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  • Question 1 - A 32-year-old man presents with a range of neurological symptoms. He has been...

    Correct

    • A 32-year-old man presents with a range of neurological symptoms. He has been experiencing painless double vision over the past day and is becoming worried. Approximately six months ago, he also recalled a two-week period where he had no feeling in his right arm. When directly asked, he also confesses to feeling tired and quite depressed.

      What is the SINGLE most probable diagnosis?

      Your Answer: Multiple sclerosis

      Explanation:

      Multiple sclerosis is a condition characterized by the demyelination of nerve cells in the brain and spinal cord. It is an autoimmune disease mediated by cells and is caused by recurring inflammation. Typically, it presents in early adulthood, with a female to male ratio of 3:2.

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

      There are three main patterns of multiple sclerosis. The most common is relapsing and remitting MS, which is characterized by periods of no symptoms followed by relapses (this is seen in 80% of patients at the time of diagnosis). Another pattern is primary progressive MS, where symptoms develop and worsen from the beginning with few remissions (seen in 10-15% of patients at diagnosis). Lastly, there is secondary progressive MS, which occurs after relapsing/remitting MS. In this pattern, symptoms worsen with fewer remissions, and approximately 50% of those with relapsing/remitting MS will develop this within 10 years of diagnosis.

      The key to diagnosing MS lies in the history of neurological symptoms that are discrete in time and location of the affected body. Patients often experience fatigue and low mood, particularly during a relapse.

    • This question is part of the following fields:

      • Neurology
      14.6
      Seconds
  • Question 2 - A 35 year old female presents to the emergency department complaining of sudden...

    Correct

    • A 35 year old female presents to the emergency department complaining of sudden abdominal pain. She mentions that she has been consuming alcohol excessively for the past 48 hours and suspects it may be the cause of her discomfort. After a thorough evaluation and necessary tests, the patient is deemed stable enough to be discharged. You counsel her on the importance of consuming alcohol within safe limits.

      According to the department of health, what is the recommended maximum number of units per week for women in order to minimize health risks?

      Your Answer: 14

      Explanation:

      The UK chief medical officer and Department of Health recommend that both men and women should limit their alcohol consumption to no more than 14 units per week in order to minimize health risks. It is advised that individuals who consume up to 14 units per week should spread this amount over at least 3 days. Pregnant women are advised to completely avoid alcohol for the safest approach. Hazardous drinking refers to a pattern of alcohol consumption that increases the risk of harm. This includes consuming more than 14 units per week, but less than 35 units per week for women.

      Further Reading:

      Alcoholic liver disease (ALD) is a spectrum of disease that ranges from fatty liver at one end to alcoholic cirrhosis at the other. Fatty liver is generally benign and reversible with alcohol abstinence, while alcoholic cirrhosis is a more advanced and irreversible form of the disease. Alcoholic hepatitis, which involves inflammation of the liver, can lead to the development of fibrotic tissue and cirrhosis.

      Several factors can increase the risk of progression of ALD, including female sex, genetics, advanced age, induction of liver enzymes by drugs, and co-existent viral hepatitis, especially hepatitis C.

      The development of ALD is multifactorial and involves the metabolism of alcohol in the liver. Alcohol is metabolized to acetaldehyde and then acetate, which can result in the production of damaging reactive oxygen species. Genetic polymorphisms and co-existing hepatitis C infection can enhance the pathological effects of alcohol metabolism.

      Patients with ALD may be asymptomatic or present with non-specific symptoms such as abdominal discomfort, vomiting, or anxiety. Those with alcoholic hepatitis may have fever, anorexia, and deranged liver function tests. Advanced liver disease can manifest with signs of portal hypertension and cirrhosis, such as ascites, varices, jaundice, and encephalopathy.

      Screening tools such as the AUDIT questionnaire can be used to assess alcohol consumption and identify hazardous or harmful drinking patterns. Liver function tests, FBC, and imaging studies such as ultrasound or liver biopsy may be performed to evaluate liver damage.

      Management of ALD involves providing advice on reducing alcohol intake, administering thiamine to prevent Wernicke’s encephalopathy, and addressing withdrawal symptoms with benzodiazepines. Complications of ALD, such as intoxication, encephalopathy, variceal bleeding, ascites, hypoglycemia, and coagulopathy, require specialized interventions.

      Heavy alcohol use can also lead to thiamine deficiency and the development of Wernicke Korsakoff’s syndrome, characterized by confusion, ataxia, hypothermia, hypotension, nystagmus, and vomiting. Prompt treatment is necessary to prevent progression to Korsakoff’s psychosis.

      In summary, alcoholic liver disease is a spectrum of disease that can range from benign fatty liver to irreversible cirrhosis. Risk factors for progression include female sex, genetics, advanced age, drug-induced liver enzyme induction, and co-existing liver conditions.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      5.7
      Seconds
  • Question 3 - You evaluate a 50-year-old woman with recent-onset carpal tunnel syndrome after injuring her...

    Correct

    • You evaluate a 50-year-old woman with recent-onset carpal tunnel syndrome after injuring her wrist.
      Which of the following hand muscles is the LEAST likely to be impacted in this patient?

      Your Answer: Abductor digiti minimi

      Explanation:

      Carpal tunnel syndrome is a condition where the median nerve becomes trapped, resulting in nerve damage. This can lead to weakness and abnormal sensations in the areas supplied by the median nerve. To remember the muscles that are innervated by the median nerve, you can use the acronym ‘LOAF’: L for the lateral two lumbricals, O for the Opponens pollicis, A for the Abductor pollicis, and F for the Flexor pollicis brevis. It’s important to note that the abductor digiti minimi is not affected by carpal tunnel syndrome as it is innervated by the deep branch of the ulnar nerve.

    • This question is part of the following fields:

      • Neurology
      18.7
      Seconds
  • Question 4 - A 35-year-old woman of Asian descent comes to the Emergency Department with swelling...

    Correct

    • A 35-year-old woman of Asian descent comes to the Emergency Department with swelling of the face, lips, and tongue. Despite receiving IM adrenaline, her symptoms do not improve. She mentions that her doctor recently prescribed her a new medication.

      Which of the following drugs is most likely causing her symptoms?

      Your Answer: Ramipril

      Explanation:

      Angiotensin-converting enzyme (ACE) inhibitors are the primary cause of drug-induced angioedema in the UK and USA, mainly due to their widespread use. The incidence of angioedema caused by ACE inhibitors ranges from 0.1 to 0.7% among recipients, with evidence suggesting a consistent and persistent risk each year. Interestingly, individuals of African descent are approximately five times more likely to experience this adverse reaction.

      The most common symptoms observed in patients with ACE inhibitor-induced angioedema include swelling of the lips, tongue, or face. However, another manifestation of this condition is episodic abdominal pain caused by intestinal angioedema. Notably, urticaria (hives) and itching are absent in these cases.

      The underlying mechanism of ACE inhibitor-induced angioedema appears to involve the activation of the complement system or other pro-inflammatory cytokines, such as prostaglandins and histamine. These substances trigger rapid dilation of blood vessels and the accumulation of fluid, leading to edema.

      Although less frequently associated with angioedema, other medications that may cause this condition include angiotensin-receptor blockers (ARBs), nonsteroidal anti-inflammatory drugs (NSAIDs), bupropion (e.g., Zyban and Wellbutrin), beta-lactam antibiotics, statins, and proton pump inhibitors.

      Fortunately, most cases of drug-induced angioedema are mild and can be effectively managed by discontinuing the medication and prescribing oral antihistamines.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      41.2
      Seconds
  • Question 5 - A 28-year-old man is being investigated for a potential acute hepatitis B infection....

    Correct

    • A 28-year-old man is being investigated for a potential acute hepatitis B infection. What is the earliest sign of acute infection in acute hepatitis B?

      Your Answer: Hepatitis B surface Ag

      Explanation:

      Hepatitis B surface antigen (HBsAg) is a protein found on the surface of the hepatitis B virus. It is the first marker to appear in the blood after exposure to the virus, usually within 1 to 2 weeks. Symptoms of hepatitis B typically develop around 4 weeks after exposure. HBsAg can be detected in high levels in the blood during both acute and chronic hepatitis B infections. Its presence indicates that the person is infectious and can transmit the virus to others. The body naturally produces antibodies to HBsAg as part of the immune response to the infection. In fact, HBsAg is used to create the hepatitis B vaccine.

      Hepatitis B surface antibody (anti-HBs) indicates that a person has recovered from a hepatitis B infection and is now immune to the virus. It can also develop in individuals who have been successfully vaccinated against hepatitis B.

      Total hepatitis B core antibody (anti-HBc) appears at the onset of symptoms in acute hepatitis B and remains detectable for life. Its presence indicates that a person has either had a previous or ongoing infection with the hepatitis B virus, although the exact timing of the infection cannot be determined. Anti-HBc is not present in individuals who have received the hepatitis B vaccine.

      IgM antibody to hepatitis B core antigen (IgM anti-HBc) indicates a recent or acute infection with the hepatitis B virus, typically within the past 6 months.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      46.8
      Seconds
  • Question 6 - A 65-year-old patient presents with sudden-onset spontaneous epistaxis. You are struggling to control...

    Incorrect

    • A 65-year-old patient presents with sudden-onset spontaneous epistaxis. You are struggling to control the bleeding and decide to insert bilateral ‘Rapid Rhino’ nasal packs. The patient informs you that he has von Willebrand disease.
      What is dysfunctional in von Willebrand disease?

      Your Answer: Conversion of fibrinogen to fibrin

      Correct Answer: Platelet adhesion

      Explanation:

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

      In many cases, vWD goes unnoticed as patients do not experience any symptoms. It is often diagnosed incidentally during a routine clotting profile check. However, if symptoms do occur, the most common ones are easy bruising, nosebleeds, and heavy menstrual bleeding. In severe cases, more serious bleeding and joint bleeds can occur.

      For mild cases of von Willebrand disease, bleeding can be treated with desmopressin. This medication helps increase the patient’s own levels of vWF by releasing stored vWF from the Weibel-Palade bodies in the endothelial cells. These bodies are storage granules found in the inner lining of blood vessels and the heart. In more severe cases, replacement therapy is necessary, which involves infusing cryoprecipitate or Factor VIII concentrate. Replacement therapy is recommended for patients with severe von Willebrand’s disease who are undergoing moderate or major surgical procedures.

    • This question is part of the following fields:

      • Haematology
      22.6
      Seconds
  • Question 7 - You requested an evaluation of a 50-year-old individual who has come in with...

    Correct

    • You requested an evaluation of a 50-year-old individual who has come in with a two-day history of dizziness. The medical student has examined the patient and provided a tentative diagnosis of vestibular neuritis. What characteristics would typically be observed in a patient with vestibular neuritis?

      Your Answer: Recent viral infection

      Explanation:

      Vestibular neuronitis is believed to occur when the vestibular nerve becomes inflamed, often following a viral infection like a cold. This condition causes a constant feeling of dizziness, which can worsen with head movements. On the other hand, BPPV (benign paroxysmal positional vertigo) is characterized by brief episodes of vertigo lasting around 10-20 seconds, triggered by specific head movements. To diagnose BPPV, the Dix-Hallpike test is performed, and a positive result is indicated by a specific type of eye movement called nystagmus. In contrast, vestibular neuritis typically presents with horizontal nystagmus that only occurs in one direction.

      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
      44.9
      Seconds
  • Question 8 - A 3-year-old child is brought in by ambulance to the resus area of...

    Incorrect

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

      Your Answer: 0.1 mg/kg

      Correct Answer: 0.5 mg/kg

      Explanation:

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

    • This question is part of the following fields:

      • Neurology
      18.3
      Seconds
  • Question 9 - A 32-year-old man is brought to the hospital with a known notifiable illness.
    What...

    Correct

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

      Your Answer: Haemolytic uraemic syndrome

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Infectious Diseases
      53.6
      Seconds
  • Question 10 - A 68-year-old individual presents with rest tremor, rigidity, and bradykinesia. A diagnosis of...

    Incorrect

    • A 68-year-old individual presents with rest tremor, rigidity, and bradykinesia. A diagnosis of Parkinson's disease is determined.
      Parkinson's disease primarily occurs due to a loss of dopaminergic cells in which anatomical regions?

      Your Answer: Thalamus

      Correct Answer: Midbrain

      Explanation:

      Parkinson’s disease is primarily characterized by the degeneration of cells in the substantia nigra, a region located in the midbrain. The most severely affected part is the pars compacta, which plays a crucial role in motor control. As a result, there is a significant decrease in the activity of cells that secrete dopamine.

      The main symptoms of Parkinson’s disease include tremors that occur when the body is at rest, rigidity in the muscles, and bradykinesia, which refers to a slowness in movement. These symptoms can greatly impact a person’s ability to perform everyday tasks and can progressively worsen over time.

    • This question is part of the following fields:

      • Neurology
      12.6
      Seconds
  • Question 11 - A 35-year-old man who resides in a Traveller community comes in with a...

    Correct

    • A 35-year-old man who resides in a Traveller community comes in with a severe paroxysmal cough and a fever that has persisted for the last 10 days. He reports not having received any vaccinations. A nasopharyngeal swab for pertussis comes back positive. He is currently 18 weeks into his wife's pregnancy.
      What is the most suitable initial antibiotic to prescribe?

      Your Answer: Erythromycin

      Explanation:

      Pertussis, also known as whooping cough, is a respiratory infection caused by the bacteria Bordetella pertussis. Despite being a bacterial disease, antibiotics do not change the course of the illness once it has taken hold. However, macrolide antibiotics have been proven to shorten the period of contagiousness. Therefore, it is important to administer antibiotics as soon as possible after the onset of symptoms to eliminate the bacteria and reduce further transmission. It is crucial to start antibiotics within three weeks of symptom onset, as they do not affect the progression of the illness or the contagious period.

      First-line treatment for pertussis includes macrolide antibiotics. For babies under one month old, clarithromycin is recommended. For children one month and older, as well as non-pregnant adults, azithromycin or clarithromycin are the preferred options. Pregnant women should be treated with erythromycin. In cases where macrolides are not suitable or well-tolerated, co-trimoxazole can be used off-label.

    • This question is part of the following fields:

      • Respiratory
      28.7
      Seconds
  • Question 12 - A 60-year-old man who has recently undergone treatment for lymphoma presents with retrosternal...

    Correct

    • A 60-year-old man who has recently undergone treatment for lymphoma presents with retrosternal pain, dysphagia, and difficulty swallowing. Despite unsuccessful treatment, he has been informed that he only has a few months left to live.

      What is the SINGLE most probable diagnosis?

      Your Answer: Oesophageal candidiasis

      Explanation:

      This patient’s symptoms are consistent with a diagnosis of oesophageal candidiasis, which is commonly seen in patients undergoing treatment for haematopoietic or lymphatic malignancies.

      The classic combination of symptoms associated with oesophageal candidiasis includes dysphagia, odynophagia, and retrosternal pain. This infection can be life-threatening and often requires hospital admission.

      The recommended treatment for oesophageal candidiasis is as follows:

      – First-line treatment involves taking oral fluconazole at a daily dose of 200-400 mg.
      – If the patient is unable to tolerate oral treatment, intravenous fluconazole can be used instead.
      – Second-line treatment options include oral itraconazole, oral posaconazole, or intravenous or oral voriconazole.

      It is important to seek medical attention promptly for oesophageal candidiasis, as timely treatment is crucial in managing this potentially serious infection.

    • This question is part of the following fields:

      • Palliative & End Of Life Care
      39.4
      Seconds
  • Question 13 - A 45-year-old patient is admitted to the emergency department with severe burns. It...

    Correct

    • A 45-year-old patient is admitted to the emergency department with severe burns. It is determined that a central venous catheter needs to be inserted. Before the central line insertion, the skin on the front of the neck is numbed with 1% lidocaine.

      Which vein in the anterior neck triangle is utilized for the placement of the central venous line?

