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Question 1
Correct
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A 65-year-old woman with a history of Parkinson's disease and depression has experienced a gradual decline in her cognitive abilities over the past year. Her memory and ability to focus have been noticeably impaired recently. Additionally, she has experienced a few episodes of unexplained temporary loss of consciousness and occasional visual hallucinations.
What is the SINGLE most probable diagnosis?Your Answer: Dementia with Lewy bodies (DLB)
Explanation:Dementia with Lewy bodies (DLB), also known as Lewy body dementia (LBD), is a progressive neurodegenerative condition that is closely linked to Parkinson’s disease (PD). It is the third most common cause of dementia in older individuals, following Alzheimer’s disease and vascular dementia.
DLB is characterized by several clinical features, including the presence of Parkinsonism or co-existing PD, a gradual decline in cognitive function, fluctuations in cognition, alertness, and attention span, episodes of temporary loss of consciousness, recurrent falls, visual hallucinations, depression, and complex, systematized delusions. The level of cognitive impairment can vary from hour to hour and day to day.
Pathologically, DLB is marked by the formation of abnormal protein collections called Lewy bodies within the cytoplasm of neurons. These intracellular protein collections share similar structural characteristics with the classic Lewy bodies observed in Parkinson’s disease.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 2
Correct
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A 4-year-old child is brought in by ambulance. He has been experiencing seizures for the past 15 minutes. IV access is established and his blood sugar level is 4.5. He weighs 20 kg.
According to the latest APLS guidelines, what would be the most suitable next course of action in managing his condition?Your Answer: IV lorazepam 2 mg
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.
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This question is part of the following fields:
- Neurology
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Question 3
Incorrect
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A 35 year old male is brought into the emergency department after being found disoriented and lethargic by a family member. The family member informs you that the patient has a history of depression and that there were multiple empty bottles of aspirin at the patient's residence. Initial tests are conducted, including a salicylate level.
What is the plasma salicylate concentration threshold for initiating urinary alkalinization in adult patients?Your Answer: > 750 mg/L
Correct Answer: > 500 mg/L
Explanation:In adults, urinary alkalinisation is initiated when the salicylate level exceeds 500 mg/L (>3.6 mmol/L). For children, the threshold is set at a salicylate concentration of > 350 mg/L (2.5 mmol/L).
Further Reading:
Salicylate poisoning, particularly from aspirin overdose, is a common cause of poisoning in the UK. One important concept to understand is that salicylate overdose leads to a combination of respiratory alkalosis and metabolic acidosis. Initially, the overdose stimulates the respiratory center, leading to hyperventilation and respiratory alkalosis. However, as the effects of salicylate on lactic acid production, breakdown into acidic metabolites, and acute renal injury occur, it can result in high anion gap metabolic acidosis.
The clinical features of salicylate poisoning include hyperventilation, tinnitus, lethargy, sweating, pyrexia (fever), nausea/vomiting, hyperglycemia and hypoglycemia, seizures, and coma.
When investigating salicylate poisoning, it is important to measure salicylate levels in the blood. The sample should be taken at least 2 hours after ingestion for symptomatic patients or 4 hours for asymptomatic patients. The measurement should be repeated every 2-3 hours until the levels start to decrease. Other investigations include arterial blood gas analysis, electrolyte levels (U&Es), complete blood count (FBC), coagulation studies (raised INR/PTR), urinary pH, and blood glucose levels.
To manage salicylate poisoning, an ABC approach should be followed to ensure a patent airway and adequate ventilation. Activated charcoal can be administered if the patient presents within 1 hour of ingestion. Oral or intravenous fluids should be given to optimize intravascular volume. Hypokalemia and hypoglycemia should be corrected. Urinary alkalinization with intravenous sodium bicarbonate can enhance the elimination of aspirin in the urine. In severe cases, hemodialysis may be necessary.
Urinary alkalinization involves targeting a urinary pH of 7.5-8.5 and checking it hourly. It is important to monitor for hypokalemia as alkalinization can cause potassium to shift from plasma into cells. Potassium levels should be checked every 1-2 hours.
In cases where the salicylate concentration is high (above 500 mg/L in adults or 350 mg/L in children), sodium bicarbonate can be administered intravenously. Hemodialysis is the treatment of choice for severe poisoning and may be indicated in cases of high salicylate levels, resistant metabolic acidosis, acute kidney injury, pulmonary edema, seizures and coma.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 4
Correct
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A 62 year old male presents to the emergency department with worsening cellulitis. The patient informs you that he visited the after-hours GP earlier in the week. The after-hours GP prescribed oral antibiotics, which the patient has been taking for 3 days. However, the patient notices that the red area is spreading despite the medication. The patient mentions to you that he informed the GP about his susceptibility to infections, and the GP ordered a blood test for diabetes, advising him to follow up with his regular GP. You come across an HbA1c result on the pathology system. What is the diagnostic threshold for diabetes?
Your Answer: HbA1c ≥ 48 mmol/mol
Explanation:An HBA1C result between 42-47 mmol/mol indicates a pre-diabetic condition.
Further Reading:
Diabetes Mellitus:
– Definition: a group of metabolic disorders characterized by persistent hyperglycemia caused by deficient insulin secretion, resistance to insulin, or both.
– Types: Type 1 diabetes (absolute insulin deficiency), Type 2 diabetes (insulin resistance and relative insulin deficiency), Gestational diabetes (develops during pregnancy), Other specific types (monogenic diabetes, diabetes secondary to pancreatic or endocrine disorders, diabetes secondary to drug treatment).
– Diagnosis: Type 1 diabetes diagnosed based on clinical grounds in adults presenting with hyperglycemia. Type 2 diabetes diagnosed in patients with persistent hyperglycemia and presence of symptoms or signs of diabetes.
– Risk factors for type 2 diabetes: obesity, inactivity, family history, ethnicity, history of gestational diabetes, certain drugs, polycystic ovary syndrome, metabolic syndrome, low birth weight.Hypoglycemia:
– Definition: lower than normal blood glucose concentration.
– Diagnosis: defined by Whipple’s triad (signs and symptoms of low blood glucose, low blood plasma glucose concentration, relief of symptoms after correcting low blood glucose).
– Blood glucose level for hypoglycemia: NICE defines it as <3.5 mmol/L, but there is inconsistency across the literature.
– Signs and symptoms: adrenergic or autonomic symptoms (sweating, hunger, tremor), neuroglycopenic symptoms (confusion, coma, convulsions), non-specific symptoms (headache, nausea).
– Treatment options: oral carbohydrate, buccal glucose gel, glucagon, dextrose. Treatment should be followed by re-checking glucose levels.Treatment of neonatal hypoglycemia:
– Treat with glucose IV infusion 10% given at a rate of 5 mL/kg/hour.
– Initial stat dose of 2 mL/kg over five minutes may be required for severe hypoglycemia.
– Mild asymptomatic persistent hypoglycemia may respond to a single dose of glucagon.
– If hypoglycemia is caused by an oral anti-diabetic drug, the patient should be admitted and ongoing glucose infusion or other therapies may be required.Note: Patients who have a hypoglycemic episode with a loss of warning symptoms should not drive and should inform the DVLA.
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This question is part of the following fields:
- Endocrinology
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Question 5
Correct
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Whilst assessing a patient in the Emergency Department, you observe a pansystolic murmur.
Which of the following is NOT a potential cause of a pansystolic murmur?Your Answer: Aortic stenosis
Explanation:Aortic stenosis leads to the presence of a murmur during the ejection phase of the cardiac cycle. This murmur is most audible at the right second intercostal space and can be heard extending into the right neck.
Mitral regurgitation, on the other hand, produces a high-pitched murmur that occurs throughout the entire systolic phase of the cardiac cycle. This murmur is best heard at the apex of the heart and can be heard radiating into the axilla.
Tricuspid regurgitation is characterized by a blowing murmur that occurs throughout the entire systolic phase of the cardiac cycle. This murmur is most clearly heard at the lower left sternal edge.
Ventricular septal defect results in a harsh murmur that occurs throughout the entire systolic phase of the cardiac cycle. This murmur is best heard at the third or fourth left intercostal space and can be heard radiating throughout the praecordium.
Aortopulmonary shunts are an extremely rare cause of a murmur that occurs throughout the entire systolic phase of the cardiac cycle.
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This question is part of the following fields:
- Cardiology
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Question 6
Correct
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A 45-year-old presents to the emergency department complaining of occasional right-sided facial swelling over the past 3 days. The patient describes the swelling as uncomfortable and it occurs after eating a meal, but then goes away within an hour or so. The patient mentions that the swelling has gone down since arriving at the department. Upon examination, there is no visible redness or tenderness when the face is touched. The patient's vital signs are as follows:
Blood pressure: 142/82 mmHg
Pulse rate: 86 bpm
Respiration rate: 15 bpm
Temperature: 36.5ºC
What is the probable diagnosis?Your Answer: Sialolithiasis
Explanation:Salivary gland stones often cause intermittent swelling that tends to worsen during meal times. This pattern of symptoms is indicative of Sialolithiasis, which refers to the presence of stones in the salivary glands. In cases of acute sialadenitis, the affected gland or duct would typically be enlarged and tender to touch, accompanied by signs of infection such as redness or fever. While mucoepidermoid carcinoma is the most common type of salivary gland cancer, malignant salivary gland tumors are rare. On the other hand, pleomorphic adenoma is the most common benign neoplasm of the salivary glands, with an incidence rate of approximately 2-3.5 cases per 100,000 population. However, it is important to note that salivary gland stones are much more common than tumors, with an annual incidence rate that is 10 times higher.
Further Reading:
Salivary gland disease refers to various conditions that affect the salivary glands, which are responsible for producing saliva. Humans have three pairs of major salivary glands, including the parotid, submandibular, and sublingual glands, as well as numerous minor salivary glands. These glands produce around 1 to 1.5 liters of saliva each day, which serves several functions such as moistening and lubricating the mouth, dissolving food, aiding in swallowing, and protecting the mucosal lining.
There are several causes of salivary gland dysfunction, including infections (such as bacterial or viral infections like mumps), the presence of stones in the salivary ducts, benign or malignant tumors, dry mouth (xerostomia) due to medication, dehydration, or certain medical conditions like Sjögren’s syndrome, granulomatous diseases like sarcoidosis, and rare conditions like HIV-related lymphocytic infiltration. Mucoceles can also affect the minor salivary glands.
Salivary gland stones, known as sialolithiasis, are the most common salivary gland disorder. They typically occur in adults between the ages of 30 and 60, with a higher incidence in males. These stones can develop within the salivary glands or their ducts, leading to obstruction and swelling of the affected gland. Risk factors for stones include certain medications, dehydration, gout, smoking, chronic periodontal disease, and hyperparathyroidism. Diagnosis of salivary gland stones can be made through imaging techniques such as X-ray, ultrasound, sialography, CT, or MRI. Management options include conservative measures like pain relief, antibiotics if there is evidence of infection, hydration, warm compresses, and gland massage. Invasive options may be considered if conservative management fails.
Salivary gland infection, known as sialadenitis, can be caused by bacterial or viral pathogens. Decreased salivary flow, often due to factors like dehydration, malnutrition, immunosuppression, or certain medications, can contribute to the development of sialadenitis. Risk factors for sialadenitis include age over 40, recent dental procedures, Sjögren’s syndrome, immunosuppression, and conditions that decrease salivary flow. Staphylococcus aureus is the most common bacterial cause, while mumps is the most common viral cause. Ac
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 7
Correct
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A 52-year-old woman comes in with a history of two episodes of atrial fibrillation (AF). The most recent episode lasted for six days before resolving on its own. How would you classify the type of AF she has experienced?
Your Answer: Paroxysmal
Explanation:In order to gain a comprehensive understanding of AF management, it is crucial to familiarize oneself with the terminology used to describe its various subtypes. These terms help categorize different episodes of AF based on their characteristics and outcomes.
Acute AF refers to any episode that occurs within the previous 48 hours. It can manifest with or without symptoms and may or may not recur. On the other hand, paroxysmal AF describes episodes that spontaneously end within 7 days, typically within 48 hours. While these episodes are often recurrent, they can progress into a sustained form of AF.
Recurrent AF is defined as experiencing two or more episodes of AF. If the episodes self-terminate, they are classified as paroxysmal AF. However, if the episodes do not self-terminate, they are categorized as persistent AF. Persistent AF lasts longer than 7 days or has occurred after a previous cardioversion. To terminate persistent AF, electrical or pharmacological intervention is required. In some cases, persistent AF can progress into permanent AF.
Permanent AF, also known as Accepted AF, refers to episodes that cannot be successfully terminated, have relapsed after termination, or where cardioversion is not pursued. This subtype signifies a more chronic and ongoing form of AF.
By understanding and utilizing these terms, healthcare professionals can effectively communicate and manage the different subtypes of AF.
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This question is part of the following fields:
- Cardiology
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Question 8
Correct
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A 70-year-old patient arrives at the emergency department complaining of fever, fatigue, and loss of appetite for the past 3 weeks. During the examination, you observe a pansystolic murmur that was not detected during a pre-operative assessment for a cholecystectomy 4 months ago. You start considering the likelihood of infective endocarditis. Which of the following symptoms is commonly associated with infective endocarditis?
Your Answer: Janeway lesions
Explanation:Infective endocarditis is a condition that can be identified by certain signs, although none of them are definitive proof of the disease. The most reliable indicators are the presence of a heart murmur and a fever. However, there are other signs that are commonly associated with infective endocarditis, including splinter hemorrhages, Osler’s nodes, Janeway lesions, and Roth spots. It is important to note that these signs can also appear in other conditions, and they are not always present in patients with infective endocarditis. In fact, each of these signs is typically found in less than a third of patients diagnosed with the disease.
Further Reading:
Infective endocarditis (IE) is an infection that affects the innermost layer of the heart, known as the endocardium. It is most commonly caused by bacteria, although it can also be caused by fungi or viruses. IE can be classified as acute, subacute, or chronic depending on the duration of illness. Risk factors for IE include IV drug use, valvular heart disease, prosthetic valves, structural congenital heart disease, previous episodes of IE, hypertrophic cardiomyopathy, immune suppression, chronic inflammatory conditions, and poor dental hygiene.
The epidemiology of IE has changed in recent years, with Staphylococcus aureus now being the most common causative organism in most industrialized countries. Other common organisms include coagulase-negative staphylococci, streptococci, and enterococci. The distribution of causative organisms varies depending on whether the patient has a native valve, prosthetic valve, or is an IV drug user.
Clinical features of IE include fever, heart murmurs (most commonly aortic regurgitation), non-specific constitutional symptoms, petechiae, splinter hemorrhages, Osler’s nodes, Janeway’s lesions, Roth’s spots, arthritis, splenomegaly, meningism/meningitis, stroke symptoms, and pleuritic pain.
The diagnosis of IE is based on the modified Duke criteria, which require the presence of certain major and minor criteria. Major criteria include positive blood cultures with typical microorganisms and positive echocardiogram findings. Minor criteria include fever, vascular phenomena, immunological phenomena, and microbiological phenomena. Blood culture and echocardiography are key tests for diagnosing IE.
In summary, infective endocarditis is an infection of the innermost layer of the heart that is most commonly caused by bacteria. It can be classified as acute, subacute, or chronic and can be caused by a variety of risk factors. Staphylococcus aureus is now the most common causative organism in most industrialized countries. Clinical features include fever, heart murmurs, and various other symptoms. The diagnosis is based on the modified Duke criteria, which require the presence of certain major and minor criteria. Blood culture and echocardiography are important tests for diagnosing IE.
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This question is part of the following fields:
- Infectious Diseases
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Question 9
Correct
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A 42-year-old woman with a long-standing history of ulcerative colitis presents with a fever, itching, and yellowing of the skin. An ERCP is scheduled, which reveals a characteristic beads-on-a-string appearance.
What is the SINGLE most probable diagnosis?Your Answer: Primary sclerosing cholangitis
Explanation:Primary sclerosing cholangitis (PSC) is a condition that affects the bile ducts, causing inflammation and blockage over time. It is more commonly seen in men than women, with a ratio of 3 to 1, and is typically diagnosed around the age of 40. PSC is characterized by recurring episodes of cholangitis and progressive scarring of the bile ducts. If left untreated, it can lead to liver cirrhosis, liver failure, and even hepatocellular carcinoma. PSC is often associated with ulcerative colitis, with more than 80% of PSC patients also having this condition. Other associations include fibrosis in the retroperitoneal and mediastinal areas.
When performing an endoscopic retrograde cholangiopancreatography (ERCP) to diagnose PSC, certain findings are typically observed. These include ulceration of the common bile duct, irregular narrowing with saccular dilatation above the structured ducts (resembling beads-on-a-string or a beaded appearance), and involvement of both the intra- and extrahepatic ducts simultaneously.
Complications that can arise from PSC include liver cirrhosis, portal hypertension, liver failure, and cholangiocarcinoma. Treatment options for PSC include the use of ursodeoxycholic acid to improve symptoms and liver function (although it does not affect the overall prognosis), cholestyramine to alleviate itching, and correction of deficiencies in fat-soluble vitamins. In some cases, endoscopic dilatation of strictures may be necessary.
Liver transplantation is the definitive treatment for PSC. The 10-year survival rate after transplantation is approximately 65%, and the average survival time from the time of diagnosis is around seven years. Patients with PSC often succumb to complications such as secondary biliary cirrhosis, portal hypertension, or cholangitis. Additionally, about 10% of PSC patients will develop cholangiocarcinoma.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 10
Correct
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A 30-year-old woman with a history of schizophrenia comes in with a side effect caused by the antipsychotic medication she is currently using.
Which ONE statement about the side effects of antipsychotic drugs is accurate?Your Answer: Haloperidol is the most common antipsychotic drug to cause extrapyramidal side effects
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 rhythmic and involuntary movements of the tongue, face, and jaw, typically develops after long-term treatment or high doses. It is the most severe manifestation of extrapyramidal symptoms, as it may become irreversible even after discontinuing the causative drug, 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 occur 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.
Elderly patients with dementia-related psychosis who are treated with haloperidol have an increased risk of mortality. This is believed to be due to a higher likelihood of experiencing cardiovascular events and infections such as pneumonia.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 11
Correct
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A 21 year old female is brought to the emergency department by her boyfriend as he is concerned the patient has become drowsy after intermittent vomiting throughout the day. The boyfriend informs you that the patient is a type 1 diabetic. After evaluation, the patient is diagnosed with diabetic ketoacidosis and started on fluids and an insulin infusion. Due to a lack of available beds, the patient is transferred to the A&E observation ward. Several hours later, you are asked about discontinuing the insulin infusion. What criteria must be met before stopping the insulin infusion?
Your Answer: Ketones less than 0.3 mmol/l and venous pH over 7.3
Explanation:In the treatment of diabetic ketoacidosis (DKA), it is important to continue the infusion of insulin until certain criteria are met. These criteria include ketone levels being less than 0.3 mmol/L and the pH of the blood being above 7.3 or the bicarbonate levels being above 18 mmol/L. Additionally, the patient should feel comfortable enough to eat at this point. It is crucial not to stop the intravenous insulin infusion until at least 30 minutes after administering subcutaneous short-acting insulin.
Further Reading:
Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs due to a lack of insulin in the body. It is most commonly seen in individuals with type 1 diabetes but can also occur in type 2 diabetes. DKA is characterized by hyperglycemia, acidosis, and ketonaemia.
The pathophysiology of DKA involves insulin deficiency, which leads to increased glucose production and decreased glucose uptake by cells. This results in hyperglycemia and osmotic diuresis, leading to dehydration. Insulin deficiency also leads to increased lipolysis and the production of ketone bodies, which are acidic. The body attempts to buffer the pH change through metabolic and respiratory compensation, resulting in metabolic acidosis.
DKA can be precipitated by factors such as infection, physiological stress, non-compliance with insulin therapy, acute medical conditions, and certain medications. The clinical features of DKA include polydipsia, polyuria, signs of dehydration, ketotic breath smell, tachypnea, confusion, headache, nausea, vomiting, lethargy, and abdominal pain.
The diagnosis of DKA is based on the presence of ketonaemia or ketonuria, blood glucose levels above 11 mmol/L or known diabetes mellitus, and a blood pH below 7.3 or bicarbonate levels below 15 mmol/L. Initial investigations include blood gas analysis, urine dipstick for glucose and ketones, blood glucose measurement, and electrolyte levels.
Management of DKA involves fluid replacement, electrolyte correction, insulin therapy, and treatment of any underlying cause. Fluid replacement is typically done with isotonic saline, and potassium may need to be added depending on the patient’s levels. Insulin therapy is initiated with an intravenous infusion, and the rate is adjusted based on blood glucose levels. Monitoring of blood glucose, ketones, bicarbonate, and electrolytes is essential, and the insulin infusion is discontinued once ketones are below 0.3 mmol/L, pH is above 7.3, and bicarbonate is above 18 mmol/L.
