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  • Question 1 - A 45-year-old doctor in the Emergency Department complains of a red and itchy...

    Correct

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

      Your Answer: Type I hypersensitivity reaction

      Explanation:

      Type I hypersensitivity reactions, also known as allergic reactions, are triggered when a person is exposed again to a particular antigen, which is referred to as the allergen. These reactions are mediated by IgE and typically manifest within 15 to 30 minutes after exposure to the allergen. One common symptom of a type I hypersensitivity reaction is the rapid onset of a urticarial rash, which occurs shortly after coming into contact with the allergen, such as latex.

    • This question is part of the following fields:

      • Allergy
      22.5
      Seconds
  • Question 2 - Your consultant has observed that the senior medical students assigned to the department...

    Incorrect

    • Your consultant has observed that the senior medical students assigned to the department have a limited understanding of vertigo. You have been tasked with delivering a teaching session on the typical causes of vertigo. In relation to vestibular neuronitis, which of the following statements is accurate?

      Your Answer: Presents with episodic bouts of vertigo typically lasting less than 20 seconds brought on by change of head position

      Correct Answer: Benign paroxysmal positional vertigo develops in around 10% of people following an episode of vestibular neuritis

      Explanation:

      Vestibular neuritis is a common complication of vestibular neuronitis, characterized by a following of people experiencing symptoms such as persistent dizziness, unsteadiness, and fear of falling. However, a rare complication called phobic postural vertigo may also occur, where individuals experience these symptoms despite not actually falling.

      On the other hand, benign paroxysmal positional vertigo (BPPV) presents with short episodes of vertigo, usually lasting less than 20 seconds, triggered by changes in head position. In contrast, vestibular neuronitis causes constant vertigo, even when at rest, which can be worsened by head movements.

      Recovery from vestibular neuronitis is a gradual process that typically takes a few weeks, up to 6 weeks. It is believed that this condition is caused by inflammation of the vestibular nerve following a viral infection. On the other hand, BPPV is thought to occur due to the presence of cellular debris or crystal formation in the semicircular canals.

      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
      35.2
      Seconds
  • Question 3 - Your consultant requests that you organize a teaching session on thyroid dysfunction and...

    Correct

    • Your consultant requests that you organize a teaching session on thyroid dysfunction and the interpretation of thyroid function tests. Which of the subsequent biochemical patterns is indicative of primary hypothyroidism?

      Your Answer: High thyroid stimulating hormone (TSH) & low thyroxine (T4)

      Explanation:

      The levels of thyroid stimulating hormone (TSH) and thyroxine (T4) are both below the normal range.

      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
      17.6
      Seconds
  • Question 4 - A 65-year-old patient presents with nausea and vomiting and decreased urine output. He...

    Correct

    • A 65-year-old patient presents with nausea and vomiting and decreased urine output. He has only produced a small amount of urine in the last day, and he has noticeable swelling in his ankles. His blood tests show a sudden increase in his creatinine levels in the last 48 hours, leading to a diagnosis of acute kidney injury (AKI).
      What is an example of an intrinsic renal cause of AKI?

      Your Answer: Acute tubular necrosis

      Explanation:

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

      The causes of AKI can be categorized into pre-renal, intrinsic renal, and post-renal factors. The majority of AKI cases that develop outside of healthcare settings are due to pre-renal causes, accounting for 90% of cases. These causes typically involve low blood pressure associated with conditions like sepsis and fluid depletion. Medications, particularly ACE inhibitors and NSAIDs, are also frequently implicated.

      Pre-renal:
      – Volume depletion (e.g., severe bleeding, excessive vomiting or diarrhea, burns)
      – Oedematous states (e.g., heart failure, liver cirrhosis, nephrotic syndrome)
      – Low blood pressure (e.g., cardiogenic shock, sepsis, anaphylaxis)
      – Cardiovascular conditions (e.g., severe heart failure, arrhythmias)
      – Renal hypoperfusion: NSAIDs, COX-2 inhibitors, ACE inhibitors or ARBs, abdominal aortic aneurysm
      – Renal artery stenosis
      – Hepatorenal syndrome

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

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

    • This question is part of the following fields:

      • Nephrology
      6.3
      Seconds
  • Question 5 - A 40 year old male has been brought into the ED during the...

    Correct

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

      Your Answer: Withhold adrenaline

      Explanation:

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

      Further Reading:

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

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

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

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

    • This question is part of the following fields:

      • Environmental Emergencies
      13.5
      Seconds
  • Question 6 - A 25 year old male is brought to the emergency department by the...

    Incorrect

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

      Your Answer: Böhler's angle greater than 20º indicates a calcaneal fracture

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

      Explanation:

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

      Further Reading:

      Calcaneus fractures are a common type of lower limb and joint injury. The calcaneus, or heel bone, is the most frequently fractured tarsal bone. These fractures are often intra-articular, meaning they involve the joint. The most common cause of calcaneus fractures is a fall or jump from a height.

