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Question 1
Correct
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A 32-year-old man with a known history of diabetes presents with fatigue, frequent urination, and blurred vision. His blood glucose levels are significantly elevated. He currently takes insulin injections and metformin for his diabetes. You organize for a urine sample to be taken and find that his ketone levels are markedly elevated, and he also has electrolyte abnormalities evident.
Which of the following electrolyte abnormalities is most likely to be present?Your Answer: Hypokalaemia
Explanation:The clinical manifestations of theophylline toxicity are more closely associated with acute poisoning rather than chronic overexposure. The primary clinical features of theophylline toxicity include headache, dizziness, nausea and vomiting, abdominal pain, tachycardia and dysrhythmias, seizures, mild metabolic acidosis, hypokalaemia, hypomagnesaemia, hypophosphataemia, hypo- or hypercalcaemia, and hyperglycaemia. Seizures are more prevalent in cases of acute overdose compared to chronic overexposure. In contrast, chronic theophylline overdose typically presents with minimal gastrointestinal symptoms. Cardiac dysrhythmias are more frequently observed in individuals who have experienced chronic overdose rather than acute overdose.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 2
Correct
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A 7-year-old boy is brought to the Emergency Department with lower abdominal pain and a high temperature. During the examination, he experiences tenderness in the right iliac fossa, leading to a working diagnosis of acute appendicitis. However, he adamantly refuses to flex his thigh at the hip. When his thigh is passively extended, his abdominal pain intensifies significantly.
What is the probable location of the appendix in this particular patient?Your Answer: Retrocaecal
Explanation:This patient is exhibiting the psoas sign, which is a medical indication of irritation in the iliopsoas group of hip flexors located in the abdomen. In this particular case, it is highly likely that the patient has acute appendicitis.
The psoas sign can be observed by extending the patient’s thigh while they are lying on their side with their knees extended, or by asking the patient to actively flex their thigh at the hip. If these movements result in abdominal pain or if the patient resists due to pain, then the psoas sign is considered positive.
The pain occurs because the psoas muscle is adjacent to the peritoneal cavity. When the muscles are stretched or contracted, they rub against the inflamed tissues nearby, causing discomfort. This strongly suggests that the appendix is positioned retrocaecal.
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This question is part of the following fields:
- Surgical Emergencies
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Question 3
Correct
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You are called to a VF cardiac arrest in the resus area of your Pediatric Emergency Department.
Epinephrine should be administered at which of the following points during a pediatric VF arrest?Your Answer: After the 3rd shock once chest compressions have been resumed
Explanation:Adrenaline is recommended to be administered after the third shock in a shockable cardiac arrest (Vf/pVT) once chest compressions have been resumed. The recommended dose is 1 mg, which can be administered as either 10 mL of a 1:10,000 solution or 1 mL of a 1:1000 solution.
Subsequently, adrenaline should be given every 3-5 minutes, alternating with chest compressions. It is important to administer adrenaline without interrupting chest compressions to ensure continuous circulation and maximize the chances of successful resuscitation.
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This question is part of the following fields:
- Cardiology
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Question 4
Correct
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Large numbers of casualties are observed after a suspected CBRN (chemical, biological, radiological, and nuclear) incident. It is believed that sarin gas is the responsible agent. Which combination of clinical features is most likely to be present?
Your Answer: Miosis, bronchorrhoea, salivation and muscle weakness
Explanation:The nerve agents, also known as nerve gases, are a group of highly toxic chemical warfare agents that were initially developed just before and during World War II.
The first compounds to be created are called the G agents (G stands for German, as they were discovered and synthesized by German scientists). These include Tabun (GA), Sarin (GB), and Soman (GD).
In the 1950s, the V agents (V stands for venomous) were synthesized and are approximately 10 times more poisonous than sarin. These include Venomous agent X (VX), Venomous agent E (VE), Venomous agent G (VG), and Venomous agent M (VM).
One of the most well-known incidents involving the use of a nerve agent was the March 1995 Tokyo subway sarin attack. During this attack, Sarin was released into the Tokyo subway system during rush hour. As a result, over 5,000 people sought medical attention. Among them, 984 were moderately poisoned, 54 were severely poisoned, and 12 died.
Nerve agents are organophosphorus esters that are chemically related to organophosphorus insecticides. They work by inhibiting acetylcholinesterase (AChE), an enzyme that breaks down the neurotransmitter acetylcholine (ACh). This leads to an accumulation of ACh at both muscarinic and nicotinic cholinergic receptors.
Nerve agents can be absorbed through any body surface. When dispersed as a spray or aerosol, they can be absorbed through the skin, eyes, and respiratory tract. When dispersed as a vapor, they are primarily absorbed through the respiratory tract and eyes. If a sufficient amount of agent is absorbed, local effects are followed by generalized systemic effects.
The clinical features observed after exposure are a result of a combination of muscarinic, nicotinic, and central nervous system effects.
Muscarinic effects (DUMBBELS):
– Diarrhea
– Urination
– Miosis
– Bronchorrhea
– Bronchospasm
– Emesis
– Lacrimation
– Salivation
Plus bradycardia and hypotension.Nicotinic effects:
– Sweating
– Tremor
– Fasciculations
– Muscle weakness
– Flaccid paralysisCentral nervous system effects:
– Agitation and irritability
– Amnesia
– Ataxia
– Respiratory -
This question is part of the following fields:
- Major Incident Management & PHEM
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Question 5
Correct
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You are requested to evaluate a 62-year-old individual who has arrived with complaints of chest discomfort. The nurse has handed you the ECG report, as the ECG machine has indicated 'anterior infarction' in its comments.
Which leads would you anticipate observing ST elevation in an acute anterior STEMI?Your Answer: V3-V4
Explanation:The leads V3 and V4 represent the anterior myocardial area.
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.
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This question is part of the following fields:
- Cardiology
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Question 6
Correct
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A 40-year-old male patient presents with a history of dizziness and fainting episodes. He has also been suffering from a mild flu-like illness for the past few days. He had a syncopal episode in the department and was moved into the resuscitation area. His observations are as follows: Temperature 38.4°C, HR 112, BP 78/44, oxygen saturation 98% on high-flow oxygen, GCS 14/15, BM 1.5.
His initial blood results are shown below:
Na+: 118 mmol/l
K+: 6.1 mmol/l
Urea: 11.6 mmol/l
Creatinine: 132 mmol/l
What is the SINGLE most likely diagnosis?Your Answer: Addisonian crisis
Explanation:This patient has presented with an Addisonian crisis, which is a rare but potentially catastrophic condition if not diagnosed promptly. It is more commonly seen in women than men and typically occurs between the ages of 30 and 50.
Addison’s disease is caused by insufficient production of steroid hormones by the adrenal glands, affecting the production of glucocorticoids, mineralocorticoids, and sex steroids. The main causes of Addison’s disease include autoimmune adrenalitis (accounting for 80% of cases), bilateral adrenalectomy, Waterhouse-Friderichsen syndrome (hemorrhage into the adrenal glands), and tuberculosis.
The most common trigger for an Addisonian crisis in patients with Addison’s disease is the intentional or accidental withdrawal of steroid therapy. Other factors that can precipitate a crisis include infection, trauma, myocardial infarction, cerebral infarction, asthma, hypothermia, and alcohol abuse.
Clinical features of Addison’s disease include weakness, lethargy, hypotension (especially orthostatic hypotension), nausea, vomiting, weight loss, reduced axillary and pubic hair, depression, and hyperpigmentation (particularly in palmar creases, buccal mucosa, and exposed areas). In an Addisonian crisis, the main symptoms are usually hypoglycemia and shock, characterized by tachycardia, peripheral vasoconstriction, hypotension, altered consciousness, and even coma.
Biochemical markers of Addison’s disease typically include increased ACTH levels (as a compensatory response to stimulate the adrenal glands), elevated serum renin levels, hyponatremia, hyperkalemia, hypercalcemia, hypoglycemia, and metabolic acidosis. Confirmatory investigations may involve the Synacthen test, plasma ACTH level measurement, plasma renin level measurement, and testing for adrenocortical antibodies.
Management of Addison’s disease should be overseen by an Endocrinologist. Treatment usually involves the administration of hydrocortisone, fludrocortisone, and dehydroepiandrosterone. Some patients may also require thyroxine if there is concurrent hypothalamic-pituitary disease. Treatment is lifelong, and patients should carry a steroid card and MedicAlert bracelet to alert healthcare professionals about their condition and the potential for an Addisonian crisis.
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This question is part of the following fields:
- Endocrinology
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Question 7
Correct
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A 40-year-old woman presents with sudden onset shortness of breath and right-sided pleuritic chest pain. She has recently returned from a vacation in Australia. Her vital signs are as follows: temperature 38.2°C, oxygen saturation 93% on room air, heart rate 110 bpm, respiratory rate 24, blood pressure 122/63 mmHg. On examination, she has a tender, swollen left calf. Her chest X-ray shows no apparent abnormalities.
What is the PRIMARY diagnosis in this case?Your Answer: Pulmonary embolism
Explanation:Based on the clinical history and examination, it strongly indicates that the patient has developed a pulmonary embolism due to a deep vein thrombosis in his right leg.
The symptoms commonly associated with a pulmonary embolism include shortness of breath, pleuritic chest pain, coughing, and/or coughing up blood. These symptoms may also suggest the presence of a deep vein thrombosis. Other clinical features that may be observed are rapid breathing and heart rate, fever, and in severe cases, signs of systemic shock, a gallop heart rhythm, and increased jugular venous pressure.
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This question is part of the following fields:
- Respiratory
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Question 8
Correct
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You intend to administer plain 1% lidocaine for a peripheral nerve block on a healthy young male weighing 70 kg. What is the maximum amount of plain lidocaine that can be given in this scenario?
Your Answer: 200 mg lidocaine hydrochloride
Explanation:The maximum safe dose of plain lidocaine is 3 mg per kilogram of body weight, with a maximum limit of 200 mg. However, when administered with adrenaline 1:200,000, the maximum safe dose increases to 7 mg per kilogram of body weight, with a maximum limit of 500 mg.
For example, if a patient weighs 70 kg, the maximum safe dose of lidocaine hydrochloride would be 210 mg. However, according to the British National Formulary (BNF), the maximum safe dose is actually 200 mg.
For more information on lidocaine hydrochloride, please refer to the BNF section dedicated to this medication.
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This question is part of the following fields:
- Pain & Sedation
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Question 9
Correct
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A 35-year-old female presents to the emergency department complaining of abdominal pain accompanied by diarrhea. She states that she has experienced several similar episodes over the past year, with the diarrhea often being watery and bloody. The patient also reports feeling constantly fatigued recently. Upon examination, tenderness is noted upon deep palpation in both lower quadrants, but there is no guarding or rigidity. Bowel sounds are audible. The patient's vital signs and initial blood test results are as follows:
Blood pressure: 140/82 mmHg
Pulse: 93 bpm
Respiration rate: 16 bpm
Oxygen saturations: 98% on room air
Temperature: 37.3ºC
Hemoglobin: 111 g/l
Platelets: 324 * 109/l
White blood cells: 11.2 * 109/l
Mean corpuscular volume: 78 fL
Ferritin: 21 ng/mL
The patient has not traveled abroad in years due to COVID-19 and rarely consumes alcohol. Which of the following tests would be most helpful in confirming the suspected diagnosis?Your Answer: Colonoscopy
Explanation:Colonoscopy with histology is a useful tool in determining the extent and severity of ulcerative colitis. Chronic bloody diarrhea, lasting for more than four weeks, can be caused by various conditions. In this age group, the top differentials include inflammatory bowel disease (IBD) and infective causes such as C.diff and giardia. Other potential causes include drug use (such as laxatives and alcohol), hyperthyroidism (usually accompanied by other signs), coeliac disease (although blood in the stool is not a common symptom), and malabsorption syndromes like pancreatic insufficiency.
When IBD is suspected, fecal calprotectin is often tested and typically found to be elevated. This test is usually performed before colonoscopy and biopsy in individuals under 40 years old. However, in those over 40, a colonoscopy is often the initial investigation to assess for possible underlying malignancy. It is important to note that calprotectin is not specific to IBD and can also be elevated in other conditions such as infectious enteritis and colorectal neoplasia, which limits its diagnostic value. NICE guidelines advise against using calprotectin in individuals with bloody diarrhea.
Initial investigations for chronic bloody diarrhea should include thyroid function testing, coeliac screening, and stool analysis for microscopy and culture. It is worth noting that different hospitals may vary in the specific tests included in stool microscopy and culture, but most labs will typically test for ova, cysts, and parasites. Stool antigen tests are commonly used to detect H.pylori. Vitamin B12 testing may also be appropriate, although deficiency in this vitamin usually leads to a macrocytic anemia and is therefore unlikely to contribute significantly to the diagnosis.
Further Reading:
Inflammatory bowel disease (IBD) is a chronic condition characterized by inflammation of the intestinal tract and an imbalance of the intestinal microbiota. The two main forms of IBD are Crohn’s disease and ulcerative colitis (UC). In some cases, it is not possible to differentiate between Crohn’s disease and UC, and the term inflammatory bowel disease type-unclassified may be used.
Crohn’s disease is a chronic, relapsing-remitting inflammatory disease that can affect any part of the gastrointestinal tract, from the mouth to the anus. It most commonly involves the ileum and colon. The inflammation in Crohn’s disease affects all layers of the intestinal wall, leading to complications such as strictures, fistulas, and adhesions. Risk factors for developing Crohn’s disease include a family history, smoking, infectious gastroenteritis, appendicectomy, and the use of NSAIDs and oral contraceptive drugs. Symptoms of Crohn’s disease can vary but often include diarrhea, abdominal pain, weight loss, and perianal disease. Extraintestinal features, such as arthritis, erythema nodosum, and uveitis, can also occur.
Ulcerative colitis is a chronic, relapsing-remitting inflammatory disease that primarily affects the large bowel. The inflammation in UC is limited to the intestinal mucosa and does not involve skip lesions like in Crohn’s disease. Risk factors for developing UC include a family history, not smoking, and no appendix. Symptoms of UC include bloody diarrhea, urgency, tenesmus, and abdominal pain. Extraintestinal features, such as arthritis and uveitis, can also occur. Complications of UC include toxic megacolon, bowel obstruction, bowel perforation, strictures, fistula formation, anemia, malnutrition, and colorectal cancer.
Diagnosing IBD involves various investigations, including blood tests, stool microscopy and culture, fecal calprotectin testing, endoscopy with biopsy, and imaging modalities such as CT and MR enterography. The management of Crohn’s disease and UC is complex and may involve corticosteroids, immunosuppressive drugs, biologic therapy, surgery, and nutritional support. Patients with IBD should also be monitored for nutritional deficiencies, colorectal cancer, and osteoporosis.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 10
Correct
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A 30-year-old woman who is 10-weeks pregnant comes in with abdominal pain and vaginal bleeding. During the examination, her cervix is found to be open. A local early pregnancy assessment unit (EPAU) performs an ultrasound scan. The scan is unable to detect a fetal heartbeat but does show the presence of retained products of conception.
What is the SINGLE most probable diagnosis?Your Answer: Incomplete miscarriage
Explanation:An incomplete miscarriage occurs when a miscarriage occurs, but the products of conception have not been fully expelled from the uterus. This commonly happens between weeks 8 and 14 of pregnancy.
Symptoms of an incomplete miscarriage include pain and bleeding, and the cervix is usually open. A diagnosis can be confirmed through an ultrasound scan, which will show the absence of a fetal heartbeat and retained products.
Treatment for an incomplete miscarriage can be done medically, such as using misoprostol, or surgically, like undergoing an ERPC procedure.
There are potential complications that can arise from an incomplete miscarriage, including endometritis, myometritis, septic shock, and disseminated intravascular coagulation (DIC).
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 11
Correct
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You evaluate the pupillary light reflex in a patient with a cranial nerve impairment. Upon shining the light into the left eye, there is no alteration in pupil size in either the left or right eye. However, when the light is directed into the right eye, both the left and right pupils constrict.
What is the location of the lesion in this scenario?Your Answer: Left optic nerve
Explanation:The pupillary light reflex is a reflex that regulates the size of the pupil in response to the intensity of light that reaches the retina. It consists of two separate pathways, the afferent pathway and the efferent pathway.
The afferent pathway begins with light entering the pupil and stimulating the retinal ganglion cells in the retina. These cells then transmit the light signal to the optic nerve. At the optic chiasm, the nasal retinal fibers cross to the opposite optic tract, while the temporal retinal fibers remain in the same optic tract. The fibers from the optic tracts then project and synapse in the pretectal nuclei in the dorsal midbrain. From there, the pretectal nuclei send fibers to the ipsilateral Edinger-Westphal nucleus via the posterior commissure.
On the other hand, the efferent pathway starts with the Edinger-Westphal nucleus projecting preganglionic parasympathetic fibers. These fibers exit the midbrain and travel along the oculomotor nerve. They then synapse on post-ganglionic parasympathetic fibers in the ciliary ganglion. The post-ganglionic fibers, known as the short ciliary nerves, innervate the sphincter muscle of the pupils, causing them to constrict.
The result of these pathways is that when light is shone in one eye, both the direct pupillary light reflex (ipsilateral eye) and the consensual pupillary light reflex (contralateral eye) occur.
Lesions affecting the pupillary light reflex can be identified by comparing the direct and consensual reactions to light in both eyes. If the optic nerve of the first eye is damaged, both the direct and consensual reflexes in the second eye will be lost. However, when light is shone into the second eye, the pupil of the first eye will still constrict. If the optic nerve of the second eye is damaged, the second eye will constrict consensually when light is shone into the unaffected first eye. If the oculomotor nerve of the first eye is damaged, the first eye will have no direct light reflex, but the second eye will still constrict consensually. Finally, if the oculomotor nerve of the second eye is damaged, there will be no consensual constriction of the second eye when light is shone into the unaffected first eye.
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This question is part of the following fields:
- Ophthalmology
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Question 12
Correct
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You assess a patient who is currently undergoing systemic anticancer treatment. She has been experiencing chills and feeling unwell and is worried about the potential of having an infection. She informs you that she is currently prescribed an antibiotic as a preventive measure against neutropenic sepsis.
Which of the subsequent antibiotic classes is utilized for this specific purpose?Your Answer: Fluoroquinolones
Explanation:According to the latest guidelines from NICE, it is recommended that adult patients who are undergoing treatment for acute leukaemia, stem cell transplants, or solid tumours and are expected to experience significant neutropenia as a result of chemotherapy, should be offered prophylaxis with a fluoroquinolone such as ciprofloxacin (500 mg taken orally twice daily) during the period when neutropenia is expected. This is to help prevent the occurrence of neutropenic sepsis, a serious infection that can occur in cancer patients with low levels of neutrophils.
Reference:
NICE guidance: ‘Neutropenic sepsis: prevention and management of neutropenic sepsis in cancer patients’ -
This question is part of the following fields:
- Oncological Emergencies
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Question 13
Correct
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A 45-year-old hiker is brought in by helicopter after being stranded on a hillside overnight. The rescue team informs you that according to the Swiss Staging system, he is at stage III.
What is the most accurate description of his current medical condition?Your Answer: Unconscious
Explanation:Hypothermia occurs when the core body temperature drops below 35°C. It is categorized as mild (32-35°C), moderate (28-32°C), or severe (<28°C). Rescuers at the scene can use the Swiss staging system to describe the condition of victims. The stages range from clearly conscious and shivering to unconscious and not breathing, with death due to irreversible hypothermia being the most severe stage. There are several risk factors for hypothermia, including environmental exposure, unsatisfactory housing, poverty, lack of cold awareness, drugs, alcohol, acute confusion, hypothyroidism, and sepsis. The clinical features of hypothermia vary depending on the severity. At 32-35°C, symptoms may include apathy, amnesia, ataxia, and dysarthria. At 30-32°C, there may be a decreased level of consciousness, hypotension, arrhythmias, respiratory depression, and muscular rigidity. Below 30°C, ventricular fibrillation may occur, especially with excessive movement or invasive procedures. Diagnosing hypothermia involves checking the core temperature using an oesophageal, rectal, or tympanic probe with a low reading thermometer. Rectal and tympanic temperatures may lag behind core temperature and are unreliable in hypothermia. Various investigations should be carried out, including blood tests, blood glucose, amylase, blood cultures, arterial blood gas, ECG, chest X-ray, and CT head if there is suspicion of head injury or CVA. The management of hypothermia involves supporting the ABCs, treating the patient in a warm room, removing wet clothes and drying the skin, monitoring the ECG, providing warmed, humidified oxygen, correcting hypoglycemia with IV glucose, and handling the patient gently to avoid VF arrest. Rewarming methods include passive Rewarming with warm blankets or Bair hugger/polythene sheets, surface Rewarming with a water bath, core Rewarming with heated, humidified oxygen or peritoneal lavage, and extracorporeal Rewarming via cardiopulmonary bypass for severe hypothermia/cardiac arrest. In the case of hypothermic cardiac arrest, CPR should be performed with chest compressions and ventilations at standard rates.
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This question is part of the following fields:
- Environmental Emergencies
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Question 14
Correct
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A 35-year-old woman comes in with intense one-sided abdominal pain starting in the right flank and spreading to the groin. Her urine test shows blood. A CT scan is scheduled and confirms a diagnosis of ureteric colic. She was given diclofenac through an intramuscular injection, but her pain is still not well managed.