Complications of DKA and its treatment include gastric stasis, thromboembolism, electrolyte disturbances, cerebral edema, hypoglycemia, acute respiratory distress syndrome, and acute kidney injury. Prompt medical intervention is crucial in managing DKA to prevent potentially fatal outcomes.
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This question is part of the following fields:
- Endocrinology
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Question 12
Correct
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A 40 year old is brought to the emergency department by his hiking guide after complaining of right sided chest pain and difficulty breathing whilst on the hike back to the trailhead following a strenuous climb. On examination you note reduced breath sounds and hyper-resonant percussion to the right base and right apex. Observations are shown below:
Pulse 98 bpm
Blood pressure 130/82 mmHg
Respiratory rate 22 bpm
Oxygen saturations 96% on air
Temperature 37.2°C
What is the likely diagnosis?Your Answer: Pneumothorax
Explanation:SCUBA divers face the potential danger of developing pulmonary barotrauma, which can lead to conditions like arterial gas embolism (AGE) or pneumothorax. Based on the patient’s diving history and clinical symptoms, it is highly likely that they are experiencing a left-sided pneumothorax caused by barotrauma. To confirm the presence of pneumothorax, a chest X-ray is usually performed, unless the patient shows signs of tension pneumothorax. In such cases, immediate decompression is necessary, which can be achieved by inserting a chest tube.
Further Reading:
Decompression illness (DCI) is a term that encompasses both decompression sickness (DCS) and arterial gas embolism (AGE). When diving underwater, the increasing pressure causes gases to become more soluble and reduces the size of gas bubbles. As a diver ascends, nitrogen can come out of solution and form gas bubbles, leading to decompression sickness or the bends. Boyle’s and Henry’s gas laws help explain the changes in gases during changing pressure.
Henry’s law states that the amount of gas that dissolves in a liquid is proportional to the partial pressure of the gas. Divers often use atmospheres (ATM) as a measure of pressure, with 1 ATM being the pressure at sea level. Boyle’s law states that the volume of gas is inversely proportional to the pressure. As pressure increases, volume decreases.
Decompression sickness occurs when nitrogen comes out of solution as a diver ascends. The evolved gas can physically damage tissue by stretching or tearing it as bubbles expand, or by provoking an inflammatory response. Joints and spinal nervous tissue are commonly affected. Symptoms of primary damage usually appear immediately or soon after a dive, while secondary damage may present hours or days later.
Arterial gas embolism occurs when nitrogen bubbles escape into the arterial circulation and cause distal ischemia. The consequences depend on where the embolism lodges, ranging from tissue ischemia to stroke if it lodges in the cerebral arterial circulation. Mechanisms for distal embolism include pulmonary barotrauma, right to left shunt, and pulmonary filter overload.
Clinical features of decompression illness vary, but symptoms often appear within six hours of a dive. These can include joint pain, neurological symptoms, chest pain or breathing difficulties, rash, vestibular problems, and constitutional symptoms. Factors that increase the risk of DCI include diving at greater depth, longer duration, multiple dives close together, problems with ascent, closed rebreather circuits, flying shortly after diving, exercise shortly after diving, dehydration, and alcohol use.
Diagnosis of DCI is clinical, and investigations depend on the presentation. All patients should receive high flow oxygen, and a low threshold for ordering a chest X-ray should be maintained. Hydration is important, and IV fluids may be necessary. Definitive treatment is recompression therapy in a hyperbaric oxygen chamber, which should be arranged as soon as possible. Entonox should not be given, as it will increase the pressure effect in air spaces.
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This question is part of the following fields:
- Respiratory
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Question 13
Correct
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A 28 year old male is brought into the ED after being discovered in a collapsed state. The patient is making minimal effort to breathe. The patient is a known IV drug user. The attending physician requests that you obtain an arterial blood gas sample from the radial artery. The blood gas is collected and the results are as follows:
pH 7.30
pO2 8.8 kPa
pCO2 7.4 kPa
Bicarbonate 26 mmol/L
Chloride 98 mmol/L
Potassium 5.6 mmol/L
Sodium 135 mmol/L
What type of acid-base abnormality is indicated?Your Answer: Respiratory acidosis
Explanation:Respiratory acidosis occurs when the respiratory system is unable to effectively remove carbon dioxide from the body, leading to an increase in acidity. This is often seen in cases of opioid overdose, where respiratory depression can occur. In respiratory acidosis, the bicarbonate levels may rise as the body’s metabolic system tries to compensate for the increased acidity.
Further Reading:
Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.
To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.
Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.
The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.
The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.
The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.
Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.
The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.
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This question is part of the following fields:
- Respiratory
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Question 14
Correct
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A 72 year old male patient presents to the emergency department complaining of worsening shortness of breath. You observe moderate mitral stenosis on the patient's most recent echocardiogram 10 months ago.
What is a typical finding in individuals with mitral stenosis?Your Answer: Loud 1st heart sound
Explanation:Mitral stenosis is a condition characterized by a narrowing of the mitral valve in the heart. One of the key features of this condition is a loud first heart sound, which is often described as having an opening snap. This sound is typically heard during mid-late diastole and is best heard during expiration. Other signs of mitral stenosis include a low volume pulse, a flushed appearance of the cheeks (known as malar flush), and the presence of atrial fibrillation. Additionally, patients with mitral stenosis may exhibit signs of pulmonary edema, such as crepitations (crackling sounds) in the lungs and the production of white or pink frothy sputum. It is important to note that a water hammer pulse is associated with a different condition called aortic regurgitation.
Further Reading:
Mitral Stenosis:
– Causes: Rheumatic fever, Mucopolysaccharidoses, Carcinoid, Endocardial fibroelastosis
– Features: Mid-late diastolic murmur, loud S1, opening snap, low volume pulse, malar flush, atrial fibrillation, signs of pulmonary edema, tapping apex beat
– Features of severe mitral stenosis: Length of murmur increases, opening snap becomes closer to S2
– Investigation findings: CXR may show left atrial enlargement, echocardiography may show reduced cross-sectional area of the mitral valveMitral Regurgitation:
– Causes: Mitral valve prolapse, Myxomatous degeneration, Ischemic heart disease, Rheumatic fever, Connective tissue disorders, Endocarditis, Dilated cardiomyopathy
– Features: pansystolic murmur radiating to left axilla, soft S1, S3, laterally displaced apex beat with heave
– Signs of acute MR: Decompensated congestive heart failure symptoms
– Signs of chronic MR: Leg edema, fatigue, arrhythmia (atrial fibrillation)
– Investigation findings: Doppler echocardiography to detect regurgitant flow and pulmonary hypertension, ECG may show signs of LA enlargement and LV hypertrophy, CXR may show LA and LV enlargement in chronic MR and pulmonary edema in acute MR. -
This question is part of the following fields:
- Cardiology
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Question 15
Correct
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A 14-year-old girl was cycling down a hill when a car backed up in front of her, resulting in a collision. She visits the emergency department, reporting upper abdominal pain caused by the handlebars. You determine that a FAST scan is necessary. What is the main objective of performing a FAST scan for blunt abdominal trauma?
Your Answer: Detect the presence of intraperitoneal fluid
Explanation:The primary goal of performing a FAST scan in cases of blunt abdominal trauma is to identify the existence of intraperitoneal fluid. According to the Royal College of Emergency Medicine (RCEM), the purpose of using ultrasound in the initial evaluation of abdominal trauma is specifically to confirm the presence of fluid within the peritoneal cavity, with the assumption that it is blood. However, it is important to note that ultrasound is not reliable for diagnosing injuries to solid organs or hollow viscus.
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.
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This question is part of the following fields:
- Trauma
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Question 16
Correct
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A 72 year old male presents to the emergency department following a fall onto an outstretched hand. Following assessment you order an X-ray of the wrist which confirms a dorsally angulated extra-articular fracture of the right distal radius. You also observe cortical thinning and increased radiolucency of the bone and consider the possibility of underlying osteoporosis. What is a risk factor for osteoporosis?
Your Answer: Menopause
Explanation:Osteoporosis and fragility fractures are more likely to occur in individuals with low levels of estrogen. Menopause, which causes a decrease in estrogen, can lead to estrogen deficiency. Estrogen plays a role in preventing bone breakdown by inhibiting osteoclast activity. After menopause, there is an increase in osteoclast activity, resulting in a rapid decline in bone mineral density. Osteoporosis is also associated with the long-term use of corticosteroids.
Further Reading:
Fragility fractures are fractures that occur following a fall from standing height or less, and may be atraumatic. They often occur in the presence of osteoporosis, a disease characterized by low bone mass and structural deterioration of bone tissue. Fragility fractures commonly affect the wrist, spine, hip, and arm.
Osteoporosis is defined as a bone mineral density (BMD) of 2.5 standard deviations below the mean peak mass, as measured by dual-energy X-ray absorptiometry (DXA). Osteopenia, on the other hand, refers to low bone mass between normal bone mass and osteoporosis, with a T-score between -1 to -2.5.
The pathophysiology of osteoporosis involves increased osteoclast activity relative to bone production by osteoblasts. The prevalence of osteoporosis increases with age, from approximately 2% at 50 years to almost 50% at 80 years.
There are various risk factors for fragility fractures, including endocrine diseases, GI causes of malabsorption, chronic kidney and liver diseases, menopause, immobility, low body mass index, advancing age, oral corticosteroids, smoking, alcohol consumption, previous fragility fractures, rheumatological conditions, parental history of hip fracture, certain medications, visual impairment, neuromuscular weakness, cognitive impairment, and unsafe home environment.
Assessment of a patient with a possible fragility fracture should include evaluating the risk of further falls, the risk of osteoporosis, excluding secondary causes of osteoporosis, and ruling out non-osteoporotic causes for fragility fractures such as metastatic bone disease, multiple myeloma, osteomalacia, and Paget’s disease.
Management of fragility fractures involves initial management by the emergency clinician, while treatment of low bone density is often delegated to the medical team or general practitioner. Management considerations include determining who needs formal risk assessment, who needs a DXA scan to measure BMD, providing lifestyle advice, and deciding who requires drug treatment.
Medication for osteoporosis typically includes vitamin D, calcium, and bisphosphonates. Vitamin D and calcium supplementation should be considered based on individual needs, while bisphosphonates are advised for postmenopausal women and men over 50 years with confirmed osteoporosis or those taking high doses of oral corticosteroids.
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This question is part of the following fields:
- Endocrinology
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Question 17
Correct
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You are summoned to a cardiac arrest in the resuscitation area of your Emergency Department.
Which ONE statement about the utilization of amiodarone in cardiac arrest is NOT true?Your Answer: It should be administered as an infusion of 300 mg over 20-60 minutes
Explanation:Amiodarone is a medication that is recommended to be administered after the third shock in a shockable cardiac arrest (Vf/pVT) while chest compressions are being performed. The prescribed dose is 300 mg, given as an intravenous bolus that is diluted in 5% dextrose to a volume of 20 mL. It is important to note that amiodarone is not suitable for treating PEA or asystole.
In cases where VF/pVT persists after five defibrillation attempts, an additional dose of 150 mg of amiodarone should be given. However, if amiodarone is not available, lidocaine can be used as an alternative. The recommended dose of lidocaine is 1 mg/kg. It is crucial to avoid administering lidocaine if amiodarone has already been given.
Amiodarone is classified as a membrane-stabilizing antiarrhythmic drug. It works by prolonging the duration of the action potential and the refractory period in both the atrial and ventricular myocardium. This medication also slows down atrioventricular conduction and has a similar effect on accessory pathways.
Additionally, amiodarone has a mild negative inotropic action, meaning it weakens the force of heart contractions. It also causes peripheral vasodilation through non-competitive alpha-blocking effects.
It is important to note that while there is no evidence of long-term benefits from using amiodarone, it may improve short-term survival rates, which justifies its continued use.
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This question is part of the following fields:
- Cardiology
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Question 18
Incorrect
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A 68-year-old man with asthma has been experiencing persistent diarrhea for the past week. A stool sample has been sent for analysis, which has cultured Salmonella enteritidis. He currently takes a daily maintenance dose of prednisolone for control of his asthma.
Which of the following antibacterial agents would be most suitable to prescribe in this situation?Your Answer: Clarithromycin
Correct Answer: Ciprofloxacin
Explanation:The current recommendations by NICE and the BNF for non-typhoid salmonella enteritis suggest that ciprofloxacin should be used as the first-line treatment if necessary. Alternatively, cefotaxime can be considered as a suitable alternative. It is important to note that cases of salmonella enteritis often resolve on their own without treatment and are frequently self-limiting. Therefore, the BNF advises against treatment unless there is a risk of developing invasive infection. This includes individuals who are immunocompromised, have haemoglobinopathy, or are children under 6 months old. However, in the case of an elderly patient who is regularly taking corticosteroids, treatment would be recommended.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 19
Correct
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You are overseeing the care of a trauma patient in the resuscitation bay. A chest tube has been inserted through thoracostomy to drain the hemothorax. The initial amount of blood drained is documented, and there are plans to monitor the additional blood volume drained every hour. What would be an indication for thoracotomy in this patient?
Your Answer: 250 ml blood drained from pleural cavity (in addition to previous volumes) between hours 2 and 3 post insertion
Explanation:The main indications for thoracotomy in patients with haemothorax are prompt drainage of at least 1500 ml of blood, ongoing blood loss of more than 200 ml per hour for 2-4 hours, and the need for continued blood transfusion. Option 3 in the given choices meets these criteria as the blood loss remains above 200 ml per hour for more than 2 hours after the drain is inserted. Option 1 does not meet the criteria as the blood volume is below 1500 ml. Option 2 does not meet the criteria as the blood loss has not been ongoing for at least 2 hours. Option 4 does not meet the criteria as there is no information indicating the need for ongoing blood transfusion.
Further Reading:
Haemothorax is the accumulation of blood in the pleural cavity of the chest, usually resulting from chest trauma. It can be difficult to differentiate from other causes of pleural effusion on a chest X-ray. Massive haemothorax refers to a large volume of blood in the pleural space, which can impair physiological function by causing blood loss, reducing lung volume for gas exchange, and compressing thoracic structures such as the heart and IVC.
The management of haemothorax involves replacing lost blood volume and decompressing the chest. This is done through supplemental oxygen, IV access and cross-matching blood, IV fluid therapy, and the insertion of a chest tube. The chest tube is connected to an underwater seal and helps drain the fluid, pus, air, or blood from the pleural space. In cases where there is prompt drainage of a large amount of blood, ongoing significant blood loss, or the need for blood transfusion, thoracotomy and ligation of bleeding thoracic vessels may be necessary. It is important to have two IV accesses prior to inserting the chest drain to prevent a drop in blood pressure.
In summary, haemothorax is the accumulation of blood in the pleural cavity due to chest trauma. Managing haemothorax involves replacing lost blood volume and decompressing the chest through various interventions, including the insertion of a chest tube. Prompt intervention may be required in cases of significant blood loss or ongoing need for blood transfusion.
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This question is part of the following fields:
- Trauma
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Question 20
Correct
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A 25 year old male presents to the emergency department with a significant laceration on his right forearm. You suggest that the wound can be stitched under local anesthesia. You opt to use 1% lidocaine for the procedure. The patient has a weight of 70kg. Determine the maximum amount of lidocaine 1% that can be administered.
Your Answer: 18 ml
Explanation:Lidocaine is a medication that is available in a concentration of 10 mg per milliliter. The maximum recommended dose of lidocaine is 18 milliliters.
Further Reading:
Local anaesthetics, such as lidocaine, bupivacaine, and prilocaine, are commonly used in the emergency department for topical or local infiltration to establish a field block. Lidocaine is often the first choice for field block prior to central line insertion. These anaesthetics work by blocking sodium channels, preventing the propagation of action potentials.
However, local anaesthetics can enter the systemic circulation and cause toxic side effects if administered in high doses. Clinicians must be aware of the signs and symptoms of local anaesthetic systemic toxicity (LAST) and know how to respond. Early signs of LAST include numbness around the mouth or tongue, metallic taste, dizziness, visual and auditory disturbances, disorientation, and drowsiness. If not addressed, LAST can progress to more severe symptoms such as seizures, coma, respiratory depression, and cardiovascular dysfunction.
The management of LAST is largely supportive. Immediate steps include stopping the administration of local anaesthetic, calling for help, providing 100% oxygen and securing the airway, establishing IV access, and controlling seizures with benzodiazepines or other medications. Cardiovascular status should be continuously assessed, and conventional therapies may be used to treat hypotension or arrhythmias. Intravenous lipid emulsion (intralipid) may also be considered as a treatment option.
If the patient goes into cardiac arrest, CPR should be initiated following ALS arrest algorithms, but lidocaine should not be used as an anti-arrhythmic therapy. Prolonged resuscitation may be necessary, and intravenous lipid emulsion should be administered. After the acute episode, the patient should be transferred to a clinical area with appropriate equipment and staff for further monitoring and care.
It is important to report cases of local anaesthetic toxicity to the appropriate authorities, such as the National Patient Safety Agency in the UK or the Irish Medicines Board in the Republic of Ireland. Additionally, regular clinical review should be conducted to exclude pancreatitis, as intravenous lipid emulsion can interfere with amylase or lipase assays.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 21
Correct
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A 22 year old student presents to the emergency department with a complaint of headache and nausea persisting for the last 24 hours. He reports feeling unwell shortly after he finished moving his belongings into his newly shared student accommodation. Carbon monoxide poisoning is suspected. What test will confirm the diagnosis?
Your Answer: Carboxyhaemoglobin
Explanation:Carboxyhaemoglobin (COHb) blood levels are utilized for the identification of carbon monoxide poisoning. COHb is the substance produced when carbon monoxide attaches to haemoglobin. It is important to note that carbaminohemoglobin (also known as carbaminohaemoglobin, carboxyhemoglobin, and carbohemoglobin) is the compound formed when carbon dioxide binds to hemoglobin, and should not be mistaken for COHb.
Further Reading:
Carbon monoxide (CO) is a dangerous gas that is produced by the combustion of hydrocarbon fuels and can be found in certain chemicals. It is colorless and odorless, making it difficult to detect. In England and Wales, there are approximately 60 deaths each year due to accidental CO poisoning.
When inhaled, carbon monoxide binds to haemoglobin in the blood, forming carboxyhaemoglobin (COHb). It has a higher affinity for haemoglobin than oxygen, causing a left-shift in the oxygen dissociation curve and resulting in tissue hypoxia. This means that even though there may be a normal level of oxygen in the blood, it is less readily released to the tissues.
The clinical features of carbon monoxide toxicity can vary depending on the severity of the poisoning. Mild or chronic poisoning may present with symptoms such as headache, nausea, vomiting, vertigo, confusion, and weakness. More severe poisoning can lead to intoxication, personality changes, breathlessness, pink skin and mucosae, hyperpyrexia, arrhythmias, seizures, blurred vision or blindness, deafness, extrapyramidal features, coma, or even death.
To help diagnose domestic carbon monoxide poisoning, there are four key questions that can be asked using the COMA acronym. These questions include asking about co-habitees and co-occupants in the house, whether symptoms improve outside of the house, the maintenance of boilers and cooking appliances, and the presence of a functioning CO alarm.
Typical carboxyhaemoglobin levels can vary depending on whether the individual is a smoker or non-smoker. Non-smokers typically have levels below 3%, while smokers may have levels below 10%. Symptomatic individuals usually have levels between 10-30%, and severe toxicity is indicated by levels above 30%.
When managing carbon monoxide poisoning, the first step is to administer 100% oxygen. Hyperbaric oxygen therapy may be considered for individuals with a COHb concentration of over 20% and additional risk factors such as loss of consciousness, neurological signs, myocardial ischemia or arrhythmia, or pregnancy. Other management strategies may include fluid resuscitation, sodium bicarbonate for metabolic acidosis, and mannitol for cerebral edema.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 22
Correct
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A 45-year-old man comes in with a fever, chills, headache, cough, and difficulty breathing. He also complains of a sore throat and occasional nosebleeds. He works at a nearby zoo in the bird exhibit. During the examination, a reddish macular rash is observed on his face, along with significant crackling sounds in both lower lobes of his lungs and an enlarged spleen.
What is the specific name of the rash on his face that is associated with this condition?Your Answer: Horder’s spots
Explanation:Psittacosis is a type of infection that can be transmitted from animals to humans, caused by a bacterium called Chlamydia psittaci. It is most commonly seen in people who own domestic birds, as well as those who work in pet shops or zoos. The typical symptoms of psittacosis include pneumonia that is acquired within the community, along with flu-like symptoms. Many patients also experience severe headaches and sensitivity to light. Enlargement of the spleen is a common finding in about two-thirds of individuals with this infection.
Infected individuals often develop a rash on their face, known as Horder’s spots, which appear as reddish macules. In some cases, erythema nodosum and erythema multiforme may also occur. The recommended treatment for psittacosis is a course of tetracycline or doxycycline for a period of 2-3 weeks.