      Your Answer: Internal jugular vein

      Explanation:

      The internal jugular vein is situated in the anterior triangle of the neck and is frequently utilized for the insertion of central lines. It is important for candidates to have a good understanding of the anatomy of the anterior triangle, including its contents, according to the RCEM.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Resus
      7.1
      Seconds
  • Question 14 - A 7 year old male is brought into the emergency department by concerned...

    Correct

    • A 7 year old male is brought into the emergency department by concerned parents. The child has been feeling unwell for the past 2-3 days, complaining of stomach pain and feeling nauseous. The parents have also noticed that the child has been drinking more than usual and constantly feels thirsty. Tests confirm a diagnosis of diabetic ketoacidosis (DKA) and appropriate treatment is initiated. About 4 hours after starting treatment, one of the nursing staff asks you to assess the patient as he has been experiencing headaches and has started vomiting. The following repeat observations are recorded:

      Pulse: 58 bpm
      Respiration rate: 28 bpm
      Temperature: 37.2ºC

      What is the most appropriate course of action?

      Your Answer: Administer mannitol (20%) 0.5-1 g/kg over 10-15 minutes

      Explanation:

      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:

      • Paediatric Emergencies
      26.1
      Seconds
  • Question 15 - A 42-year-old woman comes in with a gradual onset of severe colicky abdominal...

    Correct

    • A 42-year-old woman comes in with a gradual onset of severe colicky abdominal pain and vomiting. She has not had a bowel movement today. Her only significant medical history is gallstones. During the examination, her abdomen appears distended, and a mass can be felt in the upper right quadrant. Bowel sounds can be heard as 'tinkling' on auscultation.

      What is the SINGLE most probable diagnosis?

      Your Answer: Small bowel obstruction

      Explanation:

      Gallstone ileus occurs when a gallstone becomes stuck in the small intestine, specifically at the caeco-ileal valve. This condition presents with similar symptoms to other causes of small bowel obstruction. Patients may experience colicky central abdominal pain, which can have a gradual onset. Vomiting is common and tends to occur earlier in the course of the illness compared to large bowel obstruction. Abdominal distension and the absence of flatus are also typical signs. Additionally, there may be a lack of normal bowel sounds or the presence of high-pitched tinkling sounds. A mass in the right upper quadrant of the abdomen may be palpable.

    • This question is part of the following fields:

      • Surgical Emergencies
      22
      Seconds
  • Question 16 - 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
      12.1
      Seconds
  • Question 17 - A 62 year old male is brought into the emergency department by concerned...

    Correct

    • A 62 year old male is brought into the emergency department by concerned family members. They inform you that the patient is a heavy drinker but appeared very confused and disoriented, which is unusual for him. The patient scores 4/10 on the abbreviated mental test score (AMTS). Upon examination, you observe that the patient has yellowing of the eyes, shifting dullness on abdominal palpation, dilated abdominal veins, and asterixis. The patient's vital signs and initial blood tests are as follows:

      Blood pressure: 122/80 mmHg
      Pulse: 92 bpm
      Respiration rate: 18 bpm
      Temperature: 37.7ºC

      Bilirubin: 68 µmol/l
      ALP: 198 u/l
      ALT: 274 u/l
      Albumin: 26 g/l
      INR: 1.7

      What is the most likely diagnosis?

      Your Answer: Hepatic encephalopathy

      Explanation:

      Hepatic encephalopathy occurs when a person with liver disease experiences an episode where their brain function is affected. This happens because the liver is unable to properly process waste products, leading to an accumulation of nitrogenous waste in the body. These waste products then cross into the brain, where they cause changes in the brain’s osmotic pressure and disrupt neurotransmitter function. As a result, individuals may experience altered consciousness, behavior, and personality. Symptoms can range from confusion and forgetfulness to coma, and signs such as slurred speech and increased muscle tone may also be present. Hepatic encephalopathy is often triggered by factors like gastrointestinal bleeding, infections, or certain medications.

      Further Reading:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      20.8
      Seconds
  • Question 18 - A 35-year-old patient with a history of exhaustion and weariness has a complete...

    Correct

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

      Your Answer: Haemolysis

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Haematology
      16.1
      Seconds
  • Question 19 - A 30-year-old woman who is 10-weeks pregnant comes in with abdominal pain and...

    Correct

    • A 30-year-old woman who is 10-weeks pregnant comes in with abdominal pain and vaginal bleeding. During the examination, her cervix is found to be open. A local early pregnancy assessment unit (EPAU) performs an ultrasound scan. The scan is unable to detect a fetal heartbeat but does show the presence of retained products of conception.

      What is the SINGLE most probable diagnosis?

      Your Answer: Incomplete miscarriage

      Explanation:

      An incomplete miscarriage occurs when a miscarriage occurs, but the products of conception have not been fully expelled from the uterus. This commonly happens between weeks 8 and 14 of pregnancy.

      Symptoms of an incomplete miscarriage include pain and bleeding, and the cervix is usually open. A diagnosis can be confirmed through an ultrasound scan, which will show the absence of a fetal heartbeat and retained products.

      Treatment for an incomplete miscarriage can be done medically, such as using misoprostol, or surgically, like undergoing an ERPC procedure.

      There are potential complications that can arise from an incomplete miscarriage, including endometritis, myometritis, septic shock, and disseminated intravascular coagulation (DIC).

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      12.4
      Seconds
  • Question 20 - A 32-year-old triathlete is brought in by ambulance after collapsing during a triathlon...

    Correct

    • A 32-year-old triathlete is brought in by ambulance after collapsing during a triathlon event. Due to a summer heatwave, several participants have been admitted with heat-related illnesses. The patient is diagnosed with heat stroke and is in critical condition with a low GCS and signs of organ damage. You decide to transfer the patient to a critical care unit.
      Which of the following cooling methods would be the LEAST suitable option for this patient?

      Your Answer: Cold water immersion

      Explanation:

      There are various cooling techniques that are recommended, but currently, there is limited conclusive evidence on which approach is the most effective. Some possible methods include simple measures such as consuming cold beverages, using fans, applying ice water packs, and spraying tepid water. Cold water immersion therapy can also be beneficial, but it requires the patient to be stable and cooperative, making it impractical for very ill individuals. For patients who are in a more critical condition, advanced cooling techniques like administering cold intravenous fluids, using surface cooling devices (SCD), employing intravascular cooling devices (ICD), or utilizing extracorporeal circuits may be utilized.

    • This question is part of the following fields:

      • Environmental Emergencies
      20.2
      Seconds
  • Question 21 - A 35-year-old man develops a viral infection as a result of a blood...

    Correct

    • A 35-year-old man develops a viral infection as a result of a blood transfusion.
      Which virus is most frequently transmitted through blood transfusions?

      Your Answer: Parvovirus B19

      Explanation:

      The most frequently encountered virus transmitted through blood transfusion is parvovirus B19. This particular occurrence happens in roughly 1 out of every 10,000 transfusions.

      On the other hand, the transmission of other viruses is extremely uncommon. The likelihood of contracting Hepatitis B through a blood transfusion is estimated to be around 1 in 100,000 to 200,000. Similarly, the chances of acquiring Hepatitis C or HIV through a blood transfusion are even rarer, with the odds being approximately 1 in 1 million for both viruses.

    • This question is part of the following fields:

      • Haematology
      9.5
      Seconds
  • Question 22 - A 65-year-old woman comes in with lower abdominal discomfort and rectal bleeding. An...

    Correct

    • A 65-year-old woman comes in with lower abdominal discomfort and rectal bleeding. An abdominal CT scan is conducted and reveals a diagnosis of diverticulitis.
      Which part of her large intestine is most likely to be impacted?

      Your Answer: Sigmoid colon

      Explanation:

      Diverticulitis primarily affects the sigmoid colon in about 90% of cases. As a result, it is more commonly associated with pain in the left iliac fossa.

    • This question is part of the following fields:

      • Surgical Emergencies
      206.8
      Seconds
  • Question 23 - You evaluate the airway and breathing of a child who has been brought...

    Incorrect

    • You evaluate the airway and breathing of a child who has been brought into the emergency room by an ambulance after being rescued from a house fire. You suspect that the child may have signs of airway obstruction.
      Which of the following statements about managing the airway and breathing in burned patients is correct?

      Your Answer: 100% oxygen should be continued until carboxyhaemoglobin levels fall to <5%

      Correct Answer:

      Explanation:

      Patients who have suffered burns should receive high-flow oxygen (15 L) through a reservoir bag while their breathing is being evaluated. If intubation is necessary, it is crucial to use an appropriately sized endotracheal tube (ETT). Using a tube that is too small can make it difficult or even impossible to ventilate the patient, clear secretions, or perform bronchoscopy.

      According to the ATLS guidelines, adults should be intubated using an ETT with an internal diameter (ID) of at least 7.5 mm or larger. Children, on the other hand, should have an ETT with an ID of at least 4.5 mm. Once a patient has been intubated, it is important to continue administering 100% oxygen until their carboxyhemoglobin levels drop to less than 5%.

      To protect the lungs, it is recommended to use lung protective ventilation techniques. This involves using low tidal volumes (4-8 mL/kg) and ensuring that peak inspiratory pressures do not exceed 30 cmH2O.

    • This question is part of the following fields:

      • Trauma
      16.7
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  • Question 24 - A 68 year old male visits the emergency department on a Saturday night...

    Correct

    • A 68 year old male visits the emergency department on a Saturday night complaining of severe watery diarrhea that has been ongoing for the past five days. The patient mentions that he saw his primary care physician a few days ago regarding the diarrhea, and the physician sent a stool sample for testing. The patient informs you that his physician was concerned because he had recently completed two courses of antibiotics, which may have triggered the diarrhea. Upon reviewing the pathology results, you observe that the stool has tested positive for clostridium difficile cytotoxin.

      Which of the following antibiotics is most likely responsible for causing this patient's diarrhea?

      Your Answer: Clindamycin

      Explanation:

      C. difficile infection is often linked to the use of certain antibiotics such as clindamycin, cephalosporins (particularly third and fourth generation), fluoroquinolones, and broad-spectrum penicillins. To treat C. difficile diarrhea, metronidazole and vancomycin are commonly prescribed.

      Further Reading:

      Clostridium difficile (C.diff) is a gram positive rod commonly found in hospitals. Some strains of C.diff produce exotoxins that can cause intestinal damage, leading to pseudomembranous colitis. This infection can range from mild diarrhea to severe illness. Antibiotic-associated diarrhea is often caused by C.diff, with 20-30% of cases being attributed to this bacteria. Antibiotics such as clindamycin, cephalosporins, fluoroquinolones, and broad-spectrum penicillins are frequently associated with C.diff infection.

      Clinical features of C.diff infection include diarrhea, distinctive smell, abdominal pain, raised white blood cell count, and in severe cases, toxic megacolon. In some severe cases, diarrhea may be absent due to the infection causing paralytic ileus. Diagnosis is made by detecting Clostridium difficile toxin (CDT) in the stool. There are two types of exotoxins produced by C.diff, toxin A and toxin B, which cause mucosal damage and the formation of a pseudomembrane in the colon.

      Risk factors for developing C.diff infection include age over 65, antibiotic treatment, previous C.diff infection, exposure to infected individuals, proton pump inhibitor or H2 receptor antagonist use, prolonged hospitalization or residence in a nursing home, and chronic disease or immunosuppression. Complications of C.diff infection can include toxic megacolon, colon perforation, sepsis, and even death, especially in frail elderly individuals.

      Management of C.diff infection involves stopping the causative antibiotic if possible, optimizing hydration with IV fluids if necessary, and assessing the severity of the infection. Treatment options vary based on severity, ranging from no antibiotics for mild cases to vancomycin or fidaxomicin for moderate cases, and hospital protocol antibiotics (such as oral vancomycin with IV metronidazole) for severe or life-threatening cases. Severe cases may require admission under gastroenterology or GI surgeons.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      17.8
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  • Question 25 - A 65-year-old man has experienced a stroke affecting the blood vessels in his...

    Correct

    • A 65-year-old man has experienced a stroke affecting the blood vessels in his brain. Testing of his visual field reveals that he has a quadrantanopia in the lower left side of his vision.
      Where in the visual pathway has this injury occurred?

      Your Answer: Upper optic radiation

      Explanation:

      Homonymous quadrantanopia occur when there are lesions in the optic radiation. The optic tract passes through the posterolateral angle of the optic chiasm, running alongside the cerebral peduncle and inside the uncus of the temporal lobe. Eventually, it reaches the lateral geniculate body (LGN) in the thalamus. Acting as a relay center, the LGN sends axons through the optic radiation to the primary visual cortex in the occipital lobe. The upper optic radiation carries fibers from the superior retinal quadrants (which corresponds to the lower half of the visual field) and travels through the parietal lobe. On the other hand, the lower optic radiation carries fibers from the inferior retinal quadrants (which corresponds to the upper half of the visual field) and travels through the temporal lobe. Consequently, lesions in the temporal lobe can lead to superior homonymous quadrantanopia, while lesions in the parietal lobe can cause inferior homonymous quadrantanopia. The diagram below provides a summary of the different visual field defects resulting from lesions at various points in the visual pathway.

    • This question is part of the following fields:

      • Ophthalmology
      23.6
      Seconds
  • Question 26 - You assess a 65-year-old woman with a history of progressively increasing shortness of...

    Correct

    • You assess a 65-year-old woman with a history of progressively increasing shortness of breath. As part of the patient's treatment plan, your supervisor requests that you carry out a pleural aspiration.
      Based on the BTS guidelines, what is one of the indications for performing a pleural aspiration?

      Your Answer: Unilateral exudative pleural effusion

      Explanation:

      A pleural effusion refers to an excess accumulation of fluid in the pleural cavity, which is the space between the parietal and visceral pleura. Normally, this cavity contains a small amount of lubricating fluid, around 5-10 ml, that allows the pleurae to slide smoothly over each other. This fluid also creates surface tension, bringing the two membranes together and ensuring that as the thorax expands, the lungs expand and fill with air. However, when there is too much fluid in the pleural cavity, it hinders breathing by limiting lung expansion.

      Percutaneous pleural aspiration is commonly performed for two main reasons. Firstly, it is used to investigate pleural effusion, particularly when it is unilateral and exudative in nature. Secondly, it provides symptomatic relief for breathlessness caused by pleural effusion. However, the British Thoracic Society (BTS) guidelines recommend that pleural aspiration should not be carried out if there is suspicion of unilateral or bilateral transudative effusion, unless there are atypical features or failure of response to therapy. In urgent cases where respiratory distress is caused by pleural effusion, pleural aspiration can also be used to quickly decompress the pleural space.

      During the procedure, the patient is typically seated upright with a pillow supporting their arms and head. It is important for the patient not to lean too far forward, as this increases the risk of injury to the liver and spleen. The conventional site for aspiration is in the mid-scapular line, about 10 cm lateral to the spine, and one or two spaces below the upper level of the fluid. To avoid damaging the intercostal nerves and vessels that run just below the rib, the needle should be inserted just above the upper border of the chosen rib.

    • This question is part of the following fields:

      • Respiratory
      18.7
      Seconds
  • Question 27 - You examine a 60-year-old woman with known presbycusis affecting both ears equally.
    Which SINGLE...

    Correct

    • You examine a 60-year-old woman with known presbycusis affecting both ears equally.
      Which SINGLE combination of examination findings would you anticipate discovering?

      Your Answer: Central Weber’s test and bilaterally diminished Rinne’s tests

      Explanation:

      presbycusis is a type of hearing loss that occurs gradually as a person ages. It affects both ears and is characterized by a decrease in hearing ability, particularly at higher frequencies. This type of hearing loss worsens over time. When a person has bilateral sensorineural hearing loss, a central Weber’s test and bilaterally diminished Rinne’s tests would be expected.