According to the latest NICE guidelines, what is the recommended next option for pain relief in this patient?Your Answer: Intravenous paracetamol
Explanation:Renal colic, also known as ureteric colic, refers to a sudden and intense pain in the lower back caused by a blockage in the ureter, which is the tube that carries urine from the kidney to the bladder. This condition is commonly associated with the presence of a urinary tract stone.
The main symptoms of renal or ureteric colic include severe abdominal pain on one side, starting in the lower back or flank and radiating to the groin or genital area in men, or to the labia in women. The pain comes and goes in spasms, lasting for minutes to hours, with periods of no pain or a dull ache. Nausea, vomiting, and the presence of blood in the urine are often accompanying symptoms.
People experiencing renal or ureteric colic are usually restless and unable to find relief by lying still, which helps to distinguish this condition from peritonitis. They may have a history of previous episodes and may also present with fever and sweating if there is an associated urinary infection. Some individuals may complain of painful urination, frequent urination, and straining when the stone reaches the junction between the ureter and the bladder, as the stone irritates the detrusor muscle.
In terms of pain management, the first-line treatment for adults, children, and young people with suspected renal colic is a non-steroidal anti-inflammatory drug (NSAID), which can be administered through various routes. If NSAIDs are contraindicated or not providing sufficient pain relief, intravenous paracetamol can be offered as an alternative. Opioids may be considered if both NSAIDs and intravenous paracetamol are contraindicated or not effective in relieving pain. Antispasmodics should not be given to individuals with suspected renal colic.
For more detailed information, you can refer to the NICE guidelines on the assessment and management of renal and ureteric stones.
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This question is part of the following fields:
- Urology
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Question 15
Incorrect
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A 45-year-old man presents with acute severe asthma. You initiate management for the patient, guided by the most recent BTS guidelines.
According to the BTS guidelines, which of the following is NOT a suitable treatment?Your Answer: 50 mg oral prednisolone
Correct Answer: 1 hourly ipratropium bromide nebulisers
Explanation:The BTS guidelines for managing acute asthma in adults provide the following recommendations:
Oxygen:
– It is important to give supplementary oxygen to all patients with acute severe asthma who have low levels of oxygen in their blood (hypoxemia). The goal is to maintain a blood oxygen saturation level (SpO2) between 94-98%. Even if pulse oximetry is not available, oxygen should still be administered.β2 agonists therapy:
– High-dose inhaled β2 agonists should be used as the first-line treatment for patients with acute asthma. It is important to administer these medications as early as possible.
– Intravenous β2 agonists should be reserved for patients who cannot reliably use inhaled therapy.
– For patients with life-threatening asthma symptoms, nebulized β2 agonists driven by oxygen are recommended.
– In cases of severe asthma that does not respond well to an initial dose of β2 agonist, continuous nebulization with an appropriate nebulizer may be considered.Ipratropium bromide:
– Nebulized ipratropium bromide (0.5 mg every 4-6 hours) should be added to β2 agonist treatment for patients with acute severe or life-threatening asthma, or those who do not respond well to initial β2 agonist therapy.Steroid therapy:
– Steroids should be given in adequate doses for all cases of acute asthma attacks.
– Prednisolone should be continued at a dose of 40-50 mg daily for at least five days or until the patient recovers.Other therapies:
– Nebulized magnesium is not recommended for the treatment of acute asthma in adults.
– A single dose of intravenous magnesium sulfate may be considered for patients with acute severe asthma (peak expiratory flow rate <50% of the best or predicted value) who do not respond well to inhaled bronchodilator therapy. However, this should only be done after consulting with senior medical staff.
– Routine prescription of antibiotics is not necessary for patients with acute asthma.For more information, please refer to the BTS/SIGN Guideline on the Management of Asthma.
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This question is part of the following fields:
- Respiratory
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Question 16
Correct
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A 45-year-old man presents with a history of feeling generally unwell and having experienced fevers at home. He has a history of lung cancer for which he is currently receiving radiation therapy. His observations are as follows: HR 92 bpm, BP 130/80, SaO2 98% on air, temperature 38.9°C. A diagnosis of neutropenic sepsis is suspected.
According to the current NICE guidelines what is the cut off point for the neutrophil count for a diagnosis of neutropenic sepsis to be made?Your Answer: 0.5 x 109 per litre or lower
Explanation:Neutropenic sepsis is a serious complication that can arise when a person has low levels of neutrophils, which are a type of white blood cell. This condition can be life-threatening and is commonly seen in individuals undergoing treatments such as cytotoxic chemotherapy or taking immunosuppressive drugs. Other causes of neutropenia include infections, bone marrow disorders like aplastic anemia and myelodysplastic syndromes, as well as nutritional deficiencies.
To diagnose neutropenic sepsis, doctors look for specific criteria in patients receiving anticancer treatment. These criteria include having a neutrophil count of 0.5 x 109 per liter or lower, along with either a body temperature higher than 38°C or other signs and symptoms that indicate a clinically significant sepsis.
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This question is part of the following fields:
- Oncological Emergencies
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Question 17
Correct
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A 45 year old male comes to the emergency department complaining of raised itchy red skin lesions on his torso and upper limbs. After examination, you diagnose him with urticaria. You observe that the patient is currently on multiple medications for anxiety and pain management. What is the most frequently encountered drug that can cause urticaria?
Your Answer: Non-steroidal anti-inflammatory drugs (NSAIDs)
Explanation:Angioedema and urticaria are related conditions that involve swelling in different layers of tissue. Angioedema refers to swelling in the deeper layers of tissue, such as the lips and eyelids, while urticaria, also known as hives, refers to swelling in the epidermal skin layers, resulting in raised red areas of skin with itching. These conditions often coexist and may have a common underlying cause.
Angioedema can be classified into allergic and non-allergic types. Allergic angioedema is the most common type and is usually triggered by an allergic reaction, such as to certain medications like penicillins and NSAIDs. Non-allergic angioedema has multiple subtypes and can be caused by factors such as certain medications, including ACE inhibitors, or underlying conditions like hereditary angioedema (HAE) or acquired angioedema.
HAE is an autosomal dominant disease characterized by a deficiency of C1 esterase inhibitor. It typically presents in childhood and can be inherited or acquired as a result of certain disorders like lymphoma or systemic lupus erythematosus. Acquired angioedema may have similar clinical features to HAE but is caused by acquired deficiencies of C1 esterase inhibitor due to autoimmune or lymphoproliferative disorders.
The management of urticaria and allergic angioedema focuses on ensuring the airway remains open and addressing any identifiable triggers. In mild cases without airway compromise, patients may be advised that symptoms will resolve without treatment. Non-sedating antihistamines can be used for up to 6 weeks to relieve symptoms. Severe cases of urticaria may require systemic corticosteroids in addition to antihistamines. In moderate to severe attacks of allergic angioedema, intramuscular epinephrine may be considered.
The management of HAE involves treating the underlying deficiency of C1 esterase inhibitor. This can be done through the administration of C1 esterase inhibitor, bradykinin receptor antagonists, or fresh frozen plasma transfusion, which contains C1 inhibitor.
In summary, angioedema and urticaria are related conditions involving swelling in different layers of tissue. They can coexist and may have a common underlying cause. Management involves addressing triggers, using antihistamines, and in severe cases, systemic corticosteroids or other specific treatments for HAE.
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This question is part of the following fields:
- Dermatology
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Question 18
Correct
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A 45 year old female is brought into the emergency department with burns sustained in a house fire. You evaluate the patient for potential inhalation injury and the severity of the burns to the patient's limbs. In terms of the pathophysiology of burns, what is the central component of the burn known as according to the Jackson's Burn wound model?
Your Answer: Zone of coagulation
Explanation: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.
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This question is part of the following fields:
- Surgical Emergencies
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Question 19
Correct
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A 32-year-old man with a long-standing history of ulcerative colitis presents with a complication of his illness.
What is the SINGLE least likely complication that he has developed?Your Answer: Perianal fistula
Explanation:Ulcerative colitis can lead to various complications, although the development of fistulae is rare and less likely compared to other complications. Perianal complications associated with ulcerative colitis are uncommon and typically occur in cases with more extensive inflammation and a severe disease course.
The complications of ulcerative colitis can be categorized into localized and systemic complications. Localized complications include bleeding, electrolyte imbalance, toxic megacolon, perforation, an increased risk of colonic carcinoma, an increased risk of lymphoma, and the rare occurrence of stricture and fistula formation.
On the other hand, systemic complications of ulcerative colitis involve malnutrition and weight loss, iron-deficiency anemia, vitamin B12 deficiency, hypoproteinaemia, primary sclerosing cholangitis, primary biliary cirrhosis, chronic active hepatitis, joint pain or arthropathy, ankylosing spondylitis, pyoderma gangrenosum, and erythema nodosum. Additionally, ulcerative colitis can also lead to complications affecting the eyes, such as iritis, episcleritis, and uveitis.
Overall, while ulcerative colitis can present with various complications, the development of fistulae is rare and less likely compared to other complications. Perianal complications are infrequent and typically associated with more extensive inflammation and a severe disease course.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 20
Correct
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A 5-year-old girl is brought into the Emergency Department with stomach pain and throwing up. Her mom tells you that she has been losing weight lately and seems to be drinking a lot and peeing a lot. During the examination, she appears tired and you notice that she is dehydrated. She is breathing deeply and quickly. Her blood sugar levels are found to be extremely high when her blood is tested.
What is the MOST likely diagnosis?Your Answer: Diabetic ketoacidosis
Explanation:Diabetic ketoacidosis (DKA) is a life-threatening condition that occurs when there is a lack of insulin, leading to an inability to process glucose. This results in high blood sugar levels and excessive thirst. As the body tries to eliminate the excess glucose through urine, dehydration becomes inevitable. Without insulin, the body starts using fat as its main energy source, which leads to the production of ketones and a buildup of acid in the blood.
The main characteristics of DKA are high blood sugar levels (above 11 mmol/l), the presence of ketones in the blood or urine, and acidosis (low bicarbonate levels and/or low venous pH). Symptoms of DKA include nausea, vomiting, excessive thirst, frequent urination, abdominal pain, signs of dehydration, a distinct smell of ketones on the breath, rapid and deep breathing, confusion or reduced consciousness, and cardiovascular symptoms like rapid heartbeat, low blood pressure, and shock.
To diagnose DKA, various tests should be performed, including blood glucose measurement, urine dipstick test (which shows high levels of glucose and ketones), blood ketone assay (more accurate than urine dipstick), complete blood count, and electrolyte levels. Arterial or venous blood gas analysis can confirm the presence of metabolic acidosis.
The management of DKA involves careful fluid administration and insulin replacement. Fluid boluses should only be given if there are signs of shock and should be administered slowly in 10 ml/kg increments. Once shock is resolved, rehydration should be done over 48 hours. The first 20 ml/kg of fluid given for resuscitation should not be subtracted from the total fluid volume calculated for the 48-hour replacement. In cases of hypotensive shock, consultation with a pediatric intensive care specialist may be necessary.
Insulin replacement should begin 1-2 hours after starting intravenous fluid therapy. A soluble insulin infusion should be used at a dosage of 0.05-0.1 units/kg/hour. The goal is to bring blood glucose levels close to normal. Regular monitoring of electrolytes and blood glucose levels is important to prevent imbalances and rapid changes in serum osmolarity. Identifying and treating the underlying cause of DKA is also crucial.
When calculating fluid requirements for children and young people with DKA, assume a 5% fluid deficit for mild-to-moderate cases (blood pH of 7.1 or above) and a 10% fluid deficit in severe DKA (indicated by a blood pH below 7.1). The total replacement fluid to be given over 48 hours is calculated as follows: Hourly rate = (deficit/48 hours) + maintenance per hour.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 21
Correct
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A 65 year old patient arrives at the emergency department complaining of a productive cough and fever. The patient's primary care physician had prescribed antibiotics a few days ago to treat a suspected respiratory infection. The patient's INR is tested as they are on warfarin for atrial fibrillation. The INR comes back as 6.7. How should you approach managing this patient's elevated INR?
Your Answer: Withhold 1-2 doses of warfarin and recheck INR
Explanation:If a patient’s INR reading is above 5, it is necessary to take action. In this case, the patient’s INR is between 5 and 8, but there is no evidence of bleeding. According to the provided table, it is recommended to temporarily stop 1-2 doses of warfarin and closely monitor the INR. While it may be optional to switch antibiotics, it is not a crucial step in this situation.
Further Reading:
Management of High INR with Warfarin
Major Bleeding:
– Stop warfarin immediately.
– Administer intravenous vitamin K 5 mg.
– Administer 25-50 u/kg four-factor prothrombin complex concentrate.
– If prothrombin complex concentrate is not available, consider using fresh frozen plasma (FFP).
– Seek medical attention promptly.INR > 8.0 with Minor Bleeding:
– Stop warfarin immediately.
– Administer intravenous vitamin K 1-3mg.
– Repeat vitamin K dose if INR remains high after 24 hours.
– Restart warfarin when INR is below 5.0.
– Seek medical advice if bleeding worsens or persists.INR > 8.0 without Bleeding:
– Stop warfarin immediately.
– Administer oral vitamin K 1-5 mg using the intravenous preparation orally.
– Repeat vitamin K dose if INR remains high after 24 hours.
– Restart warfarin when INR is below 5.0.
– Seek medical advice if any symptoms or concerns arise.INR 5.0-8.0 with Minor Bleeding:
– Stop warfarin immediately.
– Administer intravenous vitamin K 1-3mg.
– Restart warfarin when INR is below 5.0.
– Seek medical advice if bleeding worsens or persists.INR 5.0-8.0 without Bleeding:
– Withhold 1 or 2 doses of warfarin.
– Reduce subsequent maintenance dose.
– Monitor INR closely and seek medical advice if any concerns arise.Note: In cases of intracranial hemorrhage, prothrombin complex concentrate should be considered as it is faster acting than fresh frozen plasma (FFP).
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This question is part of the following fields:
- Haematology
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Question 22
Correct
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A 30-year-old woman presents with a persistent sore throat that has been bothering her for five days. She has also been experiencing symptoms of a cold for the past few days and has a bothersome dry cough. Upon examination, she does not have a fever and there are no swollen lymph nodes in her neck. Her throat appears red overall, but her tonsils are not enlarged and there is no visible discharge.
Using the FeverPAIN Score to evaluate her sore throat, what would be the most appropriate course of action for her at this point?Your Answer: No treatment is required, and she should be reassured
Explanation:The FeverPAIN score is a scoring system recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, recommendations for antibiotic use are as follows: a score of 0-1 indicates an unlikely streptococcal infection, with antibiotics not recommended; a score of 2-3 suggests a 34-40% chance of streptococcus, and delayed prescribing of antibiotics may be considered; a score of 4 or higher indicates a 62-65% chance of streptococcus, and immediate antibiotic use is recommended for severe cases, or a short back-up prescription may be given for 48 hours.
The Fever PAIN score was developed through a study involving 1760 adults and children aged three and over. It was tested in a trial comparing three prescribing strategies: empirical delayed prescribing, score-directed prescribing, and a combination of the score with a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and reduced antibiotic prescribing by one third. The addition of the NPT did not provide any additional benefit.
According to the current NICE guidelines, if antibiotics are necessary, phenoxymethylpenicillin is recommended as the first-choice antibiotic. In cases of true penicillin allergy, clarithromycin can be used as an alternative. For pregnant women with a penicillin allergy, erythromycin is prescribed. It is important to note that the threshold for prescribing antibiotics should be lower for individuals at risk of rheumatic fever and vulnerable groups managed in primary care, such as infants, the elderly, and those who are immunosuppressed or immunocompromised. Antibiotics should not be withheld if the person has severe symptoms and there are concerns about their clinical condition.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 23
Correct
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A 45 year old female visits the emergency department complaining of abdominal cramps and bloating that are alleviated by defecation. Blood tests and an abdominal X-ray are conducted, all of which come back normal. It is observed that the patient has visited the hospital twice in the past 4 months with similar symptoms and has also consulted her primary care physician regarding these recurring issues. The suspicion is that the patient may be suffering from irritable bowel syndrome (IBS). What diagnostic criteria would be most suitable for diagnosing IBS?
Your Answer: ROME IV
Explanation:The ROME IV criteria are utilized in secondary care to diagnose IBS, as recommended by NICE. The DSM-5 criteria are employed in diagnosing various mental health disorders. Coeliac disease diagnosis involves the use of modified marsh typing. Gastro-oesophageal reflux disease diagnosis relies on the Lyon Consensus.
Further Reading:
Irritable bowel syndrome (IBS) is a chronic disorder that affects the interaction between the gut and the brain. The exact cause of IBS is not fully understood, but factors such as genetics, drug use, enteric infections, diet, and psychosocial factors are believed to play a role. The main symptoms of IBS include abdominal pain, changes in stool form and/or frequency, and bloating. IBS can be classified into subtypes based on the predominant stool type, including diarrhea-predominant, constipation-predominant, mixed, and unclassified.
Diagnosing IBS involves using the Rome IV criteria, which includes recurrent abdominal pain associated with changes in stool frequency and form. It is important to rule out other more serious conditions that may mimic IBS through a thorough history, physical examination, and appropriate investigations. Treatment for IBS primarily involves diet and lifestyle modifications. Patients are advised to eat regular meals with a healthy, balanced diet and adjust their fiber intake based on symptoms. A low FODMAP diet may be trialed, and a dietician may be consulted for guidance. Regular physical activity and weight management are also recommended.
Psychosocial factors, such as stress, anxiety, and depression, should be addressed and managed appropriately. If constipation is a predominant symptom, soluble fiber supplements or foods high in soluble fiber may be recommended. Laxatives can be considered if constipation persists, and linaclotide may be tried if optimal doses of previous laxatives have not been effective. Antimotility drugs like loperamide can be used for diarrhea, and antispasmodic drugs or low-dose tricyclic antidepressants may be prescribed for abdominal pain. If symptoms persist or are refractory to treatment, alternative diagnoses should be considered, and referral to a specialist may be necessary.
Overall, the management of IBS should be individualized based on the patient’s symptoms and psychosocial situation. Clear explanation of the condition and providing resources for patient education, such as the NHS patient information leaflet and support from organizations like The IBS Network, can also be beneficial.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 24
Correct
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You are summoned to the resuscitation bay to provide assistance with a patient who has experienced cardiac arrest. The team is getting ready to administer amiodarone. What is the mechanism of action of amiodarone in the context of cardiac arrest?
Your Answer: Blockade of potassium channels
Explanation:Amiodarone functions by inhibiting voltage-gated potassium channels, leading to an extended repolarization period and decreased excitability of the heart muscle.
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.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 25
Correct
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A patient who was diagnosed with Parkinson's disease five years ago has experienced a sudden and significant deterioration in her functioning. Her motor symptoms are limited to her right arm and leg. She has lost nearly all functionality in her right hand, but there is no noticeable tremor. Additionally, her right arm frequently exhibits involuntary jerking movements and is held in a contracted position. The patient also reports a decline in her memory abilities.
What is the most probable diagnosis in this case?Your Answer: Corticobasal degeneration
Explanation:The Parkinson-plus syndromes are a group of neurodegenerative disorders that share similar features with Parkinson’s disease but also have additional clinical characteristics that set them apart from idiopathic Parkinson’s disease (iPD). These syndromes include Multiple System Atrophy (MSA), Progressive Supranuclear Palsy (PSP), Corticobasal degeneration (CBD), and Dementia with Lewy Bodies (DLB).
Multiple System Atrophy (MSA) is a less common condition than iPD and PSP. It is characterized by the loss of cells in multiple areas of the nervous system. MSA progresses rapidly, often leading to wheelchair dependence within 3-4 years of diagnosis. Some distinguishing features of MSA include autonomic dysfunction, bladder control problems, erectile dysfunction, blood pressure changes, early-onset balance problems, neck or facial dystonia, and a high-pitched voice.
To summarize the distinguishing features of the Parkinson-plus syndromes compared to iPD, the following table provides a comparison:
iPD:
– Symptom onset: One side of the body affected more than the other
– Tremor: Typically starts at rest on one side of the body
– Levodopa response: Excellent response
– Mental changes: Depression
– Balance/falls: Late in the disease
– Common eye abnormalities: Dry eyes, trouble focusingMSA:
– Symptom onset: Both sides equally affected
– Tremor: Not common but may occur
– Levodopa response: Minimal response (but often tried in early stages of disease)
– Mental changes: Depression
– Balance/falls: Within 1-3 years
– Common eye abnormalities: Dry eyes, trouble focusingPSP:
– Symptom onset: Both sides equally affected
– Tremor: Less common, if present affects both sides
– Levodopa response: Minimal response (but often tried in early stages of disease)
– Mental changes: Personality changes, depression
– Balance/falls: Within 1 year
– Common eye abnormalities: Dry eyes, difficulty in looking downwardsCBD:
– Symptom onset: One side of the body affected more than the other
– Tremor: Not common but may occur
– Levodopa response: Minimal response (but often tried in early stages of disease)
– Mental changes: Depression
– Balance/falls: Within 1-3 years
– Common eye abnormalities: Dry eyes, trouble focusing -
This question is part of the following fields:
- Neurology
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Question 26
Incorrect
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A 72-year-old woman presents with severe central chest pain. An ECG is performed, which shows ST elevation in the anterolateral leads. She was given aspirin and morphine upon arrival. Her observations are as follows: SaO2 99% on air, HR 89 bpm, and BP 149/87 mmHg. Upon discussion with the cardiology team, a decision is made to perform an urgent percutaneous coronary intervention (PCI).
