrosternal chest pain that worsens with lying flat and improves when sitting forwards, along with shortness of breath, rapid heartbeat, and the presence of a pericardial friction rub.

      Characteristic electrocardiogram (ECG) changes associated with pericarditis typically show widespread concave or ‘saddle-shaped’ ST elevation, widespread PR depression, reciprocal ST depression and PR elevation in aVR (and sometimes V1), and sinus tachycardia is commonly observed.

    • This question is part of the following fields:

      • Cardiology
      0
      Seconds
  • Question 79 - A 3-year-old toddler is brought to the Emergency Department after ingesting a few...

    Incorrect

    • A 3-year-old toddler is brought to the Emergency Department after ingesting a few of his mother's ibuprofen tablets 30 minutes ago. The child is currently showing no symptoms and is stable. The attending physician recommends giving a dose of activated charcoal. The child weighs 15 kg.
      What is the appropriate dosage of activated charcoal to administer in this case?

      Your Answer:

      Correct Answer: 20 g orally

      Explanation:

      Activated charcoal is a commonly utilized substance for decontamination in cases of poisoning. Its main function is to attract and bind molecules of the ingested toxin onto its surface.

      Activated charcoal is a chemically inert form of carbon. It is a fine black powder that has no odor or taste. This powder is created by subjecting carbonaceous matter to high heat, a process known as pyrolysis, and then concentrating it with a solution of zinc chloride. Through this process, the activated charcoal develops a complex network of pores, providing it with a large surface area of approximately 3,000 m2/g. This extensive surface area allows it to effectively hinder the absorption of the harmful toxin by up to 50%.

      The typical dosage for adults is 50 grams, while children are usually given 1 gram per kilogram of body weight. Activated charcoal can be administered orally or through a nasogastric tube. It is crucial to administer it within one hour of ingestion, and if necessary, a second dose may be repeated after one hour.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 80 - A 28-year-old woman gives birth to a baby with microcephaly at 36-weeks gestation....

    Incorrect

    • A 28-year-old woman gives birth to a baby with microcephaly at 36-weeks gestation. She remembers experiencing a flu-like illness and skin rash early in the pregnancy after being bitten by a mosquito while visiting relatives in Brazil.

      What is the SINGLE most probable organism responsible for causing this birth defect?

      Your Answer:

      Correct Answer: Zika virus

      Explanation:

      The Zika virus is a newly emerging virus that is transmitted by mosquitoes. It was first discovered in humans in Uganda in 1952. Recently, there has been a significant outbreak of the virus in South America.

      When a person contracts the Zika virus, about 1 in 5 individuals will experience clinical illness, while the rest will show no symptoms at all. The most common symptoms of the virus include fever, rash, joint pain, and conjunctivitis. These symptoms typically last for no more than a week.

      While not completely conclusive, the evidence from the recent outbreak strongly suggests a connection between Zika virus infection and microcephaly.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
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  • Question 81 - You witness the sudden arrival of a baby in one of the rooms...

    Incorrect

    • You witness the sudden arrival of a baby in one of the rooms in the Emergency Department. Your supervisor evaluates the newborn one minute after birth and informs you that:
      The entire body appears pale
      The heart rate is 90 beats per minute
      The baby reacts with a grimace when suctioned
      There is some bending of the limbs
      The cry is feeble, and the baby is gasping for breath
      What is the Apgar score of the newborn at one minute?

      Your Answer:

      Correct Answer: 4

      Explanation:

      The Apgar score is a straightforward way to evaluate the well-being of a newborn baby right after birth. It consists of five criteria, each assigned a score ranging from zero to two. Typically, the assessment is conducted at one and five minutes after delivery, with the possibility of repeating it later if the score remains low. A score of 7 or higher is considered normal, while a score of 4-6 is considered fairly low, and a score of 3 or below is regarded as critically low. To remember the five criteria, you can use the acronym APGAR:

      Appearance
      Pulse rate
      Grimace
      Activity
      Respiratory effort

      The Apgar score criteria are as follows:

      Score of 0:
      Appearance (skin color): Blue or pale all over
      Pulse rate: Absent
      Reflex irritability (grimace): No response to stimulation
      Activity: None
      Respiratory effort: Absent

      Score of 1:
      Appearance (skin color): Blue at extremities (acrocyanosis)
      Pulse rate: Less than 100 per minute
      Reflex irritability (grimace): Grimace on suction or aggressive stimulation
      Activity: Some flexion
      Respiratory effort: Weak, irregular, gasping

      Score of 2:
      Appearance (skin color): No cyanosis, body and extremities pink
      Pulse rate: More than 100 per minute
      Reflex irritability (grimace): Cry on stimulation
      Activity: Flexed arms and legs that resist extension
      Respiratory effort: Strong, robust cry

    • This question is part of the following fields:

      • Neonatal Emergencies
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  • Question 82 - A 45 year old female with a history of alcohol-related visits to the...

    Incorrect

    • A 45 year old female with a history of alcohol-related visits to the emergency department is currently in the emergency department after tripping while intoxicated. She has a 7 cm laceration on the frontal area of the scalp. You examine the wound using local anesthesia. What tissue layer lies directly beneath the scalp skin?

