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  • Question 1 - A 3-year-old girl comes in with a low-grade fever and rosy cheeks. You...

    Incorrect

    • A 3-year-old girl comes in with a low-grade fever and rosy cheeks. You suspect a diagnosis of slapped cheek syndrome.
      Which ONE statement about this condition is accurate?

      Your Answer: It is caused by parvovirus B16

      Correct Answer: It is also known as erythema infectiosum

      Explanation:

      Slapped cheek syndrome, also known as fifth disease or erythema infectiosum, is caused by parvovirus B19. It is most commonly seen in children aged 4-12, but can affect individuals of any age. In the UK, the peak occurrence of this condition is in April and May. Slapped cheek syndrome is contagious, with the period of infectivity occurring before the appearance of the characteristic rash. The rash itself is painless.

      Diagnosing slapped cheek syndrome is typically based on clinical presentation, characterized by the sudden onset of bright red cheeks resembling a slap mark. In some cases, a faint rash may also appear on other parts of the body. The rash usually lasts for a few days, but in rare instances, it may persist for a few weeks. Treatment for this condition is usually focused on managing symptoms. Additional symptoms that may accompany the rash include a mild fever and joint pain.

      While slapped cheek syndrome is generally mild and resolves on its own, certain groups of individuals require extra caution. Pregnant women, for instance, are at an increased risk of miscarriage if exposed to fifth disease. Patients with sickle cell disease or weakened immune systems also need to take extra precautions.

    • This question is part of the following fields:

      • Dermatology
      14.5
      Seconds
  • Question 2 - You are resuscitating a 68-year-old patient with suspected sepsis and your attending physician...

    Correct

    • You are resuscitating a 68-year-old patient with suspected sepsis and your attending physician requests you perform a central line insertion. You discuss the most appropriate approach for the central line. Which approach carries the highest risk of infection?

      Your Answer: Femoral

      Explanation:

      The risk of infection is highest with femoral central lines.

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

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

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

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

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

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

    • This question is part of the following fields:

      • Resus
      9.5
      Seconds
  • Question 3 - A 25-year-old woman comes in seeking the morning after pill. She explains that...

    Correct

    • A 25-year-old woman comes in seeking the morning after pill. She explains that she had unprotected sexual intercourse (UPSI) with her long-term partner within the past 48 hours. She is in good health and is eager to resume taking the oral contraceptive pill after addressing this situation.
      What is the BEST choice for her in this case?

      Your Answer: Levonelle 1.5 mg

      Explanation:

      Women have three options when requesting emergency contraception. The first option is Levonelle 1.5 mg, which contains levonorgestrel and can be used up to 72 hours after unprotected sexual intercourse (UPSI). If vomiting occurs within 2 hours of taking the tablet, another one should be given. Levonelle mainly works by preventing ovulation.

      The second option is ulipristal acetate, the newest treatment available. It can be used up to 120 hours after UPSI. If vomiting occurs within 3 hours of ingestion, another tablet should be given. Ulipristal acetate also works by inhibiting ovulation. However, it should be avoided in patients taking enzyme-inducing drugs, those with severe hepatic impairment, or those with severe asthma requiring oral steroids.

      The third option is the copper IUD, which can be fitted up to 5 days after UPSI or ovulation, whichever is longer. The failure rate of the copper IUD is less than 1 in 1000, making it 10-20 times more effective than oral emergency contraceptive options. It is important to note that Levonelle and ulipristal may be less effective in women with higher BMIs.

    • This question is part of the following fields:

      • Sexual Health
      54.3
      Seconds
  • Question 4 - A 32-year-old man that has been involved in a car crash develops symptoms...

    Correct

    • A 32-year-old man that has been involved in a car crash develops symptoms of acute airway blockage. You determine that he needs intubation through a rapid sequence induction. You intend to use etomidate as your induction medication.
      Etomidate functions by acting on what type of receptor?

      Your Answer: Gamma-aminobutyric acid (GABA)

      Explanation:

      Etomidate is a derivative of imidazole that is commonly used to induce anesthesia due to its short-acting nature. Its main mechanism of action is believed to involve the modulation of fast inhibitory synaptic transmission within the central nervous system by acting on GABA type A receptors.

    • This question is part of the following fields:

      • Basic Anaesthetics
      9.8
      Seconds
  • Question 5 - A 35-year-old individual presents with intense one-sided abdominal pain starting in the right...

    Correct

    • A 35-year-old individual presents with intense one-sided abdominal pain starting in the right flank and extending to the groin. They are also experiencing severe nausea and vomiting. The urine dipstick test shows the presence of blood. A CT KUB is scheduled, and a diagnosis of ureteric colic is confirmed.
      What is a reason for immediate hospital admission in a patient with ureteric colic?

      Your Answer: Signs of systemic infection

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Urology
      10.1
      Seconds
  • Question 6 - You assess a 70-year-old woman who is admitted to the clinical decision unit...

    Correct

    • You assess a 70-year-old woman who is admitted to the clinical decision unit (CDU) after a fall last night. She has a significant cardiac history, having experienced a heart attack 3 years ago and is currently being evaluated for cardiac arrhythmias. She occasionally experiences episodes of angina. Upon reviewing her medication list, you identify one specific medication that should be discontinued immediately.

      Your Answer: Verapamil

      Explanation:

      Verapamil is a type of calcium-channel blocker that is commonly used to treat irregular heart rhythms and chest pain. It is important to note that verapamil should not be taken at the same time as beta-blockers like atenolol. This is because when these medications are combined, they can have a negative impact on the heart’s ability to contract and its heart rate. This can lead to low blood pressure, slow heart rate, problems with the electrical signals in the heart, heart failure, and even a pause in the heart’s normal rhythm. However, the other medications mentioned in this question can be safely used together with beta-blockers.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      43.5
      Seconds
  • Question 7 - A 68-year-old woman with a history of chronic anemia receives a blood transfusion...

    Correct

    • A 68-year-old woman with a history of chronic anemia receives a blood transfusion as part of her treatment plan. She has a known history of heart failure and takes bisoprolol and furosemide. Her most recent BNP level was measured at 123 pmol/l. Five hours after starting the transfusion, she experiences shortness of breath and her existing peripheral edema worsens. Her blood pressure increases to 170/105 mmHg and her BNP level is rechecked, now measuring 192 pmol/l.

      Which of the following treatment options is the most appropriate?

      Your Answer: Slow the transfusion rate and administer diuretics

      Explanation:

      Blood transfusion is a potentially life-saving treatment that can provide great clinical benefits. However, it also carries several risks and potential problems. These include immunological complications, administration errors, infections, and immune dilution. While there has been an increased awareness of these risks and improved reporting systems, transfusion errors and serious adverse reactions still occur and may go unreported.

      One specific transfusion reaction is transfusion-associated circulatory overload (TACO), which occurs when a large volume of blood is rapidly infused. It is the second leading cause of transfusion-related deaths, accounting for about 20% of fatalities. TACO is more likely to occur in patients with diminished cardiac reserve or chronic anemia, particularly in the elderly, infants, and severely anemic patients.

      The typical clinical features of TACO include acute respiratory distress, tachycardia, hypertension, acute or worsening pulmonary edema on chest X-ray, and evidence of positive fluid balance. The B-type natriuretic peptide (BNP) can be a useful diagnostic tool for TACO, with levels usually elevated to at least 1.5 times the pre-transfusion baseline.

      In many cases, simply slowing the transfusion rate, placing the patient in an upright position, and administering diuretics can be sufficient for managing TACO. In more severe cases, the transfusion should be stopped, and non-invasive ventilation may be considered.

    • This question is part of the following fields:

      • Haematology
      31
      Seconds
  • Question 8 - A 45-year-old man comes to the clinic complaining of sudden pain in his...

    Correct

    • A 45-year-old man comes to the clinic complaining of sudden pain in his left scrotum and fever for the past 5 days. Upon examination, the epididymis is swollen and tender, and the skin over the scrotum is red and warm. The pain is relieved when the scrotum is elevated. The patient has no known allergies to medications.
      What is the most suitable treatment for this patient?

      Your Answer: Ofloxacin

      Explanation:

      Epididymo-orchitis refers to the inflammation of the epididymis and/or testicle. It typically presents with sudden pain, swelling, and inflammation in the affected area. This condition can also occur chronically, which means that the pain and inflammation last for more than six months.

      The causes of epididymo-orchitis vary depending on the age of the patient. In men under 35 years old, the infection is usually sexually transmitted and caused by Chlamydia trachomatis or Neisseria gonorrhoeae. In men over 35 years old, the infection is usually non-sexually transmitted and occurs as a result of enteric organisms that cause urinary tract infections, with Escherichia coli being the most common. However, there can be some overlap between these groups, so it is important to obtain a thorough sexual history in all age groups.

      Mumps should also be considered as a potential cause of epididymo-orchitis in the 15 to 30 age group, as mumps orchitis occurs in around 40% of post-pubertal boys with mumps.

      While most cases of epididymo-orchitis are infective, non-infectious causes can also occur. These include genito-urinary surgery, vasectomy, urinary catheterization, Behcet’s disease, sarcoidosis, and drug-induced cases such as those caused by amiodarone.

      Patients with epididymo-orchitis typically present with unilateral scrotal pain and swelling that develops relatively quickly. The affected testis will be tender to touch, and there is usually a palpable swelling of the epididymis that starts at the lower pole of the testis and spreads towards the upper pole. The testis itself may also be involved, and there may be redness and/or swelling of the scrotum on the affected side. Patients may experience fever and urethral discharge as well.

      The most important differential diagnosis to consider is testicular torsion, which requires immediate medical attention within 6 hours of onset to save the testicle. Testicular torsion is more likely in men under the age of 20, especially if the pain is very severe and sudden. It typically presents around four hours after onset. In this case, the patient’s age, longer history of symptoms, and the presence of fever are more indicative of epididymo-orchitis.

    • This question is part of the following fields:

      • Urology
      21
      Seconds
  • Question 9 - A 32-year-old man is brought in by ambulance following a car crash. A...

    Correct

    • A 32-year-old man is brought in by ambulance following a car crash. A FAST scan is conducted to evaluate for a haemoperitoneum.
      Which of the subsequent anatomical regions is evaluated as part of a typical 4 view FAST scan?

      Your Answer: Left upper quadrant

      Explanation:

      A Focussed Assessment with Sonography for Trauma (FAST) scan is a point-of-care ultrasound examination conducted when a trauma patient arrives. Its primary purpose is to identify the presence of intra-abdominal free fluid, which is typically assumed to be haemoperitoneum in the context of trauma. This information helps healthcare providers make decisions regarding further management of the patient.

      The sensitivity of FAST scanning for detecting intraperitoneal fluid is approximately 90%, while its specificity is around 95%. However, its sensitivity for detecting solid organ injuries is much lower. As a result, FAST scanning has largely replaced diagnostic peritoneal lavage as the preferred initial method for assessing haemoperitoneum.

      During a standard FAST scan, four regions are assessed. The first is the subxiphoid transverse view, which is used to check for pericardial effusion and left lobe liver injuries. The second is the longitudinal view of the right upper quadrant, which helps identify right liver injuries, right kidney injuries, and fluid in the hepatorenal recess (Morison’s pouch). The third is the longitudinal view of the left upper quadrant, which is used to assess for splenic injury and left kidney injury. Lastly, the transverse and longitudinal views of the suprapubic region are examined to assess the bladder and fluid in the pouch of Douglas.

      In addition to the standard FAST scan, an extended FAST or eFAST may also be performed. This involves examining the left and right thoracic regions to assess for the presence of pneumothorax and haemothorax.

      The hepatorenal recess is the deepest part of the peritoneal cavity when a patient is lying flat. Therefore, it is the most likely area for fluid to accumulate in a supine position.

    • This question is part of the following fields:

      • Trauma
      12.5
      Seconds
  • Question 10 - A 38 year old male arrives at the emergency department complaining of sudden...

    Correct

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

      Your Answer: Phenoxybenzamine 10 mg by slow intravenous injection

      Explanation:

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

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
      7.7
      Seconds
  • Question 11 - You conduct a medication review on a 68-year-old man with a history of...

    Correct

    • You conduct a medication review on a 68-year-old man with a history of angina. He is currently prescribed 10 mg bisoprolol once daily and GTN spray as needed. However, he continues to experience symptoms.
      Which ONE medication should be avoided in this patient?

      Your Answer: Verapamil

      Explanation:

      Beta-blockers, like bisoprolol, and verapamil have a strong negative effect on the force of ventricular contraction. When these medications are taken together, they can significantly reduce ventricular contraction and lead to a slow heart rate, known as bradycardia. Additionally, the risk of developing AV block is increased. In certain situations, this combination can result in severe low blood pressure or even a complete absence of heart rhythm, known as asystole. Therefore, it is important to avoid using these medications together to prevent these potentially dangerous effects.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      27.9
      Seconds
  • Question 12 - A 35 year old male is brought to the emergency department by his...

    Correct

    • A 35 year old male is brought to the emergency department by his wife with a 24 hour history of vomiting and increasing fatigue over the past 1-2 hours. Initial tests confirm a diagnosis of diabetic ketoacidosis and the patient is started on intravenous fluids and an insulin infusion. You are reminded by your attending physician to monitor the bicarbonate level and adjust the insulin infusion rate if it is not improving as anticipated. What is the minimum desired change in bicarbonate that should be aimed for?

      Your Answer: Venous bicarbonate rising by at least 3 mmol/L/hr

      Explanation:

      When patients with diabetic ketoacidosis (DKA) are treated with insulin infusion, it is expected that their plasma bicarbonate levels will increase by at least 3 mmol/L per hour. Insulin therapy is aimed at correcting both hyperglycemia and ketoacidosis. However, if capillary ketones are not decreasing by at least 0.5 mmol/L per hour, venous bicarbonate is not rising by at least 3 mmol/L per hour, or plasma glucose is not decreasing by at least 3 mmol/L per hour, the insulin infusion rate should be reevaluated.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
      8.6
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  • Question 13 - A 16 year old girl arrives at the emergency department with her friend...

    Correct

    • 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.

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      17
      Seconds
  • Question 14 - A patient arrives at the emergency department with confusion and abdominal pain. They...

    Correct

    • A patient arrives at the emergency department with confusion and abdominal pain. They have a previous diagnosis of Addison's disease but have recently run out of their steroid medication. You suspect the patient is experiencing an Addisonian crisis.
      Which ONE clinical feature is NOT typically associated with an Addisonian crisis?

      Your Answer: Hyperglycaemia

      Explanation:

      An Addisonian crisis is characterized by several distinct features. These include experiencing pain in the legs and abdomen, as well as symptoms of vomiting and dehydration. Hypotension, or low blood pressure, is also commonly observed during an Addisonian crisis. Confusion and psychosis may also occur, along with the presence of a fever. In some cases, convulsions may be present as well. Additionally, individuals experiencing an Addisonian crisis may also exhibit hypoglycemia, hyponatremia, hyperkalemia, hypercalcemia, eosinophilia, and metabolic acidosis.

    • This question is part of the following fields:

      • Endocrinology
      14.4
      Seconds
  • Question 15 - A 25-year-old male arrives at the emergency department following a fall from a...

    Correct

    • A 25-year-old male arrives at the emergency department following a fall from a wall and hitting his face on a concrete bollard. There is a suspicion of a Le Fort fracture. What clinical tests would you perform to confirm this?

      Your Answer: Place one hand on the forehead to stabilise it. With the other hand gently grip the upper teeth and anterior maxilla and gently rock the hard palate back and forth

      Explanation:

      To clinically test for Le Fort fractures, one can perform the following procedure: Place one hand on the forehead to stabilize it, and with the other hand, gently grip the upper teeth and anterior maxilla. Then, gently rock the hard palate back and forth.

      This test is useful in suspected cases of Le Fort fractures. In a Le Fort I fracture, only the teeth and hard palate will move, while the rest of the mid face and skull remain still. In Le Fort II fractures, the teeth, hard palate, and nose will move, but the eyes and zygomatic arches will remain still. In Le Fort III fractures, the entire face will move in relation to the forehead.

      Further Reading:

      The Le Fort fracture classification describes three fracture patterns seen in midface fractures, all involving the maxilla and pterygoid plate disruption. As the classification grading increases, the anatomic level of the maxillary fracture ascends from inferior to superior.

      Le Fort I fractures, also known as floating palate fractures, typically result from a downward blow struck above the upper dental row. Signs include swelling of the upper lip, bruising to the upper buccal sulcus, malocclusion, and mobile upper teeth.

      Le Fort II fractures, also known as floating maxilla fractures, are typically the result of a forceful blow to the midaxillary area. Signs include a step deformity at the infraorbital margin, oedema over the middle third of the face, sensory disturbance of the cheek, and bilateral circumorbital ecchymosis.

      Le Fort III fractures, also known as craniofacial dislocation or floating face fractures, are typically the result of high force blows to the nasal bridge or upper maxilla. These fractures involve the zygomatic arch and extend through various structures in the face. Signs include tenderness at the frontozygomatic suture, lengthening of the face, enophthalmos, and bilateral circumorbital ecchymosis.

      Management of Le Fort fractures involves securing the airway as a priority, following the ABCDE approach, and identifying and managing other injuries, especially cervical spine injuries. Severe bleeding may occur and should be addressed appropriately. Surgery is almost always required, and patients should be referred to maxillofacial surgeons. Other specialties, such as neurosurgery and ophthalmology, may need to be involved depending on the specific case.

    • This question is part of the following fields:

      • Maxillofacial & Dental
      6.5
      Seconds
  • Question 16 - You conduct a cardiovascular examination on a 62-year-old man who complains of shortness...