Which of the following medications could you also consider administering to this patient?Your Answer: Fondaparinux
Correct Answer: Bivalirudin
Explanation:This patient is displaying symptoms consistent with a diagnosis of an acute myocardial infarction. It is important to provide pain relief as soon as possible. One option for pain relief is GTN, which can be taken sublingually or buccally. However, if there is suspicion of an acute myocardial infarction, it is recommended to offer intravenous opioids such as morphine.
Aspirin should be offered to all patients with unstable angina or NSTEMI as soon as possible and should be continued indefinitely, unless there are contraindications such as a bleeding risk or aspirin hypersensitivity. A loading dose of 300 mg should be administered promptly after presentation.
For patients without a high bleeding risk who do not have coronary angiography planned within 24 hours of admission, fondaparinux should be administered. However, for patients who are likely to undergo coronary angiography within 24 hours, unfractionated heparin can be offered as an alternative to fondaparinux. In cases of significant renal impairment (creatinine above 265 micromoles per litre), unfractionated heparin with dose adjustment guided by clotting function monitoring can also be considered as an alternative to fondaparinux.
Routine administration of oxygen is no longer recommended, but it is important to monitor oxygen saturation using pulse oximetry as soon as possible, preferably before hospital admission. Supplemental oxygen should only be offered to individuals with an oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, with a target SpO2 range of 94-98%. For individuals with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure, a target SpO2 range of 88-92% should be aimed for until blood gas analysis is available.
Bivalirudin, a specific and reversible direct thrombin inhibitor (DTI), is recommended by NICE as a possible treatment for adults with STEMI who are undergoing percutaneous coronary intervention.
For more information, please refer to the NICE guidelines on the assessment and diagnosis of chest pain of recent onset.
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This question is part of the following fields:
- Cardiology
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Question 27
Correct
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A 45-year-old man presents with generalized weakness and palpitations. Upon reviewing his blood results, you note that his potassium level is significantly elevated. His ECG shows a broad QRS and peaked T waves. As part of his treatment, you administer a dose of calcium chloride.
How does calcium chloride work in the treatment of hyperkalemia?Your Answer: Stabilisation of the cell membrane
Explanation:Calcium is effective in treating hyperkalaemia by counteracting the harmful effects on the heart caused by high levels of potassium. It achieves this by stabilizing the cardiac cell membrane and preventing unwanted depolarization. The onset of action is rapid, typically within 15 minutes, but the effects do not last for a long duration. Calcium is considered the first-line treatment for severe hyperkalaemia (potassium levels above 7 mmol/l) and when significant ECG abnormalities are present, such as widened QRS interval, loss of P wave, or cardiac arrhythmias. However, if the ECG only shows peaked T waves, calcium is usually not recommended.
It is important to note that calcium does not directly affect the serum potassium levels. Therefore, when administering calcium, it should be accompanied by other therapies that actively lower the serum potassium levels, such as insulin and salbutamol.
When hyperkalaemia is accompanied by hemodynamic compromise, calcium chloride is preferred over calcium gluconate. This is because calcium chloride contains approximately three times more elemental calcium than an equal volume of calcium gluconate.
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This question is part of the following fields:
- Nephrology
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Question 28
Correct
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A 30 year old patient is brought to the emergency department by bystanders after a hit and run incident. Upon examination, you observe that the patient is experiencing difficulty breathing and has tracheal deviation towards the left side. Based on these findings, you suspect the presence of a tension pneumothorax. What signs would you anticipate observing in this patient?
Your Answer: Elevated jugular venous pressure
Explanation:Tension pneumothorax is a condition characterized by certain clinical signs. These signs include pulsus paradoxus, which is an abnormal decrease in blood pressure during inspiration; elevated JVP or distended neck veins; diaphoresis or excessive sweating; and cyanosis, which is a bluish discoloration of the skin. Tracheal deviation to the left is often observed in patients with a right-sided pneumothorax. On the affected side, hyper-resonance and absent breath sounds can be expected. Patients with tension pneumothorax typically appear agitated and distressed, and they experience noticeable difficulty in breathing. Hypotension, a pulse rate exceeding 135 bpm, pulsus paradoxus, and elevated JVP are additional signs associated with tension pneumothorax. These signs occur because the expanding pneumothorax compresses the mediastinum, leading to impaired venous return and cardiac output.
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.
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This question is part of the following fields:
- Respiratory
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Question 29
Correct
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A 65-year-old woman presents with a history of recurrent falls. She is accompanied by her daughter, who tells you that the falls have been getting worse over the past year and that she has also been acting strangely and showing signs of memory loss. Recently, she has also experienced several episodes of urinary incontinence. On examination, you observe that she has a wide-based, shuffling gait.
What is the definitive treatment for the underlying condition in this scenario?Your Answer: Surgical insertion of a CSF shunt
Explanation:This patient is displaying symptoms that are characteristic of normal-pressure hydrocephalus (NPH). NPH is a type of communicating hydrocephalus where the pressure inside the skull, as measured through lumbar puncture, is either normal or occasionally elevated. It primarily affects elderly individuals, and the likelihood of developing NPH increases with age.
Around 50% of NPH cases are idiopathic, meaning that no clear cause can be identified. The remaining cases are secondary to various conditions such as head injury, meningitis, subarachnoid hemorrhage, central nervous system tumors, and radiotherapy.
The typical presentation of NPH includes a classic triad of symptoms: gait disturbance (often characterized by a broad-based and shuffling gait), sphincter disturbance leading to incontinence (usually urinary incontinence), and progressive dementia with memory loss, inattention, inertia, and bradyphrenia.
Diagnosing NPH primarily relies on identifying the classic clinical triad mentioned above. Additional investigations can provide supportive evidence and may involve CT and MRI scans, which reveal enlarged ventricles and periventricular lucency. Lumbar puncture can also be performed to assess cerebrospinal fluid (CSF) levels, which are typically normal or intermittently elevated. Intraventricular monitoring may show beta waves present for more than 5% of a 24-hour period.
NPH is one of the few reversible causes of dementia, making early recognition and treatment crucial. Medical treatment options include the use of carbonic anhydrase inhibitors (such as acetazolamide) and repeated lumbar punctures as temporary measures. However, the definitive treatment for NPH involves surgically inserting a cerebrospinal fluid (CSF) shunt. This procedure provides lasting clinical benefits for 70% to 90% of patients compared to their pre-operative state.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 30
Correct
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You evaluate a 62-year-old man with a painful swollen left big toe. The pain began this morning and is described as the most severe pain he has ever experienced. It has progressively worsened over the past 8 hours. He is unable to wear socks or shoes and had to come to the appointment in open-toe sandals. The skin over the affected area appears red and shiny.
His only significant medical history is hypertension, which has been challenging to control. He is currently prescribed amlodipine 10 mg and ramipril 10 mg daily for this condition and is awaiting a medication review for his antihypertensive treatment. His blood pressure reading today is 165/94 mmHg.
What is the MOST appropriate next step in managing his condition?Your Answer: Commence colchicine
Explanation:The diagnosis in this case is clearly gout. According to the guidelines from the European League Against Rheumatism (EULAR), the development of sudden joint pain accompanied by swelling, tenderness, and redness, which worsens over a period of 6-12 hours, strongly suggests crystal arthropathy.
Checking serum urate levels to confirm high levels of uric acid before starting treatment for acute gout attacks has little benefit and should not delay treatment. While these levels can be useful for monitoring treatment response, they often decrease during an acute attack and can even be within the normal range. If levels are checked and found to be normal during the attack, they should be rechecked once the attack has resolved.
The first-line treatment for acute gout attacks is non-steroidal anti-inflammatory drugs (NSAIDs) like naproxen. However, caution should be exercised when using NSAIDs in patients with a history of hypertension. Since this patient has had difficulty controlling their blood pressure and remains hypertensive, it would be wise to avoid NSAIDs in this case.
Colchicine is an effective alternative for treating gout, although it may take longer to take effect. It is often used in patients who cannot take NSAIDs due to contraindications such as hypertension or a history of peptic ulcer disease. Therefore, it is the most suitable choice for this patient.
During an acute gout attack, allopurinol should not be used as it can prolong the attack and even trigger another acute episode. However, if a patient is already taking allopurinol for chronic gout management, it should be continued, and the acute attack should be treated with NSAIDs or colchicine as appropriate.
Febuxostat (Uloric) is an alternative to allopurinol for managing chronic gout. Like allopurinol, it should not be used for treating acute gout episodes.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 31
Correct
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A 3-year-old boy is brought in by his parents with a history of breathing difficulties, fever, and a cough. He is irritable and having difficulty eating. On examination, his temperature is 38.6°C, and you hear fine inspiratory crackles throughout his chest.
What is the SINGLE most appropriate investigation?Your Answer: Nasopharyngeal aspirate
Explanation:Bronchiolitis is a short-term infection of the lower respiratory tract that primarily affects infants aged 2 to 6 months. It is commonly caused by a viral infection, with respiratory syncytial virus (RSV) being the most prevalent culprit. RSV infections are most prevalent during the winter months, typically occurring between November and March. In the UK, bronchiolitis is the leading cause of hospitalization among infants.
The typical symptoms of bronchiolitis include fever, difficulty breathing, coughing, poor feeding, irritability, apnoeas (more common in very young infants), and wheezing or fine inspiratory crackles. To confirm the diagnosis, a nasopharyngeal aspirate can be taken for RSV rapid testing. This test is useful in preventing unnecessary further testing and facilitating the isolation of the affected infant.
Most infants with acute bronchiolitis experience a mild, self-limiting illness that does not require hospitalization. Treatment primarily focuses on supportive measures, such as ensuring adequate fluid and nutritional intake and controlling the infant’s temperature. The illness typically lasts for 7 to 10 days.
However, hospital referral and admission are recommended in certain cases, including poor feeding (less than 50% of usual intake over the past 24 hours), lethargy, a history of apnoea, a respiratory rate exceeding 70 breaths per minute, nasal flaring or grunting, severe chest wall recession, cyanosis, oxygen saturations below 90% for children aged 6 weeks and over, and oxygen saturations below 92% for babies under 6 weeks or those with underlying health conditions.
If hospitalization is necessary, treatment involves supportive measures, supplemental oxygen, and nasogastric feeding as needed. There is limited or no evidence supporting the use of antibiotics, antivirals, bronchodilators, corticosteroids, hypertonic saline, or adrenaline nebulizers in the management of bronchiolitis.
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This question is part of the following fields:
- Respiratory
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Question 32
Correct
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A 25-year-old woman presents with a 5-day history of a painful throat, high temperature, diarrhea, and muscle aches. Her temperature today is 38.6°C. Approximately 8 months ago, she began misusing intravenous drugs and acknowledges sharing needles. During the examination, you confirm the existence of lymph node swelling in the neck and armpits. Additionally, she has developed a widespread rash consisting of small raised bumps on her chest and abdomen.
Select from the options below the most probable diagnosis.Your Answer: HIV seroconversion illness
Explanation:This man is at high risk of contracting HIV due to his history of intravenous drug abuse and sharing needles. If a patient has a flu-like illness and a history of risk factors, it is important to suspect that they may be experiencing an HIV seroconversion illness.
Around 20-60% of individuals who contract HIV go through a seroconversion illness. This typically occurs within 1 to 6 weeks after exposure and presents with symptoms similar to the flu. Common clinical features include fever, malaise, myalgia, pharyngitis, diarrhea, headaches, maculopapular rash, lymphadenopathy, and neuralgia.
During this stage of the disease, antibody tests will show negative results. However, a diagnosis of HIV can still be made by conducting a P24 antigen test or measuring HIV RNA levels. CD4 and CD8 counts are usually within the normal range at this stage.
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This question is part of the following fields:
- Infectious Diseases
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Question 33
Correct
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A 32-year-old woman presents with a history of persistent foul-smelling discharge from her right ear. She has undergone three separate courses of antibiotic drops, but they have been ineffective in resolving the issue. Additionally, she is experiencing hearing difficulties in her right ear. Her medical history includes recurrent ear infections. Upon examination, a retraction pocket is observed in the attic, along with granulation tissue on the tympanic membrane and a significant amount of debris.
What is the MOST suitable next step in managing this patient?Your Answer: Urgent referral to ENT
Explanation:This individual is diagnosed with an acquired cholesteatoma, which is an expanding growth of the stratified keratinising epithelium in the middle ear. It develops due to dysfunction of the Eustachian tube and chronic otitis media caused by the retraction of the squamous elements of the tympanic membrane into the middle ear space.
The most important method for assessing the presence of a cholesteatoma is otoscopy. A retraction pocket observed in the attic or posterosuperior quadrant of the tympanic membrane is a characteristic sign of an acquired cholesteatoma. This is often accompanied by the presence of granulation tissue and squamous debris. The presence of a granular polyp within the ear canal also strongly suggests a cholesteatoma.
If left untreated, a cholesteatoma can lead to various complications including conductive deafness, facial nerve palsy, brain abscess, meningitis, and labyrinthitis. Therefore, it is crucial to urgently refer this individual to an ear, nose, and throat (ENT) specialist for a CT scan and surgical removal of the lesion.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 34
Correct
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You are overseeing the care of a 70-year-old male who suffered extensive burns in a residential fire. After careful calculation, you have determined that the patient's fluid requirement for the next 24 hours is 6 liters. How would you prescribe this amount?
Your Answer: 50% (3 litres in this case) over first 8 hours then remaining 50% (3 litres in this case) over following 16 hours
Explanation: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.
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This question is part of the following fields:
- Trauma
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Question 35
Correct
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A 30-year-old woman is given carbamazepine for her epilepsy during her pregnancy. As a result of this medication, the newborn develops a defect.
What is the most probable defect that will occur as a result of using this drug during pregnancy?Your Answer: Haemorrhagic disease of the newborn
Explanation:There is an increased risk of neural tube defects in women with epilepsy who take carbamazepine during pregnancy, ranging from 2 to 10 times higher. Additionally, there is a risk of haemorrhagic disease of the newborn associated with this medication. It is crucial to have discussions about epilepsy treatments with women of childbearing age during the planning stages so that they can start early supplementation of folic acid.
Below is a list outlining the most commonly encountered drugs that have adverse effects during pregnancy:
ACE inhibitors (e.g. ramipril): If given in the second and third trimester, these medications can cause hypoperfusion, renal failure, and the oligohydramnios sequence.
Aminoglycosides (e.g. gentamicin): These drugs can lead to ototoxicity and deafness in the fetus.
Aspirin: High doses of aspirin can cause first-trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) do not pose significant risks.
Benzodiazepines (e.g. diazepam): When given late in pregnancy, these medications can result in respiratory depression and a neonatal withdrawal syndrome.
Calcium-channel blockers: If given in the first trimester, these drugs can cause phalangeal abnormalities. If given in the second and third trimesters, they can lead to fetal growth retardation.
Carbamazepine: This medication is associated with haemorrhagic disease of the newborn and neural tube defects.
Chloramphenicol: Use of this drug can cause grey baby syndrome in newborns.
Corticosteroids: If given in the first trimester, corticosteroids may cause orofacial clefts in the fetus.
Danazol: When administered in the first trimester, danazol can cause masculinization of the female fetuses genitals.
Finasteride: Pregnant women should avoid handling finasteride tablets. Crushed or broken tablets can be absorbed through the skin and affect male sex organ development in the fetus.
Haloperidol: If given in the first trimester, haloperidol may cause limb malformations. In the third trimester, there is an increased risk of extrapyramidal symptoms in the neonate.
Heparin: Use of heparin during pregnancy is associated with an acceptable bleeding rate and a low rate of thrombotic recurrence in the mother.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 36
Correct
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A 16 year old girl arrives at the emergency department with her friend following a fall from her skateboard. An X-ray reveals a dislocated shoulder. You inform the patient that the shoulder will require sedation for reduction. At what age is it generally assumed that a patient has the capacity to provide consent for treatment?
Your Answer: 16
Explanation:Patients who are 16 years old and above are presumed to have the ability to make decisions about their treatment.
Further Reading:
Patients have the right to determine what happens to their own bodies, and for consent to be valid, certain criteria must be met. These criteria include the person being informed about the intervention, having the capacity to consent, and giving consent voluntarily and freely without any pressure or undue influence.
In order for a person to be deemed to have capacity to make a decision on a medical intervention, they must be able to understand the decision and the information provided, retain that information, weigh up the pros and cons, and communicate their decision.
Valid consent can only be provided by adults, either by the patient themselves, a person authorized under a Lasting Power of Attorney, or someone with the authority to make treatment decisions, such as a court-appointed deputy or a guardian with welfare powers.
In the UK, patients aged 16 and over are assumed to have the capacity to consent. If a patient is under 18 and appears to lack capacity, parental consent may be accepted. However, a young person of any age may consent to treatment if they are considered competent to make the decision, known as Gillick competence. Parental consent may also be given by those with parental responsibility.
The Fraser guidelines apply to the prescription of contraception to under 16’s without parental involvement. These guidelines allow doctors to provide contraceptive advice and treatment without parental consent if certain criteria are met, including the young person understanding the advice, being unable to be persuaded to inform their parents, and their best interests requiring them to receive contraceptive advice or treatment.
Competent adults have the right to refuse consent, even if it is deemed unwise or likely to result in harm. However, there are exceptions to this, such as compulsory treatment authorized by the mental health act or if the patient is under 18 and refusing treatment would put their health at serious risk.
In emergency situations where a patient is unable to give consent, treatment may be provided without consent if it is immediately necessary to save their life or prevent a serious deterioration of their condition. Any treatment decision made without consent must be in the patient’s best interests, and if a decision is time-critical and the patient is unlikely to regain capacity in time, a best interest decision should be made. The treatment provided should be the least restrictive on the patient’s future choices.
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This question is part of the following fields:
- Safeguarding & Psychosocial Emergencies
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Question 37
Correct
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You are managing a 32-year-old male patient who leaped off a bridge. There is noticeable bruising and extreme sensitivity over the calcaneus. You are currently waiting for an X-ray to confirm the presence of a calcaneal fracture. Which of the following statements is accurate regarding the assessment of the X-ray?
Your Answer: The normal angle of Gissane is 120-145°
Explanation:The typical range for the normal angle of Gissane is between 120 and 145 degrees. An increase in this angle suggests that the posterior facet of the subtalar joint is depressed, which may indicate a calcaneal fracture. Similarly, the normal range for Bohler’s angle is between 20 and 40 degrees. For more detailed information and visual representations of these angles, please refer to the accompanying notes.
Further Reading:
calcaneus fractures are a common type of lower limb and joint injury. The calcaneus, or heel bone, is the most frequently fractured tarsal bone. These fractures are often intra-articular, meaning they involve the joint. The most common cause of calcaneus fractures is a fall or jump from a height.
When assessing calcaneus fractures, X-rays are used to visualize the fracture lines. Two angles are commonly assessed to determine the severity of the fracture. Böhler’s angle, which measures the angle between two tangent lines drawn across the anterior and posterior borders of the calcaneus, should be between 20-40 degrees. If it is less than 20 degrees, it indicates a calcaneal fracture with flattening. The angle of Gissane, which measures the depression of the posterior facet of the subtalar joint, should be between 120-145 degrees. An increased angle of Gissane suggests a calcaneal fracture.
In the emergency department, the management of a fractured calcaneus involves identifying the injury and any associated injuries, providing pain relief, elevating the affected limb(s), and referring the patient to an orthopedic specialist. It is important to be aware that calcaneus fractures are often accompanied by other injuries, such as bilateral fractures of vertebral fractures.
The definitive management of a fractured calcaneus can be done conservatively or through surgery, specifically open reduction internal fixation (ORIF). The orthopedic team will typically order a CT or MRI scan to classify the fracture and determine the most appropriate treatment. However, a recent UK heel fracture trial suggests that in most cases, ORIF does not improve fracture outcomes.
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This question is part of the following fields:
- Trauma
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Question 38
Correct
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A 45-year-old woman with a longstanding history of heavy tobacco use and lung cancer presents with cough, chest pain, worsening shortness of breath, and fatigue.
What is the SINGLE most likely diagnosis?Your Answer: Spontaneous bacterial peritonitis
Explanation:Spontaneous bacterial peritonitis (SBP) is a sudden bacterial infection of the fluid in the abdomen. It typically occurs in patients with high blood pressure in the portal vein, and about 70% of patients are classified as Child-Pugh class C. In any given year, around 30% of patients with ascites, a condition characterized by fluid buildup in the abdomen, will develop SBP.
SBP can present with a wide range of symptoms, so it’s important to be vigilant when caring for patients with ascites, especially if there is a sudden decline in their condition. Some patients may not show any symptoms at all.
Common clinical features of SBP include fever, chills, nausea, vomiting, abdominal pain, tenderness, worsening ascites, general malaise, and hepatic encephalopathy. Certain factors can increase the risk of developing SBP, such as severe liver disease, gastrointestinal bleeding, urinary tract infection, intestinal bacterial overgrowth, indwelling lines (e.g., central venous catheters or urinary catheters), previous episodes of SBP, and low levels of protein in the ascitic fluid.
