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  • Question 1 - A 42-year-old woman was involved in a car accident where her car collided...

    Incorrect

    • A 42-year-old woman was involved in a car accident where her car collided with a tree at high speed. She was not wearing a seatbelt and was thrown forward onto the steering wheel of her car. She has severe bruising over her anterior chest wall and is experiencing chest pain. A chest X-ray reveals a significantly widened mediastinum, deviation of the trachea to the left, and fractures of the third and fourth ribs. Her vital signs are HR 88, BP 130/78, SaO2 98% on high flow oxygen.

      At which anatomical site is an injury MOST likely to have occurred in this case?

      Your Answer: Near the opening of the aortic valve

      Correct Answer: Near the ligamentum arteriosum

      Explanation:

      Traumatic aortic rupture is a relatively common cause of sudden death following major trauma, especially high-speed road traffic accidents (RTAs). It is estimated that 15-20% of deaths from RTAs are due to this injury. If the aortic rupture is promptly recognized and treated, patients who survive the initial injury can fully recover.

      Surviving patients often have an incomplete laceration near the ligamentum arteriosum of the aorta. The continuity is maintained by either an intact adventitial layer or a contained mediastinal hematoma, which prevents immediate exsanguination and death.

      Detecting traumatic aortic rupture can be challenging as many patients do not exhibit specific symptoms, and other injuries may also be present, making the diagnosis unclear.

      Chest X-ray findings can aid in the diagnosis and include fractures of the 1st and 2nd ribs, a grossly widened mediastinum, a hazy left lung field, obliteration of the aortic knob, deviation of the trachea to the right, presence of a pleural cap, elevation and rightward shift of the right mainstem bronchus, depression of the left mainstem bronchus, obliteration of the space between the pulmonary artery and aorta, and deviation of the esophagus (or NG tube) to the right.

      Helical contrast-enhanced CT scanning is highly sensitive and specific for detecting aortic rupture, but it should only be performed on hemodynamically stable patients.

      Treatment options include primary repair or resection of the torn segment with replacement using an interposition graft. Endovascular repair is also now considered an acceptable alternative approach.

    • This question is part of the following fields:

      • Trauma
      17.8
      Seconds
  • Question 2 - A 68 year old is brought into the emergency department by ambulance after...

    Correct

    • A 68 year old is brought into the emergency department by ambulance after falling down the stairs. The patient typically receives assistance from carers four times a day for bathing, getting dressed, and using the restroom. The ambulance crew informs you that the patient has a poor appetite as they have advanced lung cancer and discontinued chemotherapy 3 months ago due to disease progression and deteriorating health. The ambulance crew also mentions that the patient's palliative care specialist recently estimated their life expectancy to be a matter of weeks during their last consultation. What would be the clinical frailty score for this patient?

      Your Answer: 9

      Explanation:

      The clinical frailty score is a tool used to evaluate frailty and determine the level of safety for a patient’s discharge from the hospital. A higher CFS score indicates a greater likelihood of an extended hospital stay, increased need for support after discharge, and higher risk of mortality. In the case of this patient with terminal cancer and a life expectancy of less than 6 months, they would be classified as having the highest possible frailty score.

      Further Reading:

      Falls are a common occurrence in the elderly population, with a significant number of individuals over the age of 65 experiencing at least one fall per year. These falls are often the result of various risk factors, including impaired balance, muscle weakness, visual impairment, cognitive impairment, depression, alcohol misuse, polypharmacy, and environmental hazards. The more risk factors a person has, the higher their risk of falling.

      Falls can have serious complications, particularly in older individuals. They are a leading cause of injury, injury-related disability, and death in this population. Approximately 50% of falls in the elderly result in major lacerations, traumatic brain injuries, or fractures. About 5% of falls in older people living in the community lead to hospitalization or fractures. Hip fractures, in particular, are commonly caused by falls and have a high mortality rate within one year.

      Complications of falls include fractures, soft tissue injuries, fragility fractures, distress, pain, loss of self-confidence, reduced quality of life, loss of independence, fear of falls and activity avoidance, social isolation, increasing frailty, functional decline, depression, and institutionalization. Additionally, individuals who remain on the floor for more than one hour after a fall are at risk of dehydration, pressure sores, pneumonia, hypothermia, and rhabdomyolysis.

      Assessing falls requires a comprehensive history, including the course of events leading up to the fall, any pre-fall symptoms, and details about the fall itself. A thorough examination is also necessary, including an assessment of injuries, neurological and cardiovascular function, tests for underlying causes, vision assessment, and medication review. Home hazard assessments and frailty assessments are also important components of the assessment process.

      Determining the frailty of older patients is crucial in deciding if they can be safely discharged and what level of care they require. The clinical Frailty Scale (CFS or Rockwood score) is commonly used for this purpose. It helps healthcare professionals evaluate the overall frailty of a patient and make appropriate care decisions.

      In summary, falls are a significant concern in the elderly population, with multiple risk factors contributing to their occurrence. These falls can lead to serious complications and have a negative impact on an individual’s quality of life. Assessing falls requires a comprehensive approach, including a thorough history, examination, and consideration of frailty.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      6.1
      Seconds
  • Question 3 - A 45 year old male presents to the emergency department complaining of worsening...

    Correct

    • A 45 year old male presents to the emergency department complaining of worsening headaches and visual disturbances over the past week. Upon examination, you observe that the patient has a round face, stretch marks on the abdomen, and excessive hair growth. You suspect that the patient may have Cushing syndrome.

      Which of the following tests would be the most suitable to confirm the diagnosis?

      Your Answer: 24-hour urinary free cortisol

      Explanation:

      The recommended diagnostic tests for Cushing’s syndrome include the 24-hour urinary free cortisol test, the 1 mg overnight dexamethasone suppression test, and the late-night salivary cortisol test. In this case, the patient exhibits symptoms of Cushing syndrome such as a moon face, abdominal striae, and hirsutism. These symptoms may be caused by Cushing’s disease, which is Cushing syndrome due to a pituitary adenoma. The patient also experiences headaches and visual disturbances, which could potentially be caused by high blood sugar levels. It is important to note that Cushing syndrome caused by an adrenal or pituitary tumor is more common in females, with a ratio of 5:1. The peak incidence of Cushing syndrome caused by an adrenal or pituitary adenoma occurs between the ages of 25 and 40 years.

      Further Reading:

      Cushing’s syndrome is a clinical syndrome caused by prolonged exposure to high levels of glucocorticoids. The severity of symptoms can vary depending on the level of steroid exposure. There are two main classifications of Cushing’s syndrome: ACTH-dependent disease and non-ACTH-dependent disease. ACTH-dependent disease is caused by excessive ACTH production from the pituitary gland or ACTH-secreting tumors, which stimulate excessive cortisol production. Non-ACTH-dependent disease is characterized by excess glucocorticoid production independent of ACTH stimulation.

      The most common cause of Cushing’s syndrome is exogenous steroid use. Pituitary adenoma is the second most common cause and the most common endogenous cause. Cushing’s disease refers specifically to Cushing’s syndrome caused by an ACTH-producing pituitary tumor.

      Clinical features of Cushing’s syndrome include truncal obesity, supraclavicular fat pads, buffalo hump, weight gain, moon facies, muscle wasting and weakness, diabetes or impaired glucose tolerance, gonadal dysfunction, hypertension, nephrolithiasis, skin changes (such as skin atrophy, striae, easy bruising, hirsutism, acne, and hyperpigmentation in ACTH-dependent causes), depression and emotional lability, osteopenia or osteoporosis, edema, irregular menstrual cycles or amenorrhea, polydipsia and polyuria, poor wound healing, and signs related to the underlying cause, such as headaches and visual problems.

      Diagnostic tests for Cushing’s syndrome include 24-hour urinary free cortisol, 1 mg overnight dexamethasone suppression test, and late-night salivary cortisol. Other investigations aim to assess metabolic disturbances and identify the underlying cause, such as plasma ACTH, full blood count (raised white cell count), electrolytes, and arterial blood gas analysis. Imaging, such as CT or MRI of the abdomen, chest, and/or pituitary, may be required to assess suspected adrenal tumors, ectopic ACTH-secreting tumors, and pituitary tumors. The choice of imaging is guided by the ACTH result, with undetectable ACTH and elevated serum cortisol levels indicating ACTH-independent Cushing’s syndrome and raised ACTH suggesting an ACTH-secreting tumor.

    • This question is part of the following fields:

      • Endocrinology
      6.6
      Seconds
  • Question 4 - A 45-year-old woman was involved in a car accident where her car collided...

    Correct

    • A 45-year-old woman was involved in a car accident where her car collided with a tree at high speed. She was not wearing a seatbelt and was thrown forward onto the steering wheel of her car. She has bruising over her anterior chest wall and is experiencing chest pain. Her chest X-ray in the emergency room reveals evidence of a traumatic aortic injury.
      Which of the following fractures are most indicative of this injury?

      Your Answer: 1st and 2nd ribs

      Explanation:

      Traumatic aortic rupture, also known as traumatic aortic disruption or transection, occurs when the aorta is torn or ruptured due to physical trauma. This condition often leads to sudden death because of severe bleeding. Motor vehicle accidents and falls from great heights are the most common causes of this injury.

      The patients with the highest chances of survival are those who have an incomplete tear near the ligamentum arteriosum of the proximal descending aorta, close to where the left subclavian artery branches off. The presence of an intact adventitial layer or contained mediastinal hematoma helps maintain continuity and prevents immediate bleeding and death. If promptly identified and treated, survivors of these injuries can recover. In cases where traumatic aortic rupture leads to sudden death, approximately 50% of patients have damage at the aortic isthmus, while around 15% have damage in either the ascending aorta or the aortic arch.

      Initial chest X-rays may show signs consistent with a traumatic aortic injury. However, false-positive and false-negative results can occur, and sometimes there may be no abnormalities visible on the X-ray. Some of the possible X-ray findings include a widened mediastinum, hazy left lung field, obliteration of the aortic knob, fractures of the 1st and 2nd ribs, deviation of the trachea to the right, presence of a pleural cap, elevation and rightward shift of the right mainstem bronchus, depression of the left mainstem bronchus, obliteration of the space between the pulmonary artery and aorta, and deviation of the esophagus or NG tube to the right.

      A helical contrast-enhanced CT scan of the chest is the preferred initial investigation for suspected blunt aortic injury. It has proven to be highly accurate, with close to 100% sensitivity and specificity. CT scanning should be performed liberally, as chest X-ray findings can be unreliable. However, hemodynamically unstable patients should not be placed in a CT scanner. If the CT results are inconclusive, aortography or trans-oesophageal echo can be performed for further evaluation.

      Immediate surgical intervention is necessary for these injuries. Endovascular repair is the most common method used and has excellent short-term outcomes. Open repair may also be performed depending on the circumstances. It is important to control heart rate and blood pressure during stabilization to reduce the risk of rupture. Pain should be managed with appropriate analgesic

    • This question is part of the following fields:

      • Trauma
      8.2
      Seconds
  • Question 5 - A 65-year-old patient presents to the emergency department and informs you that they...

    Correct

    • A 65-year-old patient presents to the emergency department and informs you that they have taken an overdose. The patient states that they are unsure of the exact number of tablets consumed but estimate it to be around 100 aspirin tablets. You are concerned about the severity of the overdose and its potential consequences. Which of the following is an indication for haemodialysis in patients with salicylate poisoning?

      Your Answer: Salicylate level of 715 mg/L

      Explanation:

      Haemodialysis is recommended for patients with salicylate poisoning if they meet any of the following criteria: plasma salicylate level exceeding 700 mg/L, metabolic acidosis that does not improve with treatment (plasma pH below 7.2), acute kidney injury, pulmonary edema, seizures, coma, unresolved central nervous system effects despite correcting acidosis, persistently high salicylate concentrations that do not respond to urinary alkalinisation. Severe cases of salicylate poisoning, especially in patients under 10 years old or over 70 years old, may require dialysis earlier than the listed indications.

      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
      8.2
      Seconds
  • Question 6 - A middle-aged man who lives alone is brought in by ambulance; he is...

    Correct

    • A middle-aged man who lives alone is brought in by ambulance; he is drowsy, vomiting and complaining of a headache. There is currently a summer heatwave, and you suspect a diagnosis of heat stroke.

      What is the threshold temperature used in the definition of heat stroke?

      Your Answer: Above 40.6°C

      Explanation:

      Heat stroke is a condition characterized by a systemic inflammatory response, where the core body temperature rises above 40.6°C. It is accompanied by alterations in mental state and varying degrees of organ dysfunction.

      There are two types of heat stroke. The first is classic non-exertional heat stroke, which occurs when individuals are exposed to high environmental temperatures. This form of heat stroke is commonly seen in elderly patients during heat waves.

      The second type is exertional heat stroke, which occurs during intense physical activity in hot weather conditions. This form of heat stroke is often observed in endurance athletes who participate in strenuous exercise in high temperatures.

    • This question is part of the following fields:

      • Environmental Emergencies
      3.8
      Seconds
  • Question 7 - A 42 year old male is brought into the ED resuscitation room. The...

    Correct

    • A 42 year old male is brought into the ED resuscitation room. The paramedics report the patient was discovered outdoors and unconscious. CPR was initiated in the ambulance. You observe that the patient is hypothermic with a temperature of 30.4ºC. What modifications would you make to the management of cardio-respiratory arrest based on this finding?

      Your Answer: Pulse check for up to 1 minute

      Explanation:

      In patients with hypothermia, the pulse check during CPR should be extended to 1 minute. Additionally, several adjustments need to be made to the CPR protocol. Firstly, mechanical ventilation should be used due to the stiffness of the chest wall. Secondly, the dosing or omission of cardiac arrest drugs should be adjusted based on the patient’s temperature. The defibrillation pattern should also be modified, with 3 shocks attempted before re-attempting defibrillation only when the body temperature is above 30ºC. Certain electrolyte disturbances, such as mild hypokalemia, should not be treated as potassium levels typically rise with Rewarming. It is important to plan for prolonged resuscitation in these cases. Lastly, uncorrected ABG results should be used, without adjusting for temperature.

      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:

      • Resus
      9.4
      Seconds
  • Question 8 - A 70-year-old woman presents with vertigo. You gather a history and conduct an...

    Correct

    • A 70-year-old woman presents with vertigo. You gather a history and conduct an examination to distinguish between a central and peripheral cause.
      What SINGLE characteristic would indicate a higher likelihood of a central cause rather than a peripheral cause for her symptoms?

      Your Answer: Nystagmus towards the side of the lesion

      Explanation:

      Peripheral and central vertigo can be differentiated based on certain characteristics. Peripheral vertigo typically has a sudden onset and is associated with more severe symptoms of vertigo. The vertigo symptoms may come and go intermittently. Individuals with peripheral vertigo often experience severe nausea and vomiting. Their vertigo is also affected by head movement, particularly in certain positions. Peripheral vertigo is usually not accompanied by any focal neurology. Nystagmus, which is an involuntary eye movement, tends to occur away from the side of the lesion. In some cases, hearing may also be impaired, as seen in conditions like Meniere’s disease and labyrinthitis.

      On the other hand, central vertigo tends to have a gradual onset and milder symptoms of vertigo. The vertigo symptoms are constant and do not fluctuate. Nausea and vomiting may be present but are usually less severe compared to peripheral vertigo. Unlike peripheral vertigo, central vertigo is not influenced by head movement and is considered fixed. Individuals with central vertigo may experience new-onset headaches. Additionally, central vertigo is often accompanied by focal neurology, indicating involvement of specific areas of the brain. Nystagmus in central vertigo occurs towards the side of the lesion. Unlike peripheral vertigo, hearing is typically unaffected in central vertigo cases.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      12.4
      Seconds
  • Question 9 - A 32 year old male attends the emergency department following a fall in...

    Correct

    • A 32 year old male attends the emergency department following a fall in which he sustained a minor head injury. You observe that the patient is a Ukrainian refugee and has recently arrived in the UK. During the assessment, you notice a significant goitre. Upon checking his thyroid function, it confirms hypothyroidism. What is the most probable reason for his hypothyroidism?

      Your Answer: Iodine deficiency

      Explanation:

      Iodine deficiency is a widespread issue globally and is the leading cause of hypothyroidism worldwide. It is particularly prevalent in numerous African countries, as well as in developed nations such as Norway, Germany, Russia, and Ukraine. In the UK, however, autoimmune thyroiditis is the most common cause of hypothyroidism.

      Further Reading:

      The thyroid gland is an endocrine organ located in the anterior neck. It consists of two lobes connected by an isthmus. The gland produces hormones called thyroxine (T4) and triiodothyronine (T3), which regulate energy use, protein synthesis, and the body’s sensitivity to other hormones. The production of T4 and T3 is stimulated by thyroid-stimulating hormone (TSH) secreted by the pituitary gland, which is in turn stimulated by thyrotropin-releasing hormone (TRH) from the hypothalamus.

      Thyroid disorders can occur when there is an imbalance in the production or regulation of thyroid hormones. Hypothyroidism is characterized by a deficiency of thyroid hormones, while hyperthyroidism is characterized by an excess. The most common cause of hypothyroidism is autoimmune thyroiditis, also known as Hashimoto’s thyroiditis. It is more common in women and is often associated with goiter. Other causes include subacute thyroiditis, atrophic thyroiditis, and iodine deficiency. On the other hand, the most common cause of hyperthyroidism is Graves’ disease, which is also an autoimmune disorder. Other causes include toxic multinodular goiter and subacute thyroiditis.

      The symptoms and signs of thyroid disorders can vary depending on whether the thyroid gland is underactive or overactive. In hypothyroidism, common symptoms include weight gain, lethargy, cold intolerance, and dry skin. In hyperthyroidism, common symptoms include weight loss, restlessness, heat intolerance, and increased sweating. Both hypothyroidism and hyperthyroidism can also affect other systems in the body, such as the cardiovascular, gastrointestinal, and neurological systems.

      Complications of thyroid disorders can include dyslipidemia, metabolic syndrome, coronary heart disease, heart failure, subfertility and infertility, impaired special senses, and myxedema coma in severe cases of hypothyroidism. In hyperthyroidism, complications can include Graves’ orbitopathy, compression of the esophagus or trachea by goiter, thyrotoxic periodic paralysis, arrhythmias, osteoporosis, mood disorders, and increased obstetric complications.

      Myxedema coma is a rare and life-threatening complication of severe hypothyroidism. It can be triggered by factors such as infection or physiological insult and presents with lethargy, bradycardia, hypothermia, hypotension, hypoventilation, altered mental state, seizures and/or coma.

    • This question is part of the following fields:

      • Endocrinology
      5
      Seconds
  • Question 10 - A 25-year-old traveler comes back from a journey to South America with a...

    Correct

    • A 25-year-old traveler comes back from a journey to South America with a fever, headache, and feeling nauseous. After a diagnosis, it is determined that she has contracted yellow fever.

      Upon examination, it is observed that she has an uncommon combination of an extremely high body temperature (39.7°C) and a relative bradycardia (48 bpm).

      What is the name of the clinical sign that she has developed, which is named after a person?

      Your Answer: Faget sign

      Explanation:

      Faget sign is a unique occurrence where a fever and a relatively slow heart rate, known as bradycardia, are observed together. This phenomenon is sometimes called sphygmothermic dissociation. It can be observed in various infectious diseases, such as yellow fever, typhoid fever, tularaemia, brucellosis, Colorado tick fever, Legionella pneumonia, and Mycoplasma pneumonia. Normally, when a person has a fever, their heart rate increases, but in cases of Faget sign, the heart rate remains slow. Another term used to describe the combination of fever and increased heart rate is Leibermeister’s rule.

      Auspitz’s sign is a characteristic feature seen in psoriasis. When the scales of psoriasis are scraped off, small bleeding spots, known as punctate bleeding spots, appear. This sign helps in the diagnosis of psoriasis.

      Frank sign is a term used to describe a diagonal crease that appears on the earlobe. It has been hypothesized that this crease may be linked to cardiovascular disease and diabetes.

      Levine’s sign refers to a specific response to chest pain caused by reduced blood flow to the heart, known as ischemic chest pain. In this sign, the person clenches their fist and holds it over their chest in an instinctive reaction to the pain.

    • This question is part of the following fields:

      • Infectious Diseases
      9.2
      Seconds
  • Question 11 - A 35-year-old man with a past of episodes of excessive sweating, rapid heartbeat,...

    Correct

    • A 35-year-old man with a past of episodes of excessive sweating, rapid heartbeat, and sudden high blood pressure is diagnosed with a phaeochromocytoma.
      A phaeochromocytoma is a functioning tumor that originates from cells in which of the following?

      Your Answer: Adrenal medulla

      Explanation:

      A phaeochromocytoma is an uncommon functional tumor that develops from chromaffin cells in the adrenal medulla. Extra-adrenal paragangliomas, also known as extra-adrenal pheochromocytomas, are closely associated but less prevalent tumors that originate in the ganglia of the sympathetic nervous system. These tumors release catecholamines and result in a range of symptoms and indications linked to hyperactivity of the sympathetic nervous system.

    • This question is part of the following fields:

      • Endocrinology
      3.8
      Seconds
  • Question 12 - 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: Atrioventricular nodal re-entrant tachycardia

      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
      7.3
      Seconds
  • Question 13 - You are managing a 72-year-old patient with type 2 respiratory failure. It has...

    Incorrect

    • You are managing a 72-year-old patient with type 2 respiratory failure. It has been decided to initiate BiPAP therapy. What initial EPAP and IPAP pressure settings would you recommend?

      Your Answer: EPAP 3-5 cmH2O IPAP 5-9 cmH2O

      Correct Answer:

      Explanation:

      When determining the initial EPAP and IPAP pressure settings for this patient, it is important to consider their specific needs and condition. In general, the EPAP pressure should be set between 3-5 cmH2O, which helps to maintain positive pressure in the airways during exhalation, preventing them from collapsing. This can improve oxygenation and reduce the work of breathing.

      The IPAP pressure, on the other hand, should be set between 10-15 cmH2O. This higher pressure during inhalation helps to overcome any resistance in the airways and ensures adequate ventilation. It also assists in improving the patient’s tidal volume and reducing carbon dioxide levels.

      Therefore, the recommended initial EPAP and IPAP pressure settings for this patient would be EPAP 3-5 cmH2O / IPAP 10-15 cmH2O. These settings provide a balance between maintaining airway patency during exhalation and ensuring sufficient ventilation during inhalation. However, it is important to regularly assess the patient’s response to therapy and adjust the settings as needed to optimize their respiratory function.

      Further Reading:

      Mechanical ventilation is the use of artificial means to assist or replace spontaneous breathing. It can be invasive, involving instrumentation inside the trachea, or non-invasive, where there is no instrumentation of the trachea. Non-invasive mechanical ventilation (NIV) in the emergency department typically refers to the use of CPAP or BiPAP.

      CPAP, or continuous positive airways pressure, involves delivering air or oxygen through a tight-fitting face mask to maintain a continuous positive pressure throughout the patient’s respiratory cycle. This helps maintain small airway patency, improves oxygenation, decreases airway resistance, and reduces the work of breathing. CPAP is mainly used for acute cardiogenic pulmonary edema.