      To perform a Rinne’s test, a 512 Hertz tuning fork is vibrated and placed on the mastoid process until the sound can no longer be heard. Then, the top of the tuning fork is placed 2 centimeters from the external auditory meatus. The patient is asked to indicate where they hear the sound loudest.

      In individuals with normal hearing, the tuning fork should still be audible outside the external auditory canal even after it can no longer be heard on the mastoid. This is because air conduction should be better than bone conduction.

      In cases of conductive hearing loss, the patient will no longer be able to hear the tuning fork immediately after it can no longer be heard on the mastoid. This indicates that their bone conduction is better than their air conduction, and something is obstructing the passage of sound waves through the ear canal into the cochlea. This is considered a true negative result.

      However, a Rinne’s test may produce a false negative result if the patient has a severe unilateral sensorineural deficit and can sense the sound in the unaffected ear through the transmission of sound waves through the base of the skull.

      In sensorineural hearing loss, the ability to perceive the tuning fork both on the mastoid and outside the external auditory canal is equally diminished compared to the opposite ear. The sound will still be heard outside the external auditory canal, but it will disappear earlier on the mastoid process and outside the external auditory canal compared to the other ear.

      To perform Weber’s test, a 512 Hz tuning fork is vibrated and placed on the center of the patient’s forehead. The patient is then asked if they perceive the sound in the middle of the forehead or if it seems to be more on one side or the other.

      If the sound seems to be more on one side, it can indicate either ipsilateral conductive hearing loss or contralateral sensorineural hearing loss.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      59
      Seconds
  • Question 28 - A 67 year old individual experiences muscle rigidity and fever after being intubated....

    Correct

    • A 67 year old individual experiences muscle rigidity and fever after being intubated. Your supervisor instructs you to administer dantrolene. What is the mechanism of action of dantrolene?

      Your Answer: Inhibits calcium efflux from the sarcoplasmic reticulum

      Explanation:

      Dantrolene works by blocking the release of calcium ions from the sarcoplasmic reticulum in skeletal muscle cells. This reduces the amount of calcium available to bind to troponin on actin filaments, which in turn decreases the muscle’s ability to contract and reduces energy usage.

      Further Reading:

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

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      4.4
      Seconds
  • Question 29 - A 30-year-old construction worker comes in with intense pain in his left eye...

    Correct

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

      Your Answer: Open-angle glaucoma

      Explanation:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Ophthalmology
      39.7
      Seconds
  • Question 30 - A 50-year-old carpenter comes in with a chief complaint of shoulder pain that...

    Incorrect

    • A 50-year-old carpenter comes in with a chief complaint of shoulder pain that worsens with repetitive overhead tasks. Additionally, he reports experiencing nighttime pain and difficulty in raising his arm. There is no history of any injuries.
      Which muscle is most likely to be affected in this scenario?

      Your Answer: Deltoid

      Correct Answer: Supraspinatus

      Explanation:

      The supraspinatus tendon passes through a narrow space located between the underside of the acromion and acromioclavicular joint, as well as the head of the humerus. When the tendon becomes trapped in this space, it can cause pain and restrict movement, especially during overhead activities. This condition is known as subacromial impingement.

      Impingement can occur due to various factors, such as thickening of the tendon caused by partial tears, inflammation, or degeneration. It can also be a result of the space narrowing due to osteoarthritis of the acromioclavicular joint or the presence of bone spurs. Some individuals may have a naturally downward sloping acromion, which makes them more susceptible to impingement.

      Certain professions that involve a significant amount of overhead work, like plasterers, builders, and decorators, are particularly prone to developing subacromial impingement.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      22.3
      Seconds
  • Question 31 - A 2-month-old baby girl is brought in by her parents with projectile vomiting....

    Correct

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

      What is the SINGLE most likely diagnosis?

      Your Answer: Infantile hypertrophic pyloric stenosis

      Explanation:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Neonatal Emergencies
      17.2
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  • Question 32 - A 42 year old male intravenous drug user is brought to the emergency...

    Correct

    • A 42 year old male intravenous drug user is brought to the emergency department due to worsening abdominal distension, fever and new onset confusion. You observe that the patient has a pre-existing diagnosis of hepatitis C but has not attended follow up or received treatment. After evaluating the patient, you notice that he has tense ascites and decide to perform abdominal paracentesis. Ascitic fluid is sent for analysis.

      Which of the following findings is indicative of spontaneous bacterial peritonitis (SBP)?

      Your Answer: Ascitic fluid absolute neutrophil count >250 cells/mm³

      Explanation:

      Spontaneous bacterial peritonitis (SBP) is a serious infection that can occur in individuals with ascites, which is the accumulation of fluid in the abdominal cavity. In this case, the patient is a 42-year-old male intravenous drug user with a history of hepatitis C who has not received treatment. He presents to the emergency department with worsening abdominal distension, fever, and confusion.

      To evaluate the patient, an abdominal paracentesis is performed, which involves removing a sample of the ascitic fluid for analysis. The findings from the ascitic fluid analysis can provide important information about the underlying cause of the patient’s symptoms.

      In the given options, the finding that is indicative of spontaneous bacterial peritonitis (SBP) is an ascitic fluid absolute neutrophil count >250 cells/mm³. Neutrophils are a type of white blood cell that are typically elevated in the presence of infection. In SBP, there is an infection of the ascitic fluid, leading to an increase in neutrophils.

      The other options provided do not specifically indicate SBP. An ascitic fluid absolute lymphocyte count >150 cells/mm³ may suggest a different type of infection or inflammation. An ascitic fluid absolute erythrocyte count >200 cells/mm³ may indicate bleeding into the ascitic fluid. An ascitic fluid albumin concentration of > 2.0 g/dL (20 g/L) and an ascitic fluid protein concentration of > 3.0 g/dL (30 g/L) may suggest liver disease or other causes of ascites, but they do not specifically indicate SBP.

      Therefore, in this case, the presence of an ascitic fluid absolute neutrophil count >250 cells/mm³ is the finding that is indicative of spontaneous bacterial peritonitis (SBP).

      Further Reading:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      8.8
      Seconds
  • Question 33 - A 35-year-old carpenter presents with shoulder pain that worsens during repetitive overhead work....

    Correct

    • A 35-year-old carpenter presents with shoulder pain that worsens during repetitive overhead work. The patient also reports experiencing nighttime pain and difficulty in raising the arm. There is no history of any injury.
      What is the SINGLE most probable diagnosis?

      Your Answer: Subacromial impingement

      Explanation:

      The supraspinatus tendon passes through a narrow space located between the underside of the acromion and acromioclavicular joint, as well as the head of the humerus. When the tendon becomes trapped in this space, it can cause pain and restrict movement, especially during overhead activities. This condition is known as subacromial impingement.

      Impingement can occur due to various factors, such as thickening of the tendon caused by partial tears, inflammation, or degeneration. It can also be a result of the space narrowing due to osteoarthritis of the acromioclavicular joint or the presence of bone spurs. Some individuals may have a naturally downward sloping acromion, which makes them more susceptible to impingement.

      Certain professions that involve a significant amount of overhead work, like plasterers, builders, and decorators, are particularly prone to developing subacromial impingement.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      17.8
      Seconds
  • Question 34 - A 30-year-old woman with a history of bipolar disorder presents with a side...

    Correct

    • A 30-year-old woman with a history of bipolar disorder presents with a side effect from the mood stabilizer medication that she is currently taking.

      Which SINGLE statement regarding the side effects of mood stabilizer drugs is FALSE?

      Your Answer: Dystonia tends to only appear after long-term treatment

      Explanation:

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

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

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

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

      In individuals with renal impairment, there is an increased sensitivity of the brain to antipsychotic drugs, necessitating the use of reduced doses.

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

      Contraindications for the use of antipsychotic drugs include reduced consciousness or coma, central nervous system depression, and the presence of phaeochromocytoma.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      48.5
      Seconds
  • Question 35 - You assess a patient in a clinic who has been diagnosed with a...

    Correct

    • You assess a patient in a clinic who has been diagnosed with a neuropathy affecting the muscles around her shoulder joint. During the examination, you observe that she has significant restriction in the abduction of her arm. Your consultant examines the patient and instructs her to raise her arms parallel to the ground in the scapular plane. When rotating the arm internally with the thumbs pointing downwards, she is unable to sustain the position with her left arm when pressure is applied.
      Which nerve is most likely to have been affected in this scenario?

      Your Answer: Suprascapular nerve

      Explanation:

      The supraspinatus muscle is a small muscle located in the upper back. It extends from the supraspinatus fossa of the scapula to the greater tubercle of the humerus. This muscle is part of the rotator cuff, along with three other muscles. The supraspinatus muscle is innervated by the suprascapular nerve, which also innervates the infraspinatus muscle. The suprascapular nerve originates from the upper trunk of the brachial plexus.

      The main function of the supraspinatus muscle is to assist the deltoid muscle in abducting the arm at the shoulder joint. Specifically, it is responsible for the initial 15 degrees of arm abduction. Beyond this range, the deltoid muscle takes over as the primary abductor.

      In addition to its role in arm movement, the supraspinatus muscle works together with the other rotator cuff muscles to stabilize the shoulder joint. It helps keep the humeral head in the glenoid fossa and counteracts the downward gravitational forces exerted on the shoulder joint by the weight of the arm.

      One common test used to assess the supraspinatus muscle is called the empty can test. During this test, the patient is positioned either standing or sitting, with their arms raised parallel to the ground in the scapular plane. The arm is then internally rotated fully, with the thumb facing downward. The clinician applies downward pressure on either the wrists or the elbow, while the patient resists this pressure. If the patient experiences weakness, pain, or both during this resistance, it indicates a possible tear in the supraspinatus tendon or muscle, or a suprascapular nerve neuropathy.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      17
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  • Question 36 - You are managing a 62-year-old male patient presenting with symptomatic bradycardia. Despite multiple...

    Correct

    • You are managing a 62-year-old male patient presenting with symptomatic bradycardia. Despite multiple administrations of atropine, there has been no improvement in the patient's condition. Which two medications would be the most suitable options to consider next for treating this rhythm?

      Your Answer: Adrenaline/Isoprenaline

      Explanation:

      Adrenaline and isoprenaline are considered as second-line medications for the treatment of bradycardia. If atropine fails to improve the condition, transcutaneous pacing is recommended. However, if pacing is not available, the administration of second-line drugs becomes necessary. Adrenaline is typically given intravenously at a dosage of 2-10 mcg/minute, while isoprenaline is given at a dosage of 5 mcg/minute. It is important to note that glucagon is not mentioned as a treatment option for this patient’s bradycardia, as the cause of the condition is not specified as a beta-blocker overdose.

      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
      7.1
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  • Question 37 - A 35 year old accountant presents to the emergency department with a 3...

    Correct

    • A 35 year old accountant presents to the emergency department with a 3 day history of diarrhea, stomach cramps, and occasional vomiting. After evaluating the patient, you inform them that they are likely experiencing viral gastroenteritis and provide instructions for self-care at home. The patient inquires about when it would be appropriate for them to return to work.

      Your Answer: Do NOT attend work or other institutional/social settings until at least 48 hours after the last episode of diarrhoea or vomiting.

      Explanation:

      Individuals who have gastroenteritis should be instructed to refrain from going to work or participating in social activities until at least 48 hours have passed since their last episode of diarrhea or vomiting.

      Further Reading:

      Gastroenteritis is a transient disorder characterized by the sudden onset of diarrhea, with or without vomiting. It is caused by enteric infections with viruses, bacteria, or parasites. The most common viral causes of gastroenteritis in adults include norovirus, rotavirus, and adenovirus. Bacterial pathogens such as Campylobacter jejuni and coli, Escherichia coli, Clostridium perfringens, Bacillus cereus, Staphylococcus aureus, Salmonella typhi and paratyphi, and Shigella dysenteriae, flexneri, boydii, and sonnei can also cause gastroenteritis. Parasites such as Cryptosporidium, Entamoeba histolytica, and Giardia intestinalis or Giardia lamblia can also lead to diarrhea.

      Diagnosis of gastroenteritis is usually based on clinical symptoms, and investigations are not required in many cases. However, stool culture may be indicated in certain situations, such as when the patient is systemically unwell or immunocompromised, has acute painful diarrhea or blood in the stool suggesting dysentery, has recently taken antibiotics or acid-suppressing medications, or has not resolved diarrhea by day 7 or has recurrent diarrhea.

      Management of gastroenteritis in adults typically involves advice on oral rehydration. Intravenous rehydration and more intensive treatment may be necessary for patients who are systemically unwell, exhibit severe dehydration, or have intractable vomiting or high-output diarrhea. Antibiotics are not routinely required unless a specific organism is identified that requires treatment. Antidiarrheal drugs, antiemetics, and probiotics are not routinely recommended.

      Complications of gastroenteritis can occur, particularly in young children, the elderly, pregnant women, and immunocompromised individuals. These complications include dehydration, electrolyte disturbance, acute kidney injury, haemorrhagic colitis, haemolytic uraemic syndrome, reactive arthritis, Reiter’s syndrome, aortitis, osteomyelitis, sepsis, toxic megacolon, pancreatitis, sclerosing cholangitis, liver cirrhosis, weight loss, chronic diarrhea, irritable bowel syndrome, inflammatory bowel disease, acquired lactose intolerance, Guillain-Barré syndrome, meningitis, invasive entamoeba infection, and liver abscesses.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      9
      Seconds
  • Question 38 - A 32-year-old woman presents with a diagnosis of cluster headache.
    Which SINGLE clinical feature...

    Incorrect

    • A 32-year-old woman presents with a diagnosis of cluster headache.
      Which SINGLE clinical feature would be inconsistent with this diagnosis?

      Your Answer: Ipsilateral ptosis

      Correct Answer: Ipsilateral mydriasis

      Explanation:

      Cluster headaches primarily affect men in their 20s, with a male to female ratio of 6:1. Smoking is also a contributing factor to the development of cluster headaches. These headaches typically occur in clusters, hence the name, lasting for a few weeks every year or two. The pain experienced is intense and localized, often felt around or behind the eye. It tends to occur at the same time each day and can lead to restlessness, with some patients resorting to hitting their head against a wall or the floor in an attempt to distract themselves from the pain.

      In addition to the severe pain, cluster headaches also involve autonomic symptoms. These symptoms include redness and inflammation of the conjunctiva on the same side as the headache, as well as a runny nose and excessive tearing on the affected side. The pupil on the same side may also constrict, and there may be drooping of the eyelid on that side as well.

      Overall, cluster headaches are a debilitating condition that predominantly affects young men. The pain experienced is excruciating and can lead to extreme measures to alleviate it. The associated autonomic symptoms further contribute to the discomfort and distress caused by these headaches.

    • This question is part of the following fields:

      • Neurology
      30.1
      Seconds
  • Question 39 - A 35-year-old patient with a history of exhaustion and weariness has a complete...

    Correct

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

      Your Answer: Liver disease

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Haematology
      19.8
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  • Question 40 - A 35-year-old patient with a history of exhaustion and weariness has a complete...

    Correct

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

      Your Answer: Hypothyroidism

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Haematology
      16.5
      Seconds
  • Question 41 - A 70-year-old female smoker presents with intense chest discomfort. Her ECG indicates an...

    Incorrect

    • A 70-year-old female smoker presents with intense chest discomfort. Her ECG indicates an acute myocardial infarction and she is immediately taken to the cath lab. Angiography reveals a blockage in the left anterior descending artery.
      Which area of the heart is most likely affected in this scenario?

      Your Answer: Anteroseptal

      Correct Answer: Right ventricle

      Explanation:

      A summary of the vessels involved in different types of myocardial infarction, along with the corresponding ECG leads and the location of the infarction.

      For instance, an anteroseptal infarction involving the left anterior descending artery is indicated by ECG leads V1-V3. Similarly, an anterior infarction involving the left anterior descending artery is indicated by leads V3-V4.