      When assessing calcaneus fractures, X-rays are used to visualize the fracture lines. Two angles are commonly assessed to determine the severity of the fracture. Böhler’s angle, which measures the angle between two tangent lines drawn across the anterior and posterior borders of the calcaneus, should be between 20-40 degrees. If it is less than 20 degrees, it indicates a calcaneal fracture with flattening. The angle of Gissane, which measures the depression of the posterior facet of the subtalar joint, should be between 120-145 degrees. An increased angle of Gissane suggests a calcaneal fracture.

      In the emergency department, the management of a fractured calcaneus involves identifying the injury and any associated injuries, providing pain relief, elevating the affected limb(s), and referring the patient to an orthopedic specialist. It is important to be aware that calcaneus fractures are often accompanied by other injuries, such as bilateral fractures of vertebral fractures.

      The definitive management of a fractured calcaneus can be done conservatively or through surgery, specifically open reduction internal fixation (ORIF). The orthopedic team will typically order a CT or MRI scan to classify the fracture and determine the most appropriate treatment. However, a recent UK heel fracture trial suggests that in most cases, ORIF does not improve fracture outcomes.

    • This question is part of the following fields:

      • Trauma
      28.3
      Seconds
  • Question 7 - You assess a patient with sickle cell disease and a past medical history...

    Correct

    • You assess a patient with sickle cell disease and a past medical history of multiple recurrent painful episodes. What is the approved treatment for reducing the frequency of painful crises in individuals with sickle cell disease?

      Your Answer: Hydroxyurea

      Explanation:

      The majority of treatments provided to individuals with sickle cell disease are supportive measures that have limited impact on the underlying pathophysiology of the condition.

      Currently, the only approved therapy that can modify the disease is Hydroxyurea. This medication is believed to function by increasing the levels of fetal hemoglobin, which in turn decreases the concentration of HbS within the cells and reduces the abnormal hemoglobin tendency to form polymers.

      Hydroxyurea is currently authorized for use in adult patients who experience recurrent moderate-to-severe painful crises (at least three in the past 12 months). Its approval is specifically for reducing the frequency of these painful episodes and the need for blood transfusions.

    • This question is part of the following fields:

      • Haematology
      13.7
      Seconds
  • Question 8 - A 6-year-old child experiences an anaphylactic reaction after being stung by a bee....

    Correct

    • A 6-year-old child experiences an anaphylactic reaction after being stung by a bee.
      What is the appropriate dose of IM adrenaline to administer in this situation?

      Your Answer: 150 mcg

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Allergy
      32
      Seconds
  • Question 9 - A 45-year-old woman presents with lower abdominal pain and a small amount of...

    Incorrect

    • A 45-year-old woman presents with lower abdominal pain and a small amount of rectal bleeding. On examination, she has a low-grade fever (37.8°C) and tenderness in the left iliac fossa. She has a known history of diverticular disease, and you diagnose her with acute diverticulitis.
      Which of the following is NOT a reason for admitting her to the hospital?

      Your Answer: Pain cannot be managed with paracetamol

      Correct Answer: Symptoms persist after 24 hours despite conservative management at home

      Explanation:

      NICE recommends considering admission for patients with acute diverticulitis if they experience pain that cannot be effectively controlled with paracetamol. Additionally, if a patient is unable to maintain hydration through oral fluids or cannot tolerate oral antibiotics, admission should be considered. Admission is also recommended for frail patients or those with significant comorbidities, particularly if they are immunosuppressed. Furthermore, admission should be considered if any of the following suspected complications arise: rectal bleeding requiring transfusion, perforation and peritonitis, intra-abdominal abscess, or fistula. Lastly, if symptoms persist after 48 hours despite conservative management at home, admission should be considered.

    • This question is part of the following fields:

      • Surgical Emergencies
      31.7
      Seconds
  • Question 10 - A 70-year-old man has loss of motivation, difficulties with concentration and behavioral changes...

    Incorrect

    • A 70-year-old man has loss of motivation, difficulties with concentration and behavioral changes that have been ongoing for the past few years. Over the past couple of months, he has also exhibited signs of memory loss. His family is extremely worried and states that his behavior has been very different from his usual self for the past few months. His language has become vulgar, and he has been somewhat lacking in inhibition. Occasionally, he has also been excessively active and prone to pacing and wandering.

      What is the SINGLE most probable diagnosis?

      Your Answer: Vascular dementia

      Correct Answer: Pick’s disease

      Explanation:

      Pick’s disease is a rare neurodegenerative disorder that leads to a gradual decline in cognitive function known as frontotemporal dementia. One of the key features of this condition is the accumulation of tau proteins in neurons, forming silver-staining, spherical aggregations called ‘Pick bodies.’

      Typically, Pick’s disease manifests between the ages of 40 and 60. Initially, individuals may experience changes in their personality, such as disinhibition, tactlessness, and vulgarity. They may also exhibit alterations in their moral values and attempt to distance themselves from their family. Difficulties with concentration, increased activity levels, pacing, and wandering are also common during this stage.

      What sets Pick’s disease apart from Alzheimer’s disease is that the changes in personality occur before memory loss becomes apparent. As the disease progresses, patients will experience deficits in intellect, memory, and language.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      50.7
      Seconds
  • Question 11 - A 70-year-old patient comes in after a chronic overdose of digoxin. She has...