On the other hand, rose spots are typically observed in cases of typhoid fever. These spots have a similar appearance to Horder’s spots but are usually found on the trunk rather than the face. Erythema marginatum is a pale red rash seen in rheumatic fever, while malar flush, also known as ‘mitral facies’, refers to the reddish discoloration of the cheeks commonly seen in individuals with mitral stenosis. Lastly, erythema chronicum migrans is the distinctive rash seen in Lyme disease, characterized by a circular rash with a central ‘bulls-eye’ appearance that spreads outward from the site of a tick bite.
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This question is part of the following fields:
- Respiratory
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Question 23
Correct
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A 70-year-old woman presents with painless haematuria and mild urinary urgency. Urine microscopy and culture are normal. An intravenous urogram (IVU) was also performed recently and was reported as being normal. On examination, you note that her bladder feels slightly distended. The rest of her examination was entirely normal.
What is the SINGLE most likely diagnosis?Your Answer: Bladder cancer
Explanation:Bladder cancer is the most likely diagnosis in this case, as patients with painless haematuria should undergo cystoscopy to rule out bladder cancer. This procedure is typically done in an outpatient setting as part of a haematuria clinic, using a flexible cystoscope and local anaesthetic.
Prostate cancer is less likely in this case, as the patient’s prostate examination was relatively normal and he only had mild symptoms of bladder outlet obstruction.
Bladder cancer is the seventh most common cancer in the UK, with men being three times more likely to develop it than women. The main risk factors for bladder cancer are increasing age and smoking. Smoking is responsible for about 50% of bladder cancers, as it is believed to be linked to the excretion of aromatic amines and polycyclic aromatic hydrocarbons through the kidneys. Smokers have a 2-6 times higher risk of developing bladder cancer compared to non-smokers.
Painless macroscopic haematuria is the most common symptom in 80-90% of bladder cancer patients. There are usually no abnormalities found during a standard physical examination.
Current recommendations state that the following patients should be urgently referred for a urological assessment: adults over 45 years old with unexplained visible haematuria not caused by a urinary tract infection, adults over 45 years old with visible haematuria that persists or recurs after successful treatment of a urinary tract infection, and adults aged 60 and over with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.
For those aged 60 and over with recurrent or persistent unexplained urinary tract infections, a non-urgent referral for bladder cancer is recommended.
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This question is part of the following fields:
- Urology
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Question 24
Correct
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A 62-year-old man presents with severe otalgia in his right ear that has been gradually worsening over the past few weeks. He describes the pain as being ‘constant’ and he has been unable to sleep for several nights. His family have noticed that the right side of his face appears to be ‘drooping’. His past medical history includes poorly controlled type 2 diabetes mellitus. On examination, he has a right-sided lower motor neuron facial nerve palsy. His right ear canal is very swollen and purulent exudate is visible.
What is the SINGLE most likely causative organism?Your Answer: Pseudomonas aeruginosa
Explanation:Malignant otitis externa (MOE), also known as necrotizing otitis externa, is a rare form of ear canal infection that primarily affects elderly diabetic patients, particularly those with poorly controlled diabetes.
MOE initially infects the ear canal and gradually spreads to the surrounding bony structures and soft tissues. In 98% of cases, the responsible pathogen is Pseudomonas aeruginosa.
Typically, MOE presents with severe and unrelenting ear pain, which tends to worsen at night. Even after the swelling of the ear canal subsides with topical antibiotics, the pain may persist. Other symptoms may include pus drainage from the ear and temporal headaches. Approximately 50% of patients also experience facial nerve paralysis, and cranial nerves IX to XII may be affected as well.
To confirm the diagnosis, technetium scanning and contrast-enhanced CT scanning are usually performed to detect any extension of the infection into the surrounding bony structures.
If left untreated, MOE can be life-threatening and may lead to serious complications such as skull base osteomyelitis, subdural empyema, and cerebral abscess.
Treatment typically involves long-term administration of intravenous antibiotics. While surgical intervention is not effective for MOE, exploratory surgery may be necessary to obtain cultures of unusual organisms that are not responding adequately to intravenous antibiotics.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 25
Incorrect
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A 62-year-old woman comes in with a gout flare-up after starting a new blood pressure medication prescribed by her doctor.
Which of the following blood pressure medications is most likely causing this?Your Answer: Verapamil
Correct Answer: Hydrochlorothiazide
Explanation:Thiazide diuretics, like bendroflumethiazide and hydrochlorothiazide, have the potential to raise levels of uric acid in the blood, which can worsen gout symptoms in individuals who are susceptible to the condition.
Other medications, such as diuretics, beta-blockers, ACE inhibitors, and non-losartan ARBs, are also linked to an increased risk of gout.
On the other hand, calcium-channel blockers like amlodipine and verapamil, as well as losartan, have been found to lower uric acid levels and are associated with a reduced risk of gout.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 26
Correct
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A young woman with a previous case of urethritis has a urethral swab sent to the laboratory for examination. Based on the findings of this test, she is diagnosed with gonorrhea.
What is the most probable observation that would have been made on her urethral swab?Your Answer: Gram-negative diplococci
Explanation:Neisseria gonorrhoeae is a type of bacteria that causes the sexually transmitted infection known as gonorrhoea. It is a Gram-negative diplococcus, meaning it appears as pairs of bacteria under a microscope. This infection is most commonly seen in individuals between the ages of 15 and 35, and it is primarily transmitted through sexual contact. One important characteristic of Neisseria gonorrhoeae is its ability to undergo antigenic variation, which means that recovering from an infection does not provide immunity and reinfection is possible.
When Neisseria gonorrhoeae infects the body, it first attaches to the genitourinary epithelium using pili, which are hair-like structures on the surface of the bacteria. It then invades the epithelial layer and triggers a local acute inflammatory response. In men, the clinical features of gonorrhoea often include urethritis (inflammation of the urethra) in about 80% of cases, dysuria (painful urination) in around 50% of cases, and mucopurulent discharge. Rectal infection may also occur, usually without symptoms, but it can cause anal discharge. Pharyngitis, or inflammation of the throat, is usually asymptomatic in men.
In women, the clinical features of gonorrhoea commonly include vaginal discharge in about 50% of cases, lower abdominal pain in around 25% of cases, dysuria in 10-15% of cases, and pelvic/lower abdominal tenderness in less than 5% of cases. Endocervical discharge and/or bleeding may also be present. Similar to men, rectal infection is usually asymptomatic but can cause anal discharge, and pharyngitis is usually asymptomatic in women as well.
Complications of Neisseria gonorrhoeae infection can be serious and include pelvic inflammatory disease (PID) in women, epididymo-orchitis or prostatitis in men, arthritis, dermatitis, pericarditis and/or myocarditis, hepatitis, and meningitis.
To diagnose gonorrhoea, samples of pus from the urethra, cervix, rectum, or throat should be collected and promptly sent to the laboratory in specialized transport medium. Traditionally, diagnosis has been made using Gram-stain and culture techniques, but newer PCR testing methods are becoming more commonly used.
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This question is part of the following fields:
- Sexual Health
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Question 27
Correct
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A 35-year-old woman is injured in a car crash and sustains severe facial trauma. Imaging tests show that she has a Le Fort II fracture.
What is the most accurate description of the injury pattern seen in a Le Fort II fracture?Your Answer: Pyramidal-shaped fracture, with the teeth at the base of the pyramid and the nasofrontal suture at the apex
Explanation:Le Fort fractures are complex fractures of the midface that involve the maxillary bone and surrounding structures. These fractures can occur in a horizontal, pyramidal, or transverse direction. The distinguishing feature of Le Fort fractures is the traumatic separation of the pterygomaxillary region. They make up approximately 10% to 20% of all facial fractures and can have severe consequences, both in terms of potential life-threatening injuries and disfigurement.
The Le Fort classification system categorizes midface fractures into three groups based on the plane of injury. As the classification level increases, the location of the maxillary fracture moves from inferior to superior within the maxilla.
Le Fort I fractures are horizontal fractures that occur across the lower aspect of the maxilla. These fractures cause the teeth to separate from the upper face and extend through the lower nasal septum, the lateral wall of the maxillary sinus, and into the palatine bones and pterygoid plates. They are sometimes referred to as a floating palate because they often result in the mobility of the hard palate from the midface. Common accompanying symptoms include facial swelling, loose teeth, dental fractures, and misalignment of the teeth.
Le Fort II fractures are pyramidal-shaped fractures, with the base of the pyramid located at the level of the teeth and the apex at the nasofrontal suture. The fracture line extends from the nasal bridge and passes through the superior wall of the maxilla, the lacrimal bones, the inferior orbital floor and rim, and the anterior wall of the maxillary sinus. These fractures are sometimes called a floating maxilla because they typically result in the mobility of the maxilla from the midface. Common symptoms include facial swelling, nosebleeds, subconjunctival hemorrhage, cerebrospinal fluid leakage from the nose, and widening and flattening of the nasal bridge.
Le Fort III fractures are transverse fractures of the midface. The fracture line passes through the nasofrontal suture, the maxillo frontal suture, the orbital wall, and the zygomatic arch and zygomaticofrontal suture. These fractures cause separation of all facial bones from the cranial base, earning them the nickname craniofacial disjunction or floating face fractures. They are the rarest and most severe type of Le Fort fracture. Common symptoms include significant facial swelling, bruising around the eyes, facial flattening, and the entire face can be shifted.
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This question is part of the following fields:
- Maxillofacial & Dental
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Question 28
Incorrect
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A 45 year old patient presents to the emergency department with a head laceration sustained following a fall while under the influence of alcohol. You determine to evaluate the patient's alcohol consumption. Which screening tool does NICE (National Institute for Health and Care Excellence) recommend for assessing risky drinking?
Your Answer: CAGE
Correct Answer: AUDIT
Explanation:The AUDIT screening tool is recommended by NICE for identifying patients who may be at risk of hazardous drinking.
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.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 29
Correct
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You assess a 20-year-old woman who has ingested a combination of drugs 30 minutes prior to her arrival at the emergency department. You contemplate the use of activated charcoal to minimize the absorption of the ingested substances. Which of the following is not susceptible to the effects of activated charcoal?
Your Answer: Lithium
Explanation:Activated charcoal is a useful treatment for many drug poisonings, but it is not effective against certain types of poisonings. To remember these exceptions, you can use the mnemonic PHAILS. This stands for Pesticides (specifically organophosphates), Hydrocarbons, Acids (strong), alkalis (strong), alcohols (such as ethanol, methanol, and ethylene glycol), Iron, Lithium, and Solvents.
Further Reading:
Poisoning in the emergency department is often caused by accidental or intentional overdose of prescribed drugs. Supportive treatment is the primary approach for managing most poisonings. This includes ensuring a clear airway, proper ventilation, maintaining normal fluid levels, temperature, and blood sugar levels, correcting any abnormal blood chemistry, controlling seizures, and assessing and treating any injuries.
In addition to supportive treatment, clinicians may need to consider strategies for decontamination, elimination, and administration of antidotes. Decontamination involves removing poisons from the skin or gastrointestinal tract. This can be done through rinsing the skin or using methods such as activated charcoal, gastric lavage, induced emesis, or whole bowel irrigation. However, induced emesis is no longer commonly used, while gastric lavage and whole bowel irrigation are rarely used.
Elimination methods include urinary alkalinization, hemodialysis, and hemoperfusion. These techniques help remove toxins from the body.
Activated charcoal is a commonly used method for decontamination. It works by binding toxins in the gastrointestinal tract, preventing their absorption. It is most effective if given within one hour of ingestion. However, it is contraindicated in patients with an insecure airway due to the risk of aspiration. Activated charcoal can be used for many drugs, but it is ineffective for certain poisonings, including pesticides (organophosphates), hydrocarbons, strong acids and alkalis, alcohols (ethanol, methanol, ethylene glycol), iron, lithium, and solvents.
Antidotes are specific treatments for poisoning caused by certain drugs or toxins. For example, cyanide poisoning can be treated with dicobalt edetate, hydroxocobalamin, or sodium nitrite and sodium thiosulphate. Benzodiazepine poisoning can be treated with flumazanil, while opiate poisoning can be treated with naloxone. Other examples include protamine for heparin poisoning, vitamin K or fresh frozen plasma for warfarin poisoning, fomepizole or ethanol for methanol poisoning, and methylene blue for methemoglobinemia caused by benzocaine or nitrates.
There are many other antidotes available for different types of poisoning, and resources such as TOXBASE and the National Poisons Information Service (NPIS) can provide valuable advice on managing poisonings.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 30
Incorrect
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You assess a client who has recently developed severe depression and contemplate the potential presence of an underlying physiological factor contributing to this condition.
Which ONE of the following is NOT a potential physiological cause for depression?Your Answer: Hypercalcaemia
Correct Answer: Thiamine deficiency
Explanation:Thiamine deficiency is linked to episodes of acute confusion, but it is not typically associated with depression. On the other hand, depression is commonly seen in individuals with hypercalcemia. Chronic diseases like Parkinson’s disease and COPD are strongly correlated with depression. Additionally, both psychosis and depression can be associated with the use of steroids.
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This question is part of the following fields:
- Mental Health
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Question 31
Correct
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You are part of the team managing a pediatric patient, your consultant asks you what the patient's Mallampati score is. What criteria is utilized to assess the Mallampati score?
Your Answer: The distance between the tongue base and the roof of the mouth
Explanation:The Mallampati score is a measure that assesses the distance between the base of the tongue and the roof of the mouth. This score is used to classify the level of airway obstruction during certain medical procedures. Please refer to the notes below for the complete classification.
Further Reading:
A difficult airway refers to a situation where factors have been identified that make airway management more challenging. These factors can include body habitus, head and neck anatomy, mouth characteristics, jaw abnormalities, and neck mobility. The LEMON criteria can be used to predict difficult intubation by assessing these factors. The criteria include looking externally at these factors, evaluating the 3-3-2 rule which assesses the space in the mouth and neck, assessing the Mallampati score which measures the distance between the tongue base and roof of the mouth, and considering any upper airway obstructions or reduced neck mobility.
Direct laryngoscopy is a method used to visualize the larynx and assess the size of the tracheal opening. The Cormack-Lehane grading system can be used to classify the tracheal opening, with higher grades indicating more difficult access. In cases of a failed airway, where intubation attempts are unsuccessful and oxygenation cannot be maintained, the immediate priority is to oxygenate the patient and prevent hypoxic brain injury. This can be done through various measures such as using a bag-valve-mask ventilation, high flow oxygen, suctioning, and optimizing head positioning.
If oxygenation cannot be maintained, it is important to call for help from senior medical professionals and obtain a difficult airway trolley if not already available. If basic airway management techniques do not improve oxygenation, further intubation attempts may be considered using different equipment or techniques. If oxygen saturations remain below 90%, a surgical airway such as a cricothyroidotomy may be necessary.
Post-intubation hypoxia can occur for various reasons, and the mnemonic DOPES can be used to identify and address potential problems. DOPES stands for displacement of the endotracheal tube, obstruction, pneumothorax, equipment failure, and stacked breaths. If intubation attempts fail, a maximum of three attempts should be made before moving to an alternative plan, such as using a laryngeal mask airway or considering a cricothyroidotomy.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 32
Incorrect
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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: 300 mcg
Correct 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
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Question 33
Correct
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You are managing a 32-year-old woman with septic shock in the resuscitation room. The on-call intensive care team evaluates her and decides to insert a central venous catheter.
Which of the following veins would be the most suitable choice for central venous access?Your Answer: Internal jugular vein
Explanation:The internal jugular vein is a significant vein located close to the surface of the body. It is often chosen for the insertion of central venous catheters due to its accessibility. To locate the vein, a needle is inserted into the middle of a triangular area formed by the lower heads of the sternocleidomastoid muscle and the clavicle. It is important to palpate the carotid artery to ensure that the needle is inserted to the side of the artery.
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This question is part of the following fields:
- Resus
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Question 34
Correct
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You evaluate a 35-year-old male patient who has been diagnosed with an anal fissure. He has been undergoing treatment for the last two months, which includes lactulose, senna, topical creams with local anesthetics, and topical GTN ointment. However, his symptoms continue to persist, and he describes the pain during bowel movements as intolerable.
What would be the most suitable next step in managing this patient's condition?Your Answer: Botulinum toxin injection
Explanation:An anal fissure is a tear in the wall of the anal mucosa that exposes the circular muscle layer. The majority of these tears occur in the posterior midline. The most common cause is the passage of a large, hard stool after a period of constipation. If multiple fissures are present, it may indicate an underlying condition such as Crohn’s disease or tuberculosis.
Both men and women are equally affected by anal fissures, and they are most commonly seen in individuals in their thirties. The typical symptoms of an anal fissure include intense, sharp pain during bowel movements, which can last up to an hour after passing stool. Additionally, there may be spots of bright red blood on the toilet paper when wiping, and a history of constipation.
The initial management of an anal fissure involves non-operative measures such as using stool softeners and bulking agents. To alleviate the intense anal pain, analgesics and topical local anesthetics may be prescribed. According to a recent meta-analysis, first-line therapy should involve the use of topical GTN or diltiazem, with botulinum toxin being used as a rescue treatment if necessary (Modern perspectives in the treatment of chronic anal fissures. Ann R Coll Surg Engl. 2007 Jul;89(5):472-8.)
Sphincterotomy, a surgical procedure, should be reserved for fissures that do not heal and has a success rate of 90%. Anal dilatation, also known as Lord’s procedure, is rarely used nowadays due to the high risk of subsequent fecal incontinence.
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This question is part of the following fields:
- Surgical Emergencies
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Question 35
Correct
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You review a 25 year old male who presented to the emergency department after developing a raised red itchy rash to the arms, legs, and abdomen shortly after going for a hike. The patient informs you that he had eaten some trail mix and drank some water during the hike, but he had not had a reaction to these in the past. On examination, the mouth and throat are normal, the patient is speaking without difficulty, and there is no wheezing. The patient's vital signs are as follows:
Respiratory rate: 16 bpm
Blood pressure: 120/70 mmHg
Pulse rate: 75 bpm
Oxygen saturations: 98% on room air
Temperature: 37.0ºC
You diagnose urticaria. What is the most appropriate treatment to administer?Your Answer: chlorpheniramine 10 mg PO
Explanation:Most histamine receptors in the skin are of the H1 type. Therefore, when treating urticaria without airway compromise, it is appropriate to use an H1 blocking antihistamine such as chlorpheniramine, fexofenadine, or loratadine. However, if the case is mild and the trigger is easily identifiable and avoidable, NICE advises that no treatment may be necessary. In the given case, the trigger is not obvious. For more severe cases, an oral systemic steroid course like prednisolone 40 mg for 5 days may be used in addition to antihistamines. Topical steroids do not have a role in this treatment.
Further Reading:
Angioedema and urticaria are related conditions that involve swelling in different layers of tissue. Angioedema refers to swelling in the deeper layers of tissue, such as the lips and eyelids, while urticaria, also known as hives, refers to swelling in the epidermal skin layers, resulting in raised red areas of skin with itching. These conditions often coexist and may have a common underlying cause.
Angioedema can be classified into allergic and non-allergic types. Allergic angioedema is the most common type and is usually triggered by an allergic reaction, such as to certain medications like penicillins and NSAIDs. Non-allergic angioedema has multiple subtypes and can be caused by factors such as certain medications, including ACE inhibitors, or underlying conditions like hereditary angioedema (HAE) or acquired angioedema.
HAE is an autosomal dominant disease characterized by a deficiency of C1 esterase inhibitor. It typically presents in childhood and can be inherited or acquired as a result of certain disorders like lymphoma or systemic lupus erythematosus. Acquired angioedema may have similar clinical features to HAE but is caused by acquired deficiencies of C1 esterase inhibitor due to autoimmune or lymphoproliferative disorders.
The management of urticaria and allergic angioedema focuses on ensuring the airway remains open and addressing any identifiable triggers. In mild cases without airway compromise, patients may be advised that symptoms will resolve without treatment. Non-sedating antihistamines can be used for up to 6 weeks to relieve symptoms. Severe cases of urticaria may require systemic corticosteroids in addition to antihistamines. In moderate to severe attacks of allergic angioedema, intramuscular epinephrine may be considered.
The management of HAE involves treating the underlying deficiency of C1 esterase inhibitor. This can be done through the administration of C1 esterase inhibitor, bradykinin receptor antagonists, or fresh frozen plasma transfusion, which contains C1 inhibitor.
In summary, angioedema and urticaria are related conditions involving swelling in different layers of tissue. They can coexist and may have a common underlying cause. Management involves addressing triggers, using antihistamines, and in severe cases, systemic corticosteroids or other specific treatments for HAE.
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This question is part of the following fields:
- Dermatology
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Question 36
Correct
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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 and a greyish-white appearance in the discharge.
What is the most suitable treatment for this patient?Your Answer: Oral metronidazole
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.
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This question is part of the following fields:
- Sexual Health
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Question 37
Correct
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A 4 year old male is brought into the emergency department with a 24 hour history of diarrhoea and vomiting. The patient's father informs you that several of the child's preschool classmates have experienced a similar illness in the past few days. What is the most probable cause of this patient's symptoms?