      Your Answer:

      Correct Answer: Dense connective tissue

      Explanation:

      The scalp is composed of five layers, starting from the outermost layer, which is the skin, and moving towards the deepest layer, which is the periosteum of the skull. These layers can be remembered using the mnemonic: SCALP – Skin, Connective tissue, Aponeurosis, Loose areolar connective tissue, and Periosteum.

      Further Reading:

      The scalp is the area of the head that is bordered by the face in the front and the neck on the sides and back. It consists of several layers, including the skin, connective tissue, aponeurosis, loose connective tissue, and periosteum of the skull. These layers provide protection and support to the underlying structures of the head.

      The blood supply to the scalp primarily comes from branches of the external carotid artery and the ophthalmic artery, which is a branch of the internal carotid artery. These arteries provide oxygen and nutrients to the scalp tissues.

      The scalp also has a complex venous drainage system, which is divided into superficial and deep networks. The superficial veins correspond to the arterial branches and are responsible for draining blood from the scalp. The deep venous network is drained by the pterygoid venous plexus.

      In terms of innervation, the scalp receives sensory input from branches of the trigeminal nerve and the cervical nerves. These nerves transmit sensory information from the scalp to the brain, allowing us to perceive touch, pain, and temperature in this area.

    • This question is part of the following fields:

      • Dermatology
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  • Question 83 - A 48-year-old male presents to the emergency department following a workplace injury. He...

    Incorrect

    • A 48-year-old male presents to the emergency department following a workplace injury. He sustained a large contusion to the anterior abdominal wall after a pneumatic tool discharged into his abdomen. The patient's vital signs are as follows:

      - Blood pressure: 92/60 mmHg
      - Pulse rate: 104 bpm
      - Temperature: 37.1ºC
      - SpO2: 97% on air

      Which imaging modality would be most appropriate for evaluating this patient with blunt abdominal trauma?

      Your Answer:

      Correct Answer: FAST scan

      Explanation:

      The preferred imaging method for unstable patients with blunt abdominal trauma is FAST scanning (Focused Assessment with Sonography in Trauma). It has replaced DPL as the imaging modality of choice. It is important to note that the primary purpose of a FAST scan is to detect intraperitoneal fluid, assumed to be blood, and guide the decision on whether a laparotomy is necessary. In this case, a CT scan is not recommended as the patient is unstable with tachycardia and hypotension. While CT is the most diagnostically accurate imaging technique, it requires a stable and cooperative patient.

      Further Reading:

      Abdominal trauma can be classified into two categories: blunt trauma and penetrating trauma. Blunt trauma occurs when compressive or deceleration forces are applied to the abdomen, often resulting from road traffic accidents or direct blows during sports. The spleen and liver are the organs most commonly injured in blunt abdominal trauma. On the other hand, penetrating trauma involves injuries that pierce the skin and enter the abdominal cavity, such as stabbings, gunshot wounds, or industrial accidents. The bowel and liver are the organs most commonly affected in penetrating injuries.

      When it comes to imaging in blunt abdominal trauma, there are three main modalities that are commonly used: focused assessment with sonography in trauma (FAST), diagnostic peritoneal lavage (DPL), and computed tomography (CT). FAST is a non-invasive and quick method used to detect free intraperitoneal fluid, aiding in the decision on whether a laparotomy is needed. DPL is also used to detect intraperitoneal blood and can be used in both unstable blunt abdominal trauma and penetrating abdominal trauma. However, it is more invasive and time-consuming compared to FAST and has largely been replaced by it. CT, on the other hand, is the gold standard for diagnosing intra-abdominal pathology and is used in stable abdominal trauma patients. It offers high sensitivity and specificity but requires a stable and cooperative patient. It also involves radiation and may have delays in availability.

      In the case of penetrating trauma, it is important to assess these injuries with the help of a surgical team. Penetrating objects should not be removed in the emergency department as they may be tamponading underlying vessels. Ideally, these injuries should be explored in the operating theater.

      In summary, abdominal trauma can be classified into blunt trauma and penetrating trauma. Blunt trauma is caused by compressive or deceleration forces and commonly affects the spleen and liver. Penetrating trauma involves injuries that pierce the skin and commonly affect the bowel and liver. Imaging modalities such as FAST, DPL, and CT are used to assess and diagnose abdominal trauma, with CT being the gold standard. Penetrating injuries should be assessed by a surgical team and should ideally be explored in the operating theater.

    • This question is part of the following fields:

      • Trauma
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  • Question 84 - A 72 year old male is brought into the emergency department by his...

    Incorrect

    • A 72 year old male is brought into the emergency department by his wife with increasing fatigue, weakness and confusion over the past week. You note the patient takes metformin for type 2 diabetes mellitus. The patient's observations and initial tests are shown below:

      Blood pressure 96/60 mmHg
      Pulse 114 bpm
      Respiration rate 22 bpm
      Oxygen saturations 96% on air
      Na+ 147 mmol/l
      K+ 5.6 mmol/l
      Urea 21 mmol/l
      Creatinine 132 µmol/l
      Glucose 32 mmol/l
      pH 7.33
      Bicarbonate 19 mmol/l
      Ketones 2 mmol/l

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Hyperosmolar hyperglycaemic state

      Explanation:

      Hyperosmolar hyperglycaemic state (HHS) is a condition characterized by extremely high blood sugar levels, dehydration, and increased osmolality without significant ketosis. In this patient, the symptoms are consistent with HHS as they have high blood sugar levels without significant ketoacidosis (pH is above 7.3 and ketones are less than 3 mmol/L). Additionally, they show signs of dehydration with low blood pressure and a fast heart rate. The osmolality is calculated to be equal to or greater than 320 mosmol/kg, indicating increased concentration of solutes in the blood.