      BiPAP, or biphasic positive airways pressure, also provides positive airway pressure but with variations during the respiratory cycle. The pressure is higher during inspiration than expiration, generating a tidal volume that assists ventilation. BiPAP is mainly indicated for type 2 respiratory failure in patients with COPD who are already on maximal medical therapy.

      The pressure settings for CPAP typically start at 5 cmH2O and can be increased to a maximum of 15 cmH2O. For BiPAP, the starting pressure for expiratory pressure (EPAP) or positive end-expiratory pressure (PEEP) is 3-5 cmH2O, while the starting pressure for inspiratory pressure (IPAP) is 10-15 cmH2O. These pressures can be titrated up if there is persisting hypoxia or acidosis.

      In terms of lung protective ventilation, low tidal volumes of 5-8 ml/kg are used to prevent atelectasis and reduce the risk of lung injury. Inspiratory pressures (plateau pressure) should be kept below 30 cm of water, and permissible hypercapnia may be allowed. However, there are contraindications to lung protective ventilation, such as unacceptable levels of hypercapnia, acidosis, and hypoxemia.

      Overall, mechanical ventilation, whether invasive or non-invasive, is used in various respiratory and non-respiratory conditions to support or replace spontaneous breathing and improve oxygenation and ventilation.

    • This question is part of the following fields:

      • Respiratory
      7.9
      Seconds
  • Question 14 - You are present at a trauma call and have been asked to examine...

    Correct

    • You are present at a trauma call and have been asked to examine the chest of a child who has been hit by a car. According to the ATLS guidelines, what are the life-threatening chest injuries that should be identified and treated in the PRIMARY survey?

      Your Answer: Open pneumothorax

      Explanation:

      The ATLS guidelines categorize chest injuries in trauma into two groups: life-threatening injuries that require immediate identification and treatment in the primary survey, and potentially life-threatening injuries that should be identified and treated in the secondary survey.

      During the primary survey, the focus is on identifying and treating life-threatening thoracic injuries. These include airway obstruction, tracheobronchial tree injury, tension pneumothorax, open pneumothorax, massive haemothorax, and cardiac tamponade. Prompt recognition and intervention are crucial in order to prevent further deterioration and potential fatality.

      In the secondary survey, attention is given to potentially life-threatening injuries that may not be immediately apparent. These include simple pneumothorax, haemothorax, flail chest, pulmonary contusion, blunt cardiac injury, traumatic aortic disruption, traumatic diaphragmatic injury, and blunt oesophageal rupture. These injuries may not pose an immediate threat to life, but they still require identification and appropriate management to prevent complications and ensure optimal patient outcomes.

      By dividing chest injuries into these two categories and addressing them in a systematic manner, healthcare providers can effectively prioritize and manage trauma patients, ultimately improving their chances of survival and recovery.

    • This question is part of the following fields:

      • Trauma
      8.9
      Seconds
  • Question 15 - A 45-year-old man has been experiencing progressive weakness and numbness in his legs...

    Correct

    • A 45-year-old man has been experiencing progressive weakness and numbness in his legs for the past several days. Additionally, he has been feeling breathless during walking. He recently went on a vacation where he had diarrhea, and a stool culture confirmed an infection with Campylobacter jejuni.

      What is the SINGLE most probable diagnosis?

      Your Answer: Guillain-Barré syndrome

      Explanation:

      Guillain-Barré syndrome (GBS) affects approximately 1-2 individuals per 100,000 annually and is a condition that primarily affects the peripheral nervous system, including the autonomic system. The most common initial symptom is weakness in the hands or feet, often accompanied by pain and tingling sensations as the paralysis spreads. Miller Fisher syndrome, a variant of GBS, is characterized by a triad of symptoms: ataxia, areflexia, and ophthalmoplegia.

      Due to the potential serious consequences of autonomic involvement, such as fluctuations in blood pressure and cardiac arrhythmias, patients with GBS are typically hospitalized. As the diaphragm becomes paralyzed and swallowing becomes difficult, patients may require ventilation and nasogastric feeding.

      GBS is an autoimmune disease that usually develops within three weeks of an infection. The leading cause is Campylobacter jejuni, followed by Epstein-Barr virus, cytomegalovirus, and Mycoplasma pneumoniae. While the patient’s immune response effectively targets the initial infection, it also mistakenly attacks the host tissue.

      Symptoms of GBS typically peak around four weeks and then gradually improve. Diagnosis is based on clinical examination, which confirms the presence of areflexia and progressive weakness in the legs (and sometimes arms). Nerve conduction studies and lumbar puncture can also aid in diagnosis, with the latter often showing elevated protein levels and few white blood cells.

      Treatment for GBS is primarily supportive, with the use of immunoglobulins to shorten the duration of the illness being common. Plasma exchange may also be utilized, although it has become less common since the introduction of immunoglobulin therapy.

      Approximately 80% of patients with GBS make a full recovery, although this often requires a lengthy hospital stay. The mortality rate is around 5%, depending on the availability of necessary facilities such as ventilatory support during the acute phase. Additionally, about 15% of patients may experience some permanent disability, such as weakness or pain.

    • This question is part of the following fields:

      • Neurology
      5.6
      Seconds
  • Question 16 - A 65 year old who was brought to the emergency room due to...

    Correct

    • A 65 year old who was brought to the emergency room due to feeling generally ill is being assessed by one of the ER nurses. The nurse calls for your assistance as the patient has suddenly fainted and is not breathing. You call for help and decide to initiate chest compressions. Which of the following statements about cardiopulmonary resuscitation is accurate?

      Your Answer: When performing chest compressions on an adult the sternum should be compressed to a depth of 5-6 cm

      Explanation:

      When giving chest compressions to an adult, it is important to compress the sternum to a depth of 5-6 cm. The resuscitation council updated their guidance in 2015 and now recommends a ratio of 30 chest compressions to 2 rescue breaths. It is worth noting that according to the algorithm, checking for a pulse is no longer necessary in the latest BLS sequence. The chest compressions should be administered at a rate of 100-120 per minute, with a ratio of 30 compressions to 2 rescue breaths.

      Further Reading:

      Cardiopulmonary arrest is a serious event with low survival rates. In non-traumatic cardiac arrest, only about 20% of patients who arrest as an in-patient survive to hospital discharge, while the survival rate for out-of-hospital cardiac arrest is approximately 8%. The Resus Council BLS/AED Algorithm for 2015 recommends chest compressions at a rate of 100-120 per minute with a compression depth of 5-6 cm. The ratio of chest compressions to rescue breaths is 30:2.

      After a cardiac arrest, the goal of patient care is to minimize the impact of post cardiac arrest syndrome, which includes brain injury, myocardial dysfunction, the ischaemic/reperfusion response, and the underlying pathology that caused the arrest. The ABCDE approach is used for clinical assessment and general management. Intubation may be necessary if the airway cannot be maintained by simple measures or if it is immediately threatened. Controlled ventilation is aimed at maintaining oxygen saturation levels between 94-98% and normocarbia. Fluid status may be difficult to judge, but a target mean arterial pressure (MAP) between 65 and 100 mmHg is recommended. Inotropes may be administered to maintain blood pressure. Sedation should be adequate to gain control of ventilation, and short-acting sedating agents like propofol are preferred. Blood glucose levels should be maintained below 8 mmol/l. Pyrexia should be avoided, and there is some evidence for controlled mild hypothermia but no consensus on this.

      Post ROSC investigations may include a chest X-ray, ECG monitoring, serial potassium and lactate measurements, and other imaging modalities like ultrasonography, echocardiography, CTPA, and CT head, depending on availability and skills in the local department. Treatment should be directed towards the underlying cause, and PCI or thrombolysis may be considered for acute coronary syndrome or suspected pulmonary embolism, respectively.

      Patients who are comatose after ROSC without significant pre-arrest comorbidities should be transferred to the ICU for supportive care. Neurological outcome at 72 hours is the best prognostic indicator of outcome.

    • This question is part of the following fields:

      • Resus
      12.1
      Seconds
  • Question 17 - 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: Anteromedial femur

      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
      11.7
      Seconds
  • Question 18 - A 45-year-old man comes in with a history of a high temperature, loss...

    Incorrect

    • A 45-year-old man comes in with a history of a high temperature, loss of smell, a persistent cough, and increasing difficulty breathing. He underwent a COVID-19 test two days ago, which has returned positive.
      Which established scoring system can be utilized to forecast the risk of severe respiratory illness within 24 hours for patients admitted from the emergency department with COVID-19?

      Your Answer: CURB-65 Score

      Correct Answer: qCSI Score

      Explanation:

      The qCSI Score, also known as the Quick COVID-19 Severity Index, is a tool that can predict the risk of critical respiratory illness in patients who are admitted from the emergency department with COVID-19. This score takes into consideration three criteria: respiratory rate, pulse oximetry, and oxygen flow rate. By assessing these factors, the qCSI Score can provide an estimation of the 24-hour risk of severe respiratory complications in these patients.

      On the other hand, the qSOFA Score is a different tool that is used to identify high-risk patients for in-hospital mortality when there is a suspicion of infection, particularly in cases of sepsis. However, it is important to note that the qSOFA Score is not specifically designed for use in the setting of febrile neutropenia.

      Another scoring system, known as the CURB-65 Score, is utilized to estimate the mortality risk associated with community-acquired pneumonia. This score helps healthcare professionals determine whether a patient should receive inpatient or outpatient treatment based on their likelihood of experiencing adverse outcomes.

      Lastly, the SCAP Score is a scoring system that predicts the risk of adverse outcomes in patients with community-acquired pneumonia who present to the emergency department. By assessing various clinical factors, this score can provide valuable information to healthcare providers regarding the potential severity of the illness and the need for further intervention.

      In addition to these scores, there is also the MASCC Risk Index Score, which is specifically used in the context of cancer patients receiving supportive care. This score helps assess the risk of complications in this vulnerable population and aids in making informed decisions regarding their treatment and management.

    • This question is part of the following fields:

      • Respiratory
      10.7
      Seconds
  • Question 19 - You review a middle-aged man who has a non-operable brain tumor and is...

    Incorrect

    • You review a middle-aged man who has a non-operable brain tumor and is experiencing severe nausea. He has received prior radiotherapy and chemotherapy but is now solely under the care of the palliative team. During your review, he mentions that he also experiences vertigo and struggles to keep his food down due to the intensity of his nausea. His current medications only include basic pain relief.
      What is the MOST appropriate anti-emetic to prescribe for this patient?

      Your Answer: Domperidone

      Correct Answer: Cyclizine

      Explanation:

      All of the mentioned medications are antiemetics that can be used to treat nausea. However, cyclizine would be the most appropriate choice as it also possesses anti-histamine properties, which can help alleviate symptoms of vertigo. Ondansetron is a specific 5HT3 antagonist that is particularly effective for patients undergoing cytotoxic treatment. Domperidone acts on the chemoreceptor trigger zone and is also highly beneficial for patients receiving cytotoxic treatment. Metoclopramide directly affects the gastrointestinal tract and is a useful anti-emetic for individuals with gastro-duodenal, hepatic, and biliary diseases. Haloperidol may be considered in end-of-life care situations where other medications have not yielded successful results.

    • This question is part of the following fields:

      • Palliative & End Of Life Care
      13.5
      Seconds
  • Question 20 - A 32-year-old man is brought to the hospital with a known notifiable illness.
    What...

    Correct

    • A 32-year-old man is brought to the hospital with a known notifiable illness.
      What is the most probable diagnosis in this case?

      Your Answer: Haemolytic uraemic syndrome

      Explanation:

      Public Health England (PHE) has the primary goal of promptly identifying potential disease outbreaks and epidemics. While accuracy of diagnosis is not the main focus, clinical suspicion of a notifiable infection has been sufficient since 1968.

      Registered medical practitioners (RMPs) are legally obligated to inform the designated proper officer at their local council or local health protection team (HPT) about suspected cases of specific infectious diseases.

      The Health Protection (Notification) Regulations 2010 outline the diseases that RMPs must report to the proper officers at local authorities. These diseases include acute encephalitis, acute infectious hepatitis, acute meningitis, acute poliomyelitis, anthrax, botulism, brucellosis, cholera, COVID-19, diphtheria, enteric fever (typhoid or paratyphoid fever), food poisoning, haemolytic uraemic syndrome (HUS), infectious bloody diarrhoea, invasive group A streptococcal disease, Legionnaires’ disease, leprosy, malaria, measles, meningococcal septicaemia, mumps, plague, rabies, rubella, severe acute respiratory syndrome (SARS), scarlet fever, smallpox, tetanus, tuberculosis, typhus, viral haemorrhagic fever (VHF), whooping cough, and yellow fever.

    • This question is part of the following fields:

      • Infectious Diseases
      9.3
      Seconds
  • Question 21 - You review a middle-aged man on the Clinical Decision Unit (CDU) who has...

    Correct

    • You review a middle-aged man on the Clinical Decision Unit (CDU) who has presented following a car accident. He is accompanied by his close friend of many years, who is very concerned about him and his safety on the road. The friend is concerned as he has noticed that his friend has been forgetting important appointments and seems to be more absent-minded lately. You suspect that the patient may have cognitive impairment.
      Which of the following is also most likely to be present in the history?

      Your Answer: She becomes agitated when taken to new surroundings

      Explanation:

      Dementia is a collection of symptoms caused by a pathological process that leads to significant cognitive impairment, surpassing what is typically expected for a person’s age. The most prevalent form of dementia is Alzheimer’s disease.

      The symptoms of dementia are diverse and encompass various aspects. These include memory loss, particularly in the short-term. Additionally, individuals with dementia may experience fluctuations in mood, which are typically responsive to external stimuli and support. It is important to note that thoughts about death are infrequent in individuals with dementia.

      Furthermore, changes in personality may occur as a result of dementia. Individuals may struggle to find the right words when communicating and face difficulties in completing complex tasks. In later stages, urinary incontinence may become a concern, along with a loss of appetite and subsequent weight loss. Additionally, individuals with dementia may exhibit agitation when placed in unfamiliar settings.

      Overall, dementia is characterized by a range of symptoms that significantly impact cognitive functioning.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      18.8
      Seconds
  • Question 22 - A 35 year old male presents to the emergency department after twisting his...

    Correct

    • A 35 year old male presents to the emergency department after twisting his right ankle while playing basketball. He reports pain on the outer side of his ankle and foot, and experiences discomfort when putting weight on it.

      After conducting a physical examination, the healthcare provider decides to order ankle and foot X-rays based on the Ottawa foot & ankle rules. According to these guidelines, which of the following scenarios would warrant a foot X-ray?

      Your Answer: Tenderness over navicular

      Explanation:

      An X-ray of the foot is recommended when there is pain in the base of the fifth metatarsal or the navicular bone, as well as an inability to bear weight immediately after an injury or in the emergency department. The Ottawa ankle rules can also be used to determine if an X-ray is necessary for ankle injuries. These rules focus on two specific areas (the malleolar and midfoot zones) to determine if an X-ray of the ankle or foot is needed. More information on these rules can be found in the notes below.

      Further Reading:

      Ankle fractures are traumatic lower limb and joint injuries that involve the articulation between the tibia, fibula, and talus bones. The ankle joint allows for plantar and dorsiflexion of the foot. The key bony prominences of the ankle are called malleoli, with the medial and posterior malleolus being prominences of the distal tibia and the lateral malleolus being a prominence of the distal fibula. The distal fibula and tibia are joined together by the distal tibiofibular joint or syndesmosis, which is comprised of three key ligaments. An ankle X-ray series is often used to guide clinical decision making in patients with ankle injuries, using the Ottawa ankle rules to determine if an X-ray is necessary. Ankle fractures are commonly described by the anatomical fracture pattern seen on X-ray relative to the malleoli involved, such as isolated malleolus fractures, bimalleolar fractures, and trimalleolar fractures. The Weber classification is a commonly used system for distal fibula fractures, categorizing them as Weber A, B, or C based on the level and extent of the fracture.

    • This question is part of the following fields:

      • Trauma
      7.4
      Seconds
  • Question 23 - A 25-year-old woman with a previous history of depression is admitted to the...

    Correct

    • A 25-year-old woman with a previous history of depression is admitted to the emergency department following an overdose of amitriptyline tablets. The patient displays notable signs of toxicity, prompting the administration of intravenous sodium bicarbonate. What is the objective of this treatment?

      Your Answer: Serum pH 7.45 to 7.55

      Explanation:

      Sodium bicarbonate is used to treat severe TCA toxicity by reducing the risk of seizures and arrhythmia. The goal is to increase the serum pH to a range of 7.45 to 7.55 through alkalinisation.

      Further Reading:

      Tricyclic antidepressant (TCA) overdose is a common occurrence in emergency departments, with drugs like amitriptyline and dosulepin being particularly dangerous. TCAs work by inhibiting the reuptake of norepinephrine and serotonin in the central nervous system. In cases of toxicity, TCAs block various receptors, including alpha-adrenergic, histaminic, muscarinic, and serotonin receptors. This can lead to symptoms such as hypotension, altered mental state, signs of anticholinergic toxicity, and serotonin receptor effects.

      TCAs primarily cause cardiac toxicity by blocking sodium and potassium channels. This can result in a slowing of the action potential, prolongation of the QRS complex, and bradycardia. However, the blockade of muscarinic receptors also leads to tachycardia in TCA overdose. QT prolongation and Torsades de Pointes can occur due to potassium channel blockade. TCAs can also have a toxic effect on the myocardium, causing decreased cardiac contractility and hypotension.

      Early symptoms of TCA overdose are related to their anticholinergic properties and may include dry mouth, pyrexia, dilated pupils, agitation, sinus tachycardia, blurred vision, flushed skin, tremor, and confusion. Severe poisoning can lead to arrhythmias, seizures, metabolic acidosis, and coma. ECG changes commonly seen in TCA overdose include sinus tachycardia, widening of the QRS complex, prolongation of the QT interval, and an R/S ratio >0.7 in lead aVR.

      Management of TCA overdose involves ensuring a patent airway, administering activated charcoal if ingestion occurred within 1 hour and the airway is intact, and considering gastric lavage for life-threatening cases within 1 hour of ingestion. Serial ECGs and blood gas analysis are important for monitoring. Intravenous fluids and correction of hypoxia are the first-line therapies. IV sodium bicarbonate is used to treat haemodynamic instability caused by TCA overdose, and benzodiazepines are the treatment of choice for seizure control. Other treatments that may be considered include glucagon, magnesium sulfate, and intravenous lipid emulsion.

      There are certain things to avoid in TCA overdose, such as anti-arrhythmics like quinidine and flecainide, as they can prolonged depolarization.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      11.9
      Seconds
  • Question 24 - You assess a limping adolescent with hip discomfort. An X-ray is conducted, and...

    Correct

    • You assess a limping adolescent with hip discomfort. An X-ray is conducted, and a diagnosis of Slipped upper femoral epiphysis (SUFE) is confirmed.
      Which ONE statement about this condition is NOT true?

      Your Answer: It typically presents later in girls

      Explanation:

      Slipped upper femoral epiphysis (SUFE), also referred to as slipped capital femoral epiphysis, is a rare but significant hip disorder that primarily affects children. It occurs when the growth plate slips at the epiphysis, causing the head of the femur to shift from its normal position on the femoral neck. Specifically, the femoral epiphysis remains in the acetabulum while the metaphysis moves forward and externally rotates.

      SUFE typically presents later in boys, usually between the ages of 10 and 17, compared to girls who typically experience it between 8 and 15 years of age. Several risk factors contribute to its development, including being male, being overweight, having immature skeletal maturity, having a positive family history, being of Pacific Island or African origin, having hypothyroidism, growth hormone deficiency, or hypogonadism.

      Patients with SUFE commonly experience hip pain and a limp. In severe cases, a leg length discrepancy may be noticeable. While the condition may not be immediately apparent on an anteroposterior (AP) film, it is usually detectable on a frog-leg lateral film. A diagnostic sign is the failure of a line drawn up the lateral edge of the femoral neck (known as the line of Klein) to intersect the epiphysis during the acute stage, also known as Trethowan’s sign.

      Surgical pinning is the most common treatment for SUFE. In approximately 20% of cases, bilateral SUFE occurs, prompting some surgeons to recommend prophylactic pinning of the unaffected hip. If a significant deformity is present, osteotomies or even arthroplasty may be necessary.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      5.4
      Seconds
  • Question 25 - A 57-year-old man comes in with bothersome swelling in both ankles. This has...

    Incorrect

    • A 57-year-old man comes in with bothersome swelling in both ankles. This has developed since he began taking a new medication for high blood pressure a couple of weeks ago.
      Which medication is the MOST likely culprit for this side effect?

      Your Answer: Losartan

      Correct Answer: Amlodipine

      Explanation:

      Amlodipine is a medication that belongs to the class of calcium-channel blockers and is often prescribed for the management of high blood pressure. One of the most frequently observed side effects of calcium-channel blockers is the swelling of the ankles. Additionally, individuals taking these medications may also experience other common side effects such as nausea, flushing, dizziness, sleep disturbances, headaches, fatigue, abdominal pain, and palpitations.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      10.5
      Seconds
  • Question 26 - A 32-year-old woman was involved in a car accident where her car collided...

    Incorrect

    • A 32-year-old woman was involved in a car accident where her car collided with a tree at a high speed. She was not wearing a seatbelt and was thrown forward onto the steering wheel of her car. She has bruising over her anterior chest wall and is experiencing chest pain. A helical contrast-enhanced CT scan of the chest reveals a traumatic aortic injury.

      Where is her injury most likely to have occurred anatomically?

      Your Answer: Ascending aorta

      Correct Answer: Proximal descending aorta

      Explanation:

      Traumatic aortic rupture, also known as traumatic aortic disruption or transection, occurs when the aorta is torn or ruptured due to physical trauma. This condition often leads to sudden death because of severe bleeding. Motor vehicle accidents and falls from great heights are the most common causes of this injury.

      The patients with the highest chances of survival are those who have an incomplete tear near the ligamentum arteriosum of the proximal descending aorta, close to where the left subclavian artery branches off. The presence of an intact adventitial layer or contained mediastinal hematoma helps maintain continuity and prevents immediate bleeding and death. If promptly identified and treated, survivors of these injuries can recover. In cases where traumatic aortic rupture leads to sudden death, approximately 50% of patients have damage at the aortic isthmus, while around 15% have damage in either the ascending aorta or the aortic arch.

      Initial chest X-rays may show signs consistent with a traumatic aortic injury. However, false-positive and false-negative results can occur, and sometimes there may be no abnormalities visible on the X-ray. Some of the possible X-ray findings include a widened mediastinum, hazy left lung field, obliteration of the aortic knob, fractures of the 1st and 2nd ribs, deviation of the trachea to the right, presence of a pleural cap, elevation and rightward shift of the right mainstem bronchus, depression of the left mainstem bronchus, obliteration of the space between the pulmonary artery and aorta, and deviation of the esophagus or NG tube to the right.