Your Answer: Rotavirus
Explanation:Gastroenteritis is a common condition in children, particularly those under the age of 5. It is characterized by the sudden onset of diarrhea, with or without vomiting. The most common cause of gastroenteritis in infants and young children is rotavirus, although other viruses, bacteria, and parasites can also be responsible. Prior to the introduction of the rotavirus vaccine in 2013, rotavirus was the leading cause of gastroenteritis in children under 5 in the UK. However, the vaccine has led to a significant decrease in cases, with a drop of over 70% in subsequent years.
Norovirus is the most common cause of gastroenteritis in adults, but it also accounts for a significant number of cases in children. In England & Wales, there are approximately 8,000 cases of norovirus each year, with 15-20% of these cases occurring in children under 9.
When assessing a child with gastroenteritis, it is important to consider whether there may be another more serious underlying cause for their symptoms. Dehydration assessment is also crucial, as some children may require intravenous fluids. The NICE traffic light system can be used to identify the risk of serious illness in children under 5.
In terms of investigations, stool microbiological testing may be indicated in certain cases, such as when the patient has been abroad, if diarrhea lasts for more than 7 days, or if there is uncertainty over the diagnosis. U&Es may be necessary if intravenous fluid therapy is required or if there are symptoms and/or signs suggestive of hypernatremia. Blood cultures may be indicated if sepsis is suspected or if antibiotic therapy is planned.
Fluid management is a key aspect of treating children with gastroenteritis. In children without clinical dehydration, normal oral fluid intake should be encouraged, and oral rehydration solution (ORS) supplements may be considered. For children with dehydration, ORS solution is the preferred method of rehydration, unless intravenous fluid therapy is necessary. Intravenous fluids may be required for children with shock or those who are unable to tolerate ORS solution.
Antibiotics are generally not required for gastroenteritis in children, as most cases are viral or self-limiting. However, there are some exceptions, such as suspected or confirmed sepsis, Extraintestinal spread of bacterial infection, or specific infections like Clostridium difficile-associated pseudomembranous enterocolitis or giardiasis.
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This question is part of the following fields:
- Paediatric Emergencies
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Question 38
Correct
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A 22 year old female comes to the emergency department complaining of pleuritic chest pain that has been present for 2 days. She is not currently taking any medications. A chest X-ray reveals no abnormalities and her D-dimer test is negative. An ECG shows sinus rhythm, but a prolonged QTc of 500 ms is observed. The patient is diagnosed with costochondritis and an incidental finding of long QT syndrome (LQTS). What is the primary treatment approach for LQTS?
Your Answer: Beta blockers
Explanation:Beta blockers are the primary treatment for long QT syndrome (LQTS). This patient probably has an undiagnosed congenital LQTS because there is no obvious cause. If there is a known cause of LQTS that can be removed, removing it may be the only necessary treatment. However, in all other cases, beta blockers are usually needed to prevent ventricular arrhythmias. Ventricular arrhythmias happen because of increased adrenergic activity. Beta blockers reduce the effects of adrenergic stimulation.
Further Reading:
Long QT syndrome (LQTS) is a condition characterized by a prolonged QT interval on an electrocardiogram (ECG), which represents abnormal repolarization of the heart. LQTS can be either acquired or congenital. Congenital LQTS is typically caused by gene abnormalities that affect ion channels responsible for potassium or sodium flow in the heart. There are 15 identified genes associated with congenital LQTS, with three genes accounting for the majority of cases. Acquired LQTS can be caused by various factors such as certain medications, electrolyte imbalances, hypothermia, hypothyroidism, and bradycardia from other causes.
The normal QTc values, which represent the corrected QT interval for heart rate, are typically less than 450 ms for men and less than 460ms for women. Prolonged QTc intervals are considered to be greater than these values. It is important to be aware of drugs that can cause QT prolongation, as this can lead to potentially fatal arrhythmias. Some commonly used drugs that can cause QT prolongation include antimicrobials, antiarrhythmics, antipsychotics, antidepressants, antiemetics, and others.
Management of long QT syndrome involves addressing any underlying causes and using beta blockers. In some cases, an implantable cardiac defibrillator (ICD) may be recommended for patients who have experienced recurrent arrhythmic syncope, documented torsades de pointes, previous ventricular tachyarrhythmias or torsades de pointes, previous cardiac arrest, or persistent syncope. Permanent pacing may be used in patients with bradycardia or atrioventricular nodal block and prolonged QT. Mexiletine is a treatment option for those with LQT3. Cervicothoracic sympathetic denervation may be considered in patients with recurrent syncope despite beta-blockade or in those who are not ideal candidates for an ICD. The specific treatment options for LQTS depend on the type and severity of the condition.
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This question is part of the following fields:
- Cardiology
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Question 39
Correct
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The Emergency Medicine consultant in charge of the department today calls you over to show you a case of superior orbital fissure syndrome (SOFS) in a 32-year-old woman with a Le Fort II fracture of the midface following a car accident.
Which of the cranial nerves is MOST likely to be unaffected?Your Answer: Cranial nerve II
Explanation:The superior orbital fissure is a gap in the back wall of the orbit, created by the space between the greater and lesser wings of the sphenoid bone. Several structures pass through it to enter the orbit, starting from the top and going downwards. These include the lacrimal nerve (a branch of CN V1), the frontal nerve (another branch of CN V1), the superior ophthalmic vein, the trochlear nerve (CN IV), the superior division of the oculomotor nerve (CN III), the nasociliary nerve (a branch of CN V1), the inferior division of the oculomotor nerve (CN III), the abducens nerve (CN VI), and the inferior ophthalmic vein.
Adjacent to the superior orbital fissure, on the back wall of the orbit and towards the middle, is the optic canal. The optic nerve (CN II) exits the orbit through this canal, along with the ophthalmic artery.
Superior orbital fissure syndrome (SOFS) is a condition characterized by a combination of symptoms and signs that occur when cranial nerves III, IV, V1, and VI are compressed or injured as they pass through the superior orbital fissure. This condition also leads to swelling and protrusion of the eye due to impaired drainage and congestion. The main causes of SOFS are trauma, tumors, and inflammation. It is important to note that CN II is not affected by this syndrome, as it follows a separate path through the optic canal.
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This question is part of the following fields:
- Maxillofacial & Dental
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Question 40
Correct
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A 2 year old male is brought to the emergency department by concerned parents. The child started experiencing episodes of diarrhea and vomiting 2 days ago which have continued today. They are worried as the patient has become lethargic throughout the day and hasn't urinated for several hours. After initial assessment, you decide to administer a 10 ml/kg bolus of 0.9% sodium chloride fluid to treat suspected shock. After giving the fluid bolus, you repeat the patient's observations as shown below:
Initial observation observation after fluid bolus
Pulse 160 148
Respiration rate 52 42
Capillary refill time 5s 4s
Temperature 37.8ºC 37.8ºC
You notice the patient still has cool extremities and mottled skin. What is the most appropriate next step in managing this patient?Your Answer: Administer further 10 ml/kg 0.9% sodium chloride fluid bolus
Explanation:Gastroenteritis is a common condition in children, particularly those under the age of 5. It is characterized by the sudden onset of diarrhea, with or without vomiting. The most common cause of gastroenteritis in infants and young children is rotavirus, although other viruses, bacteria, and parasites can also be responsible. Prior to the introduction of the rotavirus vaccine in 2013, rotavirus was the leading cause of gastroenteritis in children under 5 in the UK. However, the vaccine has led to a significant decrease in cases, with a drop of over 70% in subsequent years.
Norovirus is the most common cause of gastroenteritis in adults, but it also accounts for a significant number of cases in children. In England & Wales, there are approximately 8,000 cases of norovirus each year, with 15-20% of these cases occurring in children under 9.
When assessing a child with gastroenteritis, it is important to consider whether there may be another more serious underlying cause for their symptoms. Dehydration assessment is also crucial, as some children may require intravenous fluids. The NICE traffic light system can be used to identify the risk of serious illness in children under 5.
In terms of investigations, stool microbiological testing may be indicated in certain cases, such as when the patient has been abroad, if diarrhea lasts for more than 7 days, or if there is uncertainty over the diagnosis. U&Es may be necessary if intravenous fluid therapy is required or if there are symptoms and/or signs suggestive of hypernatremia. Blood cultures may be indicated if sepsis is suspected or if antibiotic therapy is planned.
Fluid management is a key aspect of treating children with gastroenteritis. In children without clinical dehydration, normal oral fluid intake should be encouraged, and oral rehydration solution (ORS) supplements may be considered. For children with dehydration, ORS solution is the preferred method of rehydration, unless intravenous fluid therapy is necessary. Intravenous fluids may be required for children with shock or those who are unable to tolerate ORS solution.
Antibiotics are generally not required for gastroenteritis in children, as most cases are viral or self-limiting. However, there are some exceptions, such as suspected or confirmed sepsis, Extraintestinal spread of bacterial infection, or specific infections like Clostridium difficile-associated pseudomembranous enterocolitis or giardiasis.
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This question is part of the following fields:
- Paediatric Emergencies
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Question 41
Correct
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You are the designated team leader in the resuscitation of a cardiac arrest patient. Your colleague disagrees with the decision to continue with the resuscitation.
What is the most appropriate course of action for you to take?Your Answer: Listen to the reason that they disagree and if their concerns are justified, change your decision accordingly
Explanation:In a resuscitation scenario, problem-solving and teamwork are crucial. The pressure is high, and tough decisions need to be made. As the team leader, it is important to value the opinions of other team members, especially those with more experience. By listening to the registrar’s perspective, you may gain new insights that could impact your decision-making process. Collaboration is key in such situations, and if you find yourself unsure of the best course of action, don’t hesitate to seek assistance.
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This question is part of the following fields:
- Safeguarding & Psychosocial Emergencies
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Question 42
Correct
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A 45-year-old man presents with increasing difficulty breathing, a raspy voice, and pain radiating down the inner side of his left upper arm into his forearm and hand. He has a history of heavy smoking and has been diagnosed with COPD. Upon examination, he exhibits weakness and noticeable muscle wasting in his forearm and hand on the same side. Additionally, he has a Horner's syndrome on the affected side. The Chest X-ray image is provided below:
What is the MOST LIKELY diagnosis for this patient?Your Answer: Pancoast tumour
Explanation:This patient presents with a noticeable mass at the top of the right lung, which is clearly visible on the chest X-ray. Based on the symptoms and clinical presentation, it is highly likely that this is a Pancoast tumor, and the overall diagnosis is Pancoast syndrome.
A Pancoast tumor is a type of tumor that develops at the apex of either the right or left lung. It typically spreads to nearby tissues such as the ribs and vertebrae. The majority of Pancoast tumors are classified as non-small cell cancers.
Pancoast syndrome occurs when the tumor invades various structures and tissues around the thoracic inlet. This includes the invasion of the cervical sympathetic plexus on the same side as the tumor, leading to the development of Horner’s syndrome. Additionally, there may be reflex sympathetic dystrophy in the arm on the affected side, resulting in increased sensitivity to touch and changes in the skin.
Patients with Pancoast syndrome may also experience shoulder and arm pain due to the tumor invading the brachial plexus roots C8-T1. This can lead to muscle wasting in the hand and tingling sensations in the inner side of the arm. In some cases, there may be involvement of the unilateral recurrent laryngeal nerve, causing unilateral vocal cord paralysis and resulting in a hoarse voice and/or a bovine cough. Phrenic nerve involvement is less common but can also occur.
Horner’s syndrome, which is a key feature of Pancoast syndrome, is caused by compression of the sympathetic chain from the hypothalamus to the orbit. The three main symptoms of Horner’s syndrome are drooping of the eyelid (ptosis), constriction of the pupil (pupillary miosis), and lack of sweating on the forehead (anhydrosis).
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This question is part of the following fields:
- Respiratory
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Question 43
Correct
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A 15-year-old presents to the emergency department with facial swelling and respiratory distress. Despite attempts at ventilation, it is determined that a cricothyroidotomy procedure is necessary. Which of the following statements about cricothyroidotomy is correct?
Your Answer: Involves creating an airway via the space between thyroid and cricoid cartilages
Explanation:Jet ventilation through a needle cricothyroidotomy typically involves using a 1 bar (100 Kpa) oxygen source.
Further Reading:
Cricothyroidotomy, also known as cricothyrotomy, is a procedure used to create an airway by making an incision between the thyroid and cricoid cartilages. This can be done surgically with a scalpel or using a needle method. It is typically used as a short-term solution for establishing an airway in emergency situations where traditional intubation is not possible.
The surgical technique involves dividing the cricothyroid membrane transversely, while some recommend making a longitudinal skin incision first to identify the structures below. Complications of this procedure can include bleeding, infection, incorrect placement resulting in a false passage, fistula formation, cartilage fracture, subcutaneous emphysema, scarring leading to stenosis, and injury to the vocal cords or larynx. There is also a risk of damage to the recurrent laryngeal nerve, and failure to perform the procedure successfully can lead to hypoxia and death.
There are certain contraindications to surgical cricothyroidotomy, such as the availability of less invasive airway securing methods, patients under 12 years old (although a needle technique may be used), laryngeal fracture, pre-existing or acute laryngeal pathology, tracheal transection with retraction into the mediastinum, and obscured anatomical landmarks.
The needle (cannula) cricothyroidotomy involves inserting a cannula through the cricothyroid membrane to access the trachea. This method is mainly used in children in scenarios where ENT assistance is not available. However, there are drawbacks to this approach, including the need for high-pressure oxygen delivery, which can risk barotrauma and may not always be readily available. The cannula is also prone to kinking and displacement, and there is limited evacuation of expiratory gases, making it suitable for only a short period of time before CO2 retention becomes problematic.
In children, the cannula cricothyroidotomy and ventilation procedure involves extending the neck and stabilizing the larynx, inserting a 14g or 16g cannula at a 45-degree angle aiming caudally, confirming the position by aspirating air through a saline-filled syringe, and connecting it to an insufflation device or following specific oxygen pressure and flow settings for jet ventilation.
If a longer-term airway is needed, a cricothyroidotomy may be converted to
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This question is part of the following fields:
- Basic Anaesthetics
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Question 44
Incorrect
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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: Cerebral oedema
Correct 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.
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This question is part of the following fields:
- Neurology
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Question 45
Correct
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You are tasked with organizing a teaching session for the senior residents on head injuries & increased intracranial pressure. What is the intracranial volume of a typical adult?
Your Answer: 1400ml
Explanation:On average, the intracranial volume in adults is around 1400ml.
Intracranial pressure (ICP) refers to the pressure within the craniospinal compartment, which includes neural tissue, blood, and cerebrospinal fluid (CSF). Normal ICP for a supine adult is 5-15 mmHg. The body maintains ICP within a narrow range through shifts in CSF production and absorption. If ICP rises, it can lead to decreased cerebral perfusion pressure, resulting in cerebral hypoperfusion, ischemia, and potentially brain herniation.
The cranium, which houses the brain, is a closed rigid box in adults and cannot expand. It is made up of 8 bones and contains three main components: brain tissue, cerebral blood, and CSF. Brain tissue accounts for about 80% of the intracranial volume, while CSF and blood each account for about 10%. The Monro-Kellie doctrine states that the sum of intracranial volumes is constant, so an increase in one component must be offset by a decrease in the others.
There are various causes of raised ICP, including hematomas, neoplasms, brain abscesses, edema, CSF circulation disorders, venous sinus obstruction, and accelerated hypertension. Symptoms of raised ICP include headache, vomiting, pupillary changes, reduced cognition and consciousness, neurological signs, abnormal fundoscopy, cranial nerve palsy, hemiparesis, bradycardia, high blood pressure, irregular breathing, focal neurological deficits, seizures, stupor, coma, and death.
Measuring ICP typically requires invasive procedures, such as inserting a sensor through the skull. Management of raised ICP involves a multi-faceted approach, including antipyretics to maintain normothermia, seizure control, positioning the patient with a 30º head up tilt, maintaining normal blood pressure, providing analgesia, using drugs to lower ICP (such as mannitol or saline), and inducing hypocapnoeic vasoconstriction through hyperventilation. If these measures are ineffective, second-line therapies like barbiturate coma, optimised hyperventilation, controlled hypothermia, or decompressive craniectomy may be considered.
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This question is part of the following fields:
- Neurology
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Question 46
Correct
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A 72-year-old woman comes in with a history of passing fresh red blood mixed in with her last three bowel movements. She is experiencing low blood pressure, and her shock index is calculated to be 1.4.
Which initial investigation is recommended for hospitalized patients with lower gastrointestinal bleeding who are in a state of hemodynamic instability?Your Answer: CT angiography
Explanation:The British Society of Gastroenterology (BSG) has developed guidelines for healthcare professionals who are assessing cases of acute lower intestinal bleeding in a hospital setting. These guidelines are particularly useful when determining which patients should be referred for further evaluation.
When patients present with lower gastrointestinal bleeding (LGIB), they should be categorized as either unstable or stable. Unstable patients are defined as those with a shock index greater than 1, which is calculated by dividing the heart rate by the systolic blood pressure (HR/SBP).
For stable patients, the next step is to determine whether their bleed is major (requiring hospitalization) or minor (suitable for outpatient management). This can be determined using a risk assessment tool called the Oakland risk score, which takes into account factors such as age, hemoglobin level, and findings from a digital rectal examination.
Patients with a minor self-limiting bleed (e.g., an Oakland score of less than 8 points) and no other indications for hospital admission can be discharged with urgent follow-up for further investigation as an outpatient.
Patients with a major bleed should be admitted to the hospital and scheduled for a colonoscopy as soon as possible.
If a patient is hemodynamically unstable or has a shock index greater than 1 even after initial resuscitation, and there is suspicion of active bleeding, a CT angiography (CTA) should be considered. This can be followed by endoscopic or radiological therapy.
If no bleeding source is identified by the initial CTA and the patient remains stable after resuscitation, an upper endoscopy should be performed immediately, as LGIB associated with hemodynamic instability may indicate an upper gastrointestinal bleeding source. Gastroscopy may be the first investigation if the patient stabilizes after initial resuscitation.
If indicated, catheter angiography with the possibility of embolization should be performed as soon as possible after a positive CTA to increase the chances of success. In centers with a 24/7 interventional radiology service, this procedure should be available within 60 minutes for hemodynamically unstable patients.
Emergency laparotomy should only be considered if all efforts to locate the bleeding using radiological and/or endoscopic methods have been exhausted, except in exceptional circumstances.
In some cases, red blood cell transfusion may be necessary. It is recommended to use restrictive blood transfusion thresholds, such as a hemoglobin trigger of 7 g/dL and a target of 7-9 g/d
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This question is part of the following fields:
- Surgical Emergencies
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Question 47
Correct
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A 15-year-old girl is prescribed prochlorperazine for symptoms of dizziness and nausea. Shortly after taking the medication, she experiences an acute dystonic reaction.
What is the most suitable treatment for this reaction? Choose ONE option only.Your Answer: Procyclidine
Explanation:Drug-induced acute dystonic reactions are frequently seen in the Emergency Department. These reactions occur in approximately 0.5% to 1% of patients who have been administered metoclopramide or prochlorperazine. Procyclidine, an anticholinergic medication, has proven to be effective in treating drug-induced parkinsonism, akathisia, and acute dystonia. In emergency situations, a dose of 10 mg IV of procyclidine can be administered to promptly treat acute drug-induced dystonic reactions.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 48
Incorrect
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You review an elderly patient with a history of heart disease that has presented with shortness of breath, chest pain, and dizziness. Upon reviewing his cardiac tests today, you note that his ejection fraction has recently fallen significantly.
Elderly patients should undergo cardiac intervention when their ejection fraction (EF) reaches what level?Your Answer: 25 ml/minute
Correct Answer: 15 ml/minute
Explanation:Patients typically initiate dialysis when their glomerular filtration rate (GFR) drops to 10 ml/min. However, if the patient has diabetes, dialysis may be recommended when their GFR reaches 15 ml/min. The GFR is a measure of kidney function and indicates how well the kidneys are able to filter waste products from the blood. Dialysis is a medical procedure that helps perform the function of the kidneys by removing waste and excess fluid from the body.
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This question is part of the following fields:
- Nephrology
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Question 49
Correct
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You are a member of the team assisting with the intubation of a pediatric patient. The initial intubation attempt is unsuccessful. Your attending physician instructs you to apply pressure on the larynx during the second attempt. With the patient positioned in a semi-recumbent position, which direction should pressure be applied to aid in intubation?
Your Answer: Backwards, upwards and rightwards
Explanation:The BURP maneuver is a technique used to assist with intubation. It involves applying pressure in a specific direction on the larynx. The acronym BURP stands for backwards (B), upwards (U), rightwards (R), and pressure (P). To perform the maneuver correctly, the thyroid cartilage is moved backwards, 2 cm upwards, and 0.5cm – 2 cm to the right in relation to the anatomical position.