    Correct

    • You conduct a cardiovascular examination on a 62-year-old man who complains of shortness of breath. He informs you that he has a known heart valve issue. During auscultation, you observe reversed splitting of the second heart sound (S2).
      What is the most probable cause of this finding?

      Your Answer: Aortic stenosis

      Explanation:

      The second heart sound (S2) is created by vibrations produced when the aortic and pulmonary valves close. It marks the end of systole. It is normal to hear a split in the sound during inspiration.

      A loud S2 can be associated with certain conditions such as systemic hypertension (resulting in a loud A2), pulmonary hypertension (resulting in a loud P2), hyperdynamic states (like tachycardia, fever, or thyrotoxicosis), and atrial septal defect (which causes a loud P2).

      On the other hand, a soft S2 can be linked to decreased aortic diastolic pressure (as seen in aortic regurgitation), poorly mobile cusps (such as calcification of the aortic valve), aortic root dilatation, and pulmonary stenosis (which causes a soft P2).

      A widely split S2 can occur during deep inspiration, right bundle branch block, prolonged right ventricular systole (seen in conditions like pulmonary stenosis or pulmonary embolism), and severe mitral regurgitation. However, in the case of atrial septal defect, the splitting is fixed and does not vary with respiration.

      Reversed splitting of S2, where P2 occurs before A2 (paradoxical splitting), can occur during deep expiration, left bundle branch block, prolonged left ventricular systole (as seen in hypertrophic cardiomyopathy), severe aortic stenosis, and right ventricular pacing.

    • This question is part of the following fields:

      • Cardiology
      39.2
      Seconds
  • Question 17 - A 45-year-old woman comes in with recurring nosebleeds. During the examination, you observe...

    Correct

    • A 45-year-old woman comes in with recurring nosebleeds. During the examination, you observe a small bleeding point in the front of the nose.
      What is the PRIMARY location for anterior bleeding?

      Your Answer: Kiesselbach’s plexus

      Explanation:

      The upper part of the nose receives blood supply from the anterior and posterior ethmoidal arteries, which are derived from the internal carotid artery. On the other hand, the remaining parts of the nose and sinuses are nourished by the greater palatine, sphenopalatine, and superior labial arteries. These arteries are branches of the external carotid arteries.

      In the front part of the nasal septum, there exists a network of blood vessels where the branches of the internal and external carotid artery connect. This network is known as Kiesselbach’s plexus, also referred to as Little’s area. It is worth noting that Kiesselbach’s plexus is the most common location for anterior bleeding.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      8.3
      Seconds
  • Question 18 - A 25-year-old sex worker comes in with a painful genital ulcer. During the...

    Incorrect

    • A 25-year-old sex worker comes in with a painful genital ulcer. During the examination, a highly sensitive ulcer is found on her right labia majora, measuring around 10 mm in diameter with well-defined edges. Additionally, she has swollen inguinal lymph nodes that are tender.
      What is the MOST LIKELY causative organism for this case?

      Your Answer: Treponema pallidum

      Correct Answer: Haemophilus ducreyi

      Explanation:

      Chancroid is a sexually transmitted infection caused by the bacteria Haemophilus ducreyi. It is not very common in the UK but is prevalent in Africa, Asia, and South America. HIV is often associated with chancroid, particularly in Africa where there is a 60% correlation.

      The main symptom of chancroid is the development of painful ulcers on the genitalia. In women, these ulcers typically appear on the labia majora. Sometimes, kissing ulcers can form when ulcers are located on opposing surfaces of the labia. Painful swelling of the lymph nodes occurs in 30-60% of patients, and in some cases, these swollen nodes can turn into abscesses known as buboes.

      The CDC recommends treating chancroid with a single oral dose of 1 gram of azithromycin or a single intramuscular dose of ceftriaxone. Alternatively, a 7-day course of oral erythromycin can be used. It’s important to note that Haemophilus ducreyi is resistant to several antibiotics, including penicillins, tetracyclines, trimethoprim, ciprofloxacin, aminoglycosides, and sulfonamides.

      Possible complications of chancroid include extensive swelling of the lymph nodes, large abscesses and sinuses in the groin area, phimosis (a condition where the foreskin cannot be retracted), and superinfection with Fusarium spp. or Bacteroides spp.

      Syphilis, caused by Treponema pallidum, presents with a painless ulcer called a chancre during its primary stage. This is different from chancroid, which causes painful ulcers. Chlamydia trachomatis can lead to lymphogranuloma venereum, where a painless genital ulcer may develop initially and go unnoticed. Granuloma inguinale, caused by Klebsiella granulomatis, causes painless nodules and ulcers on the genitals that eventually burst and create open, oozing lesions. Neisseria gonorrhoeae, on the other hand, typically causes vaginal or urethral discharge and is often asymptomatic, rather than causing genital ulceration.

    • This question is part of the following fields:

      • Sexual Health
      19.5
      Seconds
  • Question 19 - Following the passing of a young patient treated for an extended cardiac arrest...

    Correct

    • Following the passing of a young patient treated for an extended cardiac arrest after a near-drowning incident, your supervisor requests that you arrange a training session for the junior physicians. Which of the following statements accurately reflects the management of near-drowning patients?

      Your Answer: Patients should be extricated from the water in the horizontal position

      Explanation:

      When rescuing drowning patients, it is important to extricate them from the water in a horizontal position whenever possible. This is because the pressure of the water on the body when submerged increases the flow of blood back to the heart, which in turn increases cardiac output. However, when the patient is removed from the water, this pressure effect is lost, which can lead to a sudden drop in blood pressure and circulatory collapse due to the loss of peripheral resistance and pooling of blood in the veins. By extricating the patient in a horizontal position, we can help counteract this effect.

      It is worth noting that the amount of water in the lungs after drowning is typically small, usually less than 4 milliliters per kilogram of body weight. Therefore, attempting to drain the water from the lungs is ineffective and not recommended.

      In cases of fresh water drowning, pneumonia may occur due to unusual pathogens such as aeromonas spp, burkholderia pseudomallei, chromobacterium spp, pseudomonas species, and leptospirosis.

      If the patient experiences bronchospasm, nebulized bronchodilators can be used as a treatment.

      To prevent secondary brain injury, it is important to prevent hyperthermia. This can be achieved by maintaining the patient’s core body temperature below 36 degrees Celsius during the rewarming process.

      Further Reading:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Respiratory
      26.9
      Seconds
  • Question 20 - A 5-year-old girl is brought to the Emergency Department by her parents. For...

    Correct

    • A 5-year-old girl is brought to the Emergency Department by her parents. For the past two days, she has had severe diarrhoea and vomiting. She has not passed urine so far today. She normally weighs 20 kg. On examination, she has sunken eyes and dry mucous membranes. She is tachycardia and tachypnoeic and has cool peripheries. Her capillary refill time is prolonged.
      What is her estimated percentage dehydration?

      Your Answer: 10%

      Explanation:

      Generally speaking, if a child shows clinical signs of dehydration but does not exhibit shock, it can be assumed that they are 5% dehydrated. On the other hand, if shock is also present, it can be assumed that the child is 10% dehydrated or more. To put it in simpler terms, 5% dehydration means that the body has lost 5 grams of fluid per 100 grams of body weight, which is equivalent to 50 milliliters per kilogram of fluid. Similarly, 10% dehydration implies a loss of 100 milliliters per kilogram of fluid.

      The clinical features of dehydration and shock are summarized below:

      Dehydration (5%):
      – The child appears unwell
      – The heart rate may be normal or increased (tachycardia)
      – The respiratory rate may be normal or increased (tachypnea)
      – Peripheral pulses are normal
      – Capillary refill time (CRT) is normal or slightly prolonged
      – Blood pressure is normal
      – Extremities feel warm
      – Decreased urine output
      – Reduced skin turgor
      – Sunken eyes
      – Depressed fontanelle
      – Dry mucous membranes

      Clinical shock (10%):
      – The child appears pale, lethargic, and mottled
      – Tachycardia (increased heart rate)
      – Tachypnea (increased respiratory rate)
      – Weak peripheral pulses
      – Prolonged CRT
      – Hypotension (low blood pressure)
      – Extremities feel cold
      – Decreased urine output
      – Decreased level of consciousness

    • This question is part of the following fields:

      • Nephrology
      8.1
      Seconds
  • Question 21 - A 3-year-old girl is brought to the Emergency Department by ambulance following an...

    Correct

    • A 3-year-old girl is brought to the Emergency Department by ambulance following an episode of fainting at home. The parents noticed that the girl suddenly collapsed and appeared pale. After lifting her up, she quickly regained consciousness and her color returned. After a thorough examination and investigation by the pediatric team, a diagnosis of a brief resolved unexplained event (BRUE) is made.
      Which of the following is NOT a recognized risk factor for a BRUE?

      Your Answer: High birth weight

      Explanation:

      The term Apparent Life-Threatening Event (ALTE) has traditionally been used to describe a specific type of event. However, in 2016, the American Academy of Paediatrics (AAP) recommended replacing ALTE with a new term called Brief Resolved Unexplained Event (BRUE).

      An ALTE is defined as an episode that is frightening to the observer and is characterized by a combination of symptoms such as apnoea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), significant change in muscle tone (usually marked limpness), choking, or gagging. In some cases, the observer may even fear that the infant has died.

      On the other hand, BRUE has stricter criteria and is only applicable to episodes that occur in infants under 12 months old. A BRUE is characterized by being brief (lasting less than 1 minute, typically 2-30 seconds), resolved (the infant must have returned to their baseline state), and not explained by any identifiable medical condition. It must also exhibit at least one of the following symptoms: cyanosis or pallor, absent, decreased, or irregular breathing, marked change in muscle tone (hyper- or hypotonia), or altered level of responsiveness.

      To diagnose a BRUE, a thorough history and physical examination of the infant must be conducted, and no explanation for the event should be found. Additionally, there are several risk factors associated with the development of a BRUE, including prematurity, age less than ten weeks, recent anesthesia, airway or maxillofacial abnormalities, history of gastro-oesophageal reflux disease, previous apnoeic episode, recent upper respiratory tract infection. Low birth weight may also be a risk factor, while high birth weight has no recognized association with BRUEs.

    • This question is part of the following fields:

      • Paediatric Emergencies
      16.5
      Seconds
  • Question 22 - A 32-year-old woman comes to the clinic complaining of palpitations. During an ECG,...

    Correct

    • A 32-year-old woman comes to the clinic complaining of palpitations. During an ECG, it is found that she has newly developed QT prolongation. She mentions that her doctor recently prescribed her a new medication and wonders if that could be the reason.
      Which of the following medications is most likely to cause QT interval prolongation?

      Your Answer: Citalopram

      Explanation:

      Prolongation of the QT interval can lead to a dangerous ventricular arrhythmia called torsades de pointes, which can result in sudden cardiac death. There are several commonly used medications that are known to cause QT prolongation.

      Low levels of potassium (hypokalaemia) and magnesium (hypomagnesaemia) can increase the risk of QT prolongation. For example, diuretics can interact with QT-prolonging drugs by causing hypokalaemia.

      The QT interval varies with heart rate, and formulas are used to correct the QT interval for heart rate. Once corrected, it is referred to as the QTc interval. The QTc interval is typically reported on the ECG printout. A normal QTc interval is less than 440 ms.

      If the QTc interval is greater than 440 ms but less than 500 ms, it is considered borderline. Although there may be some variation in the literature, a QTc interval within these values is generally considered borderline prolonged. In such cases, it is important to consider reducing the dose of QT-prolonging drugs or switching to an alternative medication that does not prolong the QT interval.

      A prolonged QTc interval exceeding 500 ms is clinically significant and is likely to increase the risk of arrhythmia. Any medications that prolong the QT interval should be reviewed immediately.

      Here are some commonly encountered drugs that are known to prolong the QT interval:

      Antimicrobials:
      – Erythromycin
      – Clarithromycin
      – Moxifloxacin
      – Fluconazole
      – Ketoconazole

      Antiarrhythmics:
      – Dronedarone
      – Sotalol
      – Quinidine
      – Amiodarone
      – Flecainide

      Antipsychotics:
      – Risperidone
      – Fluphenazine
      – Haloperidol
      – Pimozide
      – Chlorpromazine
      – Quetiapine
      – Clozapine

      Antidepressants:
      – Citalopram/escitalopram
      – Amitriptyline
      – Clomipramine
      – Dosulepin
      – Doxepin
      – Imipramine
      – Lofepramine

      Antiemetics:
      – Domperidone
      – Droperidol
      – Ondansetron/Granisetron

      Others:
      – Methadone
      – Protein kinase inhibitors (e.g. sunitinib)

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      4.6
      Seconds
  • Question 23 - A 45 year old male is brought into the emergency department following a...

    Correct

    • 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.

    • This question is part of the following fields:

      • Trauma
      20.8
      Seconds
  • Question 24 - A 25 year old male is brought to the emergency department by the...

    Correct

    • A 25 year old male is brought to the emergency department by the police. The man tried to evade capture by leaping from a ground floor window. The patient reports that both of his feet are hurting, but the left foot is significantly more painful than the right. The patient exhibits tenderness in the left heel, leading you to suspect a calcaneus fracture. Which of the following statements about calcaneus fractures is accurate?

      Your Answer: Contralateral calcaneus fractures are present in 10% of patients

      Explanation:

      Fractures that extend into the calcaneocuboid joint are commonly intra-articular. It is recommended to refer patients to orthopaedics for further evaluation and treatment. Conservative management usually involves keeping the patient non-weight bearing for a period of 6-12 weeks.

      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.

    • This question is part of the following fields:

      • Trauma
      7.4
      Seconds
  • Question 25 - A 35-year-old woman comes in with a painful swelling on the left side...

    Correct

    • A 35-year-old woman comes in with a painful swelling on the left side of her face. The pain and swelling appear to get worse before meals and then gradually improve after eating. During the examination, a solid lump can be felt in the submandibular region. There is no redness, and the patient has no fever and is in good overall health.
      What is the SINGLE most probable diagnosis?

      Your Answer: Sialolithiasis

      Explanation:

      Sialolithiasis is a condition in which a calcified stone (sialolith) forms inside a salivary gland. The submandibular gland (Wharton’s duct) is the most common site, accounting for about 90% of cases, while the parotid gland is the second most affected. In rare instances, sialoliths can also develop in the sublingual gland or minor salivary glands.

      The presence of a sialolith obstructs the flow of saliva, leading to pain and swelling in the affected gland during eating. The pain is most intense when salivary flow is high, such as before and during meals, and gradually subsides within an hour after eating. By palpating the floor of the mouth with both hands, a stone may be detected, and sometimes it can even be seen at the opening of the duct. If there is an accompanying infection, pus may be expressed from the gland.

      To assess salivary flow, acidic foods like lemon juice can be used as a simple test. X-rays of the mouth’s floor can reveal the presence of a stone. Patients should be referred to an ear, nose, and throat specialist (ENT) for the removal of the stone.

      Sialadenitis refers to inflammation of the salivary glands and can be either acute or chronic. Acute sialadenitis is most commonly caused by a bacterial infection, usually ascending from Staphylococcus aureus or Streptococcus viridans. It can occur as a result of sialolithiasis or poor oral hygiene. Clinically, there will be a painful swelling in the affected gland area, with redness of the overlying skin and potential swelling of the cheek and nearby regions. Patients often experience general malaise, with a low-grade fever and elevated inflammatory markers.

      Parotitis, on the other hand, refers to inflammation of one or both parotid glands. This inflammation can be caused by bacteria (particularly Staphylococcus aureus), viruses (such as mumps), or tuberculosis.

      Sjögren’s syndrome is an autoimmune disorder characterized by dry eyes and dry mouth.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      69.1
      Seconds
  • Question 26 - You are managing a pediatric patient in the emergency department who needs sedation...

    Correct

    • You are managing a pediatric patient in the emergency department who needs sedation for suturing. You are considering using ketamine. What is an absolute contraindication to using ketamine in this case?

      Your Answer: Aged less than 12 months

      Explanation:

      Ketamine should not be used in children under 12 months old due to the increased risk of laryngospasm and airway complications. The Royal College of Emergency Medicine advises against using ketamine in children under 1 year old in the emergency department, and it should only be administered by experienced clinicians in children aged 5 and under. Ketamine may cause a slight increase in blood pressure and heart rate, making it a suitable option for those with low blood pressure. However, it is contraindicated in individuals with malignant hypertension (blood pressure above 180 mmHg). Please refer to the notes below for additional contraindications.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Basic Anaesthetics
      9.2
      Seconds
  • Question 27 - A 45-year-old woman presents with symptoms of confusion. An MRI scan is performed,...

    Incorrect

    • A 45-year-old woman presents with symptoms of confusion. An MRI scan is performed, which reveals a temporal lobe infarct.
      Which SINGLE clinical feature would you NOT anticipate to observe during the examination of this patient?

      Your Answer: Receptive dysphasia

      Correct Answer: Expressive dysphasia

      Explanation:

      The temporal lobes play a crucial role in various functions such as processing visual and auditory information, storing memories, and helping us categorize objects. However, if this area of the brain is affected by a stroke, a space-occupying lesion, or trauma, it can lead to several issues. These include problems with understanding and producing language (known as receptive dysphasia), difficulty recognizing faces (prosopagnosia), an inability to categorize objects, difficulty understanding auditory information (auditory agnosia), and impaired perception of music.

    • This question is part of the following fields:

      • Neurology
      118.1
      Seconds
  • Question 28 - A 35 year old male presents to the emergency department with complaints of...

    Correct

    • A 35 year old male presents to the emergency department with complaints of palpitations. An ECG is conducted, revealing a regular narrow complex supraventricular tachycardia with a rate of around 160 bpm. There are no signs of ST elevation or depression. The patient's vital signs are as follows:

      Blood pressure: 128/76 mmHg
      Pulse rate: 166
      Respiration rate: 19
      Oxygen saturations: 97% on room air

      What would be the most appropriate initial treatment for this patient?