    Incorrect

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

      What is the indication for administering DigiFab in this patient?

      Your Answer: Heart rate of 40 bpm

      Correct Answer: Coexistent renal failure

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      33.4
      Seconds
  • Question 12 - A 35-year-old woman presents to the Emergency Department complaining of lower back pain...

    Correct

    • A 35-year-old woman presents to the Emergency Department complaining of lower back pain and numbness in both feet. Three days ago, she experienced a sharp, shooting pain in her back after lifting a heavy object at work. The pain has worsened over the past three days, and she has now developed weakness in her right leg. She is also experiencing difficulty with urination. Her medical history includes a previous laminectomy for a herniated lumbar disc four years ago. During the examination, normal power is observed in her left leg, but reduced power is noted in the right leg. Motor strength is reduced to 3 out of 5 in the hamstrings, 2 out of 5 in the ankle and toe plantar flexors, and 0 out of 5 in the ankle dorsiflexors and extensor hallucis longus. The right ankle and Achilles tendon reflexes are absent. Sensory examination reveals reduced sensation in the right calf, right foot, labia, and perianal area. Rectal examination reveals reduced sphincter tone.

      What is the SINGLE most likely diagnosis?

      Your Answer: Cauda equina syndrome

      Explanation:

      Cauda equina syndrome (CES) is a rare but serious complication that can occur when a disc ruptures. This happens when the material from the disc is pushed into the spinal canal and puts pressure on the bundle of nerves in the lower back and sacrum. As a result, individuals may experience loss of control over their bladder and bowel functions.

      There are certain red flags that may indicate the presence of CES. These include experiencing sciatica on both sides of the body, having severe or worsening neurological issues in both legs (such as significant weakness in knee extension, ankle eversion, or foot dorsiflexion), difficulty starting urination or a decreased sensation of urinary flow, loss of sensation in the rectum, experiencing numbness or tingling in the perianal, perineal, or genital areas (also known as saddle anesthesia or paresthesia), and having a lax anal sphincter.

      Conus medullaris syndrome (CMS) is a condition that affects the conus medullaris, which is located above the cauda equina at the T12-L2 level. Unlike CES, CMS primarily causes back pain and may have less noticeable nerve root pain. The main symptoms of CMS are urinary retention and constipation.

      To confirm a diagnosis of CES and determine the level of compression and any underlying causes, an MRI scan is considered the gold-standard investigation. In cases where an MRI is not possible or contraindicated, a CT myelogram or standard CT scans can be helpful. However, plain radiographs have limited value and may only show significant degenerative or traumatic bone diseases.

    • This question is part of the following fields:

      • Musculoskeletal (non-traumatic)
      27.3
      Seconds
  • Question 13 - A 5-year-old child weighing 20 kg shows clinical signs of shock and is...

    Incorrect

    • A 5-year-old child weighing 20 kg shows clinical signs of shock and is 10% dehydrated due to gastroenteritis. An initial fluid bolus of 20 ml/kg is given. How much fluid should be given in the next 24 hours?

      Your Answer: 1600 ml

      Correct Answer: 3100 ml

      Explanation:

      To determine the amount of fluid that should be given to the 5-year-old child over the next 24 hours, we need to account for the following components of fluid therapy:

      1. Deficit Replacement: The fluid lost due to dehydration.
      2. Maintenance Fluid: The fluid needed for normal physiological needs.
      3. Ongoing Losses: Any additional fluid loss (e.g., continued diarrhea or vomiting), which may need to be estimated and added if applicable.

      Calculation Steps

      1. Calculate the Fluid Deficit

      The child is 10% dehydrated. This means that the child has lost 10% of their body weight in fluids.

      • Body Weight: 20 kg
      • Percentage Dehydration: 10%

      Fluid Deficit=Body Weight×Percentage Dehydration

      Fluid Deficit=20 kg×0.10=2 kg=2 liters=2000 ml

      2. Calculate the Maintenance Fluid Requirement

      Use the standard maintenance fluid calculation for children (the Holliday-Segar method):

      • First 10 kg: 100 ml/kg/day
      • Next 10 kg: 50 ml/kg/day

      For a 20 kg child:

      • First 10 kg: 10 kg×100 ml/kg/day=1000 ml/day
      • Next 10 kg: 10 kg×50 ml/kg/day=500 ml/day

      Total maintenance fluid requirement:

      Maintenance Fluid=1000 ml+500 ml=1500 ml/day

      3. Subtract the Initial Fluid Bolus

      An initial fluid bolus of 20 ml/kg was given to treat shock:

      • Fluid Bolus Given: 20 ml/kg×20 kg=400 ml

      This amount should be subtracted from the deficit to avoid overhydration:

      Remaining Deficit=2000 ml−400 ml=1600 ml

      4. Total Fluid Requirement for 24 Hours

      The total fluid requirement for the next 24 hours is the sum of the remaining deficit and the maintenance fluid:

      Total Fluid for 24 hours=Remaining Deficit+Maintenance Fluid

      Total Fluid for 24 hours=1600 ml+1500 ml=3100 ml

    • This question is part of the following fields:

      • Nephrology
      63.3
      Seconds
  • Question 14 - A 45-year-old woman presents with a 4-week history of persistent hoarseness of her...