Further Reading:
A difficult airway refers to a situation where factors have been identified that make airway management more challenging. These factors can include body habitus, head and neck anatomy, mouth characteristics, jaw abnormalities, and neck mobility. The LEMON criteria can be used to predict difficult intubation by assessing these factors. The criteria include looking externally at these factors, evaluating the 3-3-2 rule which assesses the space in the mouth and neck, assessing the Mallampati score which measures the distance between the tongue base and roof of the mouth, and considering any upper airway obstructions or reduced neck mobility.
Direct laryngoscopy is a method used to visualize the larynx and assess the size of the tracheal opening. The Cormack-Lehane grading system can be used to classify the tracheal opening, with higher grades indicating more difficult access. In cases of a failed airway, where intubation attempts are unsuccessful and oxygenation cannot be maintained, the immediate priority is to oxygenate the patient and prevent hypoxic brain injury. This can be done through various measures such as using a bag-valve-mask ventilation, high flow oxygen, suctioning, and optimizing head positioning.
If oxygenation cannot be maintained, it is important to call for help from senior medical professionals and obtain a difficult airway trolley if not already available. If basic airway management techniques do not improve oxygenation, further intubation attempts may be considered using different equipment or techniques. If oxygen saturations remain below 90%, a surgical airway such as a cricothyroidotomy may be necessary.
Post-intubation hypoxia can occur for various reasons, and the mnemonic DOPES can be used to identify and address potential problems. DOPES stands for displacement of the endotracheal tube, obstruction, pneumothorax, equipment failure, and stacked breaths. If intubation attempts fail, a maximum of three attempts should be made before moving to an alternative plan, such as using a laryngeal mask airway or considering a cricothyroidotomy.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 50
Correct
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A 6 month old infant is brought to the emergency department by his father due to a 24 hour history of fever, fussiness, and crying. On examination, the infant is alert and responsive, with a temperature of 38.3ºC. The capillary refill time is less than 2 seconds, and there is mild redness in the throat. The left tympanic membrane appears red and bulging, while the chest is clear and the abdomen is soft with no rashes.
What is the most suitable course of action?Your Answer: Admit under paediatrics
Explanation:If a child under 3 months old has a temperature of 38ºC or higher, it is considered a red flag according to the NICE traffic light system. This indicates that the child may have acute otitis media and it is recommended that they be admitted for further evaluation and treatment.
Further Reading:
Acute otitis media (AOM) is an inflammation in the middle ear accompanied by symptoms and signs of an ear infection. It is commonly seen in young children below 4 years of age, with the highest incidence occurring between 9 to 15 months of age. AOM can be caused by viral or bacterial pathogens, and co-infection with both is common. The most common viral pathogens include respiratory syncytial virus (RSV), rhinovirus, adenovirus, influenza virus, and parainfluenza virus. The most common bacterial pathogens include Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pyogenes.
Clinical features of AOM include ear pain (otalgia), fever, a red or cloudy tympanic membrane, and a bulging tympanic membrane with loss of anatomical landmarks. In young children, symptoms may also include crying, grabbing or rubbing the affected ear, restlessness, and poor feeding.
Most children with AOM will recover within 3 days without treatment. Serious complications are rare but can include persistent otitis media with effusion, recurrence of infection, temporary hearing loss, tympanic membrane perforation, labyrinthitis, mastoiditis, meningitis, intracranial abscess, sinus thrombosis, and facial nerve paralysis.
Management of AOM involves determining whether admission to the hospital is necessary based on the severity of systemic infection or suspected acute complications. For patients who do not require admission, regular pain relief with paracetamol or ibuprofen is advised. Decongestants or antihistamines are not recommended. Antibiotics may be offered immediately for patients who are systemically unwell, have symptoms and signs of a more serious illness or condition, or have a high risk of complications. For other patients, a decision needs to be made on the antibiotic strategy, considering the rarity of acute complications and the possible adverse effects of antibiotics. Options include no antibiotic prescription with advice to seek medical help if symptoms worsen rapidly or significantly, a back-up antibiotic prescription to be used if symptoms do not improve within 3 days, or an immediate antibiotic prescription with advice to seek medical advice if symptoms worsen rapidly or significantly.
The first-line antibiotic choice for AOM is a 5-7 day course of amoxicillin. For individuals allergic to or intolerant of penicillin, clarithromycin or erythromycin a 5–7 day course of clarithromycin or erythromycin (erythromycin is preferred in pregnant women).
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This question is part of the following fields:
- Paediatric Emergencies
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Question 51
Correct
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A 42-year-old woman with a lengthy history of depression arrives at the Emergency Department after intentionally overdosing on the medication she takes for her heart condition. She informs you that she consumed verapamil immediate-release 240 mg tablets approximately 30 minutes ago. However, her spouse promptly discovered her and brought her to the hospital. Currently, she shows no signs of symptoms. Typically, how much time passes before symptoms manifest in cases of this overdose?
Your Answer: 1-2 hours
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.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 52
Correct
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You are caring for a 68-year-old patient who has been intubated and placed on a ventilator and is not expected to recover. Consider the facilitation of organ and tissue donation. Which of the following statements is accurate?
Your Answer: The emergency department doctor is not involved in gaining consent from the next of kin for tissue donation
Explanation:The emergency department doctor does not play a role in obtaining consent from the next of kin for tissue or organ donation. Instead, it is important to involve the Specialist Nurse in Organ Donation (SNOD) as early as possible. The SNOD can provide valuable support and guidance to both the medical team and the family. They will assess the patient’s suitability for organ donation and approach the next of kin for consent, if appropriate. On the other hand, for tissue donation, a referral should be made to the tissue donation national referral centre. Retrievals can take place within 24 hours after death. In the UK, referrals can be made by phone to the tissue donation national referral centre (the contact number can be found in the notes below). It is important to note that the responsibility of gaining consent from the next of kin does not fall on the emergency department doctor.
Further Reading:
Cardiopulmonary arrest is a serious event with low survival rates. In non-traumatic cardiac arrest, only about 20% of patients who arrest as an in-patient survive to hospital discharge, while the survival rate for out-of-hospital cardiac arrest is approximately 8%. The Resus Council BLS/AED Algorithm for 2015 recommends chest compressions at a rate of 100-120 per minute with a compression depth of 5-6 cm. The ratio of chest compressions to rescue breaths is 30:2.
After a cardiac arrest, the goal of patient care is to minimize the impact of post cardiac arrest syndrome, which includes brain injury, myocardial dysfunction, the ischaemic/reperfusion response, and the underlying pathology that caused the arrest. The ABCDE approach is used for clinical assessment and general management. Intubation may be necessary if the airway cannot be maintained by simple measures or if it is immediately threatened. Controlled ventilation is aimed at maintaining oxygen saturation levels between 94-98% and normocarbia. Fluid status may be difficult to judge, but a target mean arterial pressure (MAP) between 65 and 100 mmHg is recommended. Inotropes may be administered to maintain blood pressure. Sedation should be adequate to gain control of ventilation, and short-acting sedating agents like propofol are preferred. Blood glucose levels should be maintained below 8 mmol/l. Pyrexia should be avoided, and there is some evidence for controlled mild hypothermia but no consensus on this.
Post ROSC investigations may include a chest X-ray, ECG monitoring, serial potassium and lactate measurements, and other imaging modalities like ultrasonography, echocardiography, CTPA, and CT head, depending on availability and skills in the local department. Treatment should be directed towards the underlying cause, and PCI or thrombolysis may be considered for acute coronary syndrome or suspected pulmonary embolism, respectively.
Patients who are comatose after ROSC without significant pre-arrest comorbidities should be transferred to the ICU for supportive care. Neurological outcome at 72 hours is the best prognostic indicator of outcome.
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This question is part of the following fields:
- Palliative & End Of Life Care
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Question 53
Incorrect
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A 42 year old male is brought into the resuscitation bay with multiple injuries after a roof collapse. The patient has extensive bruising on the neck and a fractured femur caused by a beam that fell and crushed his right thigh. Your consultant intends to perform rapid sequence induction (RSI) and intubation. Which of the following medications would be inappropriate for this patient?
Your Answer: Ketamine
Correct Answer: Suxamethonium
Explanation:Suxamethonium is a medication that can cause an increase in serum potassium levels by causing potassium to leave muscle cells. This can be a problem in patients who already have high levels of potassium, such as those with crush injuries. Therefore, suxamethonium should not be used in these cases.
Further Reading:
Rapid sequence induction (RSI) is a method used to place an endotracheal tube (ETT) in the trachea while minimizing the risk of aspiration. It involves inducing loss of consciousness while applying cricoid pressure, followed by intubation without face mask ventilation. The steps of RSI can be remembered using the 7 P’s: preparation, pre-oxygenation, pre-treatment, paralysis and induction, protection and positioning, placement with proof, and post-intubation management.
Preparation involves preparing the patient, equipment, team, and anticipating any difficulties that may arise during the procedure. Pre-oxygenation is important to ensure the patient has an adequate oxygen reserve and prolongs the time before desaturation. This is typically done by breathing 100% oxygen for 3 minutes. Pre-treatment involves administering drugs to counter expected side effects of the procedure and anesthesia agents used.
Paralysis and induction involve administering a rapid-acting induction agent followed by a neuromuscular blocking agent. Commonly used induction agents include propofol, ketamine, thiopentone, and etomidate. The neuromuscular blocking agents can be depolarizing (such as suxamethonium) or non-depolarizing (such as rocuronium). Depolarizing agents bind to acetylcholine receptors and generate an action potential, while non-depolarizing agents act as competitive antagonists.
Protection and positioning involve applying cricoid pressure to prevent regurgitation of gastric contents and positioning the patient’s neck appropriately. Tube placement is confirmed by visualizing the tube passing between the vocal cords, auscultation of the chest and stomach, end-tidal CO2 measurement, and visualizing misting of the tube. Post-intubation management includes standard care such as monitoring ECG, SpO2, NIBP, capnography, and maintaining sedation and neuromuscular blockade.
Overall, RSI is a technique used to quickly and safely secure the airway in patients who may be at risk of aspiration. It involves a series of steps to ensure proper preparation, oxygenation, drug administration, and tube placement. Monitoring and post-intubation care are also important aspects of RSI.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 54
Correct
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A 35-year-old individual goes to the emergency room feeling sick for the past 48 hours after moving into a new apartment. Earlier today, a boiler technician came to conduct the gas safety inspection for the landlord and advised the patient to go to the A&E department due to high carbon monoxide levels and a faulty boiler. You suspect the presence of carbon monoxide poisoning. What is the primary symptom typically associated with carbon monoxide poisoning?
Your Answer: Headache
Explanation:The primary symptom typically associated with carbon monoxide poisoning is a headache.
Carbon monoxide (CO) is a dangerous gas that is produced by the combustion of hydrocarbon fuels and can be found in certain chemicals. It is colorless and odorless, making it difficult to detect. In England and Wales, there are approximately 60 deaths each year due to accidental CO poisoning.
When inhaled, carbon monoxide binds to haemoglobin in the blood, forming carboxyhaemoglobin (COHb). It has a higher affinity for haemoglobin than oxygen, causing a left-shift in the oxygen dissociation curve and resulting in tissue hypoxia. This means that even though there may be a normal level of oxygen in the blood, it is less readily released to the tissues.
The clinical features of carbon monoxide toxicity can vary depending on the severity of the poisoning. Mild or chronic poisoning may present with symptoms such as headache, nausea, vomiting, vertigo, confusion, and weakness. More severe poisoning can lead to intoxication, personality changes, breathlessness, pink skin and mucosae, hyperpyrexia, arrhythmias, seizures, blurred vision or blindness, deafness, extrapyramidal features, coma, or even death.
To help diagnose domestic carbon monoxide poisoning, there are four key questions that can be asked using the COMA acronym. These questions include asking about co-habitees and co-occupants in the house, whether symptoms improve outside of the house, the maintenance of boilers and cooking appliances, and the presence of a functioning CO alarm.
Typical carboxyhaemoglobin levels can vary depending on whether the individual is a smoker or non-smoker. Non-smokers typically have levels below 3%, while smokers may have levels below 10%. Symptomatic individuals usually have levels between 10-30%, and severe toxicity is indicated by levels above 30%.
When managing carbon monoxide poisoning, the first step is to administer 100% oxygen. Hyperbaric oxygen therapy may be considered for individuals with a COHb concentration of over 20% and additional risk factors such as loss of consciousness, neurological signs, myocardial ischemia or arrhythmia, or pregnancy. Other management strategies may include fluid resuscitation, sodium bicarbonate for metabolic acidosis, and mannitol for cerebral edema.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 55
Correct
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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: 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
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 56
Correct
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A 45-year-old woman was involved in a car accident where her car collided with a tree at a high speed. She was not wearing a seatbelt and was thrown forward onto the steering wheel of her car. She has bruising over her anterior chest wall and is experiencing chest pain. Her chest X-ray in the resuscitation room shows potential signs of a traumatic aortic injury, but it is uncertain.
Which investigation should be prioritized for further examination?Your Answer: Contrast-enhanced CT scan of the chest
Explanation:Traumatic aortic rupture, also known as traumatic aortic disruption or transection, occurs when the aorta is torn or ruptured due to physical trauma. This condition often leads to sudden death because of severe bleeding. Motor vehicle accidents and falls from great heights are the most common causes of this injury.
The patients with the highest chances of survival are those who have an incomplete tear near the ligamentum arteriosum of the proximal descending aorta, close to where the left subclavian artery branches off. The presence of an intact adventitial layer or contained mediastinal hematoma helps maintain continuity and prevents immediate bleeding and death. If promptly identified and treated, survivors of these injuries can recover. In cases where traumatic aortic rupture leads to sudden death, approximately 50% of patients have damage at the aortic isthmus, while around 15% have damage in either the ascending aorta or the aortic arch.
Initial chest X-rays may show signs consistent with a traumatic aortic injury. However, false-positive and false-negative results can occur, and sometimes there may be no abnormalities visible on the X-ray. Some of the possible X-ray findings include a widened mediastinum, hazy left lung field, obliteration of the aortic knob, fractures of the 1st and 2nd ribs, deviation of the trachea to the right, presence of a pleural cap, elevation and rightward shift of the right mainstem bronchus, depression of the left mainstem bronchus, obliteration of the space between the pulmonary artery and aorta, and deviation of the esophagus or NG tube to the right.
A helical contrast-enhanced CT scan of the chest is the preferred initial investigation for suspected blunt aortic injury. It has proven to be highly accurate, with close to 100% sensitivity and specificity. CT scanning should be performed liberally, as chest X-ray findings can be unreliable. However, hemodynamically unstable patients should not be placed in a CT scanner. If the CT results are inconclusive, aortography or trans-oesophageal echo can be performed for further evaluation.
Immediate surgical intervention is necessary for these injuries. Endovascular repair is the most common method used and has excellent short-term outcomes. Open repair may also be performed depending on the circumstances. It is important to control heart rate and blood pressure during stabilization to reduce the risk of rupture. Pain should be managed with appropriate analgesic
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This question is part of the following fields:
- Trauma
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Question 57
Correct
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You evaluate a 32-year-old woman who has been diagnosed with Mycoplasma pneumoniae pneumonia.
Which of the following is NOT a recognized complication of Mycoplasma pneumoniae infection?Your Answer: Infective endocarditis
Explanation:Mycoplasma pneumoniae infection does not have a connection with infective endocarditis. However, it is associated with various extra-pulmonary complications. These include skin conditions such as erythema multiforme and Stevens-Johnson syndrome. In the central nervous system, it can lead to Guillain-Barre syndrome, meningitis, encephalitis, optic neuritis, cerebellar ataxia, and cranial nerve palsies. Gastrointestinal symptoms may include anorexia, nausea, diarrhea, hepatitis, and pancreatitis. Hematological complications can manifest as cold agglutinins, hemolytic anemia, thrombocytopenia, and disseminated intravascular coagulation. Mycoplasma pneumoniae infection can also cause pericarditis and myocarditis. Rheumatic symptoms such as arthralgia and arthritides may occur, and acute glomerulonephritis can affect the kidneys.
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This question is part of the following fields:
- Respiratory
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Question 58
Correct
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A 52-year-old woman with a history of hypertension has ingested an excessive amount of atenolol tablets.
Which of the following antidotes is appropriate for treating beta-blocker overdose?Your Answer: Insulin
Explanation:There are various specific remedies available for different types of poisons and overdoses. The following list provides an outline of some of these antidotes:
Poison: Benzodiazepines
Antidote: FlumazenilPoison: Beta-blockers
Antidotes: Atropine, Glucagon, InsulinPoison: Carbon monoxide
Antidote: OxygenPoison: Cyanide
Antidotes: Hydroxocobalamin, Sodium nitrite, Sodium thiosulphatePoison: Ethylene glycol
Antidotes: Ethanol, FomepizolePoison: Heparin
Antidote: Protamine sulphatePoison: Iron salts
Antidote: DesferrioxaminePoison: Isoniazid
Antidote: PyridoxinePoison: Methanol
Antidotes: Ethanol, FomepizolePoison: Opioids
Antidote: NaloxonePoison: Organophosphates
Antidotes: Atropine, PralidoximePoison: Paracetamol
Antidotes: Acetylcysteine, MethioninePoison: Sulphonylureas
Antidotes: Glucose, OctreotidePoison: Thallium
Antidote: Prussian bluePoison: Warfarin
Antidote: Vitamin K, Fresh frozen plasma (FFP)By utilizing these specific antidotes, medical professionals can effectively counteract the harmful effects of various poisons and overdoses.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 59
Correct
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A 25-year-old woman with inflammatory bowel disease (IBD) presents with a condition associated with IBD.
Which of the following conditions is NOT linked to Crohn's disease?Your Answer: Primary sclerosing cholangitis
Explanation:Primary sclerosing cholangitis (PSC) is a condition that affects the bile ducts, causing inflammation and blockage over time. This leads to recurrent episodes of cholangitis and progressive scarring of the bile ducts. Ultimately, PSC can result in liver cirrhosis, liver failure, and even hepatocellular carcinoma. It is commonly associated with ulcerative colitis, with more than 80% of PSC patients also having ulcerative colitis. However, there is no association between PSC and Crohn’s disease.
On the other hand, Crohn’s disease has its own set of recognized associations. For instance, there is an increased incidence of Crohn’s disease among smokers, with approximately 50-60% of Crohn’s patients being smokers. Other associations include the presence of aphthous ulcers, uveitis and episcleritis (eye inflammation), seronegative spondyloarthropathies (inflammatory joint diseases), erythema nodosum (painful skin nodules), pyoderma gangrenosum (skin ulceration), finger clubbing, autoimmune hemolytic anemia, cholelithiasis (gallstones), and osteoporosis.
It is important to note the distinct associations and characteristics of these two conditions, as they have different implications for diagnosis, treatment, and management.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 60
Correct
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A 40-year-old woman is prescribed haloperidol for a psychiatric condition in the 2nd-trimester of her pregnancy. As a result of this treatment, the newborn develops a malformation.
Which of the following malformations is the most likely to occur as a result of using this medication during pregnancy?Your Answer: Extrapyramidal syndrome
Explanation:Haloperidol, when administered during the third trimester of pregnancy, can lead to extrapyramidal symptoms in the newborn. These symptoms may include agitation, poor feeding, excessive sleepiness, and difficulty breathing. The severity of these side effects can vary, with some infants requiring intensive care and extended hospital stays. It is important to closely monitor exposed neonates for signs of extrapyramidal syndrome or withdrawal. Haloperidol should only be used during pregnancy if the benefits clearly outweigh the risks to the fetus.
Below is a list outlining commonly encountered drugs that have adverse effects during pregnancy:
ACE inhibitors (e.g. ramipril): If given during the second and third trimesters, these drugs can cause hypoperfusion, renal failure, and the oligohydramnios sequence.
Aminoglycosides (e.g. gentamicin): These drugs can cause ototoxicity and deafness in the fetus.
Aspirin: High doses of aspirin can lead to first-trimester abortions, delayed onset of labor, premature closure of the fetal ductus arteriosus, and fetal kernicterus. However, low doses (e.g. 75 mg) do not pose significant risks.
Benzodiazepines (e.g. diazepam): When administered late in pregnancy, these drugs can cause respiratory depression and a neonatal withdrawal syndrome.
Calcium-channel blockers: If given during the first trimester, these drugs can cause phalangeal abnormalities. If given during the second and third trimesters, they can result in fetal growth retardation.
Carbamazepine: This drug can lead to hemorrhagic disease of the newborn and neural tube defects.
Chloramphenicol: Administration of chloramphenicol can cause gray baby syndrome in newborns.
Corticosteroids: If given during the first trimester, corticosteroids may cause orofacial clefts in the fetus.
Danazol: When administered during the first trimester, danazol can cause masculinization of the female fetuses genitals.
Finasteride: Pregnant women should avoid handling finasteride as crushed or broken tablets can be absorbed through the skin and affect male sex organ development.