      A helical contrast-enhanced CT scan of the chest is the preferred initial investigation for suspected blunt aortic injury. It has proven to be highly accurate, with close to 100% sensitivity and specificity. CT scanning should be performed liberally, as chest X-ray findings can be unreliable. However, hemodynamically unstable patients should not be placed in a CT scanner. If the CT results are inconclusive, aortography or trans-oesophageal echo can be performed for further evaluation.

      Immediate surgical intervention is necessary for these injuries. Endovascular repair is the most common method used and has excellent short-term outcomes. Open repair may also be performed depending on the circumstances. It is important to control heart rate and blood pressure during stabilization to reduce the risk of rupture. Pain should be managed with appropriate analgesic

    • This question is part of the following fields:

      • Trauma
      8.4
      Seconds
  • Question 27 - A 22-year-old arrives at the emergency department after ingesting a combination of pills...

    Correct

    • A 22-year-old arrives at the emergency department after ingesting a combination of pills 45 minutes ago following a heated dispute with their partner. The patient reports consuming approximately 30 tablets in total, consisting of four or five different types. These tablets were sourced from their grandparents medication, although the patient is uncertain about their specific names. They mention the possibility of one tablet being called bisoprolol. What is the recommended antidote for beta-blocker toxicity?

      Your Answer: Glucagon

      Explanation:

      Glucagon is the preferred initial treatment for beta-blocker poisoning when there are symptoms of slow heart rate and low blood pressure.

      Further Reading:

      Poisoning in the emergency department is often caused by accidental or intentional overdose of prescribed drugs. Supportive treatment is the primary approach for managing most poisonings. This includes ensuring a clear airway, proper ventilation, maintaining normal fluid levels, temperature, and blood sugar levels, correcting any abnormal blood chemistry, controlling seizures, and assessing and treating any injuries.

      In addition to supportive treatment, clinicians may need to consider strategies for decontamination, elimination, and administration of antidotes. Decontamination involves removing poisons from the skin or gastrointestinal tract. This can be done through rinsing the skin or using methods such as activated charcoal, gastric lavage, induced emesis, or whole bowel irrigation. However, induced emesis is no longer commonly used, while gastric lavage and whole bowel irrigation are rarely used.

      Elimination methods include urinary alkalinization, hemodialysis, and hemoperfusion. These techniques help remove toxins from the body.

      Activated charcoal is a commonly used method for decontamination. It works by binding toxins in the gastrointestinal tract, preventing their absorption. It is most effective if given within one hour of ingestion. However, it is contraindicated in patients with an insecure airway due to the risk of aspiration. Activated charcoal can be used for many drugs, but it is ineffective for certain poisonings, including pesticides (organophosphates), hydrocarbons, strong acids and alkalis, alcohols (ethanol, methanol, ethylene glycol), iron, lithium, and solvents.

      Antidotes are specific treatments for poisoning caused by certain drugs or toxins. For example, cyanide poisoning can be treated with dicobalt edetate, hydroxocobalamin, or sodium nitrite and sodium thiosulphate. Benzodiazepine poisoning can be treated with flumazanil, while opiate poisoning can be treated with naloxone. Other examples include protamine for heparin poisoning, vitamin K or fresh frozen plasma for warfarin poisoning, fomepizole or ethanol for methanol poisoning, and methylene blue for methemoglobinemia caused by benzocaine or nitrates.

      There are many other antidotes available for different types of poisoning, and resources such as TOXBASE and the National Poisons Information Service (NPIS) can provide valuable advice on managing poisonings.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      4.3
      Seconds
  • Question 28 - A 68 year old male presents to the emergency department with lower abdominal...

    Correct

    • A 68 year old male presents to the emergency department with lower abdominal pain and a strong urge to urinate but an inability to do so. Upon examination, the patient's bladder is easily palpable, leading to a diagnosis of acute urinary retention. What is the most probable underlying cause?

      Your Answer: Prostatic enlargement

      Explanation:

      The most frequent reason for sudden inability to urinate in males is an enlarged prostate.

      Further Reading:

      Urinary retention is the inability to completely or partially empty the bladder. It is commonly seen in elderly males with prostate enlargement and acute retention. Symptoms of acute urinary retention include the inability to void, inability to empty the bladder, overflow incontinence, and suprapubic discomfort. Chronic urinary retention, on the other hand, is typically painless but can lead to complications such as hydronephrosis and renal impairment.

      There are various causes of urinary retention, including anatomical factors such as urethral stricture, bladder neck contracture, and prostate enlargement. Functional causes can include neurogenic bladder, neurological diseases like multiple sclerosis and Parkinson’s, and spinal cord injury. Certain drugs can also contribute to urinary retention, such as anticholinergics, opioids, and tricyclic antidepressants. In female patients, specific causes like organ prolapse, pelvic mass, and gravid uterus should be considered.

      The pathophysiology of acute urinary retention can involve factors like increased resistance to flow, detrusor muscle dysfunction, bladder overdistension, and drugs that affect bladder tone. The primary management intervention for acute urinary retention is the insertion of a urinary catheter. If a catheter cannot be passed through the urethra, a suprapubic catheter can be inserted. Post-catheterization residual volume should be measured, and renal function should be assessed through U&Es and urine culture. Further evaluation and follow-up with a urologist are typically arranged, and additional tests like ultrasound may be performed if necessary. It is important to note that PSA testing is often deferred for at least two weeks after catheter insertion and female patients with retention should also be referred to urology for investigation.

    • This question is part of the following fields:

      • Urology
      7.5
      Seconds
  • Question 29 - A 35-year-old patient with a history of exhaustion and weariness has a complete...

    Incorrect

    • A 35-year-old patient with a history of exhaustion and weariness has a complete blood count scheduled. The complete blood count reveals that she has normocytic anemia.
      What is the most probable underlying diagnosis?

      Your Answer: Folate deficiency

      Correct Answer: Haemolysis

      Explanation:

      Anaemia can be categorized based on the size of red blood cells. Microcytic anaemia, characterized by a mean corpuscular volume (MCV) of less than 80 fl, can be caused by various factors such as iron deficiency, thalassaemia, anaemia of chronic disease (which can also be normocytic), sideroblastic anaemia (which can also be normocytic), lead poisoning, and aluminium toxicity (although this is now rare and mainly affects haemodialysis patients).

      On the other hand, normocytic anaemia, with an MCV ranging from 80 to 100 fl, can be attributed to conditions like haemolysis, acute haemorrhage, bone marrow failure, anaemia of chronic disease (which can also be microcytic), mixed iron and folate deficiency, pregnancy, chronic renal failure, and sickle-cell disease.

      Lastly, macrocytic anaemia, characterized by an MCV greater than 100 fl, can be caused by factors such as B12 deficiency, folate deficiency, hypothyroidism, reticulocytosis, liver disease, alcohol abuse, myeloproliferative disease, myelodysplastic disease, and certain drugs like methotrexate, hydroxyurea, and azathioprine.

      It is important to understand the different causes of anaemia based on red cell size as this knowledge can aid in the diagnosis and management of this condition.

    • This question is part of the following fields:

      • Haematology
      10.6
      Seconds
  • Question 30 - A 3-year-old child is brought in by his father complaining of itchy skin...

    Incorrect

    • A 3-year-old child is brought in by his father complaining of itchy skin on his arms. He has a history of allergies, and over the past few days, both of his arms have become covered in small red bumps. His father also reports that he has had a low-grade fever of 37.8°C. During the examination, you observe significant swelling of the lymph nodes in his neck. While speaking with his father, you notice a scabbing sore on the right side of his mouth.

      What is the SINGLE most likely diagnosis?

      Your Answer: Impetigo

      Correct Answer: Eczema herpeticum

      Explanation:

      Eczema herpeticum occurs when an individual with atopic eczema comes into contact with the herpes simplex virus. While some patients may only experience typical cold sores, others may develop a more extensive infection. This condition is often accompanied by systemic disturbance and can be quite painful. Administering antiviral treatment can help reduce the duration of the illness. In cases where the rash is widespread or there are concerns about eye complications, hospital admission may be necessary for intravenous antiviral therapy.

    • This question is part of the following fields:

      • Dermatology
      7.3
      Seconds
  • Question 31 - A 72 year old male comes to the emergency department complaining of central...

    Correct

    • A 72 year old male comes to the emergency department complaining of central chest pain. An ECG is performed to check for signs of ischemic changes. Which of the following results is most indicative of a non ST elevation myocardial infarction (NSTEMI)?

      Your Answer: Q wave in lead V2

      Explanation:

      Q waves in V2 and V3 are typically abnormal and indicate a pathological condition. Q waves are negative deflections that occur before an R wave. They can be either normal or abnormal. Small normal Q waves, which are less than 1mm deep, may be present in most leads. Deeper normal Q waves are commonly seen in lead III, as long as they are not present in the adjacent leads II and AVF. On the other hand, pathological Q waves are usually deeper and wider. In particular, Q waves should not be observed in V2 and V3. The specific criteria for identifying pathological Q waves are as follows: any Q wave in leads V2-V3 that is greater than 0.02s in duration or a QS complex in leads V2-V3; a Q wave that is greater than 0.03s in duration and deeper than 1mm, or a QS complex, in leads I, II, aVL, aVF, or V4-V6 in any two leads of a contiguous lead grouping; an R wave that is greater than 0.04s in duration in V1-V2 and has an R/S ratio greater than 1, along with a concordant positive T wave, in the absence of a conduction defect. In healthy individuals, the T-wave is normally inverted in aVR and inverted or flat in V1. T-wave inversion in III is also considered a normal variation. If there is ST elevation in lead V1, it would suggest a ST-elevation myocardial infarction (STEMI) rather than a non-ST-elevation myocardial infarction (NSTEMI).

      Further Reading:

      Acute Coronary Syndromes (ACS) is a term used to describe a group of conditions that involve the sudden reduction or blockage of blood flow to the heart. This can lead to a heart attack or unstable angina. ACS includes ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI), and unstable angina (UA).

      The development of ACS is usually seen in patients who already have underlying coronary heart disease. This disease is characterized by the buildup of fatty plaques in the walls of the coronary arteries, which can gradually narrow the arteries and reduce blood flow to the heart. This can cause chest pain, known as angina, during physical exertion. In some cases, the fatty plaques can rupture, leading to a complete blockage of the artery and a heart attack.

      There are both non modifiable and modifiable risk factors for ACS. non modifiable risk factors include increasing age, male gender, and family history. Modifiable risk factors include smoking, diabetes mellitus, hypertension, hypercholesterolemia, and obesity.

      The symptoms of ACS typically include chest pain, which is often described as a heavy or constricting sensation in the central or left side of the chest. The pain may also radiate to the jaw or left arm. Other symptoms can include shortness of breath, sweating, and nausea/vomiting. However, it’s important to note that some patients, especially diabetics or the elderly, may not experience chest pain.

      The diagnosis of ACS is typically made based on the patient’s history, electrocardiogram (ECG), and blood tests for cardiac enzymes, specifically troponin. The ECG can show changes consistent with a heart attack, such as ST segment elevation or depression, T wave inversion, or the presence of a new left bundle branch block. Elevated troponin levels confirm the diagnosis of a heart attack.

      The management of ACS depends on the specific condition and the patient’s risk factors. For STEMI, immediate coronary reperfusion therapy, either through primary percutaneous coronary intervention (PCI) or fibrinolysis, is recommended. In addition to aspirin, a second antiplatelet agent is usually given. For NSTEMI or unstable angina, the treatment approach may involve reperfusion therapy or medical management, depending on the patient’s risk of future cardiovascular events.

    • This question is part of the following fields:

      • Cardiology
      12.5
      Seconds
  • Question 32 - A 65 year old male is brought into the emergency department following a...

    Correct

    • A 65 year old male is brought into the emergency department following a fall with a suspected fracture of the hip. You gather a 20 gauge cannula for administration of IV fluids and pain relief. What would be considered the best approach for preparing the skin before cannulation?

      Your Answer: Skin cleaned for 30 seconds with 2% chlorhexidine gluconate in 70% alcohol

      Explanation:

      To minimize the risk of infection and promote proper healing, the best approach for preparing the skin would be to clean it for 30 seconds with 2% chlorhexidine gluconate in 70% alcohol. This solution has been shown to effectively kill bacteria and reduce the risk of infection. Other options such as povidone-iodine, 90% isopropyl alcohol, and 30% isopropyl alcohol may also have some antimicrobial properties, but they are not as effective as chlorhexidine gluconate.

      Further Reading:

      Peripheral venous cannulation is a procedure that should be performed following established guidelines to minimize the risk of infection, injury, extravasation, and early failure of the cannula. It is important to maintain good hand hygiene, use personal protective equipment, ensure sharps safety, and employ an aseptic non-touch technique during the procedure.

      According to the National Institute for Health and Care Excellence (NICE), the skin should be disinfected with a solution of 2% chlorhexidine gluconate and 70% alcohol before inserting the catheter. It is crucial to allow the disinfectant to completely dry before inserting the cannula.

      The flow rates of IV cannulas can vary depending on factors such as the gauge, color, type of fluid used, presence of a bio-connector, length of the cannula, and whether the fluid is drained under gravity or pumped under pressure. However, the following are typical flow rates for different gauge sizes: 14 gauge (orange) has a flow rate of 270 ml/minute, 16 gauge (grey) has a flow rate of 180 ml/minute, 18 gauge (green) has a flow rate of 90 ml/minute, 20 gauge (pink) has a flow rate of 60 ml/minute, and 22 gauge (blue) has a flow rate of 36 ml/minute. These flow rates are based on infusing 1000 ml of normal saline under ideal circumstances, but they may vary in practice.

    • This question is part of the following fields:

      • Resus
      5.1
      Seconds
  • Question 33 - A 42-year-old woman was involved in a car accident where her vehicle collided...

    Correct

    • A 42-year-old woman was involved in a car accident where her vehicle collided with a wall at a high speed. She was not wearing a seatbelt and was thrown forward onto the steering wheel. She is experiencing severe bruising on her anterior chest wall and is complaining of chest pain. A chest X-ray reveals a significantly widened mediastinum, tracheal deviation to the right, and fractures of the first and second ribs. Her vital signs are as follows: heart rate of 94, blood pressure of 128/73, and oxygen saturation of 99% on high flow oxygen.

      What is the SINGLE most likely diagnosis?

      Your Answer: Traumatic aortic rupture

      Explanation:

      Traumatic aortic rupture is a relatively common cause of sudden death following major trauma, especially high-speed road traffic accidents (RTAs). It is estimated that 15-20% of deaths from RTAs are due to this injury. If the aortic rupture is promptly recognized and treated, patients who survive the initial injury can fully recover.

      Surviving patients often have an incomplete laceration near the ligamentum arteriosum of the aorta. The continuity is maintained by either an intact adventitial layer or a contained mediastinal hematoma, which prevents immediate exsanguination and death.

      Detecting traumatic aortic rupture can be challenging as many patients do not exhibit specific symptoms, and other injuries may also be present, making the diagnosis unclear.

      Chest X-ray findings can aid in the diagnosis and include fractures of the 1st and 2nd ribs, a grossly widened mediastinum, a hazy left lung field, obliteration of the aortic knob, deviation of the trachea to the right, presence of a pleural cap, elevation and rightward shift of the right mainstem bronchus, depression of the left mainstem bronchus, obliteration of the space between the pulmonary artery and aorta, and deviation of the esophagus (or NG tube) to the right.

      Helical contrast-enhanced CT scanning is highly sensitive and specific for detecting aortic rupture, but it should only be performed on hemodynamically stable patients.

      Treatment options include primary repair or resection of the torn segment with replacement using an interposition graft. Endovascular repair is also now considered an acceptable alternative approach.

    • This question is part of the following fields:

      • Trauma
      7
      Seconds
  • Question 34 - A 21-year-old man comes in with a suddenly painful and swollen right testis...

    Correct

    • A 21-year-old man comes in with a suddenly painful and swollen right testis and intense abdominal pain. The pain started while he was asleep, and he has experienced multiple episodes of vomiting. His cremasteric reflex is not present, and the testis is too sensitive to touch.
      What is the SINGLE most probable diagnosis?

      Your Answer: Testicular torsion

      Explanation:

      Testicular torsion is the correct diagnosis in this case. When a patient presents with sudden, severe, and acute testicular pain, testicular torsion should be assumed until proven otherwise. There are several historical factors that support this diagnosis. These include the pain occurring suddenly, being accompanied by vomiting, happening during sleep (as half of torsions occur during sleep), a previous history of torsion in the other testis, previous episodes that have resolved recently, and a history of undescended testis.

      On examination, there are certain findings that further suggest testicular torsion. The testis may be positioned high in the scrotum and too tender to touch. The opposite testis may lie horizontally (known as Angell’s sign). Pain is not relieved by elevating the testis (negative Prehn’s sign), and the cremasteric reflex may be absent.

      It is important to recognize that testicular torsion is a surgical emergency that requires immediate assessment and intervention to restore blood flow. Irreversible damage can occur within six hours of onset, so prompt treatment is crucial in this patient.

    • This question is part of the following fields:

      • Urology
      5.1
      Seconds
  • Question 35 - You are overseeing the care of a 70-year-old male who suffered extensive burns...

    Correct

    • You are overseeing the care of a 70-year-old male who suffered extensive burns in a residential fire. You have initiated intravenous fluid replacement and inserted a urinary catheter to monitor fluid output. What is the desired urine output goal for patients with severe burns undergoing intravenous fluid therapy?

      Your Answer: 0.5 ml/kg/hr

      Explanation:

      When managing individuals with severe burns, the desired amount of urine output is 0.5 ml per kilogram of body weight per hour. For the average adult, this translates to a target urine output of 30-50 ml per hour.

      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:

      • Elderly Care / Frailty
      6.1
      Seconds
  • Question 36 - A 60-year-old woman has developed a thick cord of tissue on the sole...

    Incorrect

    • A 60-year-old woman has developed a thick cord of tissue on the sole of her left foot. She has developed a flexion deformity with her toes curled downwards. She is unable to straighten them. She has a history of epilepsy, which is well managed with her current anticonvulsant medication. A picture of her foot deformity is displayed below:
      What is the MOST LIKELY anticonvulsant that is responsible for this deformity?

      Your Answer: Carbamazepine

      Correct Answer: Phenytoin

      Explanation:

      This individual has developed Dupuytren’s contracture, which is a hand deformity characterized by a fixed flexion caused by palmar fibromatosis. The only anticonvulsant treatment believed to be connected to the development of Dupuytren’s contracture is phenytoin. Additionally, other conditions associated with its occurrence include liver cirrhosis, diabetes mellitus, alcoholism, and trauma.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      10.9
      Seconds
  • Question 37 - A 35-year-old individual arrives at the emergency department, complaining of feeling unwell for...

    Correct

    • 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: 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
      5.6
      Seconds
  • Question 38 - A 2-week-old baby comes in with vomiting, decreased weight, and an electrolyte imbalance....

    Correct

    • A 2-week-old baby comes in with vomiting, decreased weight, and an electrolyte imbalance. After being referred to the pediatricians, they are diagnosed with congenital adrenal hyperplasia (CAH).
      Which ONE statement is correct about this condition?

      Your Answer: Diagnosis can be made by finding elevated 17-hydroxyprogesterone levels

      Explanation:

      Congenital adrenal hyperplasia (CAH) is a group of inherited disorders that are caused by autosomal recessive genes. The majority of affected patients, over 90%, have a deficiency of the enzyme 21-hydroxylase. This enzyme is encoded by the 21-hydroxylase gene, which is located on chromosome 6p21 within the HLA histocompatibility complex. The second most common cause of CAH is a deficiency of the enzyme 11-beta-hydroxylase. The condition is rare, with an incidence of approximately 1 in 500 births in the UK. It is more prevalent in the offspring of consanguineous marriages.

      The deficiency of 21-hydroxylase leads to a deficiency of cortisol and/or aldosterone, as well as an excess of precursor steroids. As a result, there is an increased secretion of ACTH from the anterior pituitary, leading to adrenocortical hyperplasia.

      The severity of CAH varies depending on the degree of 21-hydroxylase deficiency. Female infants often exhibit ambiguous genitalia, such as clitoral hypertrophy and labial fusion. Male infants may have an enlarged scrotum and/or scrotal pigmentation. Hirsutism, or excessive hair growth, occurs in 10% of cases.

      Boys with CAH often experience a salt-losing adrenal crisis at around 1-3 weeks of age. This crisis is characterized by symptoms such as vomiting, weight loss, floppiness, and circulatory collapse.

      The diagnosis of CAH can be made by detecting markedly elevated levels of the metabolic precursor 17-hydroxyprogesterone. Neonatal screening is possible, primarily through the identification of persistently elevated 17-hydroxyprogesterone levels.

      In infants presenting with a salt-losing crisis, the following biochemical abnormalities are observed: hyponatremia (low sodium levels), hyperkalemia (high potassium levels), metabolic acidosis, and hypoglycemia.

      Boys experiencing a salt-losing crisis will require fluid resuscitation, intravenous dextrose, and intravenous hydrocortisone.

      Affected females will require corrective surgery for their external genitalia. However, they have an intact uterus and ovaries and are capable of having children.

      The long-term management of both sexes involves lifelong replacement of hydrocortisone (to suppress ACTH levels).

    • This question is part of the following fields:

      • Endocrinology
      11.9
      Seconds
  • Question 39 - A teenager presents following a fall. You observe that they are dressed very...

    Correct

    • A teenager presents following a fall. You observe that they are dressed very casually and have a strong smell of alcohol. Looking at their medical records, you notice that they have had multiple similar presentations in the past few months. You decide to administer a screening questionnaire to assess for potential alcohol dependency.
      According to the current NICE guidelines, which of the following screening tests is recommended for this purpose?

      Your Answer: AUDIT

      Explanation:

      The Alcohol Use Disorder Identification Test (AUDIT) has been developed by the World Health Organization as a straightforward screening tool to detect early signs of hazardous and harmful drinking, as well as mild dependence. This assessment is more comprehensive than the CAGE questionnaire and is currently recommended by NICE for identifying alcohol misuse.

      NICE, the National Institute for Health and Care Excellence, suggests the use of specific assessment tools to evaluate the nature and severity of alcohol misuse. These tools include AUDIT for identification and as a routine outcome measure, SADQ or LDQ for assessing the severity of dependence, CIWA-Ar for evaluating the severity of withdrawal symptoms, and APQ for understanding the nature and extent of problems resulting from alcohol misuse.

      For more information on this topic, you can refer to the NICE guidance titled Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence.

    • This question is part of the following fields:

      • Mental Health
      5.6
      Seconds
  • Question 40 - A 6-year-old boy is brought to the Emergency Department by his father. For...

    Incorrect

    • A 6-year-old boy is brought to the Emergency Department by his father. For the past two days, he has been experiencing severe diarrhea and vomiting. He has not urinated today. He typically weighs 25 kg. What is the child's hourly maintenance fluid requirement when he is in good health?