To diagnose SBP, an abdominal paracentesis, also known as an ascitic tap, is performed. This involves locating the area of dullness on the flank, next to the rectus abdominis muscle, and performing the tap about 5 cm above and towards the midline from the anterior superior iliac spines.
Certain features on the analysis of the peritoneal fluid strongly suggest SBP, including a total white cell count in the ascitic fluid of more than 500 cells/µL, a total neutrophil count of more than 250 cells/µL, a lactate level in the ascitic fluid of more than 25 mg/dL, a pH of less than 7.35, and the presence of bacteria on Gram-stain.
Patients diagnosed with SBP should be admitted to the hospital and given broad-spectrum antibiotics. The preferred choice is an intravenous 3rd generation cephalosporin, such as ceftriaxone. If the patient is allergic to beta-lactam antibiotics, ciprofloxacin can be considered as an alternative. Administering intravenous albumin can help reduce the risk of kidney failure and mortality.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 39
Correct
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A 32-year-old woman with a previous history of salpingitis presents with excessive vaginal bleeding. Her pregnancy test is positive, and a preliminary diagnosis of an ectopic pregnancy is made.
What is the most frequent anatomical site for an ectopic pregnancy to occur?Your Answer: Ampulla of Fallopian tube
Explanation:An ectopic pregnancy happens when the fertilized egg attaches itself outside of the uterus. In over 95% of cases, ectopic pregnancies occur in the Fallopian tubes. Although rare, they can also occur in other locations such as the abdomen, cervix, and ovary.
The most common location for an ectopic pregnancy in the Fallopian tube is the ampulla, accounting for approximately 70% of cases. The isthmus and infundibulum each account for 10-15% of cases, while the uterine part only accounts for 2-5%.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 40
Correct
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A 25-year-old woman with inflammatory bowel disease (IBD) presents with a condition associated with IBD.
Which of the following conditions is associated with ulcerative colitis?Your Answer: Cholelithiasis
Explanation:Cholelithiasis is a common occurrence in individuals with Crohn’s disease. There are several other conditions that are known to be associated with Crohn’s disease. These include a higher prevalence in smokers, with approximately 50-60% of patients being smokers. Additionally, individuals with Crohn’s disease may experience aphthous ulcers, uveitis, episcleritis, seronegative spondyloarthropathies, erythema nodosum, pyoderma gangrenosum, finger clubbing, autoimmune hemolytic anemia, and osteoporosis. However, it is important to note that primary biliary cirrhosis, primary sclerosing cholangitis, and chronic active hepatitis are associations commonly seen in ulcerative colitis rather than Crohn’s disease. Lastly, dermatitis herpetiformis is a condition that is associated with coeliac disease.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 41
Correct
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A patient with a previous history of painless rectal bleeding episodes is found to have a Meckel's diverticulum during a colonoscopy.
Which ONE statement about Meckel's diverticulum is accurate?Your Answer: They receive their blood supply from the mesentery of the ileum
Explanation:A Meckel’s diverticulum is a leftover part of the vitellointestinal duct, which is no longer needed in the body. It is the most common abnormality in the gastrointestinal tract, found in about 2% of people. Interestingly, it is twice as likely to occur in men compared to women.
When a Meckel’s diverticulum is present, it is usually located in the lower part of the small intestine, specifically within 60-100 cm (2 feet) of the ileocaecal valve. These diverticula are typically 3-6 cm (approximately 2 inches) long and may have a larger opening than the ileum.
Meckel’s diverticula are often discovered incidentally, especially during an appendectomy. Most of the time, they do not cause any symptoms. However, they can lead to complications such as bleeding (25-50% of cases), intestinal blockage (10-40% of cases), diverticulitis, or perforation.
These diverticula run in the opposite direction of the intestine’s natural folds but receive their blood supply from the ileum mesentery. They can be identified by a specific blood vessel called the vitelline artery. Typically, they are lined with the same type of tissue as the ileum, but they often contain abnormal tissue, with gastric tissue being the most common (50%) and pancreatic tissue being the second most common (5%). In rare cases, colonic or jejunal tissue may be present.
To remember some key facts about Meckel’s diverticulum, the rule of 2s can be helpful:
– It is found in 2% of the population.
– It is more common in men, with a ratio of 2:1 compared to women.
– It is located 2 feet away from the ileocaecal valve.
– It is approximately 2 inches long.
– It often contains two types of abnormal tissue: gastric and pancreatic.
– The most common age for clinical presentation is 2 years old. -
This question is part of the following fields:
- Surgical Emergencies
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Question 42
Incorrect
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A 32-year-old woman with a history of schizophrenia describes a sensation in which she feels that other people can hear what she is thinking. She is finding the sensation very distressing.
Which ONE of the following thought disorders is she exhibiting?Your Answer: Thought withdrawal
Correct Answer: Thought broadcast
Explanation:Thought broadcast is one of the primary symptoms of schizophrenia identified by Schneider. This symptom refers to the patient’s belief that their thoughts can be perceived by others.
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This question is part of the following fields:
- Mental Health
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Question 43
Correct
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A 42-year-old patient comes in with a 3-day history of urgency, increased frequency of urination, and discomfort while urinating. Upon examination, she has no fever, mild tenderness in the suprapubic area, and no tenderness in the flank region. Her pregnancy test is negative and she has no medication allergies.
What is the MOST suitable course of action for management?Your Answer: The patient should be started on a 3-day course of oral trimethoprim
Explanation:Classical symptoms of a urinary tract infection (UTI) typically include dysuria, suprapubic tenderness, urgency, haematuria, increased frequency of micturition, and polyuria. The Scottish Intercollegiate Guidelines Network (SIGN) has developed comprehensive guidelines for the management of UTIs. According to these guidelines, if a patient presents with three or more classical UTI symptoms and is not pregnant, it is recommended to initiate empirical treatment with a three-day course of either trimethoprim or nitrofurantoin. For more detailed information, you can refer to the SIGN guidelines on the management of suspected bacterial urinary tract infection in adults.
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This question is part of the following fields:
- Urology
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Question 44
Incorrect
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The FY1 doctor seeks your guidance concerning an elderly patient they are managing who has experienced a head injury. They are uncertain whether they should request a CT head scan for their patient. Which of the following is NOT among the clinical criteria for an urgent CT head scan in an elderly individual?
Your Answer: haemotympanum
Correct Answer: 1 episode of vomiting
Explanation:If an adult with a head injury experiences more than one episode of vomiting, it is recommended to undergo a CT scan of the head. There are several criteria for an urgent CT scan in individuals with a head injury, including a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment in the emergency department (ED), a GCS score of less than 15 at 2 hours after the injury on assessment in the ED, suspected open or depressed skull fracture, any sign of basal skull fracture (such as haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, or Battle’s sign), post-traumatic seizure, new focal neurological deficit, and being on anticoagulation medication. If any of these signs are present, a CT scan should be performed within 1 hour, except for patients on anticoagulation medication who should undergo a CT scan within 8 hours if none of the other signs are present. However, if a patient on anticoagulation medication has any of the other signs, the CT scan should be performed within 1 hour.
Further Reading:
Indications for CT Scanning in Head Injuries (Adults):
– CT head scan should be performed within 1 hour if any of the following features are present:
– GCS < 13 on initial assessment in the ED
– GCS < 15 at 2 hours after the injury on assessment in the ED
– Suspected open or depressed skull fracture
– Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
– Post-traumatic seizure
– New focal neurological deficit
– > 1 episode of vomitingIndications for CT Scanning in Head Injuries (Children):
– CT head scan should be performed within 1 hour if any of the features in List 1 are present:
– Suspicion of non-accidental injury
– Post-traumatic seizure but no history of epilepsy
– GCS < 14 on initial assessment in the ED for children more than 1 year of age
– Paediatric GCS < 15 on initial assessment in the ED for children under 1 year of age
– At 2 hours after the injury, GCS < 15
– Suspected open or depressed skull fracture or tense fontanelle
– Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
– New focal neurological deficit
– For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head– CT head scan should be performed within 1 hour if none of the above features are present but two or more of the features in List 2 are present:
– Loss of consciousness lasting more than 5 minutes (witnessed)
– Abnormal drowsiness
– Three or more discrete episodes of vomiting
– Dangerous mechanism of injury (high-speed road traffic accident, fall from a height. -
This question is part of the following fields:
- Trauma
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Question 45
Correct
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You have advised an elderly patient to stop driving following their visit to the emergency department. A few days later, you spot the patient at a gas station near the hospital, filling up their car and driving away. What would be the most suitable course of action to take in this situation?
Your Answer: Contact the patient and try to persuade them to stop driving
Explanation:According to the GMC, if a doctor becomes aware that a patient is driving despite being unfit to do so, they should do everything they can to convince the patient to stop driving. If these efforts are unsuccessful and the patient continues to drive, the GMC advises promptly contacting the DVLA or DVA and sharing any pertinent medical information with the medical adviser, ensuring confidentiality.
Further Reading:
Blackouts are a common occurrence in the emergency department and can have serious consequences if they happen while a person is driving. It is crucial for doctors in the ED to be familiar with the guidelines set by the DVLA (Driver and Vehicle Licensing Agency) regarding driving restrictions for patients who have experienced a blackout.
The DVLA has specific rules for different types of conditions that may cause syncope (loss of consciousness). For group 1 license holders (car/motorcycle use), if a person has had a first unprovoked isolated seizure, they must refrain from driving for 6 months or 12 months if there is an underlying causative factor that may increase the risk. They must also notify the DVLA. For group 2 license holders (bus and heavy goods vehicles), the restrictions are more stringent, with a requirement of 12 months off driving for a first unprovoked isolated seizure and 5 years off driving if there is an underlying causative factor.
For epilepsy or multiple seizures, both group 1 and group 2 license holders must remain seizure-free for 12 months before their license can be considered. They must also notify the DVLA. In the case of a stroke or isolated transient ischemic attack (TIA), group 1 license holders need to refrain from driving for 1 month, while group 2 license holders must wait for 12 months before being re-licensed subject to medical evaluation. Multiple TIAs require 3 months off driving for both groups.
Isolated vasovagal syncope requires no driving restriction for group 1 license holders, but group 2 license holders must refrain from driving for 3 months. Both groups must notify the DVLA. If syncope is caused by a reversible and treated condition, group 1 license holders need 4 weeks off driving, while group 2 license holders require 3 months. In the case of an isolated syncopal episode with an unknown cause, group 1 license holders must refrain from driving for 6 months, while group 2 license holders will have their license refused or revoked for 12 months.
For patients who continue to drive against medical advice, the GMC (General Medical Council) has provided guidance on how doctors should manage the situation. Doctors should explain to the patient why they are not allowed to drive and inform them of their legal duty to notify the DVLA or DVA (Driver and Vehicle Agency in Northern Ireland). Doctors should also record the advice given to the patient in their medical record
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This question is part of the following fields:
- Safeguarding & Psychosocial Emergencies
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Question 46
Correct
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A 7-year-old boy is brought to the Emergency Department with lower abdominal pain and a high temperature. During the examination, he experiences tenderness in the right iliac fossa, leading to a preliminary diagnosis of acute appendicitis. However, he adamantly refuses to flex his thigh at the hip, and when you attempt to extend it passively, his abdominal pain intensifies.
Which muscle is most likely in contact with the inflamed structure causing these symptoms?Your Answer: Psoas major
Explanation:This patient is exhibiting the psoas sign, which is a medical indication of irritation in the iliopsoas group of hip flexors located in the abdomen. In this particular case, it is highly likely that the patient has acute appendicitis.
The psoas sign can be observed by extending the patient’s thigh while they are lying on their side with their knees extended, or by asking the patient to actively flex their thigh at the hip. If these movements result in abdominal pain or if the patient resists due to pain, then the psoas sign is considered positive.
The pain occurs because the psoas muscle is adjacent to the peritoneal cavity. When the muscles are stretched or contracted, they rub against the inflamed tissues nearby, causing discomfort. This strongly suggests that the appendix is positioned retrocaecal.
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This question is part of the following fields:
- Surgical Emergencies
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Question 47
Correct
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You evaluate a 6-year-old boy who has been diagnosed with diabetic ketoacidosis. He experiences a complication while undergoing treatment.
What is the primary cause of mortality in children with DKA?Your Answer: Cerebral oedema
Explanation:Cerebral edema is the most significant complication of diabetic ketoacidosis (DKA), leading to death in many cases. It occurs in approximately 0.2-1% of DKA cases. The high blood glucose levels cause an osmolar gradient, resulting in the movement of water from the intracellular fluid (ICF) to the extracellular fluid (ECF) space and a decrease in cell volume. When insulin and intravenous fluids are administered to correct the condition, the effective osmolarity decreases rapidly, causing a reversal of the fluid shift and the development of cerebral edema.
Cerebral edema is associated with a higher mortality rate and poor neurological outcomes. To prevent its occurrence, it is important to slowly normalize osmolarity over a period of 48 hours, paying attention to glucose and sodium levels, as well as ensuring proper hydration. Monitoring the child for symptoms such as headache, recurrent vomiting, irritability, changes in Glasgow Coma Scale (GCS), abnormal slowing of heart rate, and increasing blood pressure is crucial.
If cerebral edema does occur, it should be treated with either a hypertonic (3%) saline solution at a dosage of 3 ml/kg or a mannitol infusion at a dosage of 250-500 mg/kg over a 20-minute period.
In addition to cerebral edema, there are other complications associated with DKA in children, including cardiac arrhythmias, pulmonary edema, and acute renal failure.
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This question is part of the following fields:
- Endocrinology
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Question 48
Correct
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A 67 year old female attends the emergency department complaining of palpitations. The patient reports experiencing brief episodes of palpitations over the past few weeks, but they usually resolve themselves after 5-10 minutes. However, today's episode has been ongoing for 30 minutes. The patient denies any chest pain or shortness of breath. She is currently taking aspirin 75mg once daily as her only medication. Blood tests are conducted, and the results are as follows:
Hemoglobin (Hb): 115 g/l
Platelets: 155 * 109/l
White blood cells (WBC): 6.4 * 109/l
Sodium: 138 mmol/l
Potassium: 3.8 mmol/l
Urea: 4.1 mmol/l
Creatinine: 74 µmol/l
Glomerular filtration rate (GFR): 68 mL/min/1.73m2
An electrocardiogram (ECG) is performed, revealing atrial fibrillation. You decide to assess the patient's bleeding risk using the ORBIT tool. What is this patient's ORBIT score?Your Answer: 3
Explanation:Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting around 5% of patients over the age of 70-75 years and 10% of patients aged 80-85 years. While AF can cause palpitations and inefficient cardiac function, the most important aspect of managing patients with AF is reducing the increased risk of stroke.
AF can be classified as first detected episode, paroxysmal, persistent, or permanent. First detected episode refers to the initial occurrence of AF, regardless of symptoms or duration. Paroxysmal AF occurs when a patient has 2 or more self-terminating episodes lasting less than 7 days. Persistent AF refers to episodes lasting more than 7 days that do not self-terminate. Permanent AF is continuous atrial fibrillation that cannot be cardioverted or if attempts to do so are deemed inappropriate. The treatment goals for permanent AF are rate control and anticoagulation if appropriate.
Symptoms of AF include palpitations, dyspnea, and chest pain. The most common sign is an irregularly irregular pulse. An electrocardiogram (ECG) is essential for diagnosing AF, as other conditions can also cause an irregular pulse.
Managing patients with AF involves two key parts: rate/rhythm control and reducing stroke risk. Rate control involves slowing down the irregular pulse to avoid negative effects on cardiac function. This is typically achieved using beta-blockers or rate-limiting calcium channel blockers. If one drug is not effective, combination therapy may be used. Rhythm control aims to restore and maintain normal sinus rhythm through pharmacological or electrical cardioversion. However, the majority of patients are managed with a rate control strategy.
Reducing stroke risk in patients with AF is crucial. Risk stratifying tools, such as the CHA2DS2-VASc score, are used to determine the most appropriate anticoagulation strategy. Anticoagulation is recommended for patients with a score of 2 or more. Clinicians can choose between warfarin and novel oral anticoagulants (NOACs) for anticoagulation.
Before starting anticoagulation, the patient’s bleeding risk should be assessed using tools like the HAS-BLED score or the ORBIT tool. These tools evaluate factors such as hypertension, abnormal renal or liver function, history of bleeding, age, and use of drugs that predispose to bleeding.
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This question is part of the following fields:
- Cardiology
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Question 49
Correct
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A 35-year-old patient arrives at the emergency department complaining of overall muscle weakness and fatigue. Upon reviewing the patient's medical history, you discover a previous diagnosis of primary hyperaldosteronism. Which of the following statements about primary hyperaldosteronism is correct?
Your Answer: Hypertension is usually resistant to drug treatment
Explanation:Primary hyperaldosteronism is a condition where hypertension is often difficult to control with antihypertensive medication. The most common electrolyte disturbance seen in this condition is hypokalaemia. To diagnose primary hyperaldosteronism, the preferred test is the plasma aldosterone-to-renin ratio (ARR), followed by imaging to identify the underlying cause. It is important to note that renal artery stenosis is a common cause of secondary hyperaldosteronism.
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.
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This question is part of the following fields:
- Endocrinology
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Question 50
Correct
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A 65-year-old man presents with a 10-week history of loose stools and occasional blood in his stool. He has experienced a weight loss of 5 kg over the past eight months. During the examination, you detect a mass in his lower right quadrant.
What is the SINGLE most probable diagnosis?Your Answer: Colorectal cancer
Explanation:In patients of this age who have experienced a change in bowel habit, rectal bleeding, and weight loss, the most probable diagnosis is colorectal carcinoma. Considering the patient’s history and examination findings, the other options in this question are significantly less likely. It is crucial to refer this patient promptly to a specialized team that focuses on the treatment of lower gastrointestinal cancer.
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This question is part of the following fields:
- Surgical Emergencies
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Question 51
Correct
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Gout is becoming more prevalent in Western societies due to various factors, including longer lifespans, high protein diets, and an increasing occurrence of metabolic syndrome.
Which of the following conditions is not typically associated with metabolic syndrome?Your Answer: Hyperthyroidism
Explanation:Gout is a form of arthritis that causes a swollen, tender, red, and hot joint. Initially, it was believed to primarily affect wealthy individuals due to dietary connections, but it is now becoming more prevalent and is estimated to impact around 1-2% of the Western population. This increase may be attributed to longer lifespans and changes in our eating habits. Additionally, there is a positive correlation between the rising rates of metabolic disease and gout.
While gout commonly affects the metatarsal-phalangeal joint of the big toe (approximately 50% of cases), it can also impact other joints such as the fingers, wrists, knees, and ankles. The pain experienced during an episode is often excruciating, and these episodes typically last about a week. Approximately half of the patients experience a recurrence within a year.
Hyperuricemia is the underlying cause of gout. Uric acid, a byproduct of purine metabolism, is typically eliminated through the kidneys. However, in about 90% of cases, hyperuricemia occurs due to the under-excretion of urate, while the remaining 10% is caused by overproduction. Elevated urate levels increase the likelihood of crystal formation. Measuring uric acid levels in the blood can be misleading, as some individuals with high levels do not develop gout, and levels can be normal during an attack. The crystallization process is complex and more likely to occur in cooler temperatures (which is why the feet are often affected, and symptoms worsen at night), during acidosis, and when there are rapid fluctuations in uric acid levels.
Diagnosing gout is primarily based on clinical evaluation. If there is a rapid onset of severe pain, swelling, and tenderness that reaches its peak within 6-12 hours, accompanied by redness, it strongly suggests crystal inflammation. The presence of monosodium urate crystals in synovial fluid or tophi confirms the diagnosis. When these crystals are examined under polarized light, they exhibit negative birefringence. Since gout symptoms can be mistaken for septic arthritis, if there is uncertainty in the diagnosis and the joint has been aspirated, it should also be sent for gram-staining.
Tophi are painless, hard lumps that develop when hyperuricemia persists for an extended period. They often appear on the elbows and ears.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 52
Correct
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A 25-year-old bartender presents to the emergency department complaining of feeling unwell for the past week. He has been experiencing muscle aches, headaches, and fatigue. This morning, he woke up with a severely sore throat and noticed the presence of pus in the back of his throat. Upon examination, the patient has a temperature of 38.4ºC and both tonsils are covered in white exudate. Additionally, he has tender enlarged cervical lymph nodes and tenderness in the left and right upper quadrants of his abdomen, with a palpable liver edge.
What is the most likely cause of this patient's symptoms?Your Answer: Epstein-Barr virus
Explanation:This individual is experiencing early symptoms such as tiredness, swollen tonsils with discharge, enlarged lymph nodes, and an enlarged liver. Additionally, they fall within the typical age group for developing glandular fever (infectious mononucleosis). Epstein-Barr virus (EBV) is responsible for the majority of glandular fever cases.
Further Reading:
Glandular fever, also known as infectious mononucleosis or mono, is a clinical syndrome characterized by symptoms such as sore throat, fever, and swollen lymph nodes. It is primarily caused by the Epstein-Barr virus (EBV), with other viruses and infections accounting for the remaining cases. Glandular fever is transmitted through infected saliva and primarily affects adolescents and young adults. The incubation period is 4-8 weeks.