    Incorrect

    • A 45-year-old woman presents with a 4-week history of persistent hoarseness of her voice. She has also been bothered by a sore throat on and off but describes this as mild, and she has no other symptoms. On examination, she is afebrile, her chest is clear, and examination of her throat is unremarkable.

      What is the SINGLE most appropriate next management step for this patient?

      Your Answer: Take a throat swab for microscopy and culture

      Correct Answer: Urgent referral to an ENT specialist (for an appointment within 2 weeks)

      Explanation:

      Laryngeal cancer should be suspected in individuals who experience prolonged and unexplained hoarseness. The majority of laryngeal cancers, about 60%, occur in the glottis, and the most common symptom is dysphonia. If the cancer is detected early, the chances of a cure are excellent, with a success rate of approximately 90%.

      Other clinical signs of laryngeal cancer include difficulty swallowing (dysphagia), the presence of a lump in the neck, a persistent sore throat, ear pain, and a chronic cough.

      According to the current guidelines from the National Institute for Health and Care Excellence (NICE) regarding the recognition and referral of suspected cancer, individuals who are over the age of 45 and present with persistent unexplained hoarseness or an unexplained lump in the neck should be considered for a suspected cancer referral pathway. This pathway aims to ensure that these individuals are seen by a specialist within two weeks for further evaluation.

      For more information, please refer to the NICE guidelines on the recognition and referral of suspected cancer.

    • This question is part of the following fields:

      • Ear, Nose & Throat
      26.9
      Seconds
  • Question 15 - You are working in the pediatric emergency department and are asked to review...

    Correct

    • You are working in the pediatric emergency department and are asked to review a child's blood gas results by the resident. What is the typical range for partial pressure of carbon dioxide (pCO2)?

      Your Answer: 4.4-6.4 kPa

      Explanation:

      The typical range for the partial pressure of carbon dioxide (pCO2) is 4.4-6.4 kilopascals (kPa). In terms of arterial blood gas (ABG) results, the normal range for pO2 (partial pressure of oxygen) is 10-14.4 kPa or 70-100 millimeters of mercury (mmHg). The normal range for pCO2 is 4.4-6.4 kPa or 35-45 mmHg. Additionally, the normal range for bicarbonate levels is 23-28 millimoles per liter (mmol/L).

      Further Reading:

      Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.

      To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.

      Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.

      The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.

      The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.

      The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.

      Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.

      The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.

    • This question is part of the following fields:

      • Respiratory
      19.7
      Seconds
  • Question 16 - You review a middle-aged man who has a non-operable brain tumor and is...

    Incorrect

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

      Your Answer: Ondansetron

      Correct Answer: Cyclizine

      Explanation:

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

    • This question is part of the following fields:

      • Palliative & End Of Life Care
      9
      Seconds
  • Question 17 - A 45 year old with asthma is brought into the ER due to...

    Correct

    • A 45 year old with asthma is brought into the ER due to worsening shortness of breath. You collect an arterial blood gas sample for analysis. What is the typical pH range for arterial blood?

      Your Answer: 7.35-7.45

      Explanation:

      Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.

      To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.

      Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.

      The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.

      The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.

      The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.

      Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.

      The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.

    • This question is part of the following fields:

      • Respiratory
      7.4
      Seconds
  • Question 18 - You review a 65-year-old man who has presented with visual problems. He has...

    Incorrect

    • You review a 65-year-old man who has presented with visual problems. He has been taking amiodarone for several years.
      Which SINGLE statement regarding the effects of amiodarone on the eye is true?

      Your Answer: Patients with corneal microdeposits often complain of seeing an ‘orange halo’

      Correct Answer: Corneal microdeposits are almost universally present in patients taking amiodarone for longer than six months

      Explanation:

      Corneal microdeposits are found in almost all individuals (over 90%) who have been taking amiodarone for more than six months, particularly at doses higher than 400 mg/day. These deposits generally do not cause any symptoms, although approximately 10% of patients may experience a perception of a ‘bluish halo’ around objects they see.

      Amiodarone can also have other effects on the eye, but these are much less common, occurring in only 1-2% of patients. These effects include optic neuropathy, nonarteritic anterior ischemic optic neuropathy (N-AION), optic disc swelling, and visual field defects.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
      18.4
      Seconds
  • Question 19 - A 4-year-old child is brought in by ambulance. He has been experiencing seizures...

    Incorrect

    • A 4-year-old child is brought in by ambulance. He has been experiencing seizures for the past 35 minutes. So far, he has received two doses of IV lorazepam. His bowel movement is normal. He has a history of epilepsy and is on phenytoin as maintenance therapy.

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

      Your Answer: Perform rapid sequence induction with thiopental

      Correct Answer: Set up phenobarbitone infusion

      Explanation:

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

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

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

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

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

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

    • This question is part of the following fields:

      • Neurology
      24.6
      Seconds
  • Question 20 - A patient presents with a blistering rash. The differential diagnosis includes pemphigoid vulgaris...