      Your Answer: Vagal manoeuvres

      Explanation:

      In stable patients with SVT, it is recommended to first try vagal manoeuvres before resorting to drug treatment. This approach is particularly applicable to patients who do not exhibit any adverse features, as mentioned in the case above.

      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.

    • This question is part of the following fields:

      • Cardiology
      18.5
      Seconds
  • Question 29 - A 28 year old male presents to the emergency department after experiencing 4...

    Correct

    • A 28 year old male presents to the emergency department after experiencing 4 days of severe vomiting and diarrhea. A peripheral cannula is inserted, and blood samples are taken, revealing the following results:

      Na+ 135 mmol/L
      K+ 2.3 mmol/L
      Ur 8.8 mmol/L
      Cr 123 umol/L

      The medical team decides to administer intravenous fluids. They plan to infuse a 1 liter bag of 0.9% saline with 40 mmol of potassium chloride. What would be the most appropriate duration for this infusion?

      Your Answer: 4 hours

      Explanation:

      The recommended maximum infusion rate for IV fluids containing potassium is 10 mmol/hr in normal circumstances outside of the HDU/ICU setting, according to NHS SPS. However, in certain situations, higher infusion rates may be used. The BNF advises a maximum infusion rate of 20 mmol/hr for saline containing KCl, which is commonly administered to patients with DKA. If infusion rates exceed 10 mmol/hr, it is recommended to administer the fluids ideally in a HDU/level 2/ICU setting, through a central line, using an infusion pump, and with cardiac monitoring in place.

      Further Reading:

      Vasoactive drugs can be classified into three categories: inotropes, vasopressors, and unclassified. Inotropes are drugs that alter the force of muscular contraction, particularly in the heart. They primarily stimulate adrenergic receptors and increase myocardial contractility. Commonly used inotropes include adrenaline, dobutamine, dopamine, isoprenaline, and ephedrine.

      Vasopressors, on the other hand, increase systemic vascular resistance (SVR) by stimulating alpha-1 receptors, causing vasoconstriction. This leads to an increase in blood pressure. Commonly used vasopressors include norepinephrine, metaraminol, phenylephrine, and vasopressin.

      Electrolytes, such as potassium, are essential for proper bodily function. Solutions containing potassium are often given to patients to prevent or treat hypokalemia (low potassium levels). However, administering too much potassium can lead to hyperkalemia (high potassium levels), which can cause dangerous arrhythmias. It is important to monitor potassium levels and administer it at a controlled rate to avoid complications.

      Hyperkalemia can be caused by various factors, including excessive potassium intake, decreased renal excretion, endocrine disorders, certain medications, metabolic acidosis, tissue destruction, and massive blood transfusion. It can present with cardiovascular, respiratory, gastrointestinal, and neuromuscular symptoms. ECG changes, such as tall tented T-waves, prolonged PR interval, flat P-waves, widened QRS complex, and sine wave, are also characteristic of hyperkalemia.

      In summary, vasoactive drugs can be categorized as inotropes, vasopressors, or unclassified. Inotropes increase myocardial contractility, while vasopressors increase systemic vascular resistance. Electrolytes, particularly potassium, are important for bodily function, but administering too much can lead to hyperkalemia. Monitoring potassium levels and ECG changes is crucial in managing hyperkalemia.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      9.8
      Seconds
  • Question 30 - A 45-year-old woman presents with increasing difficulty breathing, coughing up blood, and swelling...

    Correct

    • A 45-year-old woman presents with increasing difficulty breathing, coughing up blood, and swelling in her arms and hands. Upon examination, you observe that her face is also swollen and she has multiple enlarged veins and telangiectasia on her chest. She has a known history of lung cancer.

      What is the most probable diagnosis in this case?

      Your Answer: Superior vena cava syndrome

      Explanation:

      This patient has come in with worsening breathlessness and coughing, along with coughing up blood, all of which are occurring on top of their existing lung cancer. The diagnosis in this case is superior vena cava obstruction, which is being caused by the primary bronchial neoplasm.

      The typical clinical presentation of superior vena cava obstruction includes breathlessness and coughing, chest pain, swelling in the neck, face, and arms, dilated veins and telangiectasia on the arms, neck, and chest wall, facial flushing, stridor due to laryngeal edema, and cyanosis.

      Given the urgency of the situation, this man will require immediate treatment. Upon initial presentation, it is important to elevate his head and provide supplemental oxygen to alleviate symptoms. Additionally, corticosteroids and diuretics may be administered. Further investigation will be necessary through CT scanning, and radiotherapy may be recommended as a potential course of action.

    • This question is part of the following fields:

      • Oncological Emergencies
      15.1
      Seconds
  • Question 31 - A 35-year-old man is brought into the emergency room by an ambulance with...

    Correct

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

      Your Answer: Hoarseness of voice

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Trauma
      17.5
      Seconds
  • Question 32 - A 62-year-old woman with hypercholesterolemia is prescribed simvastatin. After taking a course of...

    Correct

    • A 62-year-old woman with hypercholesterolemia is prescribed simvastatin. After taking a course of antibiotics for a urinary tract infection, she experiences severe muscle pains. She is admitted to the hospital and diagnosed with acute renal failure, with a CK level of 1260 units/liter.
      Which of the following antibiotics is she most likely to have been prescribed?

      Your Answer: Clarithromycin

      Explanation:

      Statins, although generally safe and well-tolerated, can cause myopathy and myotoxicity. This range of muscle-related side effects can vary from mild muscle pain to the most severe case of rhabdomyolysis, which can lead to kidney failure, blood clotting issues, and even death.

      The different levels of myotoxicity associated with statins are as follows:
      – Myalgia: muscle symptoms without an increase in creatine kinase (CK) levels.
      – Asymptomatic myopathy: elevated CK levels without muscle symptoms.
      – Myositis: muscle symptoms with CK levels elevated less than 10 times the upper limit of normal.
      – Rhabdomyolysis: muscle symptoms with CK levels elevated more than 10 times the upper limit of normal, potentially leading to myoglobinuria (presence of myoglobin in urine) and renal failure.

      Most statins are broken down by the cytochrome P450 enzyme system. When taken with drugs that strongly inhibit this system, the concentration of statins in the blood can significantly increase. This, in turn, raises the risk of myopathy. A well-known example of this is the combination of statins with macrolide antibiotics like erythromycin and clarithromycin. Co-prescribing these drugs with statins has been linked to a higher risk of myopathy, hospitalization due to rhabdomyolysis, acute kidney injury, and increased mortality rates.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      31.9
      Seconds
  • Question 33 - A young woman is referred to the GUM clinic for investigation of symptoms...

    Correct

    • A young woman is referred to the GUM clinic for investigation of symptoms that can be associated with sexually transmitted infection. Following her assessment, she is diagnosed with gonorrhoea.

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

      Your Answer: Urethritis

      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 change.

      In men, the clinical signs of gonorrhoea include inflammation of the urethra, which is seen in approximately 80% of cases. Around 50% of men experience pain or discomfort during urination, and a mucopurulent discharge may also be present. Rectal infection is possible, although it is usually asymptomatic. In some cases, it can cause anal discharge. Pharyngitis, or inflammation of the throat, is also possible but typically does not cause any noticeable symptoms.

      Women with gonorrhoea may experience a vaginal discharge, which is seen in about 50% of cases. Lower abdominal pain is reported in approximately 25% of women, and dysuria, or painful urination, is seen in 10-15% of cases. Pelvic or lower abdominal tenderness is less common, occurring in less than 5% of women. Additionally, women may have an endocervical discharge and/or bleeding. Similar to men, rectal infection is usually asymptomatic but can cause anal discharge. Pharyngitis is also possible in women, but it is typically asymptomatic.

    • This question is part of the following fields:

      • Sexual Health
      10.2
      Seconds
  • Question 34 - A 68 year old man has been kept on the observation ward overnight...

    Correct

    • A 68 year old man has been kept on the observation ward overnight due to a head injury and is scheduled for discharge. While eating a sandwich, he starts coughing violently. His face is turning cyanosed and he is having difficulty breathing. The cough seems ineffective at clearing his throat. He remains conscious, coughing, and exhibits noticeable stridor. What is the most suitable immediate course of action?

      Your Answer: Give 5 back blows or 5 abdominal thrusts

      Explanation:

      When an adult patient is choking and unable to clear the obstruction by coughing, the next step is to deliver either 5 back blows or abdominal thrusts. The appropriate action depends on the severity of the airway obstruction. If the choking is mild and not causing significant difficulty in breathing, it is recommended to encourage the patient to cough and closely monitor for any worsening symptoms. However, if the choking is severe and causing a complete blockage of the airway, it is necessary to administer either back blows or abdominal thrusts to dislodge the obstruction. In the event that the patient loses consciousness, immediate CPR should be initiated.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Elderly Care / Frailty
      13.1
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  • Question 35 - A 72-year-old man has been experiencing a worsening of his arthritis symptoms lately....

    Correct

    • A 72-year-old man has been experiencing a worsening of his arthritis symptoms lately. His knees have been especially painful, and he has been using a hot water bottle in the evenings for relief. Upon examination, you observe pigmented areas with some redness on both of his knees.
      What is the SINGLE most probable diagnosis?

      Your Answer: Erythema ab igne

      Explanation:

      Erythema ab igne is a condition that is frequently observed in older individuals. It typically occurs when they spend extended periods of time near a fire or utilize a hot water bottle in an attempt to relieve pain symptoms. This condition arises due to the harmful effects of heat on the skin, resulting in the appearance of reddened and pigmented areas. Fortunately, erythema ab igne tends to resolve on its own without any specific treatment.

    • This question is part of the following fields:

      • Dermatology
      16.5
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  • Question 36 - A 68-year-old man with a history of atrial fibrillation (AF) presents with a...

    Correct

    • A 68-year-old man with a history of atrial fibrillation (AF) presents with a head injury and decreased level of consciousness. He is currently taking warfarin for his AF, and his INR was 2.5 a few days ago. A CT scan of his head reveals the presence of a subdural hematoma.
      What is the most suitable approach to manage the reversal of warfarin in this patient?

      Your Answer: Stop warfarin and give IV vitamin K and prothrombin complex concentrate

      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.

    • This question is part of the following fields:

      • Haematology
      18.8
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  • Question 37 - A 45-year-old man comes in feeling extremely sick with nausea and vomiting. He...

    Correct

    • A 45-year-old man comes in feeling extremely sick with nausea and vomiting. He is suddenly disoriented and claims that everything appears to be yellow. A blood test shows that his potassium level is 6.8 mmol/l.
      Which of the following medications is most likely causing his symptoms?

      Your Answer: Digoxin

      Explanation:

      Digoxin is a medication used to treat atrial fibrillation and flutter, as well as congestive cardiac failure. It belongs to a class of drugs called cardiac glycosides. Its mechanism of action involves inhibiting the Na/K ATPase in cardiac myocytes, which leads to an increase in intracellular sodium concentration. This, in turn, indirectly increases the availability of intracellular calcium through Na/Ca exchange.

      The rise in intracellular calcium levels caused by digoxin results in a positive inotropic effect, meaning it strengthens the force of heart contractions, and a negative chronotropic effect, meaning it slows down the heart rate.

      Therapeutic plasma levels of digoxin typically range between 1.0-1.5 nmol/l. However, higher concentrations may be necessary, and the specific value can vary between different laboratories. It is important to note that the risk of toxicity significantly increases when digoxin levels exceed 2 nmol/l.

      Signs and symptoms of digoxin toxicity include nausea, vomiting, diarrhea, abdominal pain, confusion, tachyarrhythmias or bradyarrhythmias, xanthopsia (yellow-green vision), and hyperkalemia (an early sign of significant toxicity).

      Several factors can potentially contribute to digoxin toxicity. These include being elderly, having renal failure, experiencing myocardial ischemia, having hypokalemia, hypomagnesemia, hypercalcemia, hypernatremia, acidosis, or hypothyroidism.

      Additionally, there are several drugs that can increase the risk of digoxin toxicity. These include spironolactone, amiodarone, quinidine, verapamil, diltiazem, and drugs that cause hypokalemia, such as thiazide and loop diuretics.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      13.8
      Seconds
  • Question 38 - A 25-year-old woman visits your office expressing concern about a recent unprotected sexual...

    Correct

    • A 25-year-old woman visits your office expressing concern about a recent unprotected sexual encounter that occurred three days ago. She is extremely anxious and determined to prevent pregnancy. The patient has a history of asthma and currently takes Clenil Modulite. Her BMI is 30.

      What is the most appropriate choice for her in this situation?

      Your Answer: Copper IUD

      Explanation:

      Women have three options when requesting emergency contraception. The first option is Levonelle 1.5 mg, which contains levonorgestrel and can be used up to 72 hours after unprotected sexual intercourse (UPSI). If vomiting occurs within 2 hours of taking the tablet, another one should be given. Levonelle mainly works by preventing ovulation.

      The second option is ulipristal acetate, the newest treatment available. It can be used up to 120 hours after UPSI. If vomiting occurs within 3 hours of ingestion, another tablet should be given. Ulipristal acetate also works by inhibiting ovulation. However, it should be avoided in patients taking enzyme-inducing drugs, those with severe hepatic impairment, or those with severe asthma requiring oral steroids.

      The third option is the copper IUD, which can be fitted up to 5 days after UPSI or ovulation, whichever is longer. The failure rate of the copper IUD is less than 1 in 1000, making it 10-20 times more effective than oral emergency contraceptive options. It is important to note that Levonelle and ulipristal may be less effective in women with higher BMIs.

    • This question is part of the following fields:

      • Sexual Health
      29.6
      Seconds
  • Question 39 - A 4-year-old child is brought in by ambulance. He has been experiencing seizures...

    Correct

    • A 4-year-old child is brought in by ambulance. He has been experiencing seizures for the past 35 minutes. He has received two doses of IV lorazepam. His bowel movement is normal, and he is not taking any medication.

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

      Your Answer: Set up phenytoin infusion

      Explanation:

      The current algorithm for the treatment of a convulsing child, known as APLS, is as follows:

      Step 1 (5 minutes after the start of convulsion):
      If a child has been convulsing for 5 minutes or more, the initial dose of benzodiazepine should be administered. This can be done by giving Lorazepam at a dose of 0.1 mg/kg intravenously (IV) or intraosseously (IO) if vascular access is available. Alternatively, buccal midazolam at a dose of 0.5 mg/kg or rectal diazepam at a dose of 0.5 mg/kg can be given if vascular access is not available.

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

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

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

      Please note that this algorithm is subject to change based on individual patient circumstances and the guidance of medical professionals.

    • This question is part of the following fields:

      • Neurology
      11.2
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  • Question 40 - A 45-year-old patient has been diagnosed with gonorrhea. You are preparing to initiate...

    Correct

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

      Your Answer: Ceftriaxone and azithromycin

      Explanation:

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

    • This question is part of the following fields:

      • Sexual Health
      55.1
      Seconds
  • Question 41 - A 60-year-old woman presents with a nosebleed that started after sneezing 20 minutes...

    Correct

    • A 60-year-old woman presents with a nosebleed that started after sneezing 20 minutes ago. She is currently using tissues to catch the drips, and you have been asked to see her urgently by the triage nurse. Her observations are normal, and she has no haemodynamic compromise. The nurse has gained IV access.
      What is the SINGLE most appropriate INITIAL management step for this patient?

      Your Answer: Sit patient up and tell her to apply direct pressure to the soft, fleshy part of her nose

      Explanation:

      The initial step in managing a patient with uncomplicated epistaxis is to have the patient sit up and instruct them to apply direct pressure to the soft, fleshy part of their nose for a duration of 10 minutes.

      If the bleeding persists after the 10-minute period, the next course of action would be to insert a gauze swab or pledget soaked with a solution of adrenaline (1:10,000) and lidocaine (4%) into the nasal cavity. This should be left in place for approximately 10-15 minutes before removal. Following the removal, an attempt can be made to cauterize any bleeding point.

      If the above measures prove ineffective, it would be appropriate to consider inserting a nasal pack such as a ‘rapid rhino’ pack or alternatively using ribbon gauze soaked in an oily paste like bismuth iodoform paraffin paste. At this stage, it is advisable to refer the patient to the on-call ENT specialist.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      28.5
      Seconds
  • Question 42 - A 68-year-old man suffers a fractured neck of femur. He is later diagnosed...

    Correct

    • A 68-year-old man suffers a fractured neck of femur. He is later diagnosed with osteoporosis and is prescribed medication for the secondary prevention of osteoporotic fragility fractures.
      What is the recommended initial treatment for the secondary prevention of osteoporotic fragility fractures?

      Your Answer: Oral bisphosphonate

      Explanation:

      Oral bisphosphonates are the primary choice for treating osteoporotic fragility fractures in individuals who have already experienced such fractures. After a fragility fracture, it is advised to start taking a bisphosphonate, typically alendronic acid, and consider supplementing with calcium and vitamin D.

      There are other treatment options available for preventing fragility fractures after an initial occurrence. These include raloxifene, teriparatide, and denosumab.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      7.9
      Seconds
  • Question 43 - A 35-year-old woman is involved in a car accident. Her observations are taken...

    Correct

    • A 35-year-old woman is involved in a car accident. Her observations are taken one hour after arriving at the Emergency Department. Her pulse rate is 88 bpm, BP is 130/50 mmHg, respiratory rate 16 breaths/minute, and her urine output over the past hour has been 40 ml. She has some bruising evident on her arm and is slightly nervous. The patient weighs approximately 65 kg.
      How would you classify her haemorrhage according to the ATLS haemorrhagic shock classification?