      Your Answer: 50 ml/hour

      Correct Answer: 65 ml/hour

      Explanation:

      The intravascular volume of an infant is approximately 80 ml/kg, while in older children it is around 70 ml/kg. Dehydration itself does not lead to death, but shock can occur when there is a loss of 20 ml/kg from the intravascular space. Clinical dehydration becomes evident only after total losses greater than 25 ml/kg.

      The table below summarizes the maintenance fluid requirements for well, normal children: Bodyweight:

      – First 10 kg: Daily fluid requirement of 100 ml/kg and hourly fluid requirement of 4 ml/kg.

      – Second 10 kg: Daily fluid requirement of 50 ml/kg and hourly fluid requirement of 2 ml/kg.

      – Subsequent kg: Daily fluid requirement of 20 ml/kg and hourly fluid requirement of 1 ml/kg.

      Based on this information, the hourly maintenance fluid requirements for this child can be calculated as follows:

      – First 10 kg: 4 ml/kg = 40 ml

      – Second 10 kg: 2 ml/kg = 20 ml

      – Subsequent kg: 1 ml/kg = 5 ml

      Therefore, the total hourly maintenance fluid requirement for this child is 65 ml.

    • This question is part of the following fields:

      • Neonatal Emergencies
      17.2
      Seconds
  • Question 41 - A 28-year-old woman is given an antibiotic while pregnant. As a result, the...

    Incorrect

    • A 28-year-old woman is given an antibiotic while pregnant. As a result, the baby is born prematurely with pale gray skin and cyanosis. The baby also has weak muscle tone, low blood pressure, and difficulty with feeding.

      Which of the following antibiotics is the most probable reason for these abnormalities?

      Your Answer: Tetracycline

      Correct Answer: Chloramphenicol

      Explanation:

      Grey baby syndrome is a rare but serious side effect that can occur in neonates, especially premature babies, as a result of the build-up of the antibiotic chloramphenicol. This condition is characterized by several symptoms, including ashen grey skin color, poor feeding, vomiting, cyanosis, hypotension, hypothermia, hypotonia, cardiovascular collapse, abdominal distension, and respiratory difficulties.

      During pregnancy, there are several drugs that can have adverse effects on the developing fetus. ACE inhibitors, such as ramipril, if given in the second and third trimesters, can lead to hypoperfusion, renal failure, and the oligohydramnios sequence. Aminoglycosides, like gentamicin, can cause ototoxicity and deafness. High doses of aspirin can result in first-trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses of aspirin (e.g., 75 mg) do not pose significant risks.

      Benzodiazepines, such as diazepam, when administered late in pregnancy, can cause respiratory depression and a neonatal withdrawal syndrome. Calcium-channel blockers, if given in the first trimester, may lead to phalangeal abnormalities, while their use in the second and third trimesters can result in fetal growth retardation. Carbamazepine can cause hemorrhagic disease of the newborn and neural tube defects.

      Chloramphenicol, as mentioned earlier, can cause grey baby syndrome. Corticosteroids, if given in the first trimester, may cause orofacial clefts. Danazol, if administered in the first trimester, can cause masculinization of the female fetuses genitals. Pregnant women should avoid handling crushed or broken tablets of finasteride, as it can be absorbed through the skin and affect male sex organ development.

      Haloperidol, if given in the first trimester, may cause limb malformations, while its use in the third trimester increases the risk of extrapyramidal symptoms in the neonate. Heparin can lead to maternal bleeding and thrombocytopenia. Isoniazid can cause maternal liver damage and neuropathy and seizures in the neonate. Isotretinoin carries a high risk of teratogenicity, including multiple congenital malformations, spontaneous abortion, and intellectual disability

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      12.1
      Seconds
  • Question 42 - 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:

      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)
      0
      Seconds
  • Question 43 - A 32 year old female presents to the emergency department with a painful...

    Incorrect

    • A 32 year old female presents to the emergency department with a painful burning skin rash. She has been feeling unwell for the past 2 to 3 days, experiencing a mild fever, headache, cough, and lethargy before the rash appeared. The patient recently started taking sulfasalazine one week ago for the treatment of ulcerative colitis.

      Upon examination, the patient exhibits dark centred macules and blisters primarily on the face, neck, and upper body. The conjunctiva of her eyes appear red, and there are ulcers on her tongue. What is the probable diagnosis?

      Your Answer:

      Correct Answer: Stevens-Johnson syndrome

      Explanation:

      The initial stage of SJS is characterized by a rash on the skin, specifically on the macular area. As the condition progresses, the rash transforms into blisters, known as bullae, which eventually detach from the skin.

      Further Reading:

      Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe mucocutaneous immune reactions characterized by blistering skin rash and erosions/ulceration of mucous membranes. SJS has less than 10% total body surface area (TBSA) involvement, SJS/TEN overlap has 10% to 30% TBSA involvement, and TEN has more than 30% TBSA involvement. The exact cause of SJS and TEN is not well understood, but it is believed to be a T-cell–mediated cytotoxic reaction triggered by drugs, infections, or vaccinations. Drugs are responsible for 50% of SJS cases and up to 95% of TEN cases, with antibiotics and anticonvulsants being the most common culprits.

      The clinical features of SJS and TEN include a prodrome of malaise, fever, headache, and cough, followed by the appearance of small pink-red macules with darker centers. These macules can coalesce and develop into larger blisters (bullae) that eventually break and cause the epidermis to slough off. Painful mucosal erosions can also occur, affecting various parts of the body and leading to complications such as renal failure, hepatitis, pneumonia, and urethritis. Nikolsky’s sign, which refers to the easy sloughing off of the epidermal layer with pressure, is a characteristic feature of SJS and TEN.

      The diagnosis of SJS, SJS/TEN overlap, and TEN can be confirmed through a skin biopsy, which typically shows desquamation at the epidermal-papillary dermal junction and the presence of necrotic epithelium and lymphocytes. Management of SJS and TEN involves supportive care, withdrawal of the causative agent if drug-related, monitoring for metabolic derangement and infection, maintaining the airway, treating respiratory function and pneumonia, fluid resuscitation, wound care, analgesia, and nutritional support. Ophthalmology consultation is also recommended. Intravenous immunoglobulin, ciclosporin, corticosteroids, and plasmapheresis may be used in treatment, but there is limited evidence supporting their effectiveness.

      The prognosis of SJS and TEN can be assessed using the SCORTEN score, which comprises of 7 clinical and biological parameters, with the predicted probability of mortality ranging from 3.2% to 90.0%.

    • This question is part of the following fields:

      • Dermatology
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  • Question 44 - A 5 year old girl is brought into the emergency room. Her mother...

    Incorrect

    • A 5 year old girl is brought into the emergency room. Her mother witnessed her putting something in her mouth. She believes it was a small object, but the girl swallowed it and within 5 minutes her face began to swell. You determine that she is experiencing anaphylaxis and start administering the necessary first-line medications. After stabilizing her condition, you decide to administer cetirizine. What is the appropriate dosage of cetirizine for this patient?

      Your Answer:

      Correct Answer: Cetirizine 2.5–5 mg

      Explanation:

      Antihistamines do not help in treating the life-threatening aspects of anaphylaxis and should not be used instead of adrenaline. However, they can be used to relieve symptoms such as skin reactions and itching once the patient’s condition has stabilized. The appropriate dose of cetirizine for children between the ages of 2 and 6 is 2.5-5 mg. It is important to note that chlorpheniramine is no longer recommended. The recommended doses of oral cetirizine for different age groups are as follows: less than 2 years – 250 micrograms/kg, 2-6 years – 2.5-5 mg, 6-11 years – 5-10 mg, 12 years and older – 10-20 mg.

      Further Reading:

      Anaphylaxis is a severe and life-threatening allergic reaction that affects the entire body. It is characterized by a rapid onset and can lead to difficulty breathing, low blood pressure, and loss of consciousness. In paediatrics, anaphylaxis is often caused by food allergies, with nuts being the most common trigger. Other causes include drugs and insect venom, such as from a wasp sting.

      When treating anaphylaxis, time is of the essence and there may not be enough time to look up medication doses. Adrenaline is the most important drug in managing anaphylaxis and should be administered as soon as possible. The recommended doses of adrenaline vary based on the age of the child. For children under 6 months, the dose is 150 micrograms, while for children between 6 months and 6 years, the dose remains the same. For children between 6 and 12 years, the dose is increased to 300 micrograms, and for adults and children over 12 years, the dose is 500 micrograms. Adrenaline can be repeated every 5 minutes if necessary.

      The preferred site for administering adrenaline is the anterolateral aspect of the middle third of the thigh. This ensures quick absorption and effectiveness of the medication. It is important to follow the Resuscitation Council guidelines for anaphylaxis management, as they have recently been updated.

      In some cases, it can be challenging to determine if a patient had a true episode of anaphylaxis. In such cases, serum tryptase levels may be measured, as they remain elevated for up to 12 hours following an acute episode of anaphylaxis. This can help confirm the diagnosis and guide further management.

      Overall, prompt recognition and administration of adrenaline are crucial in managing anaphylaxis in paediatrics. Following the recommended doses and guidelines can help ensure the best outcomes for patients experiencing this severe allergic reaction.

    • This question is part of the following fields:

      • Paediatric Emergencies
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  • Question 45 - A 70-year-old woman presents with a history of worsening right-sided hearing loss and...

    Incorrect

    • A 70-year-old woman presents with a history of worsening right-sided hearing loss and tinnitus. She is also experiencing occasional episodes of vertigo. On examination, she has significantly reduced hearing in the right ear and her Weber’s test lateralizes to the left.

      What is the SINGLE most appropriate investigation?

      Your Answer:

      Correct Answer: MRI internal auditory meatus

      Explanation:

      This patient is displaying symptoms and signs that are consistent with a vestibular schwannoma, which is also known as an acoustic neuroma. A vestibular schwannoma typically affects the 5th and 8th cranial nerves and is characterized by the following classic presentations: gradual deterioration of hearing in one ear, facial numbness and tingling, tinnitus, and vertigo. It is also possible for the patient to have a history of headaches, and in rare cases, the 7th, 9th, and 10th cranial nerves may be affected. It is recommended that this patient be referred to either an ENT specialist or a neurosurgeon for further assessment, including an MRI of the internal auditory meatus. The main treatment options for vestibular schwannoma include surgery, radiotherapy, and stereotactic radiosurgery.

    • This question is part of the following fields:

      • Ear, Nose & Throat
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  • Question 46 - A 35-year-old Caucasian woman comes in with itchy, hyperpigmented patches on her chest...

    Incorrect

    • A 35-year-old Caucasian woman comes in with itchy, hyperpigmented patches on her chest and back. She recently returned from her vacation in Ibiza and the areas have become much more noticeable since being exposed to the sun.
      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Pityriasis versicolor

      Explanation:

      Pityriasis versicolor, also known as tinea versicolor, is a common skin condition caused by an infection with the yeasts Malassezia furfur and Malassezia globosa. It typically presents as multiple patches of altered pigmentation, primarily on the trunk. In individuals with fair skin, these patches are usually darker in color, while in those with darker skin or a tan, they may appear lighter (known as pityriasis versicolor alba). It is not uncommon for the rash to cause itching.

      The recommended treatment for pityriasis versicolor involves the use of antifungal agents. One particularly effective option is ketoconazole shampoo, which is sold under the brand name Nizoral. To use this shampoo, it should be applied to the affected areas and left on for approximately five minutes before being rinsed off. This process should be repeated daily for a total of five days.

    • This question is part of the following fields:

      • Dermatology
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  • Question 47 - 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:

      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
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  • Question 48 - A 35-year-old woman comes in with sharp pain during bowel movements. The pain...

    Incorrect

    • A 35-year-old woman comes in with sharp pain during bowel movements. The pain usually continues for an additional 30-60 minutes afterward. She has also observed spots of bright red blood on the toilet paper when wiping. She has been experiencing constipation for the past few weeks.

      What is the MOST suitable initial treatment option for this situation?

      Your Answer:

      Correct Answer: Topical diltiazem

      Explanation:

      An anal fissure is a tear in the wall of the anal mucosa that exposes the circular muscle layer. The majority of these tears occur in the posterior midline, and they are often caused by the passage of a large, hard stool after a period of constipation. If multiple fissures are present, it may indicate an underlying condition such as Crohn’s disease or tuberculosis.

      Both men and women are equally affected by anal fissures, and they are most commonly seen in individuals in their thirties. The typical symptoms of an anal fissure include intense, sharp pain during bowel movements, which can last for up to an hour after passing stool. Additionally, there may be spots of bright red blood on the toilet paper when wiping, and a history of constipation.

      The initial management approach for an anal fissure involves non-operative measures such as using stool softeners and bulking agents. To alleviate the intense anal pain, analgesics and topical local anesthetics may be prescribed. According to a recent meta-analysis, first-line therapy should involve the use of topical GTN or diltiazem, with botulinum toxin being used as a rescue treatment if necessary (Modern perspectives in the treatment of chronic anal fissures. Ann R Coll Surg Engl. 2007 Jul;89(5):472-8.)

      Sphincterotomy, a surgical procedure, should be reserved for cases where the fissure does not heal with conservative measures. It has a success rate of 90%.

    • This question is part of the following fields:

      • Surgical Emergencies
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  • Question 49 - A 32 year old woman arrives at the emergency department complaining of abdominal...

    Incorrect

    • A 32 year old woman arrives at the emergency department complaining of abdominal pain, fever, and yellowing of her skin and eyes. Upon examination, it is evident that she is clinically jaundiced. The patient has a history of intravenous drug use. You suspect she may have acute hepatitis B infection. Which of the following serology results would best support this diagnosis?

      Your Answer:

      Correct Answer: HBsAg positive and anti-HBc IgM positive

      Explanation:

      The presence of serum HBsAg for more than 6 months indicates chronic HBV infection. HBeAg can be detected in the serum during the early stages of acute infection and some chronic infections. Higher levels of virus replication are usually associated with the presence of HBeAg, making individuals with chronic HBV more infectious. If HBeAg is cleared, anti-HBe is typically detected, indicating lower infectivity. The presence of anti-HBe, along with a decline in HBV-DNA, suggests control of viral replication and the likelihood of resolving acute hepatitis B. The presence of anti-HBc indicates current or past HBV infection, appearing at the onset of symptoms in acute infection and persisting for life. However, it may be absent in the early stages of acute infection. Anti-HBc IgM indicates recent HBV infection within the last six months and can help differentiate between acute and chronic infection. Over time, it is gradually replaced by IgG anti-HBc. IgG anti-HBc generally persists for life and indicates past infection. Anti-HBs indicates recovery from and immunity to HBV. If anti-HBs is present without anti-HBc, it suggests immunization. The quantification of anti-HBs is used to measure the response to vaccination.

      Further Reading:

      Hepatitis B is a viral infection that is transmitted through exposure to infected blood or body fluids. It can also be passed from mother to child during childbirth. The incubation period for hepatitis B is typically 6-20 weeks. Common symptoms of hepatitis B include fever, jaundice, and elevated liver transaminases.

      Complications of hepatitis B infection can include chronic hepatitis, which occurs in 5-10% of cases, fulminant liver failure, hepatocellular carcinoma, glomerulonephritis, polyarteritis nodosa, and cryoglobulinemia.

      Immunization against hepatitis B is recommended for various at-risk groups, including healthcare workers, intravenous drug users, sex workers, close family contacts of infected individuals, and those with chronic liver disease or kidney disease. The vaccine contains HBsAg adsorbed onto an aluminum hydroxide adjuvant and is prepared using recombinant DNA technology. Most vaccination schedules involve three doses of the vaccine, with a booster recommended after 5 years.

      Around 10-15% of adults may not respond adequately to the vaccine. Risk factors for poor response include age over 40, obesity, smoking, alcohol excess, and immunosuppression. Testing for anti-HBs levels is recommended for healthcare workers and patients with chronic kidney disease. Interpretation of anti-HBs levels can help determine the need for further vaccination or testing for infection.

      In terms of serology, the presence of HBsAg indicates acute disease if present for 1-6 months, and chronic disease if present for more than 6 months. Anti-HBs indicates immunity, either through exposure or immunization. Anti-HBc indicates previous or current infection, with IgM anti-HBc appearing during acute or recent infection and IgG anti-HBc persisting. HbeAg is a marker of infectivity.

      Management of hepatitis B involves notifying the Health Protection Unit for surveillance and contact tracing. Patients should be advised to avoid alcohol and take precautions to minimize transmission to partners and contacts. Referral to a gastroenterologist or hepatologist is recommended for all patients. Symptoms such as pain, nausea, and itch can be managed with appropriate drug treatment. Pegylated interferon-alpha and other antiviral medications like tenofovir and entecavir may be used to suppress viral replication in chronic carriers.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 50 - 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:

      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
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  • Question 51 - A 42-year-old woman comes in with a headache that feels like she has...

    Incorrect

    • A 42-year-old woman comes in with a headache that feels like she has been punched in the head. The headache throbs towards the back of the head and is accompanied by nausea. A CT scan of the head is performed, and it confirms a diagnosis of subarachnoid hemorrhage.
      In which of the following areas will blood have accumulated?

      Your Answer:

      Correct Answer: Between the arachnoid mater and pia mater

      Explanation:

      The meninges refer to the protective tissue layers that surround the brain and spinal cord. These layers, along with the cerebrospinal fluid (CSF), work together to safeguard the central nervous system structures from physical harm and provide support for the blood vessels in the brain and skull.

      The meninges consist of three distinct layers: the outermost layer called the dura mater, the middle layer known as the arachnoid mater, and the innermost layer called the pia mater.

      There are three types of hemorrhage that involve the meninges. The first is extradural (or epidural) hemorrhage, which occurs when blood accumulates between the dura mater and the skull. The second is subdural hemorrhage, where blood gathers between the dura mater and the arachnoid mater. Lastly, subarachnoid hemorrhage happens when blood collects in the subarachnoid space, which is the area between the arachnoid mater and the pia mater.

    • This question is part of the following fields:

      • Neurology
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  • Question 52 - A 21 year old female is brought to the emergency department by her...

    Incorrect

    • A 21 year old female is brought to the emergency department by her boyfriend as he is concerned the patient has become drowsy after intermittent vomiting throughout the day. The boyfriend informs you that the patient is a type 1 diabetic. After evaluation, the patient is diagnosed with diabetic ketoacidosis and started on fluids and an insulin infusion. Due to a lack of available beds, the patient is transferred to the A&E observation ward. Several hours later, you are asked about discontinuing the insulin infusion. What criteria must be met before stopping the insulin infusion?

      Your Answer:

      Correct Answer: Ketones less than 0.3 mmol/l and venous pH over 7.3

      Explanation:

      In the treatment of diabetic ketoacidosis (DKA), it is important to continue the infusion of insulin until certain criteria are met. These criteria include ketone levels being less than 0.3 mmol/L and the pH of the blood being above 7.3 or the bicarbonate levels being above 18 mmol/L. Additionally, the patient should feel comfortable enough to eat at this point. It is crucial not to stop the intravenous insulin infusion until at least 30 minutes after administering subcutaneous short-acting insulin.

      Further Reading:

      Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs due to a lack of insulin in the body. It is most commonly seen in individuals with type 1 diabetes but can also occur in type 2 diabetes. DKA is characterized by hyperglycemia, acidosis, and ketonaemia.

      The pathophysiology of DKA involves insulin deficiency, which leads to increased glucose production and decreased glucose uptake by cells. This results in hyperglycemia and osmotic diuresis, leading to dehydration. Insulin deficiency also leads to increased lipolysis and the production of ketone bodies, which are acidic. The body attempts to buffer the pH change through metabolic and respiratory compensation, resulting in metabolic acidosis.

      DKA can be precipitated by factors such as infection, physiological stress, non-compliance with insulin therapy, acute medical conditions, and certain medications. The clinical features of DKA include polydipsia, polyuria, signs of dehydration, ketotic breath smell, tachypnea, confusion, headache, nausea, vomiting, lethargy, and abdominal pain.

      The diagnosis of DKA is based on the presence of ketonaemia or ketonuria, blood glucose levels above 11 mmol/L or known diabetes mellitus, and a blood pH below 7.3 or bicarbonate levels below 15 mmol/L. Initial investigations include blood gas analysis, urine dipstick for glucose and ketones, blood glucose measurement, and electrolyte levels.

      Management of DKA involves fluid replacement, electrolyte correction, insulin therapy, and treatment of any underlying cause. Fluid replacement is typically done with isotonic saline, and potassium may need to be added depending on the patient’s levels. Insulin therapy is initiated with an intravenous infusion, and the rate is adjusted based on blood glucose levels. Monitoring of blood glucose, ketones, bicarbonate, and electrolytes is essential, and the insulin infusion is discontinued once ketones are below 0.3 mmol/L, pH is above 7.3, and bicarbonate is above 18 mmol/L.

      Complications of DKA and its treatment include gastric stasis, thromboembolism, electrolyte disturbances, cerebral edema, hypoglycemia, acute respiratory distress syndrome, and acute kidney injury. Prompt medical intervention is crucial in managing DKA to prevent potentially fatal outcomes.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 53 - A 72 year old male presents to the emergency department after a fall...

    Incorrect

    • A 72 year old male presents to the emergency department after a fall on his outstretched arm. X-ray results confirm a dislocated shoulder. Your consultant recommends reducing it under sedation. What are the four essential elements for successful procedural sedation?

      Your Answer:

      Correct Answer: Analgesia, anxiolysis, sedation and amnesia

      Explanation:

      The four essential elements for effective procedural sedation are analgesia, anxiolysis, sedation, and amnesia. According to the Royal College of Emergency Medicine (RCEM), it is important to prioritize pain management before sedation, using appropriate analgesics based on the patient’s pain level. Non-pharmacological methods should be considered to reduce anxiety, such as creating a comfortable environment and involving supportive family members. The level of sedation required should be determined in advance, with most procedures in the emergency department requiring moderate to deep sedation. Lastly, providing a degree of amnesia will help minimize any unpleasant memories associated with the procedure.

      Further Reading:

      Procedural sedation is commonly used by emergency department (ED) doctors to minimize pain and discomfort during procedures that may be painful or distressing for patients. Effective procedural sedation requires the administration of analgesia, anxiolysis, sedation, and amnesia. This is typically achieved through the use of a combination of short-acting analgesics and sedatives.

      There are different levels of sedation, ranging from minimal sedation (anxiolysis) to general anesthesia. It is important for clinicians to understand the level of sedation being used and to be able to manage any unintended deeper levels of sedation that may occur. Deeper levels of sedation are similar to general anesthesia and require the same level of care and monitoring.

      Various drugs can be used for procedural sedation, including propofol, midazolam, ketamine, and fentanyl. Each of these drugs has its own mechanism of action and side effects. Propofol is commonly used for sedation, amnesia, and induction and maintenance of general anesthesia. Midazolam is a benzodiazepine that enhances the effect of GABA on the GABA A receptors. Ketamine is an NMDA receptor antagonist and is used for dissociative sedation. Fentanyl is a highly potent opioid used for analgesia and sedation.