      Further Reading:

      Hyperosmolar hyperglycaemic state (HHS) is a syndrome that occurs in people with type 2 diabetes and is characterized by extremely high blood glucose levels, dehydration, and hyperosmolarity without significant ketosis. It can develop over days or weeks and has a mortality rate of 5-20%, which is higher than that of diabetic ketoacidosis (DKA). HHS is often precipitated by factors such as infection, inadequate diabetic treatment, physiological stress, or certain medications.

      Clinical features of HHS include polyuria, polydipsia, nausea, signs of dehydration (hypotension, tachycardia, poor skin turgor), lethargy, confusion, and weakness. Initial investigations for HHS include measuring capillary blood glucose, venous blood gas, urinalysis, and an ECG to assess for any potential complications such as myocardial infarction. Osmolality should also be calculated to monitor the severity of the condition.

      The management of HHS aims to correct dehydration, hyperglycaemia, hyperosmolarity, and electrolyte disturbances, as well as identify and treat any underlying causes. Intravenous 0.9% sodium chloride solution is the principal fluid used to restore circulating volume and reverse dehydration. If the osmolality does not decline despite adequate fluid balance, a switch to 0.45% sodium chloride solution may be considered. Care must be taken in correcting plasma sodium and osmolality to avoid complications such as cerebral edema and osmotic demyelination syndrome.

      The rate of fall of plasma sodium should not exceed 10 mmol/L in 24 hours, and the fall in blood glucose should be no more than 5 mmol/L per hour. Low-dose intravenous insulin may be initiated if the blood glucose is not falling with fluids alone or if there is significant ketonaemia. Potassium replacement should be guided by the potassium level, and the patient should be encouraged to drink as soon as it is safe to do so.

      Complications of treatment, such as fluid overload, cerebral edema, or central pontine myelinolysis, should be assessed for, and underlying precipitating factors should be identified and treated. Prophylactic anticoagulation is required in most patients, and all patients should be assumed to be at high risk of foot ulceration, necessitating appropriate foot protection and daily foot checks.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 85 - A 45-year-old patient arrives at the emergency department with a complaint of sudden...

    Incorrect

    • A 45-year-old patient arrives at the emergency department with a complaint of sudden hearing loss. During the examination, tuning fork tests are conducted. Weber's test shows lateralization to the left side, Rinne's test is negative on the left ear and positive on the right ear.

      Based on this assessment, which of the following can be inferred?

      Your Answer:

      Correct Answer: Right sided conductive hearing loss

      Explanation:

      In cases of conductive hearing loss, the Rinne test result is negative on the affected side, meaning that bone conduction is greater than air conduction. Additionally, the Weber test result will lateralize to the affected side. If the Weber test lateralizes to the right, it indicates either sensorineural hearing loss in the left ear (opposite side) or conductive hearing loss in the right ear (same side). A positive Rinne test result, where air conduction is greater than bone conduction, is typically seen in individuals with normal hearing or sensorineural hearing loss. In the case of conductive hearing loss in the right ear, a negative Rinne test result would be expected on the right side, indicating that bone conduction is greater than air conduction.

      Further Reading:

      Hearing loss is a common complaint that can be caused by various conditions affecting different parts of the ear and nervous system. The outer ear is the part of the ear outside the eardrum, while the middle ear is located between the eardrum and the cochlea. The inner ear is within the bony labyrinth and consists of the vestibule, semicircular canals, and cochlea. The vestibulocochlear nerve connects the inner ear to the brain.

      Hearing loss can be classified based on severity, onset, and type. Severity is determined by the quietest sound that can be heard, measured in decibels. It can range from mild to profound deafness. Onset can be sudden, rapidly progressive, slowly progressive, or fluctuating. Type of hearing loss can be either conductive or sensorineural. Conductive hearing loss is caused by issues in the external ear, eardrum, or middle ear that disrupt sound transmission. Sensorineural hearing loss is caused by problems in the cochlea, auditory nerve, or higher auditory processing pathways.

      To diagnose sensorineural and conductive deafness, a 512 Hz tuning fork is used to perform Rinne and Weber’s tests. These tests help determine the type of hearing loss based on the results. In Rinne’s test, air conduction (AC) and bone conduction (BC) are compared, while Weber’s test checks for sound lateralization.

      Cholesteatoma is a condition characterized by the abnormal accumulation of skin cells in the middle ear or mastoid air cell spaces. It is believed to develop from a retraction pocket that traps squamous cells. Cholesteatoma can cause the accumulation of keratin and the destruction of adjacent bones and tissues due to the production of destructive enzymes. It can lead to mixed sensorineural and conductive deafness as it affects both the middle and inner ear.

    • This question is part of the following fields:

      • Ear, Nose & Throat
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  • Question 86 - You are summoned to the resuscitation room to aid in the care of...