    Incorrect

    • A patient presents with a blistering rash. The differential diagnosis includes pemphigoid vulgaris and bullous pemphigoid.
      Which of the following features would indicate a diagnosis of bullous pemphigoid?

      Your Answer: Nikolsky sign positive

      Correct Answer: Prominent pruritus

      Explanation:

      Bullous pemphigoid (BP) is a chronic autoimmune disorder that affects the skin, causing blistering. It occurs when the immune system mistakenly attacks the basement membrane of the epidermis. This attack is carried out by immunoglobulins (IgG and sometimes IgE) and activated T lymphocytes. The autoantibodies bind to proteins and release cytokines, leading to complement activation, neutrophil recruitment, and the release of enzymes that destroy the hemidesmosomes. As a result, subepidermal blisters form.

      Pemphigus, on the other hand, is a group of autoimmune disorders characterized by blistering of the skin and mucosal surfaces. The most common type, pemphigus vulgaris (PV), accounts for about 70% of cases worldwide. PV is also autoimmune in nature, with autoantibodies targeting cell surface antigens on keratinocytes (desmogleins 1 and 3). This leads to a loss of adhesion between cells and their separation.

      Here is a comparison of the key differences between pemphigus vulgaris and bullous pemphigoid:

      Pemphigus vulgaris:
      – Age: Middle-aged people (average age 50)
      – Oral involvement: Common
      – Blister type: Large, flaccid, and painful
      – Blister content: Fluid-filled, often haemorrhagic
      – Areas commonly affected: Initially face and scalp, then spread to the chest and back
      – Nikolsky sign: Usually positive
      – Pruritus: Rare
      – Skin biopsy: Intra-epidermal deposition of IgG between cells throughout the epidermis

      Bullous pemphigoid:
      – Age: Elderly people (average age 80)
      – Oral involvement: Rare
      – Blister type: Large and tense
      – Blister content: Fluid-filled
      – Areas commonly affected: Upper arms, thighs, and skin flexures
      – Nikolsky sign: Usually negative
      – Pruritus: Common
      – Skin biopsy: A band of IgG and/or C3 at the dermo-epidermal junction

    • This question is part of the following fields:

      • Dermatology
      11.8
      Seconds
  • Question 21 - You review a 72-year-old man that is on the Clinical Decision Unit (CDU)...

    Incorrect

    • You review a 72-year-old man that is on the Clinical Decision Unit (CDU) following the reduction of a hip fracture. His GP recently organized a DEXA scan, and you have managed to access the results on the CDU computer. The results showed a T-score of -2.0 standard deviations. He has no independent risk factors for fractures and no other indicators of low bone mineral density.
      Which SINGLE statement regarding this case is true?

      Your Answer: The patient should be started on alendronate

      Correct Answer: The patient has osteopenia

      Explanation:

      Fragility fractures occur when a person experiences a fracture from a force that would not typically cause a fracture, such as a fall from a standing height or less. The most common areas for fragility fractures are the vertebrae, hip, and wrist. Osteoporosis is diagnosed when a patient’s bone mineral density, measured by a T-score on a DEXA scan, is -2.5 standard deviations or below. This T-score compares the patient’s bone density to the peak bone density of a population. In women over 75 years old, osteoporosis can be assumed without a DEXA scan. Osteopenia is diagnosed when a patient’s T-score is between -1 and -2.5 standard deviations below peak bone density. Risk factors for fractures include a family history of hip fractures, excessive alcohol consumption, and rheumatoid arthritis. Low bone mineral density can be indicated by a BMI below 22 kg/m2, untreated menopause, and conditions causing prolonged immobility or certain medical conditions. Medications used to prevent osteoporotic fractures in postmenopausal women include alendronate, risedronate, etidronate, and strontium ranelate. Raloxifene is not used for primary prevention. Alendronate is typically the first-choice medication and is recommended for women over 70 years old with confirmed osteoporosis and either a risk factor for fracture or low bone mineral density. Women over 75 years old with two risk factors or two indicators of low bone mineral density may be assumed to have osteoporosis without a DEXA scan. Other pharmacological interventions can be tried if alendronate is not tolerated.

    • This question is part of the following fields:

      • Elderly Care / Frailty
      23.9
      Seconds
  • Question 22 - You review a 65-year-old woman with metastatic breast cancer. Her treatment is in...

    Correct

    • You review a 65-year-old woman with metastatic breast cancer. Her treatment is in the palliative stages. She has severe fatigue, a low-grade fever, and wheezing in her left lung. You diagnose her with left lower lobe pneumonia. She appears pale, sweaty, and is breathing rapidly. Her level of consciousness is decreased, and she is currently unable to eat or drink. You believe her chances of recovery at this point are very slim.

      She had previously made an advanced directive stating that she does not want to receive intravenous fluids or parenteral nutrition. However, her husband insists that she should be started on parenteral feeding. Due to her decreased level of consciousness, she is unable to express her wishes. You strongly believe that her advanced directive should be respected and that parenteral nutrition should not be initiated.