      The doses of these drugs for procedural sedation in the ED vary depending on the drug and the route of administration. It is important for clinicians to be familiar with the appropriate doses and onset and peak effect times for each drug.

      Safe sedation requires certain requirements, including appropriate staffing levels, competencies of the sedating practitioner, location and facilities, and monitoring. The level of sedation being used determines the specific requirements for safe sedation.

      After the procedure, patients should be monitored until they meet the criteria for safe discharge. This includes returning to their baseline level of consciousness, having vital signs within normal limits, and not experiencing compromised respiratory status. Pain and discomfort should also be addressed before discharge.

    • This question is part of the following fields:

      • Basic Anaesthetics
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  • Question 54 - A 40-year-old woman who is currently experiencing a high level of stress comes...

    Incorrect

    • A 40-year-old woman who is currently experiencing a high level of stress comes in with abdominal pain. The pain intensifies at night but subsides when she gets up to have a glass of milk. The pain has gotten worse over the past few days, and she has had two instances of vomiting blood this morning.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Duodenal ulcer

      Explanation:

      Peptic ulcer disease is a fairly common condition that can affect either the stomach or the duodenum. However, the duodenum is more commonly affected, and in these cases, it is caused by a break in the mucosal lining of the duodenum.

      This condition is more prevalent in men and is most commonly seen in individuals between the ages of 20 and 60. In fact, over 95% of patients with duodenal ulcers are found to be infected with H. pylori. Additionally, chronic usage of nonsteroidal anti-inflammatory drugs (NSAIDs) is often associated with the development of duodenal ulcers.

      When it comes to the location of duodenal ulcers, they are most likely to occur in the superior (first) part of the duodenum, which is positioned in front of the body of the L1 vertebra.

      The typical clinical features of duodenal ulcers include experiencing epigastric pain that radiates to the back, with the pain often worsening at night. This pain typically occurs 2-3 hours after eating and is relieved by consuming food and drinking milk. It can also be triggered by skipping meals or experiencing stress.

      Possible complications that can arise from duodenal ulcers include perforation, which can lead to peritonitis, as well as gastrointestinal hemorrhage. Gastrointestinal hemorrhage can manifest as haematemesis (vomiting blood), melaena (black, tarry stools), or occult bleeding. Strictures causing obstruction can also occur as a result of duodenal ulcers.

      In cases where gastrointestinal hemorrhage occurs as a result of duodenal ulceration, it is usually due to erosion of the gastroduodenal artery.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
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  • Question 55 - A 57 year old type 2 diabetic presents to the emergency department with...

    Incorrect

    • A 57 year old type 2 diabetic presents to the emergency department with redness on his foot. Upon examination, a foot ulcer measuring 1 cm in diameter is observed, exposing the superficial subcutaneous tissues. There is approximately 1 cm of erythema surrounding the ulcer and some pus at the base. The patient is not running a fever and appears to be in good overall health. It is determined that antibiotics should be initiated. The patient has no known allergies to medications. Which antibiotic would be the most suitable option?

      Your Answer:

      Correct Answer: Flucloxacillin 500 mg four times a day for 7 days

      Explanation:

      When treating diabetic foot ulcers that are infected, the severity of the ulcer is used to determine the appropriate antimicrobial therapy. In the case of a mild foot infection (PEDIS 2 grade), the first-line treatment is typically flucloxacillin. Based on the information provided, there is no indication that pseudomonas or MRSA should be suspected. For mild infections, it is reasonable to prescribe flucloxacillin at a dosage of 500 mg-1g four times a day for a duration of 7 days. It is important to reassess the patient at the end of the treatment course.

      Further Reading:

      Diabetic foot is a complication that can occur in individuals with diabetes due to long-standing high blood sugar levels. This leads to a process called glycation or glycosylation, where glucose binds to proteins and lipids in the body. Abnormal protein glycation can cause cellular dysfunction and various complications.

      One of the main problems in diabetic foot is peripheral vascular disease and peripheral neuropathy. These conditions can result in significant foot issues, as trauma to the feet may go unnoticed and untreated. Vascular disease also impairs wound healing and increases the risk of developing ulcers.

      Clinical features of diabetic foot include reduced sensation, especially to vibration, non-dermatomal sensory loss, foot deformities such as pes cavus and claw toes, and weak or absent foot pulses. It is important for diabetic patients to have their feet assessed regularly, at least annually, to identify any potential problems. Additional foot assessments should also be conducted during hospital admissions.

      During a diabetic foot assessment, the healthcare provider should remove shoes, socks, and any bandages or dressings to examine both feet. They should assess for neuropathy using a 10 g monofilament to test foot sensation and check for limb ischemia by examining pulses and performing ankle brachial pressure index (ABPI) measurements. Any abnormal tissue, such as ulcers, calluses, infections, inflammation, deformities, or gangrene, should be documented. The risk of Charcot arthropathy should also be assessed.

      The severity of foot ulcers in diabetic patients can be documented using standardized systems such as SINBAD or the University of Texas classification. The presence and severity of diabetic foot infection can be determined based on criteria such as local swelling, induration, erythema, tenderness, pain, warmth, and purulent discharge.

      Management of foot ulcers involves offloading, control of foot infection, control of ischemia, wound debridement, and appropriate wound dressings. Antibiotics may be necessary depending on the severity of the infection. Diabetic patients with foot ulcers should undergo initial investigations including blood tests, wound swabs, and imaging to assess for possible osteomyelitis.

      Charcot foot is a serious complication of diabetic peripheral neuropathy that results in progressive destructive arthropathy and foot deformity. Signs of Charcot foot include redness, swelling, warm skin, pain, and deformity. The hallmark deformity is midfoot collapse, known as the rocker-bottom foot.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 56 - You review a 72-year-old woman with a diagnosis of lung cancer. You can...

    Incorrect

    • You review a 72-year-old woman with a diagnosis of lung cancer. You can see from her notes that she has an advanced decision in place.

      Which SINGLE statement is true regarding an advanced decision?

      Your Answer:

      Correct Answer: It can be used by Jehovah’s witnesses to refuse blood transfusions

      Explanation:

      An advance decision, also known as an advance directive in Scotland, is a statement made by a patient expressing their desire to refuse certain types of medical treatment or care in the event that they become unable to make or communicate decisions for themselves. These statements serve as a means of effectively communicating the patient’s wishes to healthcare professionals and family members, helping to avoid any confusion that may arise. If a patient reaches a point where they are no longer capable of making informed decisions about their care, an advance decision can provide clarity and guidance.

      An advance decision can typically be utilized in the following situations: making decisions regarding CPR, determining the use of IV fluids and parenteral nutrition, deciding on specific procedures, and addressing the use of blood products for Jehovah’s Witnesses. However, it is important to note that advance decisions have their limitations and cannot be used to grant a relative lasting power of attorney, appoint a spokesperson to make decisions on the patient’s behalf, request a specific medical treatment, advocate for something illegal (such as assisted suicide), refuse treatment for a mental health condition, or authorize treatments that are not in the patient’s best interests.

      A doctor is legally obligated to adhere to an advance decision unless certain circumstances arise. These circumstances include changes that invalidate the decision, advances or changes in treatment that alter the circumstances, ambiguity in the wording of the decision, or if the decision is unsigned or its authenticity is in doubt. If there are any doubts about the validity of an advance decision, it is advisable to seek legal advice. Unfortunately, there have been instances where advance decisions have been forged or signed under duress, and any suspicions of this nature should be raised.

      It is important to note that there is no specific time period for which an advance decision remains valid.

    • This question is part of the following fields:

      • Palliative & End Of Life Care
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  • Question 57 - A trauma patient has arrived at the emergency department for evaluation. There is...

    Incorrect

    • A trauma patient has arrived at the emergency department for evaluation. There is worry about a potential cervical spine injury. What criteria would classify the patient as high risk for cervical spine injury?

      Your Answer:

      Correct Answer: Age ≥ 65

      Explanation:

      When assessing for cervical spine injury, it is recommended to use the Canadian C-spine rules. These rules help determine the risk level for a potential injury. High-risk factors include being over the age of 65, experiencing a dangerous mechanism of injury (such as a fall from a height or a high-speed motor vehicle collision), or having paraesthesia in the upper or lower limbs. Low-risk factors include being involved in a minor rear-end motor vehicle collision, being comfortable in a sitting position, being ambulatory since the injury, having no midline cervical spine tenderness, or experiencing a delayed onset of neck pain. If a person is unable to actively rotate their neck 45 degrees to the left and right, their risk level is considered low. If they have one of the low-risk factors and can actively rotate their neck, their risk level remains low.

      If a high-risk factor is identified or if a low-risk factor is identified and the person is unable to actively rotate their neck, full in-line spinal immobilization should be maintained and imaging should be requested. Additionally, if a patient has risk factors for thoracic or lumbar spine injury, imaging should be requested. However, if a patient has low-risk factors for cervical spine injury, is pain-free, and can actively rotate their neck, full in-line spinal immobilization and imaging are not necessary.

      NICE recommends CT as the primary imaging modality for cervical spine injury in adults aged 16 and older, while MRI is recommended as the primary imaging modality for children under 16.

      Different mechanisms of spinal trauma can cause injury to the spine in predictable ways. The majority of cervical spine injuries are caused by flexion combined with rotation. Hyperflexion can result in compression of the anterior aspects of the vertebral bodies, stretching and tearing of the posterior ligament complex, chance fractures (also known as seatbelt fractures), flexion teardrop fractures, and odontoid peg fractures. Flexion and rotation can lead to disruption of the posterior ligament complex and posterior column, fractures of facet joints, lamina, transverse processes, and vertebral bodies, and avulsion of spinous processes. Hyperextension can cause injury to the anterior column, anterior fractures of the vertebral body, and potential retropulsion of bony fragments or discs into the spinal canal. Rotation can result in injury to the posterior ligament complex and facet joint dislocation.

    • This question is part of the following fields:

      • Trauma
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  • Question 58 - Your consultant requests you to arrange a teaching session on secondary causes of...

    Incorrect

    • Your consultant requests you to arrange a teaching session on secondary causes of hypertension. Which of the subsequent electrolyte abnormalities would be in line with a diagnosis of Conn's syndrome?

      Your Answer:

      Correct Answer: Hypokalaemia and hypernatraemia

      Explanation:

      Patients with primary hyperaldosteronism typically present with hypertension and hypokalemia. This is due to the fact that aldosterone encourages the reabsorption of sodium and the excretion of potassium, leading to an imbalance in these electrolytes. Additionally, hypernatremia, or high levels of sodium in the blood, is often observed in these patients.

      Further Reading:

      Hyperaldosteronism is a condition characterized by excessive production of aldosterone by the adrenal glands. It can be classified into primary and secondary hyperaldosteronism. Primary hyperaldosteronism, also known as Conn’s syndrome, is typically caused by adrenal hyperplasia or adrenal tumors. Secondary hyperaldosteronism, on the other hand, is a result of high renin levels in response to reduced blood flow across the juxtaglomerular apparatus.

      Aldosterone is the main mineralocorticoid steroid hormone produced by the adrenal cortex. It acts on the distal renal tubule and collecting duct of the nephron, promoting the reabsorption of sodium ions and water while secreting potassium ions.

      The causes of hyperaldosteronism vary depending on whether it is primary or secondary. Primary hyperaldosteronism can be caused by adrenal adenoma, adrenal hyperplasia, adrenal carcinoma, or familial hyperaldosteronism. Secondary hyperaldosteronism can be caused by renal artery stenosis, reninoma, renal tubular acidosis, nutcracker syndrome, ectopic tumors, massive ascites, left ventricular failure, or cor pulmonale.

      Clinical features of hyperaldosteronism include hypertension, hypokalemia, metabolic alkalosis, hypernatremia, polyuria, polydipsia, headaches, lethargy, muscle weakness and spasms, and numbness. It is estimated that hyperaldosteronism is present in 5-10% of patients with hypertension, and hypertension in primary hyperaldosteronism is often resistant to drug treatment.

      Diagnosis of hyperaldosteronism involves various investigations, including U&Es to assess electrolyte disturbances, aldosterone-to-renin plasma ratio (ARR) as the gold standard diagnostic test, ECG to detect arrhythmia, CT/MRI scans to locate adenoma, fludrocortisone suppression test or oral salt testing to confirm primary hyperaldosteronism, genetic testing to identify familial hyperaldosteronism, and adrenal venous sampling to determine lateralization prior to surgery.

      Treatment of primary hyperaldosteronism typically involves surgical adrenalectomy for patients with unilateral primary aldosteronism. Diet modification with sodium restriction and potassium supplementation may also be recommended.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 59 - A 35-year-old Caucasian woman comes in with itchy, hyperpigmented patches on her chest...

    Incorrect

    • A 35-year-old Caucasian woman comes in with itchy, hyperpigmented patches on her chest and back. She recently returned from her vacation in Ibiza and the areas have become more noticeable after being exposed to the sun. Which organism is commonly associated with this condition?

      Your Answer:

      Correct Answer: Malassezia furfur

      Explanation:

      Pityriasis versicolor, also known as tinea versicolor, is a common skin condition caused by an infection with the yeasts Malassezia furfur and Malassezia globosa. It typically presents as multiple patches of altered pigmentation, primarily on the trunk. In individuals with fair skin, these patches are usually darker in color, while in those with darker skin or a tan, they may appear lighter (known as pityriasis versicolor alba). It is not uncommon for the rash to cause itching.

      The recommended treatment for pityriasis versicolor involves the use of antifungal agents. One particularly effective option is ketoconazole shampoo, which is sold under the brand name Nizoral. To use this shampoo, it should be applied to the affected areas and left on for approximately five minutes before being rinsed off. This process should be repeated daily for a total of five days.

    • This question is part of the following fields:

      • Dermatology
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  • Question 60 - You have a debrief session with your mentor after a case involving a...

    Incorrect

    • You have a debrief session with your mentor after a case involving a patient who experienced systemic toxicity from local anesthesia. Towards the end of the conversation, your mentor emphasizes the importance of reporting such episodes. In the UK, which of the following organizations should be notified about incidents of local anesthetic systemic toxicity?

      Your Answer:

      Correct Answer: National Patient Safety Agency

      Explanation:

      Instances of local anaesthetic systemic toxicity (LAST) should be promptly reported to the National Patient Safety Agency (NPSA). Additionally, it is advisable to report any adverse drug reactions to the Medicines and Healthcare products Regulatory Agency (MHRA) through their yellow card scheme. Please refer to the follow-up section in the notes for further details.

      Further Reading:

      Local anaesthetics, such as lidocaine, bupivacaine, and prilocaine, are commonly used in the emergency department for topical or local infiltration to establish a field block. Lidocaine is often the first choice for field block prior to central line insertion. These anaesthetics work by blocking sodium channels, preventing the propagation of action potentials.

      However, local anaesthetics can enter the systemic circulation and cause toxic side effects if administered in high doses. Clinicians must be aware of the signs and symptoms of local anaesthetic systemic toxicity (LAST) and know how to respond. Early signs of LAST include numbness around the mouth or tongue, metallic taste, dizziness, visual and auditory disturbances, disorientation, and drowsiness. If not addressed, LAST can progress to more severe symptoms such as seizures, coma, respiratory depression, and cardiovascular dysfunction.

      The management of LAST is largely supportive. Immediate steps include stopping the administration of local anaesthetic, calling for help, providing 100% oxygen and securing the airway, establishing IV access, and controlling seizures with benzodiazepines or other medications. Cardiovascular status should be continuously assessed, and conventional therapies may be used to treat hypotension or arrhythmias. Intravenous lipid emulsion (intralipid) may also be considered as a treatment option.

      If the patient goes into cardiac arrest, CPR should be initiated following ALS arrest algorithms, but lidocaine should not be used as an anti-arrhythmic therapy. Prolonged resuscitation may be necessary, and intravenous lipid emulsion should be administered. After the acute episode, the patient should be transferred to a clinical area with appropriate equipment and staff for further monitoring and care.

      It is important to report cases of local anaesthetic toxicity to the appropriate authorities, such as the National Patient Safety Agency in the UK or the Irish Medicines Board in the Republic of Ireland. Additionally, regular clinical review should be conducted to exclude pancreatitis, as intravenous lipid emulsion can interfere with amylase or lipase assays.

    • This question is part of the following fields:

      • Basic Anaesthetics
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  • Question 61 - A 35 year old epileptic is brought into the emergency department after experiencing...

    Incorrect

    • A 35 year old epileptic is brought into the emergency department after experiencing a grand mal seizure. The patient is unable to close their mouth. You suspect temporomandibular joint dislocation. What is the initial imaging test recommended for diagnosing this condition?

      Your Answer:

      Correct Answer: Orthopantomogram

      Explanation:

      The recommended first-line diagnostic test for TMJ dislocation is an OPG. The Royal College of Emergency Medicine suggests that an OPG is the most effective initial imaging technique for diagnosing TMJ dislocation. However, mandibular series X-ray views and CT scans can also be used as alternative imaging methods.

      Further Reading:

      TMJ dislocation occurs when the mandibular condyle is displaced from its normal position in the mandibular fossa of the temporal bone. The most common type of dislocation is bilateral anterior dislocation. This occurs when the mandible is dislocated forward and the masseter and pterygoid muscles spasm, locking the condyle in place.

      The temporomandibular joint is unique because it has an articular disc that separates the joint into upper and lower compartments. Dislocation can be caused by trauma, such as a direct blow to the open mouth, or by traumatic events like excessive mouth opening during yawning, laughing, shouting, or eating. It can also occur during dental work.

      Signs and symptoms of TMJ dislocation include difficulty fully opening or closing the mouth, pain or tenderness in the TMJ region, jaw pain, ear pain, difficulty chewing, and facial pain. Connective tissue disorders like Marfan’s and Ehlers-Danlos syndrome can increase the likelihood of dislocation.

      If TMJ dislocation is suspected, X-rays may be done to confirm the diagnosis. The best initial imaging technique is an orthopantomogram (OPG) or a standard mandibular series.

      Management of anterior dislocations involves reducing the dislocated mandible, which is usually done in the emergency department. Dislocations to the posterior, medial, or lateral side are usually associated with a mandibular fracture and should be referred to a maxillofacial surgeon.

      Reduction of an anterior dislocation involves applying distraction forces to the mandible. This can be done by gripping the mandible externally or intra-orally. In some cases, procedural sedation or local anesthesia may be used, and in rare cases, reduction may be done under general anesthesia.

      After reduction, a post-reduction X-ray is done to confirm adequate reduction and rule out any fractures caused by the procedure. Discharge advice includes following a soft diet for at least 48 hours, avoiding wide mouth opening for at least 2 weeks, and supporting the mouth with the hand during yawning or laughing. A Barton bandage may be used to support the mandible if the patient is unable to comply with the discharge advice. Referral to a maxillofacial surgeon as an outpatient is also recommended.

    • This question is part of the following fields:

      • Maxillofacial & Dental
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  • Question 62 - A 42-year-old man comes in with pain in his right testis that has...

    Incorrect

    • A 42-year-old man comes in with pain in his right testis that has been present for the past three days. The pain has been gradually increasing, and there is now noticeable swelling of the testis. During the examination, he has a fever with a temperature of 38.5°C, and the scrotum appears red and swollen on the affected side. Palpation reveals extreme tenderness in the testis.

      What is the SINGLE most likely diagnosis?

      Your Answer:

      Correct Answer: Epididymo-orchitis

      Explanation:

      Epididymo-orchitis refers to the inflammation of the testis and epididymis caused by an infectious source. The most common way of infection is through local extension, often resulting from infections spreading from the urethra or bladder.

      In individuals below the age of 35, sexually transmitted pathogens like Chlamydia trachomatis and Neisseria gonorrhoeae are the primary causes. On the other hand, in individuals over the age of 35, non-sexually transmitted infections caused by Gram-negative enteric organisms that lead to urinary tract infections are more common.

      Typically, patients with epididymo-orchitis experience sudden onset of unilateral scrotal pain and swelling. The affected testis is tender to touch, and there is usually a noticeable swelling of the epididymis that starts at the lower pole of the testis and spreads towards the upper pole. The testis itself may also be affected, and there may be redness and/or swelling of the scrotum on the affected side. Patients may have a fever and may also have urethral discharge.

      It is crucial to consider testicular torsion as the most important differential diagnosis. This should be taken into account for all patients with sudden testicular pain, as the testicle needs to be saved within 6 hours of onset. Torsion is more likely in men under the age of 20, especially if the pain is extremely acute and severe. Typically, torsion presents around four hours after onset. In this case, the patient’s age, longer history of symptoms, and the presence of fever are more indicative of epididymo-orchitis.

    • This question is part of the following fields:

      • Urology
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  • Question 63 - You are overseeing the care of a 72-year-old patient who is experiencing a...

    Incorrect

    • You are overseeing the care of a 72-year-old patient who is experiencing a peri-arrest arrhythmia. Laboratory results indicate that the patient has a significant deficiency of magnesium in their blood. After careful consideration, you determine that administering magnesium sulfate is necessary. What is the appropriate dosage regimen for this treatment?

      Your Answer:

      Correct Answer: 2g IV given over 10-15 minutes

      Explanation:

      To treat serious arrhythmia caused by hypomagnesaemia, it is recommended to administer 2 g of magnesium sulphate intravenously over a period of 10-15 minutes.

      Further Reading:

      In the management of respiratory and cardiac arrest, several drugs are commonly used to help restore normal function and improve outcomes. Adrenaline is a non-selective agonist of adrenergic receptors and is administered intravenously at a dose of 1 mg every 3-5 minutes. It works by causing vasoconstriction, increasing systemic vascular resistance (SVR), and improving cardiac output by increasing the force of heart contraction. Adrenaline also has bronchodilatory effects.

      Amiodarone is another drug used in cardiac arrest situations. It blocks voltage-gated potassium channels, which prolongs repolarization and reduces myocardial excitability. The initial dose of amiodarone is 300 mg intravenously after 3 shocks, followed by a dose of 150 mg after 5 shocks.

      Lidocaine is an alternative to amiodarone in cardiac arrest situations. It works by blocking sodium channels and decreasing heart rate. The recommended dose is 1 mg/kg by slow intravenous injection, with a repeat half of the initial dose after 5 minutes. The maximum total dose of lidocaine is 3 mg/kg.

      Magnesium sulfate is used to reverse myocardial hyperexcitability associated with hypomagnesemia. It is administered intravenously at a dose of 2 g over 10-15 minutes. An additional dose may be given if necessary, but the maximum total dose should not exceed 3 g.

      Atropine is an antagonist of muscarinic acetylcholine receptors and is used to counteract the slowing of heart rate caused by the parasympathetic nervous system. It is administered intravenously at a dose of 500 mcg every 3-5 minutes, with a maximum dose of 3 mg.

      Naloxone is a competitive antagonist for opioid receptors and is used in cases of respiratory arrest caused by opioid overdose. It has a short duration of action, so careful monitoring is necessary. The initial dose of naloxone is 400 micrograms, followed by 800 mcg after 1 minute. The dose can be gradually escalated up to 2 mg per dose if there is no response to the preceding dose.