      Your Answer: Class I

      Explanation:

      This patient’s physiological parameters are mostly within normal range, but there is an increased pulse pressure and slight anxiety, suggesting a class I haemorrhage. It is crucial to be able to identify the degree of blood loss based on vital signs and mental status changes. The Advanced Trauma Life Support (ATLS) classification for haemorrhagic shock correlates the amount of blood loss with expected physiological responses in a healthy 70 kg individual. In a 70 kg male patient, the total circulating blood volume is approximately five litres, which accounts for about 7% of their total body weight.

      The ATLS haemorrhagic shock classification is as follows:

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

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

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

      CLASS IV:
      – Blood loss: More than 2000 mL
      – Blood loss (% blood volume): More than 40%
      – Pulse rate: Greater than 140 bpm
      – Systolic BP: 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
      17.8
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  • Question 44 - A 45-year-old woman is brought into resus by blue light ambulance following a...

    Correct

    • A 45-year-old woman is brought into resus by blue light ambulance following a car accident. She was hit by a truck while crossing the road and has a suspected pelvic injury. She is currently on a backboard with cervical spine protection and a pelvic binder in place. The massive transfusion protocol is activated.
      According to the ATLS guidelines, what other medication should be administered?

      Your Answer: Tranexamic acid

      Explanation:

      ATLS guidelines now suggest administering only 1 liter of crystalloid fluid during the initial assessment. If patients do not respond to the crystalloid, it is recommended to quickly transition to blood products. Studies have shown that infusing more than 1.5 liters of crystalloid fluid is associated with higher mortality rates in trauma cases. Therefore, it is advised to prioritize the early use of blood products and avoid large volumes of crystalloid fluid in trauma patients. In cases where it is necessary, massive transfusion should be considered, defined as the transfusion of more than 10 units of blood in 24 hours or more than 4 units of blood in one hour. For patients with evidence of Class III and IV hemorrhage, early resuscitation with blood and blood products in low ratios is recommended.

      Based on the findings of significant trials, such as the CRASH-2 study, the use of tranexamic acid is now recommended within 3 hours. This involves administering a loading dose of 1 gram intravenously over 10 minutes, followed by an infusion of 1 gram over eight hours. In some regions, tranexamic acid is also being utilized in the prehospital setting.

    • This question is part of the following fields:

      • Trauma
      10.2
      Seconds
  • Question 45 - A 25-year-old pregnant woman comes in with dysuria, high body temperature, chills, and...

    Correct

    • A 25-year-old pregnant woman comes in with dysuria, high body temperature, chills, and pain in her left side. During the examination, she experiences tenderness in the left renal angle and her temperature is measured at 38.6°C. The triage nurse has already inserted a cannula and sent her blood samples to the laboratory.
      What is the MOST SUITABLE antibiotic to prescribe for this situation?

      Your Answer: Cefuroxime

      Explanation:

      This patient is displaying symptoms and signs that are consistent with a diagnosis of acute pyelonephritis. Additionally, she is showing signs of sepsis and is pregnant, which makes it necessary to admit her for inpatient treatment.

      According to the National Institute for Health and Care Excellence (NICE), patients with pyelonephritis should be admitted if it is severe or if they exhibit any signs or symptoms that suggest a more serious illness or condition, such as sepsis. Signs of sepsis include significant tachycardia, hypotension, or breathlessness, as well as marked signs of illness like impaired level of consciousness, profuse sweating, rigors, pallor, or significantly reduced mobility. A temperature greater than 38°C or less than 36°C is also indicative of sepsis.

      NICE also recommends considering referral or seeking specialist advice for individuals with acute pyelonephritis if they are significantly dehydrated or unable to take oral fluids and medicines, if they are pregnant, if they have a higher risk of developing complications due to known or suspected structural or functional abnormalities of the genitourinary tract or underlying diseases like diabetes mellitus or immunosuppression, or if they have recurrent episodes of urinary tract infections (UTIs).

      For non-pregnant women and men, the recommended choice of antibacterial therapy is as follows: oral first-line options include cefalexin, ciprofloxacin, or co-amoxiclav (taking into account local microbial resistance data), and intravenous first-line options (if severely unwell or unable to take oral treatment) include amikacin, ceftriaxone, cefuroxime, ciprofloxacin, or gentamicin. Co-amoxiclav may be used if given in combination or if sensitivity is known. Antibacterials may be combined if there are concerns about susceptibility or sepsis. For intravenous second-line options, it is recommended to consult a local microbiologist.

      For pregnant women, the recommended choice of antibacterial therapy is as follows: oral first-line option is cefalexin, and intravenous first-line option (if severely unwell or unable to take oral treatment) is cefuroxime. Intravenous second-line options or combining antibacterials should be considered if there are concerns about susceptibility or sepsis, and consultation with a local microbiologist is recommended.

    • This question is part of the following fields:

      • Urology
      12.5
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  • Question 46 - You are managing a 32-year-old type 1 diabetic patient who presented feeling generally...

    Correct

    • You are managing a 32-year-old type 1 diabetic patient who presented feeling generally unwell with a blood glucose of 27 mmol/l. The patient is currently being treated for diabetic ketoacidosis. The patient weighs 70kg and is currently receiving the following:
      0.9% sodium chloride 1L with 40 mmol/l potassium chloride over 4 hours
      3 units Actrapid® insulin / hour.

      Monitoring bloods are taken and the results are shown below:

      glucose 12.8 mmol/l
      potassium 3.7 mmol/l
      sodium 145 mmol/l
      pH 7.2

      What is the most appropriate action to take for this patient?

      Your Answer: Start 10% glucose infusion at a rate of 125 mL/hour in addition to existing treatment

      Explanation:

      The healthcare provider should also assess the insulin infusion rate. It is important to note that the recommended minimum rate is 0.05 units per kilogram per hour. In this case, the patient weighs 60 kilograms and is currently receiving 3 units of Actrapid® insulin per hour, which is equivalent to 0.05 units per kilogram per hour. Therefore, the patient is already on the lowest possible dose. However, if the patient was on a higher dose of 0.1 units per kilogram per hour, it can be reduced once the glucose level falls below 14 mmol/l.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
      15.9
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  • Question 47 - A 60-year-old woman comes in with severe, crushing chest pain that spreads to...

    Correct

    • A 60-year-old woman comes in with severe, crushing chest pain that spreads to her left shoulder and jaw. The pain has improved after receiving GTN spray under the tongue and intravenous morphine.
      What other medication should be recommended at this point?

      Your Answer: Aspirin

      Explanation:

      This particular patient has a high risk of experiencing an acute coronary syndrome. Therefore, it is recommended to administer aspirin at a dosage of 300 mg and clopidogrel at a dosage ranging from 300-600 mg.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Cardiology
      6.5
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  • Question 48 - A 25-year-old engineering student returns from a hiking trip in South America with...

    Incorrect

    • A 25-year-old engineering student returns from a hiking trip in South America with a high temperature, body pains, and shivering. After further examination, they are diagnosed with malaria.

      Which of the following statements about malaria is correct?

      Your Answer: Plasmodium vivax is usually treated with quinine

      Correct Answer: Haemoglobinuria and renal failure following treatment is suggestive of Plasmodium falciparum

      Explanation:

      Plasmodium ovale has the longest incubation period, which can extend up to 40 days. On the other hand, Plasmodium falciparum has a shorter incubation period of 7-14 days. The transmission of malaria occurs through the female mosquitoes belonging to the Anopheles genus.

      Blackwater fever, which is caused by Plasmodium falciparum, can be indicated by the presence of haemoglobinuria and renal failure following treatment. This condition is a result of an autoimmune reaction between the parasite and quinine, leading to haemolysis, haemoglobinuria, jaundice, and renal failure. It is a potentially fatal complication. The diagnosis of malaria is typically done using the Indirect Fluorescence Antibody Test (IFAT).

      Currently, the recommended treatment for P. falciparum malaria is artemisinin-based combination therapy (ACT). This involves combining fast-acting artemisinin-based compounds with a drug from a different class. Some companion drugs used in ACT include lumefantrine, mefloquine, amodiaquine, sulfadoxine/pyrimethamine, piperaquine, and chlorproguanil/dapsone. Artemisinin derivatives such as dihydroartemisinin, artesunate, and artemether are also used.

      In cases where artemisinin combination therapy is not available, oral quinine or atovaquone with proguanil hydrochloride can be used as an alternative. However, quinine is highly effective but not well-tolerated in prolonged treatment, so it is usually combined with another drug, typically oral doxycycline (or clindamycin in pregnant women and young children).

      Severe or complicated falciparum malaria requires management in a high dependency unit or intensive care setting. Intravenous artesunate is recommended for all patients with severe or complicated falciparum malaria, or those at high risk of developing severe disease (e.g., if more than 2% of red blood cells are parasitized), or if the patient is unable to take oral treatment. After a minimum of 24 hours of intravenous artesunate treatment and improvement in the patient’s condition, a full course of artemisinin combination therapy should be administered orally.

      The benign malarias, namely P. vivax, P. malariae, and P. ovale,

    • This question is part of the following fields:

      • Infectious Diseases
      37.8
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  • Question 49 - A 40-year-old man presents very unwell with an acute exacerbation of his asthma.
    Which...

    Correct

    • A 40-year-old man presents very unwell with an acute exacerbation of his asthma.
      Which of the following drug doses used in the treatment of acute adult asthma is incorrect?

      Your Answer: Terbutaline 5mg via oxygen-driven nebuliser

      Explanation:

      The recommended drug doses for adult acute asthma are as follows:

      – Salbutamol: Administer 5 mg using an oxygen-driven nebulizer.
      – Ipratropium bromide: Deliver 500 mcg via an oxygen-driven nebulizer.
      – Prednisolone: Take orally at a dose of 40-50 mg.
      – Hydrocortisone: Administer 100 mg intravenously.
      – Magnesium sulphate: Infuse 1.2-2 g intravenously over a period of 20 minutes.

      Terbutaline can be used as an alternative to salbutamol, with a dose of 10 mg via an oxygen-driven nebulizer. Intravenous salbutamol may be considered (250 mcg IV 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 may be considered in 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.

    • This question is part of the following fields:

      • Respiratory
      7.3
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  • Question 50 - A 72-year-old woman presents with a painful swollen left big toe. The pain...

    Correct

    • A 72-year-old woman presents with a painful swollen left big toe. The pain started this morning and is described as the most severe pain she has ever experienced. It has gradually worsened over the past 8 hours. She is unable to wear socks or shoes and had to come to the appointment in opened toe sandals. The overlying skin is red and shiny.

      She has a history of hypertension, which has been difficult to control. She is currently taking amlodipine 10 mg and ramipril 10 mg per day for this and is awaiting a review of her antihypertensive medication. Her blood pressure today is 165/94 mmHg.

      She has recently also been diagnosed with a myelodysplastic syndrome and has to have regular blood transfusions. She is being monitored in a local haematology clinic for a low white cell count and thrombocytopenia.

      What is the SINGLE most appropriate next step in her management?

      Your Answer: Commence prednisolone

      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 is not very beneficial 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 normal. If levels are checked and found to be normal during an 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. It’s important to note that colchicine can have effects on the bone marrow, leading to an increase in neutrophils and a decrease in platelets. Therefore, it should not be used in patients with blood disorders, as is the case with this patient.

      Allopurinol should not be used during an acute gout attack as it can prolong the attack and even trigger another acute attack. If a patient is already taking allopurinol, it should be continued, and the acute attack should be treated with NSAIDs, colchicine, or corticosteroids as appropriate.

      Corticosteroids are an effective alternative for managing acute gout in patients who cannot take NSAIDs or colchicine. They can be administered orally, intramuscularly, intravenously, or directly into the affected joint. In this patient’s case, using corticosteroids would be the safest and most reasonable treatment option.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      26.9
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  • Question 51 - A 6-year-old girl is brought in by her parents with wheezing and difficulty...

    Correct

    • A 6-year-old girl is brought in by her parents with wheezing and difficulty breathing. Over the past few days, she has been feeling sick and has had a decreased appetite. Her parents have noticed that she seems to struggle with breathing, especially when she is playing or exerting herself. Her oxygen levels are at 90% on room air, but all her other vital signs are normal. A chest X-ray is taken, which is shows left lung appears overinflated and hyperlucent, with concomitant rib flaring and a depressed ipsilateral hemidiaphragm. What is the MOST likely diagnosis for this patient?

      Your Answer: Inhaled foreign body

      Explanation:

      This child’s medical history and chest X-ray findings are indicative of an inhaled foreign object. Upon careful examination, it is evident that the left lung appears more transparent than the right lung, and the foreign body is lodged in the left tracheobronchial tree.

      Airway foreign bodies in children can be life-threatening, and it is important to consider this diagnosis when young children experience unexplained difficulty breathing and wheezing. Unfortunately, there is often a delay in diagnosing this condition.

      Foreign objects typically get stuck in the right tracheobronchial tree because the right main bronchus is wider, shorter, and more vertically positioned compared to the left main bronchus. However, they can become lodged anywhere in the tracheobronchial tree.

      While there is often a history of choking prior to the symptoms, this is not always the case. Any history of running with objects in the mouth or being in close proximity to small objects that can be placed in the mouth can provide important clues. In the absence of a choking history, clinical features may include paroxysmal coughing, unexplained difficulty breathing, changes in voice, poor appetite, irritability, decreased breath sounds on one side, and localized wheezing.

      To aid in diagnosis, a chest X-ray should be taken during expiration as it can accentuate any differences between the two lungs. The following findings may be observed: the normal lung may appear smaller and denser than the affected lung, the affected lung may appear excessively transparent and overinflated, and a radio-opaque foreign object may be visible. However, it is important to note that approximately 35% of patients may have a normal chest X-ray.

      Bronchoscopy is considered the gold-standard test for diagnosing tracheobronchial foreign bodies. This procedure not only confirms the presence of a foreign object but also allows for potential retrieval.

      Possible complications of this condition include pneumonia, atelectasis (collapsed lung), bronchospasm (constriction of the airways), pneumothorax (collapsed lung due to air leakage), broncho-oesophageal fistula (abnormal connection between the bronchial tubes and the esophagus), and bronchiectasis (permanent dilation of the bronchial tubes).

    • This question is part of the following fields:

      • Respiratory
      49.7
      Seconds
  • Question 52 - A 35 year old male presents to the emergency department after twisting his...

    Correct

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

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

      Your Answer: Tenderness over navicular

      Explanation:

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

      Further Reading:

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

    • This question is part of the following fields:

      • Trauma
      22
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  • Question 53 - A 30-year-old woman who is being treated for a urinary tract infection comes...

    Correct

    • A 30-year-old woman who is being treated for a urinary tract infection comes back after 48 hours because her symptoms have not gotten better. Regrettably, the lab still hasn't provided the sensitivities from the urine sample that was sent. Her blood tests today indicate that her eGFR is >60 ml/minute. She has been taking nitrofurantoin 100 mg modified-release orally twice a day for the past two days.
      Which antibiotic would be the most suitable to prescribe in this situation?

      Your Answer: Fosfomycin

      Explanation:

      For the treatment of women with lower urinary tract infections (UTIs) who are not pregnant, it is recommended to consider either a back-up antibiotic prescription or an immediate antibiotic prescription. This decision should take into account the severity of symptoms and the risk of developing complications, which is higher in individuals with known or suspected abnormalities of the genitourinary tract or weakened immune systems. The evidence for back-up antibiotic prescriptions is limited to non-pregnant women with lower UTIs where immediate antibiotic treatment is not deemed necessary. It is also important to consider previous urine culture and susceptibility results, as well as any history of antibiotic use that may have led to the development of resistant bacteria. Ultimately, the preferences of the woman regarding antibiotic use should be taken into account.

      If a urine sample has been sent for culture and susceptibility testing and an antibiotic prescription has been given, it is crucial to review the choice of antibiotic once the microbiological results are available. If the bacteria are found to be resistant and symptoms are not improving, it is recommended to switch to a narrow-spectrum antibiotic whenever possible.

      The following antibiotics are recommended for non-pregnant women aged 16 years and older:

      First-choice:
      – Nitrofurantoin 100 mg modified-release taken orally twice daily for 3 days (if eGFR >45 ml/minute)
      – Trimethoprim 200 mg taken orally twice daily for 3 days (if low risk of resistance*)

      Second-choice (if there is no improvement in lower UTI symptoms on first-choice treatment for at least 48 hours, or if first-choice treatment is not suitable):
      – Nitrofurantoin 100 mg modified-release taken orally twice daily for 3 days (if eGFR >45 ml/minute)
      – Pivmecillinam 400 mg initial dose taken orally, followed by 200 mg taken orally three times daily for 3 days
      – Fosfomycin 3 g single sachet dose

      *The risk of resistance may be lower if the antibiotic has not been used in the past 3 months, previous urine culture suggests susceptibility (although this was not used), and in younger individuals in areas where local epidemiology data indicate low resistance rates. Conversely, the risk of resistance may be higher with recent antibiotic use and in older individuals in residential facilities.

    • This question is part of the following fields:

      • Urology
      54.1
      Seconds
  • Question 54 - A 32-year-old woman comes in with a history of worsening wheezing for the...

    Incorrect

    • A 32-year-old woman comes in with a history of worsening wheezing for the past three days. She has a history of seasonal allergies during the spring months, which have been more severe than usual in recent weeks. Upon listening to her chest, you can hear scattered polyphonic wheezes. Her peak flow at the time of presentation is 280 L/min, and her personal best peak flow is 550 L/min.
      What classification would you assign to this asthma exacerbation?

      Your Answer: Moderate asthma

      Correct Answer: Acute severe asthma

      Explanation:

      This man is experiencing an acute episode of asthma. His initial peak flow measurement is 46% of his best, indicating a severe exacerbation. According to the BTS guidelines, acute asthma can be classified as moderate, acute severe, life-threatening, or near-fatal.