    Incorrect

    • You are summoned to the resuscitation room to aid in the care of a 48-year-old woman who was saved from a residential fire. The patient has superficial partial thickness burns on the palms of her hands, which she sustained while attempting to open scorching door handles during her escape from the fire. The fire department rescued her from a bedroom filled with smoke. The paramedics inform you that the patient appeared lethargic at the scene. A blood gas sample is obtained. Which of the following findings would indicate a potential diagnosis of cyanide poisoning?

      Your Answer:

      Correct Answer: Lactate >10 mmol/L

      Explanation:

      Moderate to severe cyanide poisoning typically leads to a condition called high anion gap metabolic acidosis, characterized by elevated levels of lactate (>10 mmol/L). Cyanide toxicity can occur from inhaling smoke produced by burning materials such as plastics, wools, silk, and other natural and synthetic polymers, which can release hydrogen cyanide (HCN). Symptoms of cyanide poisoning include headaches, nausea, decreased consciousness or loss of consciousness, and seizures. Measuring cyanide levels is not immediately helpful in managing a patient suspected of cyanide toxicity. Cyanide binds to the ferric (Fe3+) ion of cytochrome oxidase, causing a condition known as histotoxic hypoxia and resulting in lactic acidosis. The presence of a high lactate level (>10) and a classic high anion gap metabolic acidosis should raise suspicion of cyanide poisoning in a clinician.

      Further Reading:

      Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.

      When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.

      Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.

      The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.

      Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.

      Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 87 - A 35-year-old woman with no significant medical history complains of chest pain on...

    Incorrect

    • A 35-year-old woman with no significant medical history complains of chest pain on the right side and difficulty breathing. She does not take any medications regularly and has no known allergies to drugs. She has been a heavy smoker for the past six years.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Pneumothorax

      Explanation:

      The risk of primary spontaneous pneumothorax is associated with smoking tobacco and increases as the duration of exposure and daily consumption rise. The changes caused by smoking in the small airways may contribute to the development of local emphysema, leading to the formation of bullae. In this case, the patient does not have any clinical features or significant risk factors for the other conditions mentioned. Therefore, primary spontaneous pneumothorax is the most probable diagnosis.

    • This question is part of the following fields:

      • Respiratory
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  • Question 88 - A 35-year-old woman is brought in by ambulance following a car accident where...

    Incorrect

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

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

      Your Answer:

      Correct Answer: Presence of borborygmi in the epigastrium

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Basic Anaesthetics
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  • Question 89 - A 40-year-old man receives a blood transfusion after surgery. Shortly after starting the...

    Incorrect

    • A 40-year-old man receives a blood transfusion after surgery. Shortly after starting the transfusion, he experiences hives and itching all over his body. He is in good health otherwise and shows no signs of any breathing difficulties or wheezing.
      Which of the following transfusion reactions is most likely to have happened?

      Your Answer:

      Correct Answer: Allergic reaction

      Explanation:

      Blood transfusion is a crucial treatment that can save lives, but it also comes with various risks and potential problems. These include immunological complications, administration errors, infections, and immune dilution. While there has been an improvement in safety procedures and a reduction in transfusion use, errors and serious adverse reactions still occur and often go unreported.

      Mild allergic reactions during blood transfusion are relatively common and typically occur within a few minutes of starting the transfusion. These reactions happen when patients have antibodies that react with foreign plasma proteins in the transfused blood components. Symptoms of mild allergic reactions include urticaria, Pruritus, and hives.

      Anaphylaxis, on the other hand, is much rarer and occurs when an individual has previously been sensitized to an allergen present in the blood. When re-exposed to the allergen, the body releases IgE or IgG antibodies, leading to severe symptoms such as bronchospasm, laryngospasm, abdominal pain, nausea, vomiting, hypotension, shock, and loss of consciousness. Anaphylaxis can be fatal.

      Mild allergic reactions can be managed by slowing down the transfusion rate and administering antihistamines. If there is no progression after 30 minutes, the transfusion may continue. Patients who have experienced repeated allergic reactions to transfusion should be given pre-treatment with chlorpheniramine. In cases of anaphylaxis, the transfusion should be stopped immediately, and the patient should receive oxygen, adrenaline, corticosteroids, and antihistamines following the ALS protocol.

      The table below summarizes the main transfusion reactions and complications, along with their features and management:

      Complication | Features | Management
      Febrile transfusion reaction | 1 degree rise in temperature, chills, malaise | Supportive care, paracetamol
      Acute haemolytic reaction | Fever, chills, pain at transfusion site, nausea, vomiting, dark urine | STOP THE TRANSFUSION, administer IV fluids, diuretics if necessary
      Delayed haemolytic reaction | Fever, anaemia, jaundice, haemoglobinuria | Monitor anaemia and renal function, treat as required
      Allergic reaction | Urticaria, Pruritus, hives | Symptomatic treatment with ant

    • This question is part of the following fields:

      • Haematology
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  • Question 90 - A 32-year-old woman comes in with complaints of dysuria and frequent urination. She...