Haloperidol: If given during the first trimester, haloperidol may cause limb malformations. If given during the third trimester, there is an increased risk of extrapyramidal symptoms in the neonate.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 61
Correct
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A 42-year-old chronic smoker comes in with a chronic productive cough, difficulty breathing, and wheezing. Blood tests reveal an elevated packed cell volume (PCV). A chest X-ray shows more than 6 ribs visible above the diaphragm in the midclavicular line. An arterial blood gas indicates slightly low pO2 levels.
What is the SINGLE most probable diagnosis?Your Answer: COPD
Explanation:Based on the provided information, it is highly probable that this patient is suffering from chronic obstructive pulmonary disease (COPD). This conclusion is supported by several factors. Firstly, the patient has a history of chronic productive cough and wheezing, which are common symptoms of COPD. Additionally, the patient has a long-term smoking history, which is a major risk factor for developing this condition.
Furthermore, the patient’s raised packed cell volume (PCV) is likely a result of chronic hypoxemia, a common complication of COPD. This indicates that the patient’s body is trying to compensate for the low oxygen levels in their blood.
Moreover, the chest X-ray reveals evidence of hyperinflation, which is a characteristic finding in patients with COPD. This suggests that the patient’s lungs are overinflated and not functioning optimally.
Lastly, the arterial blood gas analysis shows hypoxemia, indicating that the patient has low levels of oxygen in their blood. This is another significant finding that aligns with a diagnosis of COPD.
In summary, based on the patient’s history, smoking habits, raised PCV, chest X-ray findings, and arterial blood gas results, it is highly likely that they have COPD.
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This question is part of the following fields:
- Respiratory
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Question 62
Correct
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A 45-year-old woman presents with recurrent episodes of central chest pain that radiate to her left arm. She has a history of angina and uses a GTN spray for relief. She reports that the pains have been occurring more frequently in the past few days and have been triggered by less exertion. Currently, she is not experiencing any pain, and her ECG shows normal sinus rhythm with no abnormalities in T wave or ST-segment.
What is the SINGLE most probable diagnosis?Your Answer: Unstable angina
Explanation:Unstable angina is characterized by the presence of one or more of the following symptoms: angina of effort occurring over a few days with increasing frequency, episodes of angina occurring recurrently and predictably without specific provocation, or an unprovoked and prolonged episode of cardiac chest pain. The electrocardiogram (ECG) may appear normal or show T-wave/ST-segment changes, and cardiac enzymes are typically within normal range.
On the other hand, stable angina is defined by central chest pain that is triggered by activities such as exercise and emotional stress. This pain may radiate to the jaw or left arm and is relieved by resting for a few minutes. It is usually brought on by a predictable amount of exertion.
Prinzmetal angina, although rare, is a variant of angina that primarily occurs at rest between midnight and early morning. The attacks can be severe and tend to happen in clusters. This type of angina is caused by coronary artery spasm, and patients may have normal coronary arteries.
Decubitus angina, on the other hand, is angina that occurs when lying down. It often develops as a result of cardiac failure due to an increased volume of blood within the blood vessels, which places additional strain on the heart.
Lastly, Ludwig’s angina is an extremely serious and potentially life-threatening cellulitis that affects the submandibular area. It most commonly arises from an infection in the floor of the mouth, which then spreads to the submandibular space.
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This question is part of the following fields:
- Cardiology
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Question 63
Correct
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A 45 year old male presents to the emergency department with a 24 hour history of vertigo. You consider the potential underlying causes.
Which of the following characteristics is most indicative of a diagnosis of benign paroxysmal positional vertigo (BPPV)?Your Answer: Torsional and vertical nystagmus on head movement
Explanation:BPPV is a condition where patients experience vertigo and nystagmus. The Dix-Hallpike test is used to diagnose BPPV, and it involves observing torsional (rotary) and vertical nystagmus. Unlike vertigo caused by vestibular neuritis and labyrinthitis, BPPV is not associated with prodromal viral illness, hearing loss, or tinnitus. The episodes of vertigo and dizziness in BPPV usually last for 10-20 seconds, with episodes lasting over 1 minute being uncommon.
Further Reading:
Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo, characterized by sudden dizziness and vertigo triggered by changes in head position. It typically affects individuals over the age of 55 and is less common in younger patients. BPPV is caused by dysfunction in the inner ear, specifically the detachment of otoliths (calcium carbonate particles) from the utricular otolithic membrane. These loose otoliths move through the semicircular canals, triggering a sensation of movement and resulting in conflicting sensory inputs that cause vertigo.
The majority of BPPV cases involve otoliths in the posterior semicircular canal, followed by the inferior semicircular canal. BPPV in the anterior semicircular canals is rare. Clinical features of BPPV include vertigo triggered by head position changes, such as rolling over in bed or looking upwards, accompanied by nausea. Episodes of vertigo typically last 10-20 seconds and can be diagnosed through positional nystagmus, which is a specific eye movement, observed during diagnostic maneuvers like the Dix-Hallpike maneuver.
Hearing loss and tinnitus are not associated with BPPV. The prognosis for BPPV is generally good, with spontaneous resolution occurring within a few weeks to months. Symptomatic relief can be achieved through the Epley maneuver, which is successful in around 80% of cases, or patient home exercises like the Brandt-Daroff exercises. Medications like Betahistine may be prescribed but have limited effectiveness in treating BPPV.
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This question is part of the following fields:
- Ear, Nose & Throat
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Question 64
Correct
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A 35-year-old woman comes in with a red, hot, swollen left knee a few days after returning from a vacation in Thailand. She also reports feeling generally unwell and has a rash on her trunk. Which antibiotic would be the most suitable for this patient?
Your Answer: Cefotaxime
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.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 65
Correct
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You are treating a 68 year old male who has been brought into the resuscitation bay by the ambulance crew. The patient was at home when he suddenly experienced dizziness and difficulty breathing. The ambulance crew presents the patient's ECG to you. You are considering administering atropine to address the patient's bradyarrhythmia. Which of the following statements is accurate regarding the use of atropine?
Your Answer: Up to 6 doses of 500 mcg can be given every 3-5 minutes
Explanation:When treating adults with bradycardia, it is recommended to administer a maximum of 6 doses of atropine 500 mcg. These doses can be repeated every 3-5 minutes. The total cumulative dose of atropine should not exceed 3 mg in adults.
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, amyloidosisPresenting symptoms of Bradycardia:
– Presyncope (dizziness, lightheadedness)
– Syncope
– Breathlessness
– Weakness
– Chest pain
– NauseaManagement 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, glycopyrrolateBradycardia 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
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Question 66
Correct
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What is the threshold MASCC Risk Index Score for identifying patients as low risk for outpatient treatment with early antibiotics in cases of neutropenic sepsis?
Your Answer: 21
Explanation:The MASCC Risk Index Score, developed by the Multinational Association of Supportive Care in Cancer, is a globally recognized scoring system that helps identify patients with neutropenic sepsis who have a low risk of complications and can potentially be treated as outpatients with early administration of antibiotics. This scoring system takes into account various characteristics to determine the risk level of the patient. These characteristics include the burden of febrile neutropenia with no or mild symptoms, absence of hypotension, no history of chronic obstructive pulmonary disease, presence of a solid tumor or hematological malignancy without previous fungal infection, absence of dehydration requiring parenteral fluids, burden of febrile neutropenia with moderate symptoms, being in an outpatient setting at the onset of fever, and age below 60 years. Each characteristic is assigned a certain number of points, and a total score of 21 or higher indicates a low risk, while a score below 21 indicates a high risk. The MASCC Risk Index Score has been validated internationally and has shown a positive predictive value of 91%, specificity of 68%, and sensitivity of 71%. For more detailed information, you can refer to the article titled Identifying Patients at Low Risk for FN Complications: Development and Validation of the MASCC Risk Index Score.
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This question is part of the following fields:
- Oncological Emergencies
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Question 67
Correct
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A 35-year-old man comes in with swelling of his face, particularly his upper lip, and his hands. He has a confirmed diagnosis of hereditary angioedema.
Which of the following statements about hereditary angioedema is correct?Your Answer: Long-term prophylaxis can be achieved with tranexamic acid
Explanation:Hereditary angioedema is a condition caused by a lack of C1 esterase inhibitor, a protein that is part of the complement system. It is typically inherited in an autosomal dominant manner. Symptoms usually start in childhood and continue sporadically into adulthood. Attacks can be triggered by minor surgical procedures, dental work, and stress. The main clinical signs of hereditary angioedema include swelling of the skin and mucous membranes, with the face, tongue, and extremities being the most commonly affected areas. There is often a tingling sensation before an attack, sometimes accompanied by a non-itchy rash.
Angioedema and anaphylaxis resulting from C1 esterase inhibitor deficiency do not respond to adrenaline, steroids, or antihistamines. Treatment requires the use of C1 esterase inhibitor concentrate or fresh frozen plasma, both of which contain C1 esterase inhibitor. In situations that may trigger an attack, short-term prophylaxis can be achieved by administering C1 esterase inhibitor or fresh frozen plasma infusions prior to the event. For long-term prevention, androgenic steroids like stanozolol or antifibrinolytic drugs such as tranexamic acid can be used.
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This question is part of the following fields:
- Allergy
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Question 68
Incorrect
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A 68-year-old woman comes in after experiencing an episode of weakness in her left arm and leg that resolved within a few hours. Her family has noticed a sudden increase in forgetfulness over the past week, with difficulty remembering names of people and places and struggling to find the right words for things.
What is the SINGLE most probable diagnosis?Your Answer: Dementia with Lewy bodies
Correct Answer: Vascular dementia
Explanation:Vascular dementia is the second most common form of dementia, accounting for approximately 25% of all cases. It occurs when the brain is damaged due to various factors, such as major strokes, multiple smaller strokes that go unnoticed (known as multi-infarct), or chronic changes in smaller blood vessels (referred to as subcortical dementia). The term vascular cognitive impairment (VCI) is increasingly used to encompass this range of diseases.
Unlike Alzheimer’s disease, which has a gradual and subtle onset, vascular dementia can occur suddenly and typically shows a series of stepwise increases in symptom severity. The presentation and progression of the disease can vary significantly.
There are certain features that suggest a vascular cause of dementia. These include a history of transient ischemic attacks (TIAs) or cardiovascular disease, the presence of focal neurological abnormalities, prominent memory impairment in the early stages of the disease, early onset of gait disturbance and unsteadiness, frequent unprovoked falls in the early stages, bladder symptoms (such as incontinence) without any identifiable urological condition in the early stages, and seizures.
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This question is part of the following fields:
- Elderly Care / Frailty
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Question 69
Correct
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You conduct a cardiovascular examination on a 72-year-old man who complains of difficulty breathing. He informs you that he has a known heart valve issue. During the examination, you observe a pronounced first heart sound (S1).
What is the most probable cause of this finding?Your Answer: Mitral stenosis
Explanation:The first heart sound (S1) is created by vibrations produced when the mitral and tricuspid valves close. It occurs at the end of diastole and the start of ventricular systole, coming before the upstroke of the carotid pulsation.
A sample of the normal heart sounds can be listened to here (courtesy of Littman stethoscopes).
A loud S1 can be associated with the following conditions:
– Increased transvalvular gradient (e.g. mitral stenosis, tricuspid stenosis)
– Increased force of ventricular contraction (e.g. tachycardia, hyperdynamic states like fever and thyrotoxicosis)
– Shortened PR interval (e.g. Wolff-Parkinson-White syndrome)
– Mitral valve prolapse
– Thin individualsA soft S1 can be associated with the following conditions:
– Inappropriate apposition of the AV valves (e.g. mitral regurgitation, tricuspid regurgitation)
– Prolonged PR interval (e.g. heart block, digoxin toxicity)
– Decreased force of ventricular contraction (e.g. myocarditis, myocardial infarction)
– Increased distance from the heart (e.g. obesity, emphysema, pericardial effusion)A split S1 can be associated with the following conditions:
– Right bundle branch block
– LV pacing
– Ebstein anomaly -
This question is part of the following fields:
- Cardiology
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Question 70
Correct
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A 45-year-old man is brought to the resuscitation area of your Emergency Department by ambulance. He has become increasingly unwell over the past few days 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 36.9°C, HR 140 bpm, BP 83/42, RR 24, SaO2 98% on 2 L oxygen, GCS 14. He has intravenous access in situ, and his BM stick glucose is 2.1.
Which rheumatological condition is it most likely that his GP is treating?Your Answer: Polymyalgia rheumatica
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.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 71
Incorrect
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A 32-year-old patient with a known history of asthma presents with a worsening of his asthma symptoms. He typically uses a salbutamol inhaler, beclomethasone inhaler, and theophylline. However, his theophylline levels are currently below the therapeutic range. It seems that a newly prescribed medication may be causing a decrease in his theophylline levels.
Which of the following drugs is most likely causing this interaction?Your Answer: Erythromycin
Correct Answer: Phenytoin
Explanation:Theophylline, a medication commonly used to treat respiratory conditions, can be affected by certain drugs, either increasing or decreasing its plasma concentration and half-life. Drugs that can increase the plasma concentration of theophylline include calcium channel blockers like verapamil, cimetidine, fluconazole, macrolides such as erythromycin, methotrexate, and quinolones like ciprofloxacin. On the other hand, drugs like carbamazepine, phenobarbitol, phenytoin (and fosphenytoin), rifampicin, and St. John’s wort can decrease the plasma concentration of theophylline. It is important to be aware of these interactions when prescribing or taking theophylline to ensure its effectiveness and avoid potential side effects.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 72
Incorrect
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A hiker is airlifted by helicopter after being rescued from a mountain expedition. During chest examination, the doctor detects bibasal crackles and symptoms that indicate altitude sickness.
What type of acid-base imbalance would you anticipate at high elevations?Your Answer: Metabolic alkalosis
Correct Answer: Respiratory alkalosis
Explanation:The following provides a summary of common causes for different acid-base disorders.
Respiratory alkalosis can be caused by hyperventilation, such as during periods of anxiety. It can also be a result of conditions like pulmonary embolism, CNS disorders (such as stroke or encephalitis), altitude, pregnancy, or the early stages of aspirin overdose.
Respiratory acidosis, on the other hand, is often associated with chronic obstructive pulmonary disease (COPD), life-threatening asthma, pulmonary edema, sedative drug overdose (such as opiates or benzodiazepines), neuromuscular disease, obesity, or other respiratory conditions.
Metabolic alkalosis can occur due to vomiting, potassium depletion (often caused by diuretic usage), Cushing’s syndrome, or Conn’s syndrome.
Metabolic acidosis with a raised anion gap can be caused by lactic acidosis (such as in cases of hypoxemia, shock, sepsis, or infarction), ketoacidosis (such as in diabetes, starvation, or alcohol excess), renal failure, or poisoning (such as in late stages of aspirin overdose, methanol or ethylene glycol ingestion).
Lastly, metabolic acidosis with a normal anion gap can be a result of conditions like diarrhea, ammonium chloride ingestion, or adrenal insufficiency.
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This question is part of the following fields:
- Environmental Emergencies
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Question 73
Correct
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A 65-year-old man develops corneal microdeposits as a side effect of prolonged amiodarone usage.
What proportion of individuals taking amiodarone for more than six months will experience corneal microdeposits?Your Answer: Greater than 90%
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.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 74
Correct
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A middle-aged patient with a long-standing history of alcohol abuse presents feeling extremely ill. He has been on a week-long drinking spree and has consumed very little food during that time. After conducting tests, you diagnose him with alcoholic ketoacidosis.
What type of acid-base disorder would you anticipate in a patient with alcoholic ketoacidosis?Your Answer: Raised anion gap metabolic acidosis
Explanation:Respiratory alkalosis can be caused by hyperventilation, such as during periods of anxiety. It can also be a result of conditions like pulmonary embolism, CNS disorders (such as stroke or encephalitis), altitude, pregnancy, or the early stages of aspirin overdose.
Respiratory acidosis is often associated with chronic obstructive pulmonary disease (COPD) or life-threatening asthma. Other causes include pulmonary edema, sedative drug overdose (such as opiates or benzodiazepines), neuromuscular disease, obesity, or certain medications.
Metabolic alkalosis can occur due to vomiting, potassium depletion (often caused by diuretic usage), Cushing’s syndrome, or Conn’s syndrome.
Metabolic acidosis with a raised anion gap can be caused by conditions like lactic acidosis (which can result from hypoxemia, shock, sepsis, or infarction) or ketoacidosis (commonly seen in diabetes, starvation, or alcohol excess). Other causes include renal failure or poisoning (such as late stages of aspirin overdose, methanol, or ethylene glycol).
Metabolic acidosis with a normal anion gap can be attributed to conditions like renal tubular acidosis, diarrhea, ammonium chloride ingestion, or adrenal insufficiency.
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This question is part of the following fields:
- Mental Health
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Question 75
Correct
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A 25-year-old female patient arrives at the Emergency Department displaying clinical symptoms of a sexually transmitted infection.
Which of the following organisms is NOT typically transmitted through sexual contact?Your Answer: Hepatitis A
Explanation:The primary way hepatitis A is transmitted is through the ingestion of fecal matter containing the virus. On the other hand, all the other organisms mentioned in this question are typically transmitted through sexual contact.
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This question is part of the following fields:
- Sexual Health
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Question 76
Correct
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A 5-year-old girl is brought to the Emergency Department by her father after falling at the park. She has a bruise and a small scrape on her right knee and is walking with a slight limp, but she can put weight on her leg. Her pain is evaluated using a numerical rating scale, and the triage nurse informs you that she has 'mild discomfort'.
According to the RCEM guidance, which of the following analgesics is recommended for managing mild discomfort in a child of this age?Your Answer: Oral ibuprofen 10 mg/kg
Explanation:A recent audit conducted by the Royal College of Emergency Medicine (RCEM) in 2018 revealed a concerning decline in the standards of pain management for children with fractured limbs in Emergency Departments (EDs). The audit found that the majority of patients experienced longer waiting times for pain relief compared to previous years. Shockingly, more than 1 in 10 children who presented with significant pain due to a limb fracture did not receive any pain relief at all.
To address this issue, the Agency for Health Care Policy and Research (AHCPR) in the USA recommends following the ABCs of pain management for all patients, including children. This approach involves regularly asking about pain, systematically assessing it, believing the patient and their family in their reports of pain and what relieves it, choosing appropriate pain control options, delivering interventions in a timely and coordinated manner, and empowering patients and their families to have control over their pain management.
The RCEM has established standards that require a child’s pain to be assessed within 15 minutes of their arrival at the ED. This is considered a fundamental standard. Various rating scales are available for assessing pain in children, with the choice depending on the child’s age and ability to use the scale. These scales include the Wong-Baker Faces Pain Rating Scale, Numeric rating scale, and Behavioural scale.
To ensure timely administration of analgesia to children in acute pain, the RCEM has set specific standards. These standards state that 100% of patients in severe pain should receive appropriate analgesia within 60 minutes of their arrival or triage, whichever comes first. Additionally, 75% should receive analgesia within 30 minutes, and 50% within 20 minutes.
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This question is part of the following fields:
- Pain & Sedation
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Question 77
Correct
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A 25-year-old college student comes to the emergency department complaining of a worsening sore throat, fever, and feeling unwell. The patient reports that the symptoms began 10 days ago. During the examination, the patient has a temperature of 38.0ºC, swollen lymph nodes in the neck, white patches on both tonsils, and tenderness in the right upper abdomen. Glandular fever is suspected.
What would be the most suitable approach to confirm the suspected diagnosis?Your Answer: FBC and monospot test
Explanation:For adults and children over the age of 12 who are suspected to have glandular fever and have a normal immune system, it is recommended to conduct a Full Blood Count (FBC) and a monospot test during the second week of the illness. The timing and choice of investigations for glandular fever vary depending on the patient’s age, immune system status, and duration of symptoms. For children under the age of 12 and individuals with compromised immune systems, it is advised to perform a blood test for Epstein-Barr virus (EBV) viral serology after at least 7 days of illness. However, for immunocompetent adults and children older than 12, a FBC with differential white cell count and a monospot test (heterophile antibodies) should be conducted during the second week of the illness.
Further Reading:
Glandular fever, also known as infectious mononucleosis or mono, is a clinical syndrome characterized by symptoms such as sore throat, fever, and swollen lymph nodes. It is primarily caused by the Epstein-Barr virus (EBV), with other viruses and infections accounting for the remaining cases. Glandular fever is transmitted through infected saliva and primarily affects adolescents and young adults. The incubation period is 4-8 weeks.
The majority of EBV infections are asymptomatic, with over 95% of adults worldwide having evidence of prior infection. Clinical features of glandular fever include fever, sore throat, exudative tonsillitis, lymphadenopathy, and prodromal symptoms such as fatigue and headache. Splenomegaly (enlarged spleen) and hepatomegaly (enlarged liver) may also be present, and a non-pruritic macular rash can sometimes occur.
Glandular fever can lead to complications such as splenic rupture, which increases the risk of rupture in the spleen. Approximately 50% of splenic ruptures associated with glandular fever are spontaneous, while the other 50% follow trauma. Diagnosis of glandular fever involves various investigations, including viral serology for EBV, monospot test, and liver function tests. Additional serology tests may be conducted if EBV testing is negative.