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

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

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

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

    • This question is part of the following fields:

      • Respiratory
      59.1
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  • Question 55 - A 68-year-old man develops hearing loss and renal impairment after inpatient treatment for...

    Correct

    • A 68-year-old man develops hearing loss and renal impairment after inpatient treatment for urinary sepsis.

      Which of the following antibiotics is most likely to have been administered?

      Your Answer: Gentamicin

      Explanation:

      Gentamicin is an antibiotic belonging to the aminoglycoside class. It works by binding to the 30S subunit of the ribosome in bacteria, thereby preventing the binding of aminoacyl-tRNA and ultimately inhibiting the initiation of protein synthesis.

      The two most significant side effects associated with gentamicin are hearing loss and reversible nephrotoxicity. These side effects are directly related to the dosage of the medication and are more commonly observed in elderly individuals.

      Hearing loss occurs due to damage to the vestibular apparatus located in the inner ear. On the other hand, nephrotoxicity is caused by the inhibition of protein synthesis in renal cells. This inhibition leads to necrosis of the cells in the proximal convoluted tubule and results in a condition known as acute tubular necrosis.

      In summary, gentamicin mechanism of action and side effects, such as hearing loss and reversible nephrotoxicity, are closely linked to its interaction with the bacterial ribosome and its impact on protein synthesis. These effects are particularly prevalent in the elderly population.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      35.4
      Seconds
  • Question 56 - Gout is becoming more prevalent in Western societies due to various factors, including...

    Correct

    • 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.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      7.2
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  • Question 57 - A 7-year-old child experiences an anaphylactic reaction after being stung by a bee....

    Correct

    • A 7-year-old child experiences an anaphylactic reaction after being stung by a bee. How much IM adrenaline should be administered in this situation?

      Your Answer: 300 mcg

      Explanation:

      The management of anaphylaxis involves several important steps. First and foremost, it is crucial to ensure proper airway management. Additionally, early administration of adrenaline is essential, preferably in the anterolateral aspect of the middle third of the thigh. Aggressive fluid resuscitation is also necessary. In severe cases, intubation may be required. However, it is important to note that the administration of chlorpheniramine and hydrocortisone should only be considered after early resuscitation has taken place.

      Adrenaline is the most vital medication for treating anaphylactic reactions. It acts as an alpha-adrenergic receptor agonist, which helps reverse peripheral vasodilatation and reduce oedema. Furthermore, its beta-adrenergic effects aid in dilating the bronchial airways, increasing the force of myocardial contraction, and suppressing histamine and leukotriene release. Administering adrenaline as the first drug is crucial, and the intramuscular (IM) route is generally the most effective for most individuals.

      The recommended doses of IM adrenaline for different age groups during anaphylaxis are as follows:

      – Children under 6 years: 150 mcg (0.15 mL of 1:1000)
      – Children aged 6-12 years: 300 mcg (0.3 mL of 1:1000)
      – Children older than 12 years: 500 mcg (0.5 mL of 1:1000)
      – Adults: 500 mcg (0.5 mL of 1:1000)

    • This question is part of the following fields:

      • Allergy
      14.9
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  • Question 58 - A 35-year-old woman was diagnosed two years ago with multiple sclerosis (MS). She...

    Incorrect

    • A 35-year-old woman was diagnosed two years ago with multiple sclerosis (MS). She has had three relapses in that time, and with each relapse, her symptoms are getting worse. She does have periods of remission, but they don't last long.
      Which SINGLE pattern of MS is she experiencing?

      Your Answer: Progressive relapsing MS

      Correct Answer: Primary progressive MS

      Explanation:

      Multiple sclerosis (MS) is a condition characterized by the demyelination of nerve cells in the brain and spinal cord. It is an autoimmune disease caused by recurring inflammation, primarily affecting individuals in early adulthood. The ratio of affected females to males is 3:2.

      There are several risk factors associated with MS, including being of Caucasian race, living at a greater distance from the equator (as the risk increases), having a family history of the disease (with approximately 20% of MS patients having an affected relative), and smoking. Interestingly, the rates of relapse tend to decrease during pregnancy.

      MS can present in three main patterns. The most common is relapsing and remitting MS, characterized by periods of no symptoms followed by relapses (present in 80% of patients at diagnosis). Primary progressive MS is less common, with symptoms developing and worsening from the beginning and few remissions (present in 10-15% of patients at diagnosis). Secondary progressive MS follows relapsing/remitting MS, with worsening symptoms and fewer remissions (approximately 50% of those with relapsing/remitting MS will develop this within 10 years of diagnosis). Progressive relapsing MS is rare and involves a steady decline in neurological function from the onset of the disease, with superimposed attacks also occurring.

      Certain factors can indicate a more favorable prognosis for individuals with MS. These include having a relapsing/remitting course, being female, experiencing sensory symptoms, and having an early age at onset.

    • This question is part of the following fields:

      • Neurology
      14
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  • Question 59 - A 30-year-old woman is diagnosed with depression during the 2nd-trimester of her pregnancy...

    Incorrect

    • A 30-year-old woman is diagnosed with depression during the 2nd-trimester of her pregnancy and is started on fluoxetine. As a result of this treatment, the baby develops a complication.
      Which of the following complications is the most likely to occur due to the use of this medication during pregnancy?

      Your Answer: Neural tube defect

      Correct Answer: Persistent pulmonary hypertension of the newborn

      Explanation:

      During the third trimester of pregnancy, the use of selective serotonin reuptake inhibitors (SSRIs) has been associated with a discontinuation syndrome and persistent pulmonary hypertension of the newborn. It is important to be aware of the adverse effects of various drugs during pregnancy. For example, ACE inhibitors like ramipril, if given in the second and third trimester, can cause hypoperfusion, renal failure, and the oligohydramnios sequence. Aminoglycosides such as gentamicin can lead to ototoxicity and deafness. High doses of aspirin can result in first-trimester abortions, delayed onset labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g., 75 mg) do not pose significant risks. Late administration of benzodiazepines like diazepam during pregnancy can cause respiratory depression and a neonatal withdrawal syndrome. Calcium-channel blockers, if given in the first trimester, may cause phalangeal abnormalities, while their use in the second and third trimester can lead to fetal growth retardation. Carbamazepine has been associated with hemorrhagic disease of the newborn and neural tube defects. Chloramphenicol can cause grey baby syndrome. Corticosteroids, if given in the first trimester, may cause orofacial clefts. Danazol, if administered in the first trimester, can result in masculinization of the female fetuses genitals. Pregnant women should avoid handling crushed or broken tablets of finasteride as it can be absorbed through the skin and affect male sex organ development. Haloperidol, if given in the first trimester, may cause limb malformations, while its use in the third trimester increases the risk of extrapyramidal symptoms in the neonate. Heparin can lead to maternal bleeding and thrombocytopenia. Isoniazid can cause maternal liver damage and neuropathy and seizures in the neonate. Isotretinoin carries a high risk of teratogenicity, including multiple congenital malformations, spontaneous abortion, and intellectual disability. The use of lithium in the first trimester increases the risk of fetal cardiac malformations, while its use in the second and third trimesters can result in hypotonia, lethargy, feeding problems, hypothyroidism, goiter, and nephrogenic diabetes insipidus.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      34.5
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  • Question 60 - A 45-year-old female patient is known to have Parkinson’s disease. She complains of...

    Correct

    • A 45-year-old female patient is known to have Parkinson’s disease. She complains of recent excessive sleepiness, increased anxiety, and uncontrolled jerky movements in her lower limbs.
      Which SINGLE medication is most likely responsible for these symptoms?

      Your Answer: Co-beneldopa

      Explanation:

      Co-beneldopa, such as Madopar®, is a medication that combines levodopa and benserazide, a dopa-decarboxylase inhibitor. Levodopa is a precursor of dopamine and has been the primary treatment for Parkinson’s disease since the 1970s. To minimize the side effects of levodopa, it is administered with a dopa-decarboxylase inhibitor (DDI) to reduce its availability in the peripheral system. However, patients may still experience adverse effects like nausea, dizziness, sleepiness, dyskinesia, mood changes, confusion, hallucinations, and delusions.

      None of the other combination medications mentioned in this question cause the listed side effects.

      Co-dydramol is a pain reliever that contains dihydrocodeine tartrate and paracetamol.

      Co-flumactone is a medication that combines spironolactone, a potassium-sparing diuretic, and hydroflumethiazide, a type of thiazide diuretic used for managing congestive cardiac failure.

      Co-tenidone is a combination of atenolol and chlorthalidone, primarily used for treating hypertension.

      Co-simalcite, also known as Altacite plus, is an antacid that contains two main ingredients: hydrotalcite and activated dimeticone.

    • This question is part of the following fields:

      • Neurology
      22.5
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  • Question 61 - A 45-year-old man presents with palpitations and is found to have atrial fibrillation....

    Incorrect

    • A 45-year-old man presents with palpitations and is found to have atrial fibrillation. You are requested to evaluate his ECG.
      Which of the following statements is correct regarding the ECG findings in atrial fibrillation?

      Your Answer: Ashman beats are narrow complex QRS complexes following a prolonged R-R interval

      Correct Answer: Some impulses are filtered out by the AV node

      Explanation:

      The classic ECG features of atrial fibrillation include an irregularly irregular rhythm, the absence of p-waves, an irregular ventricular rate, and the presence of fibrillation waves. This irregular rhythm occurs because the atrial impulses are filtered out by the AV node.

      In addition, Ashman beats may be observed in atrial fibrillation. These beats are characterized by wide complex QRS complexes, often with a morphology resembling right bundle branch block. They occur after a short R-R interval that is preceded by a prolonged R-R interval. Fortunately, Ashman beats are generally considered harmless.

      The disorganized electrical activity in atrial fibrillation typically originates at the root of the pulmonary veins.

    • This question is part of the following fields:

      • Cardiology
      47.8
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  • Question 62 - A 65-year-old patient presents with nausea and vomiting and decreased urine output. He...

    Correct

    • 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 primary renal cause of AKI?

      Your Answer: Renal artery stenosis

      Explanation:

      Acute kidney injury (AKI), previously known as acute renal failure, is a sudden decline in kidney function. This results in the accumulation of urea and other waste products in the body and disrupts the balance of fluids and electrolytes. 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 that develop outside of healthcare settings are due to pre-renal causes, accounting for 90% of cases. These causes typically involve low blood pressure associated with conditions like sepsis and fluid depletion. Medications, particularly ACE inhibitors and NSAIDs, are also frequently implicated.
      Pre-renal:
      – Volume depletion (e.g., severe bleeding, excessive vomiting or diarrhea, burns)
      – Oedematous states (e.g., heart failure, liver cirrhosis, nephrotic syndrome)
      – Low blood pressure (e.g., cardiogenic shock, sepsis, anaphylaxis)
      – Cardiovascular conditions (e.g., severe heart failure, arrhythmias)
      – Renal hypoperfusion: NSAIDs, COX-2 inhibitors, ACE inhibitors or ARBs, abdominal aortic aneurysm
      – Renal artery stenosis
      – Hepatorenal syndrome

      Intrinsic renal:
      – Glomerular diseases (e.g., glomerulonephritis, thrombosis, hemolytic-uremic syndrome)
      – Tubular injury: acute tubular necrosis (ATN) following prolonged lack of blood supply
      – Acute interstitial nephritis due to drugs (e.g., NSAIDs), infection, or autoimmune diseases
      – Vascular diseases (e.g., vasculitis, polyarteritis nodosa, thrombotic microangiopathy, cholesterol emboli, renal vein thrombosis, malignant hypertension)
      – Eclampsia

      Post-renal:
      – Kidney stones
      – Blood clot
      – Papillary necrosis
      – Urethral stricture
      – Prostatic hypertrophy or malignancy
      – Bladder tumor
      – Radiation fibrosis
      – Pelvic malignancy
      – Retroperitoneal

    • This question is part of the following fields:

      • Nephrology
      21.6
      Seconds
  • Question 63 - A 32-year-old woman comes in with left-sided flank pain and nausea. A urine...

    Correct

    • A 32-year-old woman comes in with left-sided flank pain and nausea. A urine dipstick shows microscopic blood in the urine. She is later diagnosed with renal colic.
      What is the most frequently occurring type of kidney stone?

      Your Answer: Calcium containing stones

      Explanation:

      Urinary tract stones form when the concentration of salt and minerals in the urine becomes too high. These stones can be classified into five types based on their mineral composition and how they develop.

      The most common type of stone is the calcium stone, which can be further divided into calcium oxalate and calcium phosphate stones. These account for 60-80% of all urinary tract stones.

      Another type is the struvite or magnesium ammonium phosphate stone, making up about 10-15% of cases. Uric acid stones, also known as urate stones, occur in 3-10% of cases.

      Cystine stones are less common, accounting for less than 2% of urinary tract stones. Finally, there are drug-induced stones, which are caused by certain medications such as triamterene, protease inhibitors like indinavir sulphate, and sulfa drugs. These account for approximately 1% of cases.

      By understanding the different types of urinary tract stones, healthcare professionals can better diagnose and treat patients with this condition.

    • This question is part of the following fields:

      • Urology
      12.4
      Seconds
  • Question 64 - A 35-year-old construction worker presents with confusion, vomiting, and complaining of a severe...

    Correct

    • A 35-year-old construction worker presents with confusion, vomiting, and complaining of a severe headache. There is currently a heatwave in the area, and he has been working outdoors in heavy protective gear. His skin feels dry and hot, he is breathing rapidly, and his core temperature is currently 41.7°C. He is extremely restless and experiencing severe shivering.
      What is the most suitable initial course of treatment in this case?

      Your Answer: Diazepam

      Explanation:

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

      The typical clinical features of heat stroke include a core temperature greater than 40.6°C, extreme fatigue, headache, syncope, facial flushing, vomiting, and diarrhea. The skin is usually hot and dry, although sweating can occur in around 50% of cases of exertional heat stroke. The loss of the ability to sweat is a late and concerning sign. Hyperventilation is almost always present. Cardiovascular dysfunction, including arrhythmias, hypotension, and shock, as well as respiratory dysfunction, including acute respiratory distress syndrome (ARDS), can occur. Central nervous system dysfunction, such as seizures and coma, may also be observed. If the temperature rises above 41.5°C, multi-organ failure, coagulopathy, and rhabdomyolysis can occur.

      In the management of heat stroke, benzodiazepines like diazepam can be helpful in patients with agitation and/or shivering. They help reduce excessive heat production and agitation. In severe cases, patients may require paralysis. Antipyretics like paracetamol, aspirin, and NSAIDs have no role in the treatment of heat stroke. They do not work because the hypothalamus, which regulates body temperature, is healthy but overloaded in heat stroke. Moreover, antipyretics may actually be harmful in patients who develop complications like liver, blood, and kidney problems as they can worsen bleeding tendencies.

      Dantrolene is commonly used in the treatment of heat stroke, although there is currently no high-level evidence to support its use. Neuroleptics, such as chlorpromazine, which were once commonly used, should be avoided due to their potential adverse effects, including lowering the seizure threshold, interfering with thermoregulation, causing anticholinergic side effects, hypotension, and hepatotoxicity.

    • This question is part of the following fields:

      • Environmental Emergencies
      17.1
      Seconds
  • Question 65 - You intend to utilize 1% lidocaine with adrenaline 1:200,000 for a peripheral nerve...

    Correct

    • You intend to utilize 1% lidocaine with adrenaline 1:200,000 for a peripheral nerve block on a 60 kg healthy young female. What is the maximum amount of lidocaine that can be administered in this scenario?

      Your Answer: 420 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 lidocaine is administered with adrenaline in a 1:200,000 ratio, the maximum safe dose increases to 7 mg per kilogram of body weight, with a maximum limit of 500 mg.

      In this particular case, the patient weighs 60 kg, so the maximum safe dose of lidocaine hydrochloride would be 60 multiplied by 7 mg, resulting in a total of 420 mg.

      For more detailed information on lidocaine hydrochloride, you can refer to the BNF section dedicated to this topic.

    • This question is part of the following fields:

      • Pain & Sedation
      16.9
      Seconds
  • Question 66 - A 35-year-old woman presents to the Emergency Department with a brief history of...

    Incorrect

    • A 35-year-old woman presents to the Emergency Department with a brief history of headaches, which are more severe in the morning, and blurred vision and ringing in the ears. Her headache is worse than usual today, and she has vomited multiple times. She has no significant medical history but does take the combined oral contraceptive pill. On examination, you find her to be overweight, and her neurological system examination reveals a sixth cranial nerve palsy, but no other focal neurology and fundoscopy reveals bilateral papilloedema.

      What is the SINGLE most likely diagnosis?

      Your Answer: Venous sinus thrombosis

      Correct Answer: Idiopathic intracranial hypertension

      Explanation:

      The most probable diagnosis in this case is idiopathic intracranial hypertension, also known as benign intracranial hypertension or pseudotumour cerebri. This condition typically affects overweight women in their 20s and 30s.

      The clinical features of idiopathic intracranial hypertension include:
      – Headache: The headache is usually worse in the morning and evenings, relieved by standing, and worsened when lying down. It can also be aggravated by coughing and sneezing. Some patients may experience pain around the shoulder girdle.
      – Nausea and vomiting
      – Visual field defects: These develop gradually over time.
      – 6th nerve palsy and diplopia
      – Bilateral papilloedema

      To investigate this condition, the patient should undergo a CT scan and/or MRI of the brain, as well as a lumbar puncture to measure the opening pressure and analyze the cerebrospinal fluid (CSF).

      The primary treatment goal for idiopathic intracranial hypertension is to prevent visual loss. This can be achieved through one of the following strategies:
      – Repeated lumbar puncture to control intracranial pressure (ICP)
      – Medical treatment with acetazolamide
      – Surgical decompression of the optic nerve sheath

    • This question is part of the following fields:

      • Neurology
      37.3
      Seconds
  • Question 67 - You are requested to evaluate a 7-year-old girl who is feeling sick in...