      In cases of anterolateral infarctions, both the left anterior descending artery and the left circumflex artery are involved, and this is reflected in ECG leads V5-V6. An extensive anterior infarction involving the left anterior descending artery is indicated by leads V1-V6.

      Lateral infarcts involving the left circumflex artery are indicated by leads I, II, aVL, and V6. Inferior infarctions, on the other hand, involve either the right coronary artery (in 80% of cases) or the left circumflex artery (in 20% of cases), and this is shown by leads II, III, and aVF.

      In the case of a right ventricular infarction, the right coronary artery is involved, and this is indicated by leads V1 and V4R. Lastly, a posterior infarction involving the right coronary artery is shown by leads V7-V9.

    • This question is part of the following fields:

      • Cardiology
      8.9
      Seconds
  • Question 42 - The right of capable individuals to make well-informed choices regarding their personal healthcare...

    Correct

    • The right of capable individuals to make well-informed choices regarding their personal healthcare pertains to which of the subsequent principles?

      Your Answer: Autonomy

      Explanation:

      The principle of autonomy pertains to the right of capable individuals to make well-informed choices regarding their personal healthcare. Autonomy emphasizes the importance of respecting an individual’s ability to make decisions about their own health, based on their own values, beliefs, and preferences. It recognizes that individuals have the right to be informed about their healthcare options, to give informed consent, and to have their choices respected by healthcare providers. Autonomy is a fundamental principle in medical ethics that promotes patient-centered care and respects the individual’s right to self-determination.

      Further Reading:

      Principles of Medical Ethics:

      1. Autonomy: Competent adults have the right to make informed decisions about their own medical care.
      2. Beneficence: Healthcare professionals should take actions that serve the best interests of patients.
      3. Non-maleficence: Healthcare professionals should not take actions that may injure or harm patients.
      4. Justice: Healthcare professionals should take actions that are fair and equitable to both the individual and society as a whole.

      Confidentiality:

      1. Use minimum necessary personal information and consider anonymizing information if possible.
      2. Manage and protect personal information to prevent improper access, disclosure, or loss.
      3. Understand and adhere to information governance appropriate to your role.
      4. Comply with the law when handling personal information.
      5. Share relevant information for direct care unless the patient objects.
      6. Obtain explicit consent to disclose identifiable information for purposes other than care or local clinical audit, unless required by law or justified in the public interest.
      7. Inform patients about disclosures of personal information they would not reasonably expect, unless not practicable or undermines the purpose of the disclosure.
      8. Support patients in accessing their information and respecting their legal rights.

      Obtaining Patient’s Consent for Disclosure:

      – Consent should be obtained for disclosing personal information for purposes other than direct care or local clinical audit, unless required by law or not appropriate or practicable.

      Situations Where Patient Consent is Not Required for Disclosure:

      – Adults at risk of or suffering abuse or neglect, as required by law.
      – Adults lacking capacity, if neglect or harm is suspected, unless not overall beneficial to the patient.
      – When required by law or approved through a statutory process.
      – When justified in the public interest, such as for the prevention, detection, or prosecution of serious crime, patient’s fitness to drive, serious communicable disease, or posing a serious risk to others through being unfit for work.

      Confidentiality Following a Patient’s Death:

      – Respect the patient’s confidentiality even after their death.
      – If the patient previously requested not to share personal information with those close to them, abide by their wishes.
      – Be considerate, sensitive, and responsive to those close to the patient, providing as much information as possible.

      The Law & Caldicott Guardians:

      Data Protection Act:
      – Sets rules and standards for the use and handling of personal data by organizations.
      – Personal data must be used fairly, lawfully, transparently, and for specified purposes.
      – Individuals have rights

    • This question is part of the following fields:

      • Safeguarding & Psychosocial Emergencies
      11.9
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  • Question 43 - A 25-year-old woman is brought to the emergency department by her roommate after...

    Correct

    • A 25-year-old woman is brought to the emergency department by her roommate after intentionally overdosing on amitriptyline. You administer activated charcoal. Which other medication, listed as an antidote by RCEM/NPIS, can be used to treat tricyclic overdose?

      Your Answer: Sodium bicarbonate

      Explanation:

      Sodium bicarbonate is recommended as a treatment for TCA overdose according to the latest guidelines from RCEM and NPIS in 2021. Previous editions also suggested using glucagon if IV fluids and sodium bicarbonate were ineffective in treating the overdose.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      32
      Seconds
  • Question 44 - A 25-year-old patient visits your clinic with concerns about a recent alteration in...

    Correct

    • A 25-year-old patient visits your clinic with concerns about a recent alteration in her usual vaginal discharge. She is not sexually active at the moment and has no other health issues. She does not report any itching symptoms but has observed a strong fishy odor in the discharge.
      Which organisms should be the primary target for initial treatment in this scenario?

      Your Answer: Gardnerella vaginalis only

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Sexual Health
      36.7
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  • Question 45 - A 20-year-old woman presents with frequent urination, excessive thirst, and stomach pain. The...

    Correct

    • A 20-year-old woman presents with frequent urination, excessive thirst, and stomach pain. The results of her arterial blood gas (ABG) on air are as follows:

      pH: 7.21
      pO2: 11.4 kPa
      PCO2: 3.1 kPa
      HCO3-: 17 mmol/l
      Na+: 149 mmol/l
      Cl–: 100 mmol/l
      Lactate: 6 IU/l

      Which SINGLE statement about this patient is correct?

      Your Answer: She is likely to have a type B lactic acidosis

      Explanation:

      Arterial blood gas (ABG) interpretation is essential for evaluating a patient’s respiratory gas exchange and acid-base balance. While the normal values on an ABG may slightly vary between analyzers, they generally 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 medical history raises concerns about a possible diagnosis of diabetic ketoacidosis (DKA). The relevant ABG findings are as follows:

      Normal PO2
      Low pH (acidaemia)
      Low PCO2
      Low bicarbonate
      Raised lactate

      The anion gap refers to 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 measurement methodology but typically falls between 8 to 16 mmol/L.

      To calculate her anion gap, we can use the formula:

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

      Using the provided values, her anion gap can be calculated as:

      Anion gap = [149] – [100] – [17]
      Anion gap = 32

      Therefore, it is evident that she has a raised anion gap metabolic acidosis.

      It is likely that she is experiencing a type B lactic acidosis secondary to diabetic ketoacidosis. Some potential causes of type A and type B lactic acidosis are listed below:

      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
      – Alcoholic ketoacidosis
      – Diabetic ketoacidosis
      – Cyanide poisoning
      – Methanol poisoning
      – Biguanide poisoning

    • This question is part of the following fields:

      • Endocrinology
      43.2
      Seconds
  • Question 46 - A 55 year old female presents to the emergency department 3 hours after...

    Correct

    • A 55 year old female presents to the emergency department 3 hours after experiencing severe central chest pain that radiates to the back while gardening. The patient describes the pain as tearing and states it is the worst pain she has ever felt. You note a past medical history of poorly controlled hypertension. The patient's vital signs are as follows:

      Blood pressure 182/98 mmHg
      Pulse rate 94 bpm
      Respiration rate 22 rpm
      Oxygen saturation 97% on room air
      Temperature 37.3ºC

      An ECG is performed which shows normal sinus rhythm. Chest X-ray reveals a widened mediastinum and an abnormal aortic contour.

      What is the most appropriate initial treatment for this patient?

      Your Answer: Intravenous labetalol

      Explanation:

      The most appropriate initial treatment for this patient would be intravenous labetalol. Labetalol is a non-selective beta blocker with alpha-blocking properties. It is the preferred initial treatment for aortic dissection because it helps to reduce blood pressure and heart rate, which can help to decrease the shear forces acting on the aortic wall and prevent further dissection. Intravenous administration of labetalol allows for rapid and effective control of blood pressure.

      Other treatment options, such as intravenous magnesium sulphate, intravenous verapamil, GTN sublingual spray, and oral nifedipine, are not appropriate for the management of aortic dissection. Magnesium sulphate is used for the treatment of certain arrhythmias and pre-eclampsia, but it does not address the underlying issue of aortic dissection. Verapamil and nifedipine are calcium channel blockers that can lower blood pressure, but they can also cause reflex tachycardia, which can worsen the condition. GTN sublingual spray is used for the treatment of angina, but it does not address the underlying issue of aortic dissection.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Cardiology
      14.3
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  • Question 47 - A 5-year-old child comes in with a high-grade fever, excessive drooling, and inability...

    Correct

    • A 5-year-old child comes in with a high-grade fever, excessive drooling, and inability to speak. The child has obvious stridor and a rapid heart rate. During the examination, there is tenderness in the front of the neck around the hyoid bone and swollen lymph nodes in the neck.

      What is the SINGLE most probable diagnosis?

      Your Answer: Acute epiglottitis

      Explanation:

      Acute epiglottitis is inflammation of the epiglottis, which can be life-threatening if not treated promptly. When the soft tissues surrounding the epiglottis are also affected, it is called acute supraglottitis. This condition is most commonly seen in children between the ages of 3 and 5, but it can occur at any age, with adults typically presenting in their 40s and 50s.

      In the past, Haemophilus influenzae type B was the main cause of acute epiglottitis, but with the introduction of the Hib vaccination, it has become rare in children. Streptococcus spp. is now the most common causative organism. Other potential culprits include Staphylococcus aureus, Pseudomonas spp., Moraxella catarrhalis, Mycobacterium tuberculosis, and the herpes simplex virus. In immunocompromised patients, Candida spp. and Aspergillus spp. infections can occur.

      The typical symptoms of acute epiglottitis include fever, sore throat, painful swallowing, difficulty swallowing secretions (especially in children who may drool), muffled voice, stridor, respiratory distress, rapid heartbeat, tenderness in the front of the neck over the hyoid bone, ear pain, and swollen lymph nodes in the neck. Some patients may also exhibit the tripod sign, where they lean forward on outstretched arms to relieve upper airway obstruction.

      To diagnose acute epiglottitis, fibre-optic laryngoscopy is considered the gold standard investigation. However, this procedure should only be performed by an anaesthetist in a setting prepared for intubation or tracheostomy in case of airway obstruction. Other useful tests include a lateral neck X-ray to look for the thumbprint sign, throat swabs, blood cultures, and a CT scan of the neck if an abscess is suspected.

      When dealing with a case of acute epiglottitis, it is crucial not to panic or distress the patient, especially in pediatric cases. Avoid attempting to examine the throat with a tongue depressor, as this can trigger spasm and worsen airway obstruction. Instead, keep the patient as calm as possible and immediately call a senior anaesthetist, a senior paediatrician, and an ENT surgeon. Nebulized adrenaline can be used as a temporary measure if there is critical airway obstruction.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      10.7
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  • Question 48 - A 68 year old has been brought to the emergency department by ambulance...

    Correct

    • A 68 year old has been brought to the emergency department by ambulance with a history of collapsing shortly after complaining of severe chest pain and difficulty breathing. It has been determined that the patient needs rapid sequence induction after pre-oxygenation. What is the best position for the patient to be in during pre-oxygenation?

      Your Answer: 20-30 degrees head up tilt

      Explanation:

      Several studies have shown that elevating the head by 20-30 degrees is beneficial for increasing oxygen levels compared to lying flat on the back.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Basic Anaesthetics
      4.4
      Seconds
  • Question 49 - A 42-year-old woman is brought to the emergency department after experiencing a sudden...

    Correct

    • A 42-year-old woman is brought to the emergency department after experiencing a sudden and severe headache, which has caused confusion and drowsiness. A CT scan confirms the presence of a subarachnoid hemorrhage. Your consultant instructs you to closely observe for indications of increasing intracranial pressure, such as third cranial nerve palsy. What is the initial manifestation of third cranial nerve palsy in patients with this particular injury?

      Your Answer: Pupil dilatation

      Explanation:

      The initial indication of progressive compression on the oculomotor nerve is the dilation of the pupil. In cases where the oculomotor nerve is being compressed, the outer parasympathetic fibers are typically affected before the inner motor fibers. These parasympathetic fibers are responsible for stimulating the constriction of the pupil. When they are disrupted, the sympathetic stimulation of the pupil is unopposed, leading to the dilation of the pupil (known as mydriasis or blown pupil). This symptom is usually observed before the drooping of the eyelid (lid ptosis) and the downward and outward positioning of the eye.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Neurology
      49.8
      Seconds
  • Question 50 - A 25-year-old woman comes to the clinic with a swollen and red right...

    Correct

    • A 25-year-old woman comes to the clinic with a swollen and red right knee. She recently returned from a trip to Bangkok. During the examination, her temperature is 38.6°C and she has a rash with small blisters on her trunk. The knee feels warm to touch and is immobile. Attempts to flex or extend the knee are unsuccessful. A joint aspiration is done, and Gram-negative diplococci are observed.
      Which of the following antibiotics would be the most suitable to prescribe for this patient?

      Your Answer: Cefotaxime

      Explanation:

      The most probable diagnosis in this case is septic arthritis, which occurs when an infectious agent invades a joint and causes pus formation. The patient’s recent travel to Bangkok, presence of a vesicular rash on the trunk, and the identification of Gram-negative diplococci support this diagnosis.

      Septic arthritis is characterized by several clinical features. These include pain in the affected joint, redness, warmth, and swelling of the joint, and difficulty in moving the joint. Patients may also experience fever and systemic upset.

      The most common cause of septic arthritis is Staphylococcus aureus. Other bacteria that can lead to this condition include Streptococcus spp., Haemophilus influenzae, Neisseria gonorrhoea (typically seen in sexually active young adults with macules or vesicles on the trunk), and Escherichia coli (common in intravenous drug users, the elderly, and seriously ill individuals).

      According to the current recommendations by NICE (National Institute for Health and Care Excellence) and the BNF (British National Formulary), the treatment for septic arthritis involves the following approaches. Flucloxacillin is the first-line antibiotic. In cases of penicillin allergy, clindamycin is recommended. If there is suspicion of MRSA (methicillin-resistant Staphylococcus aureus), vancomycin should be used. For suspected gonococcal arthritis or Gram-negative infection, cefotaxime is the preferred choice. The suggested duration of treatment is 4-6 weeks, although it may be longer if the infection is complicated.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      10.1
      Seconds
  • Question 51 - A 14 year old male is brought into the emergency department with a...

    Correct

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

      Your Answer: Pneumothorax

      Explanation:

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

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Basic Anaesthetics
      4.9
      Seconds
  • Question 52 - 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 Wernicke's encephalopathy. You have been requested to evaluate the patient and initiate her treatment.

      Which of the following is the most suitable INITIAL treatment?

      Your Answer: Intravenous thiamine

      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 triad of symptoms, including acute confusion, ophthalmoplegia (paralysis or weakness of the eye muscles), and ataxia (loss of coordination). Additional features may include papilloedema (swelling of the optic disc), hearing loss, apathy, dysphagia (difficulty swallowing), memory impairment, and hypothermia. Most cases also involve peripheral neuropathy, which typically affects the legs.

      The condition is caused by capillary hemorrhages, astrocytosis (abnormal increase in astrocytes, a type of brain cell), and neuronal death in the upper brainstem and diencephalon. These changes can be visualized using MRI scanning, although CT scanning is not very useful for diagnosis.

      If left untreated, most patients with Wernicke’s encephalopathy will develop Korsakoff psychosis. This condition is characterized by retrograde amnesia (loss of memory for events that occurred before the onset of amnesia), an inability to form new memories, disordered time perception, and confabulation (fabrication of false memories).

      Patients suspected of having Wernicke’s encephalopathy should receive parenteral thiamine (such as Pabrinex) for at least 5 days. Oral thiamine should be administered after the parenteral therapy.

      It is important to note that in patients with chronic thiamine deficiency, the infusion of glucose-containing intravenous fluids without thiamine can trigger the development of Wernicke’s encephalopathy.

    • This question is part of the following fields:

      • Neurology
      15.1
      Seconds
  • Question 53 - You are caring for a patient with a declining Glasgow Coma Scale (GCS)...