    Incorrect

    • A 32-year-old woman comes in with complaints of dysuria and frequent urination. She is currently 16 weeks pregnant. A urine dipstick test shows the presence of blood, protein, white blood cells, and nitrites. Based on this, you diagnose her with a urinary tract infection (UTI) and decide to prescribe antibiotics.
      Which antibiotic would be the most suitable to prescribe in this situation?

      Your Answer:

      Correct Answer: Nitrofurantoin

      Explanation:

      For the treatment of pregnant women with lower urinary tract infections (UTIs), it is recommended to provide them with an immediate prescription for antibiotics. It is important to consider their previous urine culture and susceptibility results, as well as any prior use of antibiotics that may have contributed to the development of resistant bacteria. Before starting antibiotics, it is advised to obtain a midstream urine sample from pregnant women and send it for culture and susceptibility testing.

      Once the microbiological results are available, it is necessary to review the choice of antibiotic. If the bacteria are found to be resistant, it is recommended to switch to a narrow-spectrum antibiotic whenever possible. The choice of antibiotics for pregnant women aged 12 years and over is summarized below:

      First-choice:
      – Nitrofurantoin 100 mg modified-release taken orally twice daily for 3 days, if the estimated glomerular filtration rate (eGFR) is above 45 ml/minute.

      Second-choice (if there is no improvement in lower UTI symptoms with the first-choice antibiotic for at least 48 hours, or if the first-choice is not suitable):
      – Amoxicillin 500 mg taken orally three times daily for 7 days (only if culture results are available and show susceptibility).
      – Cefalexin 500 mg taken twice daily for 7 days.

      For alternative second-choice antibiotics, it is recommended to consult a local microbiologist and choose the appropriate antibiotics based on the culture and sensitivity results.

    • This question is part of the following fields:

      • Urology
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  • Question 91 - A 25-year-old woman with inflammatory bowel disease (IBD) presents with a condition associated...

    Incorrect

    • A 25-year-old woman with inflammatory bowel disease (IBD) presents with a condition associated with IBD.
      Which of the following conditions is associated with ulcerative colitis?

      Your Answer:

      Correct Answer: Cholelithiasis

      Explanation:

      Cholelithiasis is a common occurrence in individuals with Crohn’s disease. There are several other conditions that are known to be associated with Crohn’s disease. These include a higher prevalence in smokers, with approximately 50-60% of patients being smokers. Additionally, individuals with Crohn’s disease may experience aphthous ulcers, uveitis, episcleritis, seronegative spondyloarthropathies, erythema nodosum, pyoderma gangrenosum, finger clubbing, autoimmune hemolytic anemia, and osteoporosis. However, it is important to note that primary biliary cirrhosis, primary sclerosing cholangitis, and chronic active hepatitis are associations commonly seen in ulcerative colitis rather than Crohn’s disease. Lastly, dermatitis herpetiformis is a condition that is associated with coeliac disease.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
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  • Question 92 - A 28-year-old woman has been involved in a physical altercation outside a bar....

    Incorrect

    • A 28-year-old woman has been involved in a physical altercation outside a bar. She has been hit multiple times in the face and has a noticeable swelling on her right cheek. Her facial X-ray shows a zygomaticomaxillary complex fracture but no other injuries.
      Which of the following will NOT be visible on her X-ray?

      Your Answer:

      Correct Answer: Fracture of the superior orbital rim

      Explanation:

      Zygomaticomaxillary complex fractures, also known as quadramalar or tripod fractures, make up around 40% of all midface fractures and are the second most common facial bone fractures after nasal bone fractures.

      These injuries typically occur when a direct blow is delivered to the malar eminence of the cheek. They consist of four components:

      1. Widening of the zygomaticofrontal suture
      2. Fracture of the zygomatic arch
      3. Fracture of the inferior orbital rim and the walls of the anterior and posterior maxillary sinuses
      4. Fracture of the lateral orbital rim.

    • This question is part of the following fields:

      • Maxillofacial & Dental
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  • Question 93 - A 65 year old patient arrives at the emergency department complaining of a...

    Incorrect

    • A 65 year old patient arrives at the emergency department complaining of a productive cough and fever. The patient's primary care physician had prescribed antibiotics a few days ago to treat a suspected respiratory infection. The patient's INR is tested as they are on warfarin for atrial fibrillation. The INR comes back as 6.7.

      Which of the following antibiotics is most likely to result in an extended INR?

      Your Answer:

      Correct Answer: Erythromycin

      Explanation:

      Macrolide antibiotics, such as clarithromycin and erythromycin, are widely known to prolong the International Normalized Ratio (INR). Several drugs can increase the potency of warfarin, and the macrolides, along with ciprofloxacin and metronidazole, are the antibiotics that have the most significant impact on enhancing the effect of warfarin.

      Further Reading:

      Management of High INR with Warfarin

      Major Bleeding:
      – Stop warfarin immediately.
      – Administer intravenous vitamin K 5 mg.
      – Administer 25-50 u/kg four-factor prothrombin complex concentrate.
      – If prothrombin complex concentrate is not available, consider using fresh frozen plasma (FFP).
      – Seek medical attention promptly.

      INR > 8.0 with Minor Bleeding:
      – Stop warfarin immediately.
      – Administer intravenous vitamin K 1-3mg.
      – Repeat vitamin K dose if INR remains high after 24 hours.
      – Restart warfarin when INR is below 5.0.
      – Seek medical advice if bleeding worsens or persists.