    Correct

    • You are requested to evaluate a 7-year-old girl who is feeling sick in the Pediatric Emergency Department. Upon reviewing her urea & electrolytes, you observe that her potassium level is elevated at 6.7 mmol/l. She is experiencing occasional palpitations.
      As per the APLS guidelines, which medication should be administered promptly when an arrhythmia is present in a child with notable hyperkalemia?

      Your Answer: Calcium chloride

      Explanation:

      Hyperkalemia is a condition where the level of potassium in the blood is higher than normal, specifically greater than 5.5 mmol/l. It can be categorized as mild, moderate, or severe depending on the potassium level. Mild hyperkalemia is when the potassium level is between 5.5-5.9 mmol/l, moderate hyperkalemia is between 6.0-6.4 mmol/l, and severe hyperkalemia is above 6.5 mmol/l. The most common cause of hyperkalemia is renal failure, which can be acute or chronic. Other causes include acidosis, adrenal insufficiency, cell lysis, and excessive potassium intake.

      In the treatment of hyperkalemia, calcium plays a crucial role. It works by counteracting the harmful effects of high potassium levels on the heart by stabilizing the cardiac cell membrane. Calcium acts quickly, with its effects seen within 15 minutes, but its effects are relatively short-lived. It is considered a first-line treatment for arrhythmias and significant ECG abnormalities caused by hyperkalemia. However, it is rare to see arrhythmias occur at potassium levels below 7.5 mmol/l.

      It’s important to note that calcium does not lower the serum level of potassium. Therefore, when administering calcium, other therapies that actually help lower potassium levels, such as insulin and salbutamol, should also be used. Insulin and salbutamol are effective in reducing serum potassium levels.

      When choosing between calcium chloride and calcium gluconate, calcium chloride is preferred when hyperkalemia is accompanied by hemodynamic compromise. This is because calcium chloride contains three times more elemental calcium than an equal volume of calcium gluconate.

    • This question is part of the following fields:

      • Nephrology
      13.7
      Seconds
  • Question 68 - You are requested to standby in the resuscitation bay for a 28-year-old patient...

    Correct

    • You are requested to standby in the resuscitation bay for a 28-year-old patient who is being transported to the emergency department after being hit in the face by the side mirror of a passing truck. The paramedics inform you that the patient is suspected to have a Le Fort III fracture. What characteristic differentiates a Le Fort III fracture from a Le Fort II fracture?

      Your Answer: Involvement of the zygomatic arch

      Explanation:

      Le Fort III fractures can be distinguished from Le Fort II fractures by the presence of damage to the zygomatic arch.

      Further Reading:

      The Le Fort fracture classification describes three fracture patterns seen in midface fractures, all involving the maxilla and pterygoid plate disruption. As the classification grading increases, the anatomic level of the maxillary fracture ascends from inferior to superior.

      Le Fort I fractures, also known as floating palate fractures, typically result from a downward blow struck above the upper dental row. Signs include swelling of the upper lip, bruising to the upper buccal sulcus, malocclusion, and mobile upper teeth.

      Le Fort II fractures, also known as floating maxilla fractures, are typically the result of a forceful blow to the midaxillary area. Signs include a step deformity at the infraorbital margin, oedema over the middle third of the face, sensory disturbance of the cheek, and bilateral circumorbital ecchymosis.

      Le Fort III fractures, also known as craniofacial dislocation or floating face fractures, are typically the result of high force blows to the nasal bridge or upper maxilla. These fractures involve the zygomatic arch and extend through various structures in the face. Signs include tenderness at the frontozygomatic suture, lengthening of the face, enophthalmos, and bilateral circumorbital ecchymosis.

      Management of Le Fort fractures involves securing the airway as a priority, following the ABCDE approach, and identifying and managing other injuries, especially cervical spine injuries. Severe bleeding may occur and should be addressed appropriately. Surgery is almost always required, and patients should be referred to maxillofacial surgeons. Other specialties, such as neurosurgery and ophthalmology, may need to be involved depending on the specific case.

    • This question is part of the following fields:

      • Maxillofacial & Dental
      13.4
      Seconds
  • Question 69 - A 65-year-old woman with a history of chronic alcohol abuse is diagnosed with...

    Correct

    • A 65-year-old woman with a history of chronic alcohol abuse is diagnosed with Korsakoff's psychosis. You have been requested to assess the patient and report your observations.
      Which of the following symptoms is typically observed in individuals with Korsakoff's psychosis?

      Your Answer: Disordered time appreciation

      Explanation:

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

      The condition is marked by the presence of acute capillary haemorrhages, astrocytosis (abnormal increase in astrocytes, a type of brain cell), and neuronal death in the upper brainstem and diencephalon. These abnormalities can be visualized using MRI scanning, while CT scanning is not very useful for diagnosis.

      If left untreated, most patients with Wernicke’s encephalopathy will go on to develop a Korsakoff psychosis. This condition is characterized by retrograde amnesia (difficulty remembering past events), an inability to memorize new information, disordered time appreciation, and confabulation (fabrication of false memories).

    • This question is part of the following fields:

      • Mental Health
      21.9
      Seconds
  • Question 70 - A 25-year-old man presents having ingested an overdose of an unknown substance. He...

    Correct

    • A 25-year-old man presents having ingested an overdose of an unknown substance. He is drowsy and slurring his speech. His vital signs are as follows: heart rate 116 beats per minute, blood pressure 91/57 mmHg, oxygen saturation 96% on room air. Glasgow Coma Scale score is 11 out of 15. The results of his arterial blood gas (ABG) on room air are as follows:
      pH: 7.24
      pO2: 9.4 kPa
      PCO2: 3.3 kPa
      HCO3-: 22 mmol/l
      Na+: 143 mmol/l
      Cl–: 99 mmol/l
      Lactate: 5 IU/l
      Which SINGLE statement regarding this patient is true?

      Your Answer: Her anion gap is elevated

      Explanation:

      Arterial blood gas (ABG) interpretation is essential for evaluating a patient’s respiratory gas exchange and acid-base balance. The normal values on an ABG may slightly vary between analyzers, but generally, they fall within the following ranges:

      pH: 7.35 – 7.45
      pO2: 10 – 14 kPa
      PCO2: 4.5 – 6 kPa
      HCO3-: 22 – 26 mmol/l
      Base excess: -2 – 2 mmol/l

      In this particular case, the patient’s history indicates an overdose. However, there is no immediate need for intubation as her Glasgow Coma Scale (GCS) score is 11/15, and she can speak, albeit with slurred speech, indicating that she can maintain her own airway.

      The relevant ABG findings are as follows:

      – Mild hypoxia
      – Decreased pH (acidaemia)
      – Low PCO2
      – Normal bicarbonate
      – Elevated lactate

      The anion gap is a measure of the concentration of unmeasured anions in the plasma. It is calculated by subtracting the primary measured cations from the primary measured anions in the serum. The reference range for anion gap varies depending on the methodology used, but it is typically between 8 to 16 mmol/L.

      In this case, the patient’s anion gap can be calculated using the formula:

      Anion gap = [Na+] – [Cl-] – [HCO3-]

      Using the given values:

      Anion gap = [143] – [99] – [22]
      Anion gap = 22

      Therefore, it is evident that she has a raised anion gap metabolic acidosis. It is likely a type A lactic acidosis resulting from tissue hypoxia and hypoperfusion. Some potential causes of type A and type B lactic acidosis include:

      Type A lactic acidosis:
      – Shock (including septic shock)
      – Left ventricular failure
      – Severe anemia
      – Asphyxia
      – Cardiac arrest
      – Carbon monoxide poisoning
      – Respiratory failure
      – Severe asthma and COPD
      – Regional hypoperfusion

      Type B lactic acidosis:
      – Renal failure
      – Liver failure
      – Sepsis (non-hypoxic sepsis)
      – Thiamine deficiency
      – Al

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      64.9
      Seconds
  • Question 71 - A 68-year-old man with a history of atrial fibrillation (AF) is found to...

    Correct

    • A 68-year-old man with a history of atrial fibrillation (AF) is found to have an INR of 9.1 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: Stop warfarin and give oral vitamin K

      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.

    • This question is part of the following fields:

      • Haematology
      162.2
      Seconds
  • Question 72 - A 45-year-old man comes in with a dry cough that has been going...

    Incorrect

    • A 45-year-old man comes in with a dry cough that has been going on for a week. He also complains of muscle aches, fatigue, and a sore throat. In the past day, he has developed diarrhea and a mild throbbing headache. During the examination, his temperature is measured at 37.8°C, and faint crackles are heard at the base of his lungs.

      What is the SINGLE most probable organism responsible for these symptoms?

      Your Answer: Streptococcus pneumoniae

      Correct Answer: Mycoplasma pneumoniae

      Explanation:

      This patient is displaying symptoms and signs that are consistent with an atypical pneumonia, most likely caused by an infection from Mycoplasma pneumoniae. The clinical features commonly associated with Mycoplasma pneumoniae infection include a flu-like illness that occurs before respiratory symptoms, fever, myalgia, headache, diarrhea, and cough (initially dry but often becoming productive). Focal chest signs typically develop later in the course of the illness. It is worth noting that Mycoplasma pneumoniae is frequently linked to the development of erythema multiforme and can also be a cause of Steven-Johnson syndrome. The rash associated with erythema multiforme is characterized by multiple red lesions on the limbs that develop into target lesions a few days after the rash first appears.

    • This question is part of the following fields:

      • Respiratory
      70.2
      Seconds
  • Question 73 - A 42 year old male comes to the emergency department with a sudden...

    Correct

    • A 42 year old male comes to the emergency department with a sudden onset of 'tearing' pain in the middle of his chest that extends to the center of his back. The patient is tall and has a slender physique. Additionally, you observe that the patient has elongated arms and fingers. During the chest examination, you notice a prominent protrusion of the sternum (pectus carinatum). What is the probable underlying cause of this patient's chest pain?

      Your Answer: Aortic dissection

      Explanation:

      Marfan’s syndrome is a condition that greatly increases the risk of aortic dissection. This patient exhibits several characteristics commonly seen in individuals with Marfan syndrome, such as tall stature, low BMI, and pectoral abnormalities like pectus carinatum and excavatum. Additionally, their long limbs and fingers are also indicative of Marfan’s syndrome. It is important to note that aortic dissection tends to occur at a much younger age in individuals with Marfan syndrome compared to those without connective tissue diseases. The median age for type A dissection in Marfan’s patients is 36.7 years, while for type B dissection it is 40 years. In contrast, individuals without Marfan’s syndrome typically experience dissection at the ages of 63 and 62 years for type A and type B dissections, respectively.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Cardiology
      6.4
      Seconds
  • Question 74 - A 35-year-old Caucasian woman comes in with itchy, hyperpigmented patches on her chest...

    Correct

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

      Your Answer: Pityriasis versicolor

      Explanation:

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

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

    • This question is part of the following fields:

      • Dermatology
      14.5
      Seconds
  • Question 75 - A 72-year-old woman with a history of type II diabetes and hypertension presents...

    Correct

    • A 72-year-old woman with a history of type II diabetes and hypertension presents with a history of central chest pain that lasted approximately 45 minutes. Her ECG showed T wave inversion in the lateral leads, but her pain settled, and ECG normalized following the administration of GTN spray and IV morphine. She was also given 325 mg of aspirin on arrival. A troponin test has been organized and admission arranged.
      Which of the following medications should you also consider administering to this patient?

      Your Answer: Fondaparinux

      Explanation:

      This patient is likely experiencing an acute coronary syndrome, possibly a non-ST-elevation myocardial infarction (NSTEMI) or unstable angina. The troponin test will help confirm the diagnosis. The patient’s ECG showed ST depression in the inferior leads, but this normalized after treatment with GTN and morphine, ruling out a ST-elevation myocardial infarction (STEMI).

      Immediate pain relief should be provided. GTN (sublingual or buccal) can be used, but intravenous opioids like morphine should be considered, especially if a heart attack is suspected.

      Aspirin should be given to all patients with unstable angina or NSTEMI as soon as possible and continued indefinitely, unless there are contraindications like bleeding risk or aspirin hypersensitivity. A loading dose of 300 mg should be administered right after presentation.

      Fondaparinux should be given to patients without a high bleeding risk, unless coronary angiography is planned within 24 hours of admission. Unfractionated heparin can be an alternative to fondaparinux for patients who will undergo coronary angiography within 24 hours. For patients with significant renal impairment, unfractionated heparin can also be considered, with dose adjustment based on clotting function monitoring.

      Routine administration of oxygen is no longer recommended, but oxygen saturation should be monitored using pulse oximetry as soon as possible, preferably before hospital admission. Supplemental oxygen should only be offered to individuals with oxygen saturation (SpO2) below 94% who are not at risk of hypercapnic respiratory failure, aiming for a SpO2 of 94-98%. For individuals with chronic obstructive pulmonary disease at risk of hypercapnic respiratory failure, a target SpO2 of 88-92% should be achieved 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 undergoing percutaneous coronary intervention.

      For more information, refer to the NICE guidelines on the assessment and diagnosis of chest pain of recent onset.

    • This question is part of the following fields:

      • Cardiology
      29.7
      Seconds
  • Question 76 - A patient in their late 40s has sustained an injury to their right...

    Incorrect

    • A patient in their late 40s has sustained an injury to their right upper limb and is now experiencing peripheral neuropathy as a result. During the examination, it is observed that their hand is clawed, with the metacarpophalangeal joints hyperextended and the distal and proximal interphalangeal joints of the little and ring fingers flexed. Additionally, there is a slight weakness in wrist flexion, which is accompanied by abduction. The patient also reports sensory loss over the anterior and posterior surfaces of the medial one and a half fingers, as well as the corresponding area of the palm.

      Which nerve has been affected in this case?

      Your Answer: Median nerve at the elbow

      Correct Answer: Ulnar nerve at the elbow

      Explanation:

      The ulnar nerve originates from the medial cord of the brachial plexus, specifically from the C8-T1 nerve roots. It may also carry fibers from C7 on occasion. This nerve has both motor and sensory functions.

      In terms of motor function, the ulnar nerve innervates the muscles of the hand, excluding the thenar muscles and the lateral two lumbricals (which are supplied by the median nerve). It also innervates two muscles in the anterior forearm: the flexor carpi ulnaris and the medial half of the flexor digitorum profundus.

      Regarding sensory function, the ulnar nerve provides innervation to the anterior and posterior surfaces of the medial one and a half fingers, as well as the associated palm and dorsal hand area. There are three sensory branches responsible for the cutaneous innervation of the ulnar nerve. Two of these branches arise in the forearm and travel into the hand: the palmar cutaneous branch, which innervates the skin of the medial half of the palm, and the dorsal cutaneous branch, which innervates the dorsal skin of the medial one and a half fingers and the associated dorsal hand. The third branch arises in the hand and is called the superficial branch, which innervates the palmar surface of the medial one and a half fingers.

      When the ulnar nerve is damaged at the elbow, the flexor carpi ulnaris and the medial half of the flexor digitorum profundus muscles in the anterior forearm will be spared. However, if the ulnar nerve is injured at the wrist, these muscles will be affected. Additionally, when the ulnar nerve is damaged at the elbow, flexion of the wrist can still occur due to the intact median nerve, but it will be accompanied by abduction as the flexor carpi ulnaris adducts the hand. On the other hand, wrist flexion will be unaffected when the ulnar nerve is damaged at the wrist.

      The sensory function also differs depending on the site of damage. When the ulnar nerve is damaged at the elbow, all three cutaneous branches will be affected, resulting in complete sensory loss in the areas innervated by the ulnar nerve. However, if the damage occurs at the wrist, the two branches that arise in the forearm may be spared.

      Damage to the ulnar nerve at either the elbow or wrist leads to a characteristic claw hand appearance, characterized by hyperextension of the metacarpophalangeal joints and flexion of the distal and proximal interphalangeal joint of the little and ring fingers.

    • This question is part of the following fields:

      • Neurology
      34.8
      Seconds
  • Question 77 - A 45 year old male presents to the emergency department complaining of worsening...

    Correct

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

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

      Your Answer: 24-hour urinary free cortisol

      Explanation:

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

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
      16.4
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  • Question 78 - A 45-year-old man presents to the Emergency Department anxious, confused, and agitated. He...

    Correct

    • A 45-year-old man presents to the Emergency Department anxious, confused, and agitated. He has also vomited several times. He has recently been prescribed a course of amoxicillin for a presumed sinus infection by his primary care physician. You are unable to obtain a coherent medical history from him, but he has his regular medications with him, which include: ibuprofen, atorvastatin, and metformin. He has a friend with him who states he stopped taking his medications a few days ago. His vital signs are: temperature 38.9°C, heart rate 138, respiratory rate 23, blood pressure 173/96, and oxygen saturation 97% on room air.

      What is the SINGLE most likely diagnosis?

      Your Answer: Thyroid storm

      Explanation:

      Thyroid storm is a rare condition that affects only 1-2% of patients with hyperthyroidism. However, it is crucial to diagnose it promptly because it has a high mortality rate of approximately 10%. Thyroid storm is often triggered by a physiological stressor, such as stopping antithyroid therapy prematurely, recent surgery or radio-iodine treatment, infections (especially chest infections), trauma, diabetic ketoacidosis or hyperosmolar diabetic crisis, thyroid hormone overdose, pre-eclampsia. It typically occurs in patients with Graves’ disease or toxic multinodular goitre and presents with sudden and severe hyperthyroidism. Symptoms include high fever (over 41°C), dehydration, rapid heart rate (greater than 140 beats per minute) with or without irregular heart rhythms, low blood pressure, congestive heart failure, nausea, jaundice, vomiting, diarrhea, abdominal pain, confusion, agitation, delirium, psychosis, seizures, or coma.