    Correct

    • You are caring for a patient with a declining Glasgow Coma Scale (GCS) that you expect will need rapid sequence induction (RSI). You observe that the patient has a history of asthma. Which of the following induction medications is recognized for its bronchodilatory effects and would be appropriate for use in an asthmatic patient?

      Your Answer: Ketamine

      Explanation:

      When caring for a patient with a declining Glasgow Coma Scale (GCS) who may require rapid sequence induction (RSI), it is important to consider their medical history. In this case, the patient has a history of asthma. One of the induction medications that is recognized for its bronchodilatory effects and would be appropriate for use in an asthmatic patient is Ketamine.

      Further Reading:

      There are four commonly used induction agents in the UK: propofol, ketamine, thiopentone, and etomidate.

      Propofol is a 1% solution that produces significant venodilation and myocardial depression. It can also reduce cerebral perfusion pressure. The typical dose for propofol is 1.5-2.5 mg/kg. However, it can cause side effects such as hypotension, respiratory depression, and pain at the site of injection.

      Ketamine is another induction agent that produces a dissociative state. It does not display a dose-response continuum, meaning that the effects do not necessarily increase with higher doses. Ketamine can cause bronchodilation, which is useful in patients with asthma. The initial dose for ketamine is 0.5-2 mg/kg, with a typical IV dose of 1.5 mg/kg. Side effects of ketamine include tachycardia, hypertension, laryngospasm, unpleasant hallucinations, nausea and vomiting, hypersalivation, increased intracranial and intraocular pressure, nystagmus and diplopia, abnormal movements, and skin reactions.

      Thiopentone is an ultra-short acting barbiturate that acts on the GABA receptor complex. It decreases cerebral metabolic oxygen and reduces cerebral blood flow and intracranial pressure. The adult dose for thiopentone is 3-5 mg/kg, while the child dose is 5-8 mg/kg. However, these doses should be halved in patients with hypovolemia. Side effects of thiopentone include venodilation, myocardial depression, and hypotension. It is contraindicated in patients with acute porphyrias and myotonic dystrophy.

      Etomidate is the most haemodynamically stable induction agent and is useful in patients with hypovolemia, anaphylaxis, and asthma. It has similar cerebral effects to thiopentone. The dose for etomidate is 0.15-0.3 mg/kg. Side effects of etomidate include injection site pain, movement disorders, adrenal insufficiency, and apnoea. It is contraindicated in patients with sepsis due to adrenal suppression.

    • This question is part of the following fields:

      • Basic Anaesthetics
      5.5
      Seconds
  • Question 54 - A 45-year-old woman is brought into the emergency department after a car accident....

    Correct

    • A 45-year-old woman is brought into the emergency department after a car accident. She has significant bruising on the right side of her chest. You suspect she may have a hemothorax. What clinical signs would you anticipate observing in a patient with a hemothorax?

      Your Answer: Decreased fremitus on affected side

      Explanation:

      Haemothorax often leads to reduced or absent air entry, a dull percussion sound, and decreased fremitus on the affected side. Commonly observed symptoms in patients with haemothorax include decreased or absent air entry, a dull percussion note when the affected side is tapped, reduced fremitus on the affected side, and in cases of massive haemothorax, tracheal deviation away from the affected side. Other signs that may be present include a rapid heart rate (tachycardia), rapid breathing (tachypnoea), low blood pressure (hypotension), and signs of shock.

      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
      49.6
      Seconds
  • Question 55 - A 32-year-old woman has been brought into the Emergency Department, experiencing seizures that...

    Correct

    • A 32-year-old woman has been brought into the Emergency Department, experiencing seizures that have lasted for 15 minutes before her arrival. On arrival, she is still having a tonic-clonic seizure. She is known to be homeless and has a long history of alcohol abuse. The paramedics administered a single dose of rectal diazepam on the way, approximately 12 minutes ago. Her vital signs are as follows: HR 110, BP 100/60, SaO2 98% on high flow oxygen, temperature is 37.2°C.
      Which of the following medications would be most appropriate to administer next?

      Your Answer: Intravenous thiamine

      Explanation:

      Status epilepticus is a condition characterized by continuous seizure activity lasting for 5 minutes or more without the return of consciousness, or recurrent seizures (2 or more) without a period of neurological recovery in between. In this particular patient’s case, his history of chronic alcohol abuse, homelessness, and likely impaired nutrition necessitates the administration of intravenous thiamine in the form of Pabrinex. Additionally, a second dose of benzodiazepine should be given, and his blood glucose levels should be urgently checked.

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

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

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

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

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

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

      Monitoring during the management of status epilepticus involves regular neurological observations and measurements of pulse, blood pressure, and temperature.

    • This question is part of the following fields:

      • Neurology
      38.2
      Seconds
  • Question 56 - A 42-year-old woman comes in with a painful, red left eye and sensitivity...

    Correct

    • A 42-year-old woman comes in with a painful, red left eye and sensitivity to light. She also reports seeing floaters and experiencing a dull, throbbing headache. She is currently being evaluated by the rheumatology team for persistent pain and stiffness in her upper back and discomfort in her buttocks and thighs. Her eye appears red, and a hypopyon is visible.

      What is the SINGLE most probable diagnosis?

      Your Answer: Anterior uveitis

      Explanation:

      The most probable diagnosis in this case is anterior uveitis, which refers to inflammation of the iris. It typically presents with symptoms such as a painful and red eye, sensitivity to light, excessive tearing, and decreased visual clarity. The photo above shows a possible indication of this condition, with the presence of pus in the front chamber of the eye, known as hypopyon.

      Anterior uveitis can have various causes, including idiopathic cases where no specific cause is identified. Other potential triggers include trauma, chronic joint diseases like spondyloarthropathies and juvenile chronic arthritis, inflammatory bowel disease, psoriasis, sarcoidosis, and infections such as Lyme disease, tuberculosis, leptospirosis, herpes simplex virus (HSV), and varicella-zoster virus (VZV). Additionally, certain malignancies like non-Hodgkin lymphoma, ocular melanoma, and retinoblastoma can be associated with anterior uveitis.

      It is worth noting that there is a strong link between the HLA-B27 genotype and anterior uveitis, with approximately 50% of patients having this genetic marker. In this particular case, the likely underlying diagnosis is ankylosing spondylitis, a condition characterized by chronic pain and stiffness in the mid-spine area and sacroiliitis. It is important to mention that around 30% of men with unilateral uveitis will be found to have ankylosing spondylitis.

    • This question is part of the following fields:

      • Ophthalmology
      50.9
      Seconds
  • Question 57 - John is a 68-year-old man with a history of memory impairment and signs...

    Incorrect

    • John is a 68-year-old man with a history of memory impairment and signs of cognitive decline.
      Which ONE of the following signs is MOST indicative of a diagnosis of vascular dementia rather than Alzheimer's disease?

      Your Answer: Early personality changes

      Correct Answer: Sudden onset

      Explanation:

      Vascular dementia is not as common as Alzheimer’s disease, accounting for about 20% of dementia cases compared to 50% for Alzheimer’s. Most individuals with vascular dementia have a history of atherosclerotic cardiovascular disease and/or hypertension.

      There are notable differences in how these two diseases present themselves. Vascular dementia often has a sudden onset, while Alzheimer’s disease has a slower onset. The progression of vascular dementia tends to be stepwise, with periods of stability followed by sudden declines, whereas Alzheimer’s disease has a more gradual decline. The course of vascular dementia can also fluctuate, while Alzheimer’s disease shows a steady decline over time.

      In terms of personality and insight, individuals with vascular dementia tend to have relatively preserved personality and insight in the early stages, whereas those with Alzheimer’s disease may experience early changes and loss in these areas. Gait is also affected differently, with individuals with vascular dementia taking small steps (known as marche a petit pas), while those with Alzheimer’s disease have a normal gait.

      Sleep disturbance is less common in vascular dementia compared to Alzheimer’s disease, which commonly presents with sleep disturbances. Focal neurological signs, such as sensory and motor deficits and pseudobulbar palsy, are more common in vascular dementia, while they are uncommon in Alzheimer’s disease.

      To differentiate between Alzheimer’s disease and vascular dementia, the modified Hachinski ischemia scale can be used. This scale assigns scores based on various features, such as abrupt onset, stepwise deterioration, fluctuating course, nocturnal confusion, preservation of personality, depression, somatic complaints, emotional incontinence, history of hypertension, history of strokes, evidence of associated atherosclerosis, focal neurological symptoms, and focal neurological signs. A score of 2 or greater suggests vascular dementia.

      Overall, understanding the differences in presentation and using tools like the modified Hachinski ischemia scale can help in distinguishing between Alzheimer’s disease and vascular dementia.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      9.5
      Seconds
  • Question 58 - A 7-year-old boy presents with a sore throat and a dry cough that...

    Incorrect

    • A 7-year-old boy presents with a sore throat and a dry cough that has been present for five days. He has no medical history of note, takes no medication and reports no known drug allergies. On examination, he is febrile with a temperature of 38.5°C and has a few tender anterior cervical lymph nodes. His throat and tonsils appear red and inflamed, and you can see copious exudate on his right tonsil.
      Using the FeverPAIN Score to assess his sore throat, which of the following would be the MOST APPROPRIATE management for him at this stage?

      Your Answer: She should be immediately prescribed penicillin V

      Correct Answer: She should be offered a 'back-up prescription' for penicillin V

      Explanation:

      The FeverPAIN score is a scoring system recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, recommendations for antibiotic use are as follows: a score of 0-1 indicates an unlikely streptococcal infection, with antibiotics not recommended; a score of 2-3 suggests a 34-40% chance of streptococcus, and delayed prescribing of antibiotics may be considered; a score of 4 or higher indicates a 62-65% chance of streptococcus, and immediate antibiotic use is recommended for severe cases, or a short back-up prescription may be given for 48 hours.

      The Fever PAIN score was developed through a study involving 1760 adults and children aged three and over. It was tested in a trial comparing three prescribing strategies: empirical delayed prescribing, score-directed prescribing, and a combination of the score with a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and reduced antibiotic prescribing by one third. The addition of the NPT did not provide any additional benefit.

      According to the current NICE guidelines, if antibiotics are necessary, phenoxymethylpenicillin is recommended as the first-choice antibiotic. In cases of true penicillin allergy, clarithromycin can be used as an alternative. For pregnant women with a penicillin allergy, erythromycin is prescribed. It is important to note that the threshold for prescribing antibiotics should be lower for individuals at risk of rheumatic fever and vulnerable groups managed in primary care, such as infants, the elderly, and those who are immunosuppressed or immunocompromised. Antibiotics should not be withheld if the person has severe symptoms and there are concerns about their clinical condition.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      31.1
      Seconds
  • Question 59 - A 25 year old female is brought to the emergency department with a...

    Correct

    • A 25 year old female is brought to the emergency department with a gunshot wound to the abdomen. You observe that the patient is breathing rapidly and her neck veins are distended. The trachea is centrally located. Her vital signs are as follows:

      Blood pressure: 88/56 mmHg
      Heart rate: 127 bpm
      Respiration rate: 28 rpm
      SpO2: 99% on 15L oxygen

      What is the probable diagnosis?

      Your Answer: Cardiac tamponade

      Explanation:

      Cardiac tamponade is characterized by several classical signs, including distended neck veins, muffled heart sounds, and hypotension. When neck veins are distended, it suggests that the right ventricle is not filling properly. In cases of trauma, this is often caused by the compression of air (tension pneumothorax) or fluid (blood in the pericardial space). One important distinguishing feature is the deviation of the trachea.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Cardiology
      16.3
      Seconds
  • Question 60 - You examine the blood test results of a patient in the resuscitation room...

    Correct

    • You examine the blood test results of a patient in the resuscitation room who is experiencing an Addisonian crisis. What is the most probable SINGLE biochemical characteristic that will be observed?

      Your Answer: Increased ACTH level

      Explanation:

      Addison’s disease is characterized by several classical biochemical features. One of these features is an elevated level of ACTH, which is the body’s attempt to stimulate the adrenal glands. Additionally, individuals with Addison’s disease often experience hyponatremia, which is a decrease in the level of sodium in the blood. Another common feature is hyperkalemia, which refers to an excessive amount of potassium in the blood. Furthermore, individuals with Addison’s disease may also experience hypercalcemia, which is an elevated level of calcium in the blood. Hypoglycemia, which is low blood sugar, is another characteristic feature of this disease. Lastly, metabolic acidosis, which refers to an imbalance in the body’s acid-base levels, is also commonly observed in individuals with Addison’s disease.

    • This question is part of the following fields:

      • Endocrinology
      23.3
      Seconds
  • Question 61 - You are managing a 72-year-old male patient who has been intubated as a...

    Correct

    • You are managing a 72-year-old male patient who has been intubated as a result of developing acute severe respiratory distress syndrome (ARDS). What measure is utilized to categorize the severity of ARDS?

      Your Answer: PaO2/FiO2 ratio

      Explanation:

      The PaO2/FiO2 ratio is a measurement used to determine the severity of Acute Respiratory Distress Syndrome (ARDS). It is calculated by dividing the arterial oxygen partial pressure (PaO2) by the fraction of inspired oxygen (FiO2). However, it is important to note that this calculation should only be done when the patient is receiving a minimum positive end-expiratory pressure (PEEP) of 5 cm water. The resulting ratio is then used to classify the severity of ARDS, with specific thresholds provided below.

      Further Reading:

      ARDS is a severe form of lung injury that occurs in patients with a predisposing risk factor. It is characterized by the onset of respiratory symptoms within 7 days of a known clinical insult, bilateral opacities on chest X-ray, and respiratory failure that cannot be fully explained by cardiac failure or fluid overload. Hypoxemia is also present, as indicated by a specific threshold of the PaO2/FiO2 ratio measured with a minimum requirement of positive end-expiratory pressure (PEEP) ≥5 cm H2O. The severity of ARDS is classified based on the PaO2/FiO2 ratio, with mild, moderate, and severe categories.

      Lung protective ventilation is a set of measures aimed at reducing lung damage that may occur as a result of mechanical ventilation. Mechanical ventilation can cause lung damage through various mechanisms, including high air pressure exerted on lung tissues (barotrauma), over distending the lung (volutrauma), repeated opening and closing of lung units (atelectrauma), and the release of inflammatory mediators that can induce lung injury (biotrauma). These mechanisms collectively contribute to ventilator-induced lung injury (VILI).

      The key components of lung protective ventilation include using low tidal volumes (5-8 ml/kg), maintaining inspiratory pressures (plateau pressure) below 30 cm of water, and allowing for permissible hypercapnia. However, there are some contraindications to lung protective ventilation, such as an unacceptable level of hypercapnia, acidosis, and hypoxemia. These factors need to be carefully considered when implementing lung protective ventilation strategies in patients with ARDS.

    • This question is part of the following fields:

      • Respiratory
      4.3
      Seconds
  • Question 62 - A 42 year old female is brought into the emergency department with multiple...

    Correct

    • A 42 year old female is brought into the emergency department with multiple injuries following a severe car accident. The patient was intubated at the scene due to low GCS and concerns about their ability to maintain their airway. You are checking the patient's ventilation and blood gases. The PaO2/FiO2 ratio is 140 mmHg with PEEP 7 cm H2O. What does this suggest?

      Your Answer: Moderate acute respiratory distress syndrome

      Explanation:

      A PaO2/FiO2 ratio ranging from 100 mmHg to 200 mmHg indicates the presence of moderate Acute Respiratory Distress Syndrome (ARDS).

      Further Reading:

      ARDS is a severe form of lung injury that occurs in patients with a predisposing risk factor. It is characterized by the onset of respiratory symptoms within 7 days of a known clinical insult, bilateral opacities on chest X-ray, and respiratory failure that cannot be fully explained by cardiac failure or fluid overload. Hypoxemia is also present, as indicated by a specific threshold of the PaO2/FiO2 ratio measured with a minimum requirement of positive end-expiratory pressure (PEEP) ≥5 cm H2O. The severity of ARDS is classified based on the PaO2/FiO2 ratio, with mild, moderate, and severe categories.