Management of glandular fever involves supportive care and symptomatic relief with simple analgesia. Antiviral medication has not been shown to be beneficial. It is important to identify patients at risk of serious complications, such as airway obstruction, splenic rupture, and dehydration, and provide appropriate management. Patients can be advised to return to normal activities as soon as possible, avoiding heavy lifting and contact sports for the first month to reduce the risk of splenic rupture.
Rare but serious complications associated with glandular fever include hepatitis, upper airway obstruction, cardiac complications, renal complications, neurological complications, haematological complications, chronic fatigue, and an increased risk of lymphoproliferative cancers and multiple sclerosis.
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This question is part of the following fields:
- Infectious Diseases
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Question 78
Correct
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A 42-year-old woman comes in with a suddenly painful right eye and sensitivity to light. She describes her eye as feeling gritty and it is noticeably watery. The patient has been experiencing a mild cold for the past few days. You administer fluorescein drops to her eye, which reveal the presence of a dendritic ulcer.
What is the most suitable treatment for this patient?Your Answer: Acyclovir ointment
Explanation:There are two types of infectious agents that can lead to the development of a dendritic ulcer. The majority of cases (80%) are caused by the herpes simplex virus (type I), while the remaining cases (20%) are caused by the herpes zoster virus. To effectively treat this condition, the patient should follow a specific treatment plan. This includes applying acyclovir ointment topically five times a day for a duration of 10 days. Additionally, prednisolone 0.5% drops should be used 2-4 times daily. It is also recommended to take oral high dose vitamin C, as it has been shown to reduce the healing time of dendritic ulcers.
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This question is part of the following fields:
- Ophthalmology
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Question 79
Correct
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You assess a 27-year-old patient who is 10-weeks pregnant. She is concerned as she had contact with someone with chickenpox two days ago. She is unsure if she had chickenpox in her childhood.
What is the MOST suitable initial course of action?Your Answer: She should have a blood test to check for varicella zoster immunity
Explanation:Varicella can have serious consequences for pregnant women. If a woman contracts varicella during the first 28 weeks of pregnancy, there is a 1% chance that the fetus will be affected and develop foetal varicella syndrome (FVS). FVS is characterized by eye defects, limb underdevelopment, skin scarring, and neurological abnormalities.
Pregnant women who have not had chickenpox or who test negative for VZV IgG should be advised to minimize contact with individuals who have chickenpox or shingles. If they are exposed, they should seek immediate medical help.
If a pregnant woman is exposed to varicella, the first step is to perform a blood test to check for VZV immunity. If she is not immune and the exposure is significant, she should be given VZV immunoglobulin as soon as possible. This treatment is effective within 10 days of exposure.
If a pregnant woman develops chickenpox, she should urgently seek medical assistance. There is an increased risk of pneumonia, encephalitis, and hepatitis for the mother, as well as a 1% risk of the fetus developing FVS.
Acyclovir should be used cautiously before 20 weeks of gestation but is recommended after 20 weeks if the woman seeks medical help within 24 hours of the rash appearing.
If a woman develops any complications of varicella, she must be referred to a hospital. Additionally, she should be referred to a specialized center five weeks after the infection for a detailed ultrasound scan to determine if FVS has occurred.
For more information, refer to the Royal College of Obstetricians and Gynaecologists green-top guidelines for the management of VZV exposure and infection in pregnancy.
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This question is part of the following fields:
- Obstetrics & Gynaecology
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Question 80
Correct
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You assess a 16 year old with an open fracture dislocation of the ankle after a motorcycle accident. The patient has been given nitrous oxide during transportation in the ambulance. The orthopedic surgeon on call is currently in the emergency department and recommends that the injury be promptly treated in the operating room. Which of the following statements about nitrous oxide is correct?
Your Answer: Nitrous oxide administration increases the fractional content of inhaled anaesthetic gases
Explanation:The administration of nitrous oxide increases the amount of inhaled anaesthetic gases in the body through a phenomenon called the ‘second gas effect’. Nitrous oxide is much more soluble than nitrogen, with a solubility that is 20 to 30 times higher. When nitrous oxide is given, it causes a decrease in the volume of air in the alveoli. Additionally, nitrous oxide can enhance the absorption of other inhaled anaesthetic agents through the second gas effect. However, it is important to note that nitrous oxide alone cannot be used as the sole maintenance agent in anaesthesia.
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.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 81
Correct
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You review a patient with a history of renal failure that has presented with nausea, fatigue, and sleepiness. Upon reviewing her blood results today, you note that her glomerular filtration rate has recently fallen significantly. She has no other medical history of note.
At what level should patients generally begin dialysis when their glomerular filtration rate (GFR) reaches?Your Answer: 10 ml/minute
Explanation:Patients typically initiate dialysis when their glomerular filtration rate (GFR) drops to 10 ml/min. However, if the patient has diabetes, dialysis may be recommended when their GFR reaches 15 ml/min. The GFR is a measure of kidney function and indicates how well the kidneys are able to filter waste products from the blood. Dialysis is a medical procedure that helps perform the function of the kidneys by removing waste and excess fluid from the body.
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This question is part of the following fields:
- Nephrology
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Question 82
Incorrect
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There are numerous casualties reported after a suspected CBRN (chemical, biological, radiological and nuclear) incident, with a high likelihood of sarin gas being the responsible agent. In the management of this situation, certain casualties are administered pralidoxime as an antidote.
What is the mode of action of pralidoxime?Your Answer: Muscarinic acetylcholine receptor antagonist
Correct Answer: Reactivating acetylcholinesterase
Explanation:The primary approach to managing nerve gas exposure through medication involves the repeated administration of antidotes. The two antidotes utilized for this purpose are atropine and pralidoxime.
Atropine is the standard anticholinergic medication employed to address the symptoms associated with nerve agent poisoning. It functions as an antagonist for muscarinic acetylcholine receptors, effectively blocking the effects caused by excessive acetylcholine. Initially, a 1.2 mg intravenous bolus of atropine is administered. This dosage is then repeated and doubled every 2-3 minutes until excessive bronchial secretion ceases and miosis (excessive constriction of the pupil) resolves. In some cases, as much as 100 mg of atropine may be necessary.
Pralidoxime (2-PAMCl) is the standard oxime used in the treatment of nerve agent poisoning. Its mechanism of action involves reactivating acetylcholinesterase by scavenging the phosphoryl group attached to the functional hydroxyl group of the enzyme, thereby counteracting the effects of the nerve agent itself. For patients who are moderately or severely poisoned, pralidoxime should be administered intravenously at a dosage of 30 mg/kg of body weight (or 2 g in the case of an adult) over a period of four minutes.
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This question is part of the following fields:
- Major Incident Management & PHEM
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Question 83
Correct
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A 45 year old male presents to the emergency department complaining of worsening headaches and visual disturbances over the past week. Upon examination, you observe that the patient has a round face, stretch marks on the abdomen, and excessive hair growth. You suspect that the patient may have Cushing syndrome.
Which of the following tests would be the most suitable to confirm the diagnosis?Your Answer: 24-hour urinary free cortisol
Explanation:The recommended diagnostic tests for Cushing’s syndrome include the 24-hour urinary free cortisol test, the 1 mg overnight dexamethasone suppression test, and the late-night salivary cortisol test. In this case, the patient exhibits symptoms of Cushing syndrome such as a moon face, abdominal striae, and hirsutism. These symptoms may be caused by Cushing’s disease, which is Cushing syndrome due to a pituitary adenoma. The patient also experiences headaches and visual disturbances, which could potentially be caused by high blood sugar levels. It is important to note that Cushing syndrome caused by an adrenal or pituitary tumor is more common in females, with a ratio of 5:1. The peak incidence of Cushing syndrome caused by an adrenal or pituitary adenoma occurs between the ages of 25 and 40 years.
Further Reading:
Cushing’s syndrome is a clinical syndrome caused by prolonged exposure to high levels of glucocorticoids. The severity of symptoms can vary depending on the level of steroid exposure. There are two main classifications of Cushing’s syndrome: ACTH-dependent disease and non-ACTH-dependent disease. ACTH-dependent disease is caused by excessive ACTH production from the pituitary gland or ACTH-secreting tumors, which stimulate excessive cortisol production. Non-ACTH-dependent disease is characterized by excess glucocorticoid production independent of ACTH stimulation.
The most common cause of Cushing’s syndrome is exogenous steroid use. Pituitary adenoma is the second most common cause and the most common endogenous cause. Cushing’s disease refers specifically to Cushing’s syndrome caused by an ACTH-producing pituitary tumor.
Clinical features of Cushing’s syndrome include truncal obesity, supraclavicular fat pads, buffalo hump, weight gain, moon facies, muscle wasting and weakness, diabetes or impaired glucose tolerance, gonadal dysfunction, hypertension, nephrolithiasis, skin changes (such as skin atrophy, striae, easy bruising, hirsutism, acne, and hyperpigmentation in ACTH-dependent causes), depression and emotional lability, osteopenia or osteoporosis, edema, irregular menstrual cycles or amenorrhea, polydipsia and polyuria, poor wound healing, and signs related to the underlying cause, such as headaches and visual problems.
Diagnostic tests for Cushing’s syndrome include 24-hour urinary free cortisol, 1 mg overnight dexamethasone suppression test, and late-night salivary cortisol. Other investigations aim to assess metabolic disturbances and identify the underlying cause, such as plasma ACTH, full blood count (raised white cell count), electrolytes, and arterial blood gas analysis. Imaging, such as CT or MRI of the abdomen, chest, and/or pituitary, may be required to assess suspected adrenal tumors, ectopic ACTH-secreting tumors, and pituitary tumors. The choice of imaging is guided by the ACTH result, with undetectable ACTH and elevated serum cortisol levels indicating ACTH-independent Cushing’s syndrome and raised ACTH suggesting an ACTH-secreting tumor.
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This question is part of the following fields:
- Endocrinology
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Question 84
Incorrect
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A 70-year-old male smoker presents with intense chest discomfort. His electrocardiogram (ECG) indicates an acute myocardial infarction, and he is immediately taken to the catheterization laboratory. Angiography reveals a blockage in the left anterior descending artery.
Which area of the heart is most likely affected in this scenario?Your Answer: Right ventricle
Correct Answer: Anteroseptal
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.
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This question is part of the following fields:
- Cardiology
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Question 85
Correct
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You are managing a 32-year-old male patient who leaped off a bridge. There is noticeable bruising and extreme sensitivity over the calcaneus. You are currently waiting for an X-ray to confirm the presence of a calcaneal fracture. Which of the following statements is accurate regarding the assessment of the X-ray?
Your Answer: The normal angle of Gissane is 120-145°
Explanation:The typical range for the normal angle of Gissane is between 120 and 145 degrees. An increase in this angle suggests that the posterior facet of the subtalar joint is depressed, which may indicate a calcaneal fracture. Similarly, the normal range for Bohler’s angle is between 20 and 40 degrees. For more detailed information and visual representations of these angles, please refer to the accompanying notes.
Further Reading:
calcaneus fractures are a common type of lower limb and joint injury. The calcaneus, or heel bone, is the most frequently fractured tarsal bone. These fractures are often intra-articular, meaning they involve the joint. The most common cause of calcaneus fractures is a fall or jump from a height.
When assessing calcaneus fractures, X-rays are used to visualize the fracture lines. Two angles are commonly assessed to determine the severity of the fracture. Böhler’s angle, which measures the angle between two tangent lines drawn across the anterior and posterior borders of the calcaneus, should be between 20-40 degrees. If it is less than 20 degrees, it indicates a calcaneal fracture with flattening. The angle of Gissane, which measures the depression of the posterior facet of the subtalar joint, should be between 120-145 degrees. An increased angle of Gissane suggests a calcaneal fracture.
In the emergency department, the management of a fractured calcaneus involves identifying the injury and any associated injuries, providing pain relief, elevating the affected limb(s), and referring the patient to an orthopedic specialist. It is important to be aware that calcaneus fractures are often accompanied by other injuries, such as bilateral fractures of vertebral fractures.
The definitive management of a fractured calcaneus can be done conservatively or through surgery, specifically open reduction internal fixation (ORIF). The orthopedic team will typically order a CT or MRI scan to classify the fracture and determine the most appropriate treatment. However, a recent UK heel fracture trial suggests that in most cases, ORIF does not improve fracture outcomes.
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This question is part of the following fields:
- Trauma
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Question 86
Correct
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A 35-year-old male is brought to the emergency department with a severe head injury. Due to a decreasing Glasgow Coma Scale (GCS), it is decided to intubate him. You prepare for rapid sequence induction (RSI) and plan to use propofol as the induction agent. Which of the following statements about propofol and its impact on blood pressure is accurate?
Your Answer: Propofol causes hypotension via venodilation
Explanation:The administration of propofol can result in venodilation, leading to a significant drop in blood pressure. This effect is particularly significant in patients who are already experiencing unstable blood flow.
Further Reading:
There are four commonly used induction agents in the UK: propofol, ketamine, thiopentone, and etomidate.
Propofol is a 1% solution that produces significant venodilation and myocardial depression. It can also reduce cerebral perfusion pressure. The typical dose for propofol is 1.5-2.5 mg/kg. However, it can cause side effects such as hypotension, respiratory depression, and pain at the site of injection.
Ketamine is another induction agent that produces a dissociative state. It does not display a dose-response continuum, meaning that the effects do not necessarily increase with higher doses. Ketamine can cause bronchodilation, which is useful in patients with asthma. The initial dose for ketamine is 0.5-2 mg/kg, with a typical IV dose of 1.5 mg/kg. Side effects of ketamine include tachycardia, hypertension, laryngospasm, unpleasant hallucinations, nausea and vomiting, hypersalivation, increased intracranial and intraocular pressure, nystagmus and diplopia, abnormal movements, and skin reactions.
Thiopentone is an ultra-short acting barbiturate that acts on the GABA receptor complex. It decreases cerebral metabolic oxygen and reduces cerebral blood flow and intracranial pressure. The adult dose for thiopentone is 3-5 mg/kg, while the child dose is 5-8 mg/kg. However, these doses should be halved in patients with hypovolemia. Side effects of thiopentone include venodilation, myocardial depression, and hypotension. It is contraindicated in patients with acute porphyrias and myotonic dystrophy.
Etomidate is the most haemodynamically stable induction agent and is useful in patients with hypovolemia, anaphylaxis, and asthma. It has similar cerebral effects to thiopentone. The dose for etomidate is 0.15-0.3 mg/kg. Side effects of etomidate include injection site pain, movement disorders, adrenal insufficiency, and apnoea. It is contraindicated in patients with sepsis due to adrenal suppression.
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This question is part of the following fields:
- Basic Anaesthetics
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Question 87
Correct
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A 45 year old patient is brought to the emergency department (ED) by a family member. The patient began experiencing coughing symptoms ten days ago, but within the past 48 hours, they have developed a high fever, difficulty breathing during mild exertion, and the family reports that the patient appears confused. It is noted that the patient is currently taking azathioprine for the treatment of rheumatoid arthritis.
Upon assessing the patient's vital signs, you decide to initiate the sepsis 6 pathway. What is the recommended timeframe for implementing the 'sepsis six'?Your Answer: 1 hour
Explanation:The sepsis 6 pathway is a time-sensitive protocol that should be started promptly and all 6 initial steps should be completed within 1 hour. It is important not to confuse the sepsis 6 pathway with the 6 hour care bundle. Time is of the essence when managing septic patients, and initiating the sepsis 6 pathway immediately has been proven to enhance survival rates in sepsis patients.
Further Reading:
There are multiple definitions of sepsis, leading to confusion among healthcare professionals. The Sepsis 3 definition describes sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection. The Sepsis 2 definition includes infection plus two or more SIRS criteria. The NICE definition states that sepsis is a clinical syndrome triggered by the presence of infection in the blood, activating the body’s immune and coagulation systems. The Sepsis Trust defines sepsis as a dysregulated host response to infection mediated by the immune system, resulting in organ dysfunction, shock, and potentially death.
The confusion surrounding sepsis terminology is further compounded by the different versions of sepsis definitions, known as Sepsis 1, Sepsis 2, and Sepsis 3. The UK organizations RCEM and NICE have not fully adopted the changes introduced in Sepsis 3, causing additional confusion. While Sepsis 3 introduces the use of SOFA scores and abandons SIRS criteria, NICE and the Sepsis Trust have rejected the use of SOFA scores and continue to rely on SIRS criteria. This discrepancy creates challenges for emergency department doctors in both exams and daily clinical practice.
To provide some clarity, RCEM now recommends referring to national standards organizations such as NICE, SIGN, BTS, or others relevant to the area. The Sepsis Trust, in collaboration with RCEM and NICE, has published a toolkit that serves as a definitive reference point for sepsis management based on the sepsis 3 update.
There is a consensus internationally that the terms SIRS and severe sepsis are outdated and should be abandoned. Instead, the terms sepsis and septic shock should be used. NICE defines septic shock as a life-threatening condition characterized by low blood pressure despite adequate fluid replacement and organ dysfunction or failure. Sepsis 3 defines septic shock as persisting hypotension requiring vasopressors to maintain a mean arterial pressure of 65 mmHg or more, along with a serum lactate level greater than 2 mmol/l despite adequate volume resuscitation.
NICE encourages clinicians to adopt an approach of considering sepsis in all patients, rather than relying solely on strict definitions. Early warning or flag systems can help identify patients with possible sepsis.
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This question is part of the following fields:
- Infectious Diseases
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Question 88
Incorrect
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A 70-year-old woman with a history of chronic heart failure presents to the Emergency Department with an unrelated medical condition. Upon reviewing her medications, you discover that she is taking furosemide as part of her management.
Which ONE of the following drugs should be avoided?Your Answer: Codeine phosphate
Correct Answer: Citalopram
Explanation:When furosemide and SSRI drugs are prescribed together, there is a higher chance of developing hyponatraemia, which is a condition characterized by low levels of sodium in the blood. Additionally, there is an increased risk of hypokalaemia, which can potentially lead to a dangerous heart rhythm disorder called torsades de pointes. It is important to note that co-prescribing furosemide with citalopram should be avoided due to these risks. For more information, you can refer to the section on furosemide interactions in the BNF.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 89
Correct
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A 42 year old man visits the emergency department. He had a mishap and fell into a glass window, resulting in a significant cut on his left forearm. You suggest that this can be stitched up using local anesthesia. What is the highest dosage of lidocaine with adrenaline that can be administered for this procedure?
Your Answer: 7 mg/kg
Explanation:The recommended dose of adrenaline is 7 mg per kilogram of body weight, with a maximum limit of 500 mg.
Local anaesthetics, such as lidocaine, bupivacaine, and prilocaine, are commonly used in the emergency department for topical or local infiltration to establish a field block. Lidocaine is often the first choice for field block prior to central line insertion. These anaesthetics work by blocking sodium channels, preventing the propagation of action potentials.
However, local anaesthetics can enter the systemic circulation and cause toxic side effects if administered in high doses. Clinicians must be aware of the signs and symptoms of local anaesthetic systemic toxicity (LAST) and know how to respond. Early signs of LAST include numbness around the mouth or tongue, metallic taste, dizziness, visual and auditory disturbances, disorientation, and drowsiness. If not addressed, LAST can progress to more severe symptoms such as seizures, coma, respiratory depression, and cardiovascular dysfunction.
The management of LAST is largely supportive. Immediate steps include stopping the administration of local anaesthetic, calling for help, providing 100% oxygen and securing the airway, establishing IV access, and controlling seizures with benzodiazepines or other medications. Cardiovascular status should be continuously assessed, and conventional therapies may be used to treat hypotension or arrhythmias. Intravenous lipid emulsion (intralipid) may also be considered as a treatment option.
If the patient goes into cardiac arrest, CPR should be initiated following ALS arrest algorithms, but lidocaine should not be used as an anti-arrhythmic therapy. Prolonged resuscitation may be necessary, and intravenous lipid emulsion should be administered. After the acute episode, the patient should be transferred to a clinical area with appropriate equipment and staff for further monitoring and care.
It is important to report cases of local anaesthetic toxicity to the appropriate authorities, such as the National Patient Safety Agency in the UK or the Irish Medicines Board in the Republic of Ireland. Additionally, regular clinical review should be conducted to exclude pancreatitis, as intravenous lipid emulsion can interfere with amylase or lipase assays.
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This question is part of the following fields:
- Pharmacology & Poisoning
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Question 90
Correct
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A 32-year-old woman comes to the emergency department after falling while drunk. She has a 6.5 cm cut on the back of her head and says she feels a tingling sensation in the area of the cut. Which of the following structures provides sensory innervation to the back of the head?
Your Answer: C2 and C3 cervical nerves
Explanation:The main sensory supply to the back of the scalp comes from the C2 and C3 cervical nerves. The scalp receives innervation from branches of both the trigeminal nerve and the cervical nerves, as depicted in the illustration in the notes. The C2 and C3 cervical nerves are primarily responsible for supplying sensation to the posterior scalp.