The majority of EBV infections are asymptomatic, with over 95% of adults worldwide having evidence of prior infection. Clinical features of glandular fever include fever, sore throat, exudative tonsillitis, lymphadenopathy, and prodromal symptoms such as fatigue and headache. Splenomegaly (enlarged spleen) and hepatomegaly (enlarged liver) may also be present, and a non-pruritic macular rash can sometimes occur.
Glandular fever can lead to complications such as splenic rupture, which increases the risk of rupture in the spleen. Approximately 50% of splenic ruptures associated with glandular fever are spontaneous, while the other 50% follow trauma. Diagnosis of glandular fever involves various investigations, including viral serology for EBV, monospot test, and liver function tests. Additional serology tests may be conducted if EBV testing is negative.
Management of glandular fever involves supportive care and symptomatic relief with simple analgesia. Antiviral medication has not been shown to be beneficial. It is important to identify patients at risk of serious complications, such as airway obstruction, splenic rupture, and dehydration, and provide appropriate management. Patients can be advised to return to normal activities as soon as possible, avoiding heavy lifting and contact sports for the first month to reduce the risk of splenic rupture.
Rare but serious complications associated with glandular fever include hepatitis, upper airway obstruction, cardiac complications, renal complications, neurological complications, haematological complications, chronic fatigue, and an increased risk of lymphoproliferative cancers and multiple sclerosis.
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This question is part of the following fields:
- Infectious Diseases
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Question 53
Incorrect
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A 35-year-old woman is involved in a car accident. Her observations are taken one hour after arriving in the Emergency Department. Her pulse rate is 125 bpm, BP is 92/46 mmHg, respiratory rate 35 breaths/minute, and her urine output over the past hour has been 10 ml. She is anxious and slightly confused. The patient weighs approximately 70 kg.
How would you classify her hemorrhage according to the ATLS hemorrhagic shock classification?Your Answer: Class II
Correct Answer: Class III
Explanation:This patient is experiencing an increased heart rate and respiratory rate, as well as a decrease in urine output. Additionally, they are feeling anxious and confused. These symptoms indicate that the patient has suffered a class III haemorrhage at this point in time.
Recognizing the extent of blood loss based on vital signs and mental status abnormalities is a crucial skill. The Advanced Trauma Life Support (ATLS) haemorrhagic shock classification connects the amount of blood loss to expected physiological responses in a healthy 70 kg patient. In a 70 kg male patient, the total circulating blood volume is approximately five liters, which accounts for about 7% of their total body weight.
The ATLS haemorrhagic shock classification is summarized as follows:
CLASS I:
– Blood loss: Up to 750 mL
– Blood loss (% blood volume): Up to 15%
– Pulse rate: Less than 100 bpm
– Systolic BP: Normal
– Pulse pressure: Normal (or increased)
– Respiratory rate: 14-20 breaths per minute
– Urine output: Greater than 30 mL/hr
– CNS/mental status: Slightly anxiousCLASS II:
– Blood loss: 750-1500 mL
– Blood loss (% blood volume): 15-30%
– Pulse rate: 100-120 bpm
– Systolic BP: Normal
– Pulse pressure: Decreased
– Respiratory rate: 20-30 breaths per minute
– Urine output: 20-30 mL/hr
– CNS/mental status: Mildly anxiousCLASS III:
– Blood loss: 1500-2000 mL
– Blood loss (% blood volume): 30-40%
– Pulse rate: 120-140 bpm
– Systolic BP: Decreased
– Pulse pressure: Decreased
– Respiratory rate: 30-40 breaths per minute
– Urine output: 5-15 mL/hr
– CNS/mental status: Anxious, confusedCLASS IV:
– Blood loss: More than 2000 mL
– Blood loss (% blood volume): More than 40%
– Pulse rate: More than 140 bpm
– Systolic BP: Decreased
– Pulse pressure: Decreased
– Respiratory rate: More than 40 breaths per minute
– Urine output: Negligible
– CNS/mental status: Confused, leth -
This question is part of the following fields:
- Trauma
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Question 54
Correct
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A 65-year-old patient is presenting with upper gastrointestinal bleeding after receiving heparin. Your decision is to reverse the anticoagulation process.
What is the most appropriate option for reversing heparin?Your Answer: Protamine sulphate
Explanation:Protamine sulphate is a potent base that forms a stable salt complex with heparin, an acidic substance. This complex renders heparin inactive, making protamine sulphate a useful tool for neutralizing the effects of heparin. Additionally, protamine sulphate can be used to reverse the effects of LMWHs, although it is not as effective, providing only about two-thirds of the relative effect.
It is important to note that protamine sulphate also possesses its own weak intrinsic anticoagulant effect. This effect is believed to stem from its ability to inhibit the formation and activity of thromboplastin.
When administering protamine sulphate, it is typically done through slow intravenous injection. The dosage should be adjusted based on the amount of heparin that needs to be neutralized, the time that has passed since heparin administration, and the aPTT (activated partial thromboplastin time). As a general guideline, 1 mg of protamine can neutralize 100 IU of heparin. However, it is crucial to adhere to a maximum adult dose of 50 mg within a 10-minute period.
It is worth mentioning that protamine sulphate can have some adverse effects. It acts as a myocardial depressant, potentially leading to bradycardia (slow heart rate) and hypotension (low blood pressure). These effects may arise due to complement activation and leukotriene release.
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This question is part of the following fields:
- Haematology
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Question 55
Correct
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A 65-year-old woman with a history of smoking and a confirmed diagnosis of peripheral vascular disease presents with symptoms suggestive of acute limb ischemia. After conducting a series of tests, the medical team suspects that an embolus is the likely cause.
Which of the following investigations would be the most beneficial in determining the origin of the embolus?Your Answer: Popliteal ultrasound
Explanation:Acute limb ischaemia refers to a sudden decrease in blood flow to a limb, which puts the limb at risk of tissue damage. This condition is most commonly caused by either a sudden blockage of a partially blocked artery due to a blood clot or by an embolus that travels from another part of the body. It is considered a surgical emergency, as without prompt surgical intervention, the affected limb may suffer extensive tissue death within six hours.
The leading cause of acute limb ischaemia is the sudden blockage of a previously narrowed artery segment, accounting for 60% of cases. The second most common cause is an embolus, which makes up 30% of cases. Emboli can originate from sources such as a blood clot in the left atrium of the heart in patients with atrial fibrillation (which accounts for 80% of peripheral emboli), a clot formed on the heart wall after a heart attack, or from prosthetic heart valves. It is crucial to differentiate between these two causes, as the treatment and prognosis differ.
To properly diagnose acute limb ischaemia, several important investigations should be arranged. These include a hand-held Doppler ultrasound scan, which can help determine if there is any remaining blood flow in the arteries. Blood tests such as a full blood count, erythrocyte sedimentation rate, blood glucose level, and thrombophilia screen should also be conducted. If there is uncertainty in the diagnosis, urgent arteriography may be necessary.
In cases where an embolus is suspected as the cause, additional investigations are needed to identify its source. These investigations may include an electrocardiogram to detect atrial fibrillation, an echocardiogram to assess the heart’s structure and function, an ultrasound of the aorta, and ultrasounds of the popliteal and femoral arteries.
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This question is part of the following fields:
- Vascular
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Question 56
Correct
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You observe that a patient's temperature has risen to 41.5ºC after undergoing rapid sequence induction. You are worried that the patient might have developed malignant hyperthermia. What is the primary drug used to treat malignant hyperthermia?
Your Answer: Dantrolene
Explanation:The primary treatment for malignant hyperthermia is dantrolene. Dantrolene works by blocking the release of calcium through calcium channels, resulting in the relaxation of skeletal muscles.
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.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 57
Correct
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A 48 year old female presents to the emergency department complaining of palpitations. She reports experiencing brief episodes of palpitations over the past week, which typically resolve on their own after 5-10 minutes. However, today's episode has been ongoing for 30 minutes. The patient denies any chest pain or shortness of breath. The patient's vital signs are as follows:
Blood pressure: 110/70 mmHg
Pulse: 120 bpm
Respiration rate: 17 bpm
Temperature: 36.5ºC
Oxygen saturations: 97% on room air
An electrocardiogram (ECG) is performed and reveals atrial fibrillation. What is the most appropriate initial management for this patient?Your Answer: Administer 50 mg atenolol
Explanation:When managing newly diagnosed atrial fibrillation, a rate control strategy is often used. In this approach, beta blockers are typically the first line of treatment. However, sotalol is not recommended, and instead, other beta blockers like atenolol, acebutolol, metoprolol, nadolol, oxprenolol, and propranolol are preferred. Among these options, atenolol is commonly chosen in NHS trusts due to its cost-effectiveness.
For patients with signs of hemodynamic instability or adverse features, rhythm control (cardioversion) may be considered if they present within 48 hours of likely onset. However, in the case of this patient, their symptoms started a week ago, and there are no indications of hemodynamic instability or adverse features.
Digoxin monotherapy is typically reserved for individuals who have limited physical activity or are unable to take other first-line rate control medications due to other health conditions or contraindications.
Further Reading:
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting around 5% of patients over the age of 70-75 years and 10% of patients aged 80-85 years. While AF can cause palpitations and inefficient cardiac function, the most important aspect of managing patients with AF is reducing the increased risk of stroke.
AF can be classified as first detected episode, paroxysmal, persistent, or permanent. First detected episode refers to the initial occurrence of AF, regardless of symptoms or duration. Paroxysmal AF occurs when a patient has 2 or more self-terminating episodes lasting less than 7 days. Persistent AF refers to episodes lasting more than 7 days that do not self-terminate. Permanent AF is continuous atrial fibrillation that cannot be cardioverted or if attempts to do so are deemed inappropriate. The treatment goals for permanent AF are rate control and anticoagulation if appropriate.
Symptoms of AF include palpitations, dyspnea, and chest pain. The most common sign is an irregularly irregular pulse. An electrocardiogram (ECG) is essential for diagnosing AF, as other conditions can also cause an irregular pulse.
Managing patients with AF involves two key parts: rate/rhythm control and reducing stroke risk. Rate control involves slowing down the irregular pulse to avoid negative effects on cardiac function. This is typically achieved using beta-blockers or rate-limiting calcium channel blockers. If one drug is not effective, combination therapy may be used. Rhythm control aims to restore and maintain normal sinus rhythm through pharmacological or electrical cardioversion. However, the majority of patients are managed with a rate control strategy.
Reducing stroke risk in patients with AF is crucial. Risk stratifying tools, such as the CHA2DS2-VASc score, are used to determine the most appropriate anticoagulation strategy. Anticoagulation is recommended for patients with a score of 2 or more. Clinicians can choose between warfarin and novel oral anticoagulants (NOACs) for anticoagulation.
Before starting anticoagulation, the patient’s bleeding risk should be assessed using tools like the HAS-BLED score or the ORBIT tool. These tools evaluate factors such as hypertension, abnormal renal or liver function, history of bleeding, age, and use of drugs that predispose to bleeding.
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This question is part of the following fields:
- Cardiology
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Question 58
Correct
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A 42 year old male is brought into the resuscitation bay with multiple injuries after a roof collapse. The patient has extensive bruising on the neck and a fractured femur caused by a beam that fell and crushed his right thigh. Your consultant intends to perform rapid sequence induction (RSI) and intubation. Which of the following medications would be inappropriate for this patient?
Your Answer: Suxamethonium
Explanation:Suxamethonium is a medication that can cause an increase in serum potassium levels by causing potassium to leave muscle cells. This can be a problem in patients who already have high levels of potassium, such as those with crush injuries. Therefore, suxamethonium should not be used in these cases.
Further Reading:
Rapid sequence induction (RSI) is a method used to place an endotracheal tube (ETT) in the trachea while minimizing the risk of aspiration. It involves inducing loss of consciousness while applying cricoid pressure, followed by intubation without face mask ventilation. The steps of RSI can be remembered using the 7 P’s: preparation, pre-oxygenation, pre-treatment, paralysis and induction, protection and positioning, placement with proof, and post-intubation management.
Preparation involves preparing the patient, equipment, team, and anticipating any difficulties that may arise during the procedure. Pre-oxygenation is important to ensure the patient has an adequate oxygen reserve and prolongs the time before desaturation. This is typically done by breathing 100% oxygen for 3 minutes. Pre-treatment involves administering drugs to counter expected side effects of the procedure and anesthesia agents used.
Paralysis and induction involve administering a rapid-acting induction agent followed by a neuromuscular blocking agent. Commonly used induction agents include propofol, ketamine, thiopentone, and etomidate. The neuromuscular blocking agents can be depolarizing (such as suxamethonium) or non-depolarizing (such as rocuronium). Depolarizing agents bind to acetylcholine receptors and generate an action potential, while non-depolarizing agents act as competitive antagonists.
Protection and positioning involve applying cricoid pressure to prevent regurgitation of gastric contents and positioning the patient’s neck appropriately. Tube placement is confirmed by visualizing the tube passing between the vocal cords, auscultation of the chest and stomach, end-tidal CO2 measurement, and visualizing misting of the tube. Post-intubation management includes standard care such as monitoring ECG, SpO2, NIBP, capnography, and maintaining sedation and neuromuscular blockade.
Overall, RSI is a technique used to quickly and safely secure the airway in patients who may be at risk of aspiration. It involves a series of steps to ensure proper preparation, oxygenation, drug administration, and tube placement. Monitoring and post-intubation care are also important aspects of RSI.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 59
Correct
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A 65 year old female is brought into the emergency department with a one week history of worsening nausea, muscle cramps, fatigue, and weakness. You send urine and blood samples for analysis. The patient's observations and investigation results are shown below:
Na+ 120 mmol/l
K+ 5.3 mmol/l
Urea 6.5 mmol/l
Creatinine 87 µmol/l
Glucose 5.5 mmol/l
Urine osmolality 365 mosmol/kg
Blood pressure 138/78 mmHg
Pulse 82 bpm
Respiration rate 18 bpm
Oxygen saturations 97% on air
What is the most likely diagnosis?Your Answer: SIADH
Explanation:The patient’s symptoms of nausea, muscle cramps, fatigue, and weakness are consistent with hyponatremia, which is a low sodium level in the blood. The blood test results show a low sodium level (Na+ 120 mmol/l) and normal potassium level (K+ 5.3 mmol/l), which is commonly seen in SIADH.
Additionally, the urine osmolality of 365 mosmol/kg indicates concentrated urine, which is contrary to what would be expected in diabetes insipidus. In diabetes insipidus, the urine would be dilute due to the inability to concentrate urine properly.
The patient’s blood pressure, pulse, respiration rate, and oxygen saturations are within normal range, which does not suggest a diagnosis of Addison’s disease or Conn’s syndrome.
Therefore, based on the symptoms, laboratory results, and urine osmolality, the most likely diagnosis for this patient is SIADH.
Further Reading:
Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition characterized by low sodium levels in the blood due to excessive secretion of antidiuretic hormone (ADH). ADH, also known as arginine vasopressin (AVP), is responsible for promoting water and sodium reabsorption in the body. SIADH occurs when there is impaired free water excretion, leading to euvolemic (normal fluid volume) hypotonic hyponatremia.
There are various causes of SIADH, including malignancies such as small cell lung cancer, stomach cancer, and prostate cancer, as well as neurological conditions like stroke, subarachnoid hemorrhage, and meningitis. Infections such as tuberculosis and pneumonia, as well as certain medications like thiazide diuretics and selective serotonin reuptake inhibitors (SSRIs), can also contribute to SIADH.
The diagnostic features of SIADH include low plasma osmolality, inappropriately elevated urine osmolality, urinary sodium levels above 30 mmol/L, and euvolemic. Symptoms of hyponatremia, which is a common consequence of SIADH, include nausea, vomiting, headache, confusion, lethargy, muscle weakness, seizures, and coma.
Management of SIADH involves correcting hyponatremia slowly to avoid complications such as central pontine myelinolysis. The underlying cause of SIADH should be treated if possible, such as discontinuing causative medications. Fluid restriction is typically recommended, with a daily limit of around 1000 ml for adults. In severe cases with neurological symptoms, intravenous hypertonic saline may be used. Medications like demeclocycline, which blocks ADH receptors, or ADH receptor antagonists like tolvaptan may also be considered.
It is important to monitor serum sodium levels closely during treatment, especially if using hypertonic saline, to prevent rapid correction that can lead to central pontine myelinolysis. Osmolality abnormalities can help determine the underlying cause of hyponatremia, with increased urine osmolality indicating dehydration or renal disease, and decreased urine osmolality suggesting SIADH or overhydration.
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This question is part of the following fields:
- Endocrinology
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Question 60
Correct
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You are managing a 42 year old female who has been brought into the emergency department with burns and suspected inhalation injury following a house fire. Due to concerns about the patient's ability to maintain their airway it is decided to proceed with intubation and ventilation. Your initial attempt to intubate the patient fails. What is the maximum number of intubation attempts that should be made?
Your Answer: 3
Explanation:According to the guidelines of the Difficult Airway Society, it is recommended to limit intubation attempts to a maximum of three. However, if the first three attempts are unsuccessful, a more experienced colleague may make a fourth attempt. If all four attempts are unsuccessful, the intubation should be declared as a failure.
Further Reading:
A difficult airway refers to a situation where factors have been identified that make airway management more challenging. These factors can include body habitus, head and neck anatomy, mouth characteristics, jaw abnormalities, and neck mobility. The LEMON criteria can be used to predict difficult intubation by assessing these factors. The criteria include looking externally at these factors, evaluating the 3-3-2 rule which assesses the space in the mouth and neck, assessing the Mallampati score which measures the distance between the tongue base and roof of the mouth, and considering any upper airway obstructions or reduced neck mobility.
Direct laryngoscopy is a method used to visualize the larynx and assess the size of the tracheal opening. The Cormack-Lehane grading system can be used to classify the tracheal opening, with higher grades indicating more difficult access. In cases of a failed airway, where intubation attempts are unsuccessful and oxygenation cannot be maintained, the immediate priority is to oxygenate the patient and prevent hypoxic brain injury. This can be done through various measures such as using a bag-valve-mask ventilation, high flow oxygen, suctioning, and optimizing head positioning.
If oxygenation cannot be maintained, it is important to call for help from senior medical professionals and obtain a difficult airway trolley if not already available. If basic airway management techniques do not improve oxygenation, further intubation attempts may be considered using different equipment or techniques. If oxygen saturations remain below 90%, a surgical airway such as a cricothyroidotomy may be necessary.
Post-intubation hypoxia can occur for various reasons, and the mnemonic DOPES can be used to identify and address potential problems. DOPES stands for displacement of the endotracheal tube, obstruction, pneumothorax, equipment failure, and stacked breaths. If intubation attempts fail, a maximum of three attempts should be made before moving to an alternative plan, such as using a laryngeal mask airway or considering a cricothyroidotomy.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 61
Correct
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A 3-year-old boy has been brought into the Emergency Department having seizures that have lasted for 25 minutes prior to his arrival. On arrival, he is continuing to have a tonic-clonic seizure.
What dose of phenytoin is recommended in the treatment of the convulsing child that reaches that stage of the APLS algorithm?Your Answer: 20 mg/kg over 20 minutes
Explanation:If a child who is experiencing convulsions reaches step 3 of the APLS algorithm, it is recommended to prepare a phenytoin infusion. This infusion should be administered at a dosage of 20 mg/kg over a period of 20 minutes.
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This question is part of the following fields:
- Neurology
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Question 62
Correct
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A 35-year-old woman presents to the emergency department with neck pain after a car accident. After conducting a clinical examination and identifying a low-risk factor for cervical spine injury, you decide to order imaging for this patient. What type of imaging would you recommend?
Your Answer: CT cervical spine
Explanation:According to NICE guidelines, when it comes to imaging for cervical spine injury, CT is recommended as the primary modality for adults aged 16 and above, while MRI is recommended for children. This applies to patients who are either at high risk for cervical spine injury or are unable to actively rotate their neck 45 degrees to the left and right.
Further Reading:
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.
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This question is part of the following fields:
- Trauma
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Question 63
Correct
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A 68-year-old woman with a history of chronic anemia receives a blood transfusion as part of her treatment protocol. She has a known history of heart failure, for which she takes metoprolol and hydrochlorothiazide. She becomes short of breath, volume overloaded, and edematous during the transfusion.
Which of the following tests will be most useful in confirming the diagnosis?Your Answer: BNP
Explanation:Transfusion-associated circulatory overload (TACO) is a reaction that occurs when a large volume of blood is infused rapidly. It is the second leading cause of deaths related to transfusions, accounting for about 20% of all fatalities.
TACO typically happens in patients with limited cardiac reserve or chronic anemia who receive a fast blood transfusion. Elderly individuals, infants, and severely anemic patients are particularly vulnerable.
The common signs of TACO include acute respiratory distress, rapid heartbeat, high blood pressure, the appearance of acute or worsening fluid accumulation in the lungs on a chest X-ray, and evidence of excessive fluid retention.
The B-type natriuretic peptide (BNP) can be a helpful diagnostic tool for TACO. Usually, the BNP level is elevated to at least 1.5 times the baseline before the transfusion.
In many cases, simply slowing down the rate of transfusion, positioning the patient upright, and administering diuretics will be sufficient. In more severe cases, the transfusion should be stopped, and non-invasive ventilation may be considered.