      It is important for healthcare professionals to have knowledge of the pharmacology and dosing schedules of these drugs in order to effectively manage respiratory and cardiac arrest situations.

    • This question is part of the following fields:

      • Basic Anaesthetics
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  • Question 64 - A 14 year old male is brought into the emergency department with a...

    Incorrect

    • A 14 year old male is brought into the emergency department with a dislocated shoulder following a fall from a skateboard. The patient has been receiving Entonox during ambulance transport. What is a contraindication to administering Entonox in this case?

      Your Answer:

      Correct Answer: Pneumothorax

      Explanation:

      Nitrous oxide should not be used in cases where there is trapped air, such as pneumothorax. This is because nitrous oxide can diffuse into the trapped air and increase the pressure, which can be harmful. This can be particularly dangerous in conditions like pneumothorax, where the trapped air can expand and affect breathing, or in cases of intracranial air after a head injury, trapped air after a recent underwater dive, or recent injection of gas into the eye.

      Further Reading:

      Entonox® is a mixture of 50% nitrous oxide and 50% oxygen that can be used for self-administration to reduce anxiety. It can also be used alongside other anesthesia agents. However, its mechanism of action for anxiety reduction is not fully understood. The Entonox bottles are typically identified by blue and white color-coded collars, but a new standard will replace these with dark blue shoulders in the future. It is important to note that Entonox alone cannot be used as the sole maintenance agent in anesthesia.

      One of the effects of nitrous oxide is the second-gas effect, where it speeds up the absorption of other inhaled anesthesia agents. Nitrous oxide enters the alveoli and diffuses into the blood, displacing nitrogen. This displacement causes the remaining alveolar gases to become more concentrated, increasing the fractional content of inhaled anesthesia gases and accelerating the uptake of volatile agents into the blood.

      However, when nitrous oxide administration is stopped, it can cause diffusion hypoxia. Nitrous oxide exits the blood and diffuses back into the alveoli, while nitrogen diffuses in the opposite direction. Nitrous oxide enters the alveoli much faster than nitrogen leaves, resulting in the dilution of oxygen within the alveoli. This can lead to diffusion hypoxia, where the oxygen concentration in the alveoli is diluted, potentially causing oxygen deprivation in patients breathing air.

      There are certain contraindications for using nitrous oxide, as it can expand in air-filled spaces. It should be avoided in conditions such as head injuries with intracranial air, pneumothorax, recent intraocular gas injection, and entrapped air following a recent underwater dive.

    • This question is part of the following fields:

      • Basic Anaesthetics
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  • Question 65 - You are requested to evaluate a 75-year-old male who has been referred to...

    Incorrect

    • You are requested to evaluate a 75-year-old male who has been referred to the emergency department after visiting his local Boots™ store for a hearing assessment. The patient reports experiencing pain and hearing impairment on the right side a few days prior to the examination. The nurse who examined the patient's ears before conducting the audiogram expressed concerns regarding malignant otitis externa.

      What is the primary cause of malignant otitis externa?

      Your Answer:

      Correct Answer: Pseudomonas aeruginosa

      Explanation:

      Malignant otitis externa, also known as necrotising otitis externa, is a severe infection that affects the external auditory canal and spreads to the temporal bone and nearby tissues, leading to skull base osteomyelitis. The primary cause of this condition is usually an infection by Pseudomonas aeruginosa. It is commonly observed in older individuals with diabetes.

      Further Reading:

      Otitis externa is inflammation of the skin and subdermis of the external ear canal. It can be acute, lasting less than 6 weeks, or chronic, lasting more than 3 months. Malignant otitis externa, also known as necrotising otitis externa, is a severe and potentially life-threatening infection that can spread to the bones and surrounding structures of the ear. It is most commonly caused by Pseudomonas aeruginosa.

      Symptoms of malignant otitis externa include severe and persistent ear pain, headache, discharge from the ear, fever, malaise, vertigo, and profound hearing loss. It can also lead to facial nerve palsy and other cranial nerve palsies. In severe cases, the infection can spread to the central nervous system, causing meningitis, brain abscess, and sepsis.

      Acute otitis externa is typically caused by Pseudomonas aeruginosa or Staphylococcus aureus, while chronic otitis externa can be caused by fungal infections such as Aspergillus or Candida albicans. Risk factors for otitis externa include eczema, psoriasis, dermatitis, acute otitis media, trauma to the ear canal, foreign bodies in the ear, water exposure, ear canal obstruction, and long-term antibiotic or steroid use.

      Clinical features of otitis externa include itching of the ear canal, ear pain, tenderness of the tragus and/or pinna, ear discharge, hearing loss if the ear canal is completely blocked, redness and swelling of the ear canal, debris in the ear canal, and cellulitis of the pinna and adjacent skin. Tender regional lymphadenitis is uncommon.

      Management of acute otitis externa involves general ear care measures, optimizing any underlying medical or skin conditions that are risk factors, avoiding the use of hearing aids or ear plugs if there is a suspected contact allergy, and avoiding the use of ear drops if there is a suspected allergy to any of its ingredients. Treatment options include over-the-counter acetic acid 2% ear drops or spray, aural toileting via dry swabbing, irrigation, or microsuction, and prescribing topical antibiotics with or without a topical corticosteroid. Oral antibiotics may be prescribed in severe cases or for immunocompromised individuals.

      Follow-up is advised if symptoms do not improve within 48-72 hours of starting treatment, if symptoms have not fully resolved

    • This question is part of the following fields:

      • Ear, Nose & Throat
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  • Question 66 - A 45-year-old woman comes in with nausea, disorientation, and decreased urine production. Her...

    Incorrect

    • A 45-year-old woman comes in with nausea, disorientation, and decreased urine production. Her urine output has dropped to 0.4 mL/kg/hour for the last 7 hours. After conducting additional tests, she is diagnosed with acute kidney injury (AKI).
      What stage of AKI does she have?

      Your Answer:

      Correct Answer: Stage 1

      Explanation:

      Acute kidney injury (AKI), previously known as acute renal failure, is a sudden decline in kidney function. This leads to the accumulation of urea and other waste products in the body, as well as disturbances in fluid balance and electrolyte levels. AKI can occur in individuals with previously normal kidney function or those with pre-existing kidney disease, known as acute-on-chronic kidney disease. It is a relatively common condition, with approximately 15% of adults admitted to hospitals in the UK developing AKI.

      AKI is categorized into three stages based on specific criteria. In stage 1, there is a rise in creatinine levels of 26 micromol/L or more within 48 hours, or a rise of 50-99% from baseline within 7 days (1.5-1.99 times the baseline). Additionally, a urine output of less than 0.5 mL/kg/hour for more than 6 hours is indicative of stage 1 AKI.

      Stage 2 AKI is characterized by a creatinine rise of 100-199% from baseline within 7 days (2.0-2.99 times the baseline), or a urine output of less than 0.5 mL/kg/hour for more than 12 hours.

      In stage 3 AKI, there is a creatinine rise of 200% or more from baseline within 7 days (3.0 or more times the baseline). Alternatively, a creatinine rise to 354 micromol/L or more with an acute rise of 26 micromol/L or more within 48 hours, or a rise of 50% or more within 7 days, is indicative of stage 3 AKI. Additionally, a urine output of less than 0.3 mL/kg/hour for 24 hours or anuria (no urine output) for 12 hours also falls under stage 3 AKI.

    • This question is part of the following fields:

      • Nephrology
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  • Question 67 - A 6 year old male is brought to the emergency department due to...

    Incorrect

    • A 6 year old male is brought to the emergency department due to a rash on the flexural surfaces of both elbows. Dad informs you that there is usually some dry skin here but the redness has increased and the child has been scratching the area a lot over the past few days. You diagnose a moderate severity eczema flare.

      What is the most suitable course of action?

      Your Answer:

      Correct Answer: Advise regular use of emollients and twice daily clobetasone butyrate

      Explanation:

      Dermovate (Clobetasol propionate) is a strong steroid used for treating skin conditions. It is important to continue using emollients alongside steroid treatment. If the flare-ups are not effectively controlled by steroids, Tacrolimus can be considered as a secondary treatment option.

      Further Reading:

      Eczema is a chronic inflammatory skin disease characterized by dry, itchy skin with eczematous lesions. It often follows a chronic relapsing course and can lead to chronic skin changes such as lichenification and pigment changes. The term eczema is often used interchangeably with dermatitis, but strictly speaking, dermatitis refers to inflammation of the skin while eczema refers to specific conditions where skin inflammation is a feature.

      Atopic eczema, also known as atopic dermatitis, is the most common type of eczema. It is usually first diagnosed in young children, with 90% of cases diagnosed before the age of 5. However, it can affect individuals of any age. Symptoms often improve as patients progress into their teens and adulthood. Around 10-20% of children are affected by atopic eczema, but only 3% of adults experience symptoms.

      The exact cause of atopic eczema is not fully understood, but it is believed to be multifactorial, with both genetic and environmental factors playing a role. Genetic defects in genes that aid in the functioning of the skin barrier have been identified, which may predispose individuals to breaks in the skin barrier and increased exposure to antigens. Environmental factors such as pollution, allergen exposure, climate, and others also contribute to the development of the disease.

      Diagnosing atopic eczema involves assessing the presence of key clinical features, such as pruritus (itching), eczema/dermatitis in a pattern appropriate for age, early age of onset, and personal or family history of atopy. Various diagnostic criteria have been established to aid in the diagnosis, including those set out by the American Academy of Dermatology and the UK working party.

      The severity of atopic eczema can vary, and treatment options depend on the severity. Mild cases may be managed with emollients (moisturizers) and mild potency topical corticosteroids. Moderate cases may require moderate potency topical corticosteroids, topical calcineurin inhibitors, and bandages. Severe cases may necessitate the use of potent topical corticosteroids, topical calcineurin inhibitors, bandages, phototherapy, and systemic therapy.

      In addition to medical treatment, identifying and avoiding triggers is an important aspect of managing atopic eczema. Common triggers include irritants, contact allergens, certain foods, skin infections, inhalant triggers, stress and infection.

    • This question is part of the following fields:

      • Dermatology
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  • Question 68 - You assess a 7-year-old girl who has been brought to the ER by...

    Incorrect

    • You assess a 7-year-old girl who has been brought to the ER by her parents due to concerns about her health. They report that she has had a fever and a sore throat for the past few days, but now she has developed a red rash all over her body. After diagnosing scarlet fever, you prescribe antibiotics. What guidance would you provide to the parents regarding their child's attendance at school?

      Your Answer:

      Correct Answer: Exclusion from school until 24 hours after starting antibiotic treatment

      Explanation:

      Patients who have been diagnosed with Scarlet fever should be instructed to stay away from school or work until at least 24 hours after they have started taking antibiotics. It is also important for them to practice good hygiene habits.

      Further Reading:

      Scarlet fever is a reaction to erythrogenic toxins produced by Group A haemolytic streptococci, usually Streptococcus pyogenes. It is more common in children aged 2-6 years, with the peak incidence at 4 years. The typical presentation of scarlet fever includes fever, malaise, sore throat (tonsillitis), and a rash. The rash appears 1-2 days after the fever and sore throat symptoms and consists of fine punctate erythema that first appears on the torso and spares the face. The rash has a rough ‘sandpaper’ texture and desquamation occurs later, particularly around the fingers and toes. Another characteristic feature is the ‘strawberry tongue’, which initially has a white coating and swollen, reddened papillae, and later becomes red and inflamed. Diagnosis is usually made by a throat swab, but antibiotic treatment should be started immediately without waiting for the results. The recommended treatment is oral penicillin V, but patients with a penicillin allergy should be given azithromycin. Children can return to school 24 hours after starting antibiotics. Scarlet fever is a notifiable disease. Complications of scarlet fever include otitis media, rheumatic fever, and acute glomerulonephritis.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 69 - A 25-year-old woman arrives at the Emergency Department after ingesting an overdose 30...

    Incorrect

    • A 25-year-old woman arrives at the Emergency Department after ingesting an overdose 30 minutes ago. She is currently showing no symptoms and her vital signs are stable. The attending physician recommends administering a dose of activated charcoal.
      Which of the following substances or toxins is activated charcoal effective in decontaminating?

      Your Answer:

      Correct Answer: Amitriptyline

      Explanation:

      Activated charcoal is a commonly used substance for decontamination in cases of poisoning. Its main function is to adsorb the 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. It is produced by subjecting carbonaceous matter to high temperatures, a process known as pyrolysis, and then concentrating it with a zinc chloride solution. This creates a network of pores within the charcoal, giving it a large absorptive area of approximately 3,000 m2/g. This porous structure helps prevent the absorption of the harmful toxin by up to 50%.

      The usual dosage of activated charcoal is 50 grams for adults and 1 gram per kilogram of body weight for children. It can be administered orally or through a nasogastric tube. It is important to give the charcoal within one hour of ingestion, and it may be repeated after one hour if necessary.

      However, there are certain situations where activated charcoal should not be used. If the patient is unconscious or in a coma, there is a risk of aspiration, so the charcoal should not be given. Similarly, if seizures are likely to occur, there is a risk of aspiration and the charcoal should be avoided. Additionally, if there is reduced gastrointestinal motility, there is a risk of obstruction, so activated charcoal should not be used in such cases.

      Activated charcoal is effective in treating overdose with various drugs and toxins, including aspirin, paracetamol, barbiturates, tricyclic antidepressants, digoxin, amphetamines, morphine, cocaine, and phenothiazines. However, it is ineffective in treating overdose with substances such as iron, lithium, boric acid, cyanide, ethanol, ethylene glycol, methanol, malathion, DDT, carbamate, hydrocarbon, strong acids, or alkalis.

      There are some potential adverse effects associated with activated charcoal. These include nausea and vomiting, diarrhea, constipation, bezoar formation (a mass of undigested material that can cause blockages), bowel obstruction, pulmonary aspiration (inhaling the charcoal into the lungs), and impaired absorption of oral medications or antidotes.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 70 - A 36 year old man has arrived at the Emergency Department seeking treatment...

    Incorrect

    • A 36 year old man has arrived at the Emergency Department seeking treatment for a deep cut on his leg. He is by himself, and before examining the wound, he warns you to 'be careful' and reveals that he recently tested positive for HIV. He suspects that he contracted the virus after engaging in an extramarital affair. The nurse then approaches and asks if it is permissible for his wife to enter the room. He informs you that his wife is unaware of his diagnosis and he wishes to keep it that way. You observe that his wife appears to be in the early stages of pregnancy.
      In addition to providing appropriate medical care for the wound, what steps should you take?

      Your Answer:

      Correct Answer: If confirmed HIV infection, explain risks to his wife and unborn child and need for disclosure. If he refuses to consent to this, explain you have the right to do this against his wishes.

      Explanation:

      This is a complex situation that presents both ethical and medico-legal challenges. While patients have a right to confidentiality, it is important to recognize that this right is not absolute and may not apply in every circumstance. There are certain situations where it is appropriate to breach confidentiality, such as when mandated by law or when there is a threat to public health. However, it is crucial to make every effort to persuade the patient against disclosure and to inform them of your intentions.

      In this particular case, the patient has disclosed to you that they have recently been diagnosed with HIV, which they believe was contracted from a sexual encounter outside of their marriage. They have explicitly stated that they do not want you to inform their wife, who is in the early stages of pregnancy. Before taking any action, it is advisable to gather all the relevant facts and confirm the patient’s HIV diagnosis through their health records, including any other blood-borne viruses.

      If the facts are indeed confirmed, it is important to continue efforts to persuade the patient of the necessity for their wife to be informed. If she has been exposed, she could greatly benefit from testing and starting antiretroviral therapy. Additionally, specialized care during early pregnancy could help prevent transmission of the virus to the unborn child. However, if the patient continues to refuse disclosure, you have the right to breach confidentiality, but it is crucial to inform the patient of your intentions beforehand. Seeking support from your defense organization is also recommended in such situations.

      For further information, you may refer to the GMC Guidance on Confidentiality, specifically the section on disclosing information about serious communicable diseases.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 71 - A 2 year old toddler is brought into the resuscitation bay after collapsing...

    Incorrect

    • A 2 year old toddler is brought into the resuscitation bay after collapsing and having a seizure. A capillary blood glucose test shows a reading of 0.9 mmol/L. Your consultant instructs you to initiate an intravenous glucose infusion. What is the most suitable dosage?

      Your Answer:

      Correct Answer: 5 mL/kg/hour of 10% dextrose

      Explanation:

      Diabetes Mellitus:
      – Definition: a group of metabolic disorders characterized by persistent hyperglycemia caused by deficient insulin secretion, resistance to insulin, or both.
      – Types: Type 1 diabetes (absolute insulin deficiency), Type 2 diabetes (insulin resistance and relative insulin deficiency), Gestational diabetes (develops during pregnancy), Other specific types (monogenic diabetes, diabetes secondary to pancreatic or endocrine disorders, diabetes secondary to drug treatment).
      – Diagnosis: Type 1 diabetes diagnosed based on clinical grounds in adults presenting with hyperglycemia. Type 2 diabetes diagnosed in patients with persistent hyperglycemia and presence of symptoms or signs of diabetes.
      – Risk factors for type 2 diabetes: obesity, inactivity, family history, ethnicity, history of gestational diabetes, certain drugs, polycystic ovary syndrome, metabolic syndrome, low birth weight.

      Hypoglycemia:
      – Definition: lower than normal blood glucose concentration.
      – Diagnosis: defined by Whipple’s triad (signs and symptoms of low blood glucose, low blood plasma glucose concentration, relief of symptoms after correcting low blood glucose).
      – Blood glucose level for hypoglycemia: NICE defines it as <3.5 mmol/L, but there is inconsistency across the literature.
      – Signs and symptoms: adrenergic or autonomic symptoms (sweating, hunger, tremor), neuroglycopenic symptoms (confusion, coma, convulsions), non-specific symptoms (headache, nausea).
      – Treatment options: oral carbohydrate, buccal glucose gel, glucagon, dextrose. Treatment should be followed by re-checking glucose levels.

      Treatment of neonatal hypoglycemia:
      – Treat with glucose IV infusion 10% given at a rate of 5 mL/kg/hour.
      – Initial stat dose of 2 mL/kg over five minutes may be required for severe hypoglycemia.
      – Mild asymptomatic persistent hypoglycemia may respond to a single dose of glucagon.
      – If hypoglycemia is caused by an oral anti-diabetic drug, the patient should be admitted and ongoing glucose infusion or other therapies may be required.

      Note: Patients who have a hypoglycemic episode with a loss of warning symptoms should not drive and should inform the DVLA.

    • This question is part of the following fields:

      • Neonatal Emergencies
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  • Question 72 - A 5-year-old boy is brought to the Emergency Department by his mother. He...

    Incorrect

    • A 5-year-old boy is brought to the Emergency Department by his mother. He is known to have eczema and has recently experienced a worsening of his symptoms with some of the affected areas having weeping and crusting lesions. Upon examining his skin, you observe multiple flexural areas involved with numerous weeping lesions. He has no known allergies to any medications.

      What is the MOST suitable course of action for management?

      Your Answer:

      Correct Answer: Oral flucloxacillin

      Explanation:

      Based on the child’s medical history, it appears that they have multiple areas of infected eczema. In such cases, the NICE guidelines recommend starting treatment with flucloxacillin as the first-line option for bacterial infections. This is because staphylococcus and/or streptococcus bacteria are the most common causes of these infections. Swabs should only be taken if there is a likelihood of antibiotic resistance or if a different pathogen is suspected. In cases where the child is allergic to flucloxacillin, erythromycin can be used as an alternative. If the child cannot tolerate erythromycin, clarithromycin is the recommended option. For more information, you can refer to the NICE Clinical Knowledge Summary on the management of infected eczema.

    • This question is part of the following fields:

      • Dermatology
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  • Question 73 - You evaluate a 45-year-old woman who presents with lower abdominal and pelvic pain....

    Incorrect

    • You evaluate a 45-year-old woman who presents with lower abdominal and pelvic pain. During a bimanual vaginal examination, you detect a significant pelvic mass. She has no significant medical history or gynecological issues, such as uterine fibroids.
      What would be the MOST suitable next step in managing this patient?

      Your Answer:

      Correct Answer: Urgent referral to gynaecology service (for an appointment within 2 weeks)

      Explanation:

      Women who are 18 years or older and have a pelvic mass that is not clearly uterine fibroids should be promptly referred for assessment. In this case, an abdominal X-ray would not provide much useful information, and it is not advisable to take no action at this point. For more information, please refer to the NICE referral guidelines for suspected cancer.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
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  • Question 74 - A middle-aged patient with a previous cancer diagnosis complains of recent onset back...

    Incorrect

    • A middle-aged patient with a previous cancer diagnosis complains of recent onset back pain. After conducting a thorough examination, your findings raise significant alarm. You begin to suspect the presence of metastatic spinal cord compression (MSCC).
      What specific feature is the strongest indicator of MSCC?

      Your Answer:

      Correct Answer: Localised spinal tenderness

      Explanation:

      Metastatic spinal cord compression (MSCC) occurs when a tumor mass compresses the thecal sac and its components, leading to a spinal emergency. If the pressure on the spinal cord is not relieved promptly, it can result in irreversible loss of neurological function. The most crucial factor for predicting functional outcomes is the patient’s neurological function before treatment. Therefore, delayed treatment can lead to permanent disability and a decrease in quality of life.

      The most common cancers that cause MSCC include prostate, lung, breast, and myeloma. In approximately 10 to 20% of cancer patients, MSCC is the first noticeable symptom. It is important to consider MSCC in any patient with a history of cancer if they experience any of the following symptoms: severe or worsening lower back pain, nocturnal pain that disrupts sleep, localized spinal tenderness, radicular pain, or neurological symptoms.

      Thoracic pain can also be an indicator of MSCC or an aortic aneurysm. In patients aged 60 or older with persistent back pain, myeloma should be considered. For patients aged 60 or older with accompanying weight loss, pancreatic cancer should be taken into consideration.

    • This question is part of the following fields:

      • Oncological Emergencies
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  • Question 75 - You are summoned to the resuscitation bay to aid in the care of...

    Incorrect

    • You are summoned to the resuscitation bay to aid in the care of a 45-year-old male who has suffered a traumatic brain injury. What should be included in the initial management of a patient with elevated intracranial pressure (ICP)?

      Your Answer:

      Correct Answer: Maintain systolic blood pressure >90 mmHg

      Explanation:

      Maintaining adequate blood pressure is crucial in managing increased intracranial pressure (ICP). The recommended blood pressure targets may vary depending on the source. The Scottish Intercollegiate Guidelines Network (SIGN) suggests maintaining an adequate blood pressure, while the 4th edition of the Brain Trauma Foundation recommends maintaining a systolic blood pressure (SBP) above 100 mm Hg for individuals aged 50-69 years (or above 110 mm Hg for those aged 15-49 years) to reduce mortality and improve outcomes.