Further Reading:
The scalp is the area of the head that is bordered by the face in the front and the neck on the sides and back. It consists of several layers, including the skin, connective tissue, aponeurosis, loose connective tissue, and periosteum of the skull. These layers provide protection and support to the underlying structures of the head.
The blood supply to the scalp primarily comes from branches of the external carotid artery and the ophthalmic artery, which is a branch of the internal carotid artery. These arteries provide oxygen and nutrients to the scalp tissues.
The scalp also has a complex venous drainage system, which is divided into superficial and deep networks. The superficial veins correspond to the arterial branches and are responsible for draining blood from the scalp. The deep venous network is drained by the pterygoid venous plexus.
In terms of innervation, the scalp receives sensory input from branches of the trigeminal nerve and the cervical nerves. These nerves transmit sensory information from the scalp to the brain, allowing us to perceive touch, pain, and temperature in this area.
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This question is part of the following fields:
- Trauma
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Question 91
Correct
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A 25-year-old man comes in with severe bloody diarrhea caused by a gastrointestinal infection.
Which organism is the SINGLE LEAST likely cause?Your Answer: Enterotoxigenic Escherichia coli
Explanation:Enterotoxigenic E.coli is a strain that does not invade the body and does not lead to inflammation or bloody diarrhea. On the other hand, enterogenic strains result in excessive watery diarrhea and are typically not accompanied by abdominal cramping.
There are several infectious causes of bloody diarrhea, including Campylobacter spp., Shigella spp., Salmonella spp., Clostridium difficile, Enterohaemorrhagic Escherichia coli, Yersinia spp., Schistosomiasis, and Amoebiasis (Entamoeba histolytica).
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 92
Correct
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A 32 year old male presents to the emergency department with worsening abdominal pain and diarrhea. The patient had previously been referred to a gastroenterologist by his primary care physician for recurrent episodes of abdominal pain and diarrhea accompanied by anemia. Barium contrast studies were performed last week, and the report indicates the presence of 'cobblestoning' and 'rose thorn ulcers' in the terminal ileum and colon.
What is the probable diagnosis?Your Answer: Crohn's disease
Explanation:Cobblestoning and rose thorn ulcers are visual characteristics seen in radiological images of individuals with Crohn’s disease. Cobblestoning occurs when there are linear ulcerations running both lengthwise and widthwise, creating a cobblestone-like appearance on the intestinal wall. This effect is enhanced by the presence of nodular wall swelling, and when barium enters the deep crevices of the ulcers, it further accentuates the cobblestone pattern.
Further Reading:
Inflammatory bowel disease (IBD) is a chronic condition characterized by inflammation of the intestinal tract and an imbalance of the intestinal microbiota. The two main forms of IBD are Crohn’s disease and ulcerative colitis (UC). In some cases, it is not possible to differentiate between Crohn’s disease and UC, and the term inflammatory bowel disease type-unclassified may be used.
Crohn’s disease is a chronic, relapsing-remitting inflammatory disease that can affect any part of the gastrointestinal tract, from the mouth to the anus. It most commonly involves the ileum and colon. The inflammation in Crohn’s disease affects all layers of the intestinal wall, leading to complications such as strictures, fistulas, and adhesions. Risk factors for developing Crohn’s disease include a family history, smoking, infectious gastroenteritis, appendicectomy, and the use of NSAIDs and oral contraceptive drugs. Symptoms of Crohn’s disease can vary but often include diarrhea, abdominal pain, weight loss, and perianal disease. Extraintestinal features, such as arthritis, erythema nodosum, and uveitis, can also occur.
Ulcerative colitis is a chronic, relapsing-remitting inflammatory disease that primarily affects the large bowel. The inflammation in UC is limited to the intestinal mucosa and does not involve skip lesions like in Crohn’s disease. Risk factors for developing UC include a family history, not smoking, and no appendix. Symptoms of UC include bloody diarrhea, urgency, tenesmus, and abdominal pain. Extraintestinal features, such as arthritis and uveitis, can also occur. Complications of UC include toxic megacolon, bowel obstruction, bowel perforation, strictures, fistula formation, anemia, malnutrition, and colorectal cancer.
Diagnosing IBD involves various investigations, including blood tests, stool microscopy and culture, fecal calprotectin testing, endoscopy with biopsy, and imaging modalities such as CT and MR enterography. The management of Crohn’s disease and UC is complex and may involve corticosteroids, immunosuppressive drugs, biologic therapy, surgery, and nutritional support. Patients with IBD should also be monitored for nutritional deficiencies, colorectal cancer, and osteoporosis.
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This question is part of the following fields:
- Gastroenterology & Hepatology
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Question 93
Correct
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The Emergency Medicine consultant in charge of the department today asks for your attention to present a case of superior orbital fissure syndrome (SOFS) in a 30-year-old woman with a Le Fort II fracture of the midface after a car accident.
Which of the following anatomical structures does NOT traverse through the superior orbital fissure?Your Answer: Facial vein
Explanation:The superior orbital fissure is a gap in the back wall of the orbit, created by the space between the greater and lesser wings of the sphenoid bone. Several structures pass through it to enter the orbit, starting from the top and going downwards. These include the lacrimal nerve (a branch of CN V1), the frontal nerve (another branch of CN V1), the superior ophthalmic vein, the trochlear nerve (CN IV), the superior division of the oculomotor nerve (CN III), the nasociliary nerve (a branch of CN V1), the inferior division of the oculomotor nerve (CN III), the abducens nerve (CN VI), and the inferior ophthalmic vein.
Adjacent to the superior orbital fissure, on the back wall of the orbit and towards the middle, is the optic canal. The optic nerve (CN II) exits the orbit through this canal, along with the ophthalmic artery.
Superior orbital fissure syndrome (SOFS) is a condition characterized by a combination of symptoms and signs that occur when cranial nerves III, IV, V1, and VI are compressed or injured as they pass through the superior orbital fissure. This condition also leads to swelling and protrusion of the eye due to impaired drainage and congestion. The main causes of SOFS are trauma, tumors, and inflammation. It is important to note that CN II is not affected by this syndrome, as it follows a separate path through the optic canal.
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This question is part of the following fields:
- Maxillofacial & Dental
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Question 94
Incorrect
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A 42-year-old woman is brought in by ambulance following a high-speed car accident. There was a prolonged extraction at the scene, and a full trauma call is made. She is disoriented and slightly restless. Her vital signs are as follows: heart rate 125, blood pressure 83/45, oxygen saturation 98% on high-flow oxygen, respiratory rate 31, temperature 36.1°C. Her capillary refill time is 5 seconds, and her extremities appear pale and cool to the touch. Her cervical spine is immobilized with triple precautions. The airway is clear, and her chest examination is normal. Two large-bore needles have been inserted in her antecubital fossa, and a complete set of blood tests, including a request for a cross-match, has been sent to the laboratory. She experiences significant tenderness in the suprapubic area upon abdominal palpation, and noticeable bruising is evident around her pelvis. A pelvic X-ray reveals a vertical shear type pelvic fracture.
What approximate percentage of her circulatory volume has she lost?Your Answer: 40-50%
Correct Answer: 30-40%
Explanation:This patient is currently experiencing moderate shock, classified as class III. This level of shock corresponds to a loss of 30-40% of their circulatory volume, which is equivalent to a blood loss of 1500-2000 mL.
Hemorrhage can be categorized into four different classes based on physiological parameters and clinical signs. These classes are classified as class I, class II, class III, and class IV.
In class I hemorrhage, the blood loss is up to 750 mL or up to 15% of the blood volume. The pulse rate is less than 100 beats per minute, and the systolic blood pressure is normal. The pulse pressure may be normal or increased, and the respiratory rate is within the range of 14-20 breaths per minute. The urine output is greater than 30 mL per hour, and the patient’s CNS/mental status is slightly anxious.
In class II hemorrhage, the blood loss ranges from 750-1500 mL or 15-30% of the blood volume. The pulse rate is between 100-120 beats per minute, and the systolic blood pressure remains normal. The pulse pressure is decreased, and the respiratory rate increases to 20-30 breaths per minute. The urine output decreases to 20-30 mL per hour, and the patient may experience mild anxiety.
The patient in this case is in class III hemorrhage, with a blood loss of 1500-2000 mL or 30-40% of the blood volume. The pulse rate is elevated, ranging from 120-140 beats per minute, and the systolic blood pressure is decreased. The pulse pressure is also decreased, and the respiratory rate is elevated to 30-40 breaths per minute. The urine output decreases significantly to 5-15 mL per hour, and the patient may experience anxiety and confusion.
Class IV hemorrhage represents the most severe level of blood loss, with a loss of over 40% of the blood volume. The pulse rate is greater than 140 beats per minute, and the systolic blood pressure is significantly decreased. The pulse pressure is decreased, and the respiratory rate is over 40 breaths per minute. The urine output becomes negligible, and the patient may become confused and lethargic.
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This question is part of the following fields:
- Trauma
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Question 95
Correct
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You evaluate a 62-year-old woman with a painful swollen left big toe. The pain began this morning and is described as the most severe pain she has ever experienced. It has progressively worsened over the past 8 hours. She is unable to wear socks or shoes and had to attend the appointment wearing open-toe sandals. The skin over the affected area appears red and shiny.
What is the most probable diagnosis in this scenario?Your Answer: Gout
Explanation:The guidelines from the European League Against Rheumatism (EULAR) regarding the diagnosis of gout state that if a joint becomes swollen, tender, and red, accompanied by acute pain that intensifies over a period of 6-12 hours, it is highly likely to be a crystal arthropathy. While pseudogout is also a possibility, it is much less probable, with gout being the most likely diagnosis in such cases.
In cases of acute gout, the joint most commonly affected is the first metatarsal-phalangeal joint, accounting for 50-75% of cases. The underlying cause of gout is hyperuricaemia, and the clinical diagnosis can be confirmed by the presence of negatively birefringent crystals in the synovial fluid aspirate.
For the treatment of acute gout attacks, the usual approach involves the use of either NSAIDs or colchicine.
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This question is part of the following fields:
- Musculoskeletal (non-traumatic)
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Question 96
Correct
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A 6-year-old girl presents with cold-like symptoms that have been present for over two weeks. She is originally from South America. Her mother reports that she has been extremely tired and has been complaining of various aches and pains. During the examination, enlarged lymph nodes are found in her neck, and splenomegaly is detected. She has multiple petechiae on her legs and arms. Her blood test results are as follows:
Hemoglobin: 7.4 g/dl (11.5-15.5 g/dl)
Mean Corpuscular Volume (MCV): 80 fl (75-87 fl)
Platelets: 34 x 109/l (150-400 x 109/l)
White Cell Count (WCC): 34.4 x 109/l (4-11 x 109/l)
What is the most likely diagnosis for this patient?Your Answer: Acute lymphoblastic leukaemia (ALL)
Explanation:Acute lymphoblastic leukaemia (ALL) is the most common type of leukaemia that occurs in childhood, typically affecting children between the ages of 2 and 5 years. The symptoms of ALL can vary, but many children initially experience an acute illness that may resemble a common cold or viral infection. Other signs of ALL include general weakness and fatigue, as well as muscle, joint, and bone pain. Additionally, children with ALL may have anaemia, unexplained bruising and petechiae, swelling (oedema), enlarged lymph nodes (lymphadenopathy), and an enlarged liver and spleen (hepatosplenomegaly).
In patients with ALL, a complete blood count typically reveals certain characteristics. These include anaemia, which can be either normocytic or macrocytic. Approximately 50% of patients with ALL have a low white blood cell count (leukopaenia), with a white cell count below 4 x 109/l. On the other hand, around 60% of patients have a high white blood cell count (leukocytosis), with a white cell count exceeding 10 x 109/l. In about 25% of cases, there is an extreme elevation in white blood cell count (hyperleukocytosis), with a count surpassing 50 x 109/l. Additionally, patients with ALL often have a low platelet count (thrombocytopaenia).
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This question is part of the following fields:
- Haematology
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Question 97
Correct
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You are present for the unexpected delivery of a baby in one of the cubicles in the Emergency Department. Your consultant evaluates the newborn one minute after birth and informs you that:
The hands and feet appear bluish in color
The heart rate is 110 beats per minute
There is no response to stimulation
There is slight bending of the limbs
The cry is feeble, and the baby is gasping for breath
What is the Apgar score of the newborn at one minute?Your Answer: 5
Explanation:The Apgar score is a straightforward way to evaluate the well-being of a newborn baby right after birth. It consists of five criteria, each assigned a score ranging from zero to two. Typically, the assessment is conducted at one and five minutes after delivery, with the possibility of repeating it later if the score remains low. A score of 7 or higher is considered normal, while a score of 4-6 is considered fairly low, and a score of 3 or below is regarded as critically low. To remember the five criteria, you can use the acronym APGAR:
Appearance
Pulse rate
Grimace
Activity
Respiratory effortThe Apgar score criteria are as follows:
Score of 0:
Appearance (skin color): Blue or pale all over
Pulse rate: Absent
Reflex irritability (grimace): No response to stimulation
Activity: None
Respiratory effort: AbsentScore of 1:
Appearance (skin color): Blue at extremities (acrocyanosis)
Pulse rate: Less than 100 per minute
Reflex irritability (grimace): Grimace on suction or aggressive stimulation
Activity: Some flexion
Respiratory effort: Weak, irregular, gaspingScore of 2:
Appearance (skin color): No cyanosis, body and extremities pink
Pulse rate: More than 100 per minute
Reflex irritability (grimace): Cry on stimulation
Activity: Flexed arms and legs that resist extension
Respiratory effort: Strong, robust cry -
This question is part of the following fields:
- Neonatal Emergencies
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Question 98
Correct
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You evaluate a 14-year-old with Down syndrome. The reason for the visit is the caregiver's worry about recent occurrences of nosebleeds and bleeding gums. During the examination, the patient appears pale, but there are no other notable findings.
What is the PRIMARY diagnosis that should raise the most concern at this point?Your Answer: Acute leukaemia
Explanation:There is a known connection between trisomy 21 and acute lymphoblastic leukemia. Therefore, it is important to investigate and rule out this possibility as the first step in this case.
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This question is part of the following fields:
- Haematology
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Question 99
Correct
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Which of the following organizations is classified as a Category 2 entity according to the Civil Contingencies Act 2004 in the UK?
Your Answer: The Health and Safety Executive
Explanation:The Civil Contingencies Act 2004 establishes a framework for civil protection in the United Kingdom. This legislation categorizes local responders to major incidents into two groups, each with their own set of responsibilities.
Category 1 responders consist of organizations that play a central role in responding to most emergencies, such as the emergency services, local authorities, and NHS bodies. These Category 1 responders are obligated to fulfill a comprehensive range of civil protection duties. These duties include assessing the likelihood of emergencies occurring and using this information to inform contingency planning. They must also develop emergency plans, establish business continuity management arrangements, and ensure that information regarding civil protection matters is readily available to the public. Additionally, Category 1 responders are responsible for maintaining systems to warn, inform, and advise the public in the event of an emergency. They are expected to share information with other local responders to enhance coordination and efficiency. Furthermore, local authorities within this category are required to provide guidance and support to businesses and voluntary organizations regarding business continuity management.
On the other hand, Category 2 organizations, such as the Health and Safety Executive, transport companies, and utility companies, are considered co-operating bodies. While they may not be directly involved in the core planning work, they play a crucial role in incidents that impact their respective sectors. Category 2 responders have a more limited set of duties, primarily focused on cooperating and sharing relevant information with both Category 1 and Category 2 responders.
For more information on this topic, please refer to the Civil Contingencies Act 2004.
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This question is part of the following fields:
- Major Incident Management & PHEM
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Question 100
Incorrect
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A 25-year-old woman had unprotected sexual intercourse 3 days ago. On direct questioning it was approximately 80 hours ago. She is hesitant to have a coil inserted due to a negative past experience and is curious about alternative options that may be available to her.
What is the MOST appropriate choice for her?Your Answer: Levonelle 1.5 mg
Correct Answer: Ulipristal acetate
Explanation:Women have three options when requesting emergency contraception. The first option is Levonelle 1.5 mg, which contains levonorgestrel and can be used up to 72 hours after unprotected sexual intercourse (UPSI). If vomiting occurs within 2 hours of taking the tablet, another one should be given. Levonelle mainly works by preventing ovulation.
The second option is ulipristal acetate, the newest treatment available. It can be used up to 120 hours after UPSI. If vomiting occurs within 3 hours of ingestion, another tablet should be given. Ulipristal acetate also works by inhibiting ovulation. However, it should be avoided in patients taking enzyme-inducing drugs, those with severe hepatic impairment, or those with severe asthma requiring oral steroids.
The third option is the copper IUD, which can be fitted up to 5 days after UPSI or ovulation, whichever is longer. The failure rate of the copper IUD is less than 1 in 1000, making it 10-20 times more effective than oral emergency contraceptive options. It is important to note that Levonelle and ulipristal may be less effective in women with higher BMIs.
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This question is part of the following fields:
- Sexual Health
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Question 101
Correct
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A 65-year-old patient presents with dysuria, fevers, rigors, and left-sided loin pain. On examination, there is tenderness over his left renal angle and he has a temperature of 38.6°C. You suspect the most likely diagnosis is pyelonephritis.
Which of the following is not a reason to consider hospital admission in a patient with pyelonephritis?Your Answer: Failure to improve significantly within 12 hours of starting antibiotics
Explanation:This patient is displaying symptoms and signs that are consistent with a diagnosis of acute pyelonephritis. Additionally, they are showing signs of sepsis, which indicates a more serious illness or condition. Therefore, it would be advisable to admit the patient for inpatient treatment.
According to the recommendations from the National Institute for Health and Care Excellence (NICE), patients with pyelonephritis should be admitted if it is severe or if they exhibit any signs or symptoms that suggest a more serious condition, such as sepsis. Signs of sepsis include significant tachycardia, hypotension, or breathlessness, as well as marked signs of illness like impaired level of consciousness, profuse sweating, rigors, pallor, or significantly reduced mobility. A temperature greater than 38°C or less than 36°C is also indicative of sepsis.
NICE also advises considering referral or seeking specialist advice for individuals with acute pyelonephritis if they are significantly dehydrated or unable to take oral fluids and medicines, if they are pregnant, if they have a higher risk of developing complications due to known or suspected abnormalities of the genitourinary tract or underlying diseases like diabetes mellitus or immunosuppression, or if they have recurrent episodes of urinary tract infections (UTIs).
For non-pregnant women and men, the recommended choice of antibacterial therapy is as follows: oral first-line options include cefalexin, ciprofloxacin, or co-amoxiclav (taking into account local microbial resistance data), and trimethoprim if sensitivity is known. Intravenous first-line options are amikacin, ceftriaxone, cefuroxime, ciprofloxacin, or gentamicin if the patient is severely unwell or unable to take oral treatment. Co-amoxiclav may be used if given in combination or if sensitivity is known. Antibacterials may be combined if there are concerns about susceptibility or sepsis. For intravenous second-line options, it is recommended to consult a local microbiologist.
For pregnant women, the recommended choice of antibacterial therapy is cefalexin for oral first-line treatment. If the patient is severely unwell or unable to take oral treatment, cefuroxime is the recommended intravenous first-line option. If there are concerns about susceptibility or sepsis, it is advised to consult a local microbiologist for intravenous second-line
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This question is part of the following fields:
- Urology
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Question 102
Correct
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A 35-year-old accountant presents with a headache. Since she woke up this morning, she describes a right-sided, severe, throbbing headache. She has had similar symptoms previously but feels that this is the worst she has ever had. Her work is very stressful at the moment. She has also vomited this morning. Her husband is with her and is anxious as his mother has recently been diagnosed with a brain tumor. He is really worried that his wife might have the same. On examination, the patient is normotensive with a heart rate of 72 beats per minute, regular. Her cranial nerve examination, including fundoscopy, is normal, as is the examination of her peripheral nervous system. She has no scalp tenderness.
What is the SINGLE most likely diagnosis?Your Answer: Migraine
Explanation:Migraine without aura typically needs to meet the specific criteria set by the International Headache Society. These criteria include experiencing at least five attacks that meet the requirements outlined in criteria 2-4. The duration of these headache attacks should last between 4 to 72 hours. Additionally, the headache should exhibit at least two of the following characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, and aggravation or avoidance of routine physical activity. Furthermore, during the headache, individuals should experience at least one of the following symptoms: nausea and/or vomiting, photophobia, and phonophobia. For more detailed information, you can refer to the guidelines provided by The British Association for the Study of Headache.
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This question is part of the following fields:
- Neurology
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Question 103
Correct
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A 45 year old female is brought into the emergency department with burns sustained in a house fire. You evaluate the patient for potential inhalation injury and the severity of the burns to the patient's limbs. In terms of the pathophysiology of burns, what is the central component of the burn known as according to the Jackson's Burn wound model?
Your Answer: Zone of coagulation
Explanation:Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.
When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.
Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.
The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.
Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.
Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.
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