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This question is part of the following fields:
- Haematology
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Question 64
Correct
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A 65-year-old patient with advanced metastatic bowel cancer is experiencing symptoms of bowel obstruction and is currently suffering from nausea and vomiting. The patient has been informed that she has only a few days left to live. Upon examination, her abdomen is found to be tender and distended.
What is the most suitable course of action to address her nausea and vomiting in this situation?Your Answer: Hyoscine butylbromide
Explanation:According to NICE, hyoscine butylbromide is recommended as the initial medication for managing nausea and vomiting in individuals with obstructive bowel disorders who are in the last days of life. NICE provides guidance on how to handle these symptoms in the final days of life, which includes assessing the potential causes of nausea and vomiting in the dying person. This may involve considering factors such as certain medications, recent chemotherapy or radiotherapy, psychological causes, biochemical causes like hypercalcemia, raised intracranial pressure, gastrointestinal motility disorder, ileus, or bowel obstruction.
It is important to discuss the available options for treating nausea and vomiting with the dying person and their loved ones. Non-pharmacological methods should also be considered when managing these symptoms in someone in the last days of life. When selecting medications for nausea and vomiting, factors such as the likely cause and reversibility of the symptoms, potential side effects (including sedation), other symptoms the person may be experiencing, and the desired balancing of effects when managing other symptoms should be taken into account. Additionally, compatibility and potential drug interactions with other medications the person is taking should be considered.
For individuals in the last days of life with obstructive bowel disorders who have nausea or vomiting, hyoscine butylbromide is recommended as the first-line pharmacological treatment. If the symptoms do not improve within 24 hours of starting treatment with hyoscine butylbromide, octreotide may be considered as an alternative option.
For more information, refer to the NICE guidance on the care of dying adults in the last days of life. https://www.nice.org.uk/guidance/ng31
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This question is part of the following fields:
- Palliative & End Of Life Care
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Question 65
Correct
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You are part of the resus team treating a 42-year-old female patient with a severe head injury after falling from a ladder. As the patient's GCS continues to decline, your consultant instructs you to prepare for rapid sequence induction. You gather the necessary supplies and prepare etomidate as the induction agent. Upon reviewing the patient's details, you observe that she weighs 65kg. What would be the appropriate dose of etomidate for this patient during RSI?
Your Answer: 21mg
Explanation:The recommended dose of etomidate for rapid sequence intubation (RSI) is typically 0.3mg per kilogram of body weight. For example, a patient weighing 70 kilograms would receive a dose of 21mg (70 x 0.3 = 21mg). This dosage falls within the accepted range of 0.15-0.3 mg/kg as suggested by the British National Formulary (BNF). Therefore, the only option within this range is the fourth option.
Further Reading:
There are four commonly used induction agents in the UK: propofol, ketamine, thiopentone, and etomidate.
Propofol is a 1% solution that produces significant venodilation and myocardial depression. It can also reduce cerebral perfusion pressure. The typical dose for propofol is 1.5-2.5 mg/kg. However, it can cause side effects such as hypotension, respiratory depression, and pain at the site of injection.
Ketamine is another induction agent that produces a dissociative state. It does not display a dose-response continuum, meaning that the effects do not necessarily increase with higher doses. Ketamine can cause bronchodilation, which is useful in patients with asthma. The initial dose for ketamine is 0.5-2 mg/kg, with a typical IV dose of 1.5 mg/kg. Side effects of ketamine include tachycardia, hypertension, laryngospasm, unpleasant hallucinations, nausea and vomiting, hypersalivation, increased intracranial and intraocular pressure, nystagmus and diplopia, abnormal movements, and skin reactions.
Thiopentone is an ultra-short acting barbiturate that acts on the GABA receptor complex. It decreases cerebral metabolic oxygen and reduces cerebral blood flow and intracranial pressure. The adult dose for thiopentone is 3-5 mg/kg, while the child dose is 5-8 mg/kg. However, these doses should be halved in patients with hypovolemia. Side effects of thiopentone include venodilation, myocardial depression, and hypotension. It is contraindicated in patients with acute porphyrias and myotonic dystrophy.
Etomidate is the most haemodynamically stable induction agent and is useful in patients with hypovolemia, anaphylaxis, and asthma. It has similar cerebral effects to thiopentone. The dose for etomidate is 0.15-0.3 mg/kg. Side effects of etomidate include injection site pain, movement disorders, adrenal insufficiency, and apnoea. It is contraindicated in patients with sepsis due to adrenal suppression.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 66
Correct
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A 65-year-old woman is about to begin taking warfarin for the treatment of her atrial fibrillation. She is currently on multiple other medications.
Which ONE medication will enhance the effects of warfarin?Your Answer: Erythromycin
Explanation:Cytochrome p450 enzyme inhibitors have the ability to enhance the effects of warfarin, leading to an increase in the International Normalized Ratio (INR). To remember the commonly encountered cytochrome p450 enzyme inhibitors, the mnemonic O DEVICES can be utilized. Each letter in the mnemonic represents a specific inhibitor: O for Omeprazole, D for Disulfiram, E for Erythromycin (as well as other macrolide antibiotics), V for Valproate (specifically sodium valproate), I for Isoniazid, C for Ciprofloxacin, E for Ethanol (when consumed acutely), and S for Sulphonamides.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 67
Correct
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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: 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.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 68
Correct
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A 35 year old female is brought into the emergency department (ED) due to an altered level of consciousness. An arterial blood gas sample is collected. The results are as follows:
pH: 7.25
pO2: 12.8 kPa
pCO2: 5.9 kPa
Bicarbonate: 14 mmol/L
Chloride: 98 mmol/L
Potassium: 6.0 mmol/L
Sodium: 137 mmol/L
Which of the following options best describes the anion gap?Your Answer: High anion gap acidosis
Explanation:An anion gap greater than 11 is considered high when using modern ion-selective electrode analyzers. This indicates a condition known as high anion gap acidosis. The anion gap can be calculated using the equation: ([Na+] + [K+]) – ([Cl-] + [HCO3-]). In this particular case, the calculation results in a value of 30.4 mmol/l. Anion gaps greater than 11 are considered high.
Further Reading:
Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.
To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.
Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.
The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.
The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.
The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.
Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.
The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.
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This question is part of the following fields:
- Respiratory
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Question 69
Correct
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A 65-year-old man comes in with a sudden onset of right-sided weakness and difficulty speaking. A CT scan has ruled out a primary intracerebral hemorrhage and he is being prepared for thrombolysis. His blood pressure is currently elevated at 190/100 mmHg.
What would be the most suitable next course of action in managing his condition?Your Answer: Labetalol 10 mg IV
Explanation:Severe hypertension, defined as blood pressure greater than 180/120 mmHg, is a condition that prevents the use of thrombolysis. In order to proceed with thrombolysis, it is necessary to lower the patient’s blood pressure to below this level within the designated time frame. Oral medications are unlikely to work quickly enough, so an intravenous antihypertensive agent is required.
One commonly used agent in these situations is labetalol, which is administered intravenously at a dose of 10 mg over 1-2 minutes. This dose can be repeated if necessary, or an infusion can be set up to deliver a continuous dose of 2-8 mg per minute. Once the blood pressure is reduced to less than 180/105 mmHg, thrombolysis can be safely performed.
Alternatively, a nitrate infusion, such as Isoket, can be used in patients who cannot tolerate beta-blockers due to contraindications like asthma, heart block, or cardiac failure. This provides an alternative option for lowering blood pressure in these individuals.
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This question is part of the following fields:
- Neurology
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Question 70
Correct
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A 68-year-old man with a history of atrial fibrillation (AF) is found to have an INR of 7.3 during a routine check. He is feeling fine and does not have any signs of bleeding.
What is the most suitable approach to reverse the effects of warfarin in this patient?Your Answer: Withhold 1-2 doses of warfarin and reduce subsequent maintenance dose
Explanation:The current recommendations from NICE for managing warfarin in the presence of bleeding or an abnormal INR are as follows:
In cases of major active bleeding, regardless of the INR level, the first step is to stop administering warfarin. Next, 5 mg of vitamin K (phytomenadione) should be given intravenously. Additionally, dried prothrombin complex concentrate, which contains factors II, VII, IX, and X, should be administered. If dried prothrombin complex is not available, fresh frozen plasma can be given at a dose of 15 ml/kg.
If the INR is greater than 8.0 and there is minor bleeding, warfarin should be stopped. Slow injection of 1-3 mg of vitamin K can be given, and this dose can be repeated after 24 hours if the INR remains high. Warfarin can be restarted once the INR is less than 5.0.
If the INR is greater than 8.0 with no bleeding, warfarin should be stopped. Oral administration of 1-5 mg of vitamin K can be given, and this dose can be repeated after 24 hours if the INR remains high. Warfarin can be restarted once the INR is less than 5.0.
If the INR is between 5.0-8.0 with minor bleeding, warfarin should be stopped. Slow injection of 1-3 mg of vitamin K can be given, and warfarin can be restarted once the INR is less than 5.0.
If the INR is between 5.0-8.0 with no bleeding, one or two doses of warfarin should be withheld, and the subsequent maintenance dose should be reduced.
For more information, please refer to the NICE Clinical Knowledge Summary on the management of warfarin therapy and the BNF guidance on the use of phytomenadione.
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This question is part of the following fields:
- Haematology
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Question 71
Incorrect
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A 35-year-old woman from East Africa presents with haematuria. Urine specimens are sent, and a diagnosis of schistosomiasis is made.
What is the SINGLE most likely causative organism?Your Answer: Schistosoma mekongi
Correct Answer: Schistosoma haematobium
Explanation:Schistosomiasis, also known as bilharzia, is a tropical disease caused by parasitic trematodes (flukes) of the Schistosoma type. The transmission of this disease occurs when water becomes contaminated with faeces or urine containing eggs, and a specific freshwater snail serves as the intermediate host. Human contact with water inhabited by the intermediate host snail is necessary for transmission to occur.
There are five species of Schistosoma that can cause human disease: S. japonicum, S. mansoni, S. haematobium, S. intercalatum, and S. mekongi. Among these, S. japonicum and S. mansoni are the most significant causes of intestinal schistosomiasis, while S. haematobium is the primary cause of urogenital schistosomiasis.
Urogenital schistosomiasis occurs when adult worms migrate from their initial site in the liver to the vesical plexus. The presence of blood in the urine, known as haematuria, is a characteristic sign of urogenital schistosomiasis. In women, this condition may manifest with genital and vaginal lesions, as well as dyspareunia. pathology in the seminal vesicles and prostate. Advanced cases of urogenital schistosomiasis can result in fibrosis of the ureter and bladder, as well as kidney damage. Complications such as bladder cancer and infertility are also recognized in association with this disease.
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This question is part of the following fields:
- Urology
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Question 72
Correct
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You are summoned to the resuscitation bay to aid in the care of a 45-year-old male who has suffered a head injury. A fellow healthcare provider informs you that the patient is exhibiting Cushing's triad of symptoms. What is the most accurate description of Cushing's triad?
Your Answer: Widened pulse pressure, bradycardia and bradypnoea
Explanation:Cushing’s triad is a combination of widened pulse pressure, bradycardia, and reduced respirations. It is a physiological response of the nervous system to acute increases in intracranial pressure (ICP). This response, known as the Cushing reflex, can cause the symptoms of Cushing’s triad. These symptoms include an increase in systolic blood pressure and a decrease in diastolic blood pressure, a slower heart rate, and irregular or reduced breathing. Additionally, raised ICP can also lead to other symptoms such as headache, papilloedema, and vomiting.
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.
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This question is part of the following fields:
- Endocrinology
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Question 73
Correct
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A 52-year-old businessman returns from a visit to Los Angeles with difficulty breathing and chest pain that worsens with deep breaths. The results of his arterial blood gas (ABG) on room air are as follows:
pH: 7.48
pO2: 7.4 kPa
PCO2: 3.1 kPa
HCO3-: 24.5 mmol/l
Which ONE statement about his ABG is correct?Your Answer: He has a respiratory alkalosis
Explanation:Arterial blood gas (ABG) interpretation is crucial in evaluating a patient’s respiratory gas exchange and acid-base balance. While the normal values on an ABG may slightly vary between analysers, they generally fall within the following ranges: pH of 7.35 – 7.45, pO2 of 10 – 14 kPa, PCO2 of 4.5 – 6 kPa, HCO3- of 22 – 26 mmol/l, and base excess of -2 – 2 mmol/l.
In this particular case, the patient’s medical history raises concerns about a potential diagnosis of pulmonary embolism. The relevant ABG findings are as follows: significant hypoxia (indicating type 1 respiratory failure), elevated pH (alkalaemia), low PCO2, and normal bicarbonate levels. These findings suggest that the patient is experiencing primary respiratory alkalosis.
By analyzing the ABG results, healthcare professionals can gain valuable insights into a patient’s respiratory function and acid-base status, aiding in the diagnosis and management of various conditions.
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This question is part of the following fields:
- Respiratory
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Question 74
Correct
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A 45 year old male is brought into the emergency department following a car crash. There is significant bruising on the right side of the chest. You suspect the patient has a haemothorax. What are the two main objectives in managing this condition?
Your Answer: Replace lost circulating blood volume and decompression of the pleural space
Explanation:The main objectives in managing haemothorax are to restore the lost blood volume and relieve pressure in the pleural space. These actions are crucial for improving the patient’s oxygen levels.
Further Reading:
Haemothorax is the accumulation of blood in the pleural cavity of the chest, usually resulting from chest trauma. It can be difficult to differentiate from other causes of pleural effusion on a chest X-ray. Massive haemothorax refers to a large volume of blood in the pleural space, which can impair physiological function by causing blood loss, reducing lung volume for gas exchange, and compressing thoracic structures such as the heart and IVC.
The management of haemothorax involves replacing lost blood volume and decompressing the chest. This is done through supplemental oxygen, IV access and cross-matching blood, IV fluid therapy, and the insertion of a chest tube. The chest tube is connected to an underwater seal and helps drain the fluid, pus, air, or blood from the pleural space. In cases where there is prompt drainage of a large amount of blood, ongoing significant blood loss, or the need for blood transfusion, thoracotomy and ligation of bleeding thoracic vessels may be necessary. It is important to have two IV accesses prior to inserting the chest drain to prevent a drop in blood pressure.
In summary, haemothorax is the accumulation of blood in the pleural cavity due to chest trauma. Managing haemothorax involves replacing lost blood volume and decompressing the chest through various interventions, including the insertion of a chest tube. Prompt intervention may be required in cases of significant blood loss or ongoing need for blood transfusion.
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This question is part of the following fields:
- Trauma
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Question 75
Incorrect
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A 62 year old presents to the emergency department complaining of sudden hearing loss. During the examination, tuning fork tests are performed. Weber's test lateralizes to the left side and Rinne's testing is positive for both ears.
This assessment supports which of the following?Your Answer: Right sided sensorineural hearing loss
Correct Answer: Left sided sensorineural hearing loss
Explanation:When performing Weber’s test, if the sound lateralizes to the unaffected side, it suggests sensorineural hearing loss. If the sound lateralizes to the right, it could mean that there is sensorineural hearing loss in the left ear or conductive hearing loss in the right ear. A positive Rinne test result indicates that air conduction is greater than bone conduction, which is normal or seen in sensorineural hearing loss. On the other hand, a negative Rinne test result suggests that bone conduction is greater than air conduction, which is typically seen in conductive hearing loss. Therefore, if there is conductive hearing loss in the left ear, a negative Rinne test result would indicate sensorineural loss on the left side.
Further Reading:
Hearing loss is a common complaint that can be caused by various conditions affecting different parts of the ear and nervous system. The outer ear is the part of the ear outside the eardrum, while the middle ear is located between the eardrum and the cochlea. The inner ear is within the bony labyrinth and consists of the vestibule, semicircular canals, and cochlea. The vestibulocochlear nerve connects the inner ear to the brain.
Hearing loss can be classified based on severity, onset, and type. Severity is determined by the quietest sound that can be heard, measured in decibels. It can range from mild to profound deafness. Onset can be sudden, rapidly progressive, slowly progressive, or fluctuating. Type of hearing loss can be either conductive or sensorineural. Conductive hearing loss is caused by issues in the external ear, eardrum, or middle ear that disrupt sound transmission. Sensorineural hearing loss is caused by problems in the cochlea, auditory nerve, or higher auditory processing pathways.
To diagnose sensorineural and conductive deafness, a 512 Hz tuning fork is used to perform Rinne and Weber’s tests. These tests help determine the type of hearing loss based on the results. In Rinne’s test, air conduction (AC) and bone conduction (BC) are compared, while Weber’s test checks for sound lateralization.
Cholesteatoma is a condition characterized by the abnormal accumulation of skin cells in the middle ear or mastoid air cell spaces. It is believed to develop from a retraction pocket that traps squamous cells. Cholesteatoma can cause the accumulation of keratin and the destruction of adjacent bones and tissues due to the production of destructive enzymes. It can lead to mixed sensorineural and conductive deafness as it affects both the middle and inner ear.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 76
Incorrect
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A middle-aged woman presents with symptoms that can be associated with sexually transmitted infection. Following her investigations, she is diagnosed with gonorrhoea.
Which of the following is the most common presenting clinical feature of gonorrhoea in women?Your Answer: Dysuria
Correct Answer: Vaginal discharge
Explanation:Neisseria gonorrhoeae is a type of bacteria that is shaped like two spheres and stains pink when tested. It is responsible for causing the sexually transmitted infection known as gonorrhoea. This infection is most commonly seen in individuals between the ages of 15 and 35, and it is primarily transmitted through sexual contact. One important thing to note is that the gonococcal pili, which are hair-like structures on the bacteria, can change their appearance. This means that even if someone has recovered from a previous infection, they can still be reinfected due to the bacteria’s ability to alter its antigens.
In men, the most common symptoms of gonorrhoea include inflammation of the urethra, which is the tube that carries urine out of the body. This is seen in approximately 80% of cases. Other symptoms may include painful urination, as well as the presence of a discharge that is a combination of mucus and pus. In some cases, the infection can also affect the rectum, leading to anal discharge. It is worth noting that pharyngitis, which is inflammation of the throat, is usually asymptomatic in men.
On the other hand, women with gonorrhoea often experience a vaginal discharge as the main symptom, which is seen in about 50% of cases. Lower abdominal pain is another common symptom, occurring in approximately 25% of cases. Dysuria, or painful urination, is seen in about 10-15% of women with the infection. Some women may also experience tenderness in the pelvic or lower abdominal area. Additionally, there may be a discharge or bleeding from the endocervix, which is the opening of the cervix. Similar to men, rectal infection is usually asymptomatic in women, but it can cause anal discharge. Pharyngitis, or inflammation of the throat, is typically not accompanied by any noticeable symptoms in women.
Overall, it is important to be aware of the various clinical features of gonorrhoea in both men and women in order to recognize and seek appropriate treatment for this sexually transmitted infection.
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This question is part of the following fields:
- Sexual Health
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Question 77
Incorrect
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A 35-year-old woman comes in with a 3-day history of mild discomfort while urinating. She also reports increased frequency of urination. She denies any urgency or excessive urination and has not observed any blood in her urine. On physical examination, her abdomen is soft and nontender.
What is the MOST suitable course of action for management?Your Answer: Start her on a 3-day course of oral trimethoprim
Correct Answer: Use a urine dipstick test to help in this patient’s diagnosis
Explanation:Classical symptoms of a urinary tract infection (UTI) typically include dysuria, suprapubic tenderness, urgency, haematuria, increased frequency of micturition, and polyuria. To effectively manage UTIs, SIGN has developed excellent guidelines. According to these guidelines, if a patient presents with mild symptoms of a UTI (experiencing two or fewer classical symptoms), it is recommended to use a dipstick test to aid in the diagnosis and treatment process.
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This question is part of the following fields:
- Urology
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Question 78
Correct
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You evaluate a 62-year-old woman with a painful swollen left big toe. The pain began this morning and is described as the most severe pain she has ever experienced. It has progressively worsened over the past 8 hours. She is unable to wear socks or shoes and had to attend the appointment wearing open-toe sandals. The skin over the affected area appears red and shiny.
What is the most probable diagnosis in this scenario?Your Answer: Gout
Explanation:The guidelines from the European League Against Rheumatism (EULAR) regarding the diagnosis of gout state that if a joint becomes swollen, tender, and red, accompanied by acute pain that intensifies over a period of 6-12 hours, it is highly likely to be a crystal arthropathy. While pseudogout is also a possibility, it is much less probable, with gout being the most likely diagnosis in such cases.
In cases of acute gout, the joint most commonly affected is the first metatarsal-phalangeal joint, accounting for 50-75% of cases. The underlying cause of gout is hyperuricaemia, and the clinical diagnosis can be confirmed by the presence of negatively birefringent crystals in the synovial fluid aspirate.
For the treatment of acute gout attacks, the usual approach involves the use of either NSAIDs or colchicine.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 79
Correct
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A 28-year-old woman comes to the GP complaining of a painful lump in her breast that she noticed two days ago. She also mentions feeling tired all the time. She recently had her first baby four weeks ago and is currently breastfeeding without any issues. During the examination, a poorly defined lump measuring approximately 5 cm in diameter is found just below the left nipple in the outer lower quadrant of the left breast. The skin above the lump is red, and it feels soft and tender when touched.