      INR > 8.0 without Bleeding:
      – Stop warfarin immediately.
      – Administer oral vitamin K 1-5 mg using the intravenous preparation orally.
      – Repeat vitamin K dose if INR remains high after 24 hours.
      – Restart warfarin when INR is below 5.0.
      – Seek medical advice if any symptoms or concerns arise.

      INR 5.0-8.0 with Minor Bleeding:
      – Stop warfarin immediately.
      – Administer intravenous vitamin K 1-3mg.
      – Restart warfarin when INR is below 5.0.
      – Seek medical advice if bleeding worsens or persists.

      INR 5.0-8.0 without Bleeding:
      – Withhold 1 or 2 doses of warfarin.
      – Reduce subsequent maintenance dose.
      – Monitor INR closely and seek medical advice if any concerns arise.

      Note: In cases of intracranial hemorrhage, prothrombin complex concentrate should be considered as it is faster acting than fresh frozen plasma (FFP).

    • This question is part of the following fields:

      • Haematology
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  • Question 94 - A 38 year old male arrives at the emergency department complaining of sudden...

    Incorrect

    • A 38 year old male arrives at the emergency department complaining of sudden tremors, excessive sweating, and a rapid heartbeat. Upon triage, the patient's blood pressure is found to be extremely high at 230/124 mmHg. Phaeochromocytoma is suspected. What would be the most suitable initial treatment in this case?

      Your Answer:

      Correct Answer: Phenoxybenzamine 10 mg by slow intravenous injection

      Explanation:

      The first step in managing hypertension in patients with phaeochromocytoma is to use alpha blockade, usually with a medication called phenoxybenzamine. This is followed by beta blockade. Before undergoing surgery to remove the phaeochromocytoma, patients need to be on both alpha and beta blockers. Alpha blockade is typically achieved by giving phenoxybenzamine intravenously at a dose of 10-40 mg over one hour, and then switching to an oral form (10-60 mg/day in divided doses). It is important to start alpha blockade at least 7 to 10 days before surgery to allow for an increase in blood volume. Beta blockade is only considered once alpha blockade has been achieved, as starting beta blockers too soon can lead to a dangerous increase in blood pressure.

      Further Reading:

      Phaeochromocytoma is a rare neuroendocrine tumor that secretes catecholamines. It typically arises from chromaffin tissue in the adrenal medulla, but can also occur in extra-adrenal chromaffin tissue. The majority of cases are spontaneous and occur in individuals aged 40-50 years. However, up to 30% of cases are hereditary and associated with genetic mutations. About 10% of phaeochromocytomas are metastatic, with extra-adrenal tumors more likely to be metastatic.

      The clinical features of phaeochromocytoma are a result of excessive catecholamine production. Symptoms are typically paroxysmal and include hypertension, headaches, palpitations, sweating, anxiety, tremor, abdominal and flank pain, and nausea. Catecholamines have various metabolic effects, including glycogenolysis, mobilization of free fatty acids, increased serum lactate, increased metabolic rate, increased myocardial force and rate of contraction, and decreased systemic vascular resistance.

      Diagnosis of phaeochromocytoma involves measuring plasma and urine levels of metanephrines, catecholamines, and urine vanillylmandelic acid. Imaging studies such as abdominal CT or MRI are used to determine the location of the tumor. If these fail to find the site, a scan with metaiodobenzylguanidine (MIBG) labeled with radioactive iodine is performed. The highest sensitivity and specificity for diagnosis is achieved with plasma metanephrine assay.

      The definitive treatment for phaeochromocytoma is surgery. However, before surgery, the patient must be stabilized with medical management. This typically involves alpha-blockade with medications such as phenoxybenzamine or phentolamine, followed by beta-blockade with medications like propranolol. Alpha blockade is started before beta blockade to allow for expansion of blood volume and to prevent a hypertensive crisis.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 95 - A 45-year-old man presents with a sudden onset of severe asthma symptoms. You...

    Incorrect

    • A 45-year-old man presents with a sudden onset of severe asthma symptoms. You begin treatment for the patient, following the most recent BTS guidelines.

      According to the BTS guidelines, what is the appropriate course of action for management?

      Your Answer:

      Correct Answer: Steroids should be given in all cases of acute asthma attack

      Explanation:

      The BTS guidelines for managing acute asthma in adults provide the following recommendations:

      Oxygen:
      – It is important to give supplementary oxygen to all patients with acute severe asthma who have low levels of oxygen in their blood (hypoxemia). The goal is to maintain a blood oxygen saturation level (SpO2) between 94-98%. Even if pulse oximetry is not available, oxygen should still be administered.

      β2 agonists therapy:
      – High-dose inhaled β2 agonists should be used as the first-line treatment for patients with acute asthma. It is important to administer these medications as early as possible.
      – Intravenous β2 agonists should be reserved for patients who cannot reliably use inhaled therapy.
      – For patients with life-threatening asthma symptoms, nebulized β2 agonists driven by oxygen are recommended.
      – In cases of severe asthma that does not respond well to an initial dose of β2 agonist, continuous nebulization with an appropriate nebulizer may be considered.