      To diagnose thyroid storm, various blood tests should be conducted, including a full blood count, urea and electrolytes, blood glucose, coagulation screen, CRP, and thyroid profile (T4/T3 and TSH). A bone profile/calcium test should also be done as 10% of patients develop hypocalcemia. Blood cultures should be taken as well. Other important investigations include a urine dipstick/MC&S, chest X-ray, and ECG.

      The management of thyroid storm involves several steps. Intravenous fluids, such as 1-2 liters of 0.9% saline, should be administered. Airway support and management should be provided as necessary. A nasogastric tube should be inserted if the patient is vomiting. Urgent referral for inpatient management is essential. Paracetamol (1 g PO/IV) can be given to reduce fever. Benzodiazepines, such as diazepam (5-20 mg PO/IV), can be used for sedation. Steroids, like hydrocortisone (100 mg IV), may be necessary if there is co-existing adrenal suppression. Antibiotics should be prescribed if there is an intercurrent infection. Beta-blockers, such as propranolol (80 mg PO), can help control heart rate. High-dose carbimazole (45-60 mg/day) is recommended.

    • This question is part of the following fields:

      • Endocrinology
      28.7
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  • Question 79 - You assess a 62-year-old woman who is currently receiving treatment with a DMARD...

    Correct

    • You assess a 62-year-old woman who is currently receiving treatment with a DMARD for severe psoriatic arthropathy. She has been experiencing increasing difficulty breathing during physical activity for the past few months. During the examination, you detect fine bibasal crepitations. You order a chest X-ray, which reveals signs of pulmonary fibrosis.
      What is the SINGLE medication she is most likely taking?

      Your Answer: Methotrexate

      Explanation:

      There is a significant link between methotrexate and the development of pulmonary fibrosis. While there have been instances of pulmonary fibrosis occurring as a result of infliximab, this particular side effect is more commonly associated with methotrexate use.

      Methotrexate can also cause other side effects such as nausea and vomiting, abdominal pain, gastrointestinal bleeding, dizziness, stomatitis, hepatotoxicity, neutropenia, and pneumonitis.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      12.3
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  • Question 80 - A 40-year-old man comes in with abdominal cramps and severe bloody diarrhoea due...

    Incorrect

    • A 40-year-old man comes in with abdominal cramps and severe bloody diarrhoea due to a gastrointestinal infection.
      What is the MOST LIKELY single causative organism?

      Your Answer: Enterotoxigenic Escherichia coli

      Correct Answer: Entamoeba histolytica

      Explanation:

      Infectious causes of bloody diarrhea include Campylobacter spp., Shigella spp., Salmonella spp., Clostridium difficile, Enterohaemorrhagic Escherichia coli, Yersinia spp., Schistosomiasis, and Amoebiasis (Entamoeba histolytica). Enterotoxigenic E.coli is a non-invasive strain that does not cause inflammation or bloody diarrhea. Instead, it typically presents with profuse watery diarrhea and is not usually associated with abdominal cramping. The other organisms mentioned in this question are associated with watery diarrhea, but not bloody diarrhea.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      23.8
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  • Question 81 - A 14-month-old boy presents with a history of occasional wheezing and cough, which...

    Correct

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

      What is the SINGLE most likely diagnosis?

      Your Answer: Viral induced wheeze

      Explanation:

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

    • This question is part of the following fields:

      • Respiratory
      136.9
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  • Question 82 - A 25-year-old woman comes to the emergency department with severe and continuous nausea...

    Correct

    • A 25-year-old woman comes to the emergency department with severe and continuous nausea and vomiting. She is currently 8 weeks pregnant. She is struggling to retain any food and has experienced slight weight loss over the past two weeks. Her vital signs are as follows: heart rate 103 beats per minute, respiratory rate 14 breaths per minute, blood pressure 113/70 mmHg. Her abdomen is soft and not tender, and a urine dipstick test shows 3+ ketones.
      What is the MOST likely diagnosis?

      Your Answer: Hyperemesis gravidarum

      Explanation:

      Vomiting is a common occurrence during the early stages of pregnancy, typically happening between 7 and 12 weeks. However, there is a more severe condition called hyperemesis gravidarum, which involves uncontrollable and intense nausea and vomiting. This condition can lead to imbalances in fluids and electrolytes, significant ketonuria, malnutrition, and weight loss. It is relatively rare, affecting less than 1% of pregnancies.

      For mild cases of nausea and vomiting in early pregnancy, dietary adjustments and non-pharmacological measures like consuming ginger or using P6 wrist acupressure can often provide relief.

      In severe cases where heavy ketonuria and severe dehydration are present, hospital admission is usually necessary for intravenous fluid rehydration. The NICE Clinical Knowledge Summary (CKS) on nausea and vomiting in pregnancy recommends using oral promethazine, oral cyclizine, or oral prochlorperazine as the first-line treatment if an antiemetic is needed. After 24 hours, the situation should be reassessed to determine if the initial treatment is effective. If not, a second-line drug like metoclopramide or ondansetron should be considered.

      It’s important to note that metoclopramide should not be used in patients under the age of 20 due to the increased risk of extrapyramidal side effects. Additionally, proton pump inhibitors (e.g., omeprazole) and histamine H2-receptor antagonists (e.g., ranitidine) can be beneficial for women experiencing significant dyspepsia alongside their nausea and vomiting.

      For more information, you can refer to the NICE CKS on nausea and vomiting in pregnancy.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      16
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  • Question 83 - A 55-year-old man presents with left-sided hemiplegia and loss of joint position sense,...

    Incorrect

    • A 55-year-old man presents with left-sided hemiplegia and loss of joint position sense, vibratory sense, and discriminatory touch. While examining his cranial nerves, you also note that his tongue is deviated to the right-hand side. CT and MRI head scans are undertaken, and he is discovered to have suffered a right-sided stroke. He is subsequently admitted under the stroke team.
      What is the SINGLE most likely diagnosis?

      Your Answer: Lateral medullary syndrome

      Correct Answer: Medial medullary syndrome

      Explanation:

      Occlusion of branches of the anterior spinal artery leads to the development of the medial medullary syndrome. This condition is characterized by several distinct symptoms. Firstly, there is contralateral hemiplegia, which occurs due to damage to the pyramidal tracts. Additionally, there is contralateral loss of joint position sense, vibratory sense, and discriminatory touch, resulting from damage to the medial lemniscus. Lastly, there is ipsilateral deviation and paralysis of the tongue, which is caused by damage to the hypoglossal nucleus.

    • This question is part of the following fields:

      • Neurology
      71
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  • Question 84 - A 38-year-old man from East Africa comes in with a fever, night sweats,...

    Correct

    • A 38-year-old man from East Africa comes in with a fever, night sweats, a cough, and haemoptysis. He has a confirmed diagnosis of HIV and a CD4 count of 115 cells/mm3.

      What is the SINGLE most probable causative organism in this scenario?

      Your Answer: Mycobacterium tuberculosis

      Explanation:

      The co-epidemic of tuberculosis and HIV is a significant global health challenge at present. According to the WHO, there were 10 million new cases of tuberculosis in 2019, with approximately 11% of these cases being co-infected with HIV. Tuberculosis is the most common contagious infection in individuals with compromised immune systems due to HIV, often leading to death.

      Tuberculosis is caused by an infection with the bacterium Mycobacterium tuberculosis. While it primarily affects the lungs, it can also impact various other parts of the body. The disease is spread through aerosol transmission, meaning it is transmitted through droplets in the air.

      The primary symptoms of tuberculosis infection include a chronic cough, coughing up blood (haemoptysis), fever, night sweats, and weight loss. In individuals who have not been previously affected, tuberculosis can cause a primary lesion known as the Ghon focus. This lesion typically develops in the upper lobes of the lungs.

      In 15-20% of cases, the infection spreads to extrapulmonary sites such as the pleura, central nervous system, lymphatics, bones, joints, and genitourinary system. Extrapulmonary tuberculosis that affects the spine is known as Pott’s disease, primarily affecting the lower thoracic and upper lumbar vertebrae. Cervical tuberculous lymphadenopathy, also known as scrofula, is characterized by cold abscesses without erythema or warmth.

      Only a small percentage of patients, around 5-10%, go on to develop post-primary tuberculosis, also known as reactivation tuberculosis. This typically occurs a year or two after the primary infection and is more likely to happen in individuals with a weakened immune system. Reactivation tuberculosis often involves the lung apex.

    • This question is part of the following fields:

      • Infectious Diseases
      9.8
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  • Question 85 - A 35 year old individual arrives at the clinic with sudden vertigo that...

    Correct

    • A 35 year old individual arrives at the clinic with sudden vertigo that started within the last day. You suspect the presence of vestibular neuronitis. What characteristics would you anticipate in a patient with vestibular neuronitis?

      Your Answer: Nystagmus with fast phase away from the affected ear

      Explanation:

      Vestibular neuronitis does not typically cause hearing loss, tinnitus, or focal neurological deficits. However, it is characterized by the presence of nystagmus, which is a rapid, involuntary eye movement. In vestibular neuronitis, nystagmus is usually fine horizontal or mixed horizontal-torsional. It consistently beats in the same direction, regardless of head rotation, and can be reduced when focusing on a fixed point.

      Further Reading:

      Vestibular neuritis, also known as vestibular neuronitis, is a condition characterized by sudden and prolonged vertigo of peripheral origin. It is believed to be caused by inflammation of the vestibular nerve, often following a viral infection. It is important to note that vestibular neuritis and labyrinthitis are not the same condition, as labyrinthitis involves inflammation of the labyrinth. Vestibular neuritis typically affects individuals between the ages of 30 and 60, with a 1:1 ratio of males to females. The annual incidence is approximately 3.5 per 100,000 people, making it one of the most commonly diagnosed causes of vertigo.

      Clinical features of vestibular neuritis include nystagmus, which is a rapid, involuntary eye movement, typically in a horizontal or horizontal-torsional direction away from the affected ear. The head impulse test may also be positive. Other symptoms include spontaneous onset of rotational vertigo, which is worsened by changes in head position, as well as nausea, vomiting, and unsteadiness. These severe symptoms usually last for 2-3 days, followed by a gradual recovery over a few weeks. It is important to note that hearing is not affected in vestibular neuritis, and symptoms such as tinnitus and focal neurological deficits are not present.

      Differential diagnosis for vestibular neuritis includes benign paroxysmal positional vertigo (BPPV), labyrinthitis, Meniere’s disease, migraine, stroke, and cerebellar lesions. Management of vestibular neuritis involves drug treatment for nausea and vomiting associated with vertigo, typically through short courses of medication such as prochlorperazine or cyclizine. If symptoms are severe and fluids cannot be tolerated, admission and administration of IV fluids may be necessary. General advice should also be given, including avoiding driving while symptomatic, considering the suitability to work based on occupation and duties, and the increased risk of falls. Follow-up is required, and referral is necessary if there are atypical symptoms, symptoms do not improve after a week of treatment, or symptoms persist for more than 6 weeks.

      The prognosis for vestibular neuritis is generally good, with the majority of individuals fully recovering within 6 weeks. Recurrence is thought to occur in 2-11% of cases, and approximately 10% of individuals may develop BPPV following an episode of vestibular neuritis. A very rare complication of vestibular neuritis is ph

    • This question is part of the following fields:

      • Ear, Nose & Throat
      19.1
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  • Question 86 - A 65 year old is brought into the emergency department by two members...

    Correct

    • A 65 year old is brought into the emergency department by two members of the public after collapsing in a nearby park. The patient appears confused, looking around the room but not responding to questions or commands. Verbal output is limited to grunting and coughing. Observations are taken and are shown below:

      Blood pressure 148/76 mmHg
      Pulse 90 bpm
      Respirations 18 bpm
      Temperature 36.8ºC
      Oxygen Saturations 98% on air
      Capillary glucose 1.2 mmol/l

      What is the most appropriate next step in this patient's management?

      Your Answer: Give glucagon 1 mg via intramuscular injection

      Explanation:

      The use of glucose infusion is not recommended due to its hypertonic nature, which can potentially increase the risk of extravasation injury.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
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  • Question 87 - A 48 year old woman comes to the emergency department complaining of episodes...

    Correct

    • A 48 year old woman comes to the emergency department complaining of episodes of lightheadedness. She mentions that she is an avid jogger and noticed on her fitness tracker that her heart rate had dropped to 48 beats per minute. Which of the following characteristics would warrant drug intervention or transcutaneous pacing in a patient with bradycardia?

      Your Answer: Myocardial ischaemia

      Explanation:

      Indications for drug treatment or pacing in patients with bradycardia include shock, syncope, myocardial ischemia, heart failure, and the presence of risk factors for asystole. If any of these adverse features are present, it is important to consider drug treatment or pacing. However, even if none of these adverse features are present, patients may still require drug treatment or pacing if they have risk factors for developing asystole, such as recent asystole, Mobitz II AV block, complete heart block with broad QRS, or a ventricular pause longer than 3 seconds.

      Further Reading:

      Causes of Bradycardia:
      – Physiological: Athletes, sleeping
      – Cardiac conduction dysfunction: Atrioventricular block, sinus node disease
      – Vasovagal & autonomic mediated: Vasovagal episodes, carotid sinus hypersensitivity
      – Hypothermia
      – Metabolic & electrolyte disturbances: Hypothyroidism, hyperkalaemia, hypermagnesemia
      – Drugs: Beta-blockers, calcium channel blockers, digoxin, amiodarone
      – Head injury: Cushing’s response
      – Infections: Endocarditis
      – Other: Sarcoidosis, amyloidosis

      Presenting symptoms of Bradycardia:
      – Presyncope (dizziness, lightheadedness)
      – Syncope
      – Breathlessness
      – Weakness
      – Chest pain
      – Nausea

      Management of Bradycardia:
      – Assess and monitor for adverse features (shock, syncope, myocardial ischaemia, heart failure)
      – Treat reversible causes of bradycardia
      – Pharmacological treatment: Atropine is first-line, adrenaline and isoprenaline are second-line
      – Transcutaneous pacing if atropine is ineffective
      – Other drugs that may be used: Aminophylline, dopamine, glucagon, glycopyrrolate

      Bradycardia Algorithm:
      – Follow the algorithm for management of bradycardia, which includes assessing and monitoring for adverse features, treating reversible causes, and using appropriate medications or pacing as needed.
      https://acls-algorithms.com/wp-content/uploads/2020/12/Website-Bradycardia-Algorithm-Diagram.pdf

    • This question is part of the following fields:

      • Cardiology
      24.2
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  • Question 88 - A 30-year-old woman comes in with a persistent cough and wheezing.
    Which ONE...

    Correct

    • A 30-year-old woman comes in with a persistent cough and wheezing.
      Which ONE clinical characteristic would indicate a possible diagnosis of severe acute asthma?

      Your Answer: Heart rate of 115 bpm

      Explanation:

      Asthma can be categorized into three levels of severity: moderate exacerbation, acute severe asthma, and life-threatening asthma.

      Moderate exacerbation is characterized by an increase in symptoms and a peak expiratory flow rate (PEFR) that is between 50-75% of the best or predicted value. There are no signs of acute severe asthma present.

      Acute severe asthma is indicated by a PEFR that is between 33-50% of the best or predicted value. Additionally, the respiratory rate is higher than 25 breaths per minute and the heart rate is higher than 110 beats per minute. People experiencing acute severe asthma may have difficulty completing sentences in one breath.

      Life-threatening asthma is the most severe level and requires immediate medical attention. It is identified by a PEFR that is less than 33% of the best or predicted value. Oxygen saturations are below 92% when breathing regular air. The PaCO2 levels are within the normal range of 4.6-6.0 KPa, but the PaO2 levels are below 8 KPa. Other symptoms include a silent chest, cyanosis, feeble respiratory effort, bradycardia, arrhythmia, hypotension, and signs of exhaustion, confusion, or coma.

      It is important to recognize the severity of asthma symptoms in order to provide appropriate medical care and intervention.

    • This question is part of the following fields:

      • Respiratory
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  • Question 89 - A 70-year-old woman presents with right-sided hemiplegia and right-sided loss of joint position...

    Correct

    • A 70-year-old woman presents with right-sided hemiplegia and right-sided loss of joint position sense, vibratory sense and discriminatory touch. She also complains of blurred vision, and on further examination, you notice that she is unable to move her left eye outward and is tilting her head to the left side. A CT head scan is performed, and she is found to have experienced a left-sided stroke. She is subsequently admitted under the care of the stroke team.
      What is the SINGLE most probable diagnosis?

      Your Answer: Medial pontine syndrome

      Explanation:

      When the paramedian branches of the basilar artery are blocked, it leads to a condition known as medial pontine syndrome. This syndrome is characterized by several symptoms. Firstly, there is contralateral hemiplegia, which refers to paralysis on the opposite side of the body due to damage to the pyramidal tracts. Additionally, there is contralateral loss of joint position sense, vibratory sense, and discriminatory touch, which occurs as a result of damage to the medial lemniscus. Lastly, individuals with medial pontine syndrome may experience double vision caused by paralysis of the lateral rectus muscle, which is due to damage to the sixth cranial nerve.

    • This question is part of the following fields:

      • Neurology
      41.5
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  • Question 90 - A 70-year-old patient comes in after a chronic overdose of digoxin. She has...

    Incorrect

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

      What is the indication for administering DigiFab in this patient?

      Your Answer: Recurrent seizures

      Correct Answer: Coexistent renal failure

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      23.7
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  • Question 91 - A 28-year-old woman comes in seeking contraceptive advice. She forgot to take her...