      When managing a patient with increased ICP, the initial steps should include maintaining normal body temperature to prevent fever, positioning the patient with a 30º head-up tilt, and administering analgesia and sedation as needed. It is important to monitor and maintain blood pressure, using inotropes if necessary to achieve the target. Additionally, preparations should be made to use medications such as Mannitol or hypertonic saline to lower ICP if required. Hyperventilation may also be considered, although it carries the risk of inducing ischemia and requires monitoring of carbon dioxide levels.

      Further Reading:

      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
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  • Question 76 - You review a patient with a history of schizophrenia who is currently experiencing...

    Incorrect

    • You review a patient with a history of schizophrenia who is currently experiencing acute psychosis. He describes a sensation in which his train of thought is abruptly cut off completely. During the consultation, you observe that his speech is frequently interrupted by prolonged periods of silence, lasting for a minute or two.
      Which ONE of the following thought disorders is he exhibiting?

      Your Answer:

      Correct Answer: Thought blocking

      Explanation:

      Thought blocking is a distressing phenomenon where one’s train of thought is abruptly halted. This occurrence is observed in various psychiatric disorders, such as schizophrenia. It manifests as sudden pauses in a person’s speech, lasting from a few seconds to even a minute or more.

    • This question is part of the following fields:

      • Mental Health
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  • Question 77 - A patient with a previous complaint of upper abdominal pain and frequent bowel...

    Incorrect

    • A patient with a previous complaint of upper abdominal pain and frequent bowel movements is diagnosed with a tapeworm infection. The infection was acquired after consuming a pork dish that was contaminated with the parasite.

      Which of the following organisms is the most probable cause of this infestation?

      Your Answer:

      Correct Answer: Taenia solium

      Explanation:

      Two types of tapeworms, Taenia solium and Taenia saginata, can infest humans. Infestation occurs when people consume meat from intermediate hosts that contain the parasite’s tissue stages. Tapeworms compete for nutrients and infestation is often without symptoms. However, in more severe cases, individuals may experience epigastric pain, diarrhea, and vomiting. Diagnosis involves identifying characteristic eggs in the patient’s stool.

      Taenia solium infestation can also lead to a condition called cysticercosis. This occurs when larval cysts infiltrate and spread throughout the lung, liver, eye, or brain. Cysticercosis presents with neurological symptoms, seizures, and impaired vision. Confirmation of cysticercosis involves the presence of antibodies and imaging tests such as chest X-rays and CT brain scans.

      The treatment for tapeworm infestation is highly effective and involves the use of medications like niclosamide or praziquantel. However, it is important to seek specialist advice when managing Taenia infections in the central nervous system, as severe inflammatory reactions can occur.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 78 - A 6-month-old boy has been brought to the hospital for evaluation of a...

    Incorrect

    • A 6-month-old boy has been brought to the hospital for evaluation of a severe respiratory infection. The medical team suspects a diagnosis of pertussis (whooping cough).
      What is the MOST SUITABLE investigation for this case?

      Your Answer:

      Correct Answer: PCR testing

      Explanation:

      Whooping cough, also known as pertussis, is a respiratory infection caused by the bacteria Bordetella pertussis. It is transmitted through respiratory droplets and has an incubation period of about 7-21 days. This disease is highly contagious and can be transmitted to around 90% of close household contacts.

      The clinical course of whooping cough can be divided into two stages. The first stage is called the catarrhal stage, which resembles a mild respiratory infection with symptoms like low-grade fever and a runny nose. A cough may be present, but it is usually mild compared to the second stage. The catarrhal stage typically lasts for about a week.

      The second stage is known as the paroxysmal stage. During this phase, the cough becomes more severe as the catarrhal symptoms start to subside. The coughing occurs in spasms, often preceded by an inspiratory whoop sound, followed by a series of rapid coughs. Vomiting may occur, and patients may develop subconjunctival hemorrhages and petechiae. Patients generally feel well between coughing spasms, and there are usually no abnormal chest findings. This stage can last up to 3 months, with a gradual recovery over time. The later stages of this phase are sometimes referred to as the convalescent stage.

      Complications of whooping cough can include secondary pneumonia, rib fractures, pneumothorax, hernias, syncopal episodes, encephalopathy, and seizures.

      Public Health England (PHE) provides recommendations for testing whooping cough based on the patient’s age, time since onset of illness, and severity of symptoms. For infants under 12 months of age who are hospitalized, PCR testing is recommended. Non-hospitalized infants within two weeks of symptom onset should undergo culture testing of a nasopharyngeal swab or aspirate. Non-hospitalized infants presenting over two weeks after symptom onset should be tested for anti-pertussis toxin IgG antibody levels using serology.

      For children over 12 months of age and adults, culture testing of a nasopharyngeal swab or aspirate is recommended within two weeks of symptom onset. Children aged 5 to 16 who have not received the vaccine within the last year and present over two weeks after symptom onset should undergo oral fluid testing for anti-pertussis toxin IgG antibody levels. Children under 5 or adults over

    • This question is part of the following fields:

      • Respiratory
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  • Question 79 - A 32-year-old woman who is 38 weeks pregnant is brought to the Emergency...

    Incorrect

    • A 32-year-old woman who is 38 weeks pregnant is brought to the Emergency Department after experiencing sudden difficulty breathing. Shortly after her arrival, she loses consciousness. The cardiac monitor displays ventricular fibrillation, confirming cardiac arrest.
      Which of the following statements about cardiac arrest during pregnancy is NOT true?

      Your Answer:

      Correct Answer: The uterus should be manually displaced to the right

      Explanation:

      Cardiac arrest during pregnancy is a rare occurrence, happening in approximately 16 out of every 100,000 live births. It is crucial to consider both the mother and the fetus when dealing with cardiac arrest in pregnancy, as the best way to ensure a positive outcome for the fetus is by effectively resuscitating the mother.

      The main causes of cardiac arrest during pregnancy include pre-existing cardiac disease, pulmonary embolism, hemorrhage, ectopic pregnancy, hypertensive disorders of pregnancy, amniotic fluid embolism, and suicide. Many cardiovascular problems associated with pregnancy are caused by compression of the inferior vena cava.

      To prevent decompensation or potential cardiac arrest during pregnancy, it is important to follow these steps when dealing with a distressed or compromised pregnant patient:

      – Place the patient in the left lateral position or manually displace the uterus to the left.
      – Administer high-flow oxygen, guided by pulse oximetry.
      – Give a fluid bolus if there is low blood pressure or signs of hypovolemia.
      – Re-evaluate the need for any medications currently being administered.
      – Seek expert help and involve obstetric and neonatal specialists early.
      – Identify and treat the underlying cause.

      In the event of cardiac arrest during pregnancy, in addition to following the standard guidelines for basic and advanced life support, the following modifications should be made:

      – Immediately call for expert help, including an obstetrician, anesthetist, and neonatologist.
      – Start CPR according to the standard ALS guidelines, but adjust the hand position slightly higher on the sternum.
      – Ideally establish IV or IO access above the diaphragm to account for potential compression of the inferior vena cava.
      – Manually displace the uterus to the left to relieve caval compression.
      – Tilt the table to the left side (around 15-30 degrees of tilt).
      – Perform early tracheal intubation to reduce the risk of aspiration (seek assistance from an expert anesthetist).
      – Begin preparations for an emergency Caesarean section.

      A perimortem Caesarean section should be performed within 5 minutes of the onset of cardiac arrest. This delivery will alleviate caval compression and increase the chances of successful resuscitation by improving venous return during CPR. It will also maximize the chances of the infant’s survival, as the best survival rate occurs when delivery is achieved within 5 minutes of the mother’s cardiac arrest.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
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  • Question 80 - You evaluate a 35-year-old combat veteran named Mark, who was recently discharged from...

    Incorrect

    • You evaluate a 35-year-old combat veteran named Mark, who was recently discharged from service after being discovered to be under the influence of drugs and alcohol during a training exercise. He completed three tours of duty in Iraq and witnessed the death of a close comrade during his final deployment. Mark acknowledges experiencing frequent flashbacks and nightmares and often feels on edge. His spouse has accused him of being emotionally distant and lacking feelings, resulting in their separation. Lately, he has been heavily relying on alcohol as a coping mechanism.
      What is the SINGLE MOST probable diagnosis?

      Your Answer:

      Correct Answer: Post-traumatic stress disorder

      Explanation:

      Post-traumatic stress disorder (PTSD) develops after experiencing an extremely threatening or catastrophic event that would cause distress in almost anyone. It is important to note that PTSD does not develop from everyday upsetting situations like divorce, job loss, or failing an exam.

      The most common symptom of PTSD is re-experiencing the traumatic event involuntarily and vividly. This can manifest as flashbacks, nightmares, repetitive distressing images or sensations, and physical symptoms such as pain, sweating, nausea, or trembling. Other notable features of PTSD include avoidance, rumination, hyperarousal, emotional numbing, irritability, and insomnia.

      It is common for individuals with PTSD to also experience other mental health problems such as depression, anxiety, phobias, self-harming behaviors, and substance abuse.

      The recommended treatments for PTSD are Eye Movement Desensitization and Reprocessing (EMDR) and Trauma-focused Cognitive Behavioral Therapy (CBT). These treatments should be offered to individuals of all ages, regardless of the time that has passed since the traumatic event. Typically, 8-12 sessions are recommended, but more may be necessary in cases involving multiple traumas, chronic disability, comorbidities, or social problems.

    • This question is part of the following fields:

      • Mental Health
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  • Question 81 - You are participating in expedition medicine training organized by your emergency department. The...

    Incorrect

    • You are participating in expedition medicine training organized by your emergency department. The training session is centered on identifying and handling altitude illnesses. At what elevation does altitude sickness usually begin to manifest?

      Your Answer:

      Correct Answer: 2500 metres

      Explanation:

      Altitude sickness is usually experienced at altitudes above 2,500 meters (8,000 ft), although some individuals may be affected at lower altitudes. It is important to note that climbers in the UK, where the highest peak is Ben Nevis at 1,345 meters, do not need to worry about altitude sickness.

      Further Reading:

      High Altitude Illnesses

      Altitude & Hypoxia:
      – As altitude increases, atmospheric pressure decreases and inspired oxygen pressure falls.
      – Hypoxia occurs at altitude due to decreased inspired oxygen.
      – At 5500m, inspired oxygen is approximately half that at sea level, and at 8900m, it is less than a third.

      Acute Mountain Sickness (AMS):
      – AMS is a clinical syndrome caused by hypoxia at altitude.
      – Symptoms include headache, anorexia, sleep disturbance, nausea, dizziness, fatigue, malaise, and shortness of breath.
      – Symptoms usually occur after 6-12 hours above 2500m.
      – Risk factors for AMS include previous AMS, fast ascent, sleeping at altitude, and age <50 years old.
      – The Lake Louise AMS score is used to assess the severity of AMS.
      – Treatment involves stopping ascent, maintaining hydration, and using medication for symptom relief.
      – Medications for moderate to severe symptoms include dexamethasone and acetazolamide.
      – Gradual ascent, hydration, and avoiding alcohol can help prevent AMS.

      High Altitude Pulmonary Edema (HAPE):
      – HAPE is a progression of AMS but can occur without AMS symptoms.
      – It is the leading cause of death related to altitude illness.
      – Risk factors for HAPE include rate of ascent, intensity of exercise, absolute altitude, and individual susceptibility.
      – Symptoms include dyspnea, cough, chest tightness, poor exercise tolerance, cyanosis, low oxygen saturations, tachycardia, tachypnea, crepitations, and orthopnea.
      – Management involves immediate descent, supplemental oxygen, keeping warm, and medication such as nifedipine.

      High Altitude Cerebral Edema (HACE):
      – HACE is thought to result from vasogenic edema and increased vascular pressure.
      – It occurs 2-4 days after ascent and is associated with moderate to severe AMS symptoms.
      – Symptoms include headache, hallucinations, disorientation, confusion, ataxia, drowsiness, seizures, and manifestations of raised intracranial pressure.
      – Immediate descent is crucial for management, and portable hyperbaric therapy may be used if descent is not possible.
      – Medication for treatment includes dexamethasone and supplemental oxygen. Acetazolamide is typically used for prophylaxis.

    • This question is part of the following fields:

      • Environmental Emergencies
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  • Question 82 - A 25-year-old male arrives at the Emergency Department in evident distress. He woke...

    Incorrect

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

      What is the MOST probable diagnosis in this case?

      Your Answer:

      Correct Answer: Testicular torsion

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Urology
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  • Question 83 - A 42 year old male is brought into the emergency department by ambulance...

    Incorrect

    • A 42 year old male is brought into the emergency department by ambulance after confessing to taking a significant overdose of amitriptyline following a recent breakup. The patient later experiences a seizure. Which of the following anticonvulsant medications should not be used in TCA overdose?

      Your Answer:

      Correct Answer: Phenytoin

      Explanation:

      Patients who have taken an overdose of tricyclic antidepressants (TCAs) should not be given phenytoin.

      Further Reading:

      Tricyclic antidepressant (TCA) overdose is a common occurrence in emergency departments, with drugs like amitriptyline and dosulepin being particularly dangerous. TCAs work by inhibiting the reuptake of norepinephrine and serotonin in the central nervous system. In cases of toxicity, TCAs block various receptors, including alpha-adrenergic, histaminic, muscarinic, and serotonin receptors. This can lead to symptoms such as hypotension, altered mental state, signs of anticholinergic toxicity, and serotonin receptor effects.

      TCAs primarily cause cardiac toxicity by blocking sodium and potassium channels. This can result in a slowing of the action potential, prolongation of the QRS complex, and bradycardia. However, the blockade of muscarinic receptors also leads to tachycardia in TCA overdose. QT prolongation and Torsades de Pointes can occur due to potassium channel blockade. TCAs can also have a toxic effect on the myocardium, causing decreased cardiac contractility and hypotension.

      Early symptoms of TCA overdose are related to their anticholinergic properties and may include dry mouth, pyrexia, dilated pupils, agitation, sinus tachycardia, blurred vision, flushed skin, tremor, and confusion. Severe poisoning can lead to arrhythmias, seizures, metabolic acidosis, and coma. ECG changes commonly seen in TCA overdose include sinus tachycardia, widening of the QRS complex, prolongation of the QT interval, and an R/S ratio >0.7 in lead aVR.

      Management of TCA overdose involves ensuring a patent airway, administering activated charcoal if ingestion occurred within 1 hour and the airway is intact, and considering gastric lavage for life-threatening cases within 1 hour of ingestion. Serial ECGs and blood gas analysis are important for monitoring. Intravenous fluids and correction of hypoxia are the first-line therapies. IV sodium bicarbonate is used to treat haemodynamic instability caused by TCA overdose, and benzodiazepines are the treatment of choice for seizure control. Other treatments that may be considered include glucagon, magnesium sulfate, and intravenous lipid emulsion.

      There are certain things to avoid in TCA overdose, such as anti-arrhythmics like quinidine and flecainide, as they can prolonged depolarization.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 84 - A 25-year-old woman with a known history of generalized anxiety disorder presents hyperventilating....

    Incorrect

    • A 25-year-old woman with a known history of generalized anxiety disorder presents hyperventilating. You suspect that she is experiencing a panic attack. She was seen by a resident physician shortly before your assessment, and an arterial blood gas was taken.
      What type of acid-base disorder would you anticipate being caused by hyperventilation secondary to anxiety?

      Your Answer:

      Correct Answer: Respiratory alkalosis

      Explanation:

      Respiratory alkalosis can be caused by hyperventilation, such as during periods of anxiety. It can also be a result of conditions like pulmonary embolism, CNS disorders (such as stroke or encephalitis), altitude, pregnancy, or the early stages of aspirin overdose.

      Respiratory acidosis is often associated with chronic obstructive pulmonary disease (COPD) or life-threatening asthma. Other causes include pulmonary edema, sedative drug overdose (such as opiates or benzodiazepines), neuromuscular disease, obesity, or certain medications.

      Metabolic alkalosis can occur due to vomiting, potassium depletion (often caused by diuretic usage), Cushing’s syndrome, or Conn’s syndrome.

      Metabolic acidosis with a raised anion gap can be caused by conditions like lactic acidosis (which can result from hypoxemia, shock, sepsis, or infarction) or ketoacidosis (commonly seen in diabetes, starvation, or alcohol excess). Other causes include renal failure or poisoning (such as late stages of aspirin overdose, methanol, or ethylene glycol).

      Metabolic acidosis with a normal anion gap can be attributed to conditions like renal tubular acidosis, diarrhea, ammonium chloride ingestion, or adrenal insufficiency.

    • This question is part of the following fields:

      • Mental Health
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  • Question 85 - A 35-year-old construction worker presents with confusion, vomiting, and complaining of a headache....

    Incorrect

    • A 35-year-old construction worker presents with confusion, vomiting, and complaining of a headache. There is currently a scorching heatwave, and he has been working outdoors in heavy protective gear. His skin is dry and hot, he is hyperventilating, and his core temperature is currently 41.7°C. He is very agitated and shivering severely at present.
      Which of the following is the LEAST suitable treatment option for this patient?

      Your Answer:

      Correct Answer: Dantrolene

      Explanation:

      Heat stroke is a condition characterized by a core temperature higher than 40.6°C, accompanied by changes in mental state and varying levels of organ dysfunction. There are two forms of heat stroke: classic non-exertional heat stroke, which occurs during high environmental temperatures and typically affects elderly patients during heat waves, and exertional heat stroke, which occurs during strenuous physical exercise in hot conditions, such as endurance athletes competing in hot weather.

      The main treatment for heat stroke involves supportive measures. It is important to rapidly reduce the core temperature to around 39.0°C. Patients with severe heat stroke should be managed in a critical care setting. The ABCDE approach should be followed, with a focus on cooling the patient. This includes obtaining a definitive airway if the patient is unresponsive, providing ventilation if necessary, using haemodynamic monitoring to guide fluid therapy, correcting electrolyte imbalances, managing blood glucose levels, removing clothes, eliminating the cause of hyperthermia, and monitoring core and skin temperatures.

      There are various cooling techniques that can be used, although there is limited evidence on which approach is the most effective. Some possible methods include simple measures like cold drinks, fanning, ice water packs, and spraying tepid water. Cold water immersion therapy can be beneficial, but it requires the patient to be stable and cooperative, making it impractical for very sick patients. Advanced cooling techniques, such as cold IV fluids, surface cooling devices, intravascular cooling devices, and extracorporeal circuits, may be used for sicker patients.

      Benzodiazepines, like diazepam, can be helpful in managing agitation and shivering in heat stroke patients. They not only reduce excessive heat production but also help to calm the patient. In severe cases of agitation, paralysis may be necessary. Dantrolene is commonly used, although there is currently limited high-level evidence to support its use. Neuroleptics, such as chlorpromazine, which were once commonly used, should be avoided due to their potential adverse effects, including lowering the seizure threshold, interfering with thermoregulation, causing anticholinergic side effects, hypotension, and hepatotoxicity.

    • This question is part of the following fields:

      • Environmental Emergencies
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  • Question 86 - You are examining the hip X-rays of a 78-year-old woman who slipped while...

    Incorrect

    • You are examining the hip X-rays of a 78-year-old woman who slipped while getting out of bed. What can be helpful in identifying a femoral neck fracture on the anteroposterior X-ray?

      Your Answer:

      Correct Answer: Shenton's line

      Explanation:

      Shenton’s line is a useful tool for identifying hip fractures on radiographs. It is a curved line that is drawn along the bottom edge of the upper pubic bone and the inner lower edge of the femur neck. This line should be smooth and uninterrupted. If there are any breaks or irregularities in the line, it could indicate a fracture, dysplasia, or dislocation.

      Further Reading:

      Fractured neck of femur is a common injury, especially in elderly patients who have experienced a low impact fall. Risk factors for this type of fracture include falls, osteoporosis, and other bone disorders such as metastatic cancers, hyperparathyroidism, and osteomalacia.

      There are different classification systems for hip fractures, but the most important differentiation is between intracapsular and extracapsular fractures. The blood supply to the femoral neck and head is primarily from ascending cervical branches that arise from an arterial anastomosis between the medial and lateral circumflex branches of the femoral arteries. Fractures in the intracapsular region can damage the blood supply and lead to avascular necrosis (AVN), with the risk increasing with displacement. The Garden classification can be used to classify intracapsular neck of femur fractures and determine the risk of AVN. Those at highest risk will typically require hip replacement or arthroplasty.

      Fractures below or distal to the capsule are termed extracapsular and can be further described as intertrochanteric or subtrochanteric depending on their location. The blood supply to the femoral neck and head is usually maintained with these fractures, making them amenable to surgery that preserves the femoral head and neck, such as dynamic hip screw fixation.

      Diagnosing hip fractures can be done through radiographs, with Shenton’s line and assessing the trabecular pattern of the proximal femur being helpful techniques. X-rays should be obtained in both the AP and lateral views, and if an occult fracture is suspected, an MRI or CT scan may be necessary.

      In terms of standards of care, it is important to assess the patient’s pain score within 15 minutes of arrival in the emergency department and provide appropriate analgesia within the recommended timeframes. Patients with moderate or severe pain should have their pain reassessed within 30 minutes of receiving analgesia. X-rays should be obtained within 120 minutes of arrival, and patients should be admitted within 4 hours of arrival.

    • This question is part of the following fields:

      • Elderly Care / Frailty
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  • Question 87 - A 42-year-old man with systemic lupus erythematosus (SLE) has been diagnosed with anaemia...

    Incorrect

    • A 42-year-old man with systemic lupus erythematosus (SLE) has been diagnosed with anaemia of chronic disease.
      Which SINGLE statement regarding anaemia of chronic disease is true?

      Your Answer:

      Correct Answer: Total iron binding capacity is usually reduced

      Explanation:

      Anaemia of chronic disease is a type of anaemia that can occur in various chronic conditions, such as rheumatoid arthritis, systemic lupus erythematosus, tuberculosis, malignancy, malnutrition, hypothyroidism, hypopituitarism, chronic kidney disease, and chronic liver disease. The underlying mechanisms of this type of anaemia are complex and not fully understood, with multiple contributing factors involved. One important mediator in inflammatory diseases like rheumatoid arthritis is interleukin-6 (IL-6). Increased levels of IL-6 lead to the production of hepcidin, a hormone that regulates iron balance. Hepcidin prevents the release of iron from the reticulo-endothelial system and affects other aspects of iron metabolism.

      Anaemia of chronic disease typically presents as a normochromic, normocytic anaemia, although it can also be microcytic. It is characterized by reduced serum iron, reduced transferrin saturation, and reduced total iron-binding capacity (TIBC). However, the serum ferritin levels are usually normal or increased. Distinguishing anaemia of chronic disease from iron-deficiency anaemia can be challenging, but in iron-deficiency anaemia, the TIBC is typically elevated, and serum ferritin is usually low.

    • This question is part of the following fields:

      • Haematology
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  • Question 88 - A 58 year old female presents to the emergency department 2 hours after...