      Lung protective ventilation is a set of measures aimed at reducing lung damage that may occur as a result of mechanical ventilation. Mechanical ventilation can cause lung damage through various mechanisms, including high air pressure exerted on lung tissues (barotrauma), over distending the lung (volutrauma), repeated opening and closing of lung units (atelectrauma), and the release of inflammatory mediators that can induce lung injury (biotrauma). These mechanisms collectively contribute to ventilator-induced lung injury (VILI).

      The key components of lung protective ventilation include using low tidal volumes (5-8 ml/kg), maintaining inspiratory pressures (plateau pressure) below 30 cm of water, and allowing for permissible hypercapnia. However, there are some contraindications to lung protective ventilation, such as an unacceptable level of hypercapnia, acidosis, and hypoxemia. These factors need to be carefully considered when implementing lung protective ventilation strategies in patients with ARDS.

    • This question is part of the following fields:

      • Respiratory
      16.5
      Seconds
  • Question 63 - A 75-year-old man is brought to the resuscitation area of your Emergency Department...

    Correct

    • A 75-year-old man is brought to the resuscitation area of your Emergency Department by ambulance. He has become increasingly unwell over the past few weeks with vomiting and diarrhea. His wife tells you that he was started on a medication by his GP six months ago for pain and stiffness around his shoulders, upper arms, and hips. She describes this medication as being '6 small blue tablets.' He has been unable to take these tablets for the past few days. On examination, he is pale and sweaty and appears confused. His observations are as follows: temperature 37.2°C, HR 130 bpm, BP 90/50, RR 22, SaO2 97% on 2 L oxygen, GCS 13. He has intravenous access in situ, and his BM stick glucose is 2.5.
      What is the SINGLE most likely diagnosis?

      Your Answer: Addisonian crisis

      Explanation:

      This patient has presented with an Addisonian crisis, which is a rare but potentially catastrophic condition if not diagnosed promptly. The most likely underlying rheumatological diagnosis in this case is polymyalgia rheumatica, and it is likely that the GP started the patient on prednisolone medication.

      Addison’s disease occurs when the adrenal glands underproduce steroid hormones, affecting the production of glucocorticoids, mineralocorticoids, and sex steroids. The main causes of Addison’s disease include autoimmune adrenalitis (accounting for 80% of cases), bilateral adrenalectomy, Waterhouse-Friderichsen syndrome (hemorrhage into the adrenal glands), and tuberculosis.

      An Addisonian crisis is most commonly triggered by the deliberate or accidental withdrawal of steroid therapy in patients with Addison’s disease. Other factors that can precipitate a crisis include infection, trauma, myocardial infarction, cerebral infarction, asthma, hypothermia, and alcohol abuse.

      The clinical features of Addison’s disease include weakness, lethargy, hypotension (especially orthostatic hypotension), nausea, vomiting, weight loss, reduced axillary and pubic hair, depression, and hyperpigmentation (particularly in palmar creases, buccal mucosa, and exposed areas). In an Addisonian crisis, the main features are usually hypoglycemia and shock, characterized by tachycardia, peripheral vasoconstriction, hypotension, altered consciousness, and coma.

      Biochemically, Addison’s disease is characterized by increased ACTH levels (as a compensatory response to stimulate the adrenal glands), elevated serum renin levels, hyponatremia, hyperkalemia, hypercalcemia, hypoglycemia, and metabolic acidosis. Diagnostic investigations may include the Synacthen test, plasma ACTH level, plasma renin level, and adrenocortical antibodies.

      Management of Addison’s disease should be overseen by an Endocrinologist. Typically, patients require hydrocortisone, fludrocortisone, and dehydroepiandrosterone. Some patients may also need thyroxine if there is hypothalamic-pituitary disease present. Treatment is lifelong, and patients should carry a steroid card and a MedicAlert bracelet, being aware of the possibility of an Addisonian crisis.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      70.6
      Seconds
  • Question 64 - A 45-year-old woman presents with increasing shortness of breath at rest and severe...

    Correct

    • A 45-year-old woman presents with increasing shortness of breath at rest and severe left shoulder pain. The pain travels down the inner side of her left arm and into her ring and little finger. She has a long history of smoking, having smoked 30 packs of cigarettes per year. During the examination, her voice sounds hoarse and there is muscle wasting in her left hand and forearm. Additionally, she has a left-sided ptosis and miosis.

      What is the MOST suitable initial test to perform?

      Your Answer: Chest X-ray

      Explanation:

      This individual, who has been smoking for a long time, is likely to have squamous cell carcinoma of the lung located at the right apex. This particular type of cancer is causing Pancoast’s syndrome. Pancoast’s syndrome typically presents with rib erosion, leading to severe shoulder pain, as well as Horner’s syndrome due to the infiltration of the lower part of the brachial plexus. Additionally, there may be hoarseness of the voice and a ‘bovine cough’ due to a concurrent recurrent laryngeal nerve palsy.

      The classic description of Horner’s syndrome includes the following clinical features on the same side as the tumor: miosis (constricted pupil), ptosis (drooping eyelid), anhidrosis (lack of sweating), and enophthalmos (sunken appearance of the eye). A chest X-ray would be able to detect the presence of the apical tumor and confirm the diagnosis.

    • This question is part of the following fields:

      • Respiratory
      13.7
      Seconds
  • Question 65 - A 32-year-old woman who is 39-weeks pregnant is brought to the Emergency Department...

    Correct

    • A 32-year-old woman who is 39-weeks pregnant is brought to the Emergency Department due to severe headaches, visual disturbances, and abdominal pain. Shortly after arrival, she experiences a seizure and collapses. Her husband mentions that she has been receiving treatment for hypertension during the pregnancy.

      What is the most suitable initial treatment in this case?

      Your Answer: IV magnesium sulphate

      Explanation:

      Eclampsia is the most likely diagnosis in this case. It is characterized by the occurrence of one or more convulsions on top of pre-eclampsia. To control seizures in eclampsia, the recommended treatment is magnesium sulphate. The Collaborative Eclampsia Trial regimen should be followed for administering magnesium sulphate. Initially, a loading dose of 4 g should be given intravenously over 5 to 15 minutes. This should be followed by a continuous infusion of 1 g per hour for 24 hours. If the woman experiences another eclamptic seizure, the infusion should be continued for an additional 24 hours after the last seizure. In case of recurrent seizures, a further dose of 2-4 g should be administered intravenously over 5 to 15 minutes. It is important to note that the only cure for eclampsia is the delivery of the fetus and placenta. Once the patient is stabilized, she should be prepared for an emergency caesarean section.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      147.4
      Seconds
  • Question 66 - A 45-year-old woman that is 42-weeks pregnant becomes suddenly very breathless shortly after...

    Correct

    • A 45-year-old woman that is 42-weeks pregnant becomes suddenly very breathless shortly after going into labor. An ambulance is called, and she is ‘blue lighted’ into the resus area of your Emergency Department. She appears cyanosed and states that her heart feels like it is ‘beating very quickly’. Shortly after arriving in the Emergency Department, she becomes unresponsive. You notice a change in rhythm to ventricular fibrillation on the cardiac monitor and are unable to detect a pulse or any signs of life. She receives three stacked shocks and is managed according to the ALS algorithm, but initial attempts at resuscitation are unsuccessful.
      Which of the following management options is most likely to improve his likelihood of successful resuscitation?

      Your Answer: Peri-mortem Caesarean section

      Explanation:

      Based on her presentation, the most probable cause of the cardiac arrest in this case is either a pulmonary embolism or amniotic fluid embolism.

      When dealing with a cardiac arrest during pregnancy, there are several adjustments that need to be made compared to a regular cardiac arrest situation. These adjustments include:

      – Ensuring the presence of an obstetrician
      – Having a paediatrician or neonatologist available
      – Manually displacing the uterus to the left in order to relieve caval compression
      – Tilting the table to the left side, ideally at a 15-30 degree angle
      – Performing early tracheal intubation to reduce the risk of aspiration (it is recommended to seek expert anaesthetic assistance for this)
      – Initiating preparations for an emergency Caesarean section

      In the event of a cardiac arrest, a perimortem Caesarean section should be performed within 5 minutes of the onset. This procedure is crucial as it relieves caval compression, improves the chances of successful resuscitation by increasing venous return during CPR, and maximizes the likelihood of the infant’s survival. The best survival rate for the infant occurs when delivery is achieved within 5 minutes of the mother’s cardiac arrest.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      23.9
      Seconds
  • Question 67 - A 40-year-old man experiences anaphylaxis after being stung by a bee. He is...

    Correct

    • A 40-year-old man experiences anaphylaxis after being stung by a bee. He is rushed to the resuscitation room for immediate treatment.

      Which category of hypersensitivity reaction does anaphylaxis exemplify?

      Your Answer: Type I

      Explanation:

      Anaphylaxis is a type I hypersensitivity reaction, where the body’s response is triggered by the attachment of an antigen to a specific antibody. This attachment then leads to the release of histamine and other mediators, such as leukotrienes, tumor necrosis factor, and various cytokines, from mast cells and basophils. These substances are released when these cells are exposed to the antigen.

    • This question is part of the following fields:

      • Allergy
      4
      Seconds
  • Question 68 - A patient with a previous complaint of upper abdominal pain and frequent bowel...

    Incorrect

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

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

      Your Answer: Taenia saginata

      Correct Answer: Taenia solium

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Infectious Diseases
      15.6
      Seconds
  • Question 69 - A 45-year-old woman comes in with a history of fatigue, excessive thirst, and...

    Correct

    • A 45-year-old woman comes in with a history of fatigue, excessive thirst, and frequent urination. A urine dipstick test is done, which shows the presence of glucose in the urine.
      Which ONE result would be INCONSISTENT with a diagnosis of diabetes mellitus in this patient?

      Your Answer: An HbA1c of 40 mmol/mol

      Explanation:

      According to the 2011 recommendations from the World Health Organization (WHO), HbA1c can now be used as a diagnostic test for diabetes. However, this is only applicable if stringent quality assurance tests are in place and the assays are standardized to criteria aligned with international reference values. Additionally, accurate measurement of HbA1c is only possible if there are no conditions present that could hinder its accuracy.

      To diagnose diabetes using HbA1c, a value of 48 mmol/mol (6.5%) is recommended as the cut-off point. It’s important to note that a value lower than 48 mmol/mol (6.5%) does not exclude the possibility of diabetes, as glucose tests are still necessary for a definitive diagnosis.

      When using glucose tests, the following criteria are considered diagnostic for diabetes mellitus:
      – A random venous plasma glucose concentration greater than 11.1 mmol/l
      – A fasting plasma glucose concentration greater than 7.0 mmol/l
      – A two-hour plasma glucose concentration greater than 11.1 mmol/l, two hours after consuming 75g of anhydrous glucose in an oral glucose tolerance test (OGTT)

      However, there are certain circumstances where HbA1c is not appropriate for diagnosing diabetes mellitus. These include:
      – ALL children and young people
      – Patients of any age suspected of having Type 1 diabetes
      – Patients with symptoms of diabetes for less than two months
      – Patients at high risk of diabetes who are acutely ill, such as those requiring hospital admission
      – Patients taking medication that may cause a rapid rise in glucose levels, such as steroids or antipsychotics
      – Patients with acute pancreatic damage, including those who have undergone pancreatic surgery
      – Pregnant individuals
      – Presence of genetic, hematologic, and illness-related factors that can influence HbA1c and its measurement.

    • This question is part of the following fields:

      • Endocrinology
      12.7
      Seconds
  • Question 70 - A 25-year-old arrives at the emergency department after being involved in a car...

    Correct

    • A 25-year-old arrives at the emergency department after being involved in a car accident. A FAST scan is conducted to assess for abdominal injuries caused by blunt trauma. Which of the following is NOT among the four standard views obtained during a FAST scan?

      Your Answer: Umbilical view

      Explanation:

      FAST scans consist of four standard views that are obtained to assess different areas of the body. These views include the right upper quadrant (RUQ), left upper quadrant (LUQ), pericardial sac, and the pelvis.

      In the RUQ view, the focus is on the right flank or peri-hepatic area, which includes Morison’s pouch and the right costophrenic pleural recess.

      The LUQ view examines the left flank or peri-splenic area, which includes the spleen-renal recess and the left costophrenic pleural space.

      The pericardial sac is also assessed to evaluate any abnormalities in this area.

      Lastly, the pelvis is examined in two planes to ensure a comprehensive evaluation.

      In addition to these four standard views, an anterior pleural view is often performed alongside the others. This view used to be part of the extended FAST (eFAST) scan but is now commonly included routinely.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Trauma
      2.5
      Seconds
  • Question 71 - You assess a patient with a decreased calcium level.
    What is a known factor...

    Incorrect

    • You assess a patient with a decreased calcium level.
      What is a known factor that can cause hypocalcemia?

      Your Answer: Lithium

      Correct Answer: Rhabdomyolysis

      Explanation:

      Rhabdomyolysis leads to an increase in phosphate levels in the blood, which in turn causes a decrease in the levels of ionized calcium. On the other hand, conditions such as Addison’s disease, hyperthyroidism, the use of thiazide diuretics, and lithium can all contribute to an elevation in calcium levels. There are also other factors that can result in low calcium levels, including hypoparathyroidism, a deficiency of vitamin D, sepsis, fluoride poisoning, a lack of magnesium, renal failure, tumor lysis syndrome, pancreatitis, and the administration of EDTA infusions.

    • This question is part of the following fields:

      • Nephrology
      38.7
      Seconds
  • Question 72 - A 35 year old woman is brought into the emergency department after being...

    Correct

    • A 35 year old woman is brought into the emergency department after being rescued from a building fire. The patient does not appear to have sustained any major burns but reports that she was inhaling smoke for around 20 minutes before being rescued. What are the two types of poisoning that you would be most concerned about in this patient?

      Your Answer: Carbon monoxide and cyanide poisoning

      Explanation:

      When patients are exposed to the inhalation of combustion byproducts, they face the danger of being poisoned by carbon monoxide and cyanide. In situations where hydrocarbons and substances containing carbon and nitrogen are incompletely burned, the formation of both carbon monoxide and cyanide gas can occur. Individuals who inhale smoke are particularly vulnerable to this type of poisoning.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Environmental Emergencies
      11.2
      Seconds
  • Question 73 - 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
      8.3
      Seconds
  • Question 74 - A 42-year-old man presents with a right-sided scrotal swelling. He is also experiencing...

    Correct

    • A 42-year-old man presents with a right-sided scrotal swelling. He is also experiencing a 'pulling sensation' in the same testis, which worsens after physical activity. During the examination, you are unable to feel a lump while the patient is lying down, but upon standing, you notice a poorly defined, non-translucent mass that is clearly separate from the testis and is located above and behind the testis. The scrotum feels like 'a bag of worms', the mass increases in size when the patient performs the Valsalva maneuver, and there is a cough impulse present.
      What is the SINGLE most likely diagnosis?

      Your Answer: Varicocele

      Explanation:

      A varicocele is a condition characterized by the presence of varicose veins in the pampiniform plexus of the cord and scrotum. It is more commonly observed in the left testis compared to the right and may be linked to infertility. The primary reason for this association is believed to be the elevated temperature of the testis caused by the presence of varicosities.

      Typically, individuals with varicocele experience a dull ache in the testis, which tends to worsen after physical activity or towards the end of the day. The scrotum is often described as feeling like a bag of worms. While the varicocele cannot usually be detected when the patient is lying down, it can often be identified during examination while standing. It is felt as a poorly defined, non-transilluminable mass that is clearly separate from the testis and is located above and behind it. The dilation of the varicocele increases when the Valsalva maneuver is performed, and a cough impulse may also be present.