      Which ONE of the following would be the most appropriate course of action in this situation?

      Your Answer: A second opinion should be sought to resolve this disagreement

      Explanation:

      An advanced decision is a legally binding document that allows individuals to express their preferences for end-of-life care in advance. It serves as a means of communication between patients, healthcare professionals, and family members, ensuring that the patient’s wishes are understood and respected. In situations where a patient becomes unable to make informed decisions about their care due to the progression of their illness, an advanced directive can help prevent any confusion or disagreements.

      According to the General Medical Council (GMC), if there is a significant difference of opinion within the healthcare team or between the team and the patient’s loved ones regarding the patient’s care, it is advisable to seek advice or a second opinion from a colleague who has relevant expertise. In this particular case, it would be wise to consult a palliative care specialist to help resolve the disagreement between yourself and the patient’s wife.

      For more information, you can refer to the GMC guidelines on treatment and care towards the end of life, which provide guidance on good practice in decision making.

    • This question is part of the following fields:

      • Palliative & End Of Life Care
      4.3
      Seconds
  • Question 23 - You assess a patient with one-sided hearing loss, ringing in the ears, and...

    Incorrect

    • You assess a patient with one-sided hearing loss, ringing in the ears, and numbness in the face. An MRI scan shows the presence of an acoustic neuroma.
      Which of the following nerves is the LEAST likely to be affected?

      Your Answer: Vestibulocochlear nerve

      Correct Answer: Trochlear nerve

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Ear, Nose & Throat
      15.7
      Seconds
  • Question 24 - A traveler contracts a viral haemorrhagic fever while on a backpacking adventure during...

    Incorrect

    • A traveler contracts a viral haemorrhagic fever while on a backpacking adventure during their gap year.
      Which of the following is NOT a viral haemorrhagic fever?

      Your Answer: Lassa fever

      Correct Answer: Chagas disease

      Explanation:

      The viral hemorrhagic fevers (VHFs) are a group of infectious diseases caused by four distinct types of RNA viruses. These include Filoviruses (such as Marburg virus and Ebola), Arenaviruses (like Lassa fever and Argentine haemorrhagic fever), Bunyaviruses (including Hantavirus and Rift Valley fever), and Flavivirus (such as Yellow fever and dengue fever). VHFs are serious multi-system disorders that can be potentially fatal. Each type of VHF has a natural reservoir, which is an animal or insect host, and they are typically found in the areas where these host species reside. Outbreaks of these hemorrhagic fevers occur sporadically and irregularly, making them difficult to predict.

      The typical clinical features of VHFs include fever, headache, myalgia, fatigue, bloody diarrhea, haematemesis, petechial rashes and ecchymoses, edema, confusion and agitation, as well as hypotension and circulatory collapse.

      On the other hand, Chagas disease is not classified as a VHF. It is a tropical disease caused by the protozoan Trypanosoma cruzi. This disease is transmitted by Triatomine insects, commonly known as kissing bugs. Initially, Chagas disease causes a mild acute illness that resembles flu. However, around 10% of individuals develop chronic Chagas disease, which can lead to various complications. These complications include cardiac issues like dilated cardiomyopathy, neurological problems such as neuritis, and gastrointestinal complications like megacolon.

    • This question is part of the following fields:

      • Infectious Diseases
      8.7
      Seconds
  • Question 25 - A 45-year-old woman who is originally from Brazil has recently developed dilated cardiomyopathy...

    Incorrect

    • A 45-year-old woman who is originally from Brazil has recently developed dilated cardiomyopathy and difficulty swallowing. She remembers being bitten by an insect approximately 10 years ago, which resulted in a fever and flu-like symptoms. On her ankle, where the bite occurred, she now has a firm, violet-colored lump.
      What is the SINGLE most probable diagnosis?

      Your Answer: Tularaemia

      Correct Answer: Chagas disease

      Explanation:

      Chagas disease, also known as American Trypanosomiasis, is a tropical illness caused by the protozoan Trypanosoma cruzi. It is transmitted by Triatomine insects, commonly known as kissing bugs, which belong to the Reduviidae family. This zoonotic disease is prevalent in Central and South America, with an estimated 8 million people infected in the region. In Brazil alone, there are approximately 120,000 new cases reported each year.

      The disease progresses through two stages: the acute stage and the chronic stage. During the acute stage, many patients may not experience any symptoms, and the infection can go unnoticed. However, some individuals may exhibit symptoms such as fever, malaise, muscle pain, loss of appetite, and occasionally vomiting and diarrhea. Clinical signs may include swollen lymph nodes and enlargement of the liver and spleen. At the site of the insect bite, an inflammatory response called a chagoma can occur. This is characterized by a swollen, violet-colored nodule that can last up to 8 weeks. Another distinctive sign of acute Chagas disease is Romaña’s sign, which is eyelid swelling caused by accidentally rubbing bug feces into the eyes.