What is the MOST likely diagnosis for this patient?Your Answer: Breast abscess
Explanation:A breast abscess is a localized accumulation of pus in the breast tissue. It often occurs in women who are breastfeeding and is typically caused by bacteria entering through a crack in the nipple. However, it can also develop in non-lactating women after breast trauma or in individuals with a weakened immune system.
The common presentation of a breast abscess includes a tender lump in a specific area of the breast, which may be accompanied by redness of the skin. Additionally, the patient may experience fever and overall feelings of illness.
Diagnosis of a breast abscess is usually made based on clinical examination. However, an ultrasound scan can be utilized to assist in confirming the diagnosis. Treatment involves draining the abscess through incision and then administering antibiotics to prevent further infection.
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This question is part of the following fields:
- Surgical Emergencies
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Question 80
Incorrect
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A 7-year-old girl is brought to the Emergency Department by her father after falling at a park. Her ankle appears to be deformed, and it is suspected that she has a fracture in her distal fibula. Her pain is evaluated using a numerical rating scale, and the triage nurse informs you that she is experiencing moderate pain.
According to the RCEM guidance, which of the following analgesics is recommended for managing moderate pain in a child of this age?Your Answer: Oral codeine phosphate 1 mg/kg
Correct Answer: Rectal diclofenac 1 mg/kg
Explanation:A recent audit conducted by the Royal College of Emergency Medicine (RCEM) in 2018 revealed a concerning decline in the standards of pain management for children with fractured limbs in Emergency Departments (EDs). The audit found that the majority of patients experienced longer waiting times for pain relief compared to previous years. Shockingly, more than 1 in 10 children who presented with significant pain due to a limb fracture did not receive any pain relief at all.
To address this issue, the Agency for Health Care Policy and Research (AHCPR) in the USA recommends following the ABCs of pain management for all patients, including children. This approach involves regularly asking about pain, systematically assessing it, believing the patient and their family in their reports of pain and what relieves it, choosing appropriate pain control options, delivering interventions in a timely and coordinated manner, and empowering patients and their families to have control over their pain management.
The RCEM has established standards that require a child’s pain to be assessed within 15 minutes of their arrival at the ED. This is considered a fundamental standard. Various rating scales are available for assessing pain in children, with the choice depending on the child’s age and ability to use the scale. These scales include the Wong-Baker Faces Pain Rating Scale, Numeric rating scale, and Behavioural scale.
To ensure timely administration of analgesia to children in acute pain, the RCEM has set specific standards. These standards state that 100% of patients in severe pain should receive appropriate analgesia within 60 minutes of their arrival or triage, whichever comes first. Additionally, 75% should receive analgesia within 30 minutes, and 50% within 20 minutes.
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This question is part of the following fields:
- Pain & Sedation
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Question 81
Correct
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A 14-year-old girl comes in with a sudden onset of a painful throat that has been bothering her for the past day. She has no history of coughing or cold symptoms. During the examination, her temperature is measured at 38.5°C, and there is visible exudate on her right tonsil, which also appears to be swollen and red. No anterior cervical lymph nodes can be felt. What is her FeverPAIN Score for assessing her sore throat?
Your Answer: 5
Explanation:Two scoring systems are suggested by NICE to aid in the evaluation of sore throat: The Centor Clinical Prediction Score and The FeverPAIN Score.
The FeverPAIN score was developed from a study involving 1760 adults and children aged three and above. The score was tested in a trial that compared three prescribing strategies: empirical delayed prescribing, using the score to guide prescribing, or a combination of the score with the use of a near-patient test (NPT) for streptococcus. Utilizing the score resulted in faster symptom resolution and a reduction in the prescription of antibiotics (both reduced by one third). The inclusion of the NPT did not provide any additional benefit.
The score comprises of five factors, each of which is assigned one point: Fever (Temp >38°C) in the last 24 hours, Purulence, Attended rapidly in under three days, Inflamed tonsils, and No cough or coryza.
Based on the score, the recommendations are as follows:
– Score 0-1 = 13-18% likelihood of streptococcus infection, antibiotics are not recommended.
– Score 2-3 = 34-40% likelihood of streptococcus infection, consider delayed prescribing of antibiotics (3-5 day ‘backup prescription’).
– Score 4-5 = 62-65% likelihood of streptococcus infection, use immediate antibiotics if severe, or a 48-hour short ‘backup prescription.’ -
This question is part of the following fields:
- Ear, Nose & Throat
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Question 82
Correct
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A 45 year old female comes to the emergency department with abrupt onset tearing chest pain that spreads to the throat and back. You contemplate the likelihood of aortic dissection. What is the predominant risk factor observed in individuals with aortic dissection?
Your Answer: Hypertension
Explanation:Aortic dissection is a condition that occurs when the middle layer of the aorta, known as the tunica media, becomes weakened. This weakening leads to the development of cases of aortic dissection.
Further Reading:
Aortic dissection is a life-threatening condition in which blood flows through a tear in the innermost layer of the aorta, creating a false lumen. Prompt treatment is necessary as the mortality rate increases by 1-2% per hour. There are different classifications of aortic dissection, with the majority of cases being proximal. Risk factors for aortic dissection include hypertension, atherosclerosis, connective tissue disorders, family history, and certain medical procedures.
The presentation of aortic dissection typically includes sudden onset sharp chest pain, often described as tearing or ripping. Back pain and abdominal pain are also common, and the pain may radiate to the neck and arms. The clinical picture can vary depending on which aortic branches are affected, and complications such as organ ischemia, limb ischemia, stroke, myocardial infarction, and cardiac tamponade may occur. Common signs and symptoms include a blood pressure differential between limbs, pulse deficit, and a diastolic murmur.
Various investigations can be done to diagnose aortic dissection, including ECG, CXR, and CT with arterial contrast enhancement (CTA). CT is the investigation of choice due to its accuracy in diagnosis and classification. Other imaging techniques such as transoesophageal echocardiography (TOE), magnetic resonance imaging/angiography (MRI/MRA), and digital subtraction angiography (DSA) are less commonly used.
Management of aortic dissection involves pain relief, resuscitation measures, blood pressure control, and referral to a vascular or cardiothoracic team. Opioid analgesia should be given for pain relief, and resuscitation measures such as high flow oxygen and large bore IV access should be performed. Blood pressure control is crucial, and medications such as labetalol may be used to reduce systolic blood pressure. Hypotension carries a poor prognosis and may require careful fluid resuscitation. Treatment options depend on the type of dissection, with type A dissections typically requiring urgent surgery and type B dissections managed by thoracic endovascular aortic repair (TEVAR) and blood pressure control optimization.
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This question is part of the following fields:
- Cardiology
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Question 83
Correct
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You evaluate a 3-year-old who has been brought to the emergency department due to difficulty feeding, irritability, and a high fever. During the examination, you observe a red post-auricular lump, which raises concerns for mastoiditis. What is a commonly known complication associated with mastoiditis?
Your Answer: Facial nerve palsy
Explanation:Mastoiditis can lead to the development of cranial nerve palsies, specifically affecting the trigeminal (CN V), abducens (CN VI), and facial (CN VII) nerves. This occurs when the infection spreads to the petrous apex of the temporal bone, where these nerves are located. The close proximity of the sixth cranial nerve and the trigeminal ganglion, separated only by the dura mater, can result in inflammation and subsequent nerve damage. Additionally, the facial nerve is at risk as it passes through the mastoid via the facial canal.
Further Reading:
Mastoiditis is an infection of the mastoid air cells, which are located in the mastoid process of the skull. It is usually caused by the spread of infection from the middle ear. The most common organism responsible for mastoiditis is Streptococcus pneumoniae, but other bacteria and fungi can also be involved. The infection can spread to surrounding structures, such as the meninges, causing serious complications like meningitis or cerebral abscess.
Mastoiditis can be classified as acute or chronic. Acute mastoiditis is a rare complication of acute otitis media, which is inflammation of the middle ear. It is characterized by severe ear pain, fever, swelling and redness behind the ear, and conductive deafness. Chronic mastoiditis is usually associated with chronic suppurative otitis media or cholesteatoma and presents with recurrent episodes of ear pain, headache, and fever.
Mastoiditis is more common in children, particularly those between 6 and 13 months of age. Other risk factors include immunocompromised patients, those with intellectual impairment or communication difficulties, and individuals with cholesteatoma.
Diagnosis of mastoiditis involves a physical examination, blood tests, ear swab for culture and sensitivities, and imaging studies like contrast-enhanced CT or MRI. Treatment typically involves referral to an ear, nose, and throat specialist, broad-spectrum intravenous antibiotics, pain relief, and myringotomy (a procedure to drain fluid from the middle ear).
Complications of mastoiditis are rare but can be serious. They include intracranial abscess, meningitis, subperiosteal abscess, neck abscess, venous sinus thrombosis, cranial nerve palsies, hearing loss, labyrinthitis, extension to the zygoma, and carotid artery arteritis. However, most patients with mastoiditis have a good prognosis and do not experience long-term ear problems.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 84
Correct
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A 25-year-old woman arrives at the emergency department with complaints of palpitations and difficulty breathing. During triage, the patient reveals that she was previously diagnosed with narrow complex tachycardia a couple of years ago after experiencing palpitations during a night out. You order an ECG. What are the specific criteria used to define narrow complex tachycardia?
Your Answer: Pulse rate greater than 100 beats per minute and QRS duration less than 0.12 seconds
Explanation:Narrow QRS complex tachycardia is a term used to describe a fast heart rhythm with a pulse rate over 100 bpm and a QRS duration shorter than 120 ms.
Further Reading:
Supraventricular tachycardia (SVT) is a type of tachyarrhythmia that originates from the atria or above the bundle of His in the heart. It includes all atrial and junctional tachycardias, although atrial fibrillation is often considered separately. SVT typically produces a narrow QRS complex tachycardia on an electrocardiogram (ECG), unless there is an underlying conduction abnormality below the atrioventricular (AV) node. Narrow complex tachycardias are considered SVTs, while some broad complex tachycardias can also be SVTs with co-existent conduction delays.
SVT can be classified into three main subtypes based on where it arises: re-entrant accessory circuits (the most common type), atrial tachycardias, and junctional tachycardias. The most common SVTs are AVNRT (AV nodal re-entry tachycardia) and AVRT (AV re-entry tachycardia), which arise from accessory circuits within the heart. AVNRT involves an accessory circuit within the AV node itself, while AVRT involves an accessory pathway between the atria and ventricles that allows additional electrical signals to trigger the AV node.
Atrial tachycardias originate from abnormal foci within the atria, except for the SA node, AV node, or accessory pathway. Junctional tachycardias arise in the AV junction. The ECG features of SVTs vary depending on the type. Atrial tachycardias may have abnormal P wave morphology, an isoelectric baseline between P waves (in atrial flutter), and inverted P waves in certain leads. AVNRT may show pseudo R waves in V1 or pseudo S waves in certain leads, with an RP interval shorter than the PR interval. AVRT (WPW) may exhibit a delta wave on a resting ECG and retrograde P waves in the ST segment, with an RP interval shorter than the PR interval. Junctional tachycardias may have retrograde P waves before, during, or after the QRS complex, with inverted P waves in certain leads and upright P waves in others.
Treatment of SVT follows the 2021 resuscitation council algorithm for tachycardia with a pulse. The algorithm provides guidelines for managing stable patients with SVT.
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This question is part of the following fields:
- Cardiology
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Question 85
Incorrect
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A 4-year-old girl is diagnosed with whooping cough. There are two individuals in the household who are considered to be in a 'priority group' for post-exposure chemoprophylaxis.
What is the BEST antibiotic to prescribe for this purpose?Your Answer: Ciprofloxacin
Correct Answer: Erythromycin
Explanation:Whooping cough is a respiratory infection caused by the bacteria Bordetella pertussis. It is highly contagious and can be transmitted to about 90% of close household contacts. The Health Protection Agency has identified two priority groups for public health action in managing whooping cough contacts.
Group 1 consists of individuals who are at a higher risk of severe or complicated infection. This includes infants under one year old who have received less than three doses of the pertussis vaccine.
Group 2 consists of individuals who are at a higher risk of transmitting the infection to those in Group 1. This includes pregnant women who are at or beyond 32 weeks of gestation, healthcare workers who work with infants and pregnant women, individuals who work with infants too young to be vaccinated (under 4 months old), and individuals who share a household with infants too young to be vaccinated.
According to current guidance, antibiotic prophylaxis with a macrolide antibiotic, like erythromycin, should only be offered to close contacts if two criteria are met. First, the index case (the person with whooping cough) must have developed symptoms within the past 21 days. Second, there must be a close contact in one of the two priority groups.
If both criteria are met, all contacts, regardless of their vaccination status and age, should be offered chemoprophylaxis. In this case, the mother is in Group 2, so the current recommendation is that all household contacts, including the mother, father, and brother, should receive chemoprophylaxis.
Additionally, immunization or a booster dose should be considered for those who have been offered chemoprophylaxis, depending on their current vaccination status.
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This question is part of the following fields:
- Respiratory
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Question 86
Incorrect
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A 35-year-old woman that has been involved in a car accident is estimated to have suffered a class II haemorrhage according to the Advanced Trauma Life Support (ATLS) haemorrhagic shock classification. The patient weighs approximately 60 kg.
Which of the following physiological parameters is consistent with a diagnosis of class II haemorrhage?Your Answer: Decreased systolic blood pressure
Correct Answer: Heart rate of 110 bpm
Explanation:Recognizing the extent of blood loss based on vital sign and mental status abnormalities is a crucial skill. The Advanced Trauma Life Support (ATLS) classification for hemorrhagic shock correlates the amount of blood loss with expected physiological responses in a healthy individual weighing 70 kg. In terms of body weight, the total circulating blood volume accounts for approximately 7%, which is roughly equivalent to five liters in an average 70 kg male patient.
The ATLS classification for hemorrhagic shock is as follows:
CLASS I:
– Blood loss: Up to 750 mL
– Blood loss (% blood volume): Up to 15%
– Pulse rate: Less than 100 beats per minute (bpm)
– Systolic blood pressure: Normal
– Pulse pressure: Normal (or increased)
– Respiratory rate: 14-20 breaths per minute
– Urine output: Greater than 30 mL/hr
– CNS/mental status: Slightly anxiousCLASS II:
– Blood loss: 750-1500 mL
– Blood loss (% blood volume): 15-30%
– Pulse rate: 100-120 bpm
– Systolic blood pressure: Normal
– Pulse pressure: Decreased
– Respiratory rate: 20-30 breaths per minute
– Urine output: 20-30 mL/hr
– CNS/mental status: Mildly anxiousCLASS III:
– Blood loss: 1500-2000 mL
– Blood loss (% blood volume): 30-40%
– Pulse rate: 120-140 bpm
– Systolic blood pressure: Decreased
– Pulse pressure: Decreased
– Respiratory rate: 30-40 breaths per minute
– Urine output: 5-15 mL/hr
– CNS/mental status: Anxious, confusedCLASS IV:
– Blood loss: More than 2000 mL
– Blood loss (% blood volume): More than 40%
– Pulse rate: More than 140 bpm
– Systolic blood pressure: Decreased
– Pulse pressure: Decreased
– Respiratory rate: More than 40 breaths per minute
– Urine output: Negligible
– CNS/mental status: Confused, lethargic -
This question is part of the following fields:
- Trauma
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Question 87
Correct
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A 58-year-old woman presents with abrupt intense chest discomfort that extends to her back. She is perspiring and experiencing nausea. During the examination, her blood pressure measures 176/96 in her right arm and 143/78 in her left arm. An early diastolic murmur is audible upon auscultation.
What is the SINGLE most probable diagnosis?Your Answer: Aortic dissection
Explanation:Acute aortic dissection is characterized by the rapid formation of a false, blood-filled channel within the middle layer of the aorta. It is estimated to occur in 3 out of every 100,000 individuals per year.
Patients with aortic dissection typically experience intense chest pain that spreads to the area between the shoulder blades. The pain is often described as tearing or ripping and may also extend to the neck. Sweating, paleness, and rapid heartbeat are commonly observed at the time of presentation. Other possible symptoms include focal neurological deficits, weak pulses, fainting, and reduced blood flow to organs.
A significant difference in blood pressure between the arms, greater than 20 mmHg, is a highly sensitive indicator. If the dissection extends backward, it can involve the aortic valve, leading to the early diastolic murmur of aortic regurgitation.
Risk factors for aortic dissection include hypertension, atherosclerosis, aortic coarctation, the use of sympathomimetic drugs like cocaine, Marfan syndrome, Ehlers-Danlos syndrome, Turner’s syndrome, tertiary syphilis, and pre-existing aortic aneurysm.
Aortic dissection can be classified according to the Stanford classification system:
– Type A affects the ascending aorta and the arch, accounting for 60% of cases. These cases are typically managed surgically and may result in the blockage of coronary arteries and aortic regurgitation.
– Type B begins distal to the left subclavian artery and accounts for approximately 40% of cases. These cases are usually managed with medication to control blood pressure. -
This question is part of the following fields:
- Cardiology
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Question 88
Correct
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A 32-year-old male patient arrives at the Emergency Department after ingesting an overdose 45 minutes ago. He is currently showing no symptoms and is stable in terms of blood flow. 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: Aspirin
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 heat, a process known as pyrolysis, and then treating it with a zinc chloride solution to increase its concentration. This process creates a network of pores within the charcoal, giving it a large absorptive area of approximately 3,000 m2/g. This allows it to effectively inhibit the absorption of toxins by up to 50%.
The usual dose 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 administer it 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. These include cases where the patient is unconscious or in a coma, as there is a risk of aspiration. It should also be avoided if seizures are imminent, as there is a risk of aspiration. Additionally, if there is reduced gastrointestinal motility, activated charcoal should not be used to prevent the risk of obstruction.
Activated charcoal is effective in treating overdose with certain drugs and toxins, such as aspirin, paracetamol, barbiturates, tricyclic antidepressants, digoxin, amphetamines, morphine, cocaine, and phenothiazines. However, it is ineffective in cases of overdose with iron, lithium, boric acid, cyanide, ethanol, ethylene glycol, methanol, malathion, DDT, carbamate, hydrocarbon, strong acids, or alkalis.
There are potential adverse effects associated with the use of activated charcoal. These include nausea and vomiting, diarrhea, constipation, bezoar formation (a mass of undigested material that can cause blockages), bowel obstruction, pulmonary aspiration (inhalation of charcoal into the lungs), and impaired absorption of oral medications or antidotes.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 89
Correct
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A 72-year-old man with a known history of heart disease presents due to a general decline in his health. He complains of feeling extremely tired and has been experiencing occasional heart palpitations over the past few days. A complete set of blood tests, including a venous gas, have been sent to the laboratory, revealing a potassium level of 7.3 mmol/l. An ECG is performed, which shows abnormal, wide QRS complexes.
What is the initial treatment that should be administered first?Your Answer: IV calcium chloride
Explanation:This patient has been diagnosed with severe hyperkalemia and is showing significant ECG changes. The top priority in this situation is to protect the heart. It is recommended to administer 10 ml of 10% calcium chloride immediately over a period of 2-5 minutes. Calcium helps counteract the harmful effects of hyperkalemia on the heart by stabilizing the cardiac cell membrane and preventing unwanted depolarization.
Hyperkalemia is a commonly encountered electrolyte disorder, affecting up to 10% of hospitalized patients. It is typically caused by an increase in potassium release from cells or impaired excretion by the kidneys. The main causes of hyperkalemia include renal failure, certain medications (such as ACE inhibitors, ARBs, potassium-sparing diuretics, and NSAIDs), tissue breakdown (as seen in conditions like tumor lysis, rhabdomyolysis, and hemolysis), metabolic acidosis (often associated with renal failure or diabetic ketoacidosis), and endocrine disorders like Addison’s disease.
ECG changes that may be observed in hyperkalemia include a prolonged PR interval, peaked T-waves, widening of the QRS complex, reduced or absent P wave, sine wave pattern, AV dissociation, asystole, and bradycardia. It is important to note that the severity of ECG changes may not always correlate with the actual serum potassium levels in a patient.
The treatment approach for hyperkalemia depends on its severity. Mild hyperkalemia is defined as a potassium level of 5.5-5.9 mmol/L, moderate hyperkalemia as 6.0-6.4 mmol/L, and severe hyperkalemia as >6.5 mmol/L.
For mild hyperkalemia, the focus should be on addressing the underlying cause and preventing further increase in serum potassium levels. This may involve adjusting medications or dietary changes. If treatment is necessary, potassium exchange resins like calcium resonium can be used to remove potassium from the body.
In cases of moderate hyperkalemia, the goal is to shift potassium from the extracellular space into the cells. This can be achieved by administering insulin and glucose intravenously. Monitoring blood glucose levels is crucial in this situation. Potassium exchange resins should also be considered, and dialysis may be necessary.
Severe hyperkalemia without ECG changes requires immediate medical attention.
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This question is part of the following fields:
- Nephrology
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Question 90
Correct
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You assess a patient who has been brought into the resuscitation room in an obtunded state. The patient is wearing a MedicAlert bracelet, indicating a diagnosis of Addison's disease.