    Incorrect

    • A 58 year old female presents to the emergency department 2 hours after developing severe tearing chest pain that radiates to the back. The patient rates the severity as 10/10 on the visual analogue scale. You note the patient is prescribed medication for hypertension but the patient admits she rarely takes her tablets. The patient's observations are shown below:

      Blood pressure 180/88 mmHg
      Pulse rate 92 bpm
      Respiration rate 22 rpm
      Oxygen sats 97% on air
      Temperature 37.2ºC

      Chest X-ray shows a widened mediastinum. You prescribe antihypertensive therapy. What is the target systolic blood pressure in this patient?

      Your Answer:

      Correct Answer: 100-120 mmHg

      Explanation:

      To manage aortic dissection, it is important to lower the systolic blood pressure to a range of 100-120 mmHg. This helps decrease the strain on the damaged artery and minimizes the chances of the dissection spreading further. In this patient, symptoms such as tearing chest pain and a widened mediastinum on the chest X-ray are consistent with 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
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  • Question 89 - A 62-year-old woman presents with severe otalgia in her right ear that has...

    Incorrect

    • A 62-year-old woman presents with severe otalgia in her right ear that has been gradually worsening over the past few weeks. She describes the pain as ‘constant’, and she has been unable to sleep for several nights. Her family have noticed that the right side of her face appears to be ‘drooping’. Her past medical history includes poorly controlled type 2 diabetes mellitus. She was diagnosed with otitis externa by a colleague a few weeks earlier, but the pain has failed to settle despite two separate courses of antibiotic drops. On examination, she has a right-sided lower motor neuron facial nerve palsy. Her right ear canal is very swollen and purulent exudate is visible. You are unable to clearly view her tympanic membrane. A swab of the ear taken last week has cultured Pseudomonas aeruginosa.
      What is the SINGLE most likely diagnosis?

      Your Answer:

      Correct Answer: Malignant otitis externa

      Explanation:

      Malignant otitis externa (MOE), also known as necrotising otitis externa, is a rare type of ear infection that primarily affects older individuals with diabetes, particularly if their diabetes is poorly managed.

      MOE initially starts as an infection in the ear canal and gradually spreads to the surrounding bone and soft tissues. In about 98% of cases, the responsible pathogen is Pseudomonas aeruginosa.

      Typically, MOE presents with intense ear pain and persistent inflammation of the ear canal that does not respond well to topical antibiotics. The pain is often described as constant and tends to worsen at night. Even after the swelling of the ear canal subsides with the use of topical antibiotics, the pain may persist. Other symptoms that may be present 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 also be affected.

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

      To diagnose MOE, technetium scanning and contrast-enhanced CT scanning are typically performed. Treatment usually involves long-term administration of intravenous antibiotics.

    • This question is part of the following fields:

      • Ear, Nose & Throat
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  • Question 90 - A 4-year-old child is brought in by ambulance. He has been experiencing seizures...

    Incorrect

    • A 4-year-old child is brought in by ambulance. He has been experiencing seizures for the past 20 minutes. He has already received one dose of rectal diazepam from the ambulance crew while on the way. Intravenous access has been established, his bowel movement is 4.5, and he weighs 25 kg.

      Based on the current APLS guidelines, what would be the most suitable next course of action in managing his condition?

      Your Answer:

      Correct Answer: IV lorazepam 2.5 mg

      Explanation:

      The current algorithm for treating a convulsing child, known as APLS, is as follows:

      Step 1 (5 minutes after the start of convulsion):
      If a child has been convulsing for 5 minutes or more, they should be given an initial dose of benzodiazepine. This can be administered intravenously (IV) or intraosseously (IO) if vascular access is available. Alternatively, buccal midazolam or rectal diazepam can be given if vascular access is not available.

      Step 2 (10 minutes after the start of step 1):
      If the convulsion continues for another 10 minutes, a second dose of benzodiazepine should be given. It is also important to seek senior help at this point.

      Step 3 (10 minutes after the start of step 2):
      At this stage, it is necessary to involve senior medical personnel to reassess the child and provide guidance on further management. The recommended approach is as follows:
      – If the child is not already receiving phenytoin, a phenytoin infusion should be initiated. This involves administering 20 mg/kg of phenytoin intravenously over a period of 20 minutes.
      – If the child is already taking phenytoin, phenobarbitone can be used instead. The recommended dosage is 20 mg/kg administered intravenously over 20 minutes.
      – In the meantime, rectal paraldehyde can be considered at a dose of 0.8 ml/kg of the 50:50 mixture while preparing the infusion.

      Step 4 (20 minutes after the start of step 3):
      If the child is still experiencing convulsions at this stage, it is crucial to have an anaesthetist present. A rapid sequence induction with thiopental is recommended for further management.

      In the case of this specific child who weighs 25 kg and has already received a dose of lorazepam, they should receive a second dose of 0.1 mg/kg, which amounts to 2.5 mg.

    • This question is part of the following fields:

      • Neurology
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  • Question 91 - A 30-year-old construction worker comes in with intense pain in his left eye...

    Incorrect

    • A 30-year-old construction worker comes in with intense pain in his left eye following an incident at the job site where a significant amount of cement dust entered his left eye.
      Which of the following long-term complications is the LEAST probable to develop?

      Your Answer:

      Correct Answer: Open-angle glaucoma

      Explanation:

      Cement contains lime, which is a powerful alkali, and this can cause a serious eye emergency that requires immediate treatment. Alkaline chemicals, such as oven cleaner, ammonia, household bleach, drain cleaner, oven cleaner, and plaster, can also cause damage to the eyes. They lead to colliquative necrosis, which is a type of tissue death that results in liquefaction. On the other hand, acids cause damage through coagulative necrosis. Common acids that can harm the eyes include toilet cleaners, certain household cleaning products, and battery fluid.

      The initial management of a patient with cement or alkali exposure to the eyes should be as follows:

      1. Irrigate the eye with a large amount of normal saline for 20-30 minutes.
      2. Administer local anaesthetic drops every 5 minutes to help keep the eye open and alleviate pain.
      3. Monitor the pH every 5 minutes until a neutral pH (7.0-7.5) is achieved. Briefly pause irrigation to test the fluid from the forniceal space using litmus paper.

      After the initial management, a thorough examination should be conducted, which includes the following steps:

      1. Examine the eye directly and with a slit lamp.
      2. Remove any remaining cement debris from the surface of the eye.
      3. Evert the eyelids to check for hidden cement debris.
      4. Administer fluorescein drops and check for corneal abrasion.
      5. Assess visual acuity, which may be reduced.
      6. Perform fundoscopy to check for retinal necrosis if the alkali has penetrated the sclera.
      7. Measure intraocular pressure through tonometry to detect secondary glaucoma.

      Once the eye’s pH has returned to normal, irrigation can be stopped, and the patient should be promptly referred to an ophthalmology specialist for further evaluation.

      Potential long-term complications of cement or alkali exposure to the eyes include closed-angle glaucoma, cataract formation, entropion, keratitis sicca, and permanent vision loss.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 92 - A 14 year old patient is brought into the emergency department struggling to...

    Incorrect

    • A 14 year old patient is brought into the emergency department struggling to breathe. Upon initial assessment, you observe tracheal deviation to the right, absence of breath sounds in the left hemithorax, and hyper-resonant percussion in the left hemithorax.

      What is the most crucial immediate intervention for this patient?

      Your Answer:

      Correct Answer: Needle thoracocentesis

      Explanation:

      The key initial management for tension pneumothorax is needle thoracocentesis. This procedure is crucial as it rapidly decompresses the tension and allows for more definitive management to be implemented. It is important to note that according to ATLS guidelines, needle thoracocentesis should no longer be performed at the second intercostal space midclavicular line. Studies have shown that the fourth or fifth intercostal space midaxillary line is more successful in reaching the thoracic cavity in adult patients. Therefore, ATLS now recommends this location for needle decompression in adult patients.

      Further Reading:

      A pneumothorax is an abnormal collection of air in the pleural cavity of the lung. It can be classified by cause as primary spontaneous, secondary spontaneous, or traumatic. Primary spontaneous pneumothorax occurs without any obvious cause in the absence of underlying lung disease, while secondary spontaneous pneumothorax occurs in patients with significant underlying lung diseases. Traumatic pneumothorax is caused by trauma to the lung, often from blunt or penetrating chest wall injuries.

      Tension pneumothorax is a life-threatening condition where the collection of air in the pleural cavity expands and compresses normal lung tissue and mediastinal structures. It can be caused by any of the aforementioned types of pneumothorax. Immediate management of tension pneumothorax involves the ABCDE approach, which includes ensuring a patent airway, controlling the C-spine, providing supplemental oxygen, establishing IV access for fluid resuscitation, and assessing and managing other injuries.

      Treatment of tension pneumothorax involves needle thoracocentesis as a temporary measure to provide immediate decompression, followed by tube thoracostomy as definitive management. Needle thoracocentesis involves inserting a 14g cannula into the pleural space, typically via the 4th or 5th intercostal space midaxillary line. If the patient is peri-arrest, immediate thoracostomy is advised.

      The pathophysiology of tension pneumothorax involves disruption to the visceral or parietal pleura, allowing air to flow into the pleural space. This can occur through an injury to the lung parenchyma and visceral pleura, or through an entry wound to the external chest wall in the case of a sucking pneumothorax. Injured tissue forms a one-way valve, allowing air to enter the pleural space with inhalation but prohibiting air outflow. This leads to a progressive increase in the volume of non-absorbable intrapleural air with each inspiration, causing pleural volume and pressure to rise within the affected hemithorax.

    • This question is part of the following fields:

      • Respiratory
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  • Question 93 - A 68-year-old woman, who has been smoking for her entire life, is diagnosed...

    Incorrect

    • A 68-year-old woman, who has been smoking for her entire life, is diagnosed with a small cell carcinoma of the lung. After further examination, it is revealed that she has developed the syndrome of inappropriate ADH secretion (SIADH) as a result of this.
      What kind of electrolyte disturbance would you anticipate in this case?

      Your Answer:

      Correct Answer: Low serum Na, low serum osmolarity, high urine osmolarity

      Explanation:

      Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is characterized by the excessive and uncontrollable release of antidiuretic hormone (ADH). This can occur either from the posterior pituitary gland or from an abnormal non-pituitary source. There are various conditions that can disrupt the regulation of ADH secretion in the central nervous system and lead to SIADH. These include CNS damage such as meningitis or subarachnoid hemorrhage, paraneoplastic syndromes like small cell carcinoma of the lung, infections such as atypical pneumonia or cerebral abscess, and certain drugs like carbamazepine, TCAs, and SSRIs.

      The typical biochemical profile observed in SIADH is characterized by low levels of serum sodium (usually less than 135 mmol/l), low serum osmolality, and high urine osmolality.

    • This question is part of the following fields:

      • Oncological Emergencies
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  • Question 94 - A 42-year-old man has been brought into the Emergency Department, experiencing seizures that...

    Incorrect

    • A 42-year-old man has been brought into the Emergency Department, experiencing seizures that have lasted for 40 minutes before his arrival. On arrival, he is still having a tonic-clonic seizure. He is a known epileptic and is currently taking lamotrigine for seizure prevention. He has received a single dose of rectal diazepam by the paramedics en route approximately 15 minutes ago. His vital signs are as follows: HR 92, BP 120/70, SaO2 98% on high flow oxygen, temperature is 36.8°C. His blood glucose level is 4.5 mmol/L, and he has an intravenous line in place.
      Which of the following medications would be most appropriate to administer next?

      Your Answer:

      Correct Answer: Intravenous lorazepam

      Explanation:

      Status epilepticus is a condition characterized by continuous seizure activity lasting for 5 minutes or more without the return of consciousness, or recurrent seizures (2 or more) without a period of neurological recovery in between. In such cases, the next step in managing the patient would be to administer a second dose of benzodiazepine. Since the patient already has an intravenous line in place, this would be the most appropriate route to choose.

      The management of status epilepticus involves several general measures, which are outlined in the following table:

      1st stage (Early status, 0-10 minutes):
      – Secure the airway and provide resuscitation
      – Administer oxygen
      – Assess cardiorespiratory function
      – Establish intravenous access

      2nd stage (0-30 minutes):
      – Institute regular monitoring
      – Consider the possibility of non-epileptic status
      – Start emergency antiepileptic drug (AED) therapy
      – Perform emergency investigations
      – Administer glucose (50 ml of 50% solution) and/or intravenous thiamine as Pabrinex if there is any suggestion of alcohol abuse or impaired nutrition
      – Treat severe acidosis if present

      3rd stage (0-60 minutes):
      – Determine the underlying cause of status epilepticus
      – Alert the anaesthetist and intensive care unit (ITU)
      – Identify and treat any medical complications
      – Consider pressor therapy when appropriate

      4th stage (30-90 minutes):
      – Transfer the patient to the intensive care unit
      – Establish intensive care and EEG monitoring
      – Initiate intracranial pressure monitoring if necessary
      – Start initial long-term, maintenance AED therapy

      Emergency investigations for status epilepticus include blood tests for gases, glucose, renal and liver function, calcium and magnesium, full blood count (including platelets), blood clotting, and AED drug levels. Serum and urine samples should be saved for future analysis, including toxicology if the cause of the convulsive status epilepticus is uncertain. A chest radiograph may be performed to evaluate the possibility of aspiration. Additional investigations, such as brain imaging or lumbar puncture, depend on the clinical circumstances.

      Monitoring during the management of status epilepticus involves regular neurological observations and measurements of pulse, blood pressure, and temperature. ECG, biochemistry, blood gases, clotting, and blood count should also be monitored.

    • This question is part of the following fields:

      • Neurology
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  • Question 95 - A 40-year-old woman presents with a painful, swollen right ankle following a recent...

    Incorrect

    • A 40-year-old woman presents with a painful, swollen right ankle following a recent hike in the mountains. You assess her for a possible sprained ankle.
      At which of the following locations do the NICE guidelines recommend that you measure the ankle circumference?

      Your Answer:

      Correct Answer: 10 cm below the tibial tuberosity

      Explanation:

      The NICE guidelines for suspected deep vein thrombosis (DVT) suggest considering the possibility of DVT if typical symptoms and signs are present, particularly if the person has risk factors like previous venous thromboembolism and immobility.

      Typical signs and symptoms of DVT include unilateral localized pain (often throbbing) that occurs during walking or bearing weight, as well as calf swelling (or, less commonly, swelling of the entire leg). Other signs to look out for are tenderness, skin changes such as edema, redness, and warmth, and vein distension.

      To rule out other potential causes for the symptoms and signs, it is important to conduct a physical examination and review the person’s general medical history.

      When assessing leg and thigh swelling, it is recommended to measure the circumference of the leg 10 cm below the tibial tuberosity and compare it with the unaffected leg. A difference of more than 3 cm between the two legs increases the likelihood of DVT.

      Additionally, it is important to check for edema and dilated collateral superficial veins on the affected side.

      To assess the likelihood of DVT and guide further management, the two-level DVT Wells score can be used.

      For more information, you can refer to the NICE Clinical Knowledge Summary on deep vein thrombosis.

    • This question is part of the following fields:

      • Vascular
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  • Question 96 - A 60-year-old woman comes in with a red, hot, swollen great toe. The...

    Incorrect

    • A 60-year-old woman comes in with a red, hot, swollen great toe. The diagnosis is acute gout. You decide to start her on a non-steroidal anti-inflammatory drug (NSAID). Her husband was recently diagnosed with a peptic ulcer after an endoscopy, and she is worried about the potential side effects of NSAIDs.
      Which of the following NSAIDs has the lowest occurrence of side effects?

      Your Answer:

      Correct Answer: Ibuprofen

      Explanation:

      The differences in anti-inflammatory activity among NSAIDs are minimal, but there is significant variation in how individuals respond to and tolerate these drugs. Approximately 60% of patients will experience a positive response to any NSAID, and those who do not respond to one may find relief with another. Pain relief typically begins shortly after taking the first dose, and a full analgesic effect is usually achieved within a week. However, it may take up to 3 weeks to see an anti-inflammatory effect, which may not be easily assessed. If desired results are not achieved within these timeframes, it is recommended to try a different NSAID.

      NSAIDs work by reducing the production of prostaglandins through the inhibition of the enzyme cyclo-oxygenase. Different NSAIDs vary in their selectivity for inhibiting different types of cyclo-oxygenase. Selective inhibition of cyclo-oxygenase-2 is associated with a lower risk of gastrointestinal intolerance. Other factors also play a role in susceptibility to gastrointestinal effects, so the choice of NSAID should consider the incidence of gastrointestinal and other side effects.

      Ibuprofen, a propionic acid derivative, possesses anti-inflammatory, analgesic, and antipyretic properties. It generally has fewer side effects compared to other non-selective NSAIDs, but its anti-inflammatory properties are weaker. For rheumatoid arthritis, doses of 1.6 to 2.4 g daily are required, and it may not be suitable for conditions where inflammation is prominent, such as acute gout.

      Naproxen is often a preferred choice due to its combination of good efficacy and low incidence of side effects. However, it does have a higher occurrence of side effects compared to ibuprofen.

      Ketoprofen and diclofenac have similar anti-inflammatory properties to ibuprofen but are associated with more side effects.

      Indometacin has an action that is equal to or superior to naproxen, but it also has a high incidence of side effects, including headache, dizziness, and gastrointestinal disturbances.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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  • Question 97 - You evaluate a 40-year-old man with a sudden onset entrapment neuropathy involving the...

    Incorrect

    • You evaluate a 40-year-old man with a sudden onset entrapment neuropathy involving the ulnar nerve in his left arm.
      Which of the following hand muscles is MOST likely to be impacted in this individual?

      Your Answer:

      Correct Answer: Medial two lumbricals

      Explanation:

      The ulnar nerve provides innervation to several muscles in the hand. These include the palmar interossei, dorsal interossei, medial two lumbricals, and abductor digiti minimi. On the other hand, the median nerve innervates the opponens pollicis, lateral two lumbricals, and flexor pollicis brevis. Lastly, the radial nerve is responsible for innervating the extensor digitorum muscle.

    • This question is part of the following fields:

      • Neurology
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  • Question 98 - A 32-year-old woman comes in with a history of worsening wheezing for the...

    Incorrect

    • A 32-year-old woman comes in with a history of worsening wheezing for the past two days. She has a history of seasonal allergies in the summer months, which have been more severe than usual in recent weeks. On auscultation of her chest, scattered polyphonic wheezes are heard. Her peak flow at presentation is 275 L/min, and her personal best peak flow is 500 L/min.
      How would you categorize this asthma episode?

      Your Answer:

      Correct Answer: Moderate asthma

      Explanation:

      This man is experiencing an acute asthma episode. His initial peak flow is 55% of his best, indicating a moderate exacerbation according to the BTS guidelines. Acute asthma can be classified as moderate, acute severe, life-threatening, or near-fatal.

      Moderate asthma is characterized by increasing symptoms and a peak expiratory flow rate (PEFR) between 50-75% of the individual’s best or predicted value. There are no signs of acute severe asthma in this case.

      Acute severe asthma is identified by any one of the following criteria: a PEFR between 33-50% of the best or predicted value, a respiratory rate exceeding 25 breaths per minute, a heart rate over 110 beats per minute, or the inability to complete sentences in one breath.

      Life-threatening asthma is indicated by any one of the following: a PEFR below 33% of the best or predicted value, oxygen saturation (SpO2) below 92%, arterial oxygen pressure (PaO2) below 8 kPa, normal arterial carbon dioxide pressure (PaCO2) between 4.6-6.0 kPa, a silent chest, cyanosis, poor respiratory effort, arrhythmia, exhaustion, altered conscious level, or hypotension.

      Near-fatal asthma is characterized by elevated PaCO2 levels and/or the need for mechanical ventilation with increased inflation pressures.

    • This question is part of the following fields:

      • Respiratory
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  • Question 99 - You admit a 65-year-old woman to the clinical decision unit (CDU) following a...

    Incorrect

    • You admit a 65-year-old woman to the clinical decision unit (CDU) following a fall at her assisted living facility. You can see from her notes that she has mild-to-moderate Alzheimer’s disease. While writing up her drug chart, you note that there are some medications you are not familiar with.
      Which ONE of the following medications can be used as a first-line drug in the management of mild-to-moderate Alzheimer’s disease?

      Your Answer:

      Correct Answer: Rivastigmine

      Explanation:

      According to NICE, one of the recommended treatments for mild-to-moderate Alzheimer’s disease is the use of acetylcholinesterase (AChE) inhibitors. These inhibitors include Donepezil (Aricept), Galantamine, and Rivastigmine. They work by inhibiting the enzyme that breaks down acetylcholine, a neurotransmitter involved in memory and cognitive function.

      On the other hand, Memantine is a different type of medication that acts by blocking NMDA-type glutamate receptors. It is recommended for patients with moderate Alzheimer’s disease who cannot tolerate or have a contraindication to AChE inhibitors, or for those with severe Alzheimer’s disease.

    • This question is part of the following fields:

      • Elderly Care / Frailty
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  • Question 100 - You request your colleague to assess a patient you have evaluated with wrist...

    Incorrect

    • You request your colleague to assess a patient you have evaluated with wrist discomfort. After conducting a thorough history and examination, your colleague diagnoses the individual with de Quervain's tenosynovitis.
      Which specific tendon is commonly impacted in cases of de Quervain's tenosynovitis?

      Your Answer:

      Correct Answer: Extensor pollicis brevis

      Explanation:

      De Quervain’s tenosynovitis is a condition characterized by inflammation and thickening of the sheath that contains the tendons of the extensor pollicis brevis and abductor pollicis longus. This leads to pain on the radial side of the wrist. The condition is more commonly observed in men than women, particularly in the age group of 30 to 50 years. It is often associated with repetitive activities that involve pinching and grasping.

      During examination, swelling and tenderness along the tendon sheath may be observed. The tendon sheath itself may also appear thickened. The most pronounced tenderness is usually felt over the tip of the radial styloid. A positive Finkelstein’s test, which involves flexing the wrist and moving it towards the ulnar side while the thumb is flexed across the palm, can help confirm the diagnosis.

      Treatment for De Quervain’s tenosynovitis involves avoiding movements that can trigger symptoms and using a thumb splint to immobilize the thumb. In cases where symptoms persist, a local corticosteroid injection or surgical decompression may be considered.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
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SESSION STATS - PERFORMANCE PER SPECIALTY

Trauma (4/7) 57%
Elderly Care / Frailty (3/3) 100%
Endocrinology (4/4) 100%
Pharmacology & Poisoning (4/7) 57%
Environmental Emergencies (1/1) 100%
Resus (3/3) 100%
Ear, Nose & Throat (1/1) 100%
Infectious Diseases (2/2) 100%
Cardiology (1/2) 50%
Respiratory (0/2) 0%
Neurology (1/1) 100%
Palliative & End Of Life Care (0/1) 0%
Musculoskeletal (non-traumatic) (1/1) 100%
Urology (2/2) 100%
Haematology (0/1) 0%
Dermatology (0/1) 0%
Mental Health (1/1) 100%
Neonatal Emergencies (0/1) 0%
Passmed