      Following the acute stage, an estimated 10-30% of individuals progress to the chronic stage of Chagas disease. There is typically a latent phase between the acute and chronic phases, which can last for as long as 20-30 years. The chronic phase is associated with various complications, including cardiovascular problems such as dilated cardiomyopathy, heart failure, and arrhythmias. Gastrointestinal issues like megacolon, megaesophagus, and secondary achalasia can also arise. Neurological complications, such as neuritis, sensory and motor deficits, and encephalopathy, may occur. Additionally, psychiatric symptoms, including dementia, can manifest in some cases.

    • This question is part of the following fields:

      • Infectious Diseases
      2.8
      Seconds
  • Question 26 - You are part of the team managing a 60 year old patient who...

    Correct

    • You are part of the team managing a 60 year old patient who has experienced cardiac arrest. What is the appropriate dosage of adrenaline to administer to this patient?

      Your Answer: 1 mg IV

      Explanation:

      In cases of cardiac arrest, it is recommended to administer 1 mg of adrenaline intravenously (IV) every 3-5 minutes. According to the 2021 resus council guidelines for adult advanced life support (ALS), the administration of vasopressors should follow these guidelines:
      – For adult patients in cardiac arrest with a non-shockable rhythm, administer 1 mg of adrenaline IV (or intraosseous) as soon as possible.
      – For adult patients in cardiac arrest with a shockable rhythm, administer 1 mg of adrenaline IV (or intraosseous) after the third shock.
      – Continuously repeat the administration of 1 mg of adrenaline IV (or intraosseous) every 3-5 minutes throughout the ALS procedure.

      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
      10.1
      Seconds
  • Question 27 - A 3-year-old girl comes in with stridor and a barking cough. Her mother...

    Correct

    • A 3-year-old girl comes in with stridor and a barking cough. Her mother mentions that she has had a slight cold for a few days and her voice has been hoarse. Here are her observations: temperature 38.1°C, HR 135, RR 30, SaO2 97% on air. Her chest examination appears normal, but you notice the presence of stridor at rest.

      Which of the following medications is most likely to alleviate her symptoms?

      Your Answer: Nebulised budesonide

      Explanation:

      Croup, also known as laryngo-tracheo-bronchitis, is typically caused by the parainfluenza virus. Other viruses such as rhinovirus, influenza, and respiratory syncytial viruses can also be responsible. Before the onset of stridor, there is often a mild cold-like illness that lasts for 1-2 days. Symptoms usually reach their peak within 1-3 days, with the cough often being more troublesome at night. A milder cough may persist for another 7-10 days.

      A distinctive feature of croup is a barking cough, but it does not indicate the severity of the condition. To reduce airway swelling, dexamethasone and prednisolone are commonly prescribed. If a child is experiencing vomiting, nebulized budesonide can be used as an alternative. However, it is important to note that steroids do not shorten the duration of the illness. In severe cases, nebulized adrenaline can be administered.

      Hospitalization for croup is uncommon and typically reserved for children who are experiencing worsening respiratory distress or showing signs of drowsiness or agitation.

    • This question is part of the following fields:

      • Respiratory
      38.1
      Seconds
  • Question 28 - A 45-year-old woman returns from a recent vacation on a cruise ship with...

    Correct

    • A 45-year-old woman returns from a recent vacation on a cruise ship with a persistent cough and a high temperature. Today she has also experienced frequent episodes of diarrhea and has developed sharp chest pain on both sides. She reports feeling short of breath, especially when she exerts herself. The cruise ship doctor had prescribed her amoxicillin a few days ago, but she has not seen any improvement.
      Her blood test results today are as follows:
      Hemoglobin (Hb): 14.4 g/dl (normal range: 13-17 g/dl)
      White blood cell count (WCC): 13.5 x 109/l (normal range: 4-11 x 109/l)
      Neutrophils: 10.2 x 109/l (normal range: 2.5-7.5 x 109/l)
      Lymphocytes: 0.6 x 109/l (normal range: 1.3-3.5 x 109/l)
      Eosinophils: 0.35 x 109/l (normal range: 0.04-0.44 x 109/l)
      C-reactive protein (CRP): 87 mg/l (normal range: <5 mg/l)
      Sodium (Na): 122 mmol/l (normal range: 133-147 mmol/l)
      Potassium (K): 4.4 mmol/l (normal range: 3.5-5.0 mmol/l)
      Creatinine (Creat): 112 micromol/l (normal range: 60-120 micromol/l)
      Urea: 6.8 mmol/l (normal range: 2.5-7.5 mmol/l)
      What is the SINGLE most likely causative organism?

      Your Answer: Legionella pneumophila

      Explanation:

      Legionella pneumophila is a type of Gram-negative bacterium that can be found in natural water supplies and soil. It is responsible for causing Legionnaires’ disease, a serious illness. Outbreaks of this disease have been associated with poorly maintained air conditioning systems, whirlpool spas, and hot tubs. In the past, there have been instances of Legionnaires’ disease outbreaks on cruise ships due to inadequate maintenance of air conditioning and shower units.

      The pneumonic form of Legionnaires’ disease presents with certain clinical features. Initially, there may be a mild flu-like prodrome lasting for 1-3 days. A persistent cough, which is usually non-productive and occurs in approximately 90% of cases, is also common. Other symptoms include pleuritic chest pain, haemoptysis, headache, nausea, vomiting, diarrhoea, and anorexia. Additionally, some individuals may experience a condition called syndrome of inappropriate antidiuretic hormone secretion (SIADH), which can lead to hyponatraemia.