Which ONE statement accurately describes this condition?Your Answer: ACTH levels are usually elevated
Explanation:Addison’s disease occurs when the adrenal glands do not produce enough steroid hormones. This includes glucocorticoids, mineralocorticoids, and sex steroids. The most common cause is autoimmune adrenalitis, which accounts for about 70-80% of cases. It is more prevalent in women and typically occurs between the ages of 30 and 50.
The clinical symptoms of Addison’s disease include weakness, lethargy, low blood pressure (especially when standing up), nausea, vomiting, weight loss, reduced hair in the armpits and pubic area, depression, and hyperpigmentation (darkening of the skin in certain areas like the palms, mouth, and exposed skin).
Biochemically, Addison’s disease is characterized by increased levels of ACTH (a hormone that tries to stimulate the adrenal glands), low sodium levels, high potassium levels, high calcium levels, low blood sugar, and metabolic acidosis.
People with Addison’s disease have a higher risk of developing type 1 diabetes, Hashimoto’s thyroiditis, Grave’s disease, premature ovarian failure, pernicious anemia, vitiligo, and alopecia.
Management of Addison’s disease should be overseen by an Endocrinologist. Treatment typically involves taking hydrocortisone, fludrocortisone, and dehydroepiandrosterone. Some patients may also need thyroxine if there is hypothalamic-pituitary disease present. Treatment is lifelong, and patients should carry a steroid card and a MedicAlert bracelet in case of an Addisonian crisis.
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This question is part of the following fields:
- Endocrinology
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Question 91
Incorrect
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You evaluate a 35-year-old woman who has recently been diagnosed with epilepsy. She has been initiated on an anti-epileptic drug but has subsequently developed a tremor when assuming a certain posture.
Which INDIVIDUAL anti-epileptic medication is most likely to be accountable for this?Your Answer: Carbamazepine
Correct Answer: Sodium valproate
Explanation:Postural tremor is frequently seen as a neurological side effect in individuals taking sodium valproate. Additionally, a resting tremor may also manifest. It has been observed that around 25% of patients who begin sodium valproate therapy develop a tremor within the first year. Other potential side effects of sodium valproate include gastric irritation, nausea and vomiting, involuntary movements, temporary hair loss, weight gain in females, and impaired liver function.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 92
Correct
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A 72 year old male comes to the emergency department complaining of sudden difficulty breathing, heart palpitations, and a cough that produces pink frothy sputum. During the examination, you observe an irregular heart rhythm, crackling sounds in the lower parts of the lungs, a loud first heart sound, and a mid-late diastolic murmur. What is the probable diagnosis?
Your Answer: Mitral stenosis
Explanation:Mitral stenosis is a condition characterized by a narrowing of the mitral valve, which can lead to various symptoms. One common symptom is a mid-late diastolic murmur, which can be heard during a physical examination. This murmur may also be described as mid-diastolic, late-diastolic, or mid-late diastolic. Additionally, patients with chronic mitral stenosis may not experience any symptoms, and the murmur may only be detected incidentally.
A significant risk associated with mitral stenosis is the development of atrial fibrillation (AF). When AF occurs in patients with mitral stenosis, it can trigger acute pulmonary edema. This happens because the left atrium, which is responsible for pumping blood across the narrowed mitral valve into the left ventricle, needs to generate higher pressure. However, when AF occurs, the atrial contraction becomes inefficient, leading to impaired emptying of the left atrium. This, in turn, causes increased back pressure in the pulmonary circulation.
The elevated pressure in the left atrium and pulmonary circulation can result in the rupture of bronchial veins, leading to the production of pink frothy sputum. This symptom is often observed in patients with mitral stenosis who develop acute pulmonary edema.
Further Reading:
Mitral Stenosis:
– Causes: Rheumatic fever, Mucopolysaccharidoses, Carcinoid, Endocardial fibroelastosis
– Features: Mid-late diastolic murmur, loud S1, opening snap, low volume pulse, malar flush, atrial fibrillation, signs of pulmonary edema, tapping apex beat
– Features of severe mitral stenosis: Length of murmur increases, opening snap becomes closer to S2
– Investigation findings: CXR may show left atrial enlargement, echocardiography may show reduced cross-sectional area of the mitral valveMitral Regurgitation:
– Causes: Mitral valve prolapse, Myxomatous degeneration, Ischemic heart disease, Rheumatic fever, Connective tissue disorders, Endocarditis, Dilated cardiomyopathy
– Features: pansystolic murmur radiating to left axilla, soft S1, S3, laterally displaced apex beat with heave
– Signs of acute MR: Decompensated congestive heart failure symptoms
– Signs of chronic MR: Leg edema, fatigue, arrhythmia (atrial fibrillation)
– Investigation findings: Doppler echocardiography to detect regurgitant flow and pulmonary hypertension, ECG may show signs of LA enlargement and LV hypertrophy, CXR may show LA and LV enlargement in chronic MR and pulmonary edema in acute MR. -
This question is part of the following fields:
- Cardiology
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Question 93
Correct
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A 32 year old female presents to the emergency department complaining of feeling something enter her left ear and experiencing a persistent sensation of it being stuck inside. Upon examination using an otoscope, a small fly is observed moving within the ear canal but appears to be trapped in earwax. The tympanic membrane appears intact.
What is the most suitable initial approach to managing this patient?Your Answer: Instill the ear canal with 2% lidocaine
Explanation:Lidocaine is commonly chosen because it offers some local anesthesia. Alternatively, mineral oil can be used. Cold water irrigation can often cause nausea and vomiting, so it is recommended to use warm water for irrigation. An ENT clinician should be able to remove an insect from the ear canal. However, if removal attempts are unsuccessful or complications arise, a referral may be necessary.
Further Reading:
Foreign bodies in the ear or nose are a common occurrence, especially in children between the ages of 2 and 8. Foreign bodies in the ear are more common than those in the nose. Symptoms of foreign bodies in the ear may include ear pain, a feeling of fullness, impaired hearing, discharge, tinnitus, and vertigo. It is important to consider referral to an ENT specialist for the removal of potentially harmful foreign bodies such as glass, sharp objects, button batteries, and tightly wedged items. ENT involvement is also necessary if there is a perforation of the eardrum or if the foreign body is embedded in the eardrum.
When preparing a patient for removal, it is important to establish rapport and keep the patient relaxed, especially if they are a young child. The patient should be positioned comfortably and securely, and ear drops may be used to anesthetize the ear. Removal methods for foreign bodies in the ear include the use of forceps or a hook, irrigation (except for batteries, perforations, or organic material), suction, and magnets for ferrous metal foreign bodies. If there is an insect in the ear, it should be killed with alcohol, lignocaine, or mineral oil before removal.
After the foreign body is removed, it is important to check for any residual foreign bodies and to discharge the patient with appropriate safety net advice. Prophylactic antibiotic drops may be considered if there has been an abrasion of the skin.
Foreign bodies in the nose are less common but should be dealt with promptly due to the risk of posterior dislodgement into the airway. Symptoms of foreign bodies in the nose may include nasal discharge, sinusitis, nasal pain, epistaxis, or blood-stained discharge. Most nasal foreign bodies are found on the anterior or middle third of the nose and may not show up on x-rays.
Methods for removing foreign bodies from the nose include the mother’s kiss technique, suction, forceps, Jobson horne probe, and foley catheter. The mother’s kiss technique involves occluding the patent nostril and having a parent blow into the patient’s mouth. A foley catheter can be used by inserting it past the foreign body and inflating the balloon to gently push the foreign body out. ENT referral may be necessary if the foreign body cannot be visualized but there is a high suspicion, if attempts to remove the foreign body have failed, if the patient requires sed
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 94
Correct
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A 35-year-old male is brought to the emergency department with a severe head injury. Due to a decreasing Glasgow Coma Scale (GCS), it is decided to intubate him. You prepare for rapid sequence induction (RSI) and plan to use propofol as the induction agent. Which of the following statements about propofol and its impact on blood pressure is accurate?
Your Answer: Propofol causes hypotension via venodilation
Explanation:The administration of propofol can result in venodilation, leading to a significant drop in blood pressure. This effect is particularly significant in patients who are already experiencing unstable blood flow.
Further Reading:
There are four commonly used induction agents in the UK: propofol, ketamine, thiopentone, and etomidate.
Propofol is a 1% solution that produces significant venodilation and myocardial depression. It can also reduce cerebral perfusion pressure. The typical dose for propofol is 1.5-2.5 mg/kg. However, it can cause side effects such as hypotension, respiratory depression, and pain at the site of injection.
Ketamine is another induction agent that produces a dissociative state. It does not display a dose-response continuum, meaning that the effects do not necessarily increase with higher doses. Ketamine can cause bronchodilation, which is useful in patients with asthma. The initial dose for ketamine is 0.5-2 mg/kg, with a typical IV dose of 1.5 mg/kg. Side effects of ketamine include tachycardia, hypertension, laryngospasm, unpleasant hallucinations, nausea and vomiting, hypersalivation, increased intracranial and intraocular pressure, nystagmus and diplopia, abnormal movements, and skin reactions.
Thiopentone is an ultra-short acting barbiturate that acts on the GABA receptor complex. It decreases cerebral metabolic oxygen and reduces cerebral blood flow and intracranial pressure. The adult dose for thiopentone is 3-5 mg/kg, while the child dose is 5-8 mg/kg. However, these doses should be halved in patients with hypovolemia. Side effects of thiopentone include venodilation, myocardial depression, and hypotension. It is contraindicated in patients with acute porphyrias and myotonic dystrophy.
Etomidate is the most haemodynamically stable induction agent and is useful in patients with hypovolemia, anaphylaxis, and asthma. It has similar cerebral effects to thiopentone. The dose for etomidate is 0.15-0.3 mg/kg. Side effects of etomidate include injection site pain, movement disorders, adrenal insufficiency, and apnoea. It is contraindicated in patients with sepsis due to adrenal suppression.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 95
Correct
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A 35-year-old man comes in with swelling of his face, particularly his upper lip, and his hands. He has a confirmed diagnosis of hereditary angioedema.
Which of the following statements about hereditary angioedema is correct?Your Answer: Long-term prophylaxis can be achieved with tranexamic acid
Explanation:Hereditary angioedema is a condition caused by a lack of C1 esterase inhibitor, a protein that is part of the complement system. It is typically inherited in an autosomal dominant manner. Symptoms usually start in childhood and continue sporadically into adulthood. Attacks can be triggered by minor surgical procedures, dental work, and stress. The main clinical signs of hereditary angioedema include swelling of the skin and mucous membranes, with the face, tongue, and extremities being the most commonly affected areas. There is often a tingling sensation before an attack, sometimes accompanied by a non-itchy rash.
Angioedema and anaphylaxis resulting from C1 esterase inhibitor deficiency do not respond to adrenaline, steroids, or antihistamines. Treatment requires the use of C1 esterase inhibitor concentrate or fresh frozen plasma, both of which contain C1 esterase inhibitor. In situations that may trigger an attack, short-term prophylaxis can be achieved by administering C1 esterase inhibitor or fresh frozen plasma infusions prior to the event. For long-term prevention, androgenic steroids like stanozolol or antifibrinolytic drugs such as tranexamic acid can be used.
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This question is part of the following fields:
- Allergy
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Question 96
Incorrect
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A 35-year-old dairy farmer presents with a flu-like illness that has been worsening for the past two weeks. He has high fevers, a pounding headache, and muscle aches. He has now also developed a dry cough, stomach pain, and diarrhea. During the examination, there are no notable chest signs, but a liver edge can be felt 4 cm below the costal margin.
Today, his blood tests show the following results:
- Hemoglobin (Hb): 13.4 g/dl (normal range: 13-17 g/dl)
- White blood cell count (WCC): 21.5 x 109/l (normal range: 4-11 x 109/l)
- Neutrophils: 17.2 x 109/l (normal range: 2.5-7.5 x 109/l)
- Platelets: 567 x 109/l (normal range: 150-400 x 109/l)
- C-reactive protein (CRP): 187 mg/l (normal range: < 5 mg/l)
- Sodium (Na): 127 mmol/l (normal range: 133-147 mmol/l)
- Potassium (K): 4.4 mmol/l (normal range: 3.5-5.0 mmol/l)
- Creatinine (Creat): 122 micromol/l (normal range: 60-120 micromol/l)
- Urea: 7.8 mmol/l (normal range: 2.5-7.5 mmol/l)
- Aspartate aminotransferase (AST): 121 IU/l (normal range: 8-40 IU/l)
- Alkaline phosphatase (ALP): 296 IU/l (normal range: 30-200 IU/l)
- Bilirubin: 14 micromol/l (normal range: 3-17 micromol/l)
What is the SINGLE most likely causative organism?Your Answer: Bacillus anthracis
Correct Answer: Coxiella burnetii
Explanation:Q fever is a highly contagious infection caused by Coxiella burnetii, which can be transmitted from animals to humans. It is commonly observed as an occupational disease among individuals working in farming, slaughterhouses, and animal research. Approximately 50% of cases do not show any symptoms, while those who are affected often experience flu-like symptoms such as headache, fever, muscle pain, diarrhea, nausea, and vomiting.
In some cases, patients may develop an atypical pneumonia characterized by a dry cough and minimal chest signs. Q fever can also lead to hepatitis and enlargement of the liver (hepatomegaly), although jaundice is not commonly observed. Typical blood test results for Q fever include an elevated white cell count (30-40%), ALT/AST levels that are usually 2-3 times higher than normal, increased ALP levels (70%), reduced sodium levels (30%), and reactive thrombocytosis.
It is important to check patients for heart murmurs and signs of valve disease, as these conditions increase the risk of developing infective endocarditis. Treatment for Q fever typically involves a two-week course of doxycycline.
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This question is part of the following fields:
- Respiratory
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Question 97
Correct
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You evaluate a 45-year-old male patient with a swollen and red right calf. His D-dimer levels are elevated, and you schedule an ultrasound scan which confirms the presence of a deep vein thrombosis (DVT) in his right calf. He has a history of a previous DVT and his INR today is 2.5.
What is the MOST suitable course of action for management in this case?Your Answer: His target INR should be raised to 3.5
Explanation:When managing a first episode of acute venous thromboembolism (VTE), it is recommended to start warfarin in combination with a parenteral anticoagulant, such as unfractionated heparin, low-molecular-weight heparin, or fondaparinux. The parental anticoagulant should be continued for a minimum of 5 days and ideally until the international normalized ratio (INR) is above 2 for at least 24 hours.
To prevent the extension of the blood clot and recurrence in calf deep vein thrombosis (DVT), at least 6 weeks of anticoagulant therapy is necessary. For proximal DVT, a minimum of 3 months of anticoagulant therapy is required.
For first episodes of VTE, the ideal target INR is 2.5. However, in cases where patients experience recurrent VTE while being anticoagulated within the therapeutic range, the target INR should be increased to 3.5.
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This question is part of the following fields:
- Vascular
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Question 98
Correct
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A 65-year-old patient presents with nausea and vomiting and decreased urine output. He has only passed a small amount of urine in the last day, and he has noticeable swelling in his ankles. His blood tests show a sudden increase in his creatinine levels in the last 48 hours, leading to a diagnosis of acute kidney injury (AKI).
Which of the following is NOT a cause of AKI that occurs before the kidneys?Your Answer: Glomerulonephritis
Explanation:Acute kidney injury (AKI), previously known as acute renal failure, is a sudden decline in kidney function. This results in the accumulation of waste products and disturbances in fluid and electrolyte balance. 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.
The causes of AKI can be categorized into pre-renal, intrinsic renal, and post-renal factors. The majority of AKI cases in the community are due to pre-renal causes, accounting for 90% of cases. These are often associated with conditions such as hypotension from sepsis or fluid depletion. Medications, particularly ACE inhibitors and NSAIDs, are also frequently implicated in AKI.
The table below summarizes the most common causes of AKI:
Pre-renal:
– Volume depletion (e.g., hemorrhage, severe vomiting or diarrhea, burns)
– Oedematous states (e.g., cardiac failure, liver cirrhosis, nephrotic syndrome)
– Hypotension (e.g., cardiogenic shock, sepsis, anaphylaxis)
– Cardiovascular conditions (e.g., severe cardiac failure, arrhythmias)
– Renal hypoperfusion: NSAIDs, COX-2 inhibitors, ACE inhibitors or ARBs, Abdominal aortic aneurysm
– Renal artery stenosis
– Hepatorenal syndromeIntrinsic renal:
– Glomerular disease (e.g., glomerulonephritis, thrombosis, hemolytic-uremic syndrome)
– Tubular injury: acute tubular necrosis (ATN) following prolonged ischemia
– Acute interstitial nephritis due to drugs (e.g., NSAIDs), infection, or autoimmune diseases
– Vascular disease (e.g., vasculitis, polyarteritis nodosa, thrombotic microangiopathy, cholesterol emboli, renal vein thrombosis, malignant hypertension)
– EclampsiaPost-renal:
– Renal stones
– Blood clot
– Papillary necrosis
– Urethral stricture
– Prostatic hypertrophy or malignancy
– Bladder tumor
– Radiation fibrosis
– Pelvic malignancy
– Retroperitoneal fibrosis -
This question is part of the following fields:
- Nephrology
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Question 99
Incorrect
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A 40-year-old man presents very sick with an acute worsening of his asthma.
Which of the following is not advised in the management of acute asthma in adults?Your Answer: IV salbutamol
Correct Answer: Nebulised magnesium
Explanation:Currently, there is no evidence to support the use of nebulised magnesium sulphate in the treatment of adults with asthma. For adults experiencing acute asthma, the recommended drug doses are as follows:
– Salbutamol: 5 mg administered through an oxygen-driven nebuliser.
– Ipratropium bromide: 500 mcg delivered via an oxygen-driven nebuliser.
– Prednisolone: 40-50 mg taken orally.
– Hydrocortisone: 100 mg administered intravenously.
– Magnesium sulphate: 1.2-2 g given intravenously over a period of 20 minutes.Intravenous salbutamol may be considered (250 mcg administered slowly) only when inhaled therapy is not possible, such as when a patient is receiving bag-mask ventilation.
According to the current ALS guidelines, IV aminophylline can be considered in cases of severe or life-threatening asthma, following senior advice. If used, a loading dose of 5 mg/kg should be given over 20 minutes, followed by an infusion of 500-700 mcg/kg/hour. It is important to maintain serum theophylline levels below 20 mcg/ml to prevent toxicity.
For more information, please refer to the BTS/SIGN Guideline on the Management of Asthma.
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This question is part of the following fields:
- Respiratory
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Question 100
Correct
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A 45-year-old man develops anaphylaxis following a bee sting. He is taken to resus for immediate treatment.
Which of the following is an absolute contraindication to the administration of adrenaline in an anaphylactic reaction?Your Answer: None of these options
Explanation:Adrenaline can be given in cases of life-threatening anaphylactic reactions, even if there are certain conditions that may make it less advisable. These conditions include coronary artery disease, uncontrolled hypertension, serious ventricular arrhythmias, and the second stage of labor. Despite these relative contraindications, adrenaline may still be administered to address the immediate danger posed by anaphylaxis.
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This question is part of the following fields:
- Allergy
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Question 101
Correct
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A 40-year-old woman comes in with tremors, anxiety, sweating, and nausea. Her vital signs reveal an elevated heart rate of 119 bpm. She typically consumes 2-3 large bottles of strong cider daily but has recently run out of money and has not had an alcoholic beverage since the previous evening.
Which ONE of the following medications, not belonging to the benzodiazepine class, is commonly prescribed in the UK for the treatment of alcohol withdrawal symptoms?Your Answer: Carbamazepine
Explanation:Benzodiazepines are commonly used in the UK to manage symptoms of alcohol withdrawal. Currently, only diazepam and chlordiazepoxide have been authorized for this purpose. Other benzodiazepines like alprazolam, clobazam, and lorazepam do not currently have authorization for treating alcohol withdrawal symptoms in the UK.
Carbamazepine is also used in the UK to manage alcohol-related withdrawal symptoms, but it does not have official authorization for this use.
Clomethiazole, on the other hand, does have UK marketing authorization for treating alcohol withdrawal symptoms, but it is only recommended for use in a hospital setting with close supervision. The product information for clomethiazole advises caution when prescribing it to individuals with a history of addiction or outpatient alcoholics. It is also not recommended for patients who continue to drink or abuse alcohol. Combining alcohol with clomethiazole, especially in alcoholics with cirrhosis, can lead to fatal respiratory depression even with short-term use. Therefore, clomethiazole should only be used in a hospital under close supervision or, in rare cases, by specialist units on an outpatient basis with careful monitoring of the daily dosage.
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This question is part of the following fields:
- Mental Health
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Question 102
Correct
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You are with a mountain expedition group and have moved from an altitude of 3380m to 3760 metres over the past two days. One of your group members, who is in their 50s, has become increasingly breathless over the past 6 hours and is now breathless at rest and has started coughing up blood stained sputum. The patient's observations are shown below:
Blood pressure 148/94 mmHg
Pulse 128 bpm
Respiration rate 30 bpm
Oxygen saturations 84% on air
What is the likely diagnosis?Your Answer: High altitude pulmonary oedema
Explanation:As a person ascends to higher altitudes, their risk of developing high altitude pulmonary edema (HAPE) increases. This patient is displaying signs and symptoms of HAPE, including a dry cough that may progress to frothy sputum, possibly containing blood. Breathlessness, initially experienced during exertion, may progress to being present even at rest.
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 103
Correct
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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: 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.
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