      Ipratropium bromide:
      – Nebulized ipratropium bromide (0.5 mg every 4-6 hours) should be added to β2 agonist treatment for patients with acute severe or life-threatening asthma, or those who do not respond well to initial β2 agonist therapy.

      Steroid therapy:
      – Steroids should be given in adequate doses for all cases of acute asthma attacks.
      – Prednisolone should be continued at a dose of 40-50 mg daily for at least five days or until the patient recovers.

      Other therapies:
      – Nebulized magnesium is not recommended for the treatment of acute asthma in adults.
      – A single dose of intravenous magnesium sulfate may be considered for patients with acute severe asthma (peak expiratory flow rate <50% of the best or predicted value) who do not respond well to inhaled bronchodilator therapy. However, this should only be done after consulting with senior medical staff.
      – Routine prescription of antibiotics is not necessary for patients with acute asthma.

      For more information, please refer to the BTS/SIGN Guideline on the Management of Asthma.

    • This question is part of the following fields:

      • Respiratory
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  • Question 96 - A 35-year-old woman comes in with intense one-sided abdominal pain starting in the...

    Incorrect

    • A 35-year-old woman comes in with intense one-sided abdominal pain starting in the left flank and extending to the groin. You suspect she may have ureteric colic.
      What are the two types of drugs that can be used for conservative treatment as medical expulsive therapy?

      Your Answer:

      Correct Answer: Alpha-blocker and calcium-channel blocker

      Explanation:

      Conservative management of ureteric stones may involve the use of medical expulsive therapy (MET), which can be achieved through the administration of either an alpha-blocker or a calcium-channel blocker. This treatment aims to facilitate the natural passage of the stone during the observation period.

      Research has shown that in adults, both alpha-blockers and calcium channel blockers have been effective in improving the passage of distal ureteric stones that are less than 10 mm in size, when compared to no treatment. Additionally, alpha-blockers have shown to be more effective than placebo in promoting stone passage. Alpha-blockers have also demonstrated more benefits than calcium channel blockers in terms of stone passage, as well as some advantages in terms of hospital stay and pain management. However, there was no significant difference in the time it took for the stone to pass or the overall quality of life.

      Currently, the National Institute for Health and Care Excellence (NICE) recommends alpha-blockers as the preferred choice for medical expulsive therapy. For more detailed information, you can refer to the NICE guidelines on the assessment and management of renal and ureteric stones.

    • This question is part of the following fields:

      • Urology
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  • Question 97 - A 60 year old male presents to the emergency department complaining of headache...

    Incorrect

    • A 60 year old male presents to the emergency department complaining of headache and palpitations. Upon assessment, the patient appears sweaty and his blood pressure is measured at 224/122 mmHg. The patient expresses fear of potential death. He mentions experiencing similar episodes in the past few weeks, although not as severe as this one. Which of the following tests would be the most suitable to determine the suspected underlying condition?

      Your Answer:

      Correct Answer: Plasma metanephrines

      Explanation:

      When there is suspicion of phaeochromocytoma, the first tests to be done are plasma and/or urinary metanephrines. This patient exhibits paroxysmal symptoms that are consistent with phaeochromocytoma, such as high blood pressure, headache, sweating, anxiety, and fear. The initial diagnostic tests aim to confirm any metabolic disturbances by measuring levels of plasma and/or urine metanephrines, catecholamines, and urine vanillylmandelic acid (VMA). If these levels are found to be elevated, further imaging tests will be needed to determine the location and structure of the phaeochromocytoma tumor.

      Further Reading:

      Phaeochromocytoma is a rare neuroendocrine tumor that secretes catecholamines. It typically arises from chromaffin tissue in the adrenal medulla, but can also occur in extra-adrenal chromaffin tissue. The majority of cases are spontaneous and occur in individuals aged 40-50 years. However, up to 30% of cases are hereditary and associated with genetic mutations. About 10% of phaeochromocytomas are metastatic, with extra-adrenal tumors more likely to be metastatic.

      The clinical features of phaeochromocytoma are a result of excessive catecholamine production. Symptoms are typically paroxysmal and include hypertension, headaches, palpitations, sweating, anxiety, tremor, abdominal and flank pain, and nausea. Catecholamines have various metabolic effects, including glycogenolysis, mobilization of free fatty acids, increased serum lactate, increased metabolic rate, increased myocardial force and rate of contraction, and decreased systemic vascular resistance.

      Diagnosis of phaeochromocytoma involves measuring plasma and urine levels of metanephrines, catecholamines, and urine vanillylmandelic acid. Imaging studies such as abdominal CT or MRI are used to determine the location of the tumor. If these fail to find the site, a scan with metaiodobenzylguanidine (MIBG) labeled with radioactive iodine is performed. The highest sensitivity and specificity for diagnosis is achieved with plasma metanephrine assay.

      The definitive treatment for phaeochromocytoma is surgery. However, before surgery, the patient must be stabilized with medical management. This typically involves alpha-blockade with medications such as phenoxybenzamine or phentolamine, followed by beta-blockade with medications like propranolol. Alpha blockade is started before beta blockade to allow for expansion of blood volume and to prevent a hypertensive crisis.

    • This question is part of the following fields:

      • Endocrinology
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      Seconds
  • Question 98 - You are called to assess a patient who has been brought in by...