    Incorrect

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

      Your Answer: She should take the most recent missed pill, emergency contraception should be considered, and she should omit the pill-free interval after the third week

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

      Explanation:

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

    • This question is part of the following fields:

      • Sexual Health
      31.7
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  • Question 92 - A 70 year old male who underwent aortic valve replacement 2 months ago...

    Correct

    • A 70 year old male who underwent aortic valve replacement 2 months ago presents to the emergency department with a 4 day history of fever, fatigue, and overall malaise. The initial observations are as follows:

      Temperature: 38.7ºC
      Pulse rate: 126 bpm
      Blood pressure: 132/76 mmHg
      Respiration rate: 24 bpm
      Oxygen saturation: 96% on room air

      During the examination, splinter hemorrhages are observed on the patient's fingernails, leading to a suspicion of infective endocarditis. What is the most likely causative organism in this particular case?

      Your Answer: Staphylococcus

      Explanation:

      In this case, a 70-year-old male who recently underwent aortic valve replacement is presenting with symptoms of fever, fatigue, and overall malaise. Upon examination, splinter hemorrhages are observed on the patient’s fingernails, which raises suspicion of infective endocarditis. Given the patient’s history and symptoms, the most likely causative organism in this particular case is Staphylococcus.

      Further Reading:

      Infective endocarditis (IE) is an infection that affects the innermost layer of the heart, known as the endocardium. It is most commonly caused by bacteria, although it can also be caused by fungi or viruses. IE can be classified as acute, subacute, or chronic depending on the duration of illness. Risk factors for IE include IV drug use, valvular heart disease, prosthetic valves, structural congenital heart disease, previous episodes of IE, hypertrophic cardiomyopathy, immune suppression, chronic inflammatory conditions, and poor dental hygiene.

      The epidemiology of IE has changed in recent years, with Staphylococcus aureus now being the most common causative organism in most industrialized countries. Other common organisms include coagulase-negative staphylococci, streptococci, and enterococci. The distribution of causative organisms varies depending on whether the patient has a native valve, prosthetic valve, or is an IV drug user.

      Clinical features of IE include fever, heart murmurs (most commonly aortic regurgitation), non-specific constitutional symptoms, petechiae, splinter hemorrhages, Osler’s nodes, Janeway’s lesions, Roth’s spots, arthritis, splenomegaly, meningism/meningitis, stroke symptoms, and pleuritic pain.

      The diagnosis of IE is based on the modified Duke criteria, which require the presence of certain major and minor criteria. Major criteria include positive blood cultures with typical microorganisms and positive echocardiogram findings. Minor criteria include fever, vascular phenomena, immunological phenomena, and microbiological phenomena. Blood culture and echocardiography are key tests for diagnosing IE.

      In summary, infective endocarditis is an infection of the innermost layer of the heart that is most commonly caused by bacteria. It can be classified as acute, subacute, or chronic and can be caused by a variety of risk factors. Staphylococcus aureus is now the most common causative organism in most industrialized countries. Clinical features include fever, heart murmurs, and various other symptoms. The diagnosis is based on the modified Duke criteria, which require the presence of certain major and minor criteria. Blood culture and echocardiography are important tests for diagnosing IE.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 93 - A 40-year-old carpenter comes in with a few weeks of persistent lower back...

    Incorrect

    • A 40-year-old carpenter comes in with a few weeks of persistent lower back pain. Despite taking the maximum dose of ibuprofen, the pain continues to be significant. What would be the most suitable course of treatment? Choose only ONE option.

      Your Answer: Diclofenac sodium

      Correct Answer: Low-dose codeine phosphate

      Explanation:

      The current guidelines from NICE provide recommendations for managing low back pain. It is suggested to consider using oral non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, while taking into account the potential risks of gastrointestinal, liver, and cardio-renal toxicity, as well as the person’s individual risk factors and age. When prescribing oral NSAIDs, it is important to conduct appropriate clinical assessments, monitor risk factors regularly, and consider the use of gastroprotective treatment. It is advised to prescribe the lowest effective dose of oral NSAIDs for the shortest duration possible. In cases where NSAIDs are contraindicated, not tolerated, or ineffective, weak opioids (with or without paracetamol) may be considered for managing acute low back pain. However, NICE does not recommend the use of paracetamol alone, opioids for chronic low back pain, serotonin reuptake inhibitors, serotonin-noradrenaline reuptake inhibitors, tricyclic antidepressants for non-neuropathic pain, anticonvulsants, or benzodiazepines for muscle spasm associated with acute low back pain. For more information, you can refer to the NICE guidance on low back pain and sciatica in individuals over 16 years old, as well as the NICE Clinical Knowledge Summary on low back pain without radiculopathy.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
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  • Question 94 - A 10-year-old boy is experiencing an anaphylactic reaction after consuming a peanut. What is...

    Correct

    • A 10-year-old boy is experiencing an anaphylactic reaction after consuming a peanut. What is the appropriate dosage of IM adrenaline to administer in this case?

      Your Answer: 0.3 mL of 1:1000

      Explanation:

      The management of anaphylaxis involves several important steps. First and foremost, it is crucial to ensure proper airway management. Additionally, early administration of adrenaline is essential, preferably in the anterolateral aspect of the middle third of the thigh. Aggressive fluid resuscitation is also necessary. In severe cases, intubation may be required. However, it is important to note that the administration of chlorpheniramine and hydrocortisone should only be considered after early resuscitation has taken place.

      Adrenaline is the most vital medication for treating anaphylactic reactions. It acts as an alpha-adrenergic receptor agonist, which helps reverse peripheral vasodilatation and reduce oedema. Furthermore, its beta-adrenergic effects aid in dilating the bronchial airways, increasing the force of myocardial contraction, and suppressing histamine and leukotriene release. Administering adrenaline as the first drug is crucial, and the intramuscular (IM) route is generally the most effective for most individuals.

      The recommended doses of IM adrenaline for different age groups during anaphylaxis are as follows:

      – Children under 6 years: 150 mcg (0.15 mL of 1:1000)
      – Children aged 6-12 years: 300 mcg (0.3 mL of 1:1000)
      – Children older than 12 years: 500 mcg (0.5 mL of 1:1000)
      – Adults: 500 mcg (0.5 mL of 1:1000)

    • This question is part of the following fields:

      • Allergy
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  • Question 95 - You are managing a 32-year-old male patient who leaped off a bridge. There...

    Correct

    • 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.

    • This question is part of the following fields:

      • Trauma
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  • Question 96 - A 42-year-old is brought into the emergency department after becoming drowsy following a...

    Correct

    • A 42-year-old is brought into the emergency department after becoming drowsy following a 5 day illness. Upon checking the patient's records you note a history of Addison's disease. Which of the following features would you expect in a patient with Addison's disease?

      Your Answer: Hypotension

      Explanation:

      Addison’s disease is characterized by hypotension, which is caused by a deficiency of glucocorticoids (mainly cortisol) and mineralocorticoids (mainly aldosterone). This deficiency leads to low blood pressure. If left untreated, it can progress to hypovolemic shock (also known as Addisonian or adrenal crisis) and can be fatal. Metabolic disturbances associated with Addison’s disease include hyponatremia, hypoglycemia, hyperkalemia, hypercalcemia, and low serum cortisol levels.

      Further Reading:

      Addison’s disease, also known as primary adrenal insufficiency or hypoadrenalism, is a rare disorder caused by the destruction of the adrenal cortex. This leads to reduced production of glucocorticoids, mineralocorticoids, and adrenal androgens. The deficiency of cortisol results in increased production of adrenocorticotropic hormone (ACTH) due to reduced negative feedback to the pituitary gland. This condition can cause metabolic disturbances such as hyperkalemia, hyponatremia, hypercalcemia, and hypoglycemia.

      The symptoms of Addison’s disease can vary but commonly include fatigue, weight loss, muscle weakness, and low blood pressure. It is more common in women and typically affects individuals between the ages of 30-50. The most common cause of primary hypoadrenalism in developed countries is autoimmune destruction of the adrenal glands. Other causes include tuberculosis, adrenal metastases, meningococcal septicaemia, HIV, and genetic disorders.

      The diagnosis of Addison’s disease is often suspected based on low cortisol levels and electrolyte abnormalities. The adrenocorticotropic hormone stimulation test is commonly used for confirmation. Other investigations may include adrenal autoantibodies, imaging scans, and genetic screening.

      Addisonian crisis is a potentially life-threatening condition that occurs when there is an acute deficiency of cortisol and aldosterone. It can be the first presentation of undiagnosed Addison’s disease. Precipitating factors of an Addisonian crisis include infection, dehydration, surgery, trauma, physiological stress, pregnancy, hypoglycemia, and acute withdrawal of long-term steroids. Symptoms of an Addisonian crisis include malaise, fatigue, nausea or vomiting, abdominal pain, fever, muscle pains, dehydration, confusion, and loss of consciousness.

      There is no fixed consensus on diagnostic criteria for an Addisonian crisis, as symptoms are non-specific. Investigations may include blood tests, blood gas analysis, and septic screens if infection is suspected. Management involves administering hydrocortisone and fluids. Hydrocortisone is given parenterally, and the dosage varies depending on the age of the patient. Fluid resuscitation with saline is necessary to correct any electrolyte disturbances and maintain blood pressure. The underlying cause of the crisis should also be identified and treated. Close monitoring of sodium levels is important to prevent complications such as osmotic demyelination syndrome.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 97 - A 2-year-old toddler is brought to the Emergency Department by his father with...

    Correct

    • A 2-year-old toddler is brought to the Emergency Department by his father with a high temperature. NICE suggests using the traffic light system to evaluate the likelihood of a severe illness in children under 3 with a fever.
      Based on the NICE traffic light system, which of the subsequent symptoms or signs indicate a low risk of a serious illness?

      Your Answer: Not crying

      Explanation:

      The traffic light system is a useful tool for evaluating the potential risk of serious illness in children. This system categorizes clinical features into three groups based on severity: red (high-risk), amber (intermediate-risk), and green (low-risk).

      Children displaying any of the following symptoms or signs fall into the high-risk group for serious illness: pale/mottled/ashen/blue skin, lips or tongue; lack of response to social cues; appearing unwell to a healthcare professional; inability to wake or stay awake when roused; weak, high-pitched, or continuous cry; grunting; respiratory rate exceeding 60 breaths per minute; moderate or severe chest indrawing; reduced skin turgor; and bulging fontanelle.

      Children exhibiting any of the following symptoms or signs are considered at least intermediate-risk for serious illness: pallor of skin, lips or tongue reported by parent or caregiver; abnormal response to social cues; absence of a smile; waking only with prolonged stimulation; decreased activity; nasal flaring; dry mucous membranes; poor feeding in infants; reduced urine output; and rigors.

      Children displaying any of the following symptoms or signs are classified as low-risk for serious illness: normal color of skin, lips, and tongue; normal response to social cues; contentment and smiles; staying awake or quickly awakening; strong normal cry or absence of crying; normal skin and eyes; and moist mucous membranes.

      To summarize, children with fever and any symptoms or signs in the red column are considered high-risk, while those with fever and any symptoms or signs in the amber column (but none in the red column) are considered intermediate-risk. Children with symptoms and signs in the green column (and none in the amber or red columns) are classified as low-risk.

      For more information, you can refer to the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.

    • This question is part of the following fields:

      • Infectious Diseases
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  • Question 98 - A 52-year-old woman presents with high fevers and severe pain in the upper...

    Correct

    • A 52-year-old woman presents with high fevers and severe pain in the upper right quadrant that radiates to her back. She is experiencing mild confusion. During examination, she exhibits tenderness in the upper right quadrant, and Murphy's sign is negative. Her vital signs are as follows: temperature is 38°C, heart rate is 114 bpm, and blood pressure is 88/54 mmHg.

      Her blood test results are as follows:
      - CRP: 134 mg/l (normal range: < 5 mg/l)
      - Hb: 11.6 g/dl (normal range: 11.5-16 g/dl)
      - WCC: 18.4 x 109/l (normal range: 4-11 x 109/l)
      - Neut: 14.0 x 109/l (normal range: 2.5-7.5 x 109/l)
      - Bilirubin: 108 mmol (normal range: 3-20)
      - ALT: 94 IU/L (normal range: 5-40)
      - ALP: 303 IU/L (normal range: 20-140)

      What is the SINGLE most likely diagnosis?

      Your Answer: Ascending cholangitis

      Explanation:

      Ascending cholangitis occurs when there is an infection in the common bile duct, often caused by a stone that has led to a buildup of bile. This condition is characterized by three main symptoms known as Charcot’s triad: jaundice, fever with rigors, and pain in the upper right quadrant of the abdomen. It is a serious medical emergency that can be life-threatening, with some patients also experiencing altered mental status and low blood pressure due to septic shock, known as Reynold’s pentad. Urgent biliary drainage is the recommended treatment for ascending cholangitis.

      In acute cholecystitis, Murphy’s sign is typically positive, indicating inflammation of the gallbladder, while it is negative in biliary colic and ascending cholangitis. The white cell count and C-reactive protein (CRP) levels are usually elevated in ascending cholangitis, and jaundice is often present, along with significantly increased levels of alkaline phosphatase (ALP) and bilirubin.

      Hepatocellular carcinoma, on the other hand, presents gradually with symptoms such as fatigue, loss of appetite, jaundice, and an enlarged liver. It often involves features of portal hypertension.

      Cholangiocarcinoma is a rare type of cancer that originates from the biliary epithelium. It typically manifests as painless jaundice and itching.

      To differentiate between biliary colic, acute cholecystitis, and ascending cholangitis, the following summarizes their key characteristics:

      Biliary colic:
      – Pain duration: Less than 12 hours
      – Fever: Absent
      – Murphy’s sign: Negative
      – WCC & CRP: Normal
      – AST, ALT & ALP: Normal
      – Bilirubin: Normal

      Acute cholecystitis:
      – Pain duration: More than 12 hours
      – Fever: Present
      – Murphy’s sign: Positive
      – WCC & CRP: Elevated
      – AST, ALT & ALP: Normal or mildly elevated
      – Bilirubin: Normal or mildly elevated

      Ascending cholangitis:
      – Pain duration: Variable
      – Fever: Present
      – Murphy’s sign: Negative
      – WCC & CRP: Elevated
      – AST, ALT & ALP: Elevated
      – Bilirubin: Elevated

    • This question is part of the following fields:

      • Surgical Emergencies
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  • Question 99 - A 3-year-old boy is brought in by his father with a red and...

    Incorrect

    • A 3-year-old boy is brought in by his father with a red and itchy right eye. On examination, there is mild redness of the conjunctiva, and small bumps are visible on the inside of the eyelid. The eyelid is swollen, and there are a few small red spots on the white part of the eye. The eye is watery, and there is no pus. He recently had a mild cold. You diagnose him with viral conjunctivitis.
      According to the current NICE guidance, which of the following should NOT be included in the management of this patient?

      Your Answer: They should be encouraged to wash their hands frequently

      Correct Answer: The child should be excluded from school until the infection has resolved

      Explanation:

      When it comes to managing viral conjunctivitis, it’s important to reassure the patient that most cases are self-limiting and don’t require antimicrobial treatment. In fact, viral conjunctivitis usually resolves on its own within one to two weeks. However, there are some self-care measures that can help ease symptoms. These include cleaning the eyelids with cotton wool soaked in sterile saline or boiled and cooled water, applying cool compresses around the eye area, and using lubricating drops or artificial tears. It’s also important to avoid prescribing antibiotics if possible.

      It’s crucial to inform the person that infective conjunctivitis is contagious and they should take steps to prevent spreading the infection to their other eye and other people. This includes washing hands frequently with soap and water, using separate towels and flannels, and avoiding close contact with others, especially if they are a healthcare professional or child-care provider. It’s worth noting that the infection can be contagious for up to 14 days from onset.

      According to Public Health England, there is no recommended exclusion period from school, nursery, or childminders unless there is an outbreak or cluster of cases. It’s important to provide written information to the patient, explain the red flags for an urgent review, and advise them to seek further help if symptoms persist beyond 7 days. If the person returns with symptoms of conjunctivitis, it may be necessary to consider sending swabs for viral PCR and bacterial culture, as well as prescribing empirical topical antibiotics if they haven’t already been prescribed. If symptoms persist for more than 7-10 days after initiating treatment, it may be necessary to discuss with or refer to ophthalmology.

    • This question is part of the following fields:

      • Ophthalmology
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  • Question 100 - You assess a patient with diabetes who has a past medical history of...

    Correct

    • You assess a patient with diabetes who has a past medical history of inadequate blood sugar control and diabetic neuropathy. What is the most prevalent form of diabetic neuropathy?

      Your Answer: Peripheral neuropathy

      Explanation:

      The most prevalent form of neuropathy in individuals with diabetes is peripheral neuropathy. Following closely behind is diabetic amyotrophy.

    • This question is part of the following fields:

      • Endocrinology
      13.4
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SESSION STATS - PERFORMANCE PER SPECIALTY

Dermatology (2/3) 67%
Resus (1/1) 100%
Sexual Health (4/6) 67%
Basic Anaesthetics (2/2) 100%
Urology (5/5) 100%
Pharmacology & Poisoning (8/10) 80%
Haematology (3/3) 100%
Trauma (8/8) 100%
Endocrinology (9/9) 100%
Safeguarding & Psychosocial Emergencies (1/1) 100%
Maxillofacial & Dental (2/2) 100%
Cardiology (6/7) 86%
Ear, Nose & Throat (4/4) 100%
Respiratory (5/7) 71%
Nephrology (3/3) 100%
Paediatric Emergencies (1/1) 100%
Neurology (3/8) 38%
Gastroenterology & Hepatology (1/2) 50%
Oncological Emergencies (1/1) 100%
Elderly Care / Frailty (2/2) 100%
Infectious Diseases (3/4)