      Conservative treatment is typically recommended for varicocele, with surgery being reserved for severe cases only.

    • This question is part of the following fields:

      • Urology
      5
      Seconds
  • Question 75 - You evaluate a 28-year-old patient with burns. Your supervisor recommends referring the patient...

    Correct

    • You evaluate a 28-year-old patient with burns. Your supervisor recommends referring the patient to the burns unit. What is a recognized criterion for referral to the burns unit?

      Your Answer: Burn ≥ 3% TBSA (total body surface area) in an adult

      Explanation:

      A recognized criterion for referral to the burns unit is when a burn involves the upper limb, any burn that has not healed in 7 days, any burn with significant blistering, a burn with a pain score on presentation greater than 8 out of 10 on a visual analogue scale, or a burn that covers 3% or more of the total body surface area in an adult.

      Further Reading:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Surgical Emergencies
      38.6
      Seconds
  • Question 76 - A 55-year-old man presents with a history of excessive urination and increased thirst....

    Correct

    • A 55-year-old man presents with a history of excessive urination and increased thirst. A diagnosis of type 2 diabetes mellitus is suspected.
      Select from the options below the SINGLE result that is most indicative of a diagnosis of diabetes mellitus.

      Your Answer: An HbA1c of 50 mmol/mol

      Explanation:

      According to the 2011 recommendations from the World Health Organization (WHO), HbA1c can now be used as a diagnostic test for diabetes. However, this is only applicable if stringent quality assurance tests are in place and the assays are standardized to criteria aligned with international reference values. Additionally, accurate measurement of HbA1c is only possible if there are no conditions present that could hinder its accuracy.

      To diagnose diabetes using HbA1c, a value of 48 mmol/mol (6.5%) is recommended as the cut-off point. It’s important to note that a value lower than 48 mmol/mol (6.5%) does not exclude the possibility of diabetes, as glucose tests are still necessary for a definitive diagnosis.

      When using glucose tests, the following criteria are considered diagnostic for diabetes mellitus:
      – A random venous plasma glucose concentration greater than 11.1 mmol/l
      – A fasting plasma glucose concentration greater than 7.0 mmol/l
      – A two-hour plasma glucose concentration greater than 11.1 mmol/l, two hours after consuming 75g of anhydrous glucose in an oral glucose tolerance test (OGTT)

      However, there are certain circumstances where HbA1c is not appropriate for diagnosing diabetes mellitus. These include:
      – ALL children and young people
      – Patients of any age suspected of having Type 1 diabetes
      – Patients with symptoms of diabetes for less than two months
      – Patients at high risk of diabetes who are acutely ill, such as those requiring hospital admission
      – Patients taking medication that may cause a rapid rise in glucose levels, such as steroids or antipsychotics
      – Patients with acute pancreatic damage, including those who have undergone pancreatic surgery
      – Pregnant individuals
      – Presence of genetic, hematologic, and illness-related factors that can influence HbA1c and its measurement.

    • This question is part of the following fields:

      • Endocrinology
      13.5
      Seconds
  • Question 77 - You are summoned to assist with a 72-year-old patient who is in the...

    Correct

    • You are summoned to assist with a 72-year-old patient who is in the resuscitation bay and has experienced two defibrillation attempts following cardiac arrest. Unfortunately, there is no supply of amiodarone available, so your consultant instructs you to prepare lidocaine for administration after the next shock. What is the initial dosage of lidocaine to be given during cardiac arrest?

      Your Answer: 1 mg/kg

      Explanation:

      During cardiac arrest, Lidocaine is administered through a slow IV injection at an initial dose of 1 mg/kg when deemed suitable.

      Further Reading:

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

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

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

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

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

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

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

    • This question is part of the following fields:

      • Basic Anaesthetics
      9.4
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  • Question 78 - You are treating an 82-year-old patient who is unable to bear weight after...

    Correct

    • You are treating an 82-year-old patient who is unable to bear weight after a fall. X-ray results confirm a fractured neck of femur. You inform the patient that they will be referred for surgery. In terms of the blood supply to the femoral neck, which artery is responsible for supplying blood to this area?

      Your Answer: Deep femoral artery

      Explanation:

      The femoral neck receives its blood supply from branches of the deep femoral artery, also known as the profunda femoris artery. The deep femoral artery gives rise to the medial and lateral circumflex branches, which form a network of blood vessels around the femoral neck.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Elderly Care / Frailty
      25.9
      Seconds
  • Question 79 - A female trauma victim that has experienced substantial blood loss is estimated to...

    Correct

    • A female trauma victim that has experienced substantial blood loss is estimated to have experienced a grade IV hemorrhage. The patient's weight is approximately 60 kg.
      Which of the following physiological indicators aligns with a diagnosis of grade IV hemorrhage?

      Your Answer: Blood loss of greater than 2 L in a 70 kg male

      Explanation:

      Recognizing the extent of blood loss based on vital sign and mental status abnormalities is a crucial skill. The Advanced Trauma Life Support (ATLS) classification for hemorrhagic shock correlates the amount of blood loss with expected physiological responses in a healthy individual weighing 70 kg. In terms of body weight, the total circulating blood volume accounts for approximately 7%, which is roughly equivalent to five liters in an average 70 kg male patient.

      The ATLS classification for hemorrhagic shock is as follows:

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

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

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

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

    • This question is part of the following fields:

      • Trauma
      16
      Seconds
  • Question 80 - A child arrives at the Emergency Department with a petechial rash, headache, neck...

    Correct

    • A child arrives at the Emergency Department with a petechial rash, headache, neck stiffness, and sensitivity to light. You suspect a diagnosis of meningococcal meningitis.
      What is the most suitable initial approach to management?

      Your Answer: Give ceftriaxone 2 g IV

      Explanation:

      Due to the potentially life-threatening nature of the disease, it is crucial to initiate treatment without waiting for laboratory confirmation. Immediate administration of antibiotics is necessary.

      In a hospital setting, the preferred agents for treatment are IV ceftriaxone (2 g for adults; 80 mg/kg for children) or IV cefotaxime (2 g for adults; 80 mg/kg for children). In the prehospital setting, IM benzylpenicillin can be given as an alternative. If there is a history of anaphylaxis to cephalosporins, chloramphenicol is a suitable alternative.

      It is important to prioritize prompt treatment due to the severity of the disease. The recommended antibiotics should be administered as soon as possible to ensure the best possible outcome for the patient.

    • This question is part of the following fields:

      • Neurology
      8.8
      Seconds
  • Question 81 - A 60 year old male presents to the emergency department complaining of headache...

    Correct

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

      Your Answer: Plasma metanephrines

      Explanation:

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

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
      17.7
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  • Question 82 - A 72 year old female is brought into the emergency department due to...

    Correct

    • A 72 year old female is brought into the emergency department due to near-fainting. Whilst in the department the patient loses consciousness and on examination there is no detectable pulse. You begin cardiopulmonary resuscitation (CPR). What is the ratio of chest compressions to rescue breaths used during CPR?

      Your Answer: 30:2

      Explanation:

      The ratio of chest compressions to rescue breaths during CPR is now 30:2. Prior to 2005, the ratio used was 15:2.

      Further Reading:

      In the event of an adult experiencing cardiorespiratory arrest, it is crucial for doctors to be familiar with the Advanced Life Support (ALS) algorithm. They should also be knowledgeable about the proper technique for chest compressions, the appropriate rhythms for defibrillation, the reversible causes of arrest, and the drugs used in advanced life support.

      During chest compressions, the rate should be between 100-120 compressions per minute, with a depth of compression of 5-6 cm. The ratio of chest compressions to rescue breaths should be 30:2. It is important to change the person giving compressions regularly to prevent fatigue.

      There are two shockable ECG rhythms that doctors should be aware of: ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT). These rhythms require defibrillation.

      There are four reversible causes of cardiorespiratory arrest, known as the 4 H’s and 4 T’s. The 4 H’s include hypoxia, hypovolemia, hypo or hyperkalemia or metabolic abnormalities, and hypothermia. The 4 T’s include thrombosis (coronary or pulmonary), tension pneumothorax, tamponade, and toxins. Identifying and treating these reversible causes is crucial for successful resuscitation.

      When it comes to resus drugs, they are considered of secondary importance during CPR due to the lack of high-quality evidence for their efficacy. However, adrenaline (epinephrine) and amiodarone are the two drugs included in the ALS algorithm. Doctors should be familiar with the dosing, route, and timing of administration for both drugs.

      Adrenaline should be administered intravenously at a concentration of 1 in 10,000 (100 micrograms/mL). It should be repeated every 3-5 minutes. Amiodarone is initially given at a dose of 300 mg, either from a pre-filled syringe or diluted in 20 mL of Glucose 5%. If required, an additional dose of 150 mg can be given by intravenous injection. This is followed by an intravenous infusion of 900 mg over 24 hours. The first dose of amiodarone is given after 3 shocks.

    • This question is part of the following fields:

      • Resus
      8.4
      Seconds
  • Question 83 - You assess a patient who is experiencing difficulty in closing their right eye...

    Correct

    • You assess a patient who is experiencing difficulty in closing their right eye due to a nerve injury. Currently, the eye is dry and necessitates regular administration of eye drops. Your consultant informs you that the orbicularis oculi muscle is solely responsible for closing the eye and suggests that if the symptoms cannot be improved, the patient may require surgical closure of the eye.
      Which nerve has been affected in this scenario?

      Your Answer: Facial nerve

      Explanation:

      The orbicularis oculi muscle encircles the eye socket and extends into the eyelid. It is composed of two parts: the orbital part, which forcefully closes the eye, and the palpebral part, which gently closes the eye. The innervation of the orbicularis oculi muscle is provided by the facial nerve. In the event of facial nerve damage, the orbicularis oculi muscle loses its functionality. As the sole muscle responsible for closing the eyelids, this can have significant clinical implications. The inability to shut the eye can lead to dryness of the cornea and the development of exposure keratitis. While mild cases can be managed with regular use of eye drops, severe cases may require surgical closure of the eye.

    • This question is part of the following fields:

      • Ophthalmology
      27.5
      Seconds
  • Question 84 - In the aftermath of a suspected CBRN (chemical, biological, radiological, and nuclear) incident,...

    Correct

    • In the aftermath of a suspected CBRN (chemical, biological, radiological, and nuclear) incident, where sarin gas is believed to be the responsible agent, healthcare workers are faced with a significant number of casualties. What is the primary focus for healthcare workers when responding to the scene of a CBRN event?

      Your Answer: The wearing of adequate personal protective equipment

      Explanation:

      Healthcare workers responding to contaminated casualties must prioritize their own safety by wearing appropriate personal protective equipment. This is crucial because secondary contamination can occur. Additionally, if working in contaminated areas, healthcare workers should maximize ventilation and use breathing equipment. Ensuring the safety of healthcare workers is essential as they cannot effectively help the casualties without it.

      The first step in managing contaminated casualties is early skin decontamination. It is important to move the casualties to a safe area and remove all contaminated clothing to minimize further exposure. The skin should then be thoroughly rinsed with water to physically remove the nerve agent. After rinsing, it should be washed with an alkaline solution of soap and water or a 0.5% hypochlorite solution to chemically neutralize the nerve agent. To prevent ongoing absorption through the eyes, contact lenses should be removed and the eyes irrigated.

      Resuscitation should be initiated using an ABCDE approach, and casualties should be supported and transferred to the hospital as quickly as possible. Ventilation may be necessary in some cases. Nerve agent antidote autoinjectors can be utilized, and the use of these should be guided by local policy for prehospital personnel.

    • This question is part of the following fields:

      • Major Incident Management & PHEM
      16.7
      Seconds
  • Question 85 - A 28-year-old primigravida woman comes in with a moderate amount of vaginal bleeding...

    Correct

    • A 28-year-old primigravida woman comes in with a moderate amount of vaginal bleeding and lower abdominal discomfort. She reports the bleeding to be heavier than her normal period. She is currently 9 weeks pregnant. During the examination, she experiences mild tenderness in her lower abdomen. A speculum examination is conducted, revealing an open cervical os.

      What is the SINGLE most probable diagnosis?

      Your Answer: Inevitable miscarriage

      Explanation:

      A threatened miscarriage happens when there is bleeding during the first trimester of pregnancy, but no fetal tissue has been expelled, and the opening of the cervix is closed.

      If cervical dilatation occurs, a threatened miscarriage can progress to become an inevitable miscarriage. In this case, the pain and bleeding are usually more intense, and upon examination, the cervix will be found to be open.

    • This question is part of the following fields:

      • Obstetrics & Gynaecology
      12
      Seconds
  • Question 86 - A 42-year-old woman with a long history of anxiety presents having taken a...

    Correct

    • A 42-year-old woman with a long history of anxiety presents having taken a deliberate overdose of the medication she takes for a thyroid condition. She informs you that the medication she takes for this condition is levothyroxine 100 mcg. She consumed the medication approximately 30 minutes ago but was promptly discovered by her husband, who quickly brought her to the Emergency Department.

      Which of the following tests will be most beneficial initially?

      Your Answer: Arterial blood gas

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      29.7
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  • Question 87 - A 65 year old female is brought into the emergency department with a...

    Correct

    • A 65 year old female is brought into the emergency department with a history of increasing fatigue, weakness and nausea over the past week. Over the last 48 hours the patient has become increasingly confused. The patient has a past medical history of hypertension and osteoporosis. The patient's observations and initial tests are shown below:

      Blood pressure 90/60 mmHg
      Pulse 110 bpm
      Respiration rate 20 bpm
      Oxygen saturations 98% on air
      Na+ 142 mmol/l
      K+ 4.2 mmol/l
      Urea 20 mmol/l
      Creatinine 110 µmol/l
      Glucose 50 mmol/l
      pH 7.35
      Bicarbonate 20 mmol/l
      Urinalysis Ketones + glucose +++

      What is the most appropriate first line treatment?

      Your Answer: Administer 1 litre 0.9% sodium chloride solution over 1 hour

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
      19.3
      Seconds
  • Question 88 - A new Emergency Department nurse is required to verify her immunity to hepatitis...

    Correct

    • A new Emergency Department nurse is required to verify her immunity to hepatitis B before starting her position. She has received a hepatitis B vaccination series in the past but cannot remember the specific dates.
      What ONE blood test result would indicate that she has developed immunity as a result of her hepatitis B vaccination?

      Your Answer: HBsAg negative, anti-HBs positive

      Explanation:

      Hepatitis B surface antigen (HBsAg) is a protein found on the surface of the hepatitis B virus. It can be detected in high levels in the blood during both acute and chronic hepatitis B virus infections. The presence of HBsAg indicates that the person is capable of spreading the infection to others. Normally, the body produces antibodies to HBsAg as part of the immune response to the infection. HBsAg is also used to create the hepatitis B vaccine.

      Hepatitis B surface antibody (anti-HBs) indicates that a person has recovered from the hepatitis B virus infection and is now immune to it. This antibody can also develop in individuals who have been successfully vaccinated against hepatitis B.

      Total hepatitis B core antibody (anti-HBc) appears when symptoms of acute hepatitis B begin and remains present for life. The presence of anti-HBc indicates that a person has either had a previous or ongoing infection with the hepatitis B virus, although the exact time frame cannot be determined. This antibody is not present in individuals who have received the hepatitis B vaccine.

      IgM antibody to hepatitis B core antigen (IgM anti-HBc) indicates a recent infection or acute hepatitis B. If this antibody is present, it suggests that the infection occurred within the past six months.

    • This question is part of the following fields:

      • Gastroenterology & Hepatology
      16.4
      Seconds
  • Question 89 - You are summoned to the resuscitation bay to aid in the care of...

    Correct

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

      Your Answer: Maintain systolic blood pressure >90 mmHg

      Explanation:

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

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

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Neurology
      13.8
      Seconds
  • Question 90 - A 78 year old male is brought into the emergency department from a...