    Incorrect

    • You are called to assess a patient who has been brought in by the Police. They had a heated argument with their partner at home, and when the police arrived, they were witnessed consuming a large quantity of tablets (later identified as paracetamol) as the police forced entry to the property. They express a desire to return home and display indifference towards their own well-being. Additionally, they disclose that they have recently received a cancer diagnosis. Despite multiple discussions, they are refusing to undergo any blood tests or receive treatment for their overdose.

      What would be the most appropriate course of action to take next?

      Your Answer:

      Correct Answer: Discuss with the patient further, establish whether he has capacity to make the decision to decline treatment. You may be in a position to treat him against his wishes if he lacks capacity.

      Explanation:

      These situations are uncommon, but it is crucial to have a plan in place for dealing with them when they arise. This emphasizes the importance of having strong history taking skills and the ability to problem-solve.

      Based on the information available, it appears that the patient may have ingested a significant amount of paracetamol, putting them at risk of toxic effects. It would be helpful to have a calm conversation with the patient to understand their perspective, as they may have a fear of needles and may not want any blood tests done.

      If there are any family members or a next of kin present, it might be worth giving them some time with the patient to see if they can persuade them to change their mind. If none of these approaches are successful, it is necessary to assess the patient’s mental capacity to make the decision to decline treatment. It is important to remember that capacity can vary depending on the situation and decision at hand.

      If it is determined that the patient lacks the capacity to make the decision to decline treatment, there may be a possibility of providing care against their expressed wishes. In such cases, it is advisable to involve the mental health team to formally assess for evidence of mental illness. This assessment may strengthen the case for the patient to be sectioned, which would allow certain actions to be taken against their wishes, including treating them for the effects of their mental illness, which in this case includes addressing the overdose.

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
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  • Question 99 - A 72-year-old man with a history of COPD complains of a headache, dizziness,...

    Incorrect

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

      Your Answer:

      Correct Answer: 4-6 hours

      Explanation:

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

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

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 100 - A 70-year-old patient comes in after a chronic overdose of digoxin. She has...

    Incorrect

    • A 70-year-old patient comes in after a chronic overdose of digoxin. She has experienced multiple episodes of vomiting, feels extremely tired, and reports that her vision seems to have a yellow tint.

      What is the indication for administering DigiFab in this patient?

      Your Answer:

      Correct Answer: Coexistent renal failure

      Explanation:

      Digoxin-specific antibody (DigiFab) is an antidote used to counteract digoxin overdose. It is a purified and sterile preparation of digoxin-immune ovine Fab immunoglobulin fragments. These fragments are derived from healthy sheep that have been immunized with a digoxin derivative called digoxin-dicarboxymethoxylamine (DDMA). DDMA is a digoxin analogue that contains the essential cyclopentanoperhydrophenanthrene: lactone ring moiety coupled to keyhole limpet hemocyanin (KLH).

      DigiFab has a higher affinity for digoxin compared to the affinity of digoxin for its sodium pump receptor, which is believed to be the receptor responsible for its therapeutic and toxic effects. When administered to a patient who has overdosed on digoxin, DigiFab binds to digoxin molecules, reducing the levels of free digoxin in the body. This shift in equilibrium away from binding to the receptors helps to reduce the cardiotoxic effects of digoxin. The Fab-digoxin complexes are then eliminated from the body through the kidney and reticuloendothelial system.

      The indications for using DigiFab in cases of acute and chronic digoxin toxicity are summarized below:

      Acute digoxin toxicity:
      – Cardiac arrest
      – Life-threatening arrhythmia
      – Potassium level >5 mmol/l
      – Ingestion of >10 mg of digoxin (in adults)
      – Ingestion of >4 mg of digoxin (in children)
      – Digoxin level >12 ng/ml

      Chronic digoxin toxicity:
      – Cardiac arrest
      – Life-threatening arrhythmia
      – Significant gastrointestinal symptoms
      – Symptoms of digoxin toxicity in the presence of renal failure

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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SESSION STATS - PERFORMANCE PER SPECIALTY

Basic Anaesthetics (5/5) 100%
Musculoskeletal (non-traumatic) (1/2) 50%
Pain & Sedation (0/2) 0%
Pharmacology & Poisoning (6/10) 60%
Paediatric Emergencies (1/1) 100%
Neurology (1/2) 50%
Haematology (3/5) 60%
Ear, Nose & Throat (3/5) 60%
Environmental Emergencies (0/1) 0%
Cardiology (2/5) 40%
Gastroenterology & Hepatology (0/3) 0%
Urology (1/3) 33%
Resus (1/1) 100%
Respiratory (1/3) 33%
Trauma (3/4) 75%
Oncological Emergencies (0/1) 0%
Sexual Health (2/3) 67%
Neonatal Emergencies (1/2) 50%
Ophthalmology (1/1) 100%
Infectious Diseases (2/2) 100%
Dermatology (1/2) 50%
Mental Health (1/2) 50%
Surgical Emergencies (1/1) 100%
Vascular (0/1) 0%
Endocrinology (3/3) 100%
Maxillofacial & Dental (1/1) 100%
Safeguarding & Psychosocial Emergencies (1/1) 100%
Passmed