      It is important to note that infections caused by Legionella pneumophila are resistant to amoxicillin. However, they can be effectively treated with macrolide antibiotics like erythromycin or quinolones such as ciprofloxacin. Tetracyclines, including doxycycline, can also be used for treatment.

    • This question is part of the following fields:

      • Respiratory
      10.5
      Seconds
  • Question 29 - A middle-aged man is brought in by ambulance, having collapsed. There is currently...

    Correct

    • A middle-aged man is brought in by ambulance, having collapsed. There is currently a summer heatwave, and he has a suspected diagnosis of heat stroke.

      Which of the following statements regarding heat stroke is true?

      Your Answer: Diazepam can be helpful in patients with agitation and/or shivering

      Explanation:

      Heat stroke is a condition characterized by a systemic inflammatory response, where the core body temperature exceeds 40.6°C. It is accompanied by changes in mental state and varying levels of organ dysfunction. Heat stroke occurs when the body’s ability to regulate temperature is overwhelmed by a combination of excessive environmental heat, excessive heat production from metabolic processes (usually due to exertion), and inadequate heat loss.

      It is important to consider other clinical conditions that can cause an increased core temperature. Sepsis can present similarly and should be ruled out. Neuroleptic malignant syndrome should be excluded in patients taking phenothiazines or other antipsychotics. Serotonin syndrome should be excluded in patients taking serotonergic medications such as SSRIs. Malignant hyperthermia should be considered in patients with a recent history of general anesthesia. Screening for recreational drug use, particularly cocaine, amphetamines, and ecstasy, is also recommended.

      In patients with agitation and/or shivering, benzodiazepines (e.g. diazepam) can be beneficial. They help reduce excessive heat production and agitation. In severe cases of agitation, paralysis may be necessary. Dantrolene is commonly used, although there is currently limited high-level evidence supporting its use. Neuroleptics, such as chlorpromazine, which were once commonly used, should be avoided due to potential adverse effects.

      Various cooling techniques are recommended, but there is currently insufficient evidence to determine the best approach. Simple measures like cold drinks, fanning, ice water packs, and spraying tepid water can be effective. Cold water immersion therapy may be helpful, but it requires patient stability and cooperation and may not be practical for critically ill patients. Advanced cooling techniques, such as cold IV fluids, surface cooling devices (SCD), intravascular cooling devices (ICD), and extracorporeal circuits, may be used for sicker patients.

    • This question is part of the following fields:

      • Environmental Emergencies
      87.1
      Seconds
  • Question 30 - A 32-year-old woman with a known history of asthma presents with a headache,...

    Incorrect

    • A 32-year-old woman with a known history of asthma presents with a headache, nausea, and abdominal pain. Her heart rate is elevated at 117 bpm. She currently takes a salbutamol inhaler and theophylline for her asthma. She had visited the Emergency Department a few days earlier and was prescribed an antibiotic.
      Which antibiotic was most likely prescribed to this patient?

      Your Answer: Amoxicillin

      Correct Answer: Ciprofloxacin

      Explanation:

      Theophylline is a medication used to treat severe asthma. It is a bronchodilator that comes in modified-release forms, which can maintain therapeutic levels in the blood for 12 hours. Theophylline works by inhibiting phosphodiesterase and blocking the breakdown of cyclic AMP. It also competes with adenosine on A1 and A2 receptors.

      Achieving the right dose of theophylline can be challenging because there is a narrow range between therapeutic and toxic levels. The half-life of theophylline can be influenced by various factors, further complicating dosage adjustments. It is recommended to aim for serum levels of 10-20 mg/l six to eight hours after the last dose.

      Unlike many other medications, the specific brand of theophylline can significantly impact its effects. Therefore, it is important to prescribe theophylline by both its brand name and generic name.

      Several factors can increase the half-life of theophylline, including heart failure, cirrhosis, viral infections, and certain drugs. Conversely, smoking, heavy drinking, and certain medications can decrease the half-life of theophylline.

      There are several drugs that can either increase or decrease the plasma concentration of theophylline. Calcium channel blockers, cimetidine, fluconazole, macrolides, methotrexate, and quinolones can increase the concentration. On the other hand, carbamazepine, phenobarbitol, phenytoin, rifampicin, and St. John’s wort can decrease the concentration.

      The clinical symptoms of theophylline toxicity are more closely associated with acute overdose rather than chronic overexposure. Common symptoms include headache, dizziness, nausea, vomiting, abdominal pain, rapid heartbeat, dysrhythmias, seizures, mild metabolic acidosis, low potassium, low magnesium, low phosphates, abnormal calcium levels, and high blood sugar.

      Seizures are more prevalent in acute overdose cases, while chronic overdose typically presents with minimal gastrointestinal symptoms. Cardiac dysrhythmias are more common in chronic overdose situations compared to acute overdose.

    • This question is part of the following fields:

      • Pharmacology & Poisoning
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