    Correct

    • A 78 year old male is brought into the emergency department from a retirement home due to increasing disorientation and drowsiness. Blood tests reveal a serum sodium level of 117 mmol/L and the patient is administered Intravenous 3% sodium chloride solution. The patient initially demonstrates some improvement, becoming more awake and less confused, but after approximately 90 minutes, he becomes lethargic and experiences difficulty speaking with noticeable dysarthria.

      What is the probable underlying reason?

      Your Answer: Central pontine myelinolysis

      Explanation:

      The probable underlying reason for the patient’s symptoms is central pontine myelinolysis. This condition is characterized by the destruction of the myelin sheath in the pons, a region of the brainstem. It is often caused by a rapid correction of hyponatremia, which is a low level of sodium in the blood. In this case, the patient’s serum sodium level was initially low at 117 mmol/L, and the administration of intravenous 3% sodium chloride solution caused a rapid increase in sodium levels. This sudden change in sodium concentration can lead to the development of central pontine myelinolysis. The initial improvement in the patient’s symptoms may have been due to the correction of hyponatremia, but the subsequent development of lethargy and dysarthria suggests the onset of central pontine myelinolysis.

      Further Reading:

      Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition characterized by low sodium levels in the blood due to excessive secretion of antidiuretic hormone (ADH). ADH, also known as arginine vasopressin (AVP), is responsible for promoting water and sodium reabsorption in the body. SIADH occurs when there is impaired free water excretion, leading to euvolemic (normal fluid volume) hypotonic hyponatremia.

      There are various causes of SIADH, including malignancies such as small cell lung cancer, stomach cancer, and prostate cancer, as well as neurological conditions like stroke, subarachnoid hemorrhage, and meningitis. Infections such as tuberculosis and pneumonia, as well as certain medications like thiazide diuretics and selective serotonin reuptake inhibitors (SSRIs), can also contribute to SIADH.

      The diagnostic features of SIADH include low plasma osmolality, inappropriately elevated urine osmolality, urinary sodium levels above 30 mmol/L, and euvolemic. Symptoms of hyponatremia, which is a common consequence of SIADH, include nausea, vomiting, headache, confusion, lethargy, muscle weakness, seizures, and coma.

      Management of SIADH involves correcting hyponatremia slowly to avoid complications such as central pontine myelinolysis. The underlying cause of SIADH should be treated if possible, such as discontinuing causative medications. Fluid restriction is typically recommended, with a daily limit of around 1000 ml for adults. In severe cases with neurological symptoms, intravenous hypertonic saline may be used. Medications like demeclocycline, which blocks ADH receptors, or ADH receptor antagonists like tolvaptan may also be considered.

      It is important to monitor serum sodium levels closely during treatment, especially if using hypertonic saline, to prevent rapid correction that can lead to central pontine myelinolysis. Osmolality abnormalities can help determine the underlying cause of hyponatremia, with increased urine osmolality indicating dehydration or renal disease, and decreased urine osmolality suggesting SIADH or overhydration.

    • This question is part of the following fields:

      • Neurology
      24.1
      Seconds
  • Question 91 - A 35-year-old woman comes in with a femoral shaft fracture sustained in a...

    Correct

    • A 35-year-old woman comes in with a femoral shaft fracture sustained in a car accident. You have been requested to administer a femoral nerve block.
      Which of the following two landmarks should be utilized?

      Your Answer: The anterior superior iliac spine and the pubic symphysis

      Explanation:

      To perform a landmark guided femoral nerve block, first locate the inguinal ligament. This can be done by drawing an imaginary line between the anterior superior iliac spine (ASIS) and the pubic symphysis. The femoral nerve passes through the center of this line and is most superficial at the level of the inguinal crease.

      Next, palpate the femoral pulse at the level of the inguinal ligament. The femoral nerve is located approximately 1-1.5 cm lateral to this point. This is where the needle entry point should be.

      By following these steps and using the landmarks provided, you can accurately perform a femoral nerve block.

    • This question is part of the following fields:

      • Pain & Sedation
      19.3
      Seconds
  • Question 92 - A 32-year-old woman arrives at the emergency department with lip swelling and wheezing....

    Correct

    • A 32-year-old woman arrives at the emergency department with lip swelling and wheezing. According to her partner, she has a nut allergy. Anaphylaxis is suspected. What type of hypersensitivity reaction is allergic anaphylaxis?

      Your Answer: Type I hypersensitivity reaction

      Explanation:

      Anaphylaxis is a severe allergic reaction that is caused by the immune system overreaction to a specific allergen. This reaction is classified as a Type I hypersensitivity reaction, which means it is mediated by the IgE antibodies.

      Further Reading:

      Anaphylaxis is a severe and life-threatening hypersensitivity reaction that can have sudden onset and progression. It is characterized by skin or mucosal changes and can lead to life-threatening airway, breathing, or circulatory problems. Anaphylaxis can be allergic or non-allergic in nature.

      In allergic anaphylaxis, there is an immediate hypersensitivity reaction where an antigen stimulates the production of IgE antibodies. These antibodies bind to mast cells and basophils. Upon re-exposure to the antigen, the IgE-covered cells release histamine and other inflammatory mediators, causing smooth muscle contraction and vasodilation.

      Non-allergic anaphylaxis occurs when mast cells degrade due to a non-immune mediator. The clinical outcome is the same as in allergic anaphylaxis.

      The management of anaphylaxis is the same regardless of the cause. Adrenaline is the most important drug and should be administered as soon as possible. The recommended doses for adrenaline vary based on age. Other treatments include high flow oxygen and an IV fluid challenge. Corticosteroids and chlorpheniramine are no longer recommended, while non-sedating antihistamines may be considered as third-line treatment after initial stabilization of airway, breathing, and circulation.

      Common causes of anaphylaxis include food (such as nuts, which is the most common cause in children), drugs, and venom (such as wasp stings). Sometimes it can be challenging to determine if a patient had a true episode of anaphylaxis. In such cases, serum tryptase levels may be measured, as they remain elevated for up to 12 hours following an acute episode of anaphylaxis.

      The Resuscitation Council (UK) provides guidelines for the management of anaphylaxis, including a visual algorithm that outlines the recommended steps for treatment.
      https://www.resus.org.uk/sites/default/files/2021-05/Emergency%20Treatment%20of%20Anaphylaxis%20May%202021_0.pdf

    • This question is part of the following fields:

      • Allergy
      63.2
      Seconds
  • Question 93 - A 5-year-old boy is brought to the Emergency Department by his mother. He...

    Correct

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

      What is the MOST suitable course of action for management?

      Your Answer: Oral flucloxacillin

      Explanation:

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

    • This question is part of the following fields:

      • Dermatology
      37.4
      Seconds
  • Question 94 - A 25 year old female has been brought into the emergency department (ED)...

    Correct

    • A 25 year old female has been brought into the emergency department (ED) in the early hours of the morning after being discovered unresponsive in a parking lot behind a nightclub by the authorities. The paramedics initiated cardiopulmonary resuscitation (CPR) which has been ongoing since the patient's arrival in the ED. The patient's core temperature is recorded at 28ºC. You contemplate the most effective Rewarming strategy to employ. Which method of Rewarming is known for producing a rapid increase in core body temperature?

      Your Answer: Cardiopulmonary bypass

      Explanation:

      Cardiopulmonary bypass (CPB) is the most efficient technique for warming up a patient who is experiencing hypothermia. While other methods may also be suitable and may have already been initiated by the paramedic team, CPB stands out as the most effective approach.

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Environmental Emergencies
      5.9
      Seconds
  • Question 95 - A 55-year-old woman presents with a swollen, red, and painful right knee. Septic...

    Correct

    • A 55-year-old woman presents with a swollen, red, and painful right knee. Septic arthritis is suspected, and a joint aspirate is sent for laboratory testing. The patient's medical history reveals that she is a known carrier of MRSA, raising concerns of an MRSA infection.
      What is the recommended first-line antibiotic for septic arthritis when MRSA is suspected?

      Your Answer: Vancomycin

      Explanation:

      Septic arthritis occurs when an infectious agent invades a joint, causing it to become purulent. The main symptoms of septic arthritis include pain in the affected joint, redness, warmth, and swelling of the joint, and difficulty moving the joint. Patients may also experience fever and systemic upset. The most common cause of septic arthritis is Staphylococcus aureus, but other bacteria such as Streptococcus spp., Haemophilus influenzae, Neisseria gonorrhoea, and Escherichia coli can also be responsible.

      According to the current recommendations by NICE and the BNF, the initial treatment for septic arthritis is flucloxacillin. However, if a patient is allergic to penicillin, clindamycin can be used instead. If there is a suspicion of MRSA infection, vancomycin is the recommended choice. In cases where gonococcal arthritis or a Gram-negative infection is suspected, cefotaxime is the preferred treatment. The suggested duration of treatment is typically 4-6 weeks, although it may be longer if the infection is complicated.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      5.6
      Seconds
  • Question 96 - A 45 year old male presents to the emergency department complaining of abnormal...

    Correct

    • A 45 year old male presents to the emergency department complaining of abnormal sensations in his right hand. During the history, the patient mentions feeling constantly fatigued and experiencing a weight gain of approximately 10 kg over the last 3 months. Thyroid function tests reveal hypothyroidism. What is the leading cause of hypothyroidism in the United Kingdom?

      Your Answer: Autoimmune thyroiditis

      Explanation:

      In the UK, the most prevalent cause of hypothyroidism is autoimmune thyroiditis, also known as Hashimoto’s thyroiditis. On a global scale, hypothyroidism is primarily caused by iodine deficiency. However, in areas where iodine levels are sufficient, such as the UK, hypothyroidism and subclinical hypothyroidism are most commonly attributed to autoimmune thyroiditis. This condition can manifest with or without a goitre, known as atrophic thyroiditis.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
      23.5
      Seconds
  • Question 97 - A 65-year-old patient with advanced metastatic lung cancer is experiencing discomfort in his...

    Correct

    • A 65-year-old patient with advanced metastatic lung cancer is experiencing discomfort in his limbs and chest. He is currently prescribed 15 mg sustained-release morphine twice daily for pain management, but is now encountering breakthrough pain.
      According to NICE guidelines, what is the recommended first-line rescue medication for breakthrough pain?

      Your Answer: Oral immediate-release morphine

      Explanation:

      When starting treatment with strong opioids for pain relief in palliative care, it is recommended to offer patients regular oral sustained-release or oral immediate-release morphine, depending on their preference. In addition, provide rescue doses of oral immediate-release morphine for breakthrough pain. For patients without renal or hepatic comorbidities, a typical total daily starting dose schedule of 20-30 mg of oral morphine is suggested, along with 5 mg of oral immediate-release morphine for rescue doses during the titration phase. It is important to adjust the dose until a good balance is achieved between pain control and side effects. If this balance is not reached after a few dose adjustments, it is advisable to seek specialist advice. Patients should be reviewed frequently, especially during the titration phase. For patients with moderate to severe renal or hepatic impairment, it is recommended to consult a specialist before prescribing strong opioids.

      For maintenance therapy, oral sustained-release morphine is recommended as the first-line treatment for patients with advanced and progressive disease who require strong opioids. Transdermal patch formulations should not be routinely offered as first-line maintenance treatment unless oral opioids are not suitable. If pain remains inadequately controlled despite optimizing first-line maintenance treatment, it is important to review the analgesic strategy and consider seeking specialist advice.

      When it comes to breakthrough pain, oral immediate-release morphine should be offered as the first-line rescue medication for patients on maintenance oral morphine treatment. Fast-acting fentanyl should not be offered as the first-line rescue medication. If pain continues to be inadequately controlled despite optimizing treatment, it may be necessary to seek specialist advice.

      In cases where oral opioids are not suitable and analgesic requirements are stable, transdermal patches with the lowest acquisition cost can be considered. However, it is important to consult a specialist for guidance if needed. Similarly, for patients in whom oral opioids are not suitable and analgesic requirements are unstable, subcutaneous opioids with the lowest acquisition cost can be considered, with specialist advice if necessary.

      For more information, please refer to the NICE Clinical Knowledge Summary: Opioids for pain relief in palliative care. https://www.nice.org.uk/guidance/cg140

    • This question is part of the following fields:

      • Palliative & End Of Life Care
      4.9
      Seconds
  • Question 98 - A 58 year old male comes to the emergency department complaining of palpitations,...

    Correct

    • A 58 year old male comes to the emergency department complaining of palpitations, swollen legs, and excessive sweating. Thyroid function tests are requested and reveal low TSH and elevated free T4 levels. Which of the following medications is most likely responsible for these symptoms?

      Your Answer: Amiodarone

      Explanation:

      Amiodarone, a medication used to treat heart rhythm problems, can have effects on the thyroid gland. It can either cause hypothyroidism (low thyroid hormone levels) or hyperthyroidism (high thyroid hormone levels). Amiodarone is a highly fat-soluble drug that accumulates in various tissues, including the thyroid. Even after stopping the medication, its effects can still be seen due to its long elimination half-life of around 100 days.

      The reason behind amiodarone impact on the thyroid is believed to be its high iodine content. In patients with sufficient iodine levels, amiodarone-induced hypothyroidism is more likely to occur. On the other hand, in populations with low iodine levels, amiodarone can lead to a condition called iodine-induced thyrotoxicosis, which is characterized by hyperthyroidism.

      The mechanism of amiodarone-induced hypothyroidism involves the release of iodide from the drug, which blocks the uptake of further iodide by the thyroid gland and hampers the production of thyroid hormones. Additionally, amiodarone inhibits the conversion of the inactive thyroid hormone T4 to the active form T3.

      Amiodarone-induced hyperthyroidism, on the other hand, is thought to occur in individuals with abnormal thyroid glands, such as those with nodular goiters, autonomous nodules, or latent Graves’ disease. In these cases, the excess iodine from amiodarone overwhelms the thyroid’s normal regulatory mechanisms, leading to hyperthyroidism.

      Further Reading:

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

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology
      5.4
      Seconds
  • Question 99 - A 62-year-old man presents with right-sided hemiplegia of the limbs, face, and tongue...

    Incorrect

    • A 62-year-old man presents with right-sided hemiplegia of the limbs, face, and tongue and left-sided deficits in motor eye activity. He has a past medical history of hypertension, diabetes, and a previous ischemic stroke. A CT head scan is undertaken, and he is discovered to have suffered a left-sided stroke. He is subsequently admitted under the stroke team.
      What is the SINGLE most likely diagnosis?

      Your Answer: Medial medullary syndrome

      Correct Answer: Weber’s syndrome

      Explanation:

      Occlusion of the branches of the basilar artery that supply the midbrain leads to the development of Weber’s syndrome. This condition is characterized by contralateral hemiplegia, which affects the limbs, face, and tongue due to damage to the descending motor tracts within the crus cerebri. Additionally, there are ipsilateral deficits in eye motor activity caused by damage to cranial nerve III.

    • This question is part of the following fields:

      • Neurology
      15.8
      Seconds
  • Question 100 - A 21-year-old man comes in with a suddenly painful and swollen right testis...

    Correct

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

      Your Answer: Testicular torsion

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Urology
      5.5
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Neurology (8/12) 67%
Gastroenterology & Hepatology (8/8) 100%
Pharmacology & Poisoning (5/5) 100%
Haematology (4/5) 80%
Ear, Nose & Throat (3/4) 75%
Infectious Diseases (1/2) 50%
Respiratory (6/6) 100%
Palliative & End Of Life Care (2/2) 100%
Resus (2/2) 100%
Paediatric Emergencies (1/1) 100%
Surgical Emergencies (3/3) 100%
Obstetrics & Gynaecology (4/4) 100%
Environmental Emergencies (3/3) 100%
Trauma (3/4) 75%
Ophthalmology (4/4) 100%
Musculoskeletal (non-traumatic) (4/5) 80%
Neonatal Emergencies (1/1) 100%
Cardiology (3